Cold snare for large colorectal polyps: safer, but more recurrence

Design

Individual-patient-data meta-analysis of four randomised trials

Population

1,509 large non-pedunculated colorectal polyps in 1,423 patients

Primary outcome

Major adverse events and residual or recurrent adenoma

Effect

Adverse events 1.7% vs 5.9% (OR 0.26); recurrence 26.5% vs 12.8% (OR 2.61)

Cold snare resection has displaced hot endoscopic mucosal resection for small polyps, and the question is whether it should extend to large (20 mm or more) non-pedunculated lesions. This individual-patient meta-analysis pooled four randomised trials, 1,509 polyps in 1,423 patients.

The trade-off is now quantified. Major adverse events, chiefly deep mural injury and delayed bleeding, were far lower with cold snare (1.7% vs 5.9%, odds ratio 0.26), and cold resection was the only independent factor reducing them. But residual or recurrent adenoma was more than doubled (26.5% vs 12.8%, odds ratio 2.61), with the gap widest in adenomas with high-grade dysplasia (40.8% vs 18.0%).

The practical reading is to match the technique to the lesion and patient. Cold snare is attractive for sessile serrated lesions and for patients on anticoagulants or with high bleeding risk, where safety dominates; hot EMR remains preferable where complete clearance matters most, such as adenomas with high-grade dysplasia.

• Individual-patient meta-analysis of four trials, 1,509 large non-pedunculated colorectal polyps.
• Major adverse events were lower with cold snare (1.7% vs 5.9%, odds ratio 0.26).
• Residual or recurrent adenoma was more than doubled with cold snare (26.5% vs 12.8%).
• The recurrence gap was widest in adenomas with high-grade dysplasia (40.8% vs 18.0%).
• Favour cold snare for bleeding-risk patients and serrated lesions; hot EMR where clearance matters most.

Why it matters

It turns the cold-versus-hot choice for large polyps into a lesion- and patient-specific decision rather than a blanket preference.

Don't overread it

This is a post-hoc individual-patient analysis; the doubled recurrence means cold snare is not a universal replacement for hot EMR in large adenomas.

The statistics, in plain English

An odds ratio of 0.26 for adverse events is a large safety gain, while an odds ratio of 2.61 for recurrence is a large offsetting cost. Which matters more depends on the lesion's malignant potential and the patient's bleeding risk.

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