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  • Review Article
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Colonoscopy: basic principles and novel techniques

Abstract

Colonoscopy is considered the 'gold standard' for detection and removal of premalignant lesions in the colon. However, studies suggest that colonoscopy is less protective for right-sided than for left-sided colorectal cancer. Optimizing the effectiveness of colonoscopy is a continuous process, and during the past decade several important quality indicators have been defined that can be used to measure the performance of colonoscopy and to identify areas for quality improvement. The quality of bowel preparation can be enhanced by split-dose regimens, which are superior to single-dose regimens. Cecal intubation rates should approximate 95% and can be optimized by good technique. In selected patients, specific devices can be used to facilitate cecal intubation. Adenoma detection rates should be monitored and exceed a minimum of 25% in men and 15% in women. To this aim, optimal withdrawal technique and adequate time for inspection are of utmost importance. Of all advanced imaging techniques, chromoendoscopy is the only technique with proven benefit for adenoma detection. Finally, the technique of polypectomy affects the number of complications as well as the success of completely removing a lesion. In this Review, we provide an overview of both standard and novel colonoscopy techniques and their impact on quality indicators.

Key Points

  • Quality assurance using a minimal set of indicators is essential to continuously improve the effectiveness of colonoscopy

  • Split-dose preparation is superior to single-dose preparation for both the quality of preparation and the tolerability

  • The use of variable stiffness colonoscopes is associated with a higher cecal intubation rate than are standard colonoscopes

  • Of all advanced imaging techniques, panchromoendoscopy is the only one proven to improve adenoma detection

  • Cold biopsy polypectomy seems to be associated with a high incomplete resection rate

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Figure 1: Representation of the magnetic endoscopic imaging system.
Figure 2: Advanced imaging of the colon.
Figure 3: Cap-assisted colonoscopy.
Figure 4: Paris endoscopy classification for superficial lesions.
Figure 5: Endoscopic mucosal resection.

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References

  1. Ko, C. W. et al. Serious complications within 30 days of screening and surveillance colonoscopy are uncommon. Clin. Gastroenterol. Hepatol. 8, 166–173 (2010).

    PubMed  Google Scholar 

  2. Rabeneck, L. et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice. Gastroenterology 135, 1899–1906 (2008).

    PubMed  Google Scholar 

  3. Singh, H. et al. Colonoscopy and its complications across a Canadian regional health authority. Gastrointest. Endosc. 69, 665–671 (2009).

    PubMed  Google Scholar 

  4. Levin, T. R. et al. Complications of colonoscopy in an integrated health care delivery system. Ann. Intern. Med. 145, 880–886 (2006).

    PubMed  Google Scholar 

  5. Regula, J. et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. N. Engl. J. Med. 355, 1863–1872 (2006).

    CAS  PubMed  Google Scholar 

  6. Sieg, A., Hachmoeller-Eisenbach, U. & Eisenbach, T. Prospective evaluation of complications in outpatient GI endoscopy: a survey among German gastroenterologists. Gastrointest. Endosc. 53, 620–627 (2001).

    CAS  PubMed  Google Scholar 

  7. Viiala, C. H., Zimmerman, M., Cullen, D. J. & Hoffman, N. E. Complication rates of colonoscopy in an Australian teaching hospital environment. Intern. Med. J. 33, 355–359 (2003).

    CAS  PubMed  Google Scholar 

  8. Spiegel, B. M. et al. Development and validation of a novel patient educational booklet to enhance colonoscopy preparation. Am. J. Gastroenterol. 106, 875–883 (2011).

    PubMed  Google Scholar 

  9. Froehlich, F., Wietlisbach, V., Gonvers, J. J., Burnand, B. & Vader, J. P. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest. Endosc. 61, 378–384 (2005).

    PubMed  Google Scholar 

  10. Harewood, G. C., Sharma, V. K. & de Garmo, P. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest. Endosc. 58, 76–79 (2003).

