Laparo-endoscopic resection for extensive and inaccessible colorectal polyps: a feasible and safe procedure

Combined endoscopic and laparoscopic surgery for the treatment of complex benign colonic polyps (CELS): Observational study

PURPOSE

Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment.

METHOD

Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated.

RESULTS

Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5-6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82.4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study.

CONCLUSION

CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

Multidisciplinary decision-making strategies may reduce the need for secondary surgery in complex colonic polyps - A systematic review and pooled analysis

AIM

The recognition of complex colonic polyps is increasing. Management varies considerably and the impact of this on clinical outcomes is unclear. The aim of this systematic review was to assess the impact of group decision-making strategies and defined selection criteria on the treatment outcomes of complex colonic polyps.

METHOD

A systematic literature review identified studies reporting complex polyp treatment outcomes and describing their decision-making strategies. Databases searched included PubMed, Web of Science, CINAHL and Scopus. Articles were identified by two blinded reviewers using defined inclusion criteria. The review protocol was registered on PROSPERO and performed in line with PRISMA guidelines.

RESULTS

There were 303 identified articles describing treatment outcomes of complex colonic polyps. Only nine of these fully described the decision-making strategy and met the inclusion criteria. Adverse events ranged from 1.3% to 10% across the studies. Unsuspected malignancy and secondary surgery rates ranged from 2.4% to 15.4% and 3.3% to 43.9%, respectively. Grouping of articles into a hierarchy of decision-making strategies demonstrated a sequential reduction in secondary surgery rates with improving strategies. There were no differences in comparisons of adverse event or unsuspected malignancy rates.

CONCLUSIONS

There is limited description of decision-making strategies and variability in reporting of studies describing complex polyp treatment outcomes. The use of multidisciplinary decision-making and defined selection criteria may reduce the need for secondary surgical intervention in complex colonic polyps, but further evidence is required to draw definite conclusions.

Combined endoscopic and laparoscopic surgery for the treatment of complex benign colonic polyps (CELS): observational study

PURPOSE

Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment.

METHOD

Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated.

RESULTS

Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5 - 6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82,4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study.

CONCLUSION

CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

Combined endo-laparoscopic surgery for difficult benign colorectal polyps

Prevention of colorectal cancer (CRC) depends largely on the detection and removal of colorectal polyps. Despite the advances in endoscopic techniques, there are still a subgroup of polyps that cannot be treated purely by endoscopic approach, which comprise of about 10-15% of all the polyps. These so-called "difficult colorectal polyps" are polyps with large size, morphology, at difficult location, scarring or due to recurrence, which have historically been managed by surgical segmental resection. In treating benign difficult colorectal polyps, we have to balance the operative risks and morbidities associated with surgical segmental resection. Therefore, combined endoscopic and laparoscopic surgery (CELS) has been developed to remove this subgroup of difficult benign polyps. We review the currently use of CELS for difficult benign colorectal polyps which includes laparoscopy-assisted endoscopic polypectomy (LACP), full-thickness laparo-endoscopic excision (FLEX) and colonoscopy-assisted laparoscopic wedge resection (CAL-WR).

Evaluation of an early-stage innovation for full-thickness excision of benign colonic polyps using the IDEAL framework

AIMS

Colectomy is the current approach for patients with endoscopically unresectable benign polyps but risks considerable morbidity. Full-thickness laparoendoscopic excision (FLEX) is a novel procedure, specifically developed to treat endoscopically unresectable benign colonic polyps, which could reduce the treatment burden of the current approach and improve outcomes. However, traditional evaluations of surgical innovations lack methodological rigour. This study reports the development and feasibility of the FLEX procedure in selected patients.

METHOD

A prospective development study using the Idea, Development, Evaluation, Assessment, Long-term study (IDEAL) framework was undertaken, by one surgeon, of the FLEX procedure in selected patients with endoscopically unresectable benign colonic polyps. Three-dimensional (3D)-CT colonography reconstructions were used preoperatively to rehearse patient-specific, critical manoeuvres. Targetted, full-thickness excision was performed: after marking the margin of the caecal polyp using circumferential endoscopic argon plasma coagulation, transmural endoscopic sutures were used to evert the bowel and resection was undertaken by laparoscopic linear stapling. Feasibility outcomes (establishing 'local success') included evidence of complete polyp resection without adverse events (especially safe closure of the excision site).

