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Comparative efficacy and safety of resection techniques for treating 6 to 20mm, nonpedunculated colorectal polyps: A systematic review and network meta-analysis

Published:November 04, 2022DOI:https://doi.org/10.1016/j.dld.2022.10.011

      Abstract

      Introduction

      Various endoscopic resection techniques have been proposed for the treatment of nonpedunculated colorectal polyps sized 6–20 mm, however the optimal technique still remains unclear.

      Methods

      A comprehensive literature review was conducted for randomized controlled trials (RCTs), investigating the efficacy of endoscopic treatments for the management of 6–20 mm nonpedunculated colorectal polyps. Primary outcomes were complete and en bloc resection rates and adverse event rate was the secondary. Effect size on outcomes is presented as risk ratio (RR; 95% confidence interval [CI]).

      Results

      Fourteen RCTs (5219 polypectomies) were included. Endoscopic mucosal resection(EMR) significantly outperformed cold snare polypectomy(CSP) in terms of complete [(RR 95%CI): 1.04(1.00–1.07)] and en bloc resection rate [RR:1.12(1.04–1.21)]. EMR was superior to hot snare polypectomy (HSP) [RR:1.04(1.00–1.08)] regarding complete resection, while underwater EMR (U-EMR) achieved significantly higher rate of en bloc resection compared to CSP [RR:1.15(1.01–1.30)]. EMR yielded the highest ranking for complete resection(SUCRA-score 0.81), followed by cold-snare EMR(CS-EMR,SUCRA-score 0.76). None of the modalities was different regarding adverse event rate compared to CSP, however EMR and CS-EMR resulted in fewer adverse events compared to HSP [RR:0.44(0.26–0.77) and 0.43(0.21–0.87),respectively].

      Conclusion

      EMR achieved the highest performance in resecting 6–20 mm nonpedunculated colorectal polyps, with this effect being consistent for polyps 6–9 and ≥10 mm; findings supported by very low quality of evidence.

      Keywords

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      References

        • Zauber A.G.
        • Winawer S.J.
        • O'Brien M.J.
        • et al.
        Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.
        N Engl J Med. 2012; 366: 687-696
        • 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
        • Repici A.
        • Hassan C.
        • Vitetta E.
        • et al.
        Safety of cold polypectomy for <10 mm polyps at colonoscopy: a prospective multicenter study.
        Endoscopy. 2012; 44: 27-31
        • Djinbachian R.
        • Iratni R.
        • Durand M.
        • et al.
        Rates of incomplete resection of 1- to 20-mm colorectal polyps: a systematic review and meta-analysis.
        Gastroenterology. 2020; 159 (e912): 904-914
        • 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
        • Farrar W.D.
        • Sawhney M.S.
        • Nelson D.B.
        • et al.
        Colorectal cancers found after a complete colonoscopy.
        Clin Gastroenterol Hepatol. 2006; 4: 1259-1264
        • Kandel P.
        • Wallace M.B.
        Colorectal endoscopic mucosal resection (EMR).
        Best Pract Res Clin Gastroenterol. 2017; 31: 455-471
        • Tziatzios G.
        • Gkolfakis P.
        • Papadopoulos V.
        • et al.
        Modified endoscopic mucosal resection techniques for treating precancerous colorectal lesions.
        Ann Gastroenterol. 2021; 34: 757-769
        • Hutton B.
        • Salanti G.
        • Caldwell D.M.
        • et al.
        The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.
        Ann Intern Med. 2015; 162: 777-784
        • Higgins JPT GS
        Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011].
        The Cochrane Collaboration. 2011; (Available from) (2011, DOI:)
        • DerSimonian R.
        • Laird N.
        Meta-analysis in clinical trials revisited.
        Contemp Clin Trials. 2015; 45: 139-145
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • et al.
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Dias S.
        • Sutton A.J.
        • Ades A.E.
        • et al.
        Evidence synthesis for decision making 2: a generalized linear modeling framework for pairwise and network meta-analysis of randomized controlled trials.
        Med Decis Making. 2013; 33: 607-617
        • Salanti G.
        • Ades A.E.
        • Ioannidis J.P.
        Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial.
        J Clin Epidemiol. 2011; 64: 163-171
        • Puhan M.A.
        • Schünemann H.J.
        • Murad M.H.
        • et al.
        A GRADE Working Group approach for rating the quality of treatment effect estimates from network meta-analysis.
        Bmj. 2014; 349: g5630
      1. Schünemann H. B.J, Guyatt G., Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations (Updated October 2013). The GRADE Working Group, 2013 https://gdtgradeproorg/app/handbook/handbookhtml [Accessed Jan 28, 2019] 2013, DOI:

