Non-surgical approaches to treat precancerous lesions of the colon were proposed as early as the 1970s. In recent decades, endoscopic polypectomy has continued to advance due to improved colonoscopic techniques and ancillary facilities. Endoscopists can perform relatively simple procedures such as removal of small polyps with biopsy forceps or stranglers, and endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (EMD) are used for removal of large polyps or early stage colorectal cancers, decreasing the need for surgical intervention. Polypectomy is important because it interferes with the natural history of colorectal cancer. Polyps are categorized as micropolyps (≤5 mm), small polyps (6-9 mm), large polyps (≥10 mm), and giant polyps (>30 mm), and there is a direct correlation between whether or not a polyp develops into a malignant tumor and its size. Recent studies have found that colonoscopy detected progressive adenomas in 5.6% of cases, with the larger the polyp, the greater the likelihood of progressive adenomas, micropolyps in 0.9% of cases, sub-centimeter polyps in 1.7% of cases, and large polyps in 73.5% of cases. However, some studies have suggested that even small or micropolyps have a 9-10% chance of developing progressive malignancy, thus emphasizing the need for population-based studies to examine and remove polyps, even if they are small. The detection rate (ADR) of polyps and adenomas is considered to be the most important colonoscopy quality marker, as a strong correlation between ADR and colorectal cancer risk has been clearly observed. Colonoscopic polypectomy is a method of stopping colorectal cancer, but it is less useful in the right colon. Heterochronic cancers are colorectal cancers diagnosed within 5 years of a negative colonoscopy, and their incidence rate is indirectly related to the quality of the colonoscopy. It is estimated that missed polyps are responsible for the majority of heterochronous cancer cases (50-80%), followed by incomplete resection of precancerous lesions (15-30%), and finally by new invasive tumors in genetically predisposed patients. Jagged polyps need to be looked for carefully as they are important precursor alterations of important heterochronic colorectal cancers. Such polyps are poorly known by endoscopists, and seeing such polyps microscopically is very challenging because their microscopic features are very unremarkable and margins are difficult to characterize, resulting in a high rate of missed diagnoses with incomplete resections. Hence the need for high quality colonoscopy, both to detect polyps or adenomas and to effectively remove them completely. Many reasons are associated with low quality diagnostic colonoscopy and low ADR, such as the quality of bowel preparation and the experience of the operator. Many efforts have been made to improve ADR, such as high-resolution white light endoscopy, pigmented endoscopy with added optical capabilities, backward viewing devices, stained or virtual or electrochromic endoscopy, such as narrow-spectrum endoscopes with variable spectral imaging contrast enhancement, and scanning and autofluorescence confocal laser microscopy. On the other hand, less attention has been paid to whether or not excision is complete, and only recently has some direct evidence on the completeness of polyp excision and the emergence of specific criteria for the assessment of the quality of polyp excision. The result of this lack of information is that there are many methods of polypectomy, particularly for polyps smaller than 10 mm, but the variety of methods has led to dismal polypectomy rates. Improvements in complete polypectomy include improved techniques, development of virtual and technical training courses, and objective quality assessment criteria for polypectomy. Despite its shortcomings, colonoscopic polypectomy has been very helpful in reducing colon cancer incidence and mortality over the past few decades and has become the cornerstone of colorectal cancer prevention in the future. In an article in Clinical and Experimental Gastroenterology, an Italian professor reviews the progress and problems and complications of polypectomy (Table 1). Micropolyps and Small Polyps General Principles Most polyps are micropolyps or small polyps encountered during routine colonoscopy, so the removal of these polyps can have a significant impact on clinical outcomes. There is little data on which resection is more appropriate for such polyps, leading different endoscopists to perform different polypectomies. In a survey of endoscopists in the United States, 50% used biopsy forceps to remove 1-3 mm polyps, electrosurgical strangulation was performed for 7-9 mm polyps, and there was no preferred method for 4-6 mm polyps. Biopsy forceps polypectomy Cold biopsy forceps polypectomy is quick and easy to perform and is inexpensive. Unfortunately, this technique is significantly associated with incomplete polypectomy, increasing the risk of polyp recurrence and the development of allogeneic colorectal cancer. The reason for this may be related to the fact that