RESULTS

Ten patients [median (interquartile range) age: 74 (59-78) years] with polyp median diameters of 35 (30-41) mm, were referred for and consented to receive the FLEX procedure. During the same time frame, no patient underwent colectomy for benign polyps. One further patient received FLEX for local excision of a presumed malignant polyp because severe comorbidity prohibited standard procedures. The FLEX procedure was successfully performed locally, with complete resection of the polyp and safe closure of the excision site, in eight patients. Three noncompleted procedures were converted to laparoscopic segmental colectomy under the same anaesthetic because of endoscopic inaccessibility (two patients) and transcolonic suture failure (one patient).

CONCLUSIONS

The FLEX procedure is still under development. Early data demonstrate that it is safe for excision of selected benign polyps. Modifications to transcolonic suture delivery are now required and there is a need for wider adoption before more definitive evaluation can be performed.

Laparoscopic and endoscopic cooperative surgery (LECS) to overcome the limitations of endoscopic resection for colorectal tumors

Background and study aims  We developed a laparoscopy endoscopy cooperative surgery (LECS) to overcome the limitations of endoscopic resection for colorectal tumors. The aim of this study was to evaluate the feasibility of LECS, which combines endoscopic submucosal dissection (ESD) and laparoscopic partial colectomy. Patients and methods  We performed LECS for 17 colorectal tumors in 17 patients (male:female 10:7; mean age, 66.5 years). The clinicopathological outcomes of these 17 cases and the feasibility of LECS were evaluated retrospectively. Indications for LECS were as follows: 1) intramucosal cancer and adenoma accompanied by wide and severe fibrosis; 2) intramucosal cancer and adenoma involving the diverticulum or appendix; and 3) submucosal tumors. Results  We successfully performed LECS procedures in 17 cases (intramucosal cancer [n = 6], adenoma [n = 9], schwannoma [n = 1], and gastro-intestinal stromal tumour [GIST] [n = 1]. Mean tumor diameter was 22.4 mm (range, 8 - 41 mm). LECS was successfully performed in all 17 cases without conversion to open surgery; the R0 rate was 100 %. LECS was applied to the following situations: involving the appendix (n = 6), tumor accompanied by severe fibrosis (n = 5), involving the diverticulum (n = 3), submucosal tumor (n = 2), and poor endoscopic operability (n = 1). We experienced no adverse events (e. g., leakage or anastomotic stricture) and the median hospital stay was 6.4 dayus (range, 4 to 12). All 17 patients who were followed for ≥ 3 months (median, 30.8 months; range, 3 - 72 months) showed no residual/local recurrence. Conclusion  LECS was a safe, feasible, minimally invasive procedure that achieved full-thickness resection of colorectal tumors and showed excellent clinical outcomes.

Management of complex polyps of the colon and rectum

PUPRPOSE

Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options.

METHODS

A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum.

RESULTS

Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery.

CONCLUSION

Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

The Difficult Colorectal Polyp

Difficult colorectal polyps represent lesions that pose a challenge to traditional endoscopic snare polypectomy. These polyps have historically been managed by surgical resection. Currently, several less invasive options are available to avoid colectomy. Repeat colonoscopy and snare polypectomy by an expert endoscopist, endoscopic mucosal resection, endoscopic submucosal dissection, and combined endoscopic and laparoscopic surgery have been developed to remove difficult polyps without the need for formal surgical resection. Patients with rectal polyps have the advantage of additional transanal minimally invasive techniques to enhance their resectability. Today, most colorectal polyps can be managed without the need for formal surgical resection.

Combined Endoscopic Laparoscopic Surgery Procedures for Colorectal Surgery

Colonoscopy is the standard of care for screening and surveillance of colorectal cancers. Removal of adenomatous polyps prevents the transformation of adenomas to potential adenocarcinoma. While most polyps are amenable to simple endoscopic polypectomy, difficult polyps that are large, broad-based, or located in haustral folds or in tortuous colon segments can present a challenge for endoscopists. Traditionally, patients with endoscopically unresectable polyps have been referred for oncologic surgical resection due to the underlying risk of malignancy within the polyp; however, the majority of these polyps are benign on final pathology. Combined endoscopic laparoscopic surgery can help facilitate endoscopic removal of difficult lesions, or allow the surgeon to select the correct laparoscopic approach for polyp excision. Current literature suggests that these procedures are safe and effective and can potentially save patients from the morbidity of laparotomy and segmental colectomy.

