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BACKGROUND AND AIM The true incidence of incomplete muscularis mucosa resection with cold snare polypectomy (CSP) is unknown. We examined the incidence of incomplete muscularis mucosa resection both with and without cold snare defect protrusion (CSDP). METHODS We prospectively enrolled patients undergoing polypectomy for 4 to 9mm nonpedunculated polyps. We evaluated the presence of CSDP immediately following CSP and biopsied the CSDP or the center of the mucosal defect without CSDP. The presence of the muscularis mucosa and any residual polyp in the biopsies was evaluated histologically. The primary outcome was the incidence of incomplete mucosal layer resection defined as the presence of muscularis mucosa or residual polyp in the biopsies. RESULTS From August 2017 to October 2018, 188 patients were screened, and 357 polyps were included. CSDP was detected in 122/355 (34%) evaluated mucosal defects. Excluding five lesions requiring hemostasis immediately following CSP, 352 mucosal defects were biopsied. After excluding 102 biopsies containing normal mucosa, we evaluated 250 biopsies. The overall incidence of incomplete mucosal layer resection was 63% (159/250), 76% (68/90) with CSDP and 57% (91/159) without CSDP (P

Background and Aim Cold snare polypectomy is safe and efficacious for removing polyps, Cold snare polypectomy of 10–20 mm sessile polyps is safe, and no complications were seen when compared with hot snare.

The quality of colonoscopy is essential for successful colon cancer screening. Inadequate polypectomy technique can contribute to incomplete polypectomy. The primary outcome of this study was to compare the incomplete resection rate (IRR) for cold jumbo forceps polypectomy (JFP) and cold snare polypectomy (CSP). Secondary outcomes were to compare the rates of tissue retrieval and rates of procedure-related complications. This prospective randomized parallel-group study assigned patients undergoing colonoscopy to jumbo biopsy forceps polypectomy (JFP) or cold snare polypectomy (CSP) for polyps ≤ 6 mm in size. After polyp removal was complete, the base of the polypectomy site was biopsied to evaluate for the presence of residual polyp tissue. The resection quality was evaluated in 151 patients with 261 polyps ≤ 6 mm. The IRR was 9.6% (25/261) for all polyps, 11.1% (16/144) for JFP, and 7.7% (9/117) for CSP (P = 0.41). Failure of tissue retrieval was noted in 0/144 (0%) of JFP and 5/117 (4.3%) of CSP (P = 0.02). There were no procedure-related complications in either group. Colon polyps are incompletely resected in a small but potentially significant percentage of cases. IRR are similar with the use of cold jumbo forceps and cold snare. Use of cold jumbo forceps may result in more successful tissue retrieval as compared to cold snare.

Background and Aim: Endoscopic mucosal resection (EMR) with a cold snare is gaining increasing acceptance as an effective therapy for large laterally spreading lesions in the colon. The cold snare technique offers a favorable risk profile, with low rates of bleeding, perforation, and post-procedure pain compared to the more widely used hot snare EMR technique. While there is increasing acceptance of cold snare EMR for the removal of medium (10-19mm) and large (≥20mm) sessile serrated lesions (SSLs), concerns remain about its suitability for the removal of similar sized adenomas. We aimed to study the differences in safety and efficacy of cold snare EMR for SSLs as compared to adenomas at our institution. Methods: Data was collected retrospectively for EMR procedures of Paris IIa SSLs and adenomas performed at a single centre between 01/02/2018 and 31/05/2020. The Provation endoscopy reporting program was used to source size, morphology, method of resection, and recurrence data. Complications were captured through a review of medical records that included a one-month follow-up phone call. Results: A total of one hundred forty-two eligible EMR procedures were performed over the study period (Table 1). The SSLs and adenomas were similarly located throughout the colon. One hundred nineteen patients had completed their six-month surveillance colonoscopy (SC1) and forty-six their eighteen-month surveillance (SC2). The overall recurrence rate at SC1 was considerably lower in the SSL group (3.2% vs 14.0%, OR 0.20, P 0.05). The difference was most appreciable in lesions 20mm or larger (3.1% vs 18.4%, OR 0.14, P 0.08). Recurrence was able to be treated endoscopically in all cases. There were no complications reported in either group. Conclusion: Our study demonstrates both safety and efficacy of the cold snare technique for medium and large SSLs, while raising concerns about efficacy, but not safety, for similarly sized adenomas. It is reassuring that recurrence was able to be treated endoscopically in all cases. Considering this and the impressive safety profile of the cold EMR technique, particularly in high risk patients, it may still have a place in the EMR of medium and large adenomas. Further research is required to understand the reasons for this increased recurrence and to determine the optimal technique for cold snare EMR of adenomas.

Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known.Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods.A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively.In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.

Background/Aim: To compare the complete resection rate of hot and cold snare polypectomy for small colorectal polyps. Patients and Methods: We retrospectively reviewed the medical records of 233 consecutive patients with 461 colorectal polyps up to 10 mm in diameter that were treated by hot or cold snare polypectomy between April 2014 and August 2016. Lesions treated by hot snare polypectomy (n = 137) and cold snare polypectomy (n = 324) were compared. The histological complete resection rates were evaluated between the two groups. We analyzed the relationship between factors for complete resection and clinical factors using multivariate analysis. Results: There was a significantly higher complete resection rate in hot snare polypectomy than in cold snare polypectomy (70.5% vs. 47.3%; P < 0.001). In the analysis of subgroups categorized according to polyp size, the complete resection rate for hot snare polypectomy was significantly higher than that for cold snare polypectomy among polyps ≥6 mm (69.0% vs. 43.5%; P < 0.001). Among polyps ≤5 mm, no significant difference regarding the complete resection rate was observed between the methods (81.3% vs. 53.4%; P = 0.057). There was no significant difference in the incidence of adverse events between the two groups. Multivariate analysis revealed that using hot snare polypectomy (odds ratio 3.03; P < 0.001), small lesion size (odds ratio 1.57; P = 0.049), and lesion location in the left colon (odds ratio 1.73; P = 0.007) were independent factors for complete resection. Conclusion: Hot snare polypectomy provides a higher complete resection rate than does cold snare polypectomy for larger (6–10 mm) subcentimeter colorectal polyps.

Background: Cold snare polypectomy (CSP) has been recently reported to be useful for the removal of small colonic polyps. However, the relationship between the histologically complete resection rate and snare size used during CSP has not been reported. Our aim was to assess the utility of CSP. Methods: We analyzed the histologically complete resection rates and the frequency of complications for 175 colon polyps removed by CSP. Moreover, we examined the histologically complete resection rate associated with different snare sizes used during CSP. Results: There was no significant difference in the histologically complete resection rate between endoscopic mucosal resection (EMR) (60.9%) and CSP (53.1%). There were also no significant differences in the frequency of complications including perforation and postoperative bleeding between EMR (perforation: none; postoperative bleeding: two patients) and CSP (perforation: none; postoperative bleeding: none). Histological examination revealed that the complete resection rate of CSP using a short snare (61.6%) was significantly higher than that of CSP using a long snare (44.9%; P < 0.05). There were no significant differences in the frequency of complications between CSP using the short snare and that using the long snare. Conclusions: CSP is a safe, useful method for the removal of colonic polyps. CSP using the short snare improved the histologically complete resection rates compared to the long snare. Future studies to further assess the utility of CSP are required. J Clin Med Res. 2016;8(9):662-666 doi: http://dx.doi.org/10.14740/jocmr2646w

Dear Editor, I read with interest the article by P. Willems et al. Medical practice as was first inherited from Hippocrates and later adopted from contemporary medical societies and the scientific ...

Most of the benefit of colorectal cancer screening and surveillance relies on the detection and resection of precancerous colorectal polyps. Although much emphasis has been given to improving adenoma detection, it is equally important to assure complete resection of neoplastic polyps. The aim of this chapter is to provide a conceptual and practical guide to effective and safe polyp resection. The chapter first highlights general considerations on polyp resection, in particular how assessment of a polyp will guide the decision for the appropriate resection technique. For instance, recognizing signs of early cancer is a prerequisite to performing advanced resection techniques such as endoscopic mucosal resection or submucosal dissection. This chapter then describes individual resection techniques of basic and advanced polypectomy. One focus on the basic polypectomy section is the shift from hot to cold snare resection for diminutive and small polyps. The section on advanced techniques describes endoscopic mucosal resection and submucosal dissection. Of particular interest are indications for submucosal dissection versus mucosal resection. Finally, this chapter provides an outlook into the future and direction for further study.

