Hot versus cold snare polypectomy for colorectal polyps: current evidence and practical guide for decision-making

Colorectal polyps can be removed using cold or hot snare techniques, which differ primarily in their use of electrocautery, safety profile, and depth of resection. This review summarizes current evidence comparing cold and hot snare resection and provides a practical framework for technique selection.

Recent guidelines and randomized trials support cold snare polypectomy (CSP) for polyps 10 mm or less because of its favorable safety profile and low risk of delayed bleeding. For 10-19 mm lesions, technique selection should be guided by histology and morphology, with hot snare polypectomy (HSP) favored for pedunculated, bulky, fibrotic, or high-risk adenomatous lesions and CSP or cold EMR increasingly supported for nondysplastic sessile serrated lesions. For large adenomatous polyps at least 20 mm, in which advanced histology is more common, hot EMR with margin treatment remains standard, where as cold EMR reduces thermal injury at the cost of higher recurrence.

CSP is preferred for most diminutive and small polyps, while larger lesions require individualized selection according to histology, morphology, invasion risk, and the need for durable eradication. The goal is to choose the least injurious technique that still achieves complete and reliable resection. Long-term data are needed to define recurrence and subsequent colorectal cancer risk after different resection strategies.