Cold Versus Hot EMR Shows Safety–Efficacy Tradeoff

An individual patient data meta-analysis published in Gut found fewer major adverse events with cold snare endoscopic mucosal resection (EMR) than with hot snare EMR for large, nonpedunculated colorectal polyps, but more residual or recurrent adenoma/neoplasia (RRA). No adenoma subgroup showed near-equivalent efficacy.

The international, multicenter, post hoc analysis pooled four randomized controlled trials and included 1,509 polyps in 1,423 patients at 50 centers. Eligible lesions were at least 20mm; 762 underwent cold snare EMR and 747 hot snare EMR. Primary outcomes were major adverse events at 14 to 30 days and RRA at endoscopic follow-up 4 to 6 months later.

Major adverse events occurred in 1.7% of cold and 5.9% of hot resections (adjusted odds ratio [OR], 0.26; 95% CI, 0.14-0.50; P<0.001). Clinically significant postendoscopic bleeding occurred in 1.7% versus 3.5%, and deep mural injury/perforation in 0% versus 2.6%. Cold snare resection was the only factor associated with fewer major adverse events in multivariable analysis (OR, 0.21; 95% CI, 0.07-0.60; P=0.004).

Among 1,315 polyps with follow-up data, RRA occurred in 26.5% after cold and 12.8% after hot EMR (adjusted OR, 2.61; 95% CI, 1.93-3.53; P<0.001). A significant interaction with lesion diameter (P=0.035) showed widening differences: 16.9% versus 11.7% for 20-29mm lesions, 27.4% versus 10.3% for 30-39mm lesions, and 46.3% versus 19.1% for lesions at least 40mm. Differences were smallest for sessile serrated lesions (15.0% vs 8.1%; P=0.053) and greatest for adenomas with high-grade dysplasia (40.8% vs 18.0%; P=0.002).

Investigators cited heterogeneity in eligibility criteria, randomization strategy, and technical approach, along with follow-up limited to one endoscopy within the first year. Clip closure was more common after hot EMR (47.8% vs 13.6%), potentially favoring hot EMR. They emphasized weighing cold resection’s lower major adverse event rate against higher recurrence and possible repeat procedures.

Source: Steinbrück I, O’Sullivan T, Nogales O, et al. Patient-level predictors of safety and recurrence after cold versus hot snare resection of large, non-pedunculated colorectal polyps: an individual patient data meta-analysis of four randomised-controlled trials. Gut. Published online September 15, 2026. doi:10.1136/gutjnl-2026-339233