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Technology status evaluation report| Volume 6, ISSUE 7, P283-293, July 2021

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Endoscopic polypectomy devices

Open AccessPublished:April 02, 2021DOI:https://doi.org/10.1016/j.vgie.2021.02.006
Endoscopic polypectomy devices
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        Video 1

        Use of submucosal injection prior to en-bloc endoscopic mucosal resection.

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        Video 2

        Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.

      Abbreviations:

      CBF (cold biopsy forceps), CSP (cold snare polypectomy), DPPB (delayed postpolypectomy bleeding), EMR (endoscopic mucosal resection), HBF (hot biopsy forceps), HSP (hot snare polypectomy), RCT (randomized controlled trial), USMSTF (United States Multi-Society Task Force)
      The American Society for Gastrointestinal Endoscopy Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, with a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the “related articles” feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors.
      Technology Status Evaluation Reports are drafted by 1 or 2 members of the American Society for Gastrointestinal Endoscopy Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through March 2020 for articles related to polypectomy and colonoscopy crossed with snare, bipolar snare, detachable snares, biopsy, hot biopsy, forceps, submucosal injection, mucosal resection cap, and hemoclip, among others. Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.

      Background

      Resection of GI polyps is one of the most commonly performed therapeutic endoscopic procedures. Polyps are found in a variety of sizes, shapes, and locations, and removal can occasionally be challenging. Various polypectomy devices and techniques are available, and their use is often subject to availability and preferences.
      • Ferlitsch M.
      • Moss A.
      • Hassan C.
      • et al.
      Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.
      Endoscopy. 2017; 49: 270-297
      Familiarity with polypectomy devices is important for optimal selection and safe use. This status evaluation will describe devices and agents available for endoscopic polypectomy.

      Technology under review

      The goal of polypectomy is the safe removal of the polyp in its entirety. Polyp removal can be achieved via “cold” mechanical cutting or with concurrent application of electrocautery for resection and/or ablation. This document will refer to devices for the performance of standard polypectomy, typically for polyps <20 mm in size. Prior documents have addressed technology for the resection of large polyps, specifically using endoscopic mucosal resection (EMR) and endoscopic submucosal dissection. Devices available for standard polypectomy include snares, biopsy forceps, submucosal injection agents, and ancillary devices.

      Snares

      Polypectomy snares are designed to entrap targeted tissue for resection and are made of monofilament or braided wires of various shapes, lengths, gauges, and stiffness. Most polypectomy snares incorporate a monopolar wire loop electrode that allows for use with electrocautery. Tissue is thereby transected using mechanical and electrosurgical cutting as the snare is closed and withdrawn into a plastic insulating catheter, also referred to as hot snare polypectomy (HSP). However, snares can be used without electrocautery, relying solely on mechanical cutting as the snare is closed, also referred to as cold snare polypectomy (CSP). Certain newer snares have been designed without a monopolar electrode solely for the use of CSP for small polyps. Rotatable snares allow for rotation of the wire loop to the desired orientation relative to the targeted tissue. Snare modifications have been designed to facilitate grasping of flat polyps, including varying snare sizes, shapes, wire thickness, and wire configuration (Table 1).
      Table 1Commonly used polypectomy snares in the United States
      ManufacturerDevice (design shape)Working length (cm)Loop diameter (mm)Sheath sizeWire diameter (mm)Minimum channel size (mm)
      Boston ScientificCaptivator Oval – Stiff
      Available in multiple sizes.
      		24013/272.4 mmNR2.8
      Captivator Large Oval – Medium Stiff240302.4 mmNR2.8
      Captivator Large Oval – Flexible240302.4 mmNR2.8
      Captivator Hexagonal – Stiff
      Available in multiple sizes.
      		24013/272.4 mmNR2.8
      Captivator Medium Crescent – Stiff240272.4 mmNR2.8
      Captivator II Rounded – Stiff
      Available in multiple sizes.
      		24010/15/20/25/332.4 mmNR2.8
      Captivator COLD240102.4 mmNR2.8
      Profile Oval-Flexible
      Available in multiple sizes.
      		24011/13/271.9 mmNR2.0
      Single-Use Rotatable Snare
      Available in multiple sizes.
      		24013/202.4 mmNR2.8
      Captiflex Oval – Flexible
      Available in multiple sizes.
      		24011/13/272.4 mmNR2.8
      Sensation Oval – Flexible
      Available in multiple sizes.
      		24013/272.4 mmNR2.8
      Sensation Oval – Medium Stiff
      Available in multiple sizes.
      		24013/27/302.4 mmNR2.8
      Sensation Medium Crescent – Medium Stiff240272.4 mmNR2.8
      ConMedSingular Oval – Firm
      Available in multiple sizes.
      		23011/16/23/322.3 mmNRNR
      Singular Oval – Soft
      Available in multiple sizes.
      		23011/16/23/322.3 mmNRNR
      Singular Crescent – Firm230242.3 mmNRNR
      Singular Hexagonal – Firm230252.3mmNRNR
      Optimizer Oval – Firm
      Available in multiple sizes.
      		23011/16/23/322.3 mmNRNR
      Optimizer Oval – Soft
      Available in multiple sizes.
      		23011/16/23/322.3 mmNRNR
      Orbit-Snare Rotatable Oval – Firm
      Available in multiple sizes.
      		23015/25/352.5 mmNRNR
      Orbit-Snare Rotatable Hexagonal – Firm230252.3 mmNRNR
      Cook MedicalAcusnare Mini24015 × 307FNR2.8
      Acusnare Standard24025 × 557FNR2.8
      Acusnare Jumbo24030 × 607FNR2.8
      Acusnare Mini Hexagonal24015 × 257FNR2.8
      Acusnare Hexagonal24030 × 457FNR2.8
      Soft Acusnare Micro Mini24010 × 157FNR2.8
      Soft Acusnare Mini24015 × 307FNR2.8
      Soft Acusnare Standard24025 × 557FNR2.8
      Soft Acusnare Jumbo24030 × 607FNR2.8
      Soft Acusnare Mini Hexagonal24015 × 257FNR2.8
      Soft Acusnare Hexagonal24030 × 457FNR2.8
      Acusnare Duckbill24015/257FNR2.8
      OlympusSnareMaster Oval
      Available in multiple sizes.
      		23010/15/25NR0.472.8
      SnareMaster Crescent165/23025NR0.32
      SnareMaster Oval Spiral23020NR0.482.8
      SnareMaster Oval Soft
      Available in multiple sizes.
      		23010/15/25NR0.42.8
      Reusable Oval165/23025NR0.432.8
      Reusable Oval165/23025NR0.472.8
      Reusable Mini Oval
      Available in multiple sizes.
      		23015NR0.43/0.472.8
      Reusable Crescent19023NR0.302
      SterisShort Throw Mini23012.5 × 302.4 mm0.462.8
      US EndoscopyShort Throw Standard Oval23025 × 542.4 mm0.462.8
      Short Throw Standard Oval Enteroscopy35025 × 542.4 mm0.462.8
      Lariat23030 × 502.4 mm0.412.8
      iSnare system – Oval23025 × 403.0 mm0.463.2
      iSnare system – Hexagonal23025 × 403.0 mm0.463.2
      Traxtion23025 × 402.4 mm0.462.8
      Exacto Cold Snare23092.4 mm0.302.8
      Histolock Resection Device23014 × 272.4 mm0.202.8
      Rotator Snare – Mini23012.5 × 302.4 mm0.462.8
      Rotator Snare – Standard23025 × 542.4 mm0.462.8
      NR, not reported.
      ∗ Available in multiple sizes.

      Biopsy forceps

      Biopsy forceps are used for grasping and removing tissue. Biopsy forceps used for polypectomy include standard cold biopsy forceps (CBF), large-capacity or jumbo biopsy forceps, and hot biopsy forceps (HBF). CBF commonly have a needle-spike between the opposing biopsy jaws to enable direct lesion sampling, stabilization of the forceps jaws, and holding tissue to permit a second biopsy.
      • Barkun A.
      • Liu J.
      • Carpenter S.
      • et al.
      Update on endoscopic tissue sampling devices.
      Gastrointest Endosc. 2006; 63: 741-745
      Jumbo biopsy forceps sample a larger area of tissue encompassing 2 to 3 times the surface area compared with standard forceps.
      • Faigel D.O.
      • Eisen G.M.
      • Baron T.H.
      • et al.
      Tissue sampling and analysis.
      Gastrointest Endosc. 2003; 57: 811-816
      HBF were developed for simultaneous tissue biopsy and coagulation. The HBF polypectomy technique involves grasping the polyp with the forceps, pulling back the forceps to tent the mucosa, and then applying thermal energy to achieve a white coagulum adjacent to the polypectomy site.
      • Carpenter S.
      • Petersen B.T.
      • Chuttani R.
      • et al.
      Polypectomy devices.
      Gastrointest Endosc. 2007; 65: 741-749
      HBF is not recommended for routine polypectomy by the United States Multi-Society Task Force (USMSTF) or American Society for Gastrointestinal Endoscopy
      • Gilbert D.
      • DiMarino A.
      • Jensen D.
      • et al.
      Status evaluation: hot biopsy forceps.
      Gastrointest Endosc. 1992; 38: 753-756
      ,
      • Kaltenbach T.
      • Anderson J.C.
      • Burke C.A.
      • et al.
      Endoscopic removal of colorectal lesions—recommendations by the US Multi-Society Task Force on Colorectal Cancer.
      Gastrointest Endosc. 2020; 91: 486-519
      (Table 2).
      Table 2Commonly used biopsy forceps in the United States
      ManufacturerDevice (design shape)Working length (cm)Jaw O.D. (mm)Needle (+ = with - = without)Minimum channel size (mm)
      Boston ScientificRadial Jaw 4 standard capacity160/2402.2+ / -2.8
      Radial Jaw 4 large capacity160/2402.4+ / -2.8
      Radial Jaw 4 jumbo160/2402.8+ / -3.2
      Radial Jaw 4 pediatric1601.8+ / -2.0
      Multibite forceps160/2402.4-2.8
      Radial Jaw 4 hot2402.2-2.8
      ConMedPrecisor EXL (oval)160/2302.3+ / -2.8
      Precisor EXL (alligator)160/2302.3+ / -2.8
      Precisor EXL Jumbo (oval)2303.1+ / -3.2
      Precisor EXL Jumbo (alligator)2303.1+ / -3.2
      Pediatric forceps (oval)1601.8-2.0
      Pediatric forceps (alligator)1601.8-2.0
      Precisor hot (oval)2302.3-2.8
      Precisor hot (alligator)2302.3-2.8
      Cook MedicalCaptura Pro (serrated)160/230+ / -2.8
      Captura Pro Jumbo (serrated)160/230+ / -3.2
      Captura Pro Max (serrated)230+ / -3.8
      Captura mini160-2.0
      Captura hot (serrated)230-2.8
      Micro-TechStandard forceps (oval)180/230+ / -2.8
      Standard forceps (alligator)180/230+ / -2.8
      Standard forceps (serrated)180/230+ / -2.8
      Large capacity forceps (alligator)230+ / -2.8
      Jumbo forceps (oval)230+ / -3.2
      Jumbo forceps (alligator)230+ / -3.2
      OlympusEndoJaw biopsy forceps (oval)155/230+ / -2-3.2
      EndoJaw biopsy forceps (alligator cup)155/230+ / -2-3.2
      EndoJaw jumbo230+ / -3.7
      EndoJaw hot230-2.8
      SterisCentra (plain cup, serrated)2302.3+ / -2.8
      US EndoscopyBiopsy forceps (oval)160/2302.3+ / -2.8
      Biopsy forceps – sheathed (oval)2302.3+2.8
      Biopsy forceps – pediatric (oval)1601.8+ / -2.0
      Hot biopsy forceps (oval)2302.3-2.8
      O.D., outer diameter.
      HBF can be used for avulsion techniques to remove visible neoplasia when snare resection is incomplete. With hot avulsion, HBF are used to grasp and retract visible neoplasia while applying low-voltage cutting current (settings vary based on the electrosurgical generator).
      • Veerappan S.G.
      • Ormonde D.
      • Yusoff I.F.
      • et al.
      Hot avulsion: a modification of an existing technique for management of nonlifting areas of a polyp (with video).
      Gastrointest Endosc. 2014; 80: 884-888
      ,
      • Holmes I.
      • Kim H.G.
      • Yang D.-H.
      • et al.
      Avulsion is superior to argon plasma coagulation for treatment of visible residual neoplasia during EMR of colorectal polyps (with videos).
      Gastrointest Endosc. 2016; 84: 822-829
      Hot avulsion differs from traditional HBF polypectomy in that mechanical traction (rather than tenting) is simultaneously combined with low-voltage cutting current (rather than coagulation current) to remove neoplastic tissue and minimize the risk of transmural injury.
      • Haber G.B.
      Residual visible neoplasia: approaches to overt and occult polyp fragments.
      Gastrointest Endosc. 2016; 84: 830-832
      Hot avulsion has been discussed in a prior technology status evaluation report.
      • Trindade A.J.
      • Kumta N.A.
      • Bhutani M.S.
      • et al.
      Devices and techniques for endoscopic treatment of residual and fibrotic colorectal polyps (with videos).
      Gastrointest Endosc. 2020; 92: 474-482

      Agents for submucosal injection

      Submucosal injection is used to lift the target lesion to facilitate polyp removal and create separation between the mucosal resection surface and deeper layers of the bowel wall to minimize the risk of deep thermal injury, bleeding, and perforation.
      • Carpenter S.
      • Petersen B.T.
      • Chuttani R.
      • et al.
      Polypectomy devices.
      Gastrointest Endosc. 2007; 65: 741-749
      ,
      • Wallace M.B.
      New strategies to improve polypectomy during colonoscopy.
      Gastroenterol Hepatol (N Y). 2017; 13: 1-12
      ,
      • Castro R.
      • Libânio D.
      • Pita I.
      • et al.
      Solutions for submucosal injection: what to choose and how to do it.
      World J Gastroenterol. 2019; 25: 777-788
      Submucosal solutions are usually delivered with 21- to 25-gauge needles, with more viscous injectates requiring larger-bore needles.
      • Maple J.T.
      • Abu Dayyeh B.K.
      • Chauhan S.S.
      • et al.
      Endoscopic submucosal dissection.
      Gastrointest Endosc. 2015; 81: 1311-1325
      Saline solution is commonly used because of its low cost and wide availability. However, disadvantages to saline solution include rapid dispersion into neighboring tissue planes and clear color.
      • Wallace M.B.
      New strategies to improve polypectomy during colonoscopy.
      Gastroenterol Hepatol (N Y). 2017; 13: 1-12
      A variety of injectable substances including dextrose 50%, glycerol, succinylated gelatin, methylcellulose, hyaluronic acid, fibrinogen, and hydroxyethyl starch have been evaluated for ease of injection and duration of submucosal lift.
      • Mehta N.
      • Strong A.T.
      • Franco M.
      • et al.
      Optimal injection solution for endoscopic submucosal dissection: a randomized controlled trial of Western solutions in a porcine model.
      Dig Endosc. 2018; 30: 347-353
      , 
      • Conio M.
      • Rajan E.
      • Sorbi D.
      • et al.
      Comparative performance in the porcine esophagus of different solutions used for submucosal injection.
      Gastrointest Endosc. 2002; 56: 513-516
      , 
      • Ferreira A.
      • Moleiro J.
      • Torres J.
      • et al.
      Solutions for submucosal injection in endoscopic resection: a systematic review and meta-analysis.
      Endosc Int Open. 2016; 4: E1-E16
      Epinephrine has been used for submucosal injection to prevent postpolypectomy bleeding.
      • Tullavardhana T.
      • Akranurakkul P.
      • Ungkitphaiboon W.
      • et al.
      Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: a meta-analysis of randomized controlled studies.
      Ann Med Surg (London). 2017; 19: 65-73
      Newer agents for submucosal injection use a combination of a viscous agent to maintain elevation and a coloring dye such as methylene blue or indigo carmine. Coloring dye can assist in both the delineation of polyp margins and identification of the submucosal plane (Video 1, available online at www.VideoGIE.org). The coloring dye may also help to identify residual polyp after endoscopic resection and improve recognition of perforations. If the muscularis propria layer is inadvertently resected during polypectomy, the transected surface will have a white/gray central circular disk surrounded by dye-stained submucosal connective tissue, giving it the appearance of a target (target sign).
      • Swan M.P.
      • Bourke M.J.
      • Moss A.
      • et al.
      The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection.
      Gastrointest Endosc. 2011; 73: 79-85
      With early recognition, small perforations can be successfully treated with various endoscopic methods.
      • Singh R.R.
      • Nussbaum J.S.
      • Kumta N.A.
      Endoscopic management of perforations, leaks and fistulas.
      Transl Gastroenterol Hepatol. 2018; 3: 85
      Two premixed injection solutions are currently approved by the U.S. Food and Drug Administration. The solutions can be drawn up into syringes for injection (SIC-8000 [Eleview], Aries Pharmaceutical, San Diego, Calif, USA) or come in prefilled syringes (ORISE Gel, Boston Scientific, Marlborough, Mass, USA). SIC-8000 consists of a 10-mL premixed emulsion of methylene blue, water, medium-chain triglycerides, bulking/cushioning agent poloxamer 188, surfactant agent polyoxyl-15-hydroxystearate, and sodium chloride.
      • Wallace M.B.
      New strategies to improve polypectomy during colonoscopy.
      Gastroenterol Hepatol (N Y). 2017; 13: 1-12
      ORISE submucosal lifting gel is a similar 10-mL solution that contains food-grade coloring dye, polysaccharide-based thickening agent, and proprietary biocompatible materials. Additional submucosal lifting agents are currently under development.

      Ancillary devices

      A variety of other devices are often used for the performance of polypectomy. These include injection needles, hemostatic clips, detachable snares and loop devices, transparent caps, retrieval devices, and a variety of ablation devices including electrosurgical generators. Many of these instruments have been discussed in other technology status evaluation reports.
      • Maple J.T.
      • Abu Dayyeh B.K.
      • Chauhan S.S.
      • et al.
      Endoscopic submucosal dissection.
      Gastrointest Endosc. 2015; 81: 1311-1325
      ,
      • Konda V.
      • Chauhan S.S.
      • Abu Dayyeh B.K.
      • et al.
      Endoscopes and devices to improve colon polyp detection.
      Gastrointest Endosc. 2015; 81: 1122-1129
      , 
      • Trindade A.J.
      • Lichtenstein D.R.
      • Aslanian H.R.
      • et al.
      Devices and methods to improve colonoscopy completion (with videos).
      Gastrointest Endosc. 2018; 87: 625-634
      , 
      • Conway J.D.
      • Adler D.G.
      • Diehl D.L.
      • et al.
      Endoscopic hemostatic devices.
      Gastrointest Endosc. 2009; 69: 987-996
      , 
      • Tokar J.L.
      • Barth B.A.
      • Banerjee S.
      • et al.
      Electrosurgical generators.
      Gastrointest Endosc. 2013; 78: 197-208
      , 
      • Hwang J.H.
      • Konda V.
      • Abu Dayyeh B.K.
      • et al.
      Endoscopic mucosal resection.
      Gastrointest Endosc. 2015; 82: 215-226

      Hemostasis devices

      Devices designed to ensure hemostasis after polypectomy include endoscopic clips, detachable loop devices, and hemostatic forceps. Clips and endoloops have been used to clamp or to ensnare the base or stalk of large pedunculated polyps before or after polypectomy to reduce the incidence of postpolypectomy bleeding. Clips are also used to close mucosal defects after polypectomy. Clips are available in a variety of sizes, and most new iterations are easily rotatable and may be reopened without deployment if initial placement is not satisfactory. They are discussed in another American Society for Gastrointestinal Endoscopy technology status evaluation report.
      • Conway J.D.
      • Adler D.G.
      • Diehl D.L.
      • et al.
      Endoscopic hemostatic devices.
      Gastrointest Endosc. 2009; 69: 987-996
      The only currently available detachable loop-ligating device in the United States is a preassembled nylon loop with a diameter of 30 mm (PolyLoop, Olympus, Center Valley, Pa, USA) (Video 2, available online at www.VideoGIE.org). A reusable loop cutter is available in a variety of lengths for removing deployed loops. Hemostatic forceps are not routinely used with standard polypectomy and are discussed in the endoscopic submucosal dissection technology status evaluation report.
      • Maple J.T.
      • Abu Dayyeh B.K.
      • Chauhan S.S.
      • et al.
      Endoscopic submucosal dissection.
      Gastrointest Endosc. 2015; 81: 1311-1325

