Endoscopic Management of Large Non-Pedunculated Colorectal Polyps

Simple Summary Endoscopic resection (ER) of large non-pedunculated colorectal polyps & GE; 20 mm (LNPCPs) is safe, effective and the preferred treatment compared to surgery. Predicted histopathology of an LNPCP based on size, morphology, granularity, pit pattern and location in the colo-rectum is essential when deciding upon resection technique. Post resection defect inspection and adjuvant techniques, such as thermal ablation of the margin, have been demonstrated to reduce recurrence rates. Follow-up surveillance colonoscopy can accurately identify recurrence. Endoscopic treatment of recurrence is effective. Large non-pedunculated colorectal polyps & GE;20 mm (LNPCPs) comprise approximately 1% of all colorectal polyps. LNPCPs more commonly contain high-grade dysplasia, covert and overt cancer. These lesions can be resected using several means, including conventional endoscopic mucosal resection (EMR), cold-snare EMR (C-EMR) and endoscopic submucosal dissection (ESD). This review aimed to provide a comprehensive, critical and objective analysis of ER techniques. Evidence-based, selective resection algorithms should be used when choosing the most appropriate technique to ensure the safe and effective removal of LNPCPs. Due to its enhanced safety and comparable efficacy, there has been a paradigm shift towards cold-snare polypectomy (CSP) for the removal of small polyps (<10 mm). This technique is now being applied to the management of LNPCPs; however, further research is required to define the optimal LNPCP subtypes to target and the viable upper size limit. Adjuvant techniques, such as thermal ablation of the resection margin, significantly reduce recurrence risk. Bleeding risk can be mitigated using through-the-scope clips to close defects in the right colon. Endoscopic surveillance is important to detect recurrence and synchronous lesions. Recurrence can be readily managed using an endoscopic approach.