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Introduction

Cold snare polypectomy (CSP) is often performed for polyps <10 mm; however, CSP should be avoided for polyps suspicious for carcinoma even if they are small [1]. Underwater endoscopic mucosal resection (UEMR) is a technique that allows colorectal polyp resection under flooded water without submucosal injection [2]. UEMR is reportedly effective in resecting large sessile colorectal neoplasms and achieves higher en bloc resection rates for polyps sized 10– 20 mm than conventional endoscopic mucosal resection (conventional EMR: CEMR) [3]. However, few studies have evaluated the effectiveness of UEMR for polyps <10 mm.

Aims & Methods

This study aimed to evaluate the usefulness of UEMR for colorectal polyps <10 mm. We retrospectively reviewed colonoscopy data collected in our institution from October 2018 to December 2022 and included cases with colorectal polyps <10 mm in diameter that had been resected using EMR. The colorectal polyps were assigned to UEMR or CEMR groups, and propensity score matching analysis was performed with the following covariates: operator's endoscopic experience (≤10 />10 years), tumour localisation (right-/left-sided colon), tumour size (≤5/6–9 mm), endoscopic diagnosis (SSL/adenoma), and macroscopic type (protruding/flat). We analysed the rate of en block and R0 resections as outcomes with the χ-square test, and p＜0.05 was considered a significant difference.

Results

Of 13,424 colonoscopies conducted in our institution from October 2018 to December 2022, 3,100 with colorectal polyps resected using EMR were identified. Colorectal polyps ≥10 mm were excluded, and 1,446 colorectal polyps were included. Moreover, we excluded lesions with uncertain size and morphology, and/or endoscopic diagnosis other than adenoma and SSL. Finally, 1,415 lesions were included in the study (UEMR group: 293 lesions; CEMR group: 1,122 lesions). Significant differences were observed in numerous factors before matching. The proportion of operators with >10-year experience was significantly higher (251/293 [85.7%] vs. 742/1,122 [66.1%]; P<0.0001) and that of endoscopic diagnosis of adenoma was significantly lower (264/293 [90.1%] vs. 1,076/1,122 [95.9%]; P<0.0001) in the UEMR than in the CEMR group, respectively. No significant differences were observed in the rate of tumour localisation, tumour size, and macroscopic type. The results of propensity score matching showed no significant differences between the two groups in any of the covariates. After excluding lesions with a pathological diagnosis other than SSL/adenoma and those with inability to evaluate margins of resected specimens, the final analysis included 253 and 252 cases in the UEMR and CEMR groups, respectively. The en bloc resection rates in the UEMR and CEMR groups were 96.0% (243/253) and 97.6% (246/252), respectively (P=0.447), and the respective R0 resection rates were 84.2% (213/253) and 80.6% (203/252), respectively (P=0.295).

Conclusion

The resection rates for UEMR and CEMR of colorectal polyps <10 mm were comparable. Therefore, UEMR, which does not require submucosal injection, can be considered a standard treatment for such colorectal polyps.

References

1. Uraoka T, Takizawa K, Tanaka S, et al. Guidelines for Colorectal Cold Polypectomy (supplement to "Guidelines for Colorectal Endoscopic Submucosal Dissection/Endoscopic Mucosal Resection"). Dig Endosc. 2022; 34: 668-675.
2. Binmoeller KF, Weilert F, Shah J, et al. “Underwater” EMR without submucosal injection for large sessile colorectal polyps (with video). Gastrointest Endosc 2012; 75: 1086-1091.
3. Yamashina T, Uedo N, Akasaka T, et al. Comparison of Underwater vs Conventional Endoscopic Mucosal Resection of Intermediate-Size Colorectal Polyps. Gastroenterology 2019; 157: 451-461.e452.

COMPARISON OF UNDERWATER AND CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION FOR COLORECTAL POLYPS LESS THAN 10 MM: A PROPENSITY SCORE MATCHING ANALYSIS

Takaaki Yoshimoto 1, Takuji Kawamura 1, Shiho Nakamura 1, Koji Uno 1

1 Kyoto Second Red Cross Hospital, Kyoto, Japan

Conference

UEG Week Copenhagen 2023

Topics

Colorectal

Submission format

Abstract

Session

Lower GI endoscopic polypectomy (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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Introduction

Colorectal endoscopic submucosal dissection (ESD) has become a widely used endoscopic technique for superficial colorectal tumors resection. ESD has a higher en bloc resection rate particularly for large lesions than endoscopic mucosal resection (EMR). Thus, ESD is associated with a better curability and can facilitate an adequate histological evaluation. However, the high incidence of postoperative adverse events, such as delayed bleeding, delayed perforation, and post-ESD electrocoagulation syndrome (PECS), which are associated with larger mucosal defects after ESD, has been a cause of concern. Recent meta-analyses have reported that the incidence of postoperative adverse events after ESD was higher than that after EMR.^¹ Therefore, these events should be controlled. Various closure techniques have been used to close larger mucosal defects in ESD.² However, the efficacy of these closure techniques in preventing adverse events remains controversial. Furthermore, few studies have been conducted to evaluate a single closure technique with a substantial number of cases.
In some cases, closure of mucosal defects after colorectal ESD is performed using a double-layered suturing technique with conventional hemostatic clips.³ In this technique, the muscle layer is first grasped directly with clips and tented inward, and then the mucosal layer is closed. Therefore, this technique has the potential to provide more reliable closure and prevent the spread of inflammation and abdominal pain than methods that merely close the mucosal layer.

Aims & Methods

This study retrospectively evaluated the impact of closure using a double-layered suturing technique on postoperative adverse events.
In total, 370 lesions in 317 patients who underwent colorectal ESD were included in this analysis. Then, patients with 197 lesions that were completely closed were assigned to the closure group. Meanwhile, patients with 173 lesions including 55 that were partially closed and 118 that were not closed were assigned to the non-closure group. Propensity score matching was performed and 136 lesions were selected for each group.

Results

The closure group had a significantly lower overall incidence rate of postoperative adverse events including delayed bleeding, delayed perforation and post-ESD electrocoagulation syndrome than the non-closure group (2.2% vs. 9.6%, p = 0.018). The closure group had a significantly lower incidence of abdominal pain on the day after ESD than the non-closure group (2.9% vs. 11.0%, p = 0.015).

Conclusion

Prophylactic closure of mucosal defects after colorectal ESD using a double-layered suturing technique could prevent postoperative adverse events and abdominal pain on the day after ESD.

References

1 Wang N, Shu L, Liu S, et al. Comparing endoscopic mucosal resection with endoscopic submucosal dissection in colorectal adenoma and tumors: Meta-analysis and system review. PLoS One 2023;18:e0291916.
2 Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc 2023;35:216-231.
3 Tanaka S, Toyonaga T, Obata D, Ishida T, Morita Y, Azuma T. Endoscopic double-layered suturing: a novel technique for closure of large mucosal defects after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Endoscopy 2012;44 Suppl 2 UCTN:E153-154.

EFFECT OF DOUBLE-LAYERED SUTURING FOR MUCOSAL DEFECTS CLOSURE AFTER COLORECTAL ENDOSCOPIC SUBMUCOSAL DISSECTION : A PROPENSITY SCORE MATCHING ANALYSIS

Hiromitsu Ban 1, Kyohei Nishino 1, Takashi Toyonaga 2

1 Omi Medical Center, Kusatsu, Japan

2 Kobe University Hospital, Kobe, Japan

Conference

UEG Week Berlin 2025

Topics

Colorectal

Submission format

Abstract

Session

Management of post-resection by endoscopy (Posters)

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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RESECTION DEPTH OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION COMPARED WITH CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION FOR INTERMEDIATE-SIZE COLORECTAL TUMORS: A MULTICENTER, RANDOMIZED, NONINFERIORITY TRIAL

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Introduction

Underwater endoscopic mucosal resection (UEMR) is an alternative to conventional EMR (CEMR) offering consistent negative horizontal margins. However, UEMR does not involve submucosal injection; thus, its ability to achieve a sufficient resection depth comparable to that of CEMR remains uncertain. This randomized controlled trial (RCT) aimed to compare UEMR and CEMR in terms of resection depth.