      Efficacy and safety

      Snares

      CSP is increasingly used for removal of colorectal polyps of less than 1 cm because of its high complete resection rates and low rates of delayed postpolypectomy bleeding (DPPB). In a randomized controlled trial (RCT) of 54 consecutive patients with 117 polyps (70% adenomas) with a mean size of 3.66 mm (+ 1.13), the rate of complete eradication was higher with CSP compared with cold forceps polypectomy (93.2% vs 75.9%; P = .009).
      • Lee C.K.
      • Shim J.J.
      • Jang J.Y.
      Cold snare polypectomy vs. cold forceps polypectomy using double-biopsy technique for removal of diminutive colorectal polyps: a prospective randomized study.
      Am J Gastroenterol. 2013; 108: 1593-1600
      CSP was also found to be faster than cold forceps polypectomy (14.3 vs 22.0 seconds; P < .001), although 6.8% of CSP specimens were not successfully retrieved. Another RCT of 208 patients with 283 diminutive colorectal polyps measuring 3 to 5 mm compared CSP with hot forceps biopsy.
      • Komeda Y.
      • Kashida H.
      • Sakurai T.
      • et al.
      Removal of diminutive colorectal polyps: a prospective randomized clinical trial between cold snare polypectomy and hot forceps biopsy.
      World J Gastroenterol. 2017; 23: 328-335
      CSP was associated with a higher rate of en bloc resection (99.3% vs 80.0%; P < .0001) and complete resection (80.4% vs 47.4%; P < .0001) with similar rates of immediate bleeding (8.6% vs 8.1%; P = 1.0) without any incidents of DPPB or perforation in either group.
      Multiple studies have now compared CSP with HSP for small polyps, including multiple meta-analyses. A meta-analysis of 8 RCTs including 1665 patients and 3195 interventions for small polyps (majority 5-7 mm) demonstrated no differences between CSP and HSP with respect to complete resection rate (RR, 1.02; 95% CI, 0.98-1.07; P = .31) and polyp retrieval rate (RR, 1.00; 95% CI, 1.00-1.01; P = .60), but did note longer procedural duration with HSP (mean difference 7.13 minutes; 95% CI, 5.32-8.94; P < .001).
      • Shinozaki S.
      • Kobayashi Y.
      • Hayashi Y.
      • et al.
      Efficacy and safety of cold versus hot snare polypectomy for resecting small colorectal polyps: systematic review and meta-analysis.
      Dig Endosc. 2018; 30: 592-599
      A second meta-analysis included 12 RCTs involving 2481 patients with 4535 diminutive (<5 mm) or small polyps (6-10 mm) and again found no difference in complete resection rates between CSP and HSP (OR, 0.86; 95% CI, 0.60-1.24).
      • Qu J.
      • Jian H.
      • Li L.
      • et al.
      Effectiveness and safety of cold versus hot snare polypectomy: a meta-analysis.
      J Gastroenterol Hepatol. 2019; 34: 49-58
      Similar incomplete resection rates (2.4% for HSP vs 4.7% for CSP; OR, 0.51; 95% CI, 0.13 - 1.99; P = .33) have been noted in a meta-analysis of 3 RCTs including 1051 patients with 1485 polyps measuring 4 to 10 mm.
      • Jegadeesan R.
      • Aziz M.
      • Desai M.
      • et al.
      Hot snare vs. cold snare polypectomy for endoscopic removal of 4 – 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies.
      Endosc Int Open. 2019; 7: E708-E716
      CSP has been associated with lower rates of DPPB compared with HSP.
      • Chang L.-C.
      • Shun C.-T.
      • Hsu W.-F.
      • et al.
      Risk of delayed bleeding before and after implementation of cold snare polypectomy in a screening colonoscopy setting.
      Endosc Int Open. 2019; 7: E232-E238
      ,
      • Yamashina T.
      • Fukuhara M.
      • Maruo T.
      • et al.
      Cold snare polypectomy reduced delayed postpolypectomy bleeding compared with conventional hot polypectomy: a propensity score-matching analysis.
      Endosc Int Open. 2017; 5: E587-E594
      Much of this difference has been attributed to thermal injury resulting in DPPB. Although CSP results in a larger immediate mucosal defect compared with HSP, this defect rapidly shrinks, whereas the defect with HSP increases after 1 day.
      • Suzuki S.
      • Gotoda T.
      • Kusano C.
      • et al.
      Width and depth of resection for small colorectal polyps: hot versus cold snare polypectomy.
      Gastrointest Endosc. 2018; 87: 1095-1103
      Furthermore, CSP results in a more superficial resection, with a small percentage of resections capturing submucosal tissue.
      • Suzuki S.
      • Gotoda T.
      • Kusano C.
      • et al.
      Width and depth of resection for small colorectal polyps: hot versus cold snare polypectomy.
      Gastrointest Endosc. 2018; 87: 1095-1103
      ,
      • Ito A.
      • Suga T.
      • Ota H.
      • et al.
      Resection depth and layer of cold snare polypectomy versus endoscopic mucosal resection.
      J Gastroenterol. 2018; 53: 1171-1178
      However, several meta-analyses have not demonstrated significant differences in immediate bleeding requiring treatment, DPPB, or overall adverse event rates between CSP and HSP, although a trend toward higher rates of DPPB with HSP was noted in one of the analyses (RR, 7.35; 95% CI, 0.91-59.33; P = .06).
      • Shinozaki S.
      • Kobayashi Y.
      • Hayashi Y.
      • et al.
      Efficacy and safety of cold versus hot snare polypectomy for resecting small colorectal polyps: systematic review and meta-analysis.
      Dig Endosc. 2018; 30: 592-599
      ,
      • Qu J.
      • Jian H.
      • Li L.
      • et al.
      Effectiveness and safety of cold versus hot snare polypectomy: a meta-analysis.
      J Gastroenterol Hepatol. 2019; 34: 49-58
      A single meta-analysis of RCTs identified a lower rate of immediate bleeding requiring treatment with HSP (3.3 %) compared with CSP (6.6%), yielding a pooled OR of 0.48 (95 % CI, 0.27-0.86; P = .01), without differences in DPPB (0.4% vs 0%; P = .45) and no perforations in either group.
      • Jegadeesan R.
      • Aziz M.
      • Desai M.
      • et al.
      Hot snare vs. cold snare polypectomy for endoscopic removal of 4 – 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies.
      Endosc Int Open. 2019; 7: E708-E716
      CSP has been associated with lower postpolypectomy bleeding rates in patients still taking antiplatelet or antithrombotic medications.
      • Arimoto J.
      • Chiba H.
      • Ashikari K.
      • et al.
      Safety of cold snare polypectomy in patients receiving treatment with antithrombotic agents.
      Dig Dis Sci. 2019; 64: 3247-3255
      , 
      • Horiuchi A.
      • Hosoi K.
      • Kajiyama M.
      • et al.
      Prospective, randomized comparison of 2 methods of cold snare polypectomy for small colorectal polyps.
      Gastrointest Endosc. 2015; 82: 686-692
      , 
      • Makino T.
      • Horiuchi A.
      • Kajiyama M.
      • et al.
      Delayed bleeding following cold snare polypectomy for small colorectal polyps in patients taking antithrombotic agents.
      J Clin Gastroenterol. 2018; 52: 502-507
      An RCT compared 92 patients treated with CSP while on anticoagulants and 90 patients treated with heparin bridging and HSP for subcentimeter colon polyps.
      • Takeuchi Y.
      • Mabe K.
      • Shimodate Y.
      • et al.
      Continuous anticoagulation and cold snare polypectomy versus heparin bridging and hot snare polypectomy in patients on anticoagulants with subcentimeter polyps.
      Ann Intern Med. 2019; 171: 229-237
      DPPB requiring endoscopic therapy was not statistically significant in the CSP group (4.7%; 95% CI, 0.2%-9.2%) compared with the HSP group (12.0%; 95% CI, 5.0%-19.1%). CSP was associated with shorter polypectomy time (60 vs 94 seconds; P < .001) and shorter mean length of hospital stay in patients receiving warfarin (2.0 vs 9.6 days; P < .001).
      A systematic review and pooled analysis also demonstrated excellent results with CSP of colorectal polyps >10 mm in terms of postpolypectomy bleeding, complete resection, and residual polyp rates.
      • Thoguluva Chandrasekar V.
      • Spadaccini M.
      • Aziz M.
      • et al.
      Cold snare endoscopic resection of nonpedunculated colorectal polyps larger than 10 mm: a systematic review and pooled-analysis.
      Gastrointest Endosc. 2019; 89: 929-936.e3
      Eight studies were included in the final analysis; these included 522 colorectal polyps with a mean polyp size of 17.5 mm (range, 10-60). The overall adverse event rate was 1.1% (95% CI, 0.2%-2.0%; I2 = 0%). Intra- and postprocedural bleeding rates were 0.7% (95% CI, 0%-1.4%) and 0.5% (95% CI, 0.1%-1.2%), respectively. Polyps >20 mm had a higher intraprocedural bleeding rate of 1.3% (95% CI, 0.7%-3.3%) and abdominal pain rate of 1.2% (95% CI, .7%-3.0%) but no delayed bleeding. No perforations were reported. The complete resection rate was 99.3% (95% CI, 98.6%-100%). Overall pooled residual rates of polyps of any histology, adenomas, and SSPs were 4.1% (95% CI, 0.2%-8.4%), 11.1% (95% CI, 4.1%-18.1%), and 1.0% (95% CI, 0.4%-2.4%), respectively, during a follow-up period ranging from 154 to 258 days. RCTs comparing cold snare resection with hot snare resection of polyps >10 mm are required for further investigation.
      Recent USMSTF guidelines suggest CSP for nonpedunculated polyps up to 10 mm to achieve en bloc resection.
      • Kaltenbach T.
      • Anderson J.C.
      • Burke C.A.
      • et al.
      Endoscopic removal of colorectal lesions—recommendations by the US Multi-Society Task Force on Colorectal Cancer.
      Gastrointest Endosc. 2020; 91: 486-519
      The USMSTF also recommends that nonpedunculated polyps 10 to 19 mm without features suggestive of submucosal invasion be removed using CSP or HSP with or without submucosal injection.

      Biopsy forceps

      Multiple studies have reported variable complete resection rates with CBF ranging from 39% to 92.3% for polyps measuring less than 7 mm.
      • Lee C.K.
      • Shim J.J.
      • Jang J.Y.
      Cold snare polypectomy vs. cold forceps polypectomy using double-biopsy technique for removal of diminutive colorectal polyps: a prospective randomized study.
      Am J Gastroenterol. 2013; 108: 1593-1600
      ,
      • Efthymiou M.
      • Taylor A.C.
      • Desmond P.V.
      • et al.
      Biopsy forceps is inadequate for the resection of diminutive polyps.
      Endoscopy. 2011; 43: 312-316
      , 
      • Jung Y.S.
      • Park J.H.
      • Kim H.J.
      • et al.
      Complete biopsy resection of diminutive polyps.
      Endoscopy. 2013; 45: 1024-1029
      , 
      • Draganov P.V.
      • Chang M.N.
      • Alkhasawneh A.
      • et al.
      Randomized, controlled trial of standard, large-capacity versus jumbo biopsy forceps for polypectomy of small, sessile, colorectal polyps.
      Gastrointest Endosc. 2012; 75: 118-126
      , 
      • Kim J.S.
      • Lee B.I.
      • Choi H.
      • et al.
      Cold snare polypectomy versus cold forceps polypectomy for diminutive and small colorectal polyps: a randomized controlled trial.
      Gastrointest Endosc. 2015; 81: 741-747
      A systematic review and meta-analysis of 5 RCTs including 668 patients and 721 polyps less than 7 mm compared CBF with CSP and jumbo forceps polypectomy.
      • Raad D.
      • Tripathi P.
      • Cooper G.
      • et al.
      Role of the cold biopsy technique in diminutive and small colonic polyp removal: a systematic review and meta-analysis.
      Gastrointest Endosc. 2016; 83: 508-515
      The pooled incomplete polyp resection rate with CBF was 19.0% versus 11.4% with CSP or jumbo forceps biopsy technique. There were no significant bleeding episodes or perforations in either group. A prospective, observational cohort study of 955 diminutive polyps (<5 mm) in 471 patients found that jumbo forceps polypectomy had an endoscopic complete resection rate of 99.4% with 2.1% local recurrence at 1-year follow-up.
      • Kuwai T.
      • Yamada T.
      • Toyokawa T.
      • et al.
      Local recurrence of diminutive colorectal polyps after cold forceps polypectomy with jumbo forceps followed by magnified narrow-band imaging: a multicenter prospective study.
      Endoscopy. 2019; 51: 253-260
      Lesions >3 mm were significantly associated with local recurrence (OR, 3.4; P = .02).
      Two RCTs compared jumbo forceps polypectomy with CSP. One prospective RCT of 169 patients with 196 diminutive colorectal polyps (<5 mm) found no significant difference between complete resection rates (92.0% vs 92.2%; P = .947), polypectomy procedure time (46.9 vs 44.5 seconds, P = .468), tissue retrieval rate, or adverse events.
      • Huh C.W.
      • Kim J.S.
      • Choi H.H.
      • et al.
      Jumbo biopsy forceps versus cold snares for removing diminutive colorectal polyps: a prospective randomized controlled trial.
      Gastrointest Endosc. 2019; 90: 105-111
      A second prospective RCT of 151 patients with 261 polyps less than 6 mm found no difference in complete resection rates, although jumbo forceps polypectomy had higher tissue retrieval rates than CSP (100% vs 95.7%, P = .02).
      • Desai S.
      • Gupta S.
      • Copur-Dahi N.
      • et al.
      A prospective randomized study comparing jumbo biopsy forceps to cold snare for the resection of diminutive colorectal polyps.
      Surg Endosc. 2020; 34: 1206-1213
      Studies have shown that the use of HBF for polypectomy is associated with incomplete polyp resection rates ranging from 17% to 22% for polyps less than 6 mm.
      • Ellis K.
      • Schiele M.
      • Marquis S.
      Efficacy of hot biopsy forceps. Cold micro- snare and micro-snare with cautery techniques in the removal of diminutive colonic polyps [abstract].
      Gastrointest Endosc. 1997; 45: AB107
      , 
      • Fyock C.J.
      • Draganov P.V.
      Colonoscopic polypectomy and associated techniques.
      World J Gastroenterol. 2010; 16: 3630-3637
      , 
      • Peluso F.
      • Goldner F.
      Follow-up of hot biopsy forceps treatment of diminutive colonic polyps.
      Gastrointest Endosc. 1991; 37: 604-606
      In a prospective study with 39 patients and 62 diminutive colon polyps removed with HBF, 17% had incomplete resection with residual polyp visualized on follow-up flexible sigmoidoscopy 1 to 2 weeks later.
      • Peluso F.
      • Goldner F.
      Follow-up of hot biopsy forceps treatment of diminutive colonic polyps.
      Gastrointest Endosc. 1991; 37: 604-606
      Specimen quality after HBF was assessed in a prospective study with 179 patients and 237 diminutive colon polyps.
      • Yasar B.
      • Kayadibi H.
      • Abut E.
      • et al.
      The histological quality and adequacy of diminutive colorectal polyps resected using jumbo versus hot biopsy forceps.
      Dig Dis Sci. 2015; 60: 217-225
      The study found the diagnostic quality of HBF specimens to be inferior to jumbo biopsy forceps (94 of 117, 80% vs 115 of 120, 96%; P < .001). Of the HBF specimens, 91.5% demonstrated cautery damage or crush artifact.
      In a retrospective study of 1525 diminutive colon polyps removed by HBF, the rate of significant hemorrhage was 0.4% overall, with the risk highest in the right colon segment (1.3% in the cecum and 1.0% in the ascending colon).
      • Weston A.
      • Campbell D.
      Diminutive colonic polyps: histopathology, spatial distribution, concomitant significant lesions, and treatment complications.
      Am J Gastroenterol. 1995; 90: 24-28
      In a study with porcine models, HBF caused a wide range of lateral and deep thermal injury, including transmural necrosis in 9 of 41 (22%) polypectomies, partial muscularis propria necrosis in 14 of 41 (34%), and full-thickness muscularis propria inflammation with histologic serositis in 13 of 41 (32%).
      • Metz A.J.
      • Moss A.
      • McLeod D.
      • et al.
      A blinded comparison of the safety and efficacy of hot biopsy forceps electrocauterization and conventional snare polypectomy for diminutive colonic polypectomy in a porcine model.
      Gastrointest Endosc. 2013; 77: 484-490
      Recent USMSTF guidelines recommend against the use of CBF polypectomy to remove diminutive (≤5 mm) polyps because of high rates of incomplete resection. For diminutive lesions of ≤2 mm, jumbo or large-capacity forceps can be considered if CSP is technically difficult.
      • Kaltenbach T.
      • Anderson J.C.
      • Burke C.A.
      • et al.
      Endoscopic removal of colorectal lesions—recommendations by the US Multi-Society Task Force on Colorectal Cancer.
      Gastrointest Endosc. 2020; 91: 486-519
      HBF is not recommended by the USMSTF or the American Society for Gastrointestinal Endoscopy for routine polypectomy because of high rates of incomplete resection, inadequate tissue sampling for histology, and high risks of adverse events such as deep thermal injury, delayed bleeding, and perforation.
      • Ferlitsch M.
      • Moss A.
      • Hassan C.
      • et al.
      Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.
      Endoscopy. 2017; 49: 270-297
      ,
      • Gilbert D.
      • DiMarino A.
      • Jensen D.
      • et al.
      Status evaluation: hot biopsy forceps.
      Gastrointest Endosc. 1992; 38: 753-756
      ,
      • Kaltenbach T.
      • Anderson J.C.
      • Burke C.A.
      • et al.
      Endoscopic removal of colorectal lesions—recommendations by the US Multi-Society Task Force on Colorectal Cancer.
      Gastrointest Endosc. 2020; 91: 486-519
      ,
      • Wadas D.D.
      • Sanowski R.A.
      Complications of the hot biopsy forceps technique.
      Gastrointest Endosc. 1988; 34: 32-37
      , 
      • Quigley E.M.
      • Donovan J.P.
      • Linder J.
      • et al.
      Delayed, massive hemorrhage following electrocoagulating biopsy (“hot biopsy”) of a diminutive colonic polyp.
      Gastrointest Endosc. 1989; 35: 559-563
      , 
      • Dyer W.S.
      • Quigley E.M.
      • Noel S.M.
      • et al.
      Major colonic hemorrhage following electrocoagulating (hot) biopsy of diminutive colonic polyps: relationship to colonic location and low-dose aspirin therapy.
      Gastrointest Endosc. 1991; 37: 361-364
      , 
      • Moss A.
      • Nalankilli K.
      Standardisation of polypectomy technique.
      Best Pract Res Clin Gastroenterol. 2017; 31: 447-453
      However, HBF can be used for hot avulsion as an adjunctive measure to remove flat or fibrotic residual polyps.
      • Rex D.K.
      • Dekker E.
      How we resect colorectal polyps <20 mm in size.
      Gastrointest Endosc. 2019; 89: 449-452
      ,
      • Bassan M.
      • Cirocco M.
      • Kandel G.
      • et al.
      A second chance at EMR: the avulsion technique to complete resection within areas of submucosal fibrosis.
      Gastrointest Endosc. 2015; 81: 757

