Optimizing detection and resection of colorectal polyps

Introduction

Colorectal cancer (CRC) is the second most common cause of cancer deaths and third leading cause of cancer in the United States (1). Worldwide, an estimated 1.9 million new CRC cases and 930,000 deaths attributed to CRC occurred in 2020 (1,2). In the US, an estimated 152,810 CRC cases and related 53,010 deaths occurred in the US in 2024 (3). CRC development follows an adenoma-carcinoma or sessile serrated lesion-to-carcinoma pathway (4-6). The stepwise progression of CRC precursors allows detection of adenomas or serrated polyps prior to their malignant transformation. Screening tools can reduce both incidence and mortality of CRC, through detection and removal of precursor lesions (7-9). Colonoscopy allows for simultaneous detection and resection of pre-cancerous polyps and endorsed by U.S. Multi-Society Task Force (USMSTF) as tier one screening tool for CRC (10). In this review article, we aim to discuss and summarize current evidence to optimize detection and resection of colorectal polyps.

Discussion

Improving polyp and neoplasia detection: techniques

High quality colonoscopy can improve polyp detection and decrease incidence of post-colonoscopy colorectal cancer (PCCRC). Various tools, techniques and advancement in technology have been utilized to improve polyp detection.

Withdrawal time

Mucosal inspection for polyp detection is performed primarily during withdrawal. At least ≥8 minutes withdrawal time from appendiceal orifice to rectum has been recommended to optimize mucosal inspection (11). Rex et al. first demonstrated a relationship between mean withdrawal time and lower adenoma miss rates (AMR) (12). Since then, multiple studies demonstrated improvement in adenoma and SSL detection and prevention of PCCRC at withdrawal time of 8–9 minutes (13-22). Recently, a meta-analysis of randomized controlled trials (RCTs) assessing 9 vs. 6 minutes withdrawal time demonstrated significantly higher adenoma detection rate (ADR) [relative risk (RR): 1.23] and adenoma per colonoscopy (APC) (mean difference: 0.14) in 9 minutes withdrawal cohort (23). The recommendation for withdrawal time is for individuals aged ≥45 years undergoing screening, surveillance, or diagnostic colonoscopy where in biopsy sampling or polypectomies are not performed and does not apply to individuals with inflammatory bowel disease and genetic polyposis syndromes.

Second forward view (SFV) and retroflexion in cecum

After an initial look from appendiceal orifice to hepatic flexure (right colon) during withdrawal, experts advice reinserting the colonoscope back to cecum for SFV of right colon or retroflexion in the cecum to detect additional polyps, thus, increasing ADR, sessile serrated lesion detection rate (SSLDR) and decreasing AMR (24-27). Right colon polyps tend to be flatter, more subtle and thus, harder to detect optically and post colonoscopy colorectal cancer (PCCRC) is more often reported in the right side of the colon (28-31). The second look provides additional opportunity to detect flat, subtle lesions which can be challenging to visualize and polyps previously obscured by folds, debris and under-distension. In a meta-analysis, Cohen et al. demonstrated 16.9% reduction in AMR with cecal retroflexion (32). Another meta-analysis of RCTs demonstrated significantly higher ADR (RR: 1.39) and polyp detection rate (RR: 1.47) in individuals undergoing SFV compared to no SFV without any difference in additional ADR with retroflexion or SFV (33).

Water assisted colonoscopy

Water assisted colonoscopy comprises two distinct techniques, water immersion (WI) and water exchange (WE). WI colonoscopy involves insufflation of colon with water as an adjunct to air insufflation to facilitate insertion followed by suction removal during withdrawal. This technique was first described in 1984 in individuals with severe diverticular disease (34). Subsequently, Leung et al. in 2007, proposed a modification of the technique, called WE, where, suction removal of infused water is predominantly performed during insertion, rather than withdrawal, to minimize pain during insertion and optimize polyp detection in right colon (35). A recent RCT demonstrated significantly reduced combined right colon AMR and serrated polyp miss rate (22.2% vs. 32.2%), and increase in right sided serrated polyp detection per colonoscopy (0.95 vs. 0.50) with WE compared to CO₂ insufflation (36). In another RCT, Cadoni et al. demonstrated higher ADR with WE compared to air insufflation (49.3% vs. 40.4%), and comparable ADR to WI (37). WE achieved higher right colon ADR (24.0% vs. 16.9%) and higher advanced ADR than air insufflation (6.1% vs. 2.5%) (37).

Dynamic patient positioning

The concept of dynamic patient positioning to optimize mucosal visualization has been adopted from radiologists experience with barium enemas, after noting that patient repositioning allowed liquid to settle in gravity dependent areas and gas accumulating at highest point (38). This corresponds best with examination of hepatic flexure (lies in right upper quadrant) in left lateral position, transverse colon (lies relatively anteriorly) in supine position and splenic flexure and descending colon (lies in left upper quadrant) in right lateral position (38). Lee et al. performed a multicenter, parallel group trial where patients were randomized to dynamic position group and control group and demonstrated significantly higher ADR (42.4% vs. 33.0%), and APC (0.90 vs. 0.67) in dynamic position group (39). The increase in the number of adenomas detected were noted in transverse colon (0.22 vs. 0.13) and left colon (0.37 vs. 0.27) (39). Subsequently, a meta-analysis of 5 RCTs concluded higher ADR [odds ratio (OR): 1.34] with dynamic patient positioning compared to static positioning, with subgroup analysis demonstrating higher ADR in transverse colon (OR: 1.72) (40). However, real world uptake of dynamic patient positioning remains limited due to challenges associated with repositioning sedated patients and time constraints.

