05657107

June 28, 2026, 14:08

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I would like to commend the authors for conducting this well-designed multicenter randomized controlled trial addressing an important clinical question in endoscopic management of flat colorectal polyps. The modified cold snare polypectomy (CSP) technique, which employs suction-assisted elevation to create a pseudopolyp, represents an innovative technical refinement that directly targets the common problem of snare slippage during resection of Paris classification 0-IIa lesions. This study is clinically relevant as flat polyps are frequently encountered in routine colonoscopy practice, and incomplete en bloc resection remains a significant concern given its established association with post-colonoscopy colorectal cancer. The concept of suction-induced pseudopolyp formation is biomechanically elegant; by generating a three-dimensional morphology with a well-defined stalk, the modified technique enhances mechanical interlock between the snare wire and tissue, thereby reducing lateral slippage during closure. Furthermore, the favorable safety profile observed in both groups—specifically the absence of delayed bleeding or perforation—is reassuring and consistent with existing CSP literature, supporting the outpatient applicability of this approach. The authors are also to be applauded for their transparency in acknowledging several methodological limitations, including the lack of histologic margin confirmation and the absence of surveillance colonoscopy to assess long-term recurrence, which reflects scientific integrity. Areas for improvement and considerations: Clustering by patient: The authors acknowledge that multiple polyps from individual patients were analyzed at the polyp level without accounting for within-patient correlation. While they cite limited sample size as justification, this remains a methodological concern. The use of generalized estimating equations or mixed-effects models, even with modest clustering, would have strengthened the statistical robustness of the findings. Lack of clinical trial registration: The statement that the study was not registered because it was "not standard departmental practice for internally initiated, therapeutic studies of this scale and nature" is concerning. Given that this is a randomized controlled trial conducted from January 2023 to June 2025—well after the establishment of mandatory trial registration norms—prospective registration should have been undertaken. This omission may affect the credibility and reproducibility of the findings. Endoscopic vs. histologic complete resection: The study reports a 100% endoscopic complete resection rate in both groups, yet acknowledges that histologic confirmation of margins was not available due to tissue fragmentation inherent to CSP. This creates a potential detection bias, as endoscopic assessment alone may overestimate true complete resection. The discrepancy with Shinozaki et al.'s meta-analysis (6.0% incomplete resection rate with CSP) warrants further investigation, and the authors' explanation, while plausible, does not fully resolve this concern. Long-term outcomes: The absence of surveillance colonoscopy data limits the clinical impact assessment. A higher en bloc resection rate is meaningful only if it translates into reduced recurrence and post-colonoscopy colorectal cancer. I would encourage the authors to report follow-up data in a subsequent study. Subgroup analysis: Given that all non-en bloc resections occurred in 7-9mm polyps, a more detailed subgroup analysis by polyp size (5-6mm vs. 7-9mm) would be informative. This could help identify the optimal size threshold for applying the modified technique. For future investigations, the authors are encouraged to incorporate histologic margin assessment where feasible, or alternatively utilize advanced imaging modalities such as confocal laser endomicroscopy or optical coherence tomography to validate complete resection. Additionally, a prospective cohort study with scheduled surveillance colonoscopy at 6-12 months would be valuable to evaluate recurrence rates, and a comparative study between the modified CSP and other emerging techniques—such as underwater EMR or cold endoscopic mucosal resection—for flat polyps in the 5-9mm range would further clarify the relative advantages of this approach. This study makes a meaningful contribution to the endoscopic management of flat colorectal polyps. The modified CSP technique is technically sound and the results are promising. However, the methodological limitations—particularly the lack of trial registration, the polyp-level analysis without patient-level clustering adjustment, and the absence of long-term follow-up—moderate the strength of the conclusions. I encourage the authors to address these issues in future work to fully establish the clinical value of this innovative technique.