Intraoperative colonoscopy in patients with colorectal cancer: Review of recent developments

The use of intraoperative colonoscopy has increased alongside progress in the development of colonoscopy-associated devices and techniques, including the colonoscope itself. In the present review, we focus on four circumstances in which intraoperative colonoscopy is beneficial to colorectal surgery: (i) intraoperative determination of a tumor's location; (ii) observation of the proximal colon in cases of obstructive colorectal cancer; (iii) confirmation of the integrity of anastomosis; and (iv) novel surgical techniques that combine laparoscopic and endoscopic surgery. In light of the findings of our review, a combination of colonoscopy and surgery-especially laparoscopic surgery-is expected to facilitate the optimal handling of a variety of colorectal tumors, ranging from benign cases to advanced and obstructive cases.

Hybrid Laparoendoscopic Approaches to Endoscopically Unresectable Colon Polyps

Secondary prevention of colorectal cancer relies on effective screening through colonoscopy and polypectomy. Resection of some polyps can present technical challenges particularly when polyps are large, flat, or behind colonic folds. Laparoscopy as an adjunct to endoscopy can aid in removing difficult colonic polyps without subjecting patients to radical segmental colectomy. Hybrid laparoendoscopic techniques are increasingly reported in literature as alternatives to segmental colectomy for the treatment of polyps that have a high likelihood of being benign. Laparoscopic-assisted colonoscopic polypectomy is the most frequently utilized technique; it harnesses the power of laparoscopy to aid endoscopic polypectomy by flattening folds, mobilizing flexures, and providing retraction. Colonoscopy-assisted laparoscopic wedge and transluminal resection are often reported in older studies and use the visualization provided by intraoperative colonoscopy to guide colonic resection that is limited to the area of the polyp. Laparoscopic-assisted endoscopic full-thickness resection (EFTR) is a relatively recent technique that provides laparoscopic monitoring of EFTR of polyp as well as endoscopic closure of the ensuing defect. Minimally invasive segmental colectomy based on oncologic principles should be utilized when none of the previous techniques are suitable or when malignancy is strongly suspected. The combined use of laparoscopy and endoscopy can expand the endoscopist's armamentarium when dealing with the most challenging polyps, while serving the patients' best interest by limiting the extent of colon resection.

Efficacy and safety of laparo-endoscopic resections of colorectal neoplasia: A systematic review

OBJECTIVE

The purpose of this review is to assess the efficacy and safety of laparo-endoscopic local resections for colorectal lesions not suitable for endoscopic resection.

SUMMARY BACKGROUND DATA

The combined laparo-endoscopic approach has been proposed for large colorectal lesions unsuitable for endoscopic resection, in order to reduce morbidity of common laparoscopic resection. However, data on the efficacy and safety of laparo-endoscopic local resections are still controversial.

METHODS

An Embase search of papers published during the period 1985-2014 was performed. Published studies that evaluated laparo-endoscopic resections for colorectal lesions were assessed using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) recommendations by two authors. Forest plots on primary (per-lesion rate of further surgery, including surgery for complications and surgery for oncologic radical treatment) and secondary outcomes were produced based on fixed and random effects models. Heterogeneity was assessed using the I (2) statistic. Risk for within-study bias was ascertained with QUADAS (Quality Assessment of Diagnostic Accuracy Studies) system.

RESULTS

A total of 11 studies provided data on 707 lesions treated with a combined laparo-endoscopic approach. A variety of techniques were reported. The overall per-lesion rate of further surgery was 9.5%, while per-lesion rate of further surgery for oncologic treatment was 7.9%, per-lesion rate of further surgery for complications treatment was 3.5%, incidence of adenocarcinoma was 10.5%, incidence of overall complications was 7.9%, incidence of conversion to open surgery 4.3% and incidence of recurrence was 5.4%.

CONCLUSIONS

Despite laparo-endoscopic approach ensures limited invasiveness, it is affected by a consistent rate of complications and oncologic inadequacy that often requires further surgical treatment.

Systematic review of surgical innovation reporting in laparoendoscopic colonic polyp resection

Background

The IDEAL framework (Idea, Development, Exploration, Assessment, Long-term study) proposes a staged assessment of surgical innovation, but whether it can be used in practice is uncertain. This study aimed to review the reporting of a surgical innovation according to the IDEAL framework.

Methods

Systematic literature searches identified articles reporting laparoendoscopic excision for benign colonic polyps. Using the IDEAL stage recommendations, data were collected on: patient selection, surgeon and unit expertise, description of the intervention and modifications, outcome reporting, and research governance. Studies were categorized by IDEAL stages: 0/1, simple technical preclinical/clinical reports; 2a, technique modifications with rationale and safety data; 2b, expanded patient selection and reporting of both innovation and standard care outcomes; 3, formal randomized controlled trials; and 4, long-term audit and registry studies. Each stage has specific requirements for reporting of surgeon expertise, governance details and outcome reporting.

