Cold snare versus hot snare endoscopic mucosal resection of large non-pedunculated colorectal adenomas and serrated lesions: a systematic review and meta-analysis

Objective Hot snare endoscopic mucosal resection (H-EMR) is traditionally used for resecting large non-pedunculated colorectal polyps (LNPCPs) but carries thermal-injury risks. Cold snare EMR (C-EMR) avoids electrocautery and may be safer. We compared efficacy, recurrence and safety of C-EMR versus H-EMR for adenomatous and serrated lesions ≥15 mm, with prespecified histology analyses. Design/method A systematic review and meta-analysis was conducted up to May 2025. Seven comparative studies (four randomised controlled trials; three observational) including 2898 LNPCPs (C-EMR 1029; H-EMR 1869) met criteria. Random-effects models produced pooled risk ratios/ORs with 95% CIs. Prespecified subgroups evaluated adenomas versus sessile serrated lesions (SSLs). Results Technical success was similar (96.3% vs 98.7%; OR 0.46, 95% CI (0.13 to 1.64); p=0.23). Overall recurrence was higher with C-EMR (23.6% vs 11.7%); RR 1.90, 95% CI (1.30 to 2.78); p<0.001. By histology, recurrence was higher for adenomas with C-EMR (26.0% vs 14.7%); RR 1.90, 95% CI (1.30 to 2.79); p<0.001, but not for SSLs (5.1% vs 4.2%); RR 1.30, 95% CI (0.54 to 3.55); p=0.50. Safety favoured C-EMR: intraprocedural bleeding (9.5% vs 10.1%; RR 0.66, 95% CI (0.46 to 0.95); p<0.05), delayed bleeding (1.0% vs 4.4%; RR 0.39, 95% CI (0.20 to 0.74); p<0.01) and perforation (0% vs 1.5%; RR 0.22, 95% CI (0.06 to 0.81); p<0.05) were all lower. Conclusions Both techniques are effective. For adenomatous LNPCPs, H-EMR lowers recurrence at the cost of more adverse events. For SSLs and in higher risk patients, C-EMR’s superior safety profile supports it as the preferred approach; recurrence differences for SSLs were not significant.