Conference Coverage

Cold snare polypectomy underused despite recommendations



Just over half of endoscopists use cold snare polypectomy to remove small polyps of less than 1 cm, despite recommendations from the U.S. Multisociety Task Force for its use in small lesions, shows new research presented this week in Vancouver at the annual meeting of the American College of Gastroenterology.

Polypectomy is a key part of colorectal cancer prevention, but endoscopists’ choice of polypectomy is a major factor in quality, and the characteristics of polypectomies in clinical practice are highly variable, said Seth D. Crockett, MD, of Oregon Health & Science University, Portland, in a presentation at the meeting.

Cold snare polypectomy is preferred for the removal of polyps less than 1 cm because of a high complete resection rate and a strong safety profile, compared to forceps and hot snares, which tend to be associated with high incomplete resection rates, inadequate histopathologic specimens, and/or complication rates. The adherence of endoscopists to the recommendations was not known until now, Dr. Crockett said.

This was a cross-sectional study of 1,589,499 colonoscopies that were conducted between 2019 and 2022 in patients (aged 40-80 years) who underwent a screening or surveillance colonoscopy in which at least one small polyp of less than 1 cm was removed. The final analysis included 3,082 endoscopists. Colonoscopies in which larger polyps were detected, or there was a confirmed case of cancer, were not included.

The mean endoscopist cold snare polypectomy rate (CSPR) was 51.2%, which was “lower than expected based on current guideline recommendations,” Dr. Crockett said.

Higher cold snare polypectomy rates were more common among specialists with training in gastroenterology, and more common among those who practiced in the Midwest (69%), as compared with practitioners in the Northeast who, at 40%, had the lowest rate. Colonoscopy volume, adenoma detection rate (ADR), serrated polyp detection rate (SDR), and cecal intubation rate (CIR), were all associated with a higher CSPR.

CSPR was more than 30% higher for endoscopists with an adenoma detection rate (ADR) of greater than 35%, compared with those with an ADR of less than 25% (58% vs. 27%, respectively; P < .0001). Lower usage rates among endoscopists with low ADRs could compound the problem of interval cancer if polyps are missed, Dr. Crockett said. Endoscopist serrated polyp detection rates of 7% of higher, cecal intubation rates of 95% or higher, and mean withdrawal times greater than 9 minutes were significantly associated with higher CSPR (P < .0001 for all).

The findings suggest a correlation between higher cold snare usage and improved quality metrics, such as adenoma detection rate and cecal intubation rate, said Jonathan A. Leighton, MD, of the Mayo Clinic, Scottsdale, Ariz., in an interview.

“I would agree with the authors that much of the focus on colonoscopy quality has been directed toward polyp detection, and little on the quality of polyp resection, which can be difficult to measure,” he said. “Their results suggest that cold snare polypectomy for removal of small polyps is currently underutilized, but as with any polypectomy, it is important that all of the dysplastic tissue is removed using good technique.”

The results were strengthened by the large sample size and high fidelity of measurements of polyp size, polypectomy tools, and quality measures. But more research is needed to determine the impact of polypectomy technique on outcomes of colonoscopy efficacy and safety. In terms of limitations, small polyps carry a relatively low risk of recurrence, and the associations between an endoscopist’s polypectomy practice and polyp recurrence, interval cancer, and adverse events were not examined, Dr. Crockett said.

The study was supported by a grant from the ACG. Dr. Crockett disclosed relationships with Carelon, Exact Sciences, Freenome, and Guardant.

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