Optimizing complete resection during colonoscopy is important as residual neoplastic tissue may play a role in interval cancers. The United States Multi-Society Task Force recommends diminutive (<5mm) and small (6-9mm) polyps be removed by cold snare polypectomy (CSP). However, evidence is less clear whether CSP retains significant advantage over cold forceps polypectomy (CFP) for polyps <3mm.
This study is a single-center prospective non-inferiority randomized clinical trial evaluating CFP and CSP for nonpedunculated polyps <3mm. Patients >18 years of age undergoing colonoscopy for any indication were recruited. During each colonoscopy, polyps underwent block randomization to removal with CFP or CSP. Following polypectomy, two biopsies were taken from the polypectomy margin. The primary non-inferiority outcome was complete resection rate, defined by absence of residual polyp in the margin biopsies.
A total of 179 patients were included. Patients had similar distribution in age, sex, race/ethnicity, as well as indication of procedure. A total of 279 polyps <3mm were identified, with 138 in the CSP group and 141 in the CFP group. Mean polypectomy time was longer for CSP compared to CFP (42.3 vs 23.2 seconds, p<0.001), though a higher proportion of polyps removed by CFP were removed in more than one piece compared to CSP (15.6 vs 3.6%, p<0.001). There were positive margin biopsies in 2 cases per cohort, with complete resection rate of 98.3% in both groups. There was no significant difference in cohorts in complete resection rates (difference in complete resection rates was 0.057%, 95% CI: -4.30 to 4.53%), demonstrating non-inferiority of CFP compared to CSP.
Use of CFP was non-inferior to CSP in the complete resection of nonpedunculated polyps <3mm. CSP required significantly more time to perform compared to CFP. CFP should be considered an acceptable alternative to CSP for removal of polyps <3mm.