bleeding after the first clamping blurs the visual field, making residual polyps difficult to detect and remove. In Efthymiou’s landmark trial, EMR excised areas of polyps that were completely resected by biopsy forceps with the naked eye, and only 39% of micropolyps were actually completely resected. Histology was the only predictor of complete resection, and adenomatous polyps were easier to remove than hyperplastic polyps. Follow-up studies have found that biopsy forceps adenomatous polyps are completely removed in only 51-79% of cases, so it appears that cold biopsy forceps are not the preferred method of removing small or microscopic polyps, except for those very small 1-2 mm polyps that can be completely removed in a single pass. This technique can be used where polyp detection is difficult because the biopsy forceps are easy to maneuver. Alternatives to traditional biopsy forceps include the use of larger cold biopsies such as large biopsy forceps or polypectomy. In one study comparing large biopsy forceps to the traditional method of one-step forceps removal of polyps smaller than 6 mm, the rates of complete resection were actually quite different between the two methods, despite visually higher rates of complete resection and shorter maneuver times. Thermal biopsy forceps excision was once popular, with the belief that it could incorporate electrocautery into the biopsy site, cauterize the tissue surrounding the biopsy to increase the rate of complete polypectomy, and induce hemostasis at the same time. This method is no longer widely used because of the increased likelihood of complications and poor tissue specimen acquisition, and the rate of complete polyp resection is not superior to that of cold biopsy forceps. Strangler polypectomy Cold strangler polypectomy is an easy-to-apply technique that is now widely used for small and microscopic polyps. Briefly, the endoscopist delivers the strangler into the bowel, opens the strangler to encircle the polyp, slowly closes the strangler to capture 1-2 mm of normal tissue around the polyp, and then cuts off the polyp after the strangler is completely closed. The polyp is sent for histologic evaluation. In a recent comparative study, cold strangulation polypectomy was found to be significantly superior to biopsy forceps excision when the rate of complete histologic excision and operative time were not taken into account, and was particularly effective for polyps larger than 4 mm, with no significant difference in the excision of smaller polyps. Leukotomy is more expensive and has a lower recovery rate compared to biopsy forceps, but this has not been statistically different. There are studies comparing cold and hot strangulation for small and microscopic polyps. No significant difference was shown between the two methods when excision and recovery rates were not taken into account. Intra-operative bleeding is higher in the cold debridement group but resolves spontaneously without specific intervention, and immediate or delayed bleeding is more common in the hot debridement group. Hot strangler polyp removal took longer and showed more postoperative abdominal symptoms. All the studies concluded that cold strangler resection is superior to hot strangler resection and should be preferred to remove small and microscopic polyps. However, nonstudded polyps may benefit more from hot strangulation. Polyp recovery Most studies have not focused on the increased polyp recovery failure rate with strangulation. In a recent large retrospective study, small polyps, sessile polyps, right-sided colonic location, and cold strangulation all affected polyp recovery. There is still debate as to whether micropolyp retrieval is necessary. The American Society for Gastrointestinal Endoscopy actually released a statement that specifies two in vivo modes of operation. One is called the resection-and-discard approach, in which if the endoscopist evaluates the polyp as benign in real time, further pathologic evaluation is not necessary. The second approach, called the abandonment approach, is that micropolyps located in the rectosigmoid colon need not be resected or sent for examination if they appear endoscopically to be only overgrown, but can simply be left in situ. These recommendations are based primarily on flow data because the likelihood of a micropolyp developing into a progressive adenoma is very low, the occurrence of micropolyps in the rectosigmoid site is common, and studies have confirmed that in vivo histologic evaluation of polyps is now very accurate. The cost analysis found that both the resection with abandonment approach and the abandonment approach significantly reduced cost and time and did not increase the risk of colorectal cancer, and it remains unclear whether these approaches can be used for serrated polyps. It is important to note, however, that the methods used in the statement are predicated on the assumption that the polyp can be completely resected, an assumption that is unlikely to hold true all the time in reality, and some studies have also reported a high incidence