Cold snare polypectomy compared to cold forceps polypectomy for endoscopic resection of guideline defined diminutive polyps: A systematic review and meta-analysis of randomized trials

Background International guidelines recommend cold snare polypectomy (CSP) for polyps < 10 mm in size. However, recent randomized clinical trials (RCTs) showed conflicting results for the use of cold forceps polypectomy (CFP) vs. CSP for the resection of diminutive colorectal polyps (DCPs) (<= 5 mm), especially for polyps <= 3 mm. Herein we compared CFP with CSP for patients with DCPs in this meta-analysis of RCTs.Methods We systematically searched the Cochrane Library, PubMed and EMBASE databases from inception to November 24, 2022, (Registration number INPLASY2022110135). The primary endpoint was DCP complete resection rate. The secondary endpoints were mean polypectomy time, polyp retrieval rate and complications.Results Seven RCTs involving 1023 DCPs were included. The complete resection rate (91.6% vs. 94.7%) for CFP was not significantly lower for polyps <= 5 mm (relative risk [RR] = 1.03; 95% confidence interval [CI]: 0.98-1.07). Sub-group analysis showed that the complete resection rate (88.7% vs. 92.4%) for CFP was not significantly lower for DCPs > 3 mm (RR = 1.04; 95% CI: 0.97-1.12). Another sub-group analysis showed that the complete resection rate (97.0% vs. 96.3%) was similar for polyps <= 3 mm for CFP vs. CSP (RR = 1.00; 95% CI: 0.98-1.03). The mean polypectomy time was not different between CFP and CSP (95% CI: -11.86-10.18). The polyp retrieval rate (100% vs. 96.9%) was not significantly higher for CFP (RR = 1.02; 95% CI: 0.98-1.07). There were no reported complications in the included studies. The overall study quality was moderate except for the removal of polyps <= 5 mm (low-quality evidence).Conclusion CFP was comparable to CSP for the resection of polyps <= 3 mm; however, caution should be taken for DCPs > 3 mm because of the low complete resection rate (< 90%).