Results

Of 615 abstracts screened, 16 papers reporting outcomes of 550 patients were included. Only two studies could be put into IDEAL categories. One animal study was classified as stage 0 and one clinical study as stage 2a through prospective ethical approval, protocol registration and data collection. Studies could not be classified according to IDEAL for insufficient reporting details of patient selection, relevant surgeon expertise, and how and why the technique was modified or adapted.

Conclusion

The reporting of innovation in the context of laparoendoscopic colonic polyp excision would benefit from standardized methods.

Endolaparoscopic removal of colonic polyps

AIM

A proportion of colonic polyps is not amenable to exclusively colonoscopic removal due to their location, size or tortuosity of the colon. A combined laparoscopic/colonoscopic polypectomy or endolaparoscopic polypectomy (ELP) is an alternative to formal segmental resection. We present our experience of ELP.

METHOD

This is a retrospective review of a consecutive series of patients who underwent ELP for preoperatively diagnosed benign polyps between 2010 and 2013. Data are presented as median (interquartile range, IQR).

RESULTS

Thirty patients commenced ELP. Eighteen were male and the median (IQR) age was 65.4 (61.6-73.5) years. Of 30 attempted cases, 22 (73%) underwent successful ELP surgery. Patients in whom combined ELP surgery was unsuccessful were converted to laparoscopic colectomy (one) or colonic mobilization and colotomy (seven). The median operation time for successful ELP was 105 (75-125) min. The complication rate was 13.3% and the median length of stay was 2.0 (1.0-3.0) days for successful ELP compared with 5.5 (3.5-6.8) days for converted patients (P = 0.014). The median polyp size was 14 (10-22) mm; eight (26.7%) had high-grade dysplasia with two cases of invasive cancer identified.

CONCLUSION

A combined endoscopic-laparoscopic approach provides an alternative to segmental resection for treating challenging colonic polyps. This approach appears to be safe and effective and should be offered to selected patients with benign colonic polyps.

A prospective case controlled study of the short-term outcome following hemicolectomy for benign compared with malignant colonic polyps

AIM

The number of patients diagnosed with advanced colonic polyps has increased due to screening. The outcome of hemicolectomy for benign lesions is poorly documented. We present a case-matched study comparing the results of hemicolectomy for benign and malignant polyps performed in two institutions.

METHODS

Data for consecutive patients undergoing surgery for benign colonic polyps (BCPs) were prospectively collected in two hospitals. Each patient was matched for age, sex, ASA grade, site and type of resection (laparoscopic, open and converted) with two controls who underwent surgery for colon cancer (CC). The length of stay (LOS) and 30-day outcome were analysed adjusting for potential confounders. Multilevel linear and logistic regression analyses were performed.

RESULTS

Forty-six patients having hemicolectomy for BCP were matched with 81 patients with CC. The median size of BCP was 4 cm [interquartile range (IQR) 2.5-5.4 cm]. Patients with a BCP had a marginally longer LOS [median 5.5 (IQR 4-8) days and 5 (IQR 3-7) days (P = 0.04)]. Twenty-one (46%) of 46 patients with BCP had a postoperative complication compared with 25 (31%) of 81 CC patients (P = 0.12, OR = 2.11, 95% CI 0.82-5.41). Four (9%) of 46 patients with BCP underwent re-operation and a further three (7%) were readmitted compared with one (1%) and two (2%) of 81 patients with CC (P = 0.07 and 0.28). There was no mortality in either group.

CONCLUSION

Complications following hemicolectomy for BCP or CC are not significantly different. The results of the study provide further impetus to develop local full thickness colonic excision for benign colonic lesions as an alternative to major surgery.

New technique of en bloc resection of colorectal tumor using laparoscopy and endoscopy cooperatively (laparoscopy and endoscopy cooperative surgery - colorectal)

BACKGROUND AND AIM

Various factors make complete en bloc resection by endoscopic techniques alone of some laterally spreading colorectal tumors difficult or unsafe. Drawing on recent radical developments in endoscopic and laparoscopic techniques for managing colorectal lesions, we aimed to develop a safe resection procedure by using a combination of laparoscopy and endoscopy. We have named this procedure laparoscopic endoscopic cooperative colorectal surgery.

PATIENTS

We have performed this procedure on 3patients who had laterally spreading colorectal tumors. The factors contraindicating endoscopic submucosal dissection were submucosal fibrosis because of previous endoscopic mucosal resection in 1 patient and multiple surrounding diverticula in 2 patients.

