Large colorectal polyps: cold snare is safer, but recurrence doubled — choose by histology

Design

Post hoc individual patient data meta-analysis of four RCTs

Population

1,509 non-pedunculated polyps 20 mm or more in 1,423 patients, 50 centres

Primary outcome

Major adverse events; residual or recurrent adenoma

Effect

Major AE 1.7% vs 5.9% (OR 0.26); recurrence 26.5% vs 12.8% (OR 2.61)

A post hoc individual patient data meta-analysis in Gut (September 2026) pooled all four randomised trials comparing cold snare resection with hot snare endoscopic mucosal resection (EMR) for non-pedunculated colorectal polyps of 20 mm or more: 1,509 polyps in 1,423 patients (mean size 31 mm) at 50 centres.

Major adverse events — deep mural injury, perforation or delayed bleeding — occurred in 1.7% after cold and 5.9% after hot resection (OR 0.26); cold snare was the only factor that independently reduced them (OR 0.21, 95% CI 0.07 to 0.60). But residual or recurrent adenoma was 26.5% after cold against 12.8% after hot (OR 2.61), and the gap widened with polyp size. The difference was smallest for sessile serrated lesions (15.0% vs 8.1%, OR 2.13, P = 0.053) and largest for adenomas with high-grade dysplasia (40.8% vs 18.0%, OR 2.88).

This is a post hoc subgroup analysis, and histology is often not known with certainty before resection; optical diagnosis will carry the decision. Recurrence can usually be treated at surveillance, but it adds procedures.

The change: rather than one technique for all large polyps, use cold snare for sessile serrated lesions and for patients in whom bleeding or perforation risk is high, and hot EMR for large conventional adenomas, especially those suspected of high-grade dysplasia.

• Consider cold snare resection for large sessile serrated lesions of 2-4 cm
• Prefer hot EMR for large conventional adenomas, particularly with features of high-grade dysplasia
• Consider cold snare for patients on antithrombotics or with major comorbidity, accepting more recurrence
• Plan early surveillance after cold resection of any large adenoma
• Use optical diagnosis to predict histology before choosing the technique

Why it matters

It replaces the choice between safety and completeness with a histology-guided rule.

Don't overread it

The subgroup comparisons are post hoc, and the sessile serrated lesion difference did not reach significance.

The statistics, in plain English

An odds ratio of 0.26 for major adverse events means about a quarter of the odds with cold snare. An odds ratio of 2.61 for recurrence means more than double the odds of residual adenoma. The SSL result (P = 0.053) sits just outside conventional significance, so the gap there is smaller and less certain.

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