Letters To The Editor Open Access
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 14, 2018; 24(14): 1579-1582
Published online Apr 14, 2018. doi: 10.3748/wjg.v24.i14.1579
Should hot biopsy forceps be abandoned for polypectomy of diminutive colorectal polyps?
Vasileios Panteris, Department of Gastroenterology, Sismanogleio-A.Fleming General Hospital, Attiki, Athens 15126, Greece
Antonios Vezakis, Department of Surgery, Aretaieio Hospital, Attiki, Athens 11528, Greece
JK Triantafillidis, Department of Gastroenterology, Iaso General Hospital, Attiki, Athens 15562, Greece
ORCID number: Vasileios Panteris (0000-0003-1165-8927); Antonios Vezakis (0000-0003-0958-7664); JK Triantafillidis (0000-0002-9115-232X).
Author contributions: All authors were involved in the article conception and design; Panteris V drafted the article; Vezakis A and Triantafillidis JK provided final approval of the article.
Conflict-of-interest statement: The authors declare that there are no conflicts of interest related to this study.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Vasileios Panteris, MD, FEBG, Consultant, Doctor, Staff Physician, Department of Gastroenterology, Sismanogleio-A.Fleming General Hospital, Sismanogliou 37, Attiki, Athens 15126, Greece. vasileios.panteris@gmail.com
Telephone: +30-6937383262
Received: March 8, 2018
Peer-review started: March 9, 2018
First decision: March 14, 2018
Revised: March 19, 2018
Accepted: March 25, 2018
Article in press: March 25, 2018
Published online: April 14, 2018


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.

Key Words: 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.


In a recent article[1], European Society of Gastrointestinal Endoscopy has released guidelines for colorectal polypectomy, which include a strong recommendation against the use of hot biopsy forceps (HBF) based on the GRADE system of clinical evidence. The release of guidelines by professional medical societies is acknowledged by the medical community as policy that functions as a deterrent to specific practices. With respect to that notion, the abandonment of a useful technique such HBF, which for many decades, has contributed to the polypectomy of diminutive colorectal polyps (DCPs), should be considered in an appropriate conscientious and judicious manner.

The reasons for the negative criticism are based on the following: (1) unacceptably high risks of adverse events (AEs); (2) inadequate tissue sampling for histopathology (ITSH); and (3) high incomplete resection rates (IRR). The studies cited in support of the recommendation are 4 human studies (1 RCT non-blinded with a small number of patients[2], one anecdotal report[3] and 2 observational studies[4,5]), 3 of which have already been determined to be of low quality, and 2 animal studies[6,7] (Table 1). The overall quality of evidence was graded as high. Actually, apart from the methodological quality of the individual studies and the questionable generalizability, these studies are heterogeneous in terms of ITSH and IRR. Moreover, all studies are consistent with respect to the absence of perforations, and the few bleeding episodes (0.36%) in one of the studies occured in patients taking antiplatelets[5].

Table 1 List of articles presented in support of European Society of Gastrointestinal Endoscopy guidelines.
Ref.Study designNo of polyps and patientsLevel of evidence
Paspatis et al[2], 2005Randomised trial38 vs 37 rectal DCPs among 50 patientsHigh quality
Bipolar electro-coagulation vs HBF
Peluso et al[3], 1991Anecdotal report62 DCPs among 39 patientsLow quality
Yasar et al[4], 2015Observational study237 DCPs among 179 patientsLow quality
Weston et al[5], 1995Observational study1964 DCPs among 687 patientsLow quality
Savides et al[6], 1995Animal study231 biopsies in 16 right colotomies of 8 mongrel dogsNot rated in Grade system
Canine model
Metz et al[7], 2013Animal study82 artificial polyps, sized 5-8 mmNot rated in Grade system
Porcine model

HBF is considered an alternative method for the removal of DCPs (≤ 5 mm). According to different surveys, it seems that HBF is still a viable option that is preferred by 30%-50% of endoscopists[8-10]. The two studies, with the largest number of patients and polyps[11,12] showed no complications. The study by Wadas et al[13], which reports a 0.38% major bleeding rate and a 0.05% perforation rate, refers to a questionnaire-type survey from an era (1988) when the HBF technique was not standardized. Even this perforation rate is lower than the reported 0.15% for therapeutic colonoscopies[14]. The rate of AEs is also lower compared with that for snare polypectomies (3.3 vs 4.5/1000), and AEs are more likely to occur when low- volume endoscopists use HBF than when high-volume endoscopists (> 300 polypectomies/year) use the technique[15].

HBF has been reported to have a 17% IRR when white coagulum is present[16] and a variable rate of ITSH that ranges from 0.19%-13%-26.7% in studies with different mean polyp sizes[11,17,18]. It is acknowledged that a significant predictor of histological misinterpretation is decreasing polyp size with a cut off limit of 2 mm. It is important to mention that even in studies with high reported rates of cautery artifacts[4], the results showed that histological diagnosis could indeed have been reached in all specimens.

