Cold Snare Polypectomy and Cold Endoscopic Mucosal Resection Versus Hot Endoscopic Mucosal Resection for Intermediate‐Size Sessile Serrated Lesions: A Randomized Controlled Trial

BACKGROUND: The current guidelines recommend cold snare polypectomy (CSP) for removing intermediate-size sessile serrated lesions (SSLs) measuring 10-20 mm. However, these supporting data come from single-arm or retrospective studies, underscoring the need for randomized controlled trials to confirm its efficacy. This study aimed to compare the efficacy of CSP and cold endoscopic mucosal resection (EMR) with that of hot EMR in achieving complete histological resection of intermediate-size SSLs. METHODS: This was a multicenter, randomized, non-inferiority trial. A total of 113 patients with 159 intermediate-size SSLs were randomized into three groups: CSP, cold EMR, and hot EMR. The primary outcome was the complete histological resection, defined as tumor-free horizontal and vertical margins, regardless of whether resection was en bloc or piecemeal. Secondary outcomes included en bloc resection rate, polypectomy time, and procedural complications. RESULTS: The complete histological resection rates were 90.6% for CSP, 88.5% for cold EMR, and 87.0% for hot EMR, demonstrating the non-inferiority of CSP and cold EMR compared to hot EMR. CSP had a shallower vertical resection depth, which was improved by submucosal injection. CSP also had shorter polypectomy and total procedure times. The En bloc resection rates were 69.8% for CSP, 78.9% for cold EMR, and 88.9% for hot EMR. Although the en bloc resection rate was lower with CSP compared with hot EMR, it improved with submucosal injection. DISCUSSION: CSP and cold EMR are effective alternatives to hot EMR for removing intermediate-size SSLs, providing strong support for their recommendations in guidelines. Further research is warranted to evaluate the long-term residual rate.