Cold snare piecemeal resection of colonic and duodenal polyps ≥1 cm

Background: Endoscopic removal of duodenal and colorectal adenomas is currently considered to be the standard of care for prevention of adenocarcinoma. The use of cautery carries a risk of delayed bleeding, post-polypectomy syndrome, and perforation. We examined the safety and feasibility of removing colonic and duodenal polyps ≥ 1 cm using a piecemeal cold snare polypectomy technique.

Patients: The study included 15 patients with duodenal polyps ≥ 1 cm and 15 patients with colonic polyps ≥ 1 cm.

Main outcome measurements: Bleeding, perforation, abdominal pain, or hospitalization occurring within 2 weeks of polypectomy.

Results: Between 24 August 2011 and 29 April 2013, 15 patients had removal of duodenal polyps ≥ 1 cm. Mean patient age was 64 years and 9/15 patients were male. The mean polyp size was 24 mm (10 – 60 mm). All polyps were removed with a cold snare and some required cold biopsy forceps. One patient required hospitalization for gastrointestinal blood loss 7 days post-polypectomy; this patient was using Coumadin. Between 27 February 2012 and 30 May 2013, 15 patients underwent resection of a ≥ 1 cm colonic polyp. Mean patient age was 68 years and 9/15 were male. The mean polyp size was 20 mm (10 – 45 mm). All polyps were primarily removed with a cold snare. None of the patients required hemostatic clips for control of immediate bleeding. One patient presented to the emergency department with abdominal pain 1 day after initial endoscopy. CT scan showed no abnormalities and the patient was discharged.

Conclusions: Cold snare polypectomy for large duodenal and colonic polyps is technically feasible and may have a favorable safety profile compared to standard electrocautery-based endoscopic resection. Comparative trials are required to determine the relative safety and efficacy of cold snare techniques for complete and durable resection of large polyps compared to standard hot snare methods.

• References

• 1 Fyock CJ, Draganov PV. Colonoscopic polypectomy and associated techniques. World J Gastroenterol 2010; 16: 3630-3637
• 2 Van Gossum A, Cozzoli A, Adler M et al. Colonoscopic snare polypectomy: analysis of 1485 resections comparing two types of current. Gastrointest Endosc 1992; 38: 472-475
• 3 Tolliver KA, Rex DK. Colonoscopic polypectomy. Gastroenterol Clin North Am 2008; 37: 229-251, ix
• 4 Walsh RM, Ackroyd FW, Shellito PC. Endoscopic resection of large sessile colorectal polyps. Gastrointest Endosc 1992; 38: 303-309
• 5 Carvalho R, Areia M, Brito D et al. Endoscopic mucosal resection of large colorectal polyps: prospective evaluation of recurrence and complications. Acta Gastroenterol Belg 2013; 76: 225-230
• 6 Levin TR, Zhao W, Conell C et al. Complications of colonoscopy in an integrated health care delivery system. Ann Intern Med 2006; 145: 880-886
• 7 Waye JD, Kahn O, Auerbach ME. Complications of colonoscopy and flexible sigmoidoscopy. Gastrointest Endosc Clin N Am 1996; 6: 343-377
• 8 Choo WK, Subhani J. Complication rates of colonic polypectomy in relation to polyp characteristics and techniques: a district hospital experience. J Interv Gastroenterol 2012; 2: 8-11
• 9 Mannath J, Subramanian V, Singh R et al. Polyp recurrence after endoscopic mucosal resection of sessile and flat colonic adenomas. Dig Dis Sci 2011; 56: 2389-2395
• 10 Ferrara F, Luigiano C, Ghersi S et al. Efficacy, safety and outcomes of 'inject and cut' endoscopic mucosal resection for large sessile and flat colorectal polyps. Digestion 2010; 82: 213-220
• 11 Su MY, Hsu CM, Ho YP et al. Endoscopic mucosal resection for colonic non-polypoid neoplasms. Am J Gastroenterol 2005; 100: 2174-2179
• 12 Katsinelos P, Kountouras J, Paroutoglou G et al. Endoscopic mucosal resection of large sessile colorectal polyps with submucosal injection of hypertonic 50 percent dextrose-epinephrine solution. Dis Colon Rectum 2006; 49: 1384-1392
• 13 Levin B, Lieberman DA, McFarland B et al. Screening and surveillance for the early detection of colorectal cancer and adenomatous polyps, 2008: a joint guideline from the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gastroenterology 2008; 134: 1570-1595
• 14 Canto MI. Staining in gastrointestinal endoscopy: the basics. Endoscopy 1999; 31: 479-486
• 15 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
• 16 Ichise Y, Horiuchi A, Nakayama Y et al. Prospective randomized comparison of cold snare polypectomy and conventional polypectomy for small colorectal polyps. Digestion 2011; 84: 78-81
• 17 Lee CK, Shim JJ, Jang JY. 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
• 18 Uraoka T, Ramberan H, Matsuda T et al. Cold polypectomy techniques for diminutive polyps in the colorectum. Dig Endosc 2014; 26: 98-103
• 19 Vormbrock K, Mönkemüller K. Difficult colon polypectomy. World J Gastrointest Endosc 2012; 4: 269-280