Skip to main content


Endoscopic mucosal resection (EMR) is a safe and effective treatment for large laterally spreading colorectal lesions. The safety and efficacy of EMR follows a key anatomical principle: complete tissue resection of a mucosal lesion above a submucosal fluid cushion to avoid injury to the deeper mural layers. The majority of polyps encountered have low risk of submucosal invasion and are suitably treated by EMR; however, appropriate lesion selection is fundamental to satisfactory patient outcomes. This chapter discusses endoscopic assessment of large colonic polyps, technical aspects of EMR, techniques to manage procedural related complications, and post-procedural follow-up of patients.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
USD 699.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 849.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others



cold forceps avulsion with adjuvant snare-tip soft coagulation




colorectal cancer


clinically significant post-endoscopic bleeding


deep mural injury


enhanced endoscopic imaging


endoscopic mucosal resection


endoscopic submucosal dissection


gastrointestinal tract


ileocecal valve


laterally spreading lesion


muscularis propria


post-polypectomy electrocoagulation syndrome


submucosal fibrosis


submucosal invasion


snare tip soft coagulation


topical submucosal chromoendoscopy


through the scope


underwater EMR


  1. Siegel RL, Fedewa SA, Anderson WF, Miller KD, Ma J, Rosenberg PS et al (2017) Colorectal cancer incidence patterns in the United States, 1974-2013. J Natl Cancer Inst 109(8)

    Google Scholar 

  2. Zauber AG, Winawer SJ, O'Brien MJ, Lansdorp-Vogelaar I, van Ballegooijen M, Hankey BF et al (2012) Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 366(8):687–696

    Article  CAS  Google Scholar 

  3. Ahlenstiel G, Hourigan LF, Brown G, Zanati S, Williams SJ, Singh R et al (2014) Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 80(4):668–676

    Article  Google Scholar 

  4. Jayanna M, Burgess NG, Singh R, Hourigan LF, Brown GJ, Zanati SA, et al (2016) Cost analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions. Clin Gastroenterol Hepatol 14(2):271–278. e1–2

    Google Scholar 

  5. Bahin FF, Heitman SJ, Rasouli KN, Mahajan H, McLeod D, Lee EYT et al (2018) Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 67(11):1965–1973

    Article  Google Scholar 

  6. Tutticci N, Klein A, Sonson R, Bourke MJ (2016) Endoscopic resection of subtotal or completely circumferential laterally spreading colonic adenomas: technique, caveats, and outcomes. Endoscopy 48(5):465–471

    Article  Google Scholar 

  7. Tutticci N, Sonson R, Bourke MJ (2014) Endoscopic resection of subtotal and complete circumferential colonic advanced mucosal neoplasia. Gastrointest Endosc 80(2):340

    Article  Google Scholar 

  8. Sidhu M, Tate DJ, Desomer L, Brown G, Hourigan LF, Lee EYT et al (2018) The size, morphology, site, and access score predicts critical outcomes of endoscopic mucosal resection in the colon. Endoscopy 50(7):684–692

    Article  Google Scholar 

  9. Participants in the Paris W The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon. Gastrointest Endosc 58(6):S3–S43

    Google Scholar 

  10. Moss A, Bourke MJ, Williams SJ, Hourigan LF, Brown G, Tam W et al (2011) Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 140(7):1909–1918

    Article  Google Scholar 

  11. Burgess NG, Hourigan LF, Zanati SA, Brown GJ, Singh R, Williams SJ, et al (2017) Risk stratification for covert invasive cancer among patients referred for colonic endoscopic mucosal resection: a large multicenter cohort. Gastroenterology 153(3):732–742. e1

    Google Scholar 

  12. Coletta M, Sami SS, Nachiappan A, Fraquelli M, Casazza G, Ragunath K (2016) Acetic acid chromoendoscopy for the diagnosis of early neoplasia and specialized intestinal metaplasia in Barrett’s esophagus: a meta-analysis. Gastrointest Endosc 83(1):57–67.e1

    Article  Google Scholar 

  13. Brown SR, Baraza W, Din S, Riley S (2016) Chromoscopy versus conventional endoscopy for the detection of polyps in the colon and rectum. Cochrane Database Syst Rev 4:Cd006439

    PubMed  Google Scholar 

  14. dos Santos CE, Lima JC, Lopes CV, Malaman D, Salomao AD, Garcia AC et al (2010) Computerized virtual chromoendoscopy versus indigo carmine chromoendoscopy combined with magnification for diagnosis of small colorectal lesions: a randomized and prospective study. Eur J Gastroenterol Hepatol 22(11):1364–1371

