Cold snare endoscopic resection for large colon polyps – a randomized trial
Notice bibliographique
Résumé
Aims Despite improvements in technique, severe adverse events (SAE), including post-procedure bleeding, remain a major concern following endoscopic resection of large colorectal polyps. We examined whether cold resection without the use of electrocautery reduces the risk of SAE and affords completeness of resection. Methods We performed a multicenter, randomized trial of patients with a large nonpedunculated colon polyp (≥20 mm) at 10 medical centers in North America from October 2019 through January 2023. Patients were randomly assigned to endoscopic mucosal resection (EMR) without electrocautery (cold EMR group) or with electrocautery (hot EMR group) and were followed until their first surveillance colonoscopy. Hot EMR included margin treatment and defect closure as indicated. The primary outcome were SAEs in intention to treat analysis, defined as an event that required hospitalization, a blood transfusion, colonoscopy, surgery, or another invasive intervention within 30 days after completion of the colonoscopy. The secondary outcome was the rate of polyp recurrence at surveillance colonoscopy. Because crossover from cold to hot EMR was expected (assumed 10%), we also performed a per protocol analysis. Additional subgroup analysis considered polyp characteristics and use of periprocedural antithrombotic medications. Results 660 patients were randomized, and 518 (78.5%) completed their first surveillance colonoscopy. Crossover occurred in 14.6% in the cold EMR group and in 13.4% in the hot EMR group. An SAE was observed in 2.1% of patients in the cold EMR group and in 4.3% in the hot EMR group (p=0.62) with postprocedure bleeding in 0.9% and 2.8%, respectively (p=0.52). When the analysis was restricted to patients who received the intervention as randomized (per protocol analysis), significantly fewer SAEs occurred in the cold EMR group as compared to the hot EMR group (1.4% vs 4.9%, p=0.017), with postprocedure bleeding in 1.1% and 2.5%, respectively (p=0.34). Polyp recurrence was detected in 28.0% in the cold EMR group and 14.2% in the hot EMR group (p<0.001). In the per protocol analysis recurrence rates were 28.7% and 15.4% (p<0.001), respectively. In subgroup analysis SAE risk differences between groups remained unchanged. However, risk of recurrence was similar for the subgroup of 20-29 mm polyps (18.5% vs 15.7%) and for sessile serrated polyps (15.0% vs 14.5%). The greatest recurrence risk was noted for adenomas with high grade dysplasia (46.5% vs 18.4%, respectively, p=0.004). Conclusions This large multicenter trial showed no significant safety benefit of universal cold EMR for large colorectal polyps. However, after accounting for a high crossover rate, cold EMR had a significantly lower SAE rate compared to hot EMR. This safety benefit of cold EMR is offset by a greater recurrence rate, particularly for advanced pathology. Our findings do not support the universal application of cold EMR for large non-pedunculated colorectal polyps. Publication History Article published online: 15 April 2024 © 2024. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,002 | 0,003 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,000 |
| Méta-épidémiologie (sens large) | 0,003 | 0,003 |
| Bibliométrie | 0,000 | 0,000 |
| Études des sciences et des technologies | 0,000 | 0,001 |
| Communication savante | 0,001 | 0,001 |
| Science ouverte | 0,001 | 0,000 |
| Intégrité de la recherche | 0,002 | 0,002 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,005 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».