      Submucosal injection

      A systematic review and meta-analysis evaluated 11 randomized controlled trials for submucosal injection with viscous solutions (hydroxyethyl starch, sodium hyaluronate solution, 50% dextrose, and succinylated gelatin, and fibrinogen).
      • Ferreira A.
      • Moleiro J.
      • Torres J.
      • et al.
      Solutions for submucosal injection in endoscopic resection: a systematic review and meta-analysis.
      Endosc Int Open. 2016; 4: E1-E16
      No solution was superior in complete resection rates or postpolypectomy adverse events. However, these viscous agents have shown superiority in other aspects of polyp resection, such as en bloc resection, Sidney resection quotient (size of the polyp divided by the number of pieces resected), and residual polyp tissue. A meta-analysis including 5 prospective RCTs with 504 patients similarly noted the superiority of viscous lifting agents compared with saline solution for resection of large sessile colon polyps (mean size of 21 mm) with a significant increase in en bloc resection (OR, 1.91; 95% CI, 1.11-3.29; P = .02; I2 = 0%) and decrease in residual lesions (OR, 0.54; 95% CI, 0.32-0.91; P =.02; I2 = 0%).
      • Yandrapu H.
      • Desai M.
      • Siddique S.
      • et al.
      Normal saline solution versus other viscous solutions for submucosal injection during endoscopic mucosal resection: a systematic review and meta-analysis.
      Gastrointest Endosc. 2017; 85: 693-699
      Newer submucosal lifting agents may have additional benefits over saline solution or other viscous lifting agents but at an increased cost. In a prospective, double-blind RCT of submucosal injection solutions for colorectal lesions greater than 20 mm, SIC-8000 compared with saline solution had a lower mean injection volume (16.1 mL vs 31.6 mL; P < .001) and a trend toward shorter procedure times, lower number of resection pieces, and higher en bloc resection rates compared with normal saline solution with methylene blue.
      • Repici A.
      • Wallace M.
      • Sharma P.
      • et al.
      A novel submucosal injection solution for endoscopic resection of large colorectal lesions: a randomized, double-blind trial.
      Gastrointest Endosc. 2018; 88: 527-535.e5
      Another prospective, double-blinded RCT found that SIC-8000 was superior to hydroxyethyl starch as a submucosal injectate for EMR.
      • Rex D.K.
      • Broadley H.M.
      • Garcia J.R.
      • et al.
      SIC-8000 versus hetastarch as a submucosal injection fluid for EMR: a randomized controlled trial.
      Gastrointest Endosc. 2019; 90: 807-812
      There were significant differences between SIC-8000 and hydroxyethyl starch in the Sydney resection quotient (9.3 vs 8.1, P = .001) and in the total amount of fluid injected (14.8 mL vs 20.6 mL, P = .038). There were nonstatistically significant trends toward superiority of SIC-8000 in the number of reinjections required, fewer numbers of resected pieces, and resection duration.
      A meta-analysis of 6 studies with 1388 patients and 1523 colorectal polyps with a mean size of 15.8 mm examined the preventative effect of submucosal epinephrine injection on postpolypectomy bleeding.
      • Tullavardhana T.
      • Akranurakkul P.
      • Ungkitphaiboon W.
      • et al.
      Efficacy of submucosal epinephrine injection for the prevention of postpolypectomy bleeding: a meta-analysis of randomized controlled studies.
      Ann Med Surg (London). 2017; 19: 65-73
      The study found statistically significant reductions in overall (OR, 0.38; 95% CI, 0.21-0.66; P = .0006) and early bleeding (OR, 0.38; 95% CI, 0.20-0.69; P = .002), but not DPPB (OR, 0.45; 95% CI, 0.11-1.81; P = .26), when prophylactic submucosal epinephrine injection was performed before polypectomy.
      A newer submucosal lifting agent, ORISE Gel, may remain present as amorphous submucosal deposits in resection specimens. The submucosal deposits are similar to mucin on hematoxylin and eosin staining and can mimic a number of other conditions, such as mucin pools, lymphangiomas, granulomatous inflammation, and amyloid deposition.
      • Ibarra-Arzamendia P.N.
      • Hanly M.G.
      Histopathological findings related to ORISETM injectable submucosa lifting agent used in the endoscopic mucosal resection of bowel neoplasms: a review of three cases.
      Case Rep Pathol. 2020; 2020: 6918093
      Endoscopists should communicate with pathologists regarding the use of these agents and their associated artefacts to minimize misdiagnosis on pathologic examination. Additional mucin stains (eg, periodic acid–Schiff with diastase digestion) may be considered if further differentiation is necessary.

