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Original research
Piecemeal cold snare polypectomy versus conventional endoscopic mucosal resection for large sessile serrated lesions: a retrospective comparison across two successive periods
  1. W Arnout van Hattem1,
  2. Neal Shahidi1,2,3,
  3. Sergei Vosko1,
  4. Imogen Hartley4,5,
  5. Kaushali Britto6,7,
  6. Mayenaaz Sidhu1,3,
  7. Iddo Bar-Yishay1,
  8. Scott Schoeman1,
  9. David James Tate1,8,
  10. Karen Byth9,
  11. David G Hewett10,11,
  12. María Pellisé12,
  13. Luke F Hourigan13,14,
  14. Alan Moss4,5,
  15. Nicholas Tutticci6,7,
  16. Michael J Bourke1,3
  1. 1Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
  2. 2Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
  3. 3Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
  4. 4Department of Gastroenterology and Hepatology, Western Health, Footscray, Victoria, Australia
  5. 5Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
  6. 6Department of gastroenterology and hepatology, Queen Elizabeth II Jubilee Hospital, Acacia Ridge, Queensland, Australia
  7. 7Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
  8. 8Department of Gastroenterology and Hepatology, University Hospital Ghent, Gent, Belgium
  9. 9Biostatistics, Sydney University, Sydney, New South Wales, Australia
  10. 10School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
  11. 11Division of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, Queensland, Australia
  12. 12Gastroenterology, Gastroenterology Department, Hospital Clínic de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Institut d’Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
  13. 13Department of gastroenterology and hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia
  14. 14Department of gastroenterology and hepatology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
  1. Correspondence to Dr Michael J Bourke, Gastroenterology and Hepatology, Westmead Hospital, WEstmead, NSW 2145, Australia; michael{at}


Objective Large (≥20 mm) sessile serrated lesions (L-SSL) are premalignant lesions that require endoscopic removal. Endoscopic mucosal resection (EMR) is the existing standard of care but carries some risk of adverse events including clinically significant post-EMR bleeding and deep mural injury (DMI). The respective risk-effectiveness ratio of piecemeal cold snare polypectomy (p-CSP) in L-SSL management is not fully known.

Design Consecutive patients referred for L-SSL management were treated by p-CSP from April 2016 to January 2020 or by conventional EMR in the preceding period between July 2008 and March 2016 at four Australian tertiary centres. Surveillance colonoscopies were conducted at 6 months (SC1) and 18 months (SC2). Outcomes on technical success, adverse events and recurrence were documented prospectively and then compared retrospectively between the subsequent time periods.

Results A total of 562 L-SSL in 474 patients were evaluated of which 156 L-SSL in 121 patients were treated by p-CSP and 406 L-SSL in 353 patients by EMR. Technical success was equal in both periods (100.0% (n=156) vs 99.0% (n=402)). No adverse events occurred in p-CSP, whereas delayed bleeding and DMI were encountered in 5.1% (n=18) and 3.4% (n=12) of L-SSL treated by EMR, respectively. Recurrence rates following p-CSP were similar to EMR at 4.3% (n=4) versus 4.6% (n=14) and 2.0% (n=1) versus 1.2% (n=3) for surveillance colonoscopy (SC)1 and SC2, respectively.

Conclusions In a historical comparison on the endoscopic management of L-SSL, p-CSP is technically equally efficacious to EMR but virtually eliminates the risk of delayed bleeding and perforation. p-CSP should therefore be considered as the new standard of care for L-SSL treatment.

  • gastrointesinal endoscopy
  • endoscopic polypectomy
  • colonic polyps

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  • Contributors Concept and design: WAvH, MJB. Acquisition of data: WAvH, NS, SV, MS, IB-Y, SS, DJT, DGH, MP, LFH, AM, NT, MJB. Database interpretation: WAvH, NS, SV, IH, KB, MS, IB-Y, SS, DJT, KB, MJB. Statistical analysis: KB. Drafting of the manuscript: WAvH. Critical revision of the manuscript for important intellectual content: NS, DGH, MP, LFH, AM, NT, MJB. Study supervision: MJB. Final approval of the article: all authors.

  • Funding WAvH and SV were supported by scholarships from the Westmead Medical Research Foundation. NS was supported by the University of British Columbia Clinician Investigator Fellowship. LH received support from the Gallipoli Medical Research Foundation. There was no influence from the institutions regarding study design or conduct, data collection, management, analysis or interpretation or preparation, review, or approval of the manuscript.

  • Competing interests MJB: Research Support by Olympus Medical, Cook Medical, Boston Scientific.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. Deidentifed individual participant data that underlie the results reported in this article will be made available upon reasonable request immediately following publication for a period of six months, to investigators who provide a methodologically sound proposal. Proposals should be directed at the corresponding author and should include a signed data access agreement.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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