Bowel preparation

Optimal bowel preparation is the cornerstone of high quality colonoscopy, and its documentation is a colonoscopy quality indicator (41). Inadequate bowel preparation occurs in up to 20% colonoscopies (42,43) (Figure 1A,1B). A meta-analysis of >55,000 colonoscopies demonstrated 1–2% reduction in advanced ADR and 5% reduction in ADR with inadequate bowel preparation compared to adequate or intermediate preparations (44). SSL detection requires higher threshold of preparation quality. In a study of 749 veterans undergoing colonoscopy, SSL detection was significantly lower in individuals with intermediate-quality preparation than high-quality preparation, for both entire colon (4.6% vs. 12.0%; OR: 0.37) and right colon (1.5% vs. 7.9%; OR: 0.19) (45). In another large population based study from Austrian Colorectal Cancer Screening Program, fair or lower bowel preparation during screening colonoscopy was associated with significantly higher risk of PCCRC (OR: 2.56) (46). Early repeat colonoscopy within 12 months should be performed for Boston Bowel Preparation Score <6 due to any segment score <2 (47). Increasing age, male sex, inpatient status, diabetes, hypertension, cirrhosis, narcotic use, constipation, stroke and tricyclic antidepressant use have been reported as predictors of inadequate bowel preparation (42). Split dose bowel preparation, providing verbal and written patient education, and patient navigation can improve bowel preparation quality (47,48). An intra-procedural bowel cleansing system (Pure-Vu EVS System, Motus GI, Tirat Carmel, Israel), utilizes high intensity water and air through 5 irrigation jets to cleanse the bowel and remove stool contents through a large caliber suction channel. (Figure 2A,2B) Herman et al. in a study of 46 veterans, demonstrated successfully utilization of device in 78% individuals with inadequate preparation, leading to improvement in mean Boston Bowel Preparation Scale from 4.7 to 8.7, without any serious adverse events (49).

Figure 1 An example of colonoscopy with (A) inadequate bowel preparation and (B) adequate bowel preparation. Solid stool within colonic lumen (A) precluded adequate mucosal exposure and visualization to detect polyps, while adequate bowel preparation in (B) allowed detection of subtle flat polyp (arrow).

Figure 2 Image demonstrates the device console (A) for intraprocedural cleansing system consisting of a single-use oversleeve device that can be used with a standard or slim colonoscope and (B) high intensity five water jets through the device allowing cleansing of bowel for colonoscopy.

Improving polyp and neoplasia detection: tools

Distal attachment devices

During colonoscopy polyps may be located behind flexures or between the folds and hence, could be missed even by the experienced endoscopists (50). Distal attachment devices can hook into the folds to flatten it to improve mucosal exposure (51). Several distal attachment devices, including the transparent caps (Olympus, Tokyo, Japan), EndoCuff (Arc Medical, Leeds, United Kingdom), EndoCuff Vision (Olympus, Center Valley, PA, USA), Reveal Cap (US Endoscopy, Mentor, Ohio, USA), AmplifEYE (Medivators Inc., Minneapolis, Minn, USA), EndoRing (EndoAid Ltd., Caesarea, Israel), and G-Eye (SMART Medical Systems Ltd., Ra’anana, Israel) have been described. (Figure 3A,3B) A pooled analysis of RCTs demonstrated improvement in ADR, adenoma per subject and cecal intubation rates using cap assisted colonoscopy compared to conventional colonoscopy (52,53). A prospective, multicenter, RCT assessing standard high definition white light endoscopy (WLE) (n=384) with cap assisted (n=379) and cuff assisted (n=379) colonoscopy performed by high adenoma detectors demonstrated no differences in ADR, APC, advanced adenoma (AA), SSL or right colon ADR (54). Multivariate analysis demonstrated no impact of device type on ADR (54). Overall, the evidence suggests that distal attachment devices may improve ADR, however, the advantage is limited to low to moderate ADR detectors. Moreover, there is a need for studies assessing cost-effectiveness of distal attachment devices and assessment of interval CRC incidence after their use during colonoscopy.

Figure 3 Demonstration (A,B) of a distal attachment device inserted on the tip of colonoscope to improve polyp detection.

IEE

Colonoscopy with standard WLE may miss subtle, or flat polyps. In a study of twelve endoscopists assessing 120 images of 30 lesions (29 adenomas, 1 SSL), miss rate of white light imaging was 16.4% (55). Numerous equipment based IEE systems including narrow band imaging (NBI, Olympus, Tokyo, Japan), linked color imaging (LCI; Fujifilm, Tokyo, Japan), i-Scan (Pentax Medical, Tokyo, Japan), texture and color enhancement imaging (TXI, Olympus) can increase ADR and APC compared to standard WLE (56-60) (Figure 4A-4F). Li et al., conducted a network meta-analysis of 54 RCTs with 28,663 participants assessing various IEE techniques with either WLE or other IEE methods with outcomes being ADR, advanced ADR and SSLDR (61). TXI ranked highest [surface under the cumulative ranking curve (SUCRA): 88.4; RR: 1.48], followed by LCI compared to WLE for ADR (61) (Figure 5A-5D). TXI (RR: 1.42) and LCI (RR: 1.23) showed superiority over WLE for AA detection. For SSLDR, LCI demonstrated the highest ranking (SUCRA: 82.0%), followed by blue light imaging (BLI) (60.9%) and new-generation NBI (60.7%). Overall superiority of TXI and LCI over standard WLE remained despite varying endoscopist experience and indication of the study (61). Combining distal attachment devices with IEE may offer complementary benefit to improve polyp detection. Pattarajierapan et al. conducted a RCT assessing TXI alone compared to a combination of TXI and endocuff vision for colorectal adenoma detection and demonstrated significantly higher ADR (65.6% vs. 52.1%), APC (1.6 vs. 1.2) while SSLDR, and withdrawal time remained similar in the combination cohort (62). In another RCT, Aniwan et al., assessing combination of LCI and endocuff to LCI alone and endocuff alone, reported no significant differences in ADR or proximal ADR in the three groups (63). The data underscores the potential role of IEE in clinical practice, given several outcome parameters are associated with PCCRC. However, further studies on endoscopists baseline ADR and outcome parameters should be performed to assess the group of endoscopists who can benefit the most. Further, linkage to interval CRC incidence and cost effectiveness of IEE techniques should be demonstrated before widespread real world uptake.

