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

Background and aims: 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 vs. hot snare polypectomy (HSP). Methods: 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 (n = 220) or HSP (n = 232). The primary endpoint was histological complete resection (R0). Subgroup analyses were performed by lesion size (10-15 mm vs. 16-19 mm). Results: R0 resection rates were similar between CSP and HSP (92.3% vs. 92.7%, p = 0.76). CSP was associated with shorter procedure time (4.53 ± 1.18 vs. 6.53 ± 1.46 min, p < 0.01) and lower hospitalization costs (p < 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. Conclusions: 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.