of histologic changes at progression in small and microscopic polyps. Incomplete polypectomy is associated with only 1/3 xenogeneic cancers, and even though the rate of incomplete excision of small and micropolyps in ideal studies can be as high as 10-60%, the rate of incomplete excision in actual clinical practice should be even higher. Biopsy forceps removal has been repeatedly reported to be an independent risk factor for incomplete polypectomy, increasing the risk of recurrence. Larger polyps, serrated adenomas, and endoscopist experience have all been associated with incomplete resection. The above factors need to be fully considered when performing polypectomy to reduce the possibility of incomplete resection and reduce heterochronous cancers. In conclusion, cold strangler polypectomy appears to be the optimal procedure of choice for small and micropolyps, and further efforts are needed to increase the rate of complete polypectomy, not only by knowing the objective fact that incomplete polypectomy exists, but also by continually improving the resection techniques and facilities. Large colonic polyps and lesions Universal principles Endoscopic treatment of large colorectal lesions is very complex. Morphologic evaluation currently uses the Parisian classification, which includes protruding lesions and polypoid lesions (0-I), nontuberculate lesions (0-Is) or pseudotuberculate lesions (0-Ip), or semipseudotuberculate lesions (0-Isp), depressed lesions (0-III), nonprotruding, nondepressed, nonpolypoid lesions (0-II), or mildly protruding lesions (0-IIa) smooth lesions (0-IIb), and Mildly down-pressurized lesions (0-IIc), or lesions coexisting with a combination of all three (0-Iia+IIc or (0-Iic+IIa). Large 0-IIa lesions, also called lateral spreading tumors (LSTs), are further classified into granular LSTs and non-granular LSTs based on surface morphology.In vivo real-time microstaining characterization and vascular pattern characterization are critical steps in the evaluation of colorectal cancer lesions. Recently it was reported that the depth of the lesion can be assessed with a high degree of accuracy by endoscopic microprobe ultrasound devices, thus necessitating the use of ultrasound in such cases. Surgery has historically been the mainstay of treatment for large polyps; however, high complications, mortality, and cost have prevented surgery from moving forward.EMR and ESD are effective alternatives to surgery, with lower complications and costs. Careful evaluation of the gross and microscopic appearance of the lesion is critical to the choice of treatment type. For example, regardless of size, nonpolypoid lesions have a greater risk of developing cancer than polypoid lesions, and nongranular LST lesions have a greater chance of submucosal invasion than granular LSTs. These factors influence not only the decision of whether to perform surgery or endoscopic resection, but also the choice of endoscopic treatment method. Microscopic evaluation, particularly of narrow-spectrum images, can also provide information to help assess the type of histology in vivo (hyperplastic, adenomatous, super-superficial, or deeply invasive) to determine whether a lesion is suitable for endoscopic resection (lesion invades only the mucosa or submucosal layer is less than 1 mm). Of course, if the lesion looks strongly suggestive of deeper invasion, such as a V staining pattern or a depressed lesion, surgery should be considered. EMR and EMD techniques The EMR or EMD procedure also involves removal of the superficial or intermediate submucosa, which makes it different from conventional polypectomy, which only removes at the mucosal level. EMR or EMD involves submucosal injection of saline, hypertonic fluid, or colloidal fluid, followed by removal with a sclerotome. If the mucosa cannot be augmented, signs of indirect invasion should be considered and are not an indication for endoscopic resection. However, other factors may induce a similar response, such as previous excision or electrocautery to form fibrous tissue, India ink tattoos, and ulceration. The inject-and-excise technique uses dynamic submucosal injection of fluid to produce a protective layer and is most commonly used in EMR techniques. Simply put, the submucosal layers are separated and fluid is injected. If the lesion is less than 2 centimeters, it can be encircled using a rigid strangulator. The retractor is lifted along the wall and slowly loosened slightly to release the potentially entrapped submucosal layer, which is then resected. If the lesion is larger, multiple resections are required. The free edge of the lesion after the first excision is used as an anchor point for the next excision until the entire lesion is removed. All resected masses should be sent for histologic evaluation. There are various methods of ESD, simply starting with a submucosal injection proximal to the lesion, followed by a semicircular resection, followed by direct excision of the submucosal layer using a variety of endoscopic knives, with the contralateral half of the lesion excised in the