Endoscopic Management of Complex Colorectal Polyps

Abstract Complex colorectal polyps pose a clinical challenge, particularly when lesions are large, nonlifting, or suspicious for submucosal (SM) invasion. While small polyps are readily managed with cold snare polypectomy, advanced endoscopic techniques are necessary to achieve complete resection and prevent progression to colorectal cancer (CRC). Endoscopic mucosal resection (EMR) is the most widely used approach due to its safety, efficiency, and broad applicability, with variants such as underwater and cold EMR improving resection quality and reducing thermal injury. However, EMR is limited in its ability to achieve en bloc resection for larger lesions. Endoscopic SM dissection offers higher en bloc and R0 resection rates and is preferred for lesions with suspected superficial SM invasion, though its use in Western practice is constrained by technical complexity, longer procedure times, and increased perforation risk. Accurate lesion characterization using classification systems such as Paris, Narrow Band Imaging International Colorectal Endoscopic, and Kudo pit patterns is essential for appropriate technique selection. Adverse events are uncommon and increasingly preventable with improved technique and prophylactic measures. Histopathologic assessment guides decisions regarding additional therapy and surveillance. Continued advances in endoscopic training, imaging, and hybrid approaches aim to reduce reliance on surgical colectomy and enhance CRC prevention.