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.
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