Hot snare polypectomy with or without saline solution/epinephrine lift for the complete resection of small colorectal polyps

Published:February 03, 2018DOI:

      Background and Aims

      The criteria for a standard polypectomy technique for complete removal of small colorectal polyps has not yet been established. This study aimed to compare the complete resection rate of hot snare polypectomy (HSP) with that of EMR for small, sessile, or flat polyps.


      Patients with 5- to 9-mm non-pedunculated colorectal polyps were prospectively randomized to the HSP or EMR group. The presence of residual polyps was assessed by performing histologic assessment of 4-quadrant forceps biopsy specimens taken from the edges of the polypectomy site. The primary outcome was the complete resection rate after HSP or EMR; the secondary outcomes were the proportion of procedure-related adverse events and specimen-loss rate. Sample size was estimated using a superiority trial design. We assumed that the complete resection rate of the EMR group would be at least 8% higher than that of the HSP group.


      A total of 382 polyps in 269 patients were assessed and randomly assigned to each method using 4 × 4 block randomization. Of these, 353 polyps were finally analyzed based on the pathology results. The mean polyp size was 6.3 ± 1.3 mm. The complete resection rate did not differ between the HSP and EMR groups (88.4% [152/172] vs 92.8% [168/181], respectively; P = .2). The intraprocedural bleeding rate, immediately after polypectomy, was significantly higher in the HSP group than in the EMR group (5.2% vs 0.6%, respectively; P = .009). However, clinically significant bleeding and tissue retrieval failure rates did not differ between the groups. In the multivariate logistic regression analysis, sessile serrated adenoma/polyps or hyperplastic polyps were almost 3 times (odds ratio, 2.824; 95% confidence interval, 1.03-7.75; P = .044) more likely to be incompletely resected compared with other conventional adenomatous polyps. Except for pathology, we found no significant independent predictors for incomplete resection.


      EMR for small non-pedunculated colorectal polyps is not superior to HSP in terms of complete resection or safety. Both methods can be performed according to the endoscopist’s preference. (Clinical trial registration number: KCT0001640;


      CI (confidence interval), HP (hyperplastic polyp), HSP (hot snare polypectomy), IER (incomplete eradication rate), IP (intraprocedural), OR (odds ratio), PCCRC (post-colonoscopy colorectal cancer), RR (relative risk), SSA/P (sessile serrated adenoma/polyp), TA (tubular adenoma), TSA (traditional serrated adenoma), TVA (tubule-villous adenoma), VA (villous adenoma)
      To read this article in full you will need to make a payment


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Winawer S.J.
        • Zauber A.G.
        • Ho M.N.
        • et al.
        Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.
        N Engl J Med. 1993; 329: 1977-1981
        • Citarda F.
        • Tomaselli G.
        • Capocaccia R.
        • et al.
        Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence.
        Gut. 2001; 48: 812-815
        • Pohl H.
        • Srivastava A.
        • Bensen S.P.
        • et al.
        Incomplete polyp resection during colonoscopy: results of the complete adenoma resection (CARE) study.
        Gastroenterology. 2013; 144: 74-80
        • Rex D.K.
        • Bond J.H.
        • Winawer S.
        • et al.
        Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer.
        Am J Gastroenterol. 2002; 97: 1296-1308
        • Sawhney M.S.
        • Farrar W.D.
        • Gudiseva S.
        • et al.
        Microsatellite instability in interval colon cancers.
        Gastroenterology. 2006; 131: 1700-1705
        • Pohl H.
        • Robertson D.J.
        Colorectal cancers detected after colonoscopy frequently result from missed lesions.
        Clin Gastroenterol Hepatol. 2010; 8: 858-864
        • Martinez M.E.
        • Baron J.A.
        • Lieberman D.A.
        • et al.
        A pooled analysis of advanced colorectal neoplasia diagnoses after colonoscopic polypectomy.
        Gastroenterology. 2009; 136: 832-841
        • Rex D.K.
        Narrow-band imaging without optical magnification for histologic analysis of colorectal polyps.
        Gastroenterology. 2009; 136: 1174-1181
        • Hassan C.
        • Pickhardt P.J.
        • Kim D.H.
        • et al.
        Systematic review: distribution of advanced neoplasia according to polyp size at screening colonoscopy.
        Aliment Pharmacol Ther. 2010; 31: 210-217
        • Kim J.S.
        • Lee B.I.
        • Choi H.
        • et al.
        Cold snare polypectomy versus cold forceps polypectomy for diminutive and small colorectal polyps: a randomized controlled trial.
        Gastrointest Endosc. 2015; 81: 741-747
        • Pohl H.
        • Srivastava A.
        • Bensen S.P.
        • et al.
        Incomplete polyp resection during colonoscopy: results of1the complete adenoma resection (CARE) study.
        Gastroenterology. 2013; 144: 74-80
        • Horiuchi A.
        • Hosoi K.
        • Kajiyama M.
        • et al.
        Prospective, randomized comparison of 2 methods of cold snare polypectomy for small colorectal polyps.
        Gastrointest Endosc. 2015; 82: 686-692
        • Singh N.
        • Harrison M.
        • Rex D.K.
        A survey of colonoscopic polypectomy practices among clinical gastroenterologists.
        Gastrointest Endosc. 2004; 60: 414-418
        • Din S.
        Polypectomy practices of sub-centimeter polyps in the English Bowel Cancer Screening Programme.
        Surg Endosc. 2015; 29: 3224-3230
        • Norton I.D.
        • Wang L.
        • Levine S.A.
        • et al.
        Efficacy of colonic submucosal saline solution injection for the reduction of iatrogenic thermal injury.
        Gastrointest Endosc. 2002; 56: 95-99
        • Iishi H.
        • Tatsuta M.
        • Kitamura S.
        • et al.
        Endoscopic resection of large sessile colorectal polyps using a submucosal saline injection technique.
        Hepatogastroenterology. 1997; 44: 698-702
        • Shirai M.
        • Nakamura T.
        • Matsuura A.
        • et al.
        Safer colonoscopic polypectomy with local submucosal injection of hypertonic saline-epinephrine solution.
        Am J Gastroenterol. 1994; 89: 334-338
        • Kim H.-S.
        • Hwang H.W.
        • Park H.J.
        • et al.
        Cold snare versus hot snare polypectomy for the complete resection of 5-9 mm sized colorectal polyps: a randomized controlled trial [abstract].
        Gastrointest Endosc. 2014; 79: AB401
        • Lee C.K.
        • Shim J.J.
        • Jang J.Y.
        Cold snare polypectomy vs. cold forceps polypectomy using double-biopsy technique for removal of diminutive colorectal polyps: a prospective randomized study.
        Am J Gastroenterol. 2013; 108: 1593-1600
        • Hewett D.G.
        • Rex D.K.
        Colonoscopy and diminutive polyps: hot or cold biopsy or snare? Do I send to pathology?.
        Clin Gastroenterol Hepatol. 2011; 9: 102-105
        • Fatima H.
        • Rex D.K.
        Minimizing endoscopic complications: colonoscopic polypectomy.
        Gastrointest Endosc Clin N Am. 2007; 17 (viii): 145-156
        • Draganov P.V.
        • Chang M.N.
        • Alkhasawneh A.
        • et al.
        Randomized, controlled trial of standard, large-capacity versus jumbo biopsy forceps for polypectomy of small, sessile, colorectal polyps.
        Gastrointest Endosc. 2012; 75: 118-126