Bleeding risk and prevention after colorectal polypectomy: What differs between cold and hot resection?

Table 1 Key controversies and evidence gaps in bleeding prevention after colorectal endoscopic resection

Clinical issue	What current evidence supports	What remains uncertain
Cold vs hot resection for 10-19 mm nonpedunculated lesions	Cold resection reduces thermal injury and delayed bleeding, but current guidelines are not fully aligned: ESGE 2024 favors hot snare polypectomy for 10-19 mm nonpedunculated adenomatous polyps, whereas USMSTF 2020 permits either cold or hot snare resection in this size range	Whether the bleeding advantage of cold resection is sufficient to outweigh concerns regarding complete excision, margin negativity, and histologic adequacy in adenomatous lesions remains unresolved
Whether cold EMR should expand to lesions ≥ 20 mm	Cold EMR appears to have a favorable safety profile in selected lesions, particularly sessile serrated lesions without suspected dysplasia. ESGE 2024 supports piecemeal CSP or cold EMR for SSLs of any size without suspected dysplasia, while reserving cold piecemeal resection of large flat adenomatous lesions for selected situations	Whether this safety advantage justifies broader use in large adenomatous lesions despite higher residual or recurrent neoplasia
Prophylactic clipping after EMR	ESGE 2024 recommends clip closure after conventional EMR of large nonpedunculated lesions in the right colon but suggests against routine clipping for lesions < 20 mm and for ≥ 20 mm lesions in the left colon	Which lesions outside this clearly high-risk subgroup derive meaningful benefit from closure remains uncertain, particularly with respect to intermediate-sized lesions, left-sided lesions, and varying antithrombotic risk
Routine vs selective closure after colorectal ESD	Recent studies and meta-analyses suggest that prophylactic closure after colorectal ESD may reduce CSDB, although the evidence remains heterogeneous	Whether routine closure is justified remains unclear, because the balance of benefit, feasibility, procedure time, cost, lesion size, location, and antithrombotic exposure varies substantially across studies and practice settings

Bleeding risk should be assessed in a procedure-specific rather than uniform manner, because the relative importance of individual risk factors differs across cold resection, endoscopic mucosal resection, and endoscopic submucosal dissection. EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; ESGE: European Society of Gastrointestinal Endoscopy; USMSTF: United States Multi-Society Task Force; CSP: Cold snare polypectomy; CSDB: Clinically significant delayed bleeding; SSLs: Sessile serrated lesions.

Table 2 Main bleeding risk factors and practical considerations after cold resection

Risk domain	Main risk factors	Suggested approach
Patient-related	Antithrombotic therapy	Assess bleeding risk and anticipated long-term oncologic benefit before selecting the resection technique
Lesion-related	Pedunculated morphology, larger size, rectal location, larger wound size	Restrict cold resection to appropriate indications. Use caution in pedunculated and larger lesions; when adenomatous lesions are treated with cold resection, closer post-resection surveillance may be appropriate
Procedure-related	Intraprocedural hematoma, persistent immediate bleeding, large cold defects	Routine prophylactic hemostasis is unnecessary in most cases, but selected high-risk defects may warrant endoscopic treatment

Table 3 Main bleeding risk factors and practical considerations after hot resection

Risk domain	Main risk factors	Suggested approach
Patient-related	Antithrombotic therapy, thrombocytopenia, renal dysfunction, cirrhosis, advanced age	Consider these factors when planning electrocautery-based resection. In higher-risk patients, limit unnecessary thermal injury and consider selective closure of large right-sided H-EMR defects or selected ESD defects
Lesion-related	Large lesion size, right-sided colonic location, rectal/rectosigmoid location, pedunculated polyps with a large head or thick stalk	Use diluted epinephrine injection and/or mechanical prophylaxis for pedunculated polyps with a large head or thick stalk. Consider selective closure after H-EMR of large right-sided lesions and after selected large rectal or rectosigmoid ESD defects
Procedure-related	Thermal injury, piecemeal EMR, large mucosal defects, extensive submucosal dissection	Carefully inspect the resection defect, treat exposed vessels when present, and reserve prophylactic closure for selected high-risk defects

H-EMR: Hot endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection.