We read with great interest the randomized trial by Chang et al. comparing cold snare polypectomy, cold endoscopic mucosal resection, and hot endoscopic mucosal resection for intermediate-size sessile serrated lesions, or SSLs. The study is timely and clinically relevant because it addresses a question that guideline recommendations had largely supported on the basis of non-randomized evidence. The finding that cold techniques were non-inferior to hot endoscopic mucosal resection for complete histological resection is encouraging 1. One issue, however, deserves closer attention. The endpoint most likely to influence practice may not be immediate histological completeness, but durable lesion clearance at surveillance. In this trial, complete histological resection was defined by negative horizontal and vertical margins regardless of whether the lesion was removed en bloc or piecemeal 1. That definition is practical, but it weakens the connection between the primary endpoint and long-term eradication. The en bloc resection rate was lower with cold snare polypectomy than with hot endoscopic mucosal resection, at 69.8% vs. 88.9% 1. For SSLs, that difference is clinically relevant because fragmented specimens make margin interpretation less secure. Histopathologic work focused on SSLs has shown that cold snare polypectomy is associated with a higher rate of positive vertical margins than endoscopic mucosal resection 2. Earlier clinical data point in the same direction. In a previous UEG Journal study, cold snare polypectomy for SSLs measuring at least 10 mm was safe and promising, but recurrence remained slightly high and close follow-up was considered necessary 3. The updated ESGE guideline now recommends cold resection techniques for SSLs without suspected dysplasia, which makes the present trial highly relevant 4. Even so, guideline support does not remove the need for convincing surveillance outcomes. We therefore view this trial as an important advance, but not yet the final word. The result most likely to change practice decisively will be confirmation that cold resection achieves acceptably low residual or recurrent lesion rates at follow-up colonoscopy. The authors declare no conflicts of interest. The authors have nothing to report.
Ye et al. (Wed,) studied this question.