Efficacy and safety ranking of endoscopic resection techniques for colorectal polyps: a systematic review and network meta-analysis

Background: The rapid evolution of endoscopic resection techniques for colorectal polyps has created a diverse but fragmented evidence base, making it challenging to determine the technique that optimally balances efficacy and safety. Objectives: To comprehensively compare the efficacy and safety of all mainstream colorectal polypectomy techniques. Design: A systematic review and Bayesian network meta-analysis (NMA), conducted in accordance with PRISMA-NMA guidelines. Data sources and methods: Databases searched included PubMed, Web of Science, Embase, Scopus, Cochrane Library, CNKI, Wanfang Database, and SinoMed. Model convergence was assured (Brooks-Gelman-Rubin diagnostic), and consistency was evaluated via node-splitting analysis. Treatment hierarchies for primary efficacy outcomes (R0 resection, En bloc resection, complete resection) and secondary safety outcomes (bleeding, perforation) were established using surface under the cumulative ranking curve (SUCRA) probabilities. Results: 100 RCTs (24,786 patients; 34,244 polyps) comparing 13 techniques were included. Underwater endoscopic mucosal resection (U-EMR) and EMR ranked highest for R0 resection (SUCRA: U-EMR 49%, EMR 30%) and En bloc resection. For complete resection, endoscopic submucosal dissection (ESD) ranked highest (SUCRA: ESD 49%). Cold forceps polypectomy (CFP) and cold snare polypectomy with submucosal injection (CSP-SI) were consistently the least effective across efficacy outcomes. Hot snare EMR (HS-EMR) was associated with the highest risk of bleeding, while cold snare polypectomy (CSP)-based techniques were generally safer for perforation. ESD demonstrated a favorable safety profile for bleeding. The evidence certainty was generally low to moderate. Conclusion: This NMA provides a comprehensive hierarchy of polypectomy techniques. U-EMR and EMR are among the most effective for R0 and En bloc resection, while CSP-based techniques are among the safest. HS-EMR carries a higher bleeding risk. These findings provide crucial evidence to guide clinical decision-making and future guideline development, while also highlighting key evidence gaps requiring further research. Trial registration: PROSPERO (CRD420251139746).