Complex colorectal polyps
Treatment options in Shanghai

Endoscopic mucosal resection removes a lesion through the colonoscope, commonly using fluid to lift the tissue and a snare to cut it. A larger lesion may be removed in several pieces. The 2024 ESGE guideline supports EMR for many large nonpedunculated adenomatous polyps; size alone does not mean ESD is required. Piece-by-piece removal is a planned method in suitable cases, not automatically a failed operation. However, it affects how the specimen is interpreted and makes the follow-up plan for the treated site particularly important.

Endoscopic submucosal dissection uses a specialised cutting technique beneath the lesion to aim for removal in one piece. An intact specimen can be important when the team needs to evaluate suspected superficial invasion and resection margins. The choice depends on the lesion and the centre's expertise; ESD is not a universal upgrade for every flat polyp. Ask why one-piece removal is needed in your case and whether another technique could achieve the same clinical goal. Greater technical complexity must be weighed against the information and treatment benefit expected.

If invasive cancer is suspected or found, removing the visible polyp may not answer every cancer-management question. The depth and other pathological features may make further staging and surgical assessment necessary. Surgery may also be considered when safe, adequate endoscopic removal is not feasible. Conversely, being referred for an expert endoscopic opinion does not mean a cancer diagnosis has been made. Ask the team to explain which finding would change the plan from endoscopic treatment to surgery, both before removal and after the final pathology becomes available.