      Clips and detachable snares/loops

      The practice of prophylactically clipping mucosal defects to reduce the rate of DPPB has been controversial; studies of efficacy demonstrate mixed results, and clips are expensive. Two meta-analyses found no benefit from prophylactic clipping.
      • Boumitri C.
      • Mir F.A.
      • Ashraf I.
      • et al.
      Prophylactic clipping and post-polypectomy bleeding: a meta-analysis and systematic review.
      Ann Gastroenterol. 2016; 29: 502-508
      ,
      • Mangira D.
      • Ket S.N.
      • Majeed A.
      • et al.
      Postpolypectomy prophylactic clip closure for the prevention of delayed postpolypectomy bleeding: a systematic review.
      JGH Open. 2018; 2: 105-110
      One consistent feature of the negative trials has been minimal bleeding in the control group. There is also heterogeneity in the studies, with polyps of varying sizes, shapes, and pathologies using both standard HSP and EMR. Among 4 published RCTs,
      • Feagins L.A.
      • Smith A.D.
      • Kim D.
      • et al.
      Efficacy of prophylactic hemoclips in prevention of delayed post-polypectomy bleeding in patients with large colonic polyps.
      Gastroenterology. 2019; 157: 967-976.e1
      , 
      • Albéniz E.
      • Fraile M.
      • Ibáñez B.
      • et al.
      A scoring system to determine risk of delayed bleeding after endoscopic mucosal resection of large colorectal lesions.
      Clin Gastroenterol Hepatol. 2016; 14: 1140-1147
      , 
      • Pohl H.
      • Grimm I.S.
      • Moyer M.T.
      • et al.
      Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial.
      Gastroenterology. 2019; 157: 977-984.e3
      , 
      • Albéniz E.
      • Álvarez M.A.
      • Espinós J.C.
      • et al.
      Clip closure after resection of large colorectal lesions with substantial risk of bleeding.
      Gastroenterology. 2019; 157: 1213-1221.e4
      3 have shown a benefit.
      • Albéniz E.
      • Fraile M.
      • Ibáñez B.
      • et al.
      A scoring system to determine risk of delayed bleeding after endoscopic mucosal resection of large colorectal lesions.
      Clin Gastroenterol Hepatol. 2016; 14: 1140-1147
      , 
      • Pohl H.
      • Grimm I.S.
      • Moyer M.T.
      • et al.
      Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial.
      Gastroenterology. 2019; 157: 977-984.e3
      , 
      • Albéniz E.
      • Álvarez M.A.
      • Espinós J.C.
      • et al.
      Clip closure after resection of large colorectal lesions with substantial risk of bleeding.
      Gastroenterology. 2019; 157: 1213-1221.e4
      The negative trial (no clipping benefit) was designed as an equivalence study and did not reach the intended sample size because of loss of funding, but the overall rate of delayed bleeding was similar to the control group, with no benefit in any subgroups.
      • Feagins L.A.
      • Smith A.D.
      • Kim D.
      • et al.
      Efficacy of prophylactic hemoclips in prevention of delayed post-polypectomy bleeding in patients with large colonic polyps.
      Gastroenterology. 2019; 157: 967-976.e1
      Mean polyp size was 14 mm (16% were >20 mm, and 30% were pedunculated). The bleeding rate of 2.9% in the control group is low compared with the positive trials, where polyps were confined to nonpedunculated lesions ≥20 mm, with a much higher control group rate of bleeding, particularly in the right colon segment, where the rate approaches 10%.
      • Pohl H.
      • Grimm I.S.
      • Moyer M.T.
      • et al.
      Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial.
      Gastroenterology. 2019; 157: 977-984.e3
      ,
      • Albéniz E.
      • Álvarez M.A.
      • Espinós J.C.
      • et al.
      Clip closure after resection of large colorectal lesions with substantial risk of bleeding.
      Gastroenterology. 2019; 157: 1213-1221.e4
      One positive RCT included 919 patients with nonpedunculated lesions >20 mm removed by EMR.
      • Pohl H.
      • Grimm I.S.
      • Moyer M.T.
      • et al.
      Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial.
      Gastroenterology. 2019; 157: 977-984.e3
      Clipping could not be performed in 13%, mostly owing to large size, and 20% were only partially closed. Furthermore, 10% of the control lesions were clipped, generally for fear of perforation or need for anticoagulation. In the intention-to-treat analysis, delayed bleeding occurred in 7.1% of the control group versus 3.5% with clipping (P = .015). The benefit was confined to the proximal colon, with a delayed bleeding rate in the proximal colon of 9.6% in controls versus 3.3% with clipping (P = .001). The results were independent of lesion size, cautery setting, and antithrombotic agents. A second positive RCT enrolled 235 nonpedunculated lesions ≥20 mm in size (mean size, 37 mm), with 90% proximal to the splenic flexure.
      • Albéniz E.
      • Álvarez M.A.
      • Espinós J.C.
      • et al.
      Clip closure after resection of large colorectal lesions with substantial risk of bleeding.
      Gastroenterology. 2019; 157: 1213-1221.e4
      In the clip arm, complete closure was achieved in 57%, partial in 28%, and 15% failed (no closure), with bleeding rates of 1.5%, 9.1%, and 11%, respectively. The complete closure group had an 89% reduction in delayed bleeding compared with controls. Only 1 of 35 transverse colon lesions in either arm bled. Thus, prophylactic clip placement may be a cost-effective strategy in patients deemed high risk for DPPB, including those with nonpedunculated lesions in the proximal colon (cecum, ascending or hepatic flexure) that are ≥20 mm and removed by EMR.
      Clips and detachable loops and snares have been evaluated for ligation of large pedunculated polyps before snare resection. Data for prophylactic clip ligation are mixed. A prospective study of 47 patients with 56 pedunculated polyps (mean size 17 mm ± 8 mm) reported an immediate postpolypectomy bleeding rate of 3.6% and DPPB rate of 1.8% using a mean of 2 clips.
      • Boo S.-J.
      • Byeon J.-S.
      • Park S.Y.
      • et al.
      Clipping for the prevention of immediate bleeding after polypectomy of pedunculated polyps: a pilot study.
      Clin Endosc. 2012; 45: 84-88
      However, another prospective randomized study that included 98 patients with 105 large pedunculated polyps compared clip placement before snare resection versus standard snare resection and reported that adverse event rates were higher in the clip group (10.6% vs 7.7%).
      • Quintanilla E.
      • Castro J.L.
      • Rábago L.R.
      • et al.
      Is the use of prophylactic hemoclips in the endoscopic resection of large pedunculated polyps useful? A prospective and randomized study.
      J Interv Gastroenterol. 2012; 2: 183-188
      Although the difference was not statistically significant, the study was terminated early because of unexpected increased morbidity in the clip group that was attributed to higher rates of mucosal burns and perforation.
      Two prospective RCTs have demonstrated that in patients with large pedunculated colorectal polyps, use of a detachable snare significantly reduced the rate of postpolypectomy bleeding when compared with conventional polypectomy (0% vs 12%; P < .05)
      • Iishi H.
      • Tatsuta M.
      • Narahara H.
      • et al.
      Endoscopic resection of large pedunculated colorectal polyps using a detachable snare.
      Gastrointest Endosc. 1996; 44: 594-597
      or compared with epinephrine injection with conventional polypectomy (3.1% vs 12.5%; P = .02).
      • Kouklakis G.
      • Mpoumponaris A.
      • Gatopoulou A.
      • et al.
      Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study.
      Surg Endosc. 2009; 23: 2732-2737
      In a study of 33 patients with large pedunculated colonic polyps, endoloop placement was not possible in 4 patients and the snare became entangled in 1 patient.
      • Katsinelos P.
      • Kountouras J.
      • Paroutoglou G.
      • et al.
      Endoloop-assisted polypectomy for large pedunculated colorectal polyps.
      Surg Endosc. 2006; 20: 1257-1261
      Of the 28 patients (85%) with successful loop placement, bleeding occurred in 4 patients (14.3%). Risk factors for immediate bleeding included transection of a thin stalk (<4 mm) by the loop, whereas risk factors for bleeding included performance of polypectomy close to the loop, with subsequent loop dislodgement. Finally, a prospective RCT of 195 patients with 203 pedunculated colorectal polyps with heads ≥10 mm and stalks ≥5 mm found that overall bleeding rates were similar for those receiving prophylactic clip ligation (5.1%) and those treated with endoloop placement (5.7%; P = .847).
      • Ji J.S.
      • Lee S.W.
      • Kim T.H.
      • et al.
      Comparison of prophylactic clip and endoloop application for the prevention of postpolypectomy bleeding in pedunculated colonic polyps: a prospective, randomized, multicenter study.
      Endoscopy. 2014; 46: 598-604
      Recent USMSTF guidelines recommend prophylactic ligation with either a detachable loop or clips for pedunculated polyps with heads ≥20 mm or stalks ≥5 mm to reduce the risk of immediate postpolypectomy bleeding and DPPB.
      • Kaltenbach T.
      • Anderson J.C.
      • Burke C.A.
      • et al.
      Endoscopic removal of colorectal lesions—recommendations by the US Multi-Society Task Force on Colorectal Cancer.
      Gastrointest Endosc. 2020; 91: 486-519