    PubMed  Google Scholar 

  11. Rex, D. K., Imperiale, T. F., Latinovich, D. R. & Bratcher, L. L. Impact of bowel preparation on efficiency and cost of colonoscopy. Am. J. Gastroenterol. 97, 1696–1700 (2002).

    PubMed  Google Scholar 

  12. National Health Service Bowel Cancer Screening Programme Endoscopy Quality Assurance Group. Quality assurance guidelines for colonoscopy publication no.6. National Health Service [online], (2011).

  13. Aronchick, C. A. Bowel preparation scale. Gastrointest. Endosc. 60, 1037–1038 (2004).

    PubMed  Google Scholar 

  14. Lai, E. J., Calderwood, A. H., Doros, G., Fix, O. K. & Jacobson, B. C. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest. Endosc. 69, 620–625 (2009).

    PubMed  PubMed Central  Google Scholar 

  15. Rostom, A. & Jolicoeur, E. Validation of a new scale for the assessment of bowel preparation quality. Gastrointest. Endosc. 59, 482–486 (2004).

    PubMed  Google Scholar 

  16. Belsey, J., Epstein, O. & Heresbach, D. Systematic review: oral bowel preparation for colonoscopy. Aliment. Pharmacol. Ther. 25, 373–384 (2007).

    CAS  PubMed  Google Scholar 

  17. Corporaal, S., Kleibeuker, J. H. & Koornstra, J. J. Low-volume PEG plus ascorbic acid versus high-volume PEG as bowel preparation for colonoscopy. Scand. J. Gastroenterol. 45, 1380–1386 (2010).

    CAS  PubMed  Google Scholar 

  18. Marmo, R. et al. Effective bowel cleansing before colonoscopy: a randomized study of split-dosage versus non-split dosage regimens of high-volume versus low-volume polyethylene glycol solutions. Gastrointest. Endosc. 72, 313–320 (2010).

    PubMed  Google Scholar 

  19. Ell, C. et al. Randomized trial of low-volume PEG solution versus standard PEG + electrolytes for bowel cleansing before colonoscopy. Am. J. Gastroenterol. 103, 883–893 (2008).

    PubMed  Google Scholar 

  20. Lawrance, I. C., Willert, R. P. & Murray, K. Bowel cleansing for colonoscopy: prospective randomized assessment of efficacy and of induced mucosal abnormality with three preparation agents. Endoscopy 43, 412–418 (2011).

    CAS  PubMed  Google Scholar 

  21. Kilgore, T. W. et al. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials. Gastrointest. Endosc. 73, 1240–1245 (2011).

    PubMed  Google Scholar 

  22. Singh, H. et al. Propofol for sedation during colonoscopy. Cochrane Database Syst. Rev. 2008, Issue 4. Art. No.: CD006268. doi: 10.1002/14651858.CD006268.pub2 (2008).

  23. Rex, D. K. et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 137, 1229–1237 (2009).

    PubMed  Google Scholar 

  24. Shah, S. G., Saunders, B. P., Brooker, J. C. & Williams, C. B. Magnetic imaging of colonoscopy: an audit of looping, accuracy and ancillary maneuvers. Gastrointest. Endosc. 52, 1–8 (2000).

    CAS  PubMed  Google Scholar 

  25. Bretthauer, M. et al. NORCCAP (Norwegian colorectal cancer prevention): a randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflation in colonoscopy. Gut 50, 604–607 (2002).

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Sumanac, K. et al. Minimizing postcolonoscopy abdominal pain by using CO2 insufflation: a prospective, randomized, double blind, controlled trial evaluating a new commercially available CO2 delivery system. Gastrointest. Endosc. 56, 190–194 (2002).

    PubMed  Google Scholar 

  27. Church, J. & Delaney, C. Randomized, controlled trial of carbon dioxide insufflation during colonoscopy. Dis. Colon Rectum 46, 322–326 (2003).