The new rival of HBF, namely, the cold snare polypectomy (CSP), has thus far presented disparate results for IRR at 3.4%-40%, retrieval failure at 1%-13%, and bleeding rates of 1.2%-20% for DCPs[19-24]. In the sole non-blinded RCT, in which HBF and CSP are directly compared, the IRR in the ITT analysis was 29.9% for CSP, which is still unacceptably high. However, the bleeding rates were statistically insignificant at 8.1% vs 8.8% for HBF and CSP, respectively, and no perforations were observed in either study arm[25].

In conclusion, it seems that available evidence is not adequate to exclude hot biopsy forceps from the routine endoscopy practice. We either need more prospective studies exhibiting beneficial comparisons with new techniques or we need to focus on proper utilization of HBF by more experienced endoscopists.


Manuscript source: Unsolicited manuscript

Specialty type: Gastroenterology and hepatology

Country of origin: Greece

Peer-review report classification

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P- Reviewer: Bujanda L, Facciorusso A, Velayos B S- Editor: Gong ZM L- Editor: A E- Editor: Huang Y

1.  Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau JM, Paspatis G, Jover R, Langner C, Bronzwaer M, Nalankilli K. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2017;49:270-297.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 559]  [Cited by in F6Publishing: 593]  [Article Influence: 98.8]  [Reference Citation Analysis (0)]
2.  Paspatis GA, Vardas E, Charoniti I, Papanikolaou N, Barbatzas C, Zois E. Bipolar electrocoagulation vs conventional monopolar hot biopsy forceps in the endoscopic treatment of diminutive rectal adenomas. Colorectal Dis. 2005;7:138-142.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 10]  [Cited by in F6Publishing: 10]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
3.  Peluso F, Goldner F. Follow-up of hot biopsy forceps treatment of diminutive colonic polyps. Gastrointest Endosc. 1991;37:604-606.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Yasar B, Kayadibi H, Abut E, Benek D, Kochan K, Gonen C. The histological quality and adequacy of diminutive colorectal polyps resected using jumbo versus hot biopsy forceps. Dig Dis Sci. 2015;60:217-225.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 11]  [Cited by in F6Publishing: 9]  [Article Influence: 1.1]  [Reference Citation Analysis (0)]
5.  Weston AP, Campbell DR. Diminutive colonic polyps: histopathology, spatial distribution, concomitant significant lesions, and treatment complications. Am J Gastroenterol. 1995;90:24-28.  [PubMed]  [DOI]  [Cited in This Article: ]
6.  Savides TJ, See JA, Jensen DM, Jutabha R, Machicado GA, Hirabayashi K. Randomized controlled study of injury in the canine right colon from simultaneous biopsy and coagulation with different hot biopsy forceps. Gastrointest Endosc. 1995;42:573-578.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 24]  [Cited by in F6Publishing: 25]  [Article Influence: 0.9]  [Reference Citation Analysis (0)]
7.  Metz AJ, Moss A, McLeod D, Tran K, Godfrey C, Chandra A, Bourke MJ. A blinded comparison of the safety and efficacy of hot biopsy forceps electrocauterization and conventional snare polypectomy for diminutive colonic polypectomy in a porcine model. Gastrointest Endosc. 2013;77:484-490.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 42]  [Cited by in F6Publishing: 48]  [Article Influence: 4.8]  [Reference Citation Analysis (0)]
8.  Din S, Ball AJ, Taylor E, Rutter M, Riley SA, Johal S. Polypectomy practices of sub-centimeter polyps in the English Bowel Cancer Screening Programme. Surg Endosc. 2015;29:3224-3230.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 13]  [Cited by in F6Publishing: 15]  [Article Influence: 1.9]  [Reference Citation Analysis (0)]
9.  Singh N, Harrison M, Rex DK. A survey of colonoscopic polypectomy practices among clinical gastroenterologists. Gastrointest Endosc. 2004;60:414-418.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 124]  [Cited by in F6Publishing: 136]  [Article Influence: 7.2]  [Reference Citation Analysis (0)]
10.  Carter D, Beer-Gabel M, Zbar A, Avidan B, Bardan E. A survey of colonoscopic polypectomy practice amongst Israeli gastroenterologists. Ann Gastroenterol. 2013;26:135-140.  [PubMed]  [DOI]  [Cited in This Article: ]
11.  Waye JD, Lewis BS, Frankel A, Geller SA. Small colon polyps. Am J Gastroenterol. 1988;83:120-122.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Mann NS, Mann SK, Alam I. The safety of hot biopsy forceps in the removal of small colonic polyps. Digestion. 1999;60:74-76.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 26]  [Cited by in F6Publishing: 24]  [Article Influence: 1.0]  [Reference Citation Analysis (0)]
