Large non-pedunculated colorectal polyp management: The elephant in the room

Abstract

Minimally invasive innovations have transformed coloproctology. Specific to colorectal cancer (CRC), there has been a shift towards less invasive surgical techniques and use of endoscopic resection as an alternative for low risk T1 CRC. The role of endoscopic resection is however much more extensive: It is now considered the first line management strategy for most large (≥ 20 mm) non-pedunculated colorectal polyps, the majority of which are benign. This is due to the well-established efficacy, safety, and cost-effectiveness of endoscopic techniques compared to surgery. Multiple endoscopic modalities now exist with distinct risk-benefit profiles and their outcomes are further improved by site-specific technical modifications, auxiliary techniques, and adverse event mitigation strategies. Endoscopic capacity continues to evolve with emerging endoscopic techniques and expanding applications, particularly in the confines of a multi-disciplinary setting.

Keywords: Cancer; Colonoscopy; Endoscopy; Polyp; Endoscopic mucosal resection; Endoscopic submucosal dissection

Core Tip: There is a movement towards minimally invasive management of colorectal disease, including the use of less invasive surgical techniques for colorectal cancer. Similarly, a paradigm shift in endoscopic resection has led to the development of a gamut of techniques, which are now first-line management strategies for most large (≥ 20 mm) non-pedunculated colorectal polyps (LNPCPs) - the majority of which are benign. This is due to their proven efficacy, safety and cost-effectiveness compared to surgery. With increasing detection of LNPCPs in universal screening programs, further adoption of an endoscopic approach in the era of minimally invasive resection techniques is anticipated.