Aims & Methods

This multicenter, parallel two-arm, open-label, noninferiority RCT was conducted across four Japanese institutions enrolling patients with colorectal tumors measuring 10–20 mm. Participants were randomly assigned in a 1:1 ratio to either to UEMR or CEMR group, using a computerized random-number generator. The primary outcome was the resection depth, which is the distance from the lower edge of the muscularis mucosa to the deep margin of the resected specimen, analyzed based on per-protocol (PP) principles (noninferiority margin of 400 µm).

Results

This study screened 217 patients from September 21, 2022, to December 2, 2024, and randomly assigned them to the UEMR (n =109) or CEMR (n =108) group. The PP analysis revealed that the mean resection depths of the UEMR and CEMR groups were 1688.9 ± 1510.0 µm and 1432.3 ± 1294.2 µm, respectively (mean difference: 256.6 µm, 95% confidence interval: -119.9 µm to 633.1 µm; P = 0.18), indicating the noninferiority of UEMR compared with CEMR in terms of resection depth. Subgroup analyses revealed that the resection depth of lesions by UEMR, especially at the cecum/ascending colon (1822.4 ± 1469.7 µm vs. 1096.5 ± 1007.6 µm; P = 0.01), and those with superficial morphology (1238.7 ± 862.2 µm vs. 731.6 ± 376.1 µm; P < 0.01), was significantly deeper than that achieved by CEMR. Moreover, even for nonexperts, UEMR tended to provide adequate resection depth compared with CEMR, approaching the proficiency level exhibited by experts (1786.6 ± 1471.6 µm vs. 1192.4 ± 1074.7 µm; P = 0.07). There were no significant differences in adverse events between the two groups, including one case of intraoperative perforation (0.9%) in the CEMR group and one case of delayed bleeding (0.9%) in the UEMR group. No EMR-related deaths were reported.

Conclusion

UEMR maintains the equivalent resection depth as CEMR and could become the gold standard endoscopic resection technique for intermediate-size colorectal tumors. UEMR is strongly recommended, especially for lesions at the cecum, ascending colon, and superficial lesions, because it could resect significantly deeper than CEMR. Furthermore, UEMR is recommended for nonexperts as a resection method that provides sufficient resection depth (Clinical trial registration number: UMIN000047432).

RESECTION DEPTH OF UNDERWATER ENDOSCOPIC MUCOSAL RESECTION COMPARED WITH CONVENTIONAL ENDOSCOPIC MUCOSAL RESECTION FOR INTERMEDIATE-SIZE COLORECTAL TUMORS: A MULTICENTER, RANDOMIZED, NONINFERIORITY TRIAL

Yuzuru Tamaru 1, Akihiro Miyakawa 2, Takuya Yamada 3, Yorinobu Sumida 4, Keitaro Sekimoto 1, Minori Yasui 1, Hiroki Kamada 1, Shigeaki Semba 1, Kazuki Nakamura 1, Yuji Teraoka 1, Takeshi Mizumoto 1, Akihito Okazaki 1, Tsuyoshi Hatakeyama 1, Shintaro Takaki 1, Shigeto Yoshida 1, Toshio Kuwai 5

1 NHO Kure Medical Center and Chugoku Cancer Center, Kure, Japan

2 Asahi General Hospital, Asahi, Japan

3 Osaka Rosai Hospital, Sakai, Japan

4 Kitakyushu Municipal Medical Center, Kitakyushu, Japan

5 Hiroshima University Hospital, Hiroshima, Japan

Event

UEG Week Berlin 2025

Topics

Colorectal Endoscopy Surgery

Submission format

Abstract

Session

Improving decision-making in colorectal lesions

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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Introduction

Cold snare polypectomy (CSP) has become popular as a safe and simple treatment for small colonic lesions. According to the Japanese guidelines, CSP is indicated for adenomas <10 mm with no suspicion of carcinoma [1]. Occasionally, colorectal carcinoma is diagnosed after resection, and there is no consensus on the treatment of such lesions [2-4].

Aims & Methods

This single-center retrospective study aimed to investigate the long-term prognosis of Japanese patients with pathologically diagnosed colorectal carcinoma after resection by CSP. Patients who underwent CSP for small colonic lesions at our hospital in 2013–2022 and were histopathologically diagnosed with colorectal carcinoma were included in this study. We examined the local residual or recurrence rate, scar detection rate, and recurrence-free survival rate in patients who underwent at least one colonoscopy after CSP.

Results

Out of 12,935 lesions (6,082 cases) that were resected using CSP during the study period, 81 lesions (0.63%; 81 cases) were histologically diagnosed as colorectal carcinoma (mean age, 69.7 years; male patients, 69% [56/81]). Histologically, all tumours were well-differentiated adenocarcinomas. Negative lateral and vertical margins of the resected specimens were 47% (38/81) and 72% (58/81), respectively. Of these 81 cases, 47 (58%) were followed up at least once by colonoscopy. The breakdown of cases that were not followed up endoscopically is as follows: concurrent advanced cancer (n=15), advanced age (n=7), dropout (n=7), and others (n=5). Endoscopic evidence of residual disease or recurrence was found in 1/47 patients (2%), and the remaining 46 patients had a median colonoscopic follow-up of 425 days (interquartile range, 192.5–1078.5 days) with no endoscopic evidence of local recurrence. In 51% (24/47) of cases, post-polypectomy scars could be identified. In one case where local residual carcinoma was confirmed, a retrospective review of the CSP revealed incomplete resection at the time of treatment. Abdominal CT performed immediately after CSP showed coincidental peritoneal dissemination, and the patient died 177 days after diagnosis. In 46 patients with no endoscopic evidence of local recurrence, the median observation period was 921 days (interquartile range, 475–1654.5 days), with six cases of death from causes other than colorectal cancer, and the others were alive without recurrence.

Conclusion

The frequency of residual disease or recurrence of colorectal carcinoma treated by CSP was low, and the long-term prognosis was favourable once the absence of residual lesions was confirmed endoscopically.

References

1. Uraoka T, Takizawa K, Tanaka S et al. Guidelines for Colorectal Cold Polypectomy (supplement to "Guidelines for Colorectal Endoscopic Submucosal Dissection/Endoscopic Mucosal Resection"). Dig Endosc 2022; 34: 668-675.
2. Yoshii S, Hayashi Y, Nakamura T et al. Endoscopic features and clinical course of colorectal carcinoma resected by cold snare polypectomy. J Gastroenterol Hepatol 2023, in press
3. Inoki K, Takamaru H, Furuhashi H et al. Management of colorectal high-grade dysplasia or cancer resected by cold snare polypectomy: a multicenter exploratory study. J Gastroenterol 2023, in press
4. Yoshida N, Fukumoto K, Hasegawa D et al. Recurrence rate and lesions characteristics after cold snare polypectomy of high-grade dysplasia and T1 lesions: A multicenter analysis. J Gastroenterol Hepatol 2021; 36: 3337-3344.

LONG-TERM PROGNOSIS OF COLORECTAL CARCINOMA TREATED BY COLD SNARE POLYPECTOMY

Shiho Nakamura 1, Takaaki Yoshimoto 1, Takuji Kawamura 1, Koji Uno 1

1 Kyoto Second Red Cross Hospital, Kyoto, Japan

Conference

UEG Week Copenhagen 2023

Topics

Colorectal

Submission format

Abstract

Session

PP 06 Other lower GI disorders (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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Introduction

Conventional endoscopic mucosal resection (CEMR) and underwater endoscopic mucosal resection (UEMR) are techniques for the removal of colorectal lesions.

Aims & Methods

The our study aim is to compare the efficacy and safety of UEMR versus CEMR in patients with lesions under 30mm in diameter.
The study included 124 patients with colorectal lesions with a diameter < 20mm, 20-30mm, type 0-Ip (hot-snare polypectomy), 0-Is, 0-IIa or 0-IIa+Is according to the Paris Classification. Cases were divided into two groups: Group I 64/124(51,61%) CEMR cases (0-Is, 0-IIa, 0-IIa+Is - < 20mm 43,75%, 20-30mm 20,31%; type 0-Ip - 35,93%) and Group II 60/124(48,38%) UEMR patients (0-Is, 0-IIa, 0-IIa+Is - < 20mm 45%, 20-30mm 23,33%; type 0-Ip - 31,66%). Cases with deep submucosal invasion were not included. Optical evaluation with chromoscopy and NBI was performed by expert endoscopist, followed by endoscopic resection. The outcomes were the lesion recurrence rate, en-bloc resection, R0 resection rates, adverse events. Data were analysed using Chi-sq, descriptive statistic by SPSS version 26.0.

