Cold Forceps on Par With Cold Snare Polypectomy for Tiny Polyps

For nonpedunculated polyps measuring 3 mm or less, cold forceps polypectomy is noninferior to cold snare polypectomy and takes significantly less time, according to the results of the TINYPOLYP trial.

“In our trial, which is the largest to date evaluating complete resection of polyps ≤3 mm using cold forceps vs cold snare, we demonstrate that it is acceptable to remove ≤3 mm polyps with either cold snare or cold forceps,” lead author Mike Wei, MD, a gastroenterology and hepatology fellow at Stanford University, in California, told Medscape Medical News.

“Cold forceps can oftentimes be the more efficient way to remove polyps compared to cold snare, and, as such, it was important to provide validation for this practice,” Wei said.

The study was published online in The American Journal of Gastroenterology.

Evaluating Two Techniques

Both the US Multi-Society Task Force on Colorectal Cancer and the European Society of Gastrointestinal Endoscopy recommend that diminutive (<5 mm) and small (6–9 mm) polyps be removed by cold snare polypectomy (CSP).

But whether CSP has a significant advantage over cold forceps polypectomy (CFP) for polyps ≤3 mm was unclear.

The TINYPOLYP trial enrolled 179 adults aged 18 years and older who underwent colonoscopy for any indication; colonoscopy was performed by four board-certified endoscopists who each had at least 4 years of experience after completing their fellowship.

A total of 279 nonpedunculated polyps ≤3 mm were identified; 138 were removed by CSP, and 141 were removed by CFP. Patient and procedure characteristics were similar in the two groups.

The polyps were similar in size in the CSP and CFP groups (2.5 and 2.6 mm, respectively), as was the distribution of polyps (33.3% and 26.2% in the ascending colon; 26.8% and 24.8% in the transverse colon). A higher proportion of tubular adenomas were removed by CSP than by CFP (79.7% vs 66.0%).

CSP took significantly longer to perform than CFP (42.3 sec vs 23.2 sec, P < .001). But with CFP, it was significantly more likely that polyps would need to be removed in more than one piece compared to CSP (15.6% vs 3.6%, P < .001).

Hemostatic clip was deployed for one polyp in the CFP group (0.7%); none were used in the CSP group, which was a nonsignificant difference.

There was also no significant difference in positive margins on biopsy (two cases in each group; 1.7%) or in the rate of complete resection (98.3% in both groups), demonstrating noninferiority of CFP compared to CSP, the study team says.

There were no 30-day complications in either group, including perforation, postpolypectomy bleeding, and postpolypectomy syndrome, and no patient required management of postpolypectomy bleeding. No patient died within 30 days of colonoscopy.

On the basis of their results, Wei and colleagues say, “When an endoscopist encounters a diminutive polyp ≤ 3 mm, either a cold forceps or cold snare can be utilized during the procedure.”

Guidance for Endoscopists

Reached for comment, Emre Gorgun, MD, in the Department of Colorectal Surgery at the Cleveland Clinic in Ohio, said this is an “interesting” study that attempts to pinpoint the “best endoscopic management of tiny polyps.”

“From previously published, well-designed studies, we know that the cold snare technique works very well for polyps up to 10 mm. There have been more recent studies showing that the cold snare technique can be used even in larger polyps, 10 mm to 15 mm,” Gorgun told Medscape Medical News.

On the other hand, for polyps <5 mm, “cold snare technique may take longer and may not provide any added benefits,” he noted. “It may be associated with higher cost due to utilizing more tools, as well as more procedure time and provider services.”

Gorgun said that the results of the TINYPOLYP study “can help endoscopists in decision-making when they come across polyps smaller than 5 mm.”

The study demonstrates that these tiny polyps can “certainly be destroyed/removed by the cold forceps approach,” he added.

The trial had no specific funding. Wei reports no relevant financial relationships. Gorgun is a consultant for Boston Scientific, Olympus, and Dilumen.

Am J Gastroenterol. Published online April 25, 2022. Abstract

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