to me, so there's really no debate, no fight, nothing. I mean, there's just one technique that is the technique, that is the cold snare polypectomy, and actually Doug has helped me already a little bit here. The video is redundant. I would like, however, to highlight that for sessile serrated lesions, it might be more difficult to delineate them well. And as this is a cold snare technique, of course, then there's a higher risk of leaving also serrated tissue in place. So you might want to do something extra to delineate either with virtual chromo or maybe with submucosal dye, like in this case. However, you have to be aware that sometimes the polyps tend to blow, and then you might need more piecemeal resection, which is fine, but just to realize. How about snares for cold snare polypectomy? Well, there's dedicated snares. They're stiff and they're more thin, monofilament, usually nine to 10 millimeters, different types, steel and nitinol, and there is different publications on this. First, it was published that probably dedicated cold snares were superior in achieving complete histologic eradication. However, a more recent study from the Australian group in a nice RCT showed that the two different snares, cold and hot snare, had equal radicality rates. However, both rates were very low at 1.5%. And they said, they concluded that it's probably more the technique than the snare itself. And you should be aware there's also larger cold snares, but they also have some side disadvantages, I would say, as you might have more difficulty in cutting such a large piece without coagulation, and there's increased flexibility, which makes it a little bit more difficult to really press down. All right, Evelyn, you're trying to convince us, but what about this white protrusion after cold polypectomy? Is there potential for neoplastic tissue? Is this dangerous? Well, no, you shouldn't worry too much about this. This is published already in 2015 by Nick Titucci. And it happens more often in polyps size over six millimeters. And it's mostly muscularis mucosae. It's definitely not residual polyp, no vessels, and it's not associated with adverse outcomes. And actually, what I do like is what Dr. Overto showed you is the irrigation with water, actually with the water jet, and usually it blows up and often even the protrusion then disappears. So how about some evidence? I only took some more recent papers, three of them, a northern paper, northern European paper showing non-inferiority was not demonstrated for cold snare. So it seems rather equal. However, SSLs were, and this is a small mistake, were more often not eradicated. Another recent study from SANS, equal completeness and bleeding rates, and then a very nice trial led by Doug Rex, randomizing for four different polypectomy techniques, cold or hot, and then piecemeal or en bloc for lesions six to 15. Looking at the small ones that we are discussing now, there were no incomplete resections by cold snare and all the incomplete resections were in the larger lesions, and actually there was just one with cold snare piecemeal MR that was not resected radically. How about the safety? Already also alluded to by Doug, it's a very, very safe technique. Actually, looking at a retrospective series, there was an odds ratio of five for hot snare polypectomy to have a bleeding complication compared to cold snare polypectomy, and the lower study, you can see there is a study already published in 2014 in GIE, showing that in anticoagulant patients, there were no delayed bleedings in patients with cold snare LMR compared to hot snare. So really safe, and a very nice recent study confirmed that again. This was a study from Taiwan, an RCT, many small polyps, and again, less delayed bleedings, also severe ones, and actually irrespective also of antithrombotics use. All right, you're doing a really good job. I see the audience is convinced. My last attempt is what about resection depth? There's data that shows with cold snare versus hot snare and underwater, that thickness of that submucosal tissue is barely minimal, zero to 52 microns with cold snare. Doesn't that worry you? Well, it's indeed something to take into account. However, if it's all about benign polyps and you make sure you have a nice tissue margin around, I'm not worried at all. But of course, this would worry me if there would be any suspicion of submucosal growth. And this is probably also, by the way, the reason that we have less bleedings, because we go less deep to the larger vessels. So cold snare polypectomy for almost all polyps smaller than a centimeter. Again, I would like to highlight the delineation for SSLs. Stalked polyps, there's not so much evidence around. I agree with Doug, for the smaller ones, it's a very easy technique, and I wouldn't worry at all. But if the head of the stalk or the stalk are larger than a centimeter, of course, we have to be aware of possible bleeding. Lesions with a suspicion of invasive growth, clearly it's a no. And then there's debates about is there any other patient-related factors? There was one interesting case described in Dan Open about a patient with a late perforation after corticosteroid use. So there might be factors in there, but not yet much evidence here. All right. I think you won. So round two, polyps 10 to 19 millimeters. Again, Evelyn, take it away. Yes. So I will discuss SSLs in this case. So cold snare EMR, again, is a very nice technique, and it's nicely done. And especially, I think, I like the margins very well. Take enough space, take enough space, but then look how nice and crisp they are. There is not yet any published RCTs so far. There's two retrospective, or there's one retrospective study and one prospective study. The prospective study was on a large number of SSLs. And as you can see here, only