S2303 Cold Endoscopic Mucosal Resection vs Hot Endoscopic Mucosal Resection for Large Colonic Polyp (>20 mm): A Two-Center Study

Introduction: Cold endoscopic mucosal resection (EMR) has recently emerged as a potentially safer alternative to traditional hot EMR with electrocautery. We therefore aimed to compare the safety and efficacy of cold versus hot EMR for large (≥20 mm) nonpedunculated colorectal polyps in a multicenter retrospective cohort study. Methods: We conducted a retrospective cohort study at 2 U.S. tertiary centers. Included were patients who underwent EMR for a polyp at least 20 mm and had a documented follow-up colonoscopy. We excluded patients who underwent surgery, ESD, or polypectomy without submucosal injection or water immersion. EMR technique (cold vs hot) was determined by the endoscopist. The primary outcome was a composite of bleeding and perforation. Secondary outcomes included early and delayed bleeding, recurrence, and predictors of adverse events. Multivariate logistic regression was used to identify independent predictors of bleeding and recurrence. Results: A total of 764 patients met inclusion criteria; 414 underwent hot EMR and 350 cold EMR. Composite adverse events were more common with hot EMR (10.6% vs 4.0%; univariate OR 2.43, 95% CI 1.29–4.56, P = 0.01). Hot EMR was associated with higher overall bleeding (9.1% vs 4.0%; OR 2.15, 95% CI 1.13–4.07, P = 0.019), early bleeding (3.6% vs 0.8%; OR 4.35, 95% CI 1.25–15.15, P = 0.021), and perforation, although this was not significant (1.4% vs 0%, P = 0.99). On univariate analysis, there was a trend towards more recurrence in the cold EMR group (22.6% vs 16.5%; OR 0.67, 95% CI 0.43–1.07, P = 0.091). Cold EMR was associated with a significantly shorter median procedure duration compared to hot EMR (44 vs 52 mins, P < 0.001). On multivariate analysis, cold EMR was independently associated with recurrence (OR 0.12, 95% CI 0.04–0.33, P < 0.001). Rectal location was independently associated with bleeding (OR 3.93, 95% CI 3.18–4.22, P = 0.03). Conclusion: Cold EMR offers a significantly improved safety profile compared to hot EMR, with lower rates of bleeding and perforation. Although recurrence rates may be slightly higher with cold EMR, the difference is modest and offset by its superior safety, making cold EMR a favorable option for resection of large nonpedunculated colorectal polyps, especially in high-risk patients or anatomically sensitive locations.