Patient-level predictors of safety and recurrence after cold versus hot snare resection of large, non-pedunculated colorectal polyps: an individual patient data meta-analysis of four randomised-controlled trials
In brief
Cold snare reduces serious complications to 1.7% but doubles recurrence
In a pooled analysis of four RCTs involving 1,423 patients with large (at least 20 mm) non-pedunculated polyps, cold snare resection lowered major adverse events to 1.7% versus 5.9% with hot EMR, yet residual or recurrent adenoma rose to 26.5% compared with 12.8%. The trade-off may favor cold snare for sessile serrated lesions or high-risk patients, but higher recurrence-especially in high-grade dysplasia-remains a concern.
- Journal
- Gut (Q1)
- Published
- 15 September 2026
- Study design
- Systematic review / meta-analysis of RCTs
- Evidence level
- Level 1, High (CEBM 1a)
- Authors
- Ingo Steinbrück, Timothy O'Sullivan, Oscar Nogales, Douglas K Rex, Viktor Rempel, Cyrus R Piraka, et al.
- PMID
- 42744598
- DOI
- 10.1136/gutjnl-2026-339233
Why clinicians should know about it
- Picked for Histology (top studies of the week, 20 September 2026): Cold vs hot snare resection, clinical endoscopy
- Picked for Gastrointestinal and Colorectal Surgery (top studies of the week, 20 September 2026): Cold vs hot snare polyp resection, endoscopic technique
- Picked for Gastroenterology (top studies of the week, 20 September 2026).
Abstract
BACKGROUND: Cold resection is standard for small colorectal polyps and sessile serrated lesions (SSLs). For large (≥20 mm) non-pedunculated adenomas, it appears safer than hot snare endoscopic mucosal resection (EMR) but is associated with higher rates of residual/recurrent adenoma (RRA). OBJECTIVE: To pool individual patient data from all available randomised controlled trials (RCTs) and determine whether RRA differs across polyp subgroups. DESIGN: International, multicentre post hoc individual patient data meta-analysis of four RCTs. Primary outcomes were rates of major adverse events (AE) (AE=deep mural injury III-V/perforation and/or delayed bleeding) and RRA. Subgroup analyses assessed outcomes by location, size, morphology and histology. RESULTS: 1509 polyps in 1423 patients (mean age 66.1 years; mean size 31.3 mm) from 50 centres were included. Major AE occurred in 1.7% of cold versus 5.9% of hot snare resections (OR 0.26; p<0.001). Cold snare was the only factor to reduce major AE in multivariate analysis (OR 0.21; 95% CI 0.07 to 0.60; p=0.004). RRA was higher after cold resection (26.5% vs 12.8%; OR 2.61; p<0.001), with a significant interaction by lesion diameter (p=0.035). By histology, differences were the smallest in SSLs (15.0% vs 8.1%; OR 2.13; p=0.053) and greatest in adenomas with high-grade dysplasia (40.8% vs 18.0%; OR 2.88; p=0.002). CONCLUSIONS: Cold resection is safer than hot EMR but results in more than double the RRA in all adenoma subgroups, especially those with high-grade dysplasia. It may be appropriate for SSLs between 2 cm and 4 cm and selected cases under anticoagulant/antiplatelet therapy or multimorbid patients, for which further studies are needed.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.