13.  Wadas DD, Sanowski RA. Complications of the hot biopsy forceps technique. Gastrointest Endosc. 1988;34:32-37.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 91]  [Cited by in F6Publishing: 86]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
14.  Panteris V, Haringsma J, Kuipers EJ. Colonoscopy perforation rate, mechanisms and outcome: from diagnostic to therapeutic colonoscopy. Endoscopy. 2009;41:941-951.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 179]  [Cited by in F6Publishing: 195]  [Article Influence: 13.9]  [Reference Citation Analysis (0)]
15.  Chukmaitov A, Bradley CJ, Dahman B, Siangphoe U, BouHaidar D, Warren JL. Polypectomy techniques, endoscopist characteristics, and serious gastrointestinal adverse events. J Surg Oncol. 2014;110:207-213.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in F6Publishing: 1]  [Reference Citation Analysis (0)]
16.  Vanagunas A, Jacob P, Vakil N. Adequacy of “hot biopsy” for the treatment of diminutive polyps: a prospective randomized trial. Am J Gastroenterol. 1989;84:383-385.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Goldstein NS, Watts JC, Neill JS, Vogel LM, Barkel D, Kadro O, Priest S, Klein S. The effect of electrothermal cautery-assisted resection of diminutive colonic polyps on histopathologic diagnosis. Am J Clin Pathol. 2001;115:356-361.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 17]  [Article Influence: 0.8]  [Reference Citation Analysis (0)]
18.  Mönkemüller KE, Fry LC, Jones BH, Wells C, Mikolaenko I, Eloubeidi M. Histological quality of polyps resected using the cold versus hot biopsy technique. Endoscopy. 2004;36:432-436.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 37]  [Cited by in F6Publishing: 36]  [Article Influence: 1.9]  [Reference Citation Analysis (0)]
19.  Horiuchi A, Hosoi K, Kajiyama M, Tanaka N, Sano K, Graham DY. Prospective, randomized comparison of 2 methods of cold snare polypectomy for small colorectal polyps. Gastrointest Endosc. 2015;82:686-692.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 87]  [Cited by in F6Publishing: 90]  [Article Influence: 11.3]  [Reference Citation Analysis (0)]
20.  Komeda Y, Suzuki N, Sarah M, Thomas-Gibson S, Vance M, Fraser C, Patel K, Saunders BP. Factors associated with failed polyp retrieval at screening colonoscopy. Gastrointest Endosc. 2013;77:395-400.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 37]  [Cited by in F6Publishing: 40]  [Article Influence: 4.0]  [Reference Citation Analysis (0)]
21.  Repici A, Hassan C, Vitetta E, Ferrara E, Manes G, Gullotti G, Princiotta A, Dulbecco P, Gaffuri N, Bettoni E. Safety of cold polypectomy for <10mm polyps at colonoscopy: a prospective multicenter study. Endoscopy. 2012;44:27-31.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 150]  [Cited by in F6Publishing: 171]  [Article Influence: 15.5]  [Reference Citation Analysis (0)]
22.  Takeuchi Y, Yamashina T, Matsuura N, Ito T, Fujii M, Nagai K, Matsui F, Akasaka T, Hanaoka N, Higashino K. Feasibility of cold snare polypectomy in Japan: A pilot study. World J Gastrointest Endosc. 2015;7:1250-1256.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 59]  [Cited by in F6Publishing: 59]  [Article Influence: 7.4]  [Reference Citation Analysis (0)]
23.  Lee CK, Shim JJ, Jang JY. Cold snare polypectomy vs. Cold forceps polypectomy using double-biopsy technique for removal of diminutive colorectal polyps: a prospective randomized study. Am J Gastroenterol. 2013;108:1593-1600.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 142]  [Cited by in F6Publishing: 153]  [Article Influence: 15.3]  [Reference Citation Analysis (0)]
24.  Matsuura N, Takeuchi Y, Yamashina T, Ito T, Aoi K, Nagai K, Kanesaka T, Matsui F, Fujii M, Akasaka T. Incomplete resection rate of cold snare polypectomy: a prospective single-arm observational study. Endoscopy. 2017;49:251-257.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 48]  [Cited by in F6Publishing: 51]  [Article Influence: 8.5]  [Reference Citation Analysis (0)]
25.  Komeda Y, Kashida H, Sakurai T, Tribonias G, Okamoto K, Kono M, Yamada M, Adachi T, Mine H, Nagai T. Removal of diminutive colorectal polyps: A prospective randomized clinical trial between cold snare polypectomy and hot forceps biopsy. World J Gastroenterol. 2017;23:328-335.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in CrossRef: 38]  [Cited by in F6Publishing: 35]  [Article Influence: 5.8]  [Reference Citation Analysis (0)]