Figure 4 Demonstration of polyp appearance under NBI with corresponding white light imaging. (A,D) White light image and NBI showing NICE I features of polyp with eventual histology hyperplastic polyp. (B,E) White light image and NBI showing NICE II features of polyp with eventual histology tubular adenoma. (C,F) White light image and NBI showing NICE III features of polyp with eventual histology adenocarcinoma. NBI, narrow band imaging; NICE, NBI International Colorectal Endoscopic.

Figure 5 An example of (A,C) normal colonic mucosa and adenomatous polyp (B,D) under TXI (Olympus) and corresponding white light imaging. TXI, texture and color enhancement imaging.

Artificial intelligence (AI) assisted colonoscopy

Real time computer aided detection (CADe) and computer aided diagnosis (CADx) systems have noted a remarkable rise in popularity across the world. These systems undergo training based on large dataset of endoscopic images and videos and have been shown to have remarkable accuracy for polyp detection in real time during colonoscopy procedures (64). Various CADe platforms like GI Genius (Medtronic), EndoScreener (Shanghai Wision AI Co., China), DISCOVERY (Pentax Medical), Endo-AID (Olympus), CADEYE (Fujifilm), Endoangel (Wuhan Medical Technology Co., Ltd. , Wuhan, China), EndoBRAIN-EYE (Cybernet Systems, Tokyo, Japan), SKOUT (Iterative Scopes, Cambridge, USA), MAGENTIQ-COLO (Magentiq Eye, Haifa, Israel), Eagle Eye, v. 5.1 (Xiamen Innovision, Xiamen, China), WISE VISION (NEC Co. , Tokyo, Japan) have been investigated in studies. Recently, a meta-analysis from 44 RCTs including 36,201 participants who underwent CADe-assisted colonoscopy reported higher ADR (44.8% vs. 37.4%; RR, 1.22) and polyp detection rate (56.1% vs. 47.9%; RR: 1.22) compared to standard colonoscopy (65). Utilizing distal attachment devices to improve mucosal exposure could confer additional benefits to CADe system by complementary mechanism of polyp detection. However, a meta-analysis of 4 RCTs demonstrated no additional benefit of using combination of CADe plus mucosal exposure device compared to CADe alone for ADR, AADR and SSLDR (66). The trial sequential analysis crossed futility boundaries, suggesting further comparison is unlikely to demonstrate any benefit in ADR (66). CADe can further improve ADR regardless of endoscopists’ experience. This was demonstrated by two companion multicenter RCT (AID-1/2) where in CADe was associated with higher ADR (RR 1.29), but examiner experience did not impact ADR (67). This was further established in a meta-analysis demonstrating that the benefit of CADe on ADR remains irrespective of endoscopists experience, setting or healthcare system (68). Emerging studies recognize diminishing returns on clinically meaningful outcomes, risk of endoscopists deskilling, cost considerations and lack of data from real world studies as potential pitfalls of CADe. In a meta-analysis, CADe system was associated with higher risk of non-neoplastic polyp resection (34.0% vs. 28.8%; RR: 1.11), withdrawal time (9.17 vs. 8.60 minutes) and inspection time (8.34 vs. 7.95 minutes) (65). The additional polyps detected by CADe system are diminutive (<5 mm) and likely of low malignant potential. Soleymanjahi et al., conducted a meta-analysis demonstrated that CADe use led to only marginal improvement in advanced colorectal neoplasia detection rate (12.7% vs. 11.5%, RR 1.16), no improvement in advanced colorectal neoplasia per colonoscopy, with the evidence being of low certainty given serious risk of bias and imprecision (65). CADe systems increases healthcare costs through device related costs, resection of benign mucosa leading to pathology related costs, increased need for surveillance and lack of reimbursement for the use of AI systems. A microsimulation model demonstrated CADe systems to be clinically implementable, if it can increase mean ADR from 26% to 30% or cost less than $579 per colonoscopy (69). However, benefits of CADe systems outside of RCT settings have not been proven. A meta-analysis of 8 real-world non-randomized studies, consisting of 9,782 patients demonstrated no additional benefit of CADe for improving ADR or APC, raising concerns for publication bias in prior published positive studies (70). Recently, Budzyń et al. demonstrated a significant decrease in the ADR of standard colonoscopy (28.4% vs. 22.4%) after exposure to routine AI use, raising concerns about endoscopists deskilling (71). The AGA did not make a recommendation in favor or against CADe use due to very low certainty of evidence for critical outcomes (64). Despite improvement in polyp detection potential, the future of CADe system remains unknown due to lack of clear sustainable benefits to patient outcomes including interval CRC incidence and mortality and barriers to real world adoption.

