Colonic polypectomy in 2024: hot or cold?

Colorectal cancer (CRC) is the second and third leading cause of cancer death in men and women respectively worldwide. Colonoscopy is the gold standard screening test to detect premalignant lesions with endoscopic polypectomy preventing evolution to CRC. Endoscopic polypectomy is effective with a higher safety profile and is less costly as compared to surgery. Bestpractice polypectomy technique is crucial, as 10% of polyps <2 cm are incompletely resected and may therefore play a significant role in the development of post colonoscopy colorectal cancer (PCCRC). Hot snare polypectomy (HSP) has traditionally been the technique of choice for endoscopic polypectomy but is associated with a small but appreciable risk of adverse events, primarily postpolypectomy bleeding and perforation. Recent high-quality studies have demonstrated the similar efficacy and superior safety profile of cold snare polypectomy (CSP) for polyps less than 10 mm in size. In daily clinical practice, the vast majority of colorectal polyps encountered by gastroenterologists are less than 10 mm, making CSP the technique of choice. Widespread use of CSP over HSP may therefore significantly reduce the number of adverse events associated with endoscopic polypectomy. The indication for CSP may be extended to larger lesions, including large, non-dysplastic sessile serrated lesions and small pedunculated polyps with a thin stalk. In addition, the risk-benefit ratio of CSP is favourable in patients in whom interruption of anticoagulants is a concern in terms of thromboembolic risk. In this review, the focus will be on safety of hot versus cold snare polypectomy as a technique for the resection of diminutive and small polyps.