same way, and finally the entire lesion is excised. In a slightly different approach, a circumferential excision is performed at the margin of the lesion, followed by a partial excision at the base of the lesion, and then either a complete excision using a strangler or a deeper circumferential excision until the lesion is removed in its entirety. Endoscopic mucosal resection with EMR is usually used for 2-cm lesions because this technique is difficult to perform for larger lesions, but it is certainly possible to treat large lesions with fractional resection using EMR. Swan has reported a 95% success rate in removing non-protected polyps larger than 2 cm with fractional EMR, which avoids further surgical procedures in 90% of patients and significantly reduces comorbidities and complications, as well as costs. More recently, it has been reported that 90-96% of colon lesions larger than 2 cm can be effectively resected in single or multiple endoscopic passes, avoiding surgery in 85% of patients and significantly reducing costs.EMR has also been used successfully in the treatment of early-stage colorectal cancers, especially when the cancer is confined to the mucosa, and for polyps that cannot be removed by standard strangulator polypectomy. In summary, EMR, when performed by an endoscopist, is successful in treating the majority of colorectal lesions, with nearly half of the lesions being resected en bloc, while the rest can be resected by segmental resection, with only 3-10% of patients requiring surgery. However, the average recurrence rate of adenomas after EMR for large or giant lesions is 25%. Predictors of recurrence after EMR have been reported to include lesions larger than 4 cm, the need for argon ion coagulation, and the need for 6 or more segmental resections. The first endoscopic follow-up is usually 3 to 6 months after EMR, as most adenoma recurrences can be detected during this period. Late recurrent adenomas are those that appear after the first follow-up with negative endoscopic results, which are less common and account for about 4% of cases. A normal-looking scar with a negative biopsy indicates complete removal of the lesion. Methods to minimize recurrence after EMR include the use of argon ion electrocoagulation of the resection margins or residual threads in the area of resection, or hybrid EMR techniques such as circumferential preexcision of lesions larger than 3 cm followed by block resection. In any case, adenomas have fewer recurrences, are usually benign, and are easily treated endoscopically. As mentioned previously, EMR is less effective in removing or curing large lesions, and factors that may lead to resection failure or incomplete resection include history of previous resections, proximal colonic or ileocecal location, segmental resections, change in morphology from 0-IIa+c, non-granular LSTs, staining pattern V, or submucosal carcinomas. Factors associated with incomplete cure include subcompacted lesions (0-III), as these often have deeper submucosal infiltration. The addition of endoscopic mucosal ablation techniques to EMR is used for the salvage treatment of previously incomplete staged resections of EMR or adenoma recurrence. The most commonly used resection technique is EMR, and other types of EMR include cap-assisted EMR, fragment ligation EMR, or underwater EMR. cap-assisted EMR and fragment ligation EMR should only be used for rectal lesions because of the high risk of perforation of the colonic location. Underwater EMR is a new fractional resection technique that does not utilize a submucosal injection technique. Early trials have shown underwater EMR to be safe and effective, with low rates of delayed bleeding and no perforation occurring. There were no early adenomatous tissue recurrences (1 year). This technique is easy to master and appears to be an alternative to conventional EMR and EMD. Split EMR resection relatively increases local recurrence and is pathologically assessed as unsatisfactory if there are further subsidence morphologic changes. Whole excision is the preferred method for adequate histologic evaluation because both the horizontal plane and deep margins can be assessed, and if all results are negative, a definitive diagnosis of complete excision can be made. Other features of curative resection include submucosal invasion of less than 1 mm, absence of lymphovascular invasion, and absence of poorly differentiated components. Split resection produces multiple tissue blocks, making histologic evaluation very difficult. Endoscopic submucosal resection ESD is a new technique that is more difficult and time-consuming to perform but is effective in overcoming the shortcomings of EMR.ESD has been used mainly in Japan but is slowly penetrating the West. Because there are no standard indications for ESD, it is usually used for difficult lesions such as those larger than 2 cm, non-granular LSTs or V-shaped stains, especially when high-grade xenografts, cancers, or superficial submucosal lesions are suspected, when other endoscopic techniques have failed or are doomed to be