CADx systems can help distinguish between neoplastic and non-neoplastic polyps, thus reducing unnecessary removal of non-neoplastic polyps. Various CADx systems like GI Genius Intelligent Endoscopy Module version 3.0.0 (Medtronic), EndoBRAIN/EndoBRAIN-PLUS/EndoBRAIN-UC (Cybernet System Corps) and CADEYE (Fujifilm) are available for use. Each CADx system gets trained on a different dataset of polyps (72-74). A recent meta-analysis (10 studies with 4,103 small rectosigmoid polyps), demonstrated 87.3% sensitivity and 88.9% specificity of CADx in predicting neoplastic change (75). Among studies comparing histology prediction before versus after CADx (4 studies with 2,503 polyps), there was no difference in proportion of neoplastic polyps that were incorrectly classified (8.2% vs. 7.5%) or non-neoplastic polyps that could potentially avoid removal (55.4% vs. 58.4%) (75). The COMBO-CAD (Characterization cOMparison Between twO CAD systems) study conducted a head to head prospective comparison trial of CAD-EYE (Fujifilm Co., Tokyo, Japan) and GI-Genius (version 3.0.0; Medtronic) on 325 rectosigmoid polyps ≤5 mm in diameter (76). Both AI platforms performed similarly, in terms of sensitivity for adenomas (81.8% vs. 86.4%) and accuracy (93.2% vs. 91.5%) with a high concordance in histology (94.7%; κ=0.81) (76). The NPV of unassisted optical diagnosis (97.8%) was not different from NPV of either AI platforms (CAD-EYE: 96.9%; GI-Genius: 97.6%) (76). Despite enthusiasm, currently, the literature on CADx systems is from RCT in a highly controlled settings or comparison with high performing endoscopists. It will be interesting to see the outcomes of CADx systems in real world practice.

Do improvement in ADR translate to clinically meaningful outcomes?

ADR is considered a validated surrogate measure of neoplasia detection and along with SSLDR, are priority quality indicator of colonoscopy (11). In a landmark study from Polish National Screening Program (45,026 colonoscopies, 294 endoscopists), Kaminski et al. first established that ADR was an independent risk factor for interval CRC (77). Subsequently, Corley et al. in a study of 314,872 colonoscopies performed by 136 endoscopists, demonstrated that 1% increase in ADR was associated with a 3% decrease in interval CRC risk [hazard ratio (HR) 0.97] and a 5% decrease in fatal interval CRC (HR 0.95) (78). Schottinger et al. further demonstrated that inverse ADR-PCCRC relationship extended serially even to higher ADR cohort (40–44.9%) compared to ADR <20% (79). In another prospective study within a National Colorectal Cancer Screening Program, Kaminski et al. demonstrated that increasing endoscopists baseline ADR translated to decrease in interval CRC incidence (OR: 0.63) and mortality (0.50) (80). Recently, Huang et al. demonstrated that higher SSLDR was associated with a significantly lower PCCRC risk, showing a dose-dependent inverse association (81). ADR only first adenoma removed during colonoscopy. To reward detection of additional adenomas after removal of first, the Quality Task Force recommends consideration of APC in practices with high ADR (11). Eventually, the goal of colonoscopy is to reduce interval CRC incidence and mortality, and the technology that reduces PCCRC incidence may see earlier adoption in the real world practice. Figure 6 summarizes operator and technology dependent tools and techniques to optimize polyp detection.

Figure 6 Summary of operator and technology dependent tools and techniques to optimize polyp detection [Created in BioRender. Wilson, N. (2026) https://BioRender.com/69uf14r]. CADe, computer aided detection; CADx, computer aided diagnosis.

Improving polyp resection

Polyp morphology and classification

The goal of polypectomy is to resect polyps utilizing appropriate technique in a safe manner, minimizing the risk of recurrence, and development of PCCRC. Accurate optical diagnosis is the pre-requisite for safe polypectomy practices. Paris Classification is the most widely stratification tool to identify polyps with likelihood of advanced histology (82). Lesions are stratified into two categories: type 0 (superficial) and types 1–5 (advanced cancers). Lesions are considered superficial, when the depth of invasion is not beyond submucosa, based on endoscopic appearance (83). Figure 7 demonstrates morphological classification of type 0 lesions. Excavated (0–III) are rare in the colon (84). Lesions with depressed morphology (0–IIc) have 27–35.9% risk of submucosally invasive cancer (SMIC), risk rising to almost absolute for polyps >20 mm (85,86). First described in 1996, lateral spreading tumors (LSTs) are colorectal polyps >10 mm in size and either sessile (0-Is) or flat (O-II) in morphology extending laterally, in addition to vertically (87). Based on presence or absence of granularity, LSTs are further classified as LST-granular (LST-G), LST-non granular (LST-NG) or LST-mixed. The risk of SMIC is highest in polyps with LST-NG morphology (31.6%) while lowest in polyps with LST-G morphology (0.5%) (88).

Figure 7 Recommended algorithm to optimize polyp diagnosis and resection [Created in BioRender. Wilson, N. (2026) https://BioRender.com/xr4a9fz]. EMR, endoscopic mucosal resection; EFTR, endoscopic full thickness resection; NBI, narrow band imaging; NICE, NBI International Colorectal Endoscopic; SSL, sessile serrated lesion.