Results

The recurrence rate was lower for II Group (UEMR) (1/14; 7,14%) in cases of 20-30mm lesions size (I Group (CEMR) - 2/13; 15,38%), and in 0-Ip (hot-snare polypectomy) cases (II Group (UEMR) - 1/19; 5,26%; I Group (CEMR) - 3/23; 13,04%); en-bloc resection rates was higher in II Group (UEMR) (13/14; 92,85%) in cases of 20-30mm lesions size. The R0 resection and adverse events showed the same tendency, only for polyps between 20 and 30 mm. There were no differences in the overall recurrence rate between groups. Underwater endoscopic mucosal resection was faster and easier to perform than CEMR.

Conclusion

Underwater endoscopic mucosal resection is safety method and could be considered for treatment of colorectal lesions with low adverse events rates.

References

Karl Kwok, Tri Tran, Daniel Lew. Polypectomy for large polyps with endoscopic mucosal resection. Gastrointest Endoscopy Clin N Am 32 (2022) 259–276.
https://doi.org/10.1016/j.giec.2021.12.004

Joaquín Rodríguez Sánchez, Marco A. Alvarez-Gonzalez, María Pellisé, et al. Underwater versus conventional EMR of large nonpedunculated colorectal lesions: a multicenter randomized controlled trial. Gastrointest Endosc 2023; Volume 97, No. 5: 941-51.e2.

Chandan S, Khan SR, Kumar A, et al. Efficacy and histologic accuracy of underwater versus conventional endoscopic mucosal resection for large (>20 mm) colorectal polyps: a comparative review and meta- analysis. Gastrointest Endosc 2021;94:471-82.e9.

UNDERWATER ENDOSCOPIC MUCOSAL RESECTION AND HOT-SNARE POLYPECTOMY IN COLONOSCOPY

Andrii Steshenko 1, Lubomir Marko 1, Michal Gurin 1, Roman Koreň 1, Matej Štiastny 1, Alena Slobodniková 1, Tatiana Koňarčiková 2

1 F. D. Roosevelt University Hospital in Banská Bystrica, Banská Bystrica, Slovakia

2 Martinské bioptické centrum, s.r.o., Banská Bystrica, Slovakia

Conference

UEG Week Vienna 2024

Topics

Colorectal

Submission format

Abstract

Session

LOWER GI (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Introduction

Endoscopic mucosal resection (EMR) is standard of care for the management of large (≥20mm) non-pedunculated colonic polyps (LNPCPs). Its efficacy and cost effectiveness were limited by recurrence. Margin thermal ablation (MTA) to the post-EMR defect, has greatly mitigated this problem. However, electrocautery-related complications of delayed bleeding and perforation incur significant morbidity.
Cold snare polypectomy is effective and safe for the resection of small polyps with negligible recurrence rates. Application of cold snare resection to LNPCPs, while an attractive alternative, lacks high-quality evidence. We conducted a randomized trial to compare the efficacy and safety of cold EMR (C-EMR) to conventional (H-EMR).

Aims & Methods

A prospective single-centre randomized controlled trial was conducted at an Australian tertiary referral centre for flat, 15-50mm adenomatous LNPCPs referred for endoscopic resection. Prior to resection, eligible LNPCPs were randomly assigned to EMR using a dedicated cold snare or conventional H-EMR with margin thermal ablation (control). First surveillance colonoscopy (SC1) was conducted 6 months following resection. Scars were evaluated with high-definition white-light, narrow-band imaging and biopsy. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at SC1. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success.

Results

931 LNPCPs were referred for endoscopic resection between November 2019-September 2023. 177 LNPCPs in 177 patients were randomized to either the C-EMR arm (n=87) or H-EMR arm (n=90). Treatment groups were equivalent with no significant difference in lesion size or technical success (86/87 (98.9%) vs 90/90 (100%); p=0.31). One C-EMR required conversion to H-EMR due to unexpected submucosal fibrosis. Following exclusions, 146 LNPCPs undertook SC1 (76 C-EMR, 70 H-EMR). 5 patients await surveillance. On intention to treat and per protocol analysis, recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; p<0.001 and 16/76, 21.1% vs 1/70, 1.4%; p<0.001 respectively). Significant deep mural injury (27/90 (30%) vs 0; p<0.001) and delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB and intraprocedural bleeding were significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); p = 0.034 and 12/90 (13.3%) vs C-EMR arm 1/87 (1.1%); p=0.002 respectively).