one lesion was not radically rejected in this prospective study using cold snare prismally EMR as discovered by biopsies from the resection margins. However, again, only very few intra-procedural bleeds and no late bleedings. To the right, you see the study from the group from Michael Burke. What they did is they looked retrospectively at all their hot snare prismally EMRs and then compared it to a prospective from a certain moment or series from cold snare EMR. And again, equal effectivity here, but clearly less complications. So again, I think for the SSLs for larger than a centimeter, almost all can be very nicely and quickly be rejected by cold snare EMR. However, of course, do a very good optical diagnosis using your virtual chroma or whatever you need to do, because there's SSLs with this plastic areas within them. And then you have to be really much more careful. Make sure it's not invasive, because again, then cold snare is absolutely not the way to go. And you have to reconsider your technique. And otherwise, if this plastic area is nicely demarcated, for sure take that piece apart and put it also specifically in a jar. And again, I think patient related factors, we don't know so much. All right, I'm going to give it to you. So how about adenomas, 10 to 19 millimeters? Is there a role for cold snare versus regular EMR or hot? So this is a nice diagram, her photos here. There is some data to support that cold snare EMR is effective and safe in adenomas of this size. Two studies here, maybe too small for you guys to read, but on the left, I think they had about a 400 polyps or so. And you'll see that recurrence rate was very low. This is a study by Mangira. On the right, this was mostly focused on polyps, 80 polyps, adenomas up to 14 millimeters. And really they found that there was no complication at all in any of those polyps, bleeding, perforation, et cetera. So this is very quick, but I think there is still a role for hot snare, even though there is evidence for efficaciousness and safety. Depends on the bulkiness of the lesion, right? If you're going to be technically successful. In that prior study, about 30% could not be completed with cold snare. Again, as Evelyn nicely said, is there suspicion of invasive growth? And there may be patient factors. We need more data on that. So let's move on to round three. You've covered SSLs very nicely. We will now tackle adenomas 20 millimeters or above, and you'll see what position I am in already. All right. So is there evidence for efficacy? And we probably assume safety, right? With cold snare EMR of adenomas of this size. You can see here, the nice EMR piece mill on the top right, coming more over on the lesion in the bottom left. I think you do see more bleeding probably than you would with hot breaks to conventional. Yeah. So there would be another worry for me because it might be more difficult to inspect the area for potential remnants of polyp tissue. I think that's one disadvantage of cold snare for these large lesions. I think another disadvantage is if there is any fibrosis, which you might predict in this polyp, right? It becomes very difficult, particularly there in that center to know if it's a complete resection. So there is some data. This is looking at safety and efficacy for cold snare alone, not comparing to hot snare of 20 millimeters versus smaller 10 to 19 millimeters. In the dark blue is the smaller polyp, in the light blue is the 20 millimeters or above. And you'll see here, safety-wise in terms of intra-procedure delayed bleeding perforation, pretty much the same. So it is safe. However, in terms of recurrence of adenoma, higher, 23% versus 11%. When we focus more on the risk of recurrent adenoma across these three different studies, you'll see it range from nine to 40%. Only Mangira's study looked at predictive factors or morphology, surface features, granularity. They only had nine recurrences, so we really can't make too many conclusions. In Suresh's study there on the right, they looked at the different types of polyps and the risk of recurrence within that type of polyp of this size. And you'll see here, very high for high-grade dysplasia and polyps 30 millimeters or above. Again, some of these factors you can't predict ahead of time, tubulobilis, systology, or high-grade dysplasia. Now again, this is not a head-to-head trial with conventional EMR, but if we look at external data from our historical reference, the range is about 15 to 30% with standard EMR. So it's probably comparable. It may be no worse, so something to consider. So in summary, for adenomas greater than a centimeter, I think for 10 to 15, yeah, I think there's a role. There's not a lot of randomized trial data, but I think it makes sense. A 15 and above, yes, especially if laterally spreading, not bulky or pedunculated, and no suspicion of invasive growth. For those 20 millimeters and above, maybe. I think the door is open. I think we need more direct comparison within a set cohort, but perhaps a higher risk of incomplete resection. There will be more data to support this going forward. I list three studies here of ongoing trials in this large polyp size. So Evelyn, take it home. So this really summarizes our debate, I would say. I think due to time, we shouldn't go through it again, but I think we had a very nice debate, and I really liked it, and I think it's for you to declare the winner. So I concede you are the winner. I think there's a narrow window. I think more and more the window for a hot conventional EMR is closing. So you are the winner. You have knocked me out. Thank you so much, but I think also through this, preparing this meeting together, this is clear. We are friends now as well.

cold snare polypectomy

polyp removal

colonoscopy

complications

sessile serrated lesions