        • Horiuchi A.
        • Makino T.
        • Kajiyama M.
        • et al.
        Comparison between endoscopic mucosal resection and hot snare resection of large nonpedunculated colorectal polyps: a randomized trial.
        Endoscopy. 2016; 48: 646-651
        • Kawamura T.
        • Takeuchi Y.
        • Asai S.
        • et al.
        A comparison of the resection rate for cold and hot snare polypectomy for 4-9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study).
        Gut. 2018; 67: 1950-1957
        • Kim H.-.S.
        • Jung H.Y.
        • Park H.J.
        • et al.
        Hot snare polypectomy with or without saline solution/epinephrine lift for the complete resection of small colorectal polyps.
        Gastrointest Endosc. 2018; 87: 1539-1547
        • Papastergiou V.
        • Paraskeva K.D.
        • Fragaki M.
        • et al.
        Cold versus hot endoscopic mucosal resection for nonpedunculated colorectal polyps sized 6-10 mm: a randomized trial.
        Endoscopy. 2018; 50: 403-411
        • Zhang Q.
        • Gao P.
        • Han B.
        • et al.
        Polypectomy for complete endoscopic resection of small colorectal polyps.
        Gastrointest Endosc. 2018; 87: 733-740
        • Yamashina T.
        • Uedo N.
        • Akasaka T.
        • et al.
        Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps.
        Gastroenterology. 2019; 157 (e452): 451-461
        • Li D.
        • Wang W.
        • Xie J.
        • et al.
        Efficacy and safety of three different endoscopic methods in treatment of 6-20 mm colorectal polyps.
        Scand J Gastroenterol. 2020; 55: 362-370
        • Yen A.W.
        • Leung J.W.
        • Wilson M.D.
        • et al.
        Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video).
        Gastrointest Endosc. 2020; 91 (e642): 643-654
        • Ito T.
        • Takahashi K.
        • Tanabe H.
        • et al.
        Safety and efficacy of cold snare polypectomy for small colorectal polyps: A prospective randomized control trial and one-year follow-up study.
        Medicine. 2021; 100: e26296
        • Kim S.-.J.
        • Lee B.-.I.
        • Jung E.S.
        • et al.
        Hot snare polypectomy versus endoscopic mucosal resection for small colorectal polyps: a randomized controlled trial.
        Surg Endosc. 2021; 35: 5096-5103
        • Varytimiadis L.
        • Viazis N.
        • Gkolfakis P.
        • et al.
        Cold snare polypectomy vs. hot snare polypectomy vs. argon plasma coagulation for small (5-9 mm) left-sided colorectal polyps: a prospective randomized trial.
        Eur J Gastroenterol Hepatol. 2021; 33: e909-e915
        • de Benito Sanz M.
        • Hernandez L.
        • Garcia Martinez M.I.
        • et al.
        Efficacy and safety of cold versus hot snare polypectomy for small (5-9 mm) colorectal polyps: a multicenter randomized controlled trial.
        Endoscopy. 2022; 54: 35-44
        • Pedersen I.B.
        • Rawa-Golebiewska A.
        • Calderwood A.H.
        • et al.
        Complete polyp resection with cold snare versus hot snare polypectomy for polyps of 4-9 mm: a randomized controlled trial.
        Endoscopy. 2022; https://doi.org/10.1055/a-1734-7952
        • Rex D.K.
        • Anderson J.C.
        • Pohl H.
        • et al.
        Cold versus hot snare resection with or without submucosal injection of 6-15 mm colorectal polyps: a randomized controlled trial.
        Gastrointest Endosc. 2022; https://doi.org/10.1016/j.gie.2022.03.006
        • Hurlstone D.P.
        • Sanders D.S.
        • Cross S.S.
        • et al.
        Colonoscopic resection of lateral spreading tumours: a prospective analysis of endoscopic mucosal resection.
        Gut. 2004; 53: 1334-1339
        • Belderbos T.D.
        • Leenders M.
        • Moons L.M.
        • et al.
        Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis.
        Endoscopy. 2014; 46: 388-402
        • Komeda Y.
        • Watanabe T.
        • Sakurai T.
        • et al.
        Risk factors for local recurrence and appropriate surveillance interval after endoscopic resection.
        World J Gastroenterol. 2019; 25: 1502-1512
        • 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
        • Hewett D.G.
        Cold snare polypectomy: optimizing technique and technology (with videos).
        Gastrointest Endosc. 2015; 82: 693-696
        • Tziatzios G.
        • Gkolfakis P.
        • Triantafyllou K.
        • et al.
        Higher rate of en bloc resection with underwater than conventional endoscopic mucosal resection: A meta-analysis.
        Dig Liver Dis. 2021; 53: 958-964
        • Rex D.K.
        Narrow-band imaging without optical magnification for histologic analysis of colorectal polyps.
        Gastroenterology. 2009; 136: 1174-1181
        • Tutticci N.J.
        • Kheir A.O.
        • Hewett D.G.
        The Cold Revolution: How Far Can It Go?.
        Gastrointest Endosc Clin N Am. 2019; 29: 721-736
        • Lieberman D.
        • Moravec M.
        • Holub J.
        • et al.
        Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography.
        Gastroenterology. 2008; 135: 1100-1105