Cold versus hot snare polypectomy for pedunculated colorectal polyps: a multicenter randomized controlled trial

Background: Cold snare polypectomy (CSP) is effective in minimizing delayed postpolypectomy bleeding (DPPB) after resection of pedunculated colorectal polyps. However, robust randomized controlled trial (RCT) evidence remains limited. We aimed to compare the safety of CSP with that of hot snare polypectomy (HSP) for pedunculated polyps. Methods: A prospective, multicenter, single-blind RCT was conducted across four endoscopy centers in China. Pedunculated colorectal polyps identified via endoscopy, with heads <20 mm and stalk thickness ≤5 mm, were randomly allocated to CSP or HSP. The primary outcome was DPPB within 30 days after polypectomy. Results: 189 polyps were included (CSP 94, HSP 95). The majority of polyps in both groups had head diameters of 6-15 mm (182/189). Compared with HSP, CSP was associated with a lower risk of DPPB (0% vs. 6.3%; risk difference -0.06 [95%CI -0.11 to -0.01]). However, CSP was associated with a greater occurrence of immediate postpolypectomy bleeding (86.2% vs. 12.6%; risk difference 0.74 [95%CI 0.64 to 0.83]), although no further severe adverse clinical events were observed. The polypectomy time was shorter with CSP than with HSP (25.0 vs. 57.0 seconds; median difference, -32.0 seconds [95%CI -41.00 to -22.50]). These findings primarily reflect polyps with heads ≤15 mm (99.5% [188/189]; no >15-mm heads in CSP). Conclusions: CSP was associated with a reduced risk of DPPB compared with HSP in pedunculated colorectal polyps with heads ≤15 mm and stalks ≤5 mm, although its applicability to polyps with heads of 16-19 mm remains uncertain.