Cold snare polypectomy for 10–19 mm colorectal adenomas in familial adenomatous polyposis: a prospective randomized controlled trial

<b>Background and aims:</b> Evidence for cold snare polypectomy (CSP) in treating 10-19 mm colorectal adenomas in patients with familial adenomatous polyposis (FAP) is limited. This study compared the efficacy and safety of CSP <i>vs.</i> hot snare polypectomy (HSP). <b>Methods:</b> This prospective non-inferiority randomized controlled trial predefined a non-inferiority margin of 4%. A total of 452 colorectal adenomas (10-19 mm) from 41 FAP patients were enrolled between May 2024 and May 2025 and randomized 1:1 to CSP (<i>n</i> <i>=</i> 220) or HSP (<i>n</i> <i>=</i> 232). The primary endpoint was histological complete resection (R0). Subgroup analyses were performed by lesion size (10-15 mm <i>vs</i>. 16-19 mm). <b>Results:</b> R0 resection rates were similar between CSP and HSP (92.3% <i>vs</i>. 92.7%, <i>p =</i> 0.76). CSP was associated with shorter procedure time (4.53 ± 1.18 <i>vs</i>. 6.53 ± 1.46 min, <i>p <</i> 0.01) and lower hospitalization costs (<i>p <</i> 0.01). Intra-procedural bleeding was more frequent with CSP, whereas delayed bleeding and post-polypectomy electrocoagulation syndrome were more common with HSP. At 6 months, recurrence was rare (one lesion in each group). No significant interaction by lesion size was observed. <b>Conclusions:</b> CSP is non-inferior to HSP for R0 resection of 10-19 mm colorectal adenomas in FAP patients and offers advantages in efficiency, safety and cost.