NBI can be useful adjunctive tools to predict polyp histology prior to deciding endoscopic resection technique. Using optical filters, NBI technology restricts endoscope illumination to blue and green, corresponding to absorption wavelength for hemoglobin, thus, enhancing the contrast between mucosa and blood vessels, and assessing distortion pattern in either. NBI International Colorectal Endoscopic (NICE) Classification is widely used and validated criteria to predict histology of polyp (Figure 4A-4F). A meta-analysis (28 studies; 6,280 polyps) assessing NBI colonoscopy demonstrated a sensitivity of 91% and specificity of 82.6% in assessing diagnostic characteristics (89). In a network meta-analysis of 9 RCT, amongst all IEE techniques, new generation NBI (AUC: 0.880) demonstrated highest performance for lesion characterization over other IEE techniques (61). Table 1 demonstrates a summary of optical diagnosis of colorectal polyps per NICE classification. Japanese Narrow-Band Imaging Expert Team (JNET) classification further classifies NICE type 2 polyp as JNET 2A (regular vascular pattern, regular tubular/branched surface pattern) with most likely histology being LGD and JNET 2B (variable caliber with irregular distribution, irregular or obscure surface pattern) with likely histology being high grade dysplasia (HGD) or superficial SMIC (90). Various other classification systems like Kudo pit classification, Workgroup serrAted polypS and Polyposis (WASP) classification enable endoscopists to predict histology prior to resection. ASGE study demonstrated >90% agreement in post-polypectomy surveillance intervals for diminutive polyps based on optical biopsy with NBI (91). The most clinically relevant utilization of optical diagnosis in routine colonoscopy practice are differentiating polyps with unfavorable histology that are not suitable for resection, leave diminutive sigmoid/rectal polyps with predicted histology being hyperplastic, resect and discard strategy for diminutive polyps, and removal of adenomatous polyp and serrated >5 mm polyps proximal to sigmoid colon.

Resection techniques for non-pedunculated polyps <10 mm

Majority of the colorectal polyps encountered in routine practices are either diminutive (≤5 mm) or small (6–9 mm). USMSTF recommends cold snare polypectomy (CSP) to achieve en bloc resection of sessile polyps <10 mm (92). (Figure 8A,8B) Cold biopsy forceps resection can be considered, if necessary for lesions ≤2 mm, and should be completed in one bite (92). The caliber of biopsy forceps may not allow en bloc removal of polyps, and the bleeding from mucosal disruption after first bite may preclude clear visualization of resection margins. Previously, a meta-analysis of 3 prospective studies, demonstrated significantly reduced incomplete polyp removal rate with cold snare compared to cold forceps (RR: 0.21) (93).

Figure 8 Demonstration of (A) cold snare polypectomy technique for polyp <10 mm with snare fully open to assess size of the polyp and (B) post polypectomy mild oozing which is usually self-limited.

A prospective, multicenter, RCT (CRESCENT study) assessed complete resection rate of CSP compared to hot snare polypectomy (HSP) for 4–9 mm polyps (94). Among 796 polyps, complete resection rate was 98.2% for CSP compared to 97.4% for HSP with 0.5% delayed bleeding in HSP cohort (94). Other prospective randomized trials have demonstrated efficacy of CSP with superior safety profile compared to HSP (95-97). In comparison, hot forceps polypectomy is associated with higher incomplete polyp removal rates, and deep thermal injury and should be avoided (98). Endoscopic surveillance should be performed for individuals with history of polypectomy due to increased risk of future CRC. Individuals with low risk adenoma (1–2 tubular adenomas <10 mm) should undergo surveillance colonoscopy in 7–10 years while those with 1–2 SSLs <10 mm should undergo surveillance in 5–10 years (99). Individuals with 3-4 adenomas/SSLs should undergo colonoscopy in 3–5 years while those with 5–10 adenomas/SSLs can undergo surveillance in 3 years (99). Guidelines recommend surveillance colonoscopy after 1 year in individuals with >10 adenomas (99).

Resection techniques for non-pedunculated polyps 10–19 mm

Optimal resection strategy for non-pedunculated polyps 10–19 mm remains less well defined compared to small or large (≥20 mm) polyps. USMSTF recommends cold or HSP with or without submucosal injection (Figure 9A-9C). Importantly, the endoscopist should perform careful WLE and NBI to ensure that no features of SMIC are present. The decision to perform CSP or HSP should be made after considering morphology, bulk, predicted histology and size while balancing the risk of immediate and delayed adverse events (AEs). Larger polyp size (15–19 mm), bulky or sessile morphology and adenomatous histology may be difficult to transect en bloc with cold snare and may need piecemeal resection. HSP or hot-EMR (h-EMR) should be considered for larger or bulky adenomas. Submucosal injection prior to hot polypectomy may provide a cushion for thermal energy, thus preventing deep mural injury and decrease immediate bleeding risk by providing a tamponade effect. A prospective RCT assessing CSP, C-EMR and h-EMR for 763 polyps 6–20 mm in size reported 81.6%, 94.1%, and 95.5% complete resection rates respectively (100). The incomplete resection rate was 53% in 16–20 mm size (100). h-EMR was associated with a higher rate of delayed bleeding compared to C-EMR (2.6% vs. 1.2%). On the other hand, flat (Paris IIa and IIb) and serrated lesions may be effectively removed with cold snare techniques (CSP or C-EMR) (92). Data for effectiveness for cold resection techniques for SSLs ≥10 mm is robust, with safety and efficacy maintained for large sized SSLs. For larger sized polyps, typically submucosal injection with lifting agent is performed to better delineate the border, followed by piecemeal resection. Operator technique is l the most important factor in decreasing risk of residual adenoma after CSP (101). Cold resection techniques are associated with low recurrence rates (0–10%), and post polypectomy bleeding (0–3%) (92).

