Cold EMR Is Safer Than Hot EMR for Large Colorectal Polyps-Endoscopy Feb.26

Introduction

Endoscopic mucosal resection (EMR) is the standard of care for large (≥20 mm), nonpedunculated colorectal polyps. Over the last few years, cold EMR and thermal ablation–assisted EMR have been increasingly adopted, aiming to reduce recurrence and adverse events. However, safety comparisons between these approaches—especially for serious adverse events—have remained limited.

This large, multicenter analysis asks a simple but critical question:

Which EMR technique is safer for large colorectal polyps—cold or hot?

Problem statement

Hot EMR has long been the default approach but carries inherent thermal injury risks—bleeding, perforation, and post-procedural pain. Cold EMR avoids cautery, but many endoscopists remain hesitant to use it for large lesions due to concerns about incomplete resection or bleeding.

At the same time, adjunctive margin or base ablation has been added to hot EMR to reduce recurrence, raising questions about whether added thermal injury worsens safety.

What the study did (plain language)

• Secondary analysis of four prospective, multicenter studies
• Included nearly 1900 large (≥20 mm) nonpedunculated polyps
• Compared:
• Cold EMR
• Hot EMR without ablation
• Hot EMR with margin ablation
• Hot EMR with margin + base ablation
• Focused specifically on serious adverse events (bleeding, perforation, mortality)

Key findings clinicians should remember

1) Cold EMR had the lowest serious adverse event rates

Across all outcomes—serious adverse events, bleeding, and perforation—cold EMR consistently showed a safer profile than hot EMR.

2) Perforation and mortality were almost exclusive to hot EMR

This is clinically meaningful: the most feared complications clustered with thermal resection, not cold techniques.

3) Thermal ablation did not worsen safety—but didn’t beat cold EMR

Hot EMR with margin or margin-plus-base ablation did not increase serious adverse events compared with hot EMR alone. However, even with these refinements, hot EMR remained less safe than cold EMR.

4) Clipping matters in hot EMR

When hot EMR was used, prophylactic clipping reduced serious post-EMR bleeding, reinforcing its role in selected cases.

Clinical interpretation

This study reinforces a growing message in therapeutic colonoscopy:

If a large nonpedunculated colorectal polyp can be removed cold, it should be.

Cold EMR appears to meaningfully reduce:

• serious bleeding,
• perforation,
• and procedure-related mortality.

Hot EMR still has a role—particularly for fibrotic lesions, non-lifting areas, or when en bloc resection is required—but it should no longer be the automatic default.

Bottom-line takeaway for practice

• Cold EMR = safest option for large nonpedunculated colorectal polyps when technically feasible.
• Hot EMR should be reserved for selected cases, with careful use of clipping.
• Ablation improves recurrence control but does not eliminate thermal risk.

One-line GastroAGI takeaway:

Cold EMR significantly reduces serious complications compared with hot EMR for large colorectal polyps.