Conclusion

Compared to conventional H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique.

Disclosure

Michael Bourke: Research Support: Olympus Medical, Cook Medical, Boston Scientific
The remaining authors have no financial, professional, or personal conflicts of interest to disclose

COLD VS HOT SNARE ENDOSCOPIC MUCOSAL RESECTION FOR LARGE (≥15MM) FLAT NON-PEDUNCULATED COLORECTAL POLYPS: A RANDOMIZED CONTROLLED TRIAL

Tim O'Sullivan 1, Oliver Cronin 1, Arnout van Hattem 2, Francesco Vito Mandarino 3, Julia Gauci 3, Clarence Kerrison 3, Anthony Whitfield 1, Sunil Gupta 1, Eric Lee 3, Stephen Williams 3, Nicholas Burgess 1, Michael John Bourke 1

1 Westmead Hospital, Sydney, Australia|||University of Sydney, Sydney, Australia

2 Antoni van Leeuwenhoek ziekenhuis / Netherlands Cancer Institute, Amsterdam, Netherlands

3 Westmead Hospital, Sydney, Australia

Conference

UEG Week Vienna 2024

Topics

Colorectal

Submission format

Abstract

Session

LOWER GI (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Introduction

Hot endoscopic mucosal resection (H-EMR) is the standard of care for large non-pedunculated colorectal polyps (LNPCPs) without suspicion of submucosal invasion, achieving low recurrence rates after en bloc resection or piecemeal resection with margin ablation in expert centers.^1,2 However, electrocautery is also responsible for complications which can lead to significant morbidity and necessitate additional invasive procedures.^3,4 Cold snare polypectomy (CSP) has proven to be preferable to H-EMR for adenomas ≤10mm and non-dysplastic sessile serrated lesions, providing comparable efficacy with improved safety, shorter procedural time and lower costs.⁵ These advantages have driven interest in expanding CSP to larger polyps.

Aims & Methods

This meta-analysis of randomized controlled trials (RCTs) aimed to compare the risk of recurrence and adverse events between cold snare polypectomy (CSP) and hot-endoscopic mucosal resection (H-EMR) for large non-pedunculated colorectal polyps (LNPCPs).
A systematic search of Medline, Embase and Cochrane Library databases was performed through August 2024 for studies comparing recurrence, bleeding and perforation rates between CSP and H-EMR for LNPCPs ≥15mm (PROSPERO ID: CRD42024568272). RCTs were included in the quantitative analysis. A random-effects meta-analysis, with heterogeneity measured with I², was conducted to generate pooled risk ratios (RR) with 95% confidence intervals.

Results

Four RCTs comprising 1516 LNPCPs (766 CSP and 750 H-EMR) in 1442 patients were included in the quantitative analysis. CSP demonstrated a higher recurrence risk at first surveillance colonoscopy than H-EMR in the pooled analysis (22.6% vs. 10.8%; RR=1.98; 95% CI: 1.22–3.21; p=0.02; moderate-certainty evidence), corresponding to a number needed to harm of 9. Regarding adverse events, CSP demonstrated a 67% reduced risk of delayed bleeding (1.2% vs. 3.9%; RR=0.33; 95% CI: 0.12-0.89; p=0.03; high-certainty evidence), corresponding to a number needed to treat of 37. Although CSP appeared to reduce the risk of intraprocedural bleeding (10.0% vs. 19.8%; RR=0.30, 95% CI: 0-52256.34, p=0.42), the wide confidence interval from the random-effects model included 1. There were no intraprocedural or delayed perforations in the CSP group.

