University of Maryland Medical Center Baltimore, MD
Introduction: Colonoscopy remains an vital tool for colorectal cancer screening and allows for early detection and removal of adenomatous polyps. While several studies have reported on cold snare polypectomy (CSP) and hot snare polypectomy (HSP) in sessile and flat elevated polyps; limited data exists on outcomes in pedunculated polyps. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of CSP for pedunculated polyps.
Methods: Multiple databases were searched till June 2022 to identify studies involving the removal of pedunculated polyps with CSP and HSP. A random effects model was used to calculate outcomes and 95% confidence intervals (CI). Heterogeneity was assessed using I2 test. Our primary goal was to assess pooled rates of immediate and delayed bleeding with CSP. Secondary outcomes included pooled rates of en-bloc & piecemeal resection as well as prophylactic and post resection clipping. Meta-regression was performed to assess if bleeding was affected by polyp location and use of antithrombotics.
Results: Six studies including 1025 patients (1,111 polyps with a mean size 4 – 8.5 mm) were analyzed. 116 and 995 polyps were removed with HSP and CSP, respectively. The overall pooled rate of immediate bleeding following CSP was 49.8% (CI 46.8-52.91; I2 98%), which was significantly higher than HSP, RR 7.89 (CI 4.36-14.29; I20%), p< 0.00001 (Figure 1a). The overall pooled rate of delayed bleeding following CSP was 0% (CI 0.00-0.00; I2 0%), which was significantly lower than HSP, RR 0.05 (CI 0.01-0.43; I20%), p=0.006 (Figure 1b). Pooled rate of en-bloc and piecemeal resection with CSP were 99.7% and 0.3%, respectively.
Pooled rate of prophylactic clipping and post procedure clipping (to control immediate bleeding) after CSP was 55.3% and 47.2%, respectively. We found no statistical difference in these outcomes when compared to HSP, RR 0.19 (CI 0.01-6.35; I2 85%), p=0.35 and RR 1.73 (CI 0.12-25.5; I2 98%), p=0.69. Meta-regression showed that concurrent use of antithrombotic and/or antiplatelet agents did not have any effect on immediate bleeding following CSP. Right colon polyp location (proximal to the hepatic flexure) significantly correlated with frequency of immediate bleeding.
Discussion: Our analysis shows that CSP is safe and effective for resection of pedunculated colorectal polyps, especially those less than 10 mm in size. While CSP may increase the risk of immediate bleeding, HSP has a higher risk of delayed bleeding.
