Should hot biopsy forceps be abandoned for polypectomy of diminutive colorectal polyps?

Abstract

Standardized approach to polypectomy of diminutive colorectal polyps (DCPs) is lacking since cold biopsy forceps have been associated with high levels of recurrence, hot biopsy forceps are considered inadequate and risky and cold snaring is currently under investigation for its efficacy and safety. This has led to confusion and a gap in clinical practice. This article discusses the usefulness and contemporary practical applicability of hot biopsy forceps and provides well-intentioned criticism of the new European guidelines for the treatment of DCPs. Diminutive colorectal polyps are a source of frustration for the endoscopist since their small size is accompanied by a considerable risk of premalignant neoplasia and a small but non-negligible risk of advanced neoplasia and even cancer. Since the proportion of diminutive colorectal polyps is substantial and exceeds that of larger polyps, their effective removal poses a considerable workload and a therapeutic challenge. During the last decade, the introduction of cold snaring to routine endoscopy practice has attempted to overcome the use of prior techniques, such as hot biopsy forceps. It is important to recognize that with the exception of endoscopic methods that are obviously unsafe and inadequate to serve their purpose, all other interventional endoscopic methods are operator-dependent in the sense that specific expertise and training are obligatory for the success of any therapeutic intervention. Since relevant publications on hot biopsy forceps are still in favor of its careful use, as it has not yet demonstrated inferiority compared with newer techniques, it would be prudent for any medical practitioner to evaluate the available tools and judge any new proposed technique based on the evidence before it is adopted.

Keywords: Hot forceps, Polypectomy, Endoscopy, Colon neoplasia, Diminutive polyps

Core tip: Selection of the appropriate endoscopic method for the removal of diminutive colorectal polyps (DCPs), according to the prospective prevention of colorectal cancer, is still a debatable topic. The new recommendation released by ESGE (European Society of Gastrointestinal Endoscopy, 2017) concerning the use of hot biopsy forceps (HBF) is expected to create a shift in daily clinical practice since this technique is still popular and viable for the removal of DCPs. In this letter, the authors request reconsideration of this policy in response to published data referring on the efficacy and safety of HBF and recommend a more cautious approach and transition to prevent the premature acceptance of alternative techniques.