      Financial considerations

      The Current Procedural Terminology codes relevant to polypectomy during upper endoscopy, colonoscopy, sigmoidoscopy, and enteroscopy are listed in Table 3. In general, when 1 or more polyps are removed during endoscopy, a separate code is reported for each technique used if the techniques are used for different polyps or separate sites. When multiple techniques are performed to resect polyps at different sites, different primary and secondary codes can be used with the -59 modifier on the second or subsequent code. If submucosal injection is performed, it can be separately used as a secondary procedure, again with -59 modifier. Control of bleeding induced by polypectomy and treated within the same session cannot be separately reported. EMR includes biopsy, control of bleeding, submucosal injection, and application of clips or cautery of residual edges within the same code as the snare lesion removal itself.
      Table 3Current procedural terminology codes for performance of polypectomy
      DescriptionCPT code
      Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance43236
      Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple43239
      Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps43250
      Esophagogastroduodenoscopy, flexible, transoral; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique43251
      Esophagogastroduodenoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s)43270
      Colonoscopy, flexible; with biopsy, single or multiple45380
      Colonoscopy, flexible; with directed submucosal injection(s), any substance45381
      Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps45384
      Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique45385
      Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s)45388
      Colonoscopy, flexible; with endoscopic mucosal resection45390
      Sigmoidoscopy, flexible; with biopsy, single or multiple45331
      Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps45333
      Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance45335
      Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique45338
      Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s)45346
      Sigmoidoscopy, flexible; with endoscopic mucosal resection45349
      Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple44361
      Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery44365
      Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique44364
      Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique44369

      Conclusion

      A wide array of devices is available for polypectomy. Ongoing review and familiarity with advances in polypectomy devices and techniques will help the practicing endoscopist achieve optimal outcomes. CSP and jumbo forceps polypectomy of diminutive and small polyps are associated with higher complete resection rates than cold forceps polypectomy. Compared with competing techniques for resecting small polyps, hot biopsy forceps polypectomy is associated with high incomplete resection rates, suboptimal pathologic specimens, and high adverse event rates. Therefore, CSP is recommended for resection of nonpedunculated polyps less than 10 mm. CSP or HSP with or without submucosal injection is recommended for nonpedunculated polyps 10 to 19 mm without features of submucosal invasion. Hot biopsy forceps are useful for hot avulsion of residual flat or fibrotic neoplastic tissue after conventional snare polypectomy. Routine clip closure does not reduce the risk of DPPB after standard uncomplicated polypectomy and should not be routinely used. Clip closure of mucosal defects can be considered in patients or lesions deemed to be at higher risk for DPPB. In particular, clip closure is recommended after EMR with electrocautery of lesions ≥20 mm from the right colon segment. Pedunculated polyps with heads ≥20 mm or stalks ≥5 mm are recommended to undergo prophylactic mechanical ligation with a detachable loop before resection or clip closure after resection to reduce the risk of immediate postpolypectomy bleeding and DPPB.

      Acknowledgment

      The authors wish to thank Todd Baron, MD, Amitabh Chak, MD, Jonathan Cohen, MD, Jason Dominitz, MD, Steve Edmundowicz, MD, Felix Leung, MD, Klaus Mergener, MD, PhD, MBA, Glenn Littenberg, MD, Bret Petersen, MD, Douglas Rex, MD, and John Vargo, MD, MPH for their review of the document.

      Supplementary data

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        Video 1

        Use of submucosal injection prior to en-bloc endoscopic mucosal resection.

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        Video 2

        Use of a detachable loop ligating device prior to hot snare resection of a pedunculated polyp.

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      Article info

      Publication history

      Published online: April 02, 2021

      Footnotes

      Disclosure: Dr Chandrasekhara is a consultant for Covidien LP, is on the advisory board for Interpace Diagnostics, and is a shareholder in Nevakar, Inc. Dr Kumta is a consultant for Boston Scientific Corporation, Gyrus ACMI, Inc., Olympus Corporation of the Americas, and Apollo Endosurgery US Inc. Dr Abu Dayyeh is a consultant for Metamodix, BFKW, DyaMx, Hemostasis, and Boston Scientific Corporation; is a consultant and has received research support from Medtronic; has received research support from Apollo Endosurgery, USGI, Spatz Medical, GI Dynamics, Cairn Diagnostics, and Aspire Bariatrics.; is a speaker for Johnson and Johnson, Endogastric Solutions Inc., and Olympus Corporation of the Americas; has received travel compensation and food and beverage from Olympus Corporation of the Americas and Endogastric Solutions, Inc.; has received food and beverage from Boston Scientific Corporation, Covidien LP, Apollo Endosurgery US Inc, and Medrobotics Inc. Dr Bhutani has received research grants from Silenseed Inc., Galera Inc, Oncosil Inc., Nanobiotix, and Augmenix Inc.; has received food and beverage from Augmenix Inc., Conmed Corporation, and Olympus Corporation of the Americas; has received travel compensation from Augmenix Inc. Dr Jirapinyo is a consultant for Endogastric Solutions, and Lumendi; is a consultant and has received research support from GI Dynamics; has received research support from Apollo Endosurgery and Fractyl; has received travel compensation and food and beverage from Boston Scientific Corporation; and has received travel compensation from Olympus Corporation of the Americas. Dr Krishnan is a consultant for Olympus Corporation of the Americas and Medtronic; has received travel compensation and food and beverage from Olympus Corporation of the Americas; has received food and beverage from Boston Scientific Corporation. Dr Maple has received food and beverage from Covidien LP, Olympus America Inc., and Boston Scientific Corporation. Dr Melson received an investigator-initiated grant from and has received food and beverage from Boston Scientific Corporation; has received food and beverage from Cook Medical LLC; and has stock options with Virgo Imaging. Dr Pannala is a consultant for HCL Technologies, has received travel compensation and food and beverage from Boston Scientific Corporation; has received food and beverage from Apollo Endosurgery US, Inc.; and is on the scientific advisory board for Nestle Health Sciences. Dr Parsi has received travel compensation and food and beverage from Olympus Corporation of the Americas; and has received food and beverage from CONMED Corporation, Salix Pharmaceuticals, AbbVie, Inc., Shionogi Inc., Shire North American Group Inc., and Boston Scientific Corporation. Dr Sethi is a consultant for Boston Scientific Corporation, Fujifilm, Medtronic, Micro-Tech, and Olympus Corporation of the Americas; has received travel compensation and food and beverage from ERBE USA, Inc., Covidien LP, Cook Medical LLC, Endogastric Solutions, and ER Squibb. Dr Trikudanathan is a consultant for and has received travel compensation and food and beverage from Boston Scientific Corporation; has received food and beverage from Cook Medical LLC. Dr Trindade is a consultant and has received food and beverage from Olympus Corporation of the Americas; is a consultant and has received travel compensation and food and beverage from PENTAX of America, Inc.; has received travel compensation and food and beverage from Gyrus ACMI, Inc.; has received food and beverage from Boston Scientific Corporation, and has a research grant from NinePoint Medical, Inc. Dr Lichtenstein is a consultant for Augmenix, Inc.; a consultant and has received travel compensation and food and beverage from Olympus Corporation of the Americas; and is a consultant and has received food and beverage from Boston Scientific Corporation. All other authors disclosed no financial relationships.

      Identification

      DOI: https://doi.org/10.1016/j.vgie.2021.02.006

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