Efficacy and safety of cold-snare endoscopic mucosal resection for colorectal adenomas 10 to 14 mm in size: a prospective observational study

      Background and Aims

      Cold-snare endoscopic mucosal resection (CS-EMR) has been adapted in a piecemeal fashion as a safe and effective procedure for resection of colorectal polyps ≥10 mm. However, few data are available on en bloc CS-EMR for adenomas of 10 to 14 mm. Thus, this study evaluated the efficacy and safety of CS-EMR for these colorectal adenomas.

      Methods

      In this single-arm, prospective, observational study, patients with at least 1 slightly elevated and sessile colorectal adenoma measuring 10 to 14 mm were recruited to undergo CS-EMR. The primary outcome was histological complete resection rate by CS-EMR, which was defined as en bloc resection, with a pathologically negative vertical margin and no neoplastic tissue obtained from 4 quadrants of the mucosal defect margin. Secondary outcomes were en bloc resection rate by CS-EMR, failure rate of CS-EMR, and the incidence of adverse events.

      Results

      A total of 80 polyps from 72 patients were included. CS-EMR failed in 11 lesions (13.7%), all of which were resected using a high-frequency electric current. The rates of en bloc resection and histologic complete resection by CS-EMR were 82.5% (66 of 80) and 63.8% (51 of 80), respectively. No bleeding occurred during the CS-EMR procedure, and there was no delayed bleeding or perforation at the site where CS-EMR was performed.

      Conclusions

      CS-EMR can be safely performed in an en bloc fashion for some colorectal adenomas measuring 10 to 14 mm. However, there is room for improvement regarding the resectability and evaluation of the vertical margin after CS-EMR. (Clinical trial registration number: UMIN000031248.)

      Graphical abstract

      Abbreviations:

      CS-EMR (cold-snare endoscopic mucosal resection), CSP (cold-snare polypectomy), HS-EMR (hot snare endoscopic mucosal resection), HSP (hot snare polypectomy), IQR (interquartile range)
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      References