Author	Study design	Number of patients		Age, mean (SD), years	Female, %	Number of LNPCPs		LNPCP size, mean/median (SD/IQR), mm	Right Location, %		Adenomatous histology, %
Author	Study design	CSP	H-EMR	Age, mean (SD), years	Female, %	CSP	H-EMR	LNPCP size, mean/median (SD/IQR), mm	CSP	H-EMR	CSP	H-EMR
O’ Sullivan T. et al., 2024	Single center, RCT	87	90	68.2 (10.0)	46.9	87	90	30 (25-35)	96.5	86.7	100	100
Steinbrück et al., 2024	Multicenter, RCT	184	192	65.9 (10.5)	48.2	193	203	30.1 (10.2)	88.1	86.2	60.7	68.5
Pohl H. et al., 2024	Multicenter, RCT	336	324	65.3 (10.2)	47.7	371	343	30 (25.4)	82.5	83.4	NR	NR
Nogales et al., 2023	Multicenter, RCT	115	114	67.9 (10.6)	43.3	115	114	25 (22-30)	80.0	78.1	71.9	77.2

Table 1. Patients, LNPCPs and procedure characteristics of the randomized controlled trials included in the quantitative analysis. (List of abbreviations: CSP, cold snare polypectomy; H-EMR, hot endoscopic mucosal resection; IQR, interquartile range; LNPCPs, large non-pedunculated colorectal polyps; NR, not reported; SD, standard deviation; RCT, randomized controlled trial)

Conclusion

CSP has nearly double the recurrence risk of H-EMR for LNPCPs. However, its superior safety profile may make it a preferable option for patients where procedural safety is prioritized over radicality, such as those with extensive comorbidities.

References

1. Ferlitsch M, Hassan C, Bisschops R et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy 2024; 56: 516-545. doi:10.1055/a-2304-3219
2. Kaltenbach T, Anderson JC, Burke CA et al. Endoscopic Removal of Colorectal Lesions: Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115: 435-464. doi:10.14309/ajg.0000000000000555
3. Sidhu M, Shahidi N, Gupta S et al. Outcomes of Thermal Ablation of the Mucosal Defect Margin After Endoscopic Mucosal Resection: A Prospective, International, Multicenter Trial of 1000 Large Nonpedunculated Colorectal Polyps. Gastroenterology 2021; 161: 163-170.e163. doi:10.1053/j.gastro.2021.03.044
4. Meulen LWT, Bogie RMM, Winkens B et al. Thermal ablation of mucosal defect margins to prevent local recurrence of large colorectal polyps: a systematic review and meta-analysis. Endosc Int Open 2022; 10: E1127-e1135. doi:10.1055/a-1869-2446
5. Rex DK, Anderson JC, Pohl H et al. Cold versus hot snare resection with or without submucosal injection of 6- to 15-mm colorectal polyps: a randomized controlled trial. Gastrointest Endosc 2022; 96: 330-338. doi:10.1016/j.gie.2022.03.006

COLD SNARE POLYPECTOMY VERSUS HOT ENDOSCOPIC MUCOSAL RESECTION FOR LARGE NON-PEDUNCULATED COLORECTAL POLYPS: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Andrea Sorge 1, Michele Montori 2, Maria Eva Argenziano 3, Pieter Jan Poortmans 4, Daniele Balducci 5, Gian Eugenio Tontini 6, Sander Smeets 3, Tamás Tornai 3, Massimo Del Fabbro 7, Sandro Sferrazza 8, Lobke Desomer 9, Gabriele Gallo Afflitto 10, David James Tate 3

1 Gent University Hospital, Gent, Belgium|||University of Milan, Milan, Italy

2 Gent University Hospital, Gent, Belgium|||Università Politecnica delle Marche, Ancona, Italy

3 Gent University Hospital, Gent, Belgium

4 Gent University Hospital, Gent, Belgium|||University Hospital Ghent, University Hospital Brussels, Asse, Belgium

5 Università Politecnica delle Marche, Ancona, Italy

6 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy

7 University of Milan, Milan, Italy

8 Arnas Ospedale Civico Palermo, Palermo, Italy

9 AZ Delta vzw, Roeselare, Belgium

10 University of Rome “Tor Vergata”, Rome, Italy

Conference

UEG Week Berlin 2025

Topics

Colorectal

Submission format

Abstract

Session

Endoscopic resection for colorectal neoplasia (Posters)

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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