    Article  Google Scholar 

  15. Kudo S, Rubio CA, Teixeira CR, Kashida H, Kogure E (2001) Pit pattern in colorectal neoplasia: endoscopic magnifying view. Endoscopy 33(4):367–373

    Article  CAS  Google Scholar 

  16. Ikematsu H, Matsuda T, Emura F, Saito Y, Uraoka T, Fu KI et al (2010) Efficacy of capillary pattern type IIIA/IIIB by magnifying narrow band imaging for estimating depth of invasion of early colorectal neoplasms. BMC Gastroenterol 10:33

    Article  Google Scholar 

  17. Hewett DG, Kaltenbach T, Sano Y, Tanaka S, Saunders BP, Ponchon T, et al (2012) Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology 143(3):599–607. e1

    Google Scholar 

  18. Dellon ES, Hawk JS, Grimm IS, Shaheen NJ (2009) The use of carbon dioxide for insufflation during GI endoscopy: a systematic review. Gastrointest Endosc 69(4):843–849

    Article  Google Scholar 

  19. Moss A, Bourke MJ, Metz AJ (2010) A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon. Am J Gastroenterol 105(11):2375–2382

    Article  CAS  Google Scholar 

  20. Burgess NG, Metz AJ, Williams SJ, Singh R, Tam W, Hourigan LF, et al (2014) Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 12(4):651–661. e1–3

    Google Scholar 

  21. Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau JM, Paspatis G et al (2017) Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 49(3):270–297

    Article  Google Scholar 

  22. Klein A, Tate DJ, Jayasekeran V, Hourigan L, Singh R, Brown G, et al (2019) Thermal ablation of mucosal defect margins reduces adenoma recurrence after colonic endoscopic mucosal resection. Gastroenterology 156(3):604–613. e3

    Google Scholar 

  23. Holt BA, Jayasekeran V, Sonson R, Bourke MJ (2013) Topical submucosal chromoendoscopy defines the level of resection in colonic EMR and may improve procedural safety (with video). Gastrointest Endosc 77(6):949–953

    Article  Google Scholar 

  24. Tate DJ, Desomer L, Klein A, Brown G, Hourigan LF, Lee EY, et al (2017) Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc 85(3):647–656. e6

    Google Scholar 

  25. Choksi N, Elmunzer BJ, Stidham RW, Shuster D, Piraka C (2015) Cold snare piecemeal resection of colonic and duodenal polyps >/=1 cm. Endosc Int Open 3(5):E508–E513

    Article  Google Scholar 

  26. Piraka C, Saeed A, Waljee AK, Pillai A, Stidham R, Elmunzer BJ (2017) Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm. Endosc Int Open 5(3):E184–E1E9

    Article  Google Scholar 

  27. Tutticci NJ, Hewett DG (2018) Cold EMR of large sessile serrated polyps at colonoscopy (with video). Gastrointest Endosc 87(3):837–842

    Article  Google Scholar 

  28. Tate DJ, Awadie H, Bahin FF, Desomer L, Lee R, Heitman SJ et al (2018) Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe. Endoscopy 50(3):248–252

    Article  Google Scholar 

  29. Schenck RJ, Jahann DA, Patrie JT, Stelow EB, Cox DG, Uppal DS et al (2017) Underwater endoscopic mucosal resection is associated with fewer recurrences and earlier curative resections compared to conventional endoscopic mucosal resection for large colorectal polyps. Surg Endosc 31(10):4174–4183

    Article  Google Scholar 

  30. Yamashina T, Uedo N, Akasaka T, Iwatsubo T, Nakatani Y, Akamatsu T, et al (2019) Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps. Gastroenterology 157(2):451–461. e2

    Google Scholar 

  31. Holt BA, Bassan MS, Sexton A, Williams SJ, Bourke MJ (2014) Advanced mucosal neoplasia of the anorectal junction: endoscopic resection technique and outcomes (with videos). Gastrointest Endosc 79(1):119–126

    Article  Google Scholar 

  32. Tate DJ, Desomer L, Awadie H, Goodrick K, Hourigan L, Singh R, et al (2018) EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video). Gastrointest Endosc 87(5):1279–1288. e2