Figure 9 Demonstration of (A) a 15-mm semi-pedunculated polyp, (B) with submucosal injection to delineate polyp borders and (C) polypectomy base after successful cold endoscopic mucosal resection.

One of the challenges for lesions >15 mm is slippage of snare during lesion capture after submucosal lift. Modification of conventional EMR techniques such as anchoring/tip-in EMR or precutting EMR may circumvent the issue of snare slippage. Tip-in EMR involves snare tip fixation in submucosa using electrocautery after submucosal injection to anchor the snare prior to resection. STAR trial demonstrated significantly higher odds of en bloc resection (OR: 3.46) with tip-in EMR compared to standard technique without increase in AE risk for 15–25 mm lesions (102). Pre-cutting EMR involves making a circumferential incision using a snare tip or endoscopic submucosal dissection (ESD) knife after lifting. In a meta-analysis of 12 studies, precutting EMR outperformed conventional EMR in en bloc resection rates (RR 1.17) and R0 resection rates (RR 1.34), particularly for flat lesions in the right colon (103). A recent randomized trial assessing precutting EMR compared to tip-in EMR for resection of 10–25 mm lesions demonstrated similar R0 resection rate, AE rate with both techniques, but, tip-in EMR was significantly faster (104).

Resection techniques for non-pedunculated polyps ≥20 mm

EMR is considered the preferred technique for removal of large non-pedunculated colorectal polyps (LNPCPs) ≥20 mm in size (Figure 10A-10F). A multicenter RCT (CHRONICLE) assessed outcomes of C-EMR compared to h-EMR in 396 LNPCPs ≥20 mm and reported significantly higher rates of residual adenoma after C-EMR (23.7% vs. 13.8% ; OR: 1.94) (105). h-EMR was associated with significantly higher rates of major AEs (7.9% vs. 1.0%), perforation (3.9% vs. 0%) and bleeding (4.4% vs. 1%) (105). In another multicenter RCT, comparing C-EMR with h-EMR in 660 patients with LNPCPs ≥ 20 mm, Pohl et al. demonstrated lower recurrence with h-EMR (13.6% vs. 27.6%) and higher severe adverse events (SAEs) (5% vs. 1.4%) (106). Overall, h-EMR is associated with decreased risk of residual adenomas at the risk of increased post-procedural AEs and these findings have been confirmed in other trials and meta-analyses (107-109). Adjuvant thermal ablation using argon plasma coagulation or snare tip soft coagulation should be performed after piecemeal h-EMR once no endoscopically visible adenomatous tissue remains to decrease the risk of recurrence (92). In another prospective study of 390 large lateral spreading lesions, adjuvant thermal ablation after EMR was associated with a significantly reduced risk of recurrence compared to controls (5.2% vs. 21.0%; RR: 0.25) (110). USMSTF recommends surveillance colonoscopy in individuals with adenomas or SSLs ≥10 mm, villous histology or HGD, SSL with dysplasia and traditional serrated adenoma after 3 years (99). Follow up colonoscopy should be performed in 6 months, followed by one year and three year after piecemeal EMR of lesions ≥20 mm (92).

Figure 10 Demonstration of (A) a 20 mm sessile cecal polyp, (B) with submucosal injection to prior, (C) hot snare polypectomy, (D) mucosal defect after hot endoscopic mucosal resection (E) defect closure with endoscopic clips and (F) polyp retrieval using a roth net.

Resection techniques for pedunculated polyps ≥10 mm

The stalk of the pedunculated polyps often contains a feeding vessel, posing risk of immediate bleeding after stalk transection. Pedunculated polyps ≥10 mm should be resected en bloc ensuring negative margins using HSP technique to decrease the risk of immediate bleeding (92). CSP can be performed for small pedunculated polyps (<10 mm). A meta-analysis of six studies including 1,025 patients, demonstrated pooled en-bloc resection of 99.7% after CSP of small pedunculated polyps (111). CSP was associated with increased risk of immediate bleeding (RR: 7.89), but lower rate of delayed bleeding (RR: 0.05), compared to HSP (111). Prophylactic polyp stalk ligation using clip or detachable loop should be performed for lesions with stalk thickness ≥5 mm or head ≥20 mm (92). Ji et al. conducted a RCT in 195 patients with pedunculated colorectal polyps, with heads ≥10 mm and stalks ≥5 mm in diameter to assess clips compared to endoloop and demonstrated similar bleeding rates in both groups (112). Injection of 4–8 mL, 1:10,000 epinephrine into polyp head and stalk may be considered for pedunculated polyps ≥30 mm to reduce polyp size, to allow the snare over polyp head to ensure en bloc resection and assess the extent of histological invasion (Haggitt level) during histological exam. ESD is an alternate technique for polyps with very thick stalks or severe fibrosis. In a retrospective study of 29 large pedunculated polyps that were not resectable by polypectomy or EMR, en bloc resection could be achieved with ESD in 95.6% with curative resection rate of 85.7% (113).

