Key Takeaways
- Clinical Bottom Line
- CSP is now the default for most polyps under 10 mm
- Why cold became the standard
- What good CSP actually looks like
Clinical Bottom Line
| Polyp scenario | 2026 practical answer |
|---|---|
| Diminutive nonpedunculated polyp <=5 mm | Cold snare polypectomy is standard. Include a small cuff of normal tissue rather than shaving the lesion flush. |
| Small nonpedunculated polyp 6-9 mm | CSP remains the default approach because it is fast, effective, and safer than routine hot snare use for this size range. |
| Tiny 1-3 mm lesion in a technically awkward position | Cold forceps can be acceptable when CSP is technically difficult, but hot forceps should not be used. |
| Pedunculated lesion <=10 mm | Do not blindly apply the same rule as for sessile 4-9 mm lesions. Cold resection may be feasible, but immediate bleeding is more common and stalk management matters. |
| Routine clip closure after polypectomy defect <20 mm | Do not routinely place clips after standard small-polyp resection. |
CSP is now the default for most polyps under 10 mm
This topic has matured. For the practicing colonoscopist, cold snare polypectomy is no longer a niche technique reserved for a few tidy diminutive lesions. Current AGA and ESGE guidance both place CSP at the center of routine resection for most nonpedunculated colorectal polyps under 10 mm, with a clear margin of normal tissue rather than a flush guillotine through the visible edge of the lesion.
The message for busy physicians is straightforward: if the lesion is nonpedunculated and under 10 mm, the default should usually be cold, not hot.
Why cold became the standard
The best practical randomized signal remains the 2023 pragmatic trial of 4270 participants with 4-10 mm colorectal polyps. Delayed bleeding occurred in 0.4% of patients treated with CSP versus 1.5% with hot snare. Severe delayed bleeding was also lower with CSP, and mean resection time was shorter at 119.0 seconds versus 162.9 seconds. Tissue retrieval, en bloc resection, and complete histologic resection did not meaningfully differ.
That is the kind of data that changes workflow. The case for hot snare in ordinary 4-9 mm lesions is weaker than many endoscopists still assume.
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