Cold Snare Defect Protrusions Are Associated With Forced Pull-Throughs and Higher Rate of Residual Polyp

Cold Snare Defect Protrusions Are Associated With Forced Pull-Throughs and Higher Rate of Residual Polyp

Douglas K. Rex, MD, MASGE, reviewing Arimoto J, et al. Endoscopy 2023 Sep 28.

Cold snare polypectomy of colorectal polyps sometimes leaves a cord of white tissue consisting of submucosa and, sometimes, muscularis mucosa. These defects are called “cold snare defect protrusions” (CSDPs). CSDPs are more common when an endoscopist forcibly pulls the snare through the tissue, known as “forced cold snare polypectomy” (FCSP).

In a study from Japan of 1315 polyps ≤10 mm in 548 patients, FCSP was necessary for 105 polyps (8%). A CSDP developed in 96.2% of lesions with FCSP compared with 6.4% of lesions without a forced pull-through. There were no perforations with either technique. The mean size of lesions requiring FCSP was 6.0 mm compared with 4.1 mm without forced pull-through. In a multivariable analysis, FCSP was associated with cecal location and size ≥6 mm. The histologic incomplete polyp resection rate was 12.5% with FCSP versus 6.2% in cases not requiring FCSP (P=.02).

Douglas K. Rex, MD, FASGE


These data indicate that forcibly pulling the snare through the tissue during cold snare polypectomy is safe but is associated with a high rate of CSDPs. In this study, CSDPs were associated with a higher rate of incomplete polyp resection. Experienced endoscopists find that forced transection is associated with larger polyp size and bulk, grasping a larger surface area of mucosa, greater lumen deflation before snare closure, and a thicker snare wire. The data from this study make an argument for the routine use of a dedicated snare, grasping a definite rim of normal tissue around the circumference of the polyp but not an excessive one, and mastering optimal deflation, with the goal of reducing forced pull-throughs.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Arimoto J, Chiba H, Yamada K, et al. Forced cold snare polypectomy is related to cold snare defect protrusions and incomplete polyp resections: a prospective observational study. Endoscopy 2023 Sep 28. (Epub ahead of print) (

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