Underwater EMR

First described by Binmoeller et al. in 2012, underwater endoscopic mucosal resection (uEMR) is becoming popular for removal of LNPCPs (114). The technique involves filling colon lumen with saline and the buoyancy effect of saline allows mucosa and submucosa of polyp to float away while muscularis propria layer remains in place (Figure 11A-11D). This phenomenon occurs due to anti-gravity effect of submucosal fat. The separation of submucosa from muscularis propria, obviates the need for submucosal injection. Multiple studies and meta-analysis have demonstrated superior en bloc resection, lower incomplete polyp resection rate and reduced recurrence with uEMR technique over h-EMR for LNPCPs (115-117). Binmoeller et al. conducted first prospective study on uEMR for large LSTs (>20 mm), demonstrating en bloc resection rate of 55%, R0 rate of 46% with 5% recurrence (118). In a meta-analysis of eleven studies, consisting of 1,071 polyps >20 mm in uEMR arm and 1,049 in h-EMR arm, uEMR was associated with superior en bloc resection rate (OR: 1.9), lower polyp recurrence (OR: 0.3) and incomplete resection rates (OR: 0.4) (115). Nagl et al. conducted a prospective randomized trial assessing uEMR compared to h-EMR for removal of sessile or flat colorectal polyps between 20 and 40 mm in size (119). uEMR cohort had a significantly higher en bloc resection rate (33.3% vs. 18.4%), R0 resection rate (32.1% vs. 15.8%) and lower resection time (8 vs. 14 min), with a similar recurrence rate (15.1% vs. 24.6%; P=0.25) (119). However, recurrence rate for polyps between >30 mm to 40 in size, were significantly lower in the uEMR group (6.3% vs. 42.9%) (119). Recently, there’s encouraging data about technical feasibility and efficacy of the technique for LNPCPs ≥40 mm in size (120).

Figure 11 Demonstration of (A) large pedunculated colorectal polyp under white light imaging, (B) snare successfully captures the entire polyp after saline immersion, (C) post-polypectomy site with no residual polypoid tissue and (D) en bloc resected and retrieved specimen.

ESD

Endoscopic resection is effective therapy for management of colorectal neoplasia. Majority of the LNPCPs can be removed via piecemeal EMR technique. ESD should be considered for LNPCPs ≥10 mm with suspected superficial submucosal invasion (92) (Figure 12A-12F). Large lesions with morphological features predictive of submucosal invasion, those with underlying fibrosis, residual early carcinoma after ER or non-polypoid colorectal dysplasia in IBD patients should be considered for ESD (121). Lesions with morphological classification Paris class IIc and IIa + IIc, non-granular surface pseudodepressed type, presence of NICE III and Kudo pit pattern V features predict presence of submucosal invasion (122). The first attempt at resection confers the best chance at success and prior attempt is a risk factor for lack of efficacy (122). Endoscopists should carefully assess lesions and large, complex, superficial neoplasms should be referred to high volume, expert centers. Non-lifting sign during endoscopy has overall accuracy of 94.8% and positive predictive value of 80% in determining the depth of invasion (123). However, non-lifting sign may also occur due to fibrosis from prior biopsy, electrocautery use and/or tattooing, and these lesions are considered appropriate for endoscopic resection (92). Non-lifting sign during endoscopy when presented with other high risk features, should alert endoscopist to consider invasive cancer and referral to surgery (92). In a Japanese multicenter, observational study assessing endoscopic resection in 1,845 early colorectal neoplasms ≥20 mm, en bloc resection could be achieved in only 56.9% in h-EMR arm compared to 94.5% in ESD arm (124). In a large multicenter RCT of EMR compared to ESD for ≥25 mm colonic lesions, Jacques et al. demonstrated significantly lower 6 months recurrence after ESD compared to EMR (0.6% vs. 5.1%, RR: 0.12), at a risk of increased AEs (35.6% vs. 24.5%; RR: 1.4) (125). ESD is associated with up to 8% risk of delayed bleeding, 0.5% risk of delayed perforation and prophylactic clip closure may be considered to mitigate the risk of delayed AEs (126-128). Bahin et al. preformed an incremental cost-effectiveness analysis using a decision tree model for lateral spreading lesions >20 mm comparing wide field EMR, universal ESD and selective ESD for lesions highly suspicious for containing submucosal invasive cancer with wide field EMR for the remainder lesions (129). Authors demonstrated that only 43 ESDs are required per 1,000 lateral spreading lesions and selective ESD was the most cost effective approach (129). Selective ESD rather than universal ESD of all lesions may be most feasible in the US given limited centers of expertise. This approach can be considered justified from health economics standpoint as well.

Figure 12 Demonstration of (A) lesion with marking prior to endoscopic submucosal dissection under white light imaging, (B) mucosal incision, (C) submucosal dissection of lesion, (D) defect examined after specimen resection, (E) defect on retroflexion and (F) prophylactic defect closure to prevent delayed adverse events.

