Cold Endoscopic Resection of Large Colorectal Polyps: A Randomized Trial
Trial Snapshot
- Phase
- Not Applicable
- Status
- Active, not recruiting
- Enrollment
- 990
- Locations
- 2
- Primary Endpoint
- Severe Adverse Events
Study Overview
Brief Summary
This study compares different approaches to endoscopic mucosal resection (EMR) of large non-pedunculated colorectal polyps (≥20mm) in a 2 x 2 randomized design. The first randomization will assign half of patients to polyp resection with electrocautery ("hot" snare EMR) and half of patient to polyp resection without electrocautery ("cold" snare EMR). The second randomization will assign half of patients to polyp removal using Eleview as the submucosal injection agent, and the other half using placebo (normal saline with methylene blue) as the submucosal injection agent.
Detailed Description
Electrocautery, or hot snare resection has long been considered the standard approach to polyp resection. A major limitation is a 5 to 10% risk of major adverse events. Recent studies suggest that snare resection without electrocautery - so-called cold snare EMR - may be safer than hot snare EMR. The concern with cold snare resection is a potentially lower efficacy, because cold snare resection requires the removal of a large polyp in smaller and greater number of pieces than with hot snare resection. This may lengthen procedure time and increase the risk of incomplete resection.
Furthermore, there is uncertainty about the optimal injection solution for lifting of the polyp prior to resection. Normal saline with methylene blue as the contrast agent is frequently used, but is limited by fast dissipation of the polyp lift. Eleview is a newly approved viscous solution (that contains methylene blue), which provides a longer polyp lift than normal saline. It is unclear how these two solutions compare with respect to resection efficacy and safety.
Study Design
- Study Type
- Interventional
- Allocation
- Randomized
- Intervention Model
- Factorial
- Primary Purpose
- Treatment
- Masking
- Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Masking Description
Randomization 1 (Cold vs. hot snare group): Masking only of participants Randomization 2 (Eleview vs Placebo): Masking of all checked above
Eligibility Criteria
- Ages
- 18 Years to — (Adult, Older Adult)
- Sex
- All
- Accepts Healthy Volunteers
- No
Inclusion Criteria
- •Any patient ≥18 who presents for a colonoscopy and who does not have criteria for exclusion
- •Patients with a ≥20mm non-pedunculated colorectal polyp
Exclusion Criteria
- •Pedunculated polyps (as defined by Paris Classification type Ip)
- •Suspected adenocarcinoma with deep submucosal invasion
- •Patients with ulcerated depressed lesions (as defined by Paris Classification type III) or confirmed adenocarcinoma
- •Patients with inflammatory bowel disease
- •Patients who are receiving an emergency colonoscopy
- •Poor general health (ASA class>3)
- •Patients with coagulopathy with an elevated INR ≥1.5, or platelets <50
- •Inadequate bowel preparation (Boston Bowel Prep Scale, total score ≤2)
- •Pregnancy
Outcomes
Primary Outcomes
Severe Adverse Events
Time Frame: up to 30 days following the procedure
Aggregate of all severe adverse events that occur at the time of the colonoscopy with resection of the large polyp or following the procedure
Secondary Outcomes
- Completeness of polyp resection(immediately following polyp resection during the colonoscopy)
- Intraprocedural bleeding(at the time of polyp resection)
- Subcategories of severe adverse events(during the procedure and up to 30 days following the procedure)
- Performance submucosal injectate(immediately following polyp resection during the colonoscopy)
- Polyp recurrence(at surveillance colonoscopies up to 5 years following the initial polyp resection)
- Efficacy of submucosal injectate(immediately following polyp resection during the colonoscopy)
- Volume of submucosal injectate(immediately following polyp resection during the colonoscopy)
- Crossover from cold to hot snare(at the time of polyp resection)
Investigators
Dr. Heiko Pohl
Associate Professor or Medicine
White River Junction Veterans Affairs Medical Center