Key Takeaways
- Clinical Bottom Line
- Cold EMR is safer in some settings, but that is not the whole story
- Where guidelines clearly support cold resection
- Why cold makes sense for smaller lesions
Clinical Bottom Line
| Lesion scenario | 2026 practical answer |
|---|---|
| Nonpedunculated lesion 6-15 mm | Cold-first resection is well supported. For many of these lesions, the key question is technique, not whether heat is required. |
| Sessile serrated lesion without suspected dysplasia, including larger lesions | Cold snare polypectomy or cold EMR is guideline-supported and often the cleaner risk-benefit choice. |
| Large adenoma >=20 mm | Cold EMR may lower delayed bleeding and perforation risk, but recurrence is higher than with standard hot EMR. This is not an automatic cold case. |
| Large lesion >=30 mm, especially adenomatous | Durability becomes a major concern. Hot EMR still has a strong role because cold recurrence rises meaningfully in this group. |
| Any lesion with suspected superficial invasion | This is not a piecemeal cold-versus-hot debate. It is a question of en bloc resection strategy or referral. |
Cold EMR is safer in some settings, but that is not the whole story
The simplest version of this debate is attractive and incomplete: cold EMR avoids thermal injury, so it must be better. The newer evidence says something more useful. Cold EMR is often safer, especially when delayed bleeding or deep thermal injury are the main concern, but that safety advantage does not automatically outweigh recurrence risk for every large flat lesion.
For busy endoscopists, the current answer is lesion-specific. Histology, size, and suspicion for dysplasia or invasion matter far more than a broad allegiance to cold or hot.
Where guidelines clearly support cold resection
ESGE’s 2024 update is the cleanest anchor for this topic.
- For sessile serrated lesions of all sizes without suspected dysplasia, ESGE recommends piecemeal cold snare polypectomy or cold EMR.
- When the risk of deep thermal injury is high or poorly tolerated, piecemeal cold snare resection may be considered.
- For lesions suspicious for superficial invasive carcinoma, en bloc strategies remain the preferred route rather than piecemeal EMR of any temperature.
That means the cold argument is strongest for serrated biology and weaker for large conventional adenomas.
Why cold makes sense for smaller lesions
The small and medium lesion data remain reassuring. In the 2022 randomized trial of 286 nonpedunculated lesions sized 6-15 mm, overall incomplete resection was low, and cold snaring had no incomplete resections, shorter procedure time, and no serious adverse events. For many lesions in this size band, heat now feels more habitual than necessary.
This is why the cold-first mindset has spread. It is efficient, safe, and technically clean when the lesion is the right lesion.
Where the 2025 data forced more caution
The more interesting question is what to do with larger flat lesions, especially adenomas.
- 2025 retrospective series: among 242 lesions treated with cold EMR, overall 6-month recurrence was 6.2%, but adenomas 20 mm or larger recurred more often than large sessile serrated lesions (16.1% vs 4.1%). Medium-sized lesions did well regardless of histology.
- 2025 randomized trial: in 229 patients with lesions 20 mm or larger, recurrence at first surveillance was higher after cold EMR than after standard hot EMR (33.0% vs 16.2%). The gap widened for lesions 30 mm or larger (43.1% vs 18.2%).
- 2025 meta-analysis of randomized trials: cold EMR reduced delayed bleeding and perforation, but recurrent or residual neoplasia was significantly higher than with hot EMR.
The take-home point is not that cold EMR failed. It is that cold EMR should be targeted, not romanticized.
A practical lesion-based framework
| Lesion type | Better default |
|---|---|
| 6-15 mm nonpedunculated lesion without invasive features | Cold snare or cold EMR, depending on size and lift needs. |
| Large sessile serrated lesion without dysplasia | Cold EMR is often a very reasonable default. |
| Large flat adenoma 20-29 mm | Individualize. Cold may improve safety, but recurrence tradeoff needs to be acceptable. |
| Large flat adenoma >=30 mm | Hot EMR still has a meaningful durability advantage in current data. |
| Lesion with dysplasia pattern or invasion concern | Use an en bloc strategy or refer. Do not hide a cancer problem inside a piecemeal cold plan. |
How I would talk about cold EMR in 2026
- Cold EMR is not just a safer version of hot EMR. It is a different tradeoff.
- That tradeoff often looks excellent for sessile serrated lesions and smaller nonpedunculated lesions.
- That tradeoff looks much less attractive for larger adenomas when durable clearance is the main endpoint.
- The more the lesion looks like a cancer problem, the less useful this debate becomes.
What to stop saying
- Stop saying cold EMR “eliminates” the important downside of larger lesion resection.
- Stop talking as if safety and efficacy move in the same direction for every lesion type.
- Stop grouping sessile serrated lesions and large adenomas into one cold-EMR bucket.
- Stop pretending recurrence at first surveillance is a minor detail when the lesion is 30 mm or larger.
Selected references
- ESGE Guideline Update: Colorectal polypectomy and endoscopic mucosal resection. 2024.
- Cold versus hot snare resection with or without submucosal injection of 6- to 15-mm colorectal polyps: a randomized controlled trial. Gastrointest Endosc. 2022.
- Efficacy of cold piecemeal EMR of medium to large adenomas compared with sessile serrated lesions. Gastrointest Endosc. 2025.
- Cold snare endoscopic mucosal resection versus standard hot technique for large flat nonpedunculated colonic lesions: a randomized controlled trial. Endoscopy. 2025.
- Cold- versus hot-snare endoscopic mucosal resection of colorectal polyps: meta-analysis of randomized controlled trials. Gastrointest Endosc. 2025.
Last reviewed April 17, 2026. This update is written for clinicians deciding when the safety profile of cold EMR outweighs the higher recurrence burden seen in some larger adenomatous lesions.
