- Design
- Post hoc individual patient data meta-analysis of four randomised trials
- Population
- 1,509 large (20 mm or more) non-pedunculated colorectal polyps in 1,423 patients
- Primary outcome
- Major adverse events and residual or recurrent adenoma
- Effect
- Major adverse events 1.7% vs 5.9% (OR 0.26); residual/recurrent adenoma 26.5% vs 12.8% (OR 2.61)
This post hoc individual patient data meta-analysis pooled four randomised trials comparing cold snare resection with hot snare endoscopic mucosal resection (EMR) for large (20 mm or more) non-pedunculated colorectal polyps. It included 1,509 polyps in 1,423 patients from 50 centres (mean age 66.1 years; mean polyp size 31.3 mm).
Major adverse events (deep mural injury or perforation, or delayed bleeding) occurred in 1.7% after cold snare and 5.9% after hot snare (odds ratio 0.26; P < 0.001), and cold snare was the only factor reducing them in multivariable analysis. Residual or recurrent adenoma was more common after cold resection (26.5% vs 12.8%; odds ratio 2.61; P < 0.001), with a significant interaction by lesion diameter. The gap was smallest in sessile serrated lesions (15.0% vs 8.1%; P = 0.053) and greatest in adenomas with high-grade dysplasia (40.8% vs 18.0%).
The analysis was post hoc, and recurrence needs treatment and follow-up. The authors suggest cold resection may suit sessile serrated lesions between 2 and 4 cm and selected patients on antithrombotic therapy or with multimorbidity, but say further studies are needed. For most large adenomas, hot EMR remains the technique with lower recurrence.
- For large adenomas, expect fewer complications but more residual adenoma with cold snare.
- Consider cold snare for sessile serrated lesions of 2 to 4 cm, or for patients on antithrombotics or with multimorbidity, where evidence is still limited.
- Plan early surveillance colonoscopy after piecemeal or cold resection.
- Record polyp histology and size, since recurrence risk differed by both.
Why it matters
The safer technique is not the more complete one, and the trade-off depends on the lesion and the patient.
Don't overread it
This is a post hoc pooled analysis; the suggestion that cold snare suits some subgroups needs further study.
The statistics, in plain English
An odds ratio of 0.26 for complications means cold snare had about a quarter of the odds of a major adverse event. The odds ratio of 2.61 for residual adenoma means the odds of finding remaining adenoma were more than double.
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