Original article
Clinical endoscopy
Cold snare piecemeal EMR of large sessile colonic polyps ≥20 mm (with video)

https://doi.org/10.1016/j.gie.2019.12.051Get rights and content

Background and Aims

Conventional EMR using a hot snare is the standard of care for resection of large (≥20 mm) nonmalignant sessile colonic polyps. Serious adverse events are predominantly because of electrocautery. This could potentially be avoided by cold snare piecemeal EMR (CSP-EMR). This study aimed to evaluate the safety and efficacy of CSP-EMR of sessile colonic polyps sized ≥20 mm.

Methods

All cases of CSP-EMR at 5 Australian academic hospitals for sessile polyps ≥20 mm over a 2-year period, from January 2016 to December 2017, were identified retrospectively. Efficacy was defined as the absence of residual or recurrent polyp tissue during the first surveillance colonoscopy (SC1) and second surveillance colonoscopy (SC2). Clinically significant intraprocedural or delayed adverse events and surveillance colonoscopy findings were assessed by reviewing medical records.

Results

CSP-EMR was performed on 204 polyps sized ≥20 mm in 186 patients (men, 33.8%; median age, 68 years). SC1 for 164 polyps (80.4%) at a median interval of 150 days showed residual or recurrent polyp in 9 cases (5.5%; 95% confidence interval, 3%-11%). SC2 for 113 polyps (72.9%) at a median interval of 18 months showed late residual or recurrent polyp in 4 cases (3.5%; 95% confidence interval, .9%-8.5%) after a normal SC1. Intraprocedural bleeding was successfully treated in 4 patients (2.2%), whereas 7 patients (3.8%) experienced self-limited clinically significant post-EMR bleeding and 1 patient (.5%) required overnight observation for nonspecific abdominal pain that resolved spontaneously. None experienced other adverse events.

Conclusions

CSP-EMR of sessile colonic polyps ≥20 mm is technically feasible, effective, and safe. The adverse event rate and polyp recurrence rate were low. Randomized or large prospective trials are required to confirm the noninferiority and improved safety of CSP-EMR compared with conventional EMR and to further determine the polyp morphologies that are best suited for CSP-EMR.

Section snippets

Methods

This study was approved by the Western Health Research Ethics Committee. We performed a retrospective multicenter review of all CSP-EMR procedures at 5 Australian academic hospitals for sessile polyps ≥20 mm over 2 years, from January 2016 to December 2017. Lesions were assessed using high-definition white-light imaging (HD-WLI) and narrow-band imaging (NBI). We recorded polyp overall morphology using the Paris classification,22 surface morphology (granular, nongranular, or mixed),23 and Kudo

Results

Over a 24-month period (January 2016 to December 2017), CSP-EMR was performed on 204 lesions (mean, 25.5 mm [standard deviation, 8.4]; median, 20 mm [IQR, 20-30]) in 186 patients (63 men [33.8%]; median age, 68 years [range, 21-91]). Ninety-two polyps (44%) were ≥25 mm, 61 (29.6%) ≥30 mm, and 19 (9.2%) ≥40 mm. One hundred eighty-nine polyps (92.6%) were from the proximal colon (proximal to the splenic flexure) and 15 polyps (7.4%) were from the distal colon (distal to the splenic flexure). The

Discussion

Colorectal EMR is a safe, effective, and less-invasive alternative to surgery.1,28 However, electrocautery use during EMR exposes patients to risks, including perforation, PPS, and clinically significant post-EMR bleeding. Avoidance of thermal energy when feasible can reduce these risks. To our knowledge, this is the largest study investigating safety and efficacy outcomes for CSP-EMR of large sessile (≥20 mm) colonic polyps. Our study of 186 patients with 204 polyps demonstrates that CSP-EMR

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    DISCLOSURE: Dr Brown: Research support from Olympus Australia. Dr Raftopoulos: Lecture fees and research support from Olympus Medical. All other authors disclosed no financial relationships.

    See CME section; p. 1378.

    If you would like to chat with an author of this article, you may contact Dr Moss at [email protected].

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