Background: Superficial tumors of the duodenum, other than ampullary tumors, have been traditionally considered rare. However, reports of this kind of tumor have increased in recent times, and the demand for minimally invasive treatments have also increasing. Summary: Adenomas and intramucosal carcinomas are target lesions for treatment. A preoperative diagnosis has not been established, but unnecessary biopsies increase the difficulty of treatment and should be avoided. Cold snare polypectomy, endoscopic mucosal resection (EMR), and underwater EMR are treatment options for small lesions. Endoscopic submucosal dissection enables secure resection even for large lesions, but it is technically demanding and associated with a higher complication rate. After endoscopic resections, exposure of digestive juices is believed to cause delayed complications. To prevent these complications, several closing and covering methods are proposed, with favorable clinical results. Key message: A treatment method should be chosen based on each patient’s situation. With any of the treatment methods, post-resection measures are required to prevent delayed complications. Secure closure of resection wounds seems promising.

Local recurrence after cold snare polypectomy (CSP) of colorectal polyps has not been well analyzed. In this study, we analyzed the characteristics of local recurrence. We retrospectively reviewed consecutive lesions resected by CSP from 2014 to 2016 and lesions that were followed up at ≥ 10 months after CSP, were analyzed. Our indication for CSP was a benign tumor of

Polyps 1 cm are the most commonly found polyps during colonoscopy. Cold snare removal is preferred given the significantly higher rate of incomplete resection associated with piecemeal biopsy forceps resection. There are currently no standardized tools to assess competence in cold snare polypectomy. This study aimed to develop and validate a cold snare polypectomy assessment tool (CSPAT).Experts in cold snare polypectomy used a Delphi method to develop the CSPAT. Metrics with a greater than 85% agreement as being "important" or "very important" were included in the CSPAT. The tool included evaluation of polyp inspection, positioning, appropriate ensnarement of tissue to ensure a rim of normal tissue, tissue retrieval, and postpolypectomy site inspection. Experts in cold snare polypectomy used the CSPAT to evaluate preselected videos that were previously evaluated using the Direct Observation of Polypectomy Skills (DOPyS) tool. Interobserver agreement was evaluated. CSPAT scores were compared with DOPyS scores to assess content validity.Sixteen experts developed the 12-item CSPAT, and 13 experts reviewed 55 videos. There was a moderate degree of agreement in 10 metrics (κ = .52-.59) and a substantial degree of agreement (κ = .61-.63) in the other 2. There was a strong correlation between the mean of individual metrics 1 to 12 compared with the global competence assessment (ρ = .88, P .001). There was a moderate correlation between the average overall DOPyS score and the overall CSPAT competence score (ρ = .56, P .001).We have developed and validated a customized CSPAT that can be easily applied to video-based assessments to assess competence in training and among practicing endoscopists.

Introduction Multiple techniques exist for the management of colorectal polyps. Recent ESGE guidelines1 have defined an evidence based guide to the optimal technique for removing different sizes of polyps. Previously this decision often depended on an individual operator’s experience and training. We sought to examine current polypectomy practice amongst United Kingdom endoscopy trainees with to these guidelines. Methods The ESGE polypectomy guideline1 suggests polyps Results 2 91 778 polypectomies were performed in 1 76 569 trainee-performed procedures by 3395 trainees over the study period. 10 584 polypectomies were missing data. 2 81 194 polypectomies were analysed. Of 2 50 783 polyps Of 219 (0.1%) adverse events reported amongst all polypectomies, 50.8% were amongst HSP, 19.2% EMR, 16.9% CSP and 12.7% after HBF p Conclusions Cold snare polypectomy is under-utilised for diminutive polypectomy, despite its proven safety and efficacy; its use amongst trainees should be promoted in line with ESGE guidance. Trainees are likely to follow the example of their trainers and, as such, this study likely provides an insight into current polypectomy practice in the wider UK endoscopic community. Trainees in the United Kingdom predominantly remove diminutive polyps with extremely low rates of adverse events. Reference . Ferlitsch M, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): Endoscopy. 2017 Mar 1;49(3):270–97.

Background and study aims Despite widespread use of cold snare polypectomy (CSP), the R0 resection rate is not well documented. We perform extended CSP, resecting polyps with a > 1 mm circumferential margin. The aim of this study is to compare the R0 resection rate of extended CSP with conventional CSP and to assess safety. Patients and methods From April 2014 to September 2016, 712 non-pedunculated colorectal polyps, Results We divided lesions into conventional CSP (n = 263) and extended CSP groups (n = 449). The baseline characteristics of these two groups were not significantly different in univariate or multivariate analyses. Sessile polyps comprised 94 % (668/712), and the remaining were flat-elevated polyps. Mean size of polyps (±standard deviation) was 4.2 ± 1.5 mm. The most frequent pathology was low grade adenoma (97 %, 689/712). The R0 resection rate was significantly higher in the extended CSP group (439/449 [98 %]) than in the conventional CSP group (222/263 [84 %], P Conclusions Extended CSP results in a higher R0 resection rate compared with conventional CSP. Extended CSP did not result in a higher rate of delayed bleeding or perforation. Extended CSP is a safe and promising procedure for endoscopic resection of non-pedunculated colorectal polyps

Background & Aims: Small colorectal polyps may be removed with cold snare polypectomy (CSP). Some of these polyps may contain unexpectedly advanced neoplasia. Thus, it is important to establish criteria for excision that will ensure that the CSP specimens are adequate for accurate histological assessment. We retrospectively investigated depth of excised small polyps and their vertical margins in patients who underwent CSP.Method: CSP-excised specimens of 376 small colorectal polyps were examined. We histologically evaluated negative tumor vertical margins and complete resection through the muscularis mucosae, which was defined as muscularis mucosae present under the tumor along more than 80% of its horizontal axis. We also evaluated the fragmentation of the retrieved specimens.Results: The mean size of the 376 polyps was 4.9 ±1.4 mm, and 25 polyps (6.6%) had unexpectedly advanced histology. Thirty-two lesions (8.5%) were fragmented. In 275 (79.9%) of the remaining 344 unfragmented polyps, muscularis mucosae resection was judged complete. Vertical margins were confirmed negative in 99.6% (274/275) of polyps that had complete muscularis mucosae resection, but in only 33.3% (23/69) of polyps with incomplete resection. In 79 polyps (21%) (32 fragmented specimens and 47 unfragmented specimens), including 5 polyps with advanced histology, negative vertical margins could not be confirmed. Sessile morphology and location in the cecum were independent risk factors for incomplete muscularis mucosae resection and fragmentation.Conclusion: Incomplete muscularis mucosae resection and fragmentation at retrieval are risk factors for inadequate histological evaluation of CSP-excised small colorectal polyps, especially for sessile polyps and polyps in the cecum.

A limitation of determination of the completeness of resection in polypectomy is polyp fragmentation. When a polyp fragments, the pathologist cannot determine resection completeness. Alternative approaches to reduce polyp fragmentation include reducing shearing forces on the polyp or removing polyps through the instrument channel. The primary aim of this study was to assess fragmentation of polyps extracted using different approaches from conventional polyp retrieval.Polyps (5-15 mm) resected by cold snare or cautery by 3 colonoscopists were extracted from the colonoscope using 1 of 4 techniques. Method I was the conventional method of pressing the suction valve button and retrieving the polyp through a trap. Method II involved removing the suction valve, covering the open suction valve cylinder with a finger. Method III used a Roth Net polyp retriever placed through the instrument channel. Method IV involved connecting a polyp trap to suction onto the instrument channel port. Fragmentation was defined as multiple pieces of the specimen in formalin, as grossly described by the pathologist. Alternative approaches (methods II, III, and IV) were all compared with the conventional method (method I).The method I fragmentation rate of polyps was 60.3% (123/204). Method II extraction reduced fragmentation to 43.0% (52/121, P = .003), proving that fragmentation occurs with passage through the suction valve channel. Method III had a lower fragmentation rate of 23.1% (6/26, P .001). Method IV likewise showed a reduced fragmentation rate of 18.5% (5/27, P .001).Polyp fragmentation is reduced by removal of the suction valve button. There is also a decrease in fragmentation rates in removing the polyp by connecting the polyp trap to the instrument port. Our study suggests that decreasing polyp fragmentation and improving pathology margin interpretability is possible through methods that extract polyps through the instrument port with currently available devices.