Large polyps: Pearls for the referring and receiving endoscopist

Abstract

Polyps are precursors to colorectal cancer, the third most common cancer in the United States. Large polyps, i.e.,, those with a size ≥ 20 mm, are more likely to harbor cancer. Colonic polyps can be removed through various techniques, with the goal to completely resect and prevent colorectal cancer; however, the management of large polyps can be relatively complex and challenging. Such polyps are generally more difficult to remove en bloc with conventional methods, and depending on level of expertise, may consequently be resected piecemeal, leading to an increased rate of incomplete removal and thus polyp recurrence. To effectively manage large polyps, endoscopists should be able to: (1) Evaluate the polyp for characteristics which predict high difficulty of resection or incomplete removal; (2) Determine the optimal resection technique (e.g., snare polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, etc.); and (3) Recognize when to refer to colleagues with greater expertise. This review covers important considerations in this regard for referring and receiving endoscopists and methods to best manage large colonic polyps.

Keywords: Adenoma, Endoscopic mucosal resection, Endoscopic tattoo, Colorectal cancer, Polypectomy

Core Tip: Large polyps, often defined as ≥ 20 mm in size, are generally more challenging to resect than smaller polyps with regard to both difficulty of complete removal and risk of adverse events. To effectively manage large polyps, endoscopists should be able to evaluate them for characteristics which may increase the difficulty of endoscopic resection, determine the optimal resection technique, and recognize when to refer to colleagues for more advanced approaches. Herein, we review important considerations and methods to best manage large colonic polyps.