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.