Trial demonstrates noninferiority of cold snare polyp removal for patients on anticoagulation

Mean procedure time per lesion was significantly shorter with cold snare polypectomy and anticoagulants, whereas the mean hospitalization period was longer in patients receiving hot snare polypectomy and heparin bridging.


Using cold snare polypectomy for subcentimeter colorectal polyps in patients receiving continuous administration of anticoagulants was noninferior to the conventional approach of hot snare polypectomy and heparin bridging, a randomized controlled trial found.

At 30 centers in Japan, researchers enrolled 184 patients who were receiving warfarin or direct oral anticoagulants (DOACs) and had at least one nonpedunculated subcentimeter colorectal polyp. Patients were randomized to receive periprocedural heparin bridging with hot snare polypectomy (HB+HSP) or continuous administration of anticoagulants and cold snare polypectomy (CA+CSP). The primary end point was incidence of polypectomy-related major bleeding, based on the incidence of poorly controlled intraprocedural bleeding or postpolypectomy bleeding requiring endoscopic hemostasis. Secondary end points included mean procedure time and mean days of hospitalization. The prespecified inferiority margin was −5%. Results were published July 16 in Annals of Internal Medicine.

There were 90 patients in the HB+HSP group and 92 in the CA+CSP group (two declined to participate after enrollment). The incidences of polypectomy-related major bleeding in the HB+HSP and CA+CSP groups were 12.0% (95% CI, 5.0% to 19.1%) and 4.7% (95% CI, 0.2% to 9.2%), respectively. The intergroup difference for the primary end point was 7.3% (95% CI, −1.0% to 15.7%), with a 0.4% lower limit of two-sided 90% CI.

Although none of the patients in the CA+CSP group who were receiving warfarin had major bleeding, four patients who were receiving DOACs did. Mean procedure time per lesion was significantly shorter in the CA+CSP group than in the HB+HSP group, and the mean hospitalization period was longer in the latter group.

Although the trial showed that CA+CSP for subcentimeter colorectal polyps is safe in patients receiving anticoagulants, “A larger trial is needed to identify a better management strategy for patients receiving DOACs,” the study authors concluded.

An editorial noted that the study provides the first comparative evidence that CA+CSP may be safer than HB+HSP. “The results warrant confirmatory studies, preferably with blinding to the use of anticoagulation and assessment of several additional factors: incomplete polyp resection, the effect of prophylactic hemostatic actions (such as clipping), and the applicability of CA+CSP to removal of larger polyps and to use of other classes of antithrombotic medications (such as thienopyridines),” the editorialists wrote.