Implementing population-based screening programs for colorectal cancer has led to an increase in the detection of large but benign histological lesions. Currently, endoscopic mucosal resection can be considered the standard technique for the removal of benign lesions of the colon due to its excellent safety profile and good clinical results. However, several studies from different geographic areas agree that many benign colon lesions are still referred for surgery. Moreover, the referral rate to surgery is not decreasing over the years, despite the theoretical improvement of endoscopic resection techniques. This article will review the leading causes for benign colorectal lesions to be referred for surgery and the influence of the endoscopist experience on the referral rate. It will also describe how to categorize a polyp as complex for resection and consider an endoscopist as an expert in endoscopic resection. And finally, we will propose a framework for the accurate and evidence-based treatment of complex benign colorectal lesions.

Background: Delayed bleeding (DB) occurs in ∼10% after colorectal EMR. Prophylactic clipping (PC) was reported to significantly decrease DB-rate in proximal lesions ≥2 cm.Objective: Our aim was to determine which predefined variables contribute to using PC in clinical practice.Methods: We performed an international discrete choice experiment (DCE) among ∼500 endoscopists. Relevant variables for PC use were selected by EMR experts: previous DB, anticoagulants, polyp size, morphology, location, intraprocedural bleeding and visible vessel(s). Respondents answered case scenarios with various variable combinations, each time choosing only one scenario for PC, or the 'none' option. Part-worth utilities and importance weights were calculated using HB regression. Subsequently, a predictive model was created to calculate the likelihood of endoscopists choosing PC in any given case.Results: The survey was completed by 190 EMR endoscopists from 17 countries. In total, 8% would never use PC, whereas 30.9% never chose the 'none' option. All variables except polyp type were significant in decision-making for PC (p < .01). The most important factor was anticoagulant use, accounting for 22.5% in decision-making. Polyps <2 cm were considered eligible for PC by 14% in the presence of high-weighing factors such as anticoagulant use. No significant differences were found between high and low-to-moderately experienced endoscopists.Conclusions: PC after EMR is often considered useful by endoscopists, usually based on risk factors for DB. Anticoagulant use was the most important factor in decision-making for PC, independent of endoscopist experience. Although not considered cost-effective, one in seven endoscopists chose PC for adenomas <2 cm.