Polypectomy – going cold

Review by Prof. Eamonn Quigley (USA)

Study Summary 

In this study the authors performed a multicenter RCT across 6 sites in Taiwan of cold- vs hot-snare for polyps ranging in size from 4 to 10 mm (mean 6 mm). In all, 4,270 were randomly assigned to hot or cold polypectomy. Demographics and all relevant patient characteristics were well matched between the two groups. The groups were also well matched in terms of polyp location (53-55% proximal colon), morphology (55-58% polypoid) and pathology (70% adenomas). Delayed bleeding was the primary outcome and occurred in 0.4% of the cold and 1.5% of the hot groups, a highly significant difference. The cold technique was also faster (mean polypectomy time 119 vs 163 seconds) and resulted in fewer emergency department visits. Polyp retrieval (98%), en bloc resection (97%) and complete histological resection (86%) rates were similar in both groups. Only one perforation occurred in the entire study, and this occurred in a patient who underwent cold polypectomy.

Commentary 

Colonoscopy with polypectomy is one of the most commonly performed procedures around the world. In recent years cold snare polypectomy has emerged as an important addition to the colonoscopists armamentarium and has been shown to be more effective than cold forceps in the complete removal of smaller polyps. This study performed by expert (as judged by their outcomes) colonoscopists now shows the superiority, in terms of safety, of the cold snare technique over the hot variety in the removal of polyps up to 10 mm in diameter. This and other studies have led many of us to adopt the cold snare as our weapon of choice in dealing with all but the tiniest, small-to-mid sized polyps. If bleeding does occur it will be immediate and can be dealt with there and then. Attention to detail is important and includes the use of a true cold snare and knowledge of and experience in, polypectomy technique.

Citation

Chang L-C, Chang C-Y, Chen C-Y, et al. Cold versus hot snare polypectomy for small colorectal polyps. A pragmatic randomized controlled trial. Ann Intern Med 2023;176:311-9.

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