Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2025 Oct 8;74(11):1804-1813.
doi: 10.1136/gutjnl-2025-335075.

Cold snare endoscopic resection for large colon polyps: a randomised trial

Heiko Pohl  1   2 , Douglas K Rex  3 , Jeremy Barber  4 , Matthew T Moyer  5 , B Joseph Elmunzer  6 , Amit Rastogi  7 , Stuart R Gordon  8 , Eugene Zolotarevsky  9 , John M Levenick  5 , Harry R Aslanian  10 , Mazen Elatrache  11 , Daniel von Renteln  12 , Michael B Wallace  13 , Bhaumik Brahmbhatt  14 , Rajesh N Keswani  15 , Nikhil A Kumta  16 , Douglas K Pleskow  17 , Zachary L Smith  18 , Mouhanna K Abu Ghanimeh  19 , Stephen Simmer  9 , Omid Sanaei  20 , Todd A Mackenzie  21 , Cyrus Piraka  22
Affiliations
Randomized Controlled Trial

Cold snare endoscopic resection for large colon polyps: a randomised trial

Heiko Pohl et al. Gut. .

Abstract

Background: Complications of endoscopic mucosal resection (EMR) of large colorectal polyps remain a concern.

Objective: We aimed to compare safety and efficacy of cold EMR (without electrocautery) to hot EMR (with electrocautery) of large colorectal polyps.

Design: In this multicentre randomised trial, patients with any large (≥20 mm) non-pedunculated colon polyp were assigned to cold or hot EMR (primary intervention), and to submucosal injection with a viscous or non-viscous solution (secondary intervention) following a 2×2 design. The primary outcome was the rate of severe adverse events (SAEs). The secondary outcome was polyp recurrence. In this study, we report results of the primary intervention.

Results: 660 patients were randomised and analysed. An SAE was observed in 2.1% of patients in the cold EMR group and in 4.3% in the hot EMR group (p=0.10) (per protocol analysis 1.4 vs 5.0%, p=0.017) with fewer perforations following cold EMR (0%) compared with hot EMR (1.6%, p=0.028). Postprocedure bleeding did not differ (1.5% vs 2.2%, p=0.57). The effect of cold resection was independent of the type of submucosal injection solution, polyp size or antithrombotic medications. Recurrence was detected in 27.6% and 13.6% in the cold and hot EMR groups, respectively (p<0.001). Recurrence was not significantly different for 20-29 mm polyps (18.6% vs 13.4%, p=0.24) and for sessile serrated polyps (14.1% vs 8.5%, p=0.33).

Conclusion: Universal application of cold EMR did not significantly lower SAEs (unless cold EMR could be completed) and doubled the recurrence rate compared with hot EMR.

Trial registration details: ClinicalTrials.gov, number: NCT03865537.

Keywords: COLONIC ADENOMAS; COLONOSCOPY; ENDOSCOPIC POLYPECTOMY; Postoperative Complications.

PubMed Disclaimer

Conflict of interest statement

Competing interests: HP is a consultant for Pentax and Olympus. DKR is a consultant for Olympus, Boston Scientific, Sebela, Laborie, Medtronic; he received research support from Olympus, Boston Scientific and ERBE and has ownership interest in Satisfai Health. JB is a consultant for Boston Scientific and Pentax. AR is a consultant for Boston Scientific, Olympus; he received research grant from Boston Scientific and Olympus. EZ is a consultant for Boston Scientific. JML received a research support from ERBE. DvR has received research funding from ERBE Elektromedizin GmbH, Ventage, Pendopharm, Fujifilm and Pentax, and has received consultant or speaker fees from Boston Scientific Inc., ERBE Elektromedizin GmbH, Fujifilm and Pendopharm. MBW is a consultant for Verily, Boston Scientific, Endiatix, Fujifilm, Medtronic, Surgical Automations, and on behalf of Mayo Clinic for Boston Scientific and Microtek and received fees from Synergy Pharmaceuticals and Cook Medical; he received research support from Fujifilm, Boston Scientific, Olympus, Medtronic, Ninepoint Medical, Cosmo/Aries Pharmaceuticals and has ownership interest in Virgo Inc., Surgical Automations. RNK is a consultant for Boston Scientific and Medtronic and received research support from Medtronic. NAK is a consultant for Apollo Endosurgery, Boston Scientific, SafeHeal, and Olympus. SRG is a consultant for Boston Scientific.

Figures

Figure 1
Figure 1
Hot EMR of Paris 2a, LST-G lesion in the sigmoid colon (A), after margin ablation using snare tip soft coagulation (B) and scar at surveillance colonoscopy (C). Cold EMR of Paris 2a, LST-G lesion (D) with wide normal resection margin (E), and scar at surveillance colonoscopy (F). EMR, endoscopic mucosal resection; LST-G, lateral spreading tumour of granular type.
Figure 2
Figure 2
Flow chart. EMR, endoscopic mucosal resection; SAEs, severe adverse events; SC1, first surveillance colonoscopy.
Figure 3
Figure 3
Severe adverse events, primary outcome and subgroup analyses (intention-to-treat analysis). EMR, endoscopic mucosal resection; NS, normal saline; VS, viscous solution.
See this image and copyright information in PMC

References

    1. Kaltenbach T, Anderson JC, Burke CA, et al. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020;158:1095–129. - PubMed
    1. Pohl H, Grimm IS, Moyer MT, et al. Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial. Gastroenterology 2019;157:977–84. - PMC - PubMed
    1. Ferlitsch M, Hassan C, Bisschops R, et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024. Endoscopy 2024;56:516–45. - PubMed
    1. Mangira D, Raftopoulos S, Vogrin S, et al. Effectiveness and safety of cold snare polypectomy and cold endoscopic mucosal resection for nonpedunculated colorectal polyps of 10–19 mm: a multicenter observational cohort study. Endoscopy 2023;55:627–35. - PubMed
    1. Rex DK, Anderson JC, Pohl H, et al. Cold versus hot snare resection with or without submucosal injection of 6- to 15-mm colorectal polyps: a randomized controlled trial. Gastrointest Endosc 2022;96:330–8. - PubMed

Publication types

Associated data

LinkOut - more resources