Cold snare endoscopic resection for large colon polyps: a randomised trial
- PMID: 40393701
- DOI: 10.1136/gutjnl-2025-335075
Cold snare endoscopic resection for large colon polyps: a randomised trial
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.
© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.
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.