TECHNIQUE

The patient is placed under general anesthesia and 5 ports are inserted. Following confirmation of the tumor location by endoscopy and laparoscopy, the colon wall at this site is exposed. First, a mucosa-to-submucosa dissection circumferential to the lesion with an appropriate safety margin is performed endoscopically. Complete full-thickness dissection and excision is then performed by using ultrasonic activating scissors, endoscopy, and laparoscopy cooperatively. The excised lesion is withdrawn intraluminally with endoscopic forceps. The opened colon is then closed with laparoscopic linear staplers.

RESULTS

The mean operating time and blood loss in this series were 205 minutes and 13 mL. There were no intraoperative or postoperative complications. Histological examination revealed tubular adenomas with severe dysplasia and adequate surgical margins in all cases.

CONCLUSION

Laparoscopic endoscopic cooperative colorectal surgery involves removal of a minimal length of colon and is a feasible procedure for en bloc resection of some colonic lateral spreading tumors that would be difficult to resect endoscopically.

Endoscopy and polyps-diagnostic and therapeutic advances in management

Despite multiple efforts aimed at early detection through screening, colon cancer remains the third leading cause of cancer-related deaths in the United States, with an estimated 51000 deaths during 2013 alone. The goal remains to identify and remove benign neoplastic polyps prior to becoming invasive cancers. Polypoid lesions of the colon vary widely from hyperplastic, hamartomatous and inflammatory to neoplastic adenomatous growths. Although these lesions are all benign, they are common, with up to one-quarter of patients over 60 years old will develop pre-malignant adenomatous polyps. Colonoscopy is the most effective screening tool to detect polyps and colon cancer, although several studies have demonstrated missed polyp rates from 6%-29%, largely due to variations in polyp size. This number can be as high as 40%, even with advanced (> 1 cm) adenomas. Other factors including sub-optimal bowel preparation, experience of the endoscopist, and patient anatomical variations all affect the detection rate. Additional challenges in decision-making exist when dealing with more advanced, and typically larger, polyps that have traditionally required formal resection. In this brief review, we will explore the recent advances in polyp detection and therapeutic options.

Combined endoscopic-laparoscopic resection of colon polyps

AIMS

To analyze the current literature on combined endoscopic-laparoscopic resection of colon polyps and to compare this new approach to standard laparoscopic colonic resection for polyps not suitable for endoscopic resection.

RESULTS

Several studies demonstrated that with a combined endoscopic-laparoscopic approach, polyps were successfully resected in 82-91% with a low morbidity of 3-10% and a short hospital stay of 1-2 days. Segmental laparoscopic resection was necessary in only 9-12%, but had a conversion rate to open surgery of 15% with an average hospital stay of 6-11 days. A cancerous polyp was found in 6-13% after a combined approach, with lymph node metastasis in 6%. Recurrent polyps after a combined endoscopic-laparoscopic resection seem to be rare, but follow-up of most studies is short and incomplete.

CONCLUSION

Combined endoscopic-laparoscopic resection of colon polyps is feasible, safe, and has a high success rate. Malignant lesions can be treated laparoscopically during the same operation, avoiding the need for a second procedure, and with good long-term oncologic outcome.

Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions

Most colonic adenomas are ≤ 10 mm and are routinely treated by colonoscopic polypectomy with long-term health benefits. Nonpolypoid lesions ≥ 20 mm, whether sessile or flat and laterally spreading, are forms of advanced mucosal neoplasia that cannot be managed by conventional polypectomy and are often referred for surgery. However, the majority of these lesions when carefully assessed are found to be noninvasive and can be safely and effectively treated by advanced endoscopic techniques including endoscopic mucosal resection or endoscopic submucosal dissection with resultant cost, morbidity, and mortality benefits. Lesion assessment is a critical component. Enhanced imaging methods provide the opportunity for accurate pathological characterization, informing treatment decisions, without the need for previous histologic confirmation. Techniques of advanced endoscopic resection are still in evolution and further improvements, including hybrid techniques, bringing less technically challenging and shorter procedures with superior safety can be reasonably expected in the next decade. Safety is a fundamental consideration. Methods of early recognition of complications, risk stratification, and management pathways are being developed and refined. Standardization, validation, and adoption of these technological developments will improve endoscopic interpretation and therapy and in combination with an increased understanding of adenoma molecular biology, will result in a progressively more individualized lesion-specific endoscopic approach. The future of advanced endoscopic resection in the colon is promising, and the next few years should see the boundaries of endoscopic resection expand well beyond the limits of what we know today.