        • Bray F.
        • Ferlay J.
        • Soerjomataram I.
        • et al.
        Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.
        CA Cancer J Clin. 2018; 68: 394-424
        • Winawer S.
        • Zauber A.
        • 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
        • Zauber A.
        • Winawer S.
        • O'Brien M.
        • et al.
        Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.
        N Engl J Med. 2012; 366: 687-696
        • Oka S.
        • Tanaka S.
        • Kanao H.
        • et al.
        Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan.
        Dig Endosc. 2010; 22: 376-380
        • Ito S.
        • Hotta K.
        • Imai K.
        • et al.
        Risk factors of post-endoscopic submucosal dissection electrocoagulation syndrome for colorectal neoplasm.
        J Gastroenterol Hepatol. 2018; 33: 2001-2006
        • Ferlitsch M.
        • Moss A.
        • Hassan C.
        • et al.
        Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.
        Endoscopy. 2017; 49: 270-297
        • Parsa N.
        • Ponugoti P.
        • Broadley H.
        • et al.
        Risk of cancer in 10-19 mm endoscopically detected colorectal lesions.
        Endoscopy. 2019; 51: 452-457
        • Horiuchi A.
        • Nakayama Y.
        • Kajiyama M.
        • et al.
        Removal of small colorectal polyps in anticoagulated patients: a prospective randomized comparison of cold snare and conventional polypectomy.
        Gastrointest Endosc. 2014; 79: 417-423
        • Kawamura T.
        • Takeuchi Y.
        • Asai S.
        • et al.
        A comparison of the resection rate for cold and hot snare polypectomy for 4-9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study).
        Gut. 2018; 67: 1950-1957
        • Hirose R.
        • Yoshida N.
        • Murakami T.
        • et al.
        Histopathological analysis of cold snare polypectomy and its indication for colorectal polyps 10-14 mm in diameter.
        Dig Endosc. 2017; 29: 594-601
        • Tutticci N.
        • Hewett D.
        Cold EMR of large sessile serrated polyps at colonoscopy (with video).
        Gastrointest Endosc. 2018; 87: 837-842
        • Rameshshanker R.
        • Tsiamoulos Z.
        • Latchford A.
        • et al.
        Resection of large sessile serrated polyps by cold piecemeal endoscopic mucosal resection: Serrated COld Piecemeal Endoscopic mucosal resection (SCOPE).
        Endoscopy. 2018; 50: E165-E167
        • Piraka C.
        • Saeed A.
        • Waljee A.
        • et al.
        Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm.
        Endosc Int Open. 2017; 5: E184-E189
        • Muniraj T.
        • Sahakian A.
        • Ciarleglio M.
        • et al.
        Cold snare polypectomy for large sessile colonic polyps: a single-center experience.
        Gastroenterol Res Pract. 2015; 2015: 175959
        • Choksi N.
        • Elmunzer B.J.
        • Stidham R.
        • et al.
        Cold snare piecemeal resection of colonic and duodenal polyps ≥1 cm.
        Endosc Int Open. 2015; 3: E508-E513
        • Yabuuchi Y.
        • Imai K.
        • Hotta K.
        A novel thin wire snare-assisted en bloc cold snare endoscopic mucosal resection of a colonic adenoma 10-14 mm in size.
        Dig Endosc. 2019; 31: e76-e77
        • Fujimoto K.
        • Fujishiro M.
        • Kato M.
        • et al.
        Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment.
        Dig Endosc. 2014; 26: 1-14
        • Kato M.
        • Uedo N.
        • Hokimoto S.
        • et al.
        Guidelines for gastroenterological endoscopy in patients undergoing antithrombotic treatment: 2017 appendix on anticoagulants including direct oral anticoagulants.
        Dig Endosc. 2018; 30: 433-440
        • Sano Y.
        • Tanaka S.
        • Kudo S.-E.
        • et al.
        Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team.
        Dig Endosc. 2016; 28: 526-533
        • Paris Workshop Group
        The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002.
        Gastrointest Endosc. 2003; 58: S3-S43
        • Japanese Society for Cancer of the Colon and Rectum
        Japanese classification of colorectal, appendiceal, and anal carcinoma.
        3rd ed. Kanehara, Tokyo2019
        • Pohl H.
        • Srivastava A.
        • Bensen S.
        • et al.
        Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study.
        Gastroenterology. 2013; 144: 74-80.e1
        • Chow S.
        • Shao J.
        • Wang H.
        Sample size calculations in clinical research.
        2nd ed. Chapman & Hall/CRC, New York2008
        • 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
        • Din S.
        • Ball A.
        • Riley S.
        • et al.
        Cold snare polypectomy: does snare type influence outcomes?.
        Dig Endosc. 2015; 27: 603-608
        • 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.e2
        • Repici A.
        • Hassan C.
        • Vitetta E.
        • et al.
        Safety of cold polypectomy for <10mm polyps at colonoscopy: a prospective multicenter study.
        Endoscopy. 2012; 44: 27-31
        • Matsuura N.
        • Takeuchi Y.
        • Yamashina T.
        • et al.
        Incomplete resection rate of cold snare polypectomy: a prospective single-arm observational study.
        Endoscopy. 2017; 49: 251-257
        • 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
        • Suzuki S.
        • Gotoda T.
        • Kusano C.
        • et al.
        Width and depth of resection for small colorectal polyps: hot versus cold snare polypectomy.
        Gastrointest Endosc. 2018; 87: 1095-1103
        • Ito A.
        • Suga T.
        • Ota H.
        • et al.
        Resection depth and layer of cold snare polypectomy versus endoscopic mucosal resection.
        J Gastroenterol. 2018; 53: 1171-1178
        • Tutticci N.
        • Burgess N.
        • Pellise M.
        • et al.
        Characterization and significance of protrusions in the mucosal defect after cold snare polypectomy.
        Gastrointest Endosc. 2015; 82: 523-528
        • Shichijo S.
        • Takeuchi Y.
        • Kitamura M.
        • et al.
        Does cold snare polypectomy completely resect the mucosal layer? A prospective single-center observational trial.
        J Gastroenterol Hepatol. 2020; 35: 241-248
        • Hassan C.
        • Quintero E.
        • Dumonceau J.M.
        • et al.
        Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
        Endoscopy. 2013; 45: 842-851
        • Gupta S.
        • Lieberman D.
        • Anderson J.C.
        • et al.
        Recommendations for follow-up after colonoscopy and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2020; 158: 1131-1153

      Linked Article

      • Cool it now: a new addition for resecting 10- to 14-mm polyps
        Gastrointestinal EndoscopyVol. 92Issue 6
        • Preview
          In this month’s Gastrointestinal Endoscopy, Yabuuchi et al1 present their prospective data on the safety and efficacy of cold snare EMR of polyps measuring 10 to 14 mm. The authors use a rigorous standard of “histologic complete resection,” defined by visual en bloc resection, a pathologically negative vertical margin, and no neoplastic tissue in 4-quadrant biopsy specimens taken around the resection margin. This leads to some illuminating data, and there are lessons to learn from the results. But let’s first ask an important question.
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