    Google Scholar 

  33. Nanda KS, Tutticci N, Burgess NG, Sonson R, Williams SJ, Bourke MJ (2015) Endoscopic mucosal resection of laterally spreading lesions involving the ileocecal valve: technique, risk factors for failure, and outcomes. Endoscopy 47(8):710–718

    Article  Google Scholar 

  34. Ma MX, Bourke MJ (2016) Complications of endoscopic polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection in the colon. Best Pract Res Clin Gastroenterol 30(5):749–767

    Article  Google Scholar 

  35. Paspatis GA, Paraskeva K, Theodoropoulou A, Mathou N, Vardas E, Oustamanolakis P, et al (2006) A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am J Gastroenterol 101(12):2805. quiz 913

    Google Scholar 

  36. Kouklakis G, Mpoumponaris A, Gatopoulou A, Efraimidou E, Manolas K, Lirantzopoulos N (2009) Endoscopic resection of large pedunculated colonic polyps and risk of postpolypectomy bleeding with adrenaline injection versus endoloop and hemoclip: a prospective, randomized study. Surg Endosc 23(12):2732–2737

    Article  Google Scholar 

  37. Tate DJ, Bahin FF, Desomer L, Sidhu M, Gupta V, Bourke MJ (2018) Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesions. Endoscopy 50(1):52–62

    PubMed  Google Scholar 

  38. Tate DJ, Desomer L, Hourigan LF, Moss A, Singh R, Bourke MJ (2017) Two-stage endoscopic mucosal resection is a safe and effective salvage therapy after a failed single-session approach. Endoscopy 49(9):888–898

    Article  Google Scholar 

  39. Burgess NG, Williams SJ, Hourigan LF, Brown GJ, Zanati SA, Singh R et al (2014) A management algorithm based on delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 12(9):1525–1533

    Article  Google Scholar 

  40. Bahin FF, Naidoo M, Williams SJ, Hourigan LF, Ormonde DG, Raftopoulos SC, et al (2015) Prophylactic endoscopic coagulation to prevent bleeding after wide-field endoscopic mucosal resection of large sessile colon polyps. Clin Gastroenterol Hepatol 13(4):724–730. e1–2

    Google Scholar 

  41. Lee HS, Jeon SW, Kwon YH, Nam SY, Shin S, Kim R et al (2019) Prophylactic endoscopic coagulation to prevent delayed post-EMR bleeding in the colorectum: a prospective randomized controlled trial (with videos). Gastrointest Endosc 90(5):813–822

    Article  Google Scholar 

  42. Albeniz E, Alvarez MA, Espinos JC, Nogales O, Guarner C, Alonso P et al (2019) Clip closure after resection of large colorectal lesions with substantial risk of bleeding. Gastroenterology 157(5):1213–21.e4

    Article  Google Scholar 

  43. Desomer L, Tate DJ, Bahin FF, Awadie H, Chiang B, Holt B et al (2019) A systematic description of the post-EMR defect to identify risk factors for clinically significant post-EMR bleeding in the colon. Gastrointest Endosc 89(3):614–624

    Article  Google Scholar 

  44. Burgess NG, Bassan MS, McLeod D, Williams SJ, Byth K, Bourke MJ (2016) Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut

    Google Scholar 

  45. Swan MP, Bourke MJ, Moss A, Williams SJ, Hopper A, Metz A (2011) The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection. Gastrointest Endosc 73(1):79–85

    Article  Google Scholar 

  46. Bahin FF, Jayanna M, Williams SJ, Lee EY, Bourke MJ (2016) Efficacy of viscous budesonide slurry for prevention of esophageal stricture formation after complete endoscopic mucosal resection of short-segment Barrett’s neoplasia. Endoscopy 48(1):71–74

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Michael J. Bourke .

Editor information

Editors and Affiliations

Section Editor information

Rights and permissions

Reprints and permissions

Copyright information

© 2022 Springer Nature Switzerland AG

About this entry

Check for updates. Verify currency and authenticity via CrossMark

Cite this entry

Ma, M.X., Bourke, M.J. (2022). Endoscopic Mucosal Resection of Colorectal Lesions. In: Testoni, P.A., Inoue, H., Wallace, M.B. (eds) Gastrointestinal and Pancreatico-Biliary Diseases: Advanced Diagnostic and Therapeutic Endoscopy. Springer, Cham.

Download citation

  • DOI:

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-56992-1

  • Online ISBN: 978-3-030-56993-8

  • eBook Packages: MedicineReference Module Medicine

Publish with us

Policies and ethics