Post written by Jeevithan Sabanathan, MBBS, from Griffith University, Brisbane, Queensland, Australia, and Logan Hospital, Brisbane, and Thomas J. Williams, MBBS, from the University of Queensland, Brisbane, and Logan Hospital.

Cold piecemeal EMR (C-EMR) has continued to gain popularity because of its simplicity and exceptional safety profile. The near-zero risk of perforation and clinically significant postpolypectomy bleeding makes it a very attractive modality for widespread adoption. This is particularly pertinent when considering variables such as patient age, surgical risk, anticoagulant usage, and the specific setting of the procedure, including regional, remote, and community centers.

However, as with any modality, safety needs to be carefully balanced against efficacy to ensure optimal patient outcomes. Intrinsic limitations to cold snaring include its inability to transect large volumes of tissue, making it unsuitable for large bulky Paris Is or Ip lesions.

Furthermore, depth of resection is often limited to the mucosal layer, raising questions about its suitability for all lesion types. Although efficacy of cold snaring in diminutive (<5 mm) and small (5-9 mm) polyps of all histological subtypes is widely accepted, its use in larger lesions is still not entirely clear.

Our study sought to address 2 specific polyp characteristics that may affect the efficacy of C-EMR: size and histology. To circumvent the previously mentioned limitation associated with tissue transection, we focused exclusively on Paris IIa lesions. We conducted a retrospective analysis of 242 medium (10-19 mm) and large (≥20 mm) colorectal Paris IIa lesions that were resected with C-EMR at our center. The lesions were further classified histologically into sessile serrated lesions (SSLs) and adenomas.

We evaluated endoscopic recurrence at the site of previous polypectomy at 6-month follow-up colonoscopy. If endoscopic recurrence was identified, further resection was performed for treatment and histologic confirmation. Routine biopsies were not performed of scars without recurrence. The recurrence rate at 6 months was notably higher for large adenomas (16%) than similarly sized SSLs (4.1%). For medium adenomas, the recurrence rate (3%) was comparable with that of medium SSLs (1.4%). There were no cases of perforation or clinically significant postpolypectomy bleeding.

The findings suggest that C-EMR could be a viable treatment option for medium-sized Paris IIa lesions of all histologies, as well as large Paris IIa SSLs. However, caution is necessary when selecting the appropriate resection method for large Paris IIa adenomas.

Alternative techniques such as hot snare EMR or endoscopic submucosal dissection should be considered based on the characteristics of the lesion and patient. In addition, use of adjunct techniques such as snare-tip soft coagulation of defect margins may enhance efficacy of C-EMR for large adenomas and could be considered for future research.

Frequency of polyp recurrence at first surveillance colonoscopy following cold-piecemeal EMR based on histology and size. SSLs, Sessile serrated lesions.

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