Difficult colon polypectomy

Table 4 Technical tips and tricks to improve the resection of difficult colon polpys

	Difficult polyps	Technical tips
Morphology	Sessile	Use submucosal cushion
	> 1 cm	Resect in toto (except cecum)
Size and form	< 1.5 cm	Use diluted epinephrine and Perform piecemeal resection, EMR or ESD
	Large (> 3 cm), on top of folds, carpet-like polyp or with villous or granular surface
		Use APC for tissue remnants
	Big head	Use diluted epinephrine in head
	Pedunculated (if large)	Use clips or loops
	Thick pedicle	Use clips or loops
	Multiple	Send to pathologist separately
Number	Right colon and cecum	Do not use hot biopsy forceps
	Located behind folds	Inject distally first
Location	Difficult endoscope position	Change scope to 5 o’clock position
		Perform abdominal compression or change patient’s position
		Use antispasmodic (e.g., butylscopolamine)
		Take air out before catching or snaring the polyp
		Resect when going in (if small) or when going out (if large)
	Increased colon motility	Mark the polyp site with India ink
General recommendations	Suspicious polyp or large, incompletely resected
Abbreviations	APC	Argon plasma coagulation
	ESD	Endoscopic submucosal dissection
	EMR	Endoscopic mucosal resection

APC: Argon plasma coagulation; ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection.