Large Colorectal Polyp Morphology Predicts Endoscopic Management Patterns

As techniques and technology have rapidly advanced over the past decade, endoscopy has had a large impact on how many gastrointestinal (GI) conditions are treated. “One of the biggest shifts we have made clinically in terms of the number of patients treated is endoscopic resection of large colorectal polyps,” says John Levenick, M.D., Penn State Hershey Gastroenterology and Hepatology. In the past, these would have been automatically referred for open or laparoscopic resection. However, not all large polyps exhibit the same clinical features and some pose relatively greater challenges and risks during resection. Levenick and colleagues determined how well an endoscopic approach performed for management across polyp types based on gross morphology.

In a retrospective analysis (2009 to 2014) of 344 large colorectal polyps (≥2 cm) referred for treatment at Penn State Hershey Medical Center, nearly all were successfully removed endoscopically. Median polyp size was 25-30 mm. Polyps with depressions or scars (Paris classification M1)1 more often required multiple sessions to achieve complete removal, compared to large polyps without scars or depression (Paris classification M0). M1 polyps were also more often associated with additional polyps identified at a follow-up colonoscopy. In most cases, endoscopic mucosal resection (EMR) using various “lift and cut” techniques was adequate for complete polyp removal; others required endoscopic submucosal dissection (ESD). Most were located proximal to the splenic flexure. Twelve polyps were not resected endoscopically and instead were surgically removed, due to biopsy results showing invasive cancer.

The review of such cases supports the safety and effectiveness of this shift toward endoscopic management of large colorectal polyps, including those with depressions and scars. Levenick notes, “Our analysis suggests clear clinical and cost advantages, with relatively few complications, compared to traditional surgical removal. The most common complication was bleeding.” The rationale for polypectomy for advanced adenomas, including polyps >2 cm, is based on evidence showing that such polyps have a higher risk of progressing to invasive cancer, particularly polyps in the proximal colon.

Lifting a polyp >2 cm before removal

1) Lifting a polyp >2 cm before removal

Complete removal of polyp shown at surveillance colonoscopy

2) Complete removal of polyp shown at surveillance colonoscopy


John M. Levenick, M.D.John M. Levenick, M.D.
Assistant Professor of Medicine
Phone: 717-531-0003, x289892 | E-mail:
Fellowships: Advanced endoscopy, Dartmouth Hitchcock Medical Center and Gastroenterology, Dartmouth Hitchcock Medical Center, Lebanon, NH
Residency: Internal medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH
Medical School: Stritch School of Medicine, Loyola University of Chicago, Maywood, IL


  1. Participants in the Paris Workshop. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon. November 30 to December 1, 2002. Gastrointest Endosc 2003;58(6):S3-S43.

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