    CAS  PubMed  Google Scholar 

  28. Baxter, N. N. et al. Association of colonoscopy and death from colorectal cancer. Ann. Intern. Med. 150, 1–8 (2009).

    PubMed  Google Scholar 

  29. Brenner, H. et al. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J. Natl Cancer Inst. 102, 89–95 (2010).

    PubMed  Google Scholar 

  30. Singh, H. et al. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology 139, 1128–1137 (2010).

    PubMed  Google Scholar 

  31. Neerincx, M. et al. Colonic work-up after incomplete colonoscopy: significant new findings during follow-up. Endoscopy 42, 730–735 (2010).

    CAS  PubMed  Google Scholar 

  32. Rizek, R. et al. Rates of complete colonic evaluation after incomplete colonoscopy and their associated factors: a population-based study. Med. Care 47, 48–52 (2009).

    PubMed  Google Scholar 

  33. Shah, H. A., Paszat, L. F., Saskin, R., Stukel, T. A. & Rabeneck, L. Factors associated with incomplete colonoscopy: a population-based study. Gastroenterology 132, 2297–2303 (2007).

    PubMed  Google Scholar 

  34. Lieberman, D. A. et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380. N. Engl. J. Med. 343, 162–168 (2000).

    CAS  PubMed  Google Scholar 

  35. Rex, D. K., Chen, S. C. & Overhiser, A. J. Colonoscopy technique in consecutive patients referred for prior incomplete colonoscopy. Clin. Gastroenterol. Hepatol. 5, 879–883 (2007).

    PubMed  Google Scholar 

  36. Shumaker, D. A., Zaman, A. & Katon, R. M. A randomized controlled trial in a training institution comparing a pediatric variable stiffness colonoscope, a pediatric colonoscope, and an adult colonoscope. Gastrointest. Endosc. 55, 172–179 (2002).

    PubMed  Google Scholar 

  37. Saifuddin, T., Trivedi, M., King, P. D., Madsen, R. & Marshall, J. B. Usefulness of a pediatric colonoscope for colonoscopy in adults. Gastrointest. Endosc. 51, 314–317 (2000).

    CAS  PubMed  Google Scholar 

  38. Marshall, J. B., Perez, R. A. & Madsen, R. W. Usefulness of a pediatric colonoscope for routine colonoscopy in women who have undergone hysterectomy. Gastrointest. Endosc. 55, 838–841 (2002).

    PubMed  Google Scholar 

  39. Othman, M. O., Bradley, A. G., Choudhary, A., Hoffman, R. M. & Roy, P. K. Variable stiffness colonoscope versus regular adult colonoscope: meta-analysis of randomized controlled trials. Endoscopy 41, 17–24 (2009).

    CAS  PubMed  Google Scholar 

  40. Shah, S. G., Brooker, J. C., Williams, C. B., Thapar, C. & Saunders, B. P. Effect of magnetic endoscope imaging on colonoscopy performance: a randomised controlled trial. Lancet 356, 1718–1722 (2000).

    CAS  PubMed  Google Scholar 

  41. Shah, S. G. et al. Effect of magnetic endoscope imaging on patient tolerance and sedation requirements during colonoscopy: a randomized controlled trial. Gastrointest. Endosc. 55, 832–837 (2002).

    PubMed  Google Scholar 

  42. Wehrmann, T., Lechowicz, I., Martchenko, K. & Riphaus, A. Routine colonoscopy with a standard gastroscope. A randomized comparative trial in a western population. Int. J. Colorectal Dis. 23, 443–446 (2008).

    PubMed  Google Scholar 

  43. Park, C. H. et al. Sedation-free colonoscopy using an upper endoscope is tolerable and effective in patients with low body mass index: a prospective randomized study. Am. J. Gastroenterol. 101, 2504–2510 (2006).

    PubMed  Google Scholar 

  44. Keswani, R. N. Single-balloon colonoscopy versus repeat standard colonoscopy for previous incomplete colonoscopy: a randomized, controlled trial. Gastrointest. Endosc. 73, 507–512 (2011).

    PubMed  Google Scholar 

  45. Rex, D. K., Khashab, M., Raju, G. S., Pasricha, J. & Kozarek, R. Insertability and safety of a shape-locking device for colonoscopy. Am. J. Gastroenterol. 10 0, 817–820 (2005).

    Google Scholar 

  46. Van Rijn, J. C. et al. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am. J. Gastroenterol. 1 01, 343–350 (2010).

    Google Scholar 

  47. Kaminski, M. F. et al. Quality indicators for colonoscopy and the risk of interval cancer. N. Engl. J. Med. 362, 1795–1803 (2010).

    CAS  PubMed  Google Scholar 

  48. Rex, D. K. et al. Quality indicators for colonoscopy. Gastrointest. Endosc. 63, S16–S28 (2006).

    PubMed  Google Scholar 

  49. Lee, R. H. et al. Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos). Gastrointest. Endosc. 74, 128–134 (2011).

    PubMed  Google Scholar 

  50. East, J. E. et al. Dynamic patient position changes during colonoscope withdrawal increase adenoma detection: a randomized, crossover trial. Gastrointest. Endosc. 73, 456–463 (2011).

    PubMed  Google Scholar 

  51. Lee, J. M. et al. Effects of hyosine N.-butyl bromide on the detection of polyps during colonoscopy. Hepatogastroenterology 57, 90–94 (2010).

    PubMed  Google Scholar 

  52. East, J. E. et al. A comparative study of standard vs. high definition colonoscopy for adenoma and hyperplastic polyp detection with optimized withdrawal technique. Aliment. Pharmacol. Ther. 28, 768–776 (2008).

    CAS  PubMed  Google Scholar 

  53. Pellise, M. et al. Impact of wide-angle, high-definition endoscopy in the diagnosis of colorectal neoplasia: a randomized controlled trial. Gastroenterology 135, 1062–1068 (2008).

    PubMed  Google Scholar 

  54. Burke, C. A., Choure, A. G., Sanaka, M. R. & Lopez, R. A comparison of high-definition versus conventional colonoscopes for polyp detection. Dig. Dis. Sci. 55, 1716–1720 (2010).

    PubMed  Google Scholar 

  55. Tribonias, G. et al. Comparison of standard vs high-definition, wide-angle colonoscopy for polyp detection: a randomized controlled trial. Colorectal Dis. 12, e260–e266 (2010).

    CAS  PubMed  Google Scholar 

  56. Buchner, A. M. et al. High-definition colonoscopy detects colorectal polyps at a higher rate than standard white-light colonoscopy. Clin. Gastroenterol. Hepatol. 8, 364–370 (2010).

    PubMed  Google Scholar 

  57. Ignjatovic, A. et al. What is the most reliable imaging modality for small colonic polyp characterization? Study of white-light, autofluorescence, and narrow-band imaging. Endoscopy 43, 94–99 (2011).

    CAS  PubMed  Google Scholar 

  58. van den Broek, F. J. et al. Combining autofluorescence imaging and narrow-band imaging for the differentiation of adenomas from non-neoplastic colonic polyps among experienced and non-experienced endoscopists. Am. J. Gastroenterol. 104, 1498–1507 (2009).

    PubMed  Google Scholar 

  59. Kiesslich, R., von, B. M., Hahn, M., Hermann, G. & Jung, M. Chromoendoscopy with indigocarmine improves the detection of adenomatous and nonadenomatous lesions in the colon. Endoscopy 33, 1001–1006 (2001).

    CAS  PubMed  Google Scholar 

  60. Pohl, J. et al. Pancolonic chromoendoscopy with indigo carmine versus standard colonoscopy for detection of neoplastic lesions: a randomised two-centre trial. Gut 60, 485–490 (2011).

