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, % |
| CSP | H-EMR | CSP | H-EMR | 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
