Safety and Efficacy of Cold Compared With Hot Endoscopic Mucosal Resection of Large Nonpedunculated Colorectal Polyps: Systematic Review and Meta-Analysis

INTRODUCTION: Endoscopic mucosal resection (EMR) is traditionally performed using electrosurgical cautery (hot snare) to resect premalignant colorectal polyps. Recent data have suggested the superior safety of cold EMR (c-EMR), even for polyps ≥20 mm in size. We aimed to perform a systematic review and meta-analysis to assess the safety and efficacy of c-EMR compared with traditional (hot) EMR (h-EMR). METHODS: We performed a comprehensive systematic review ending in December 2024. The primary outcome of interest was the odds of delayed bleeding for c-EMR compared with h-EMR of nonpedunculated colorectal polyps ≥20 mm in size. Odds ratios (ORs) with 95% confidence intervals (CIs) are reported. The secondary outcomes included early bleeding, perforation, and polyp recurrence. Publication bias was assessed using the classic fail-safe test. Forest plots were used to report the pooled effect estimates. Heterogeneity was assessed using I2 . RESULTS: Our systematic review identified 1,632 unique citations, a total of 3 randomized controlled trials and 4 nonrandomized comparative studies were identified and included in the primary analyses. Four additional cohort studies were included in the secondary analyses. On random-effects modeling, c-EMR was associated with a significantly lower risk of delayed bleeding (OR 0.25, 95% CI 0.11-0.57, P = 0.001, I2 = 0%), early bleeding (OR 0.34, 95% CI 0.2-0.6, P < 0.001, I2 = 0%), and perforation (OR 0.14, 95% CI 0.04-0.51, P = 0.003, I2 = 0%) than h-EMR. c-EMR was associated with a higher rate of recurrence (OR 1.81, 95% CI 1.01-3.25, P = 0.045, I2 = 72%). DISCUSSION: c-EMR has a superior safety profile to h-EMR for nonpedunculated colorectal polyps ≥20 mm in size, but strategies to manage the higher odds of recurrence remain essential.