Endoscopic full thickness resection (EFTR)

EFTR using full thickness resection device (FTRD; Ovesco Endoscopy, Germany; Padlock, Steris, USA) can allow for removal of lesions with underlying fibrosis and not amenable to EMR or ESD (130,131). (Figure 13A-13C) A meta-analysis of 14 studies with EFTR performed in 1936 patients demonstrated technical success in 87.6%, R0 resection rate in 78.8%, AEs in 12.2% and recurrence in 12.6% (132). In a retrospective study comparing ESD to EFTR for residual colorectal neoplasia, both techniques achieved similar R0 resection rates (83.3% vs. 77.6%, P=0.25) (133). However, for lesions 20–30 and 30–40 mm, the R0 rates in EFTR arm decreased to 57.1% and 33.3% respectively (133). This is consistent with other studies demonstrating decreasing R0 rates with increasing lesion sizes for EFTR (132). ESD remains the preferred resection strategy for lesions suspicious of superficial submucosal invasion. However, the technique has a steep learning curve, resource intensive with limited availability, and EFTR is a reasonable alternate strategy for suitable lesions. Recently, a retrospective multicenter study demonstrated feasibility of EFTR for removal of T1 CRC with R0 rate of 85% and curative resection rate of 46.7% (134). Lesions >3 cm may not be suitable for EFTR as the FTR device cap can only fit lesions up to this size. However, hybrid ESD-EFTR techniques can allow for successful EFTR of larger lesions up to 35 mm, overcoming lesion size limitation of EFTR (135).

Figure 13 Demonstration of transverse colon polyp with scarring under (A) white light imaging, (B) narrow band imaging. (C) Endoscopic full thickness resection using full thickness resection device was used for successful full thickness resection of the polyp.

Managing post polypectomy complications

A meta-analysis of 21 studies including 1,966,340 colonoscopies reported post-polypectomy bleeding rate of 9.8/1,000 and perforation rate of 0.8/1,000 (136) (Figure 14A-14C). Risk factors of post-polypectomy bleeding include lesion size ≥10 mm, LSTs, pedunculated lesions with thick stalk, right colon location, and patient related factors like cardiovascular or renal comorbidities and utilization of anticoagulants (137). Previous studies have assessed the role of prophylactic clipping to reduce the risk of post polypectomy bleeding. In a meta-analysis of 9 RCT with 71,897 colorectal lesions (22.5% 20-mm or larger; 49.2% with proximal location), post polypectomy bleeding was similar in clipping compared to no clipping cohort (2.2% vs. 3.3%). However, clipping cohort reduced bleeding risk in patients with polyps ≥20 mm (RR: 0.51) or proximal colon polyps (RR: 0.53) (138). Defect closure after ESD reduces the risk of delayed bleeding for right colon lesions (2.4% vs. 10.4%) (128).

Figure 14 Demonstration of intraprocedural (A) pulsatile bleeding (arrow) after endoscopic full thickness resection, (B) successful application of thermal therapy via hemostatic forceps and (C) resolution of bleeding after successful endoscopic therapy.

Intra-procedural perforations occur when excessive tissue is grasped within snare leading to transection of muscularis propria layer while delayed perforations occur due to electrocautery related tissue necrosis. (Figure 15A,15B) In a study of EMR of 911 colonic laterally spreading lesions with mean size 37 mm, deep mural injury was noted in 10.3% (139). Careful inspection of the resection site for deep mural injury or defects should be performed after large polypectomy. Prophylactic endoscopic clipping can be useful if resection extends to muscularis propria layer (140). Endoscopists performing EMR or ESD should be confident in prompt recognition of any intraprocedural perforation and defect closure methods including through the scope clipping, over the scope clipping and endoscopic suturing. Rarely, pneumoperitoneum can occur intra-operatively from bowel perforations and prompt recognition followed by needle decompression can be lifesaving (141).

Figure 15 Demonstration of (A) delayed full thickness perforation after rectal endoscopic submucosal dissection, and (B) successful endoscopic closure of the perforation using a combination of endoscopic suturing and endoclips.

Post-polypectomy electrocoagulation syndrome occurs due to serosal inflammation from electrocautery related full thickness injury and localized peritonitis. Patients present with fever, localized abdominal tenderness and leukocytosis and abdominal imaging demonstrates localized edema and wall thickening but no free intra-peritoneal air. Majority of the patients recover with conservative management consisting of intravenous fluids and antibiotics.

Polypectomy site surveillance

Surveillance colonoscopy after endoscopic resection involves careful evaluation of resection site, often leading to identification of scar tissue. Targeted biopsy of scar tissue is performed at follow up, however, the yield is low (142,143). A validated NBI-SCAR classification has been proposed to assess post-resection scar (144). The tool utilizes evaluation with WLE and NBI for characteristics of scar. Endoscopic features of scar with recurrence include dark brown color, elongated/branched pit pattern, and dense capillary pattern signifying recurrence and whitish, pale appearance, round/slightly large pits, and irregular sparse vessels were considered features of non-recurrence scar tissue. Scars with 2 concordant features were diagnosed with “high confidence” (144). Overall, sensitivity of NBI-SCAR was higher (100% vs. 73.7%) compared to high definition white light exam, with similar results in validation phase of the study (144). A systematic evaluation of post-resection scar may obviate the need for unnecessary biopsy, however, the evidence outside of expert centers remain limited.

Conclusions

Colonoscopy is tier one screening modality for CRC and preferred surveillance modality after polypectomy. Detection and resection of polyps is the cornerstone of gastroenterology practices. Endoscopists should be encouraged to incorporation techniques for optimizing polyp detection and safe polypectomy. Endoscopists should recognize polyps with unfavorable histology, understand one’s own limitations and refer to expert centers for large polyp resection.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://tgh.amegroups.com/article/view/10.21037/tgh-2026-0054/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tgh.amegroups.com/article/view/10.21037/tgh-2026-0054/coif). M.B. reports consulting fees from Boston Scientific, Cook Medical, Steris Endoscopy, OVESCO Medical, and Microtech Endoscopy, and research support from ASPERO Medical. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent for publication of the accompanying images was not obtained from the patients or the relatives after all possible attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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