    PubMed  Google Scholar 

  61. Lecomte, T. et al. Chromoendoscopic colonoscopy for detecting preneoplastic lesions in hereditary nonpolyposis colorectal cancer syndrome. Clin. Gastroenterol. Hepatol. 3, 897–902 (2005).

    PubMed  Google Scholar 

  62. East, J. E. et al. Narrow band imaging for colonoscopic surveillance in hereditary non-polyposis colorectal cancer. Gut 5 7, 65–70 (2008).

    Google Scholar 

  63. van den Broek, F. J., Reitsma, J. B., Curvers, W. L., Fockens, P. & Dekker, E. Systematic review of narrow-band imaging for the detection and differentiation of neoplastic and nonneoplastic lesions in the colon (with videos). Gastrointest. Endosc. 69, 124–135 (2009).

    PubMed  Google Scholar 

  64. Hoffman, A. et al. High definition colonoscopy combined with i-Scan is superior in the detection of colorectal neoplasias compared with standard video colonoscopy: a prospective randomized controlled trial. Endoscopy 42, 827–833 (2010).

    CAS  PubMed  Google Scholar 

  65. Aminalai, A. et al. Live image processing does not increase adenoma detection rate during colonoscopy: a randomized comparison between FICE and conventional imaging (Berlin Colonoscopy Project 5, BECOP-5). Am. J. Gastroenterol. 105, 2383–2388 (2010).

    PubMed  Google Scholar 

  66. Chung, S. J. et al. Efficacy of computed virtual chromoendoscopy on colorectal cancer screening: a prospective, randomized, back-to-back trial of Fuji Intelligent Color Enhancement versus conventional colonoscopy to compare adenoma miss rates. Gastrointest. Endosc. 72, 136–142 (2010).

    PubMed  Google Scholar 

  67. Pohl, J. et al. Computed virtual chromoendoscopy versus standard colonoscopy with targeted indigocarmine chromoscopy: a randomised multicentre trial. Gut 58, 73–78 (2009).

    CAS  PubMed  Google Scholar 

  68. Ramsoekh, D. et al. A back-to-back comparison of white light video endoscopy with autofluorescence endoscopy for adenoma detection in high-risk subjects. Gut 59, 785–793 (2010).

    PubMed  Google Scholar 

  69. van den Broek, F. J. et al. Clinical evaluation of endoscopic trimodal imaging for the detection and differentiation of colonic polyps. Clin. Gastroenterol. Hepatol. 7, 288–295 (2009).

    PubMed  Google Scholar 

  70. Kondo, S. et al. A randomized controlled trial evaluating the usefulness of a transparent hood attached to the tip of the colonoscope. Am. J. Gastroenterol. 102, 75–81 (2007).

    PubMed  Google Scholar 

  71. Lee, Y. T. et al. Efficacy of cap-assisted colonoscopy in comparison with regular colonoscopy: a randomized controlled trial. Am. J. Gastroenterol. 104, 41–46 (2009).

    PubMed  Google Scholar 

  72. Morgan, J., Thomas, K., Lee-Robichaud, H. & Nelson, R. L. Transparent cap colonoscopy versus standard colonoscopy for investigation of gastrointestinal tract conditions. Cochrane Database Syst. Rev. Issue 2. Art. No.: CD008211. doi: 10.1002/14651858.CD008211.pub2. (2011).

  73. Hewett, D. G. & Rex, D. K. Cap-fitted colonoscopy: a randomized, tandem colonoscopy study of adenoma miss rates. Gastrointest. Endosc. 72, 775–781 (2010).

    PubMed  Google Scholar 

  74. Tee, H. P. et al. Prospective randomized controlled trial evaluating cap-assisted colonoscopy vs standard colonoscopy. World J. Gastroenterol. 16, 3905–3910 (2010).

    PubMed  PubMed Central  Google Scholar 

  75. DeMarco, D. C. et al. Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: the Third Eye Retroscope study group. Gastrointest. Endosc. 71, 542–550 (2010).

    PubMed  Google Scholar 

  76. Waye, J. D. et al. A retrograde-viewing device improves detection of adenomas in the colon: a prospective efficacy evaluation (with videos). Gastrointest. Endosc. 71, 551–556 (2010).

    PubMed  Google Scholar 

  77. Leufkens, A. M. et al. Effect of a retrograde-viewing device on adenoma detection rate during colonoscopy: the TERRACE study. Gastrointest. Endosc. 73, 480–489 (2011).

    PubMed  Google Scholar 

  78. Endoscopy Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 37, 570–578 (2005).

  79. Winawer, S. J. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N. Engl. J. Med. 329, 1977–1981 (1993).

    CAS  PubMed  Google Scholar 

  80. Iqbal, C. W. et al. Surgical management and outcomes of 165 colonoscopic perforations from a single institution. Arch. Surg. 143, 701–706 (2008).

    PubMed  Google Scholar 

  81. Pabby, A. et al. Analysis of colorectal cancer occurrence during surveillance colonoscopy in the dietary Polyp Prevention Trial. Gastrointest. Endosc. 61, 385–391 (2005).

    PubMed  Google Scholar 

  82. Farrar, W. D., Sawhney, M. S., Nelson, D. B., Lederle, F. A. & Bond, J. H. Colorectal cancers found after a complete colonoscopy. Clin. Gastroenterol. Hepatol. 4, 1259–1264 (2006).

    PubMed  Google Scholar 

  83. Ignjatovic, A. et al. Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect and Discard; DISCARD trial): a prospective cohort study. Lancet Oncol. 10, 1171–1178 (2009).

    PubMed  Google Scholar 

  84. Efthymiou, M., Taylor, A. C., Desmond, P. V., Allen, P. B. & Chen, R. Y. Biopsy forceps is inadequate for the resection of diminutive polyps. Endoscopy 43, 312–316 (2011).

    CAS  PubMed  Google Scholar 

  85. Moss, A. et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 140, 1909–1918 (2011).

    PubMed  Google Scholar 

  86. Saito, Y. et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest. Endosc. 72, 1217–1225 (2010).

    PubMed  Google Scholar 

  87. Singh, N., Harrison, M. & Rex, D. K. A survey of colonoscopic polypectomy practices among clinical gastroenterologists. Gastrointest. Endosc. 60, 414–418 (2004).

    PubMed  Google Scholar 

  88. Hewett, D. G. & Rex, D. K. Colonoscopy and diminutive polyps: hot or cold biopsy or snare? Do I send to pathology? Clin. Gastroenterol. Hepatol. 9, 102–105 (2011).

    PubMed  Google Scholar 

  89. Woods, A., Sanowski, R. A., Wadas, D. D., Manne, R. K. & Friess, S. W. Eradication of diminutive polyps: a prospective evaluation of bipolar coagulation versus conventional biopsy removal. Gastrointest. Endosc. 35, 536–540 (1989).

    CAS  PubMed  Google Scholar 

  90. Yoo, T. W. et al. Clinical significance of small colorectal adenoma less than 10 mm: the KASID study. Hepatogastroenterology 54, 418–421 (2007).

    PubMed  Google Scholar 

  91. Lieberman, D., Moravec, M., Holub, J., Michaels, L. & Eisen, G. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography. Gastroenterology 135, 1100–1105 (2008).

    PubMed  Google Scholar 

  92. Wadas, D. D. & Sanowski, R. A. Complications of the hot biopsy forceps technique. Gastrointest. Endosc. 34, 32–37 (1988).

    CAS  PubMed  Google Scholar 

  93. Nelson, A. M. Delayed hemorrhage following “hot biopsy” of a diminutive colonic polyp. Gastrointest. Endosc. 36, 418 (1990).

    CAS  PubMed  Google Scholar 

  94. Di Giorgio, P. et al. Detachable snare versus epinephrine injection in the prevention of postpolypectomy bleeding: a randomized and controlled study. Endoscopy 36, 860–863 (2004).

    CAS  PubMed  Google Scholar 

  95. Paspatis, G. A. et al. A prospective, randomized comparison of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps. Am. J. Gastroenterol. 101, 2805 (2006).

    CAS  PubMed  Google Scholar 

  96. Matsushita, M. et al. Ineffective use of a detachable snare for colonoscopic polypectomy of large polyps. Gastrointest. Endosc. 47, 496–499 (1998).

    CAS  PubMed  Google Scholar 

  97. Heresbach, D. et al. A national survey of endoscopic mucosal resection for superficial gastrointestinal neoplasia. Endoscopy 42, 806–813 (2010).

    CAS  PubMed  Google Scholar 

  98. Tanaka, S. et al. Clinicopathologic features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm. Gastrointest. Endosc. 54, 62–66 (2001).

    CAS  PubMed  Google Scholar 

  99. Uraoka, T. et al. Endoscopic indications for endoscopic mucosal resection of laterally spreading tumours in the colorectum. Gut 55, 1592–1597 (2006).

    CAS  PubMed  PubMed Central  Google Scholar 

  100. Moss, A., Bourke, M. J. & Metz, A. J. A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon. Am. J. Gastroenterol. 105, 2375–2382 (2010).

    CAS  PubMed  Google Scholar 

  101. Swan, M. P., Bourke, M. J., Alexander, S., Moss, A. & Williams, S. J. Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos). Gastrointest. Endosc. 70, 1128–1136 (2009).

    PubMed  Google Scholar 

  102. Mannath, J., Subramanian, V., Singh, R., Telakis, E. & Ragunath, K. Polyp recurrence after endoscopic mucosal resection of sessile and flat colonic adenomas. Dig. Dis. Sci. 56, 2389–2395 (2011).

    CAS  PubMed  Google Scholar 

  103. Brooker, J. C. et al. Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations. Gastrointest. Endosc. 55, 371–375 (2002).

    PubMed  Google Scholar 

  104. Onozato, Y. et al. Endoscopic submucosal dissection for early gastric cancers and large flat adenomas. Endoscopy 38, 980–986 (2006).

    CAS  PubMed  Google Scholar 

  105. Imagawa, A. et al. Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success. Endoscopy 38, 987–990 (2006).

    CAS  PubMed  Google Scholar 

  106. Saito, Y. et al. Endoscopic treatment of large superficial colorectal tumors: a case series of 200 endoscopic submucosal dissections (with video). Gastrointest. Endosc. 66, 966–973 (2007).

    PubMed  Google Scholar 

  107. Deprez, P. H. et al. Current practice with endoscopic submucosal dissection in Europe: position statement from a panel of experts. Endoscopy 42, 853–858 (2010).

    CAS  PubMed  Google Scholar 

  108. Niimi, K. et al. Long-term outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 4 2, 723–729 (2010).

    Google Scholar 

  109. Voermans, R. P., Vergouwe, F., Breedveld, P., Fockens, P. & van Berge Henegouwen, M. I. Comparison of endoscopic closure modalities for standardized colonic perforations in a porcine colon model. Endoscopy 43, 217–222 (2011).

    CAS  PubMed  Google Scholar 

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Both authors contributed equally to researching, discussing, writing, reviewing and/or editing this manusript.

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Correspondence to Evelien Dekker.

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E. Dekker has received grant or research support from Olympus and Pentax. Y. Hazewinkel declares no competing interests.

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Hazewinkel, Y., Dekker, E. Colonoscopy: basic principles and novel techniques. Nat Rev Gastroenterol Hepatol 8, 554–564 (2011). https://doi.org/10.1038/nrgastro.2011.141

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