Cold snare polypectomy versus hot endoscopic mucosal resection for large nonpedunculated colorectal polyps: a systematic review and meta-analysis of randomized controlled trials

Background This meta-Analysis of randomized controlled trials (RCTs) aimed to compare the risk of recurrence and adverse events (AEs) between cold snare polypectomy (CSP) and hot endoscopic mucosal resection (H-EMR) for large nonpedunculated colorectal polyps (LNPCPs). Methods A systematic search of Medline, Embase, and Cochrane Library databases until August 2024 was performed for studies comparing recurrence, bleeding, and perforation rates between CSP and H-EMR for LNPCPs ≥15mm. A random-effects meta-Analysis, with heterogeneity measured with I2, was conducted to generate pooled risk ratios (RRs) with 95%CIs. Results Four RCTs comprising 1516 LNPCPs (766 CSP and 750 H-EMR) in 1442 patients were included in the quantitative analysis. CSP demonstrated a higher recurrence risk at first surveillance colonoscopy than H-EMR in the pooled analysis (22.6% vs. 10.8%; RR 1.98; 95%CI 1.22 3.21; P = 0.02; moderate certainty evidence), corresponding to a number needed to harm of 9. Regarding AEs, CSP demonstrated a 67% reduced risk of delayed bleeding (1.2% vs. 3.9%; RR 0.33; 95%CI 0.12 0.89; P = 0.03; high certainty evidence), corresponding to a number needed to treat of 37. Although CSP appeared to reduce the risk of intraprocedural bleeding (10.0% vs. 19.8%; RR 0.30, 95%CI 0 52 256, P = 0.42), the wide confidence interval from the random-effects model included 1. There were no intraprocedural or delayed perforations in the CSP group. Conclusion CSP has nearly double the recurrence risk of HEMR for LNPCPs; however, its superior safety profile may make it a preferable option for patients where procedural safety is prioritized over radicality, such as those with extensive co-morbidities.