From the Journals

Cold snare polypectomy tops hot snare for small polyps



Cold snare polypectomy (CSP) is superior to hot snare polypectomy (HSP) for colorectal polyps measuring 4-10 mm, a pragmatic randomized controlled trial confirms.

In the Taiwan Cold Polypectomy Study, CSP was not only safer than HSP, with a significantly lower risk for delayed bleeding, it was also more efficient, report Li-Chun Chang, MD, PhD, from the National Taiwan University Hospital, Taipei, and colleagues.

The study was published online in Annals of Internal Medicine.

This large study “strengthens the already significant evidence that CSP is as effective and safer than HSP for polyps 4-10 mm in size,” Rajesh N. Keswani, MD, Northwestern University, Chicago, told this news organization.

“This study evaluated all significant endpoints – safety (decreased bleeding risk with CSP), effectiveness (equivalent complete resection rates between CSP and HSP), and efficiency (CSP faster than HSP),” said Dr. Keswani, who wasn’t involved in the study.

Previous randomized controlled trials have shown that CSP is as effective as HSP but more efficient in removing small polyps. The reduction in delayed bleeding associated with CSP had been shown only in high-risk patients using antiplatelet agents or anticoagulants, however. Less was known about CSP’s effect on delayed bleeding in the general population.

To investigate, Dr. Chang and colleagues randomly assigned 4,270 adults aged 40 and older who were undergoing polypectomy to remove polyps measuring 4-10 mm to CSP or HSP.

Compared with HSP, CSP was associated with a significantly lower risk for all delayed bleeding (within 14 days after polypectomy) and severe delayed bleeding (defined as a decrease in hemoglobin of 20 g/L or more, requiring transfusion or hemostasis).

Eight of 2,137 patients (0.4%) in the CSP group had delayed bleeding versus 31 of 2,133 patients (1.5%) in the HSP group. Severe bleeding occurred in one patient who had CSP (0.05%) and eight who had HSP (0.4%).

The CSP group also had fewer emergency service visits than the HSP group – 4 visits (0.2%) versus 13 visits (0.6%).

CSP was more efficient, with mean polypectomy time reduced 26.9%, compared with HSP, with no difference between groups in successful tissue retrieval, en bloc resection, and complete histologic resection.

“CSP saves time setting up electrosurgical generators or conducting submucosal injection. Moreover, the lower rate of delayed bleeding means fewer emergency service visits or hospital stays, saving medical expenses,” Dr. Chang and colleagues write in their article.

“Given the benefit in safety and cost-effectiveness, CSP may replace HSP for removal of small polyps in the general population,” they add.

Dr. Keswani agreed. “Based on the accumulated evidence over the past decade, CSP is the clear standard of care for polyps 4-10 mm in size,” he said in an interview.

“For polyps less than 4 mm, it remains reasonable to use either large capacity/jumbo forceps or CSP. Cautery should be reserved only for polyps greater than 10 mm, although there is ongoing work regarding cold versus hot EMR [endoscopic mucosal resection],” Dr. Keswani said.

The trial was principal investigator–initiated and partially funded by Boston Scientific, which had no role in the study design, data collection or analysis, data interpretation, manuscript preparation, or decision to submit the manuscript for publication. Dr. Keswani is a consultant for Boston Scientific and Neptune Medical and receives research support from Virgo.

A version of this article first appeared on

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