Cold versus hot EMR

Endoscopic submucosal resection EMR remains the mainstream modality for managing dysplastic colorectal polyps. EMR is done with a snare by using electrical current to cut through the tissue (Hot-EMR) or using mechanical force (Cold-EMR). Cold EMR is the preferred strategy for removing small (<10 mm) polyps and has been associated with excellent outcomes. For larger lesions traditionally Hot-EMR has been utilized but has been associated with relatively high rate of delayed bleeding (around 10%), post polypectomy syndrome, and in rare cases perforation. More recently Cold-EMR has been utilized to remove large colorectal polyps and has gain popularity due to the very low rate of delayed bleeding (around 1%) and no risk for perforation or post-polypectomy syndrome. Recently four randomized controlled studies have directly compared Hot and Cold EMR. The results are congruent showing very low complication rate with cold EMR but alarmingly high residual/recurrence in the rage of 18 to 45%. Ultimately endoscopist should choose a technique based on what is most important (low risk for complications versus high risk of recurrence) from individual patient perspective (e.g. choose Hot-EMR if low recurrence is more important than higher risk of complications or choose Cold-EMR if low complications are more important than higher recurrence/residual dysplasia).