Cold forceps polypectomy (CFP) is as effective as cold snare polypectomy (CSP) for nonpedunculated polyps measuring 3 mm or less, suggests the single-center, non-inferiority, randomized TINYPOLYP trial published in the American Journal of Gastroenterology. ¹

This trial involved 179 adults who underwent colonoscopy by experienced endoscopists for any indication. There were 279 nonpedunculated polyps ≤ 3 mm; 138 were removed by CSP and 141 by CFP. 

The size of the polyps and their distribution were comparable in the two groups: size 2.5 mm in the CSP and 2.6 mm in the CFP group; 33.3% of polyps in the CSP group and 26.2% polyps in the CFP group were in the ascending colon; 26.8% polyps in the CSP group and 24.8% in the CFP group were in the transverse colon. Two histology specimens were taken from the polypectomy margin after the procedure. Complete resection rate was the primary non-inferiority outcome.

CSP took longer to perform (42.3 seconds) as compared to CFP (23.2 seconds). The polyps were removed in multiple bites during CFP more frequently (15.6%) than with CSP (3.6%). However, the complete resection rate in both groups was 98.3% and only two biopsy specimens (1.7%) in each group had positive margins. One polyp required the use of a hemostatic clip during CFP, versus none during CSP (difference not significant). At 30 days, no patient died in either group, nor was there any complication such as post-polypectomy perforation or bleeding.

The US Multi-Society Task Force on Colorectal Cancer comprising the American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy recommends CSP for removal of “diminutive (≤5 mm) and small (6-9 mm) polyps”. It does not recommend CFP for polyps that are ≤5 mm in size due to high associated incomplete resection rates, and for lesions ≤2 mm it recommends jumbo or large-capacity forceps polypectomy if CSP is technically difficult to perform. Ensuring complete resection is crucial, it says, as “one-fifth of incident colorectal cancers are related to incomplete resection”.²

However, the TINYPOLYP Trial has demonstrated the non-inferiority of CFP vis-à-vis CSP. Not only was CFP as effective as CSP in terms of complete resection rate, it was faster. Based on their observations, the authors suggest CFP as an acceptable alternative to CSP for excising diminutive or tiny polyps that are less than 3 mm in size.

References

1. Wei MT, et al. Randomized controlled Trial Investigating cold snare aNd forceps polypectomY among small POLYPs in rates of complete resection: the TINYPOLYP Trial. Am J Gastroenterol. 2022 Apr 25. doi: 10.14309/ajg.0000000000001799.
2. Kaltenbach T, et al. Endoscopic Removal of Colorectal Lesions – Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc. 2020 Mar;91(3):486-519. doi: 10.1016/j.gie.2020.01.029.