Cold snare polypectomy (CSP) is superior to hot snare polypectomy (HSP) for colorectal polyps measuring 4-10 mm, a pragmatic randomized controlled trial confirms.
In the Taiwan Cold Polypectomy Study, CSP was not only safer than HSP, with a significantly lower risk for delayed bleeding, it was also more efficient, report Li-Chun Chang, MD, PhD, from the National Taiwan University Hospital, Taipei, and colleagues.
The study was published online February 21 in Annals of Internal Medicine.
This large study “strengthens the already significant evidence that CSP is as effective and safer than HSP for polyps 4-10 mm in size,” Rajesh N. Keswani, MD, Northwestern University Feinberg School of Medicine, Chicago, Illinois, told Medscape Medical News.
“This study evaluated all significant endpoints — safety (decreased bleeding risk with CSP), effectiveness (equivalent complete resection rates between CSP and HSP), and efficiency (CSP faster than HSP),” said Keswani, who wasn’t involved in the study.
Clear Standard of Care
Previous randomized controlled trials have shown that CSP is as effective as HSP but more efficient in removing small polyps. However, the reduction in delayed bleeding associated with CSP had been shown only in high-risk patients using antiplatelet agents or anticoagulants. Less was known about CSP’s effect on delayed bleeding in the general population.
To investigate, Chang and colleagues randomly assigned 4270 adults aged 40 and older who were undergoing polypectomy to remove polyps measuring 4-10 mm to CSP or HSP.
Compared with HSP, CSP was associated with a significantly lower risk for all delayed bleeding (within 14 days after polypectomy) and severe delayed bleeding (defined as a decrease in hemoglobin of 20 g/L or more, requiring transfusion or hemostasis).
Eight of 2137 patients (0.4%) in the CSP group had delayed bleeding versus 31 of 2133 patients (1.5%) in the HSP group. Severe bleeding occurred in one patient who had CSP (0.05%) and eight who had HSP (0.4%).
The CSP group also had fewer emergency service visits than the HSP group — four visits (0.2%) vs 13 visits (0.6%).
CSP was more efficient, with mean polypectomy time reduced 26.9% compared with HSP, with no difference between groups in successful tissue retrieval, en bloc resection, and complete histologic resection.
“CSP saves time setting up electrosurgical generators or conducting submucosal injection. Moreover, the lower rate of delayed bleeding means fewer emergency service visits or hospital stays, saving medical expenses,” Chang and colleagues write in their article.
“Given the benefit in safety and cost-effectiveness, CSP may replace HSP for removal of small polyps in the general population,” they add.
Keswani agreed. “Based on the accumulated evidence over the past decade, CSP is the clear standard of care for polyps 4-10 mm in size,” he told Medscape Medical News.
“For polyps less than 4 mm, it remains reasonable to use either large capacity/jumbo forceps or CSP. Cautery should be reserved only for polyps greater than 10 mm, although there is ongoing work regarding cold versus hot EMR [endoscopic mucosal resection],” Keswani said.
Ann Intern Med. Published online February 21, 2023. Abstract
The trial was principal investigator–initiated and partially funded by the Boston Scientific Corporation, which had no role in the study design, data collection or analysis, data interpretation, manuscript preparation, or decision to submit the manuscript for publication. Keswani is a consultant for Boston Scientific and Neptune Medical and receives research support from Virgo.
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