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A Pragmatic Approach to Complex Colon Polyps

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Gastrointestinal Interventional Endoscopy
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Endoscopic resection (ER) of complex colon polyps is safe and effective. Techniques of ER include endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). The majority of polyps encountered have low risk of submucosal invasion (SMI) and thus are suitably treated by EMR. Polyps with increased risk of superficial SMI are best removed en bloc as this allows accurate staging and potential cure. Polyps with suspected superficial SMI that are ≤20 mm in size are resectable by EMR, but larger lesions require resection by ESD. Polyps with obvious SMI, such as depressed lesions with disrupted surface pit pattern, require surgical resection. This chapter discusses endoscopic assessment of large colonic polyps, technical aspects of EMR and ESD and techniques to prevent and manage ER-related complications.

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Cold-forceps avulsion with adjuvant snare tip soft coagulation


Cold snare polypectomy


Clinically significant post-endoscopy bleeding


Deep mural injury


Endoscopic mucosal resection


Endoscopic resection


Endoscopic submucosal dissection


Flexible spectral imaging colour enhancement


Gastrointestinal tract


Ileocaecal valve


Intra-procedural bleeding


Laterally spreading lesion


Muscularis propria


Narrow band imaging


NBI International Colorectal Endoscopic


Odds ratio


Submucosal fibrosis


Submucosal invasion


Sessile serrated polyp


Snare tip soft coagulation


Target sign


Topical submucosal chromoendoscopy


Through the scope


Underwater endoscopic mucosal resection


White light endoscopy


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Correspondence to Michael J. Bourke .

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Electronic Supplementary Material

This video demonstrates the technique of dynamic submucosal injection and snare placement to optimise resection. A small bleeding arteriole is seen within the resected defect and is treated by snare tip soft coagulation (MP4 67918 kb)

This video demonstrates use of snare tip soft coagulation (STSC) to treat intra-procedural bleeding (IPB) during EMR (MP4 39826 kb)

This video demonstrates the technique of piecemeal EMR by defect edge as the starting point for the subsequent snare resections of a large LSL (MP4 18036 kb)

This video demonstrates the technique of cold-forceps avulsion with adjuvant snare tip soft coagulation (CAST) to remove small residual adenomatous islands within an EMR defect (MP4 38447 kb)

This video demonstrates the technique of snare tip soft coagulation (STSC) to the EMR margin to reduce the risk of adenomatous recurrence (MP4 32012 kb)

This video demonstrates a type IV DMI (perforation) within a clean resection field. Two clips are placed over this defect. The EMR procedure is completed following satisfactory closure of the perforation (MP4 66126 kb)

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Ma, M.X., Bourke, M.J. (2020). A Pragmatic Approach to Complex Colon Polyps. In: Wagh, M., Wani, S. (eds) Gastrointestinal Interventional Endoscopy. Springer, Cham.

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