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Endoscopy
Original research
Cold versus hot snare endoscopic mucosal resection for large (≥15 mm) flat non-pedunculated colorectal polyps: a randomised controlled trial
  1. Timothy O’Sullivan1,2,
  2. Oliver Cronin1,2,
  3. W Arnout van Hattem3,
  4. Francesco Vito Mandarino1,
  5. Julia L Gauci1,
  6. Clarence Kerrison1,
  7. Anthony Whitfield1,2,
  8. Sunil Gupta1,2,
  9. Eric Lee1,
  10. Stephen J Williams1,
  11. Nicholas Burgess1,2,
  12. Michael J Bourke1,2
  1. 1Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
  2. 2Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
  3. 3Department of Gastroenterology and Hepatology, Netherlands Cancer Institute, Amsterdam, The Netherlands
  1. Correspondence to Dr Michael J Bourke, Department of Gastroenterology and Hepatology, Westmead Hospital, Westmead 2145, New South Wales, Australia; michael{at}citywestgastro.com.au

Abstract

Background and aims Conventional hot snare endoscopic mucosal resection (H-EMR) is effective for the management of large (≥20 mm) non-pedunculated colon polyps (LNPCPs) however, electrocautery-related complications may incur significant morbidity. With a superior safety profile, cold snare EMR (C-EMR) of LNPCPs is an attractive alternative however evidence is lacking. We conducted a randomised trial to compare the efficacy and safety of C-EMR to H-EMR.

Methods Flat, 15–50 mm adenomatous LNPCPs were prospectively enrolled and randomly assigned to C-EMR or H-EMR with margin thermal ablation at a single tertiary centre. The primary outcome was endoscopically visible and/or histologically confirmed recurrence at 6 months surveillance colonoscopy. Secondary outcomes were clinically significant post-EMR bleeding (CSPEB), delayed perforation and technical success.

Results 177 LNPCPs in 177 patients were randomised to C-EMR arm (n=87) or H-EMR (n=90). Treatment groups were equivalent for technical success 86/87 (98.9%) C-EMR versus H-EMR 90/90 (100%); p=0.31. Recurrence was significantly greater in C-EMR (16/87, 18.4% vs 1/90, 1.1%; relative risk (RR) 16.6, 95% CI 2.24 to 122; p<0.001).

Delayed perforation (1/90 (1.1%) vs 0; p=0.32) only occurred in the H-EMR group. CSPEB was significantly greater in the H-EMR arm (7/90 (7.8%) vs 1/87 (1.1%); RR 6.77, 95% CI 0.85 to 53.9; p=0.034).

Conclusion Compared with H-EMR, C-EMR for flat, adenomatous LNPCPs, demonstrates superior safety with equivalent technical success. However, endoscopic recurrence is significantly greater for cold snare resection and is currently a limitation of the technique.

Trial registration number NCT04138030

  • ENDOSCOPIC POLYPECTOMY
  • COLONOSCOPY
  • COLONIC ADENOMAS
  • ENDOSCOPIC PROCEDURES

Data availability statement

No data are available.

https://doi.org/10.1136/gutjnl-2024-332807

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    Data availability statement

    No data are available.

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    Footnotes

    • Contributors All authors for this manuscript contributed to the study. TO—acquisition of data, analysis and interpretation of data, drafting of the manuscript, statistical analysis. OC—acquisition of data. WAvH—study concept and design, acquisition of data. FVM—acquisition of data, analysis and interpretation of data. JLG—acquisition of data. CK—acquisition of data. AMW—acquisition of data. SG—acquisition of data. EL—acquisition of data. SJW—acquisition of data. NB—acquisition of data. MJB—acquisition of data, analysis and interpretation of data, drafting of the manuscript, study concept and design and study supervision/guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests MJB: Research Support: Olympus Medical, Cook Medical, Boston Scientific. The remaining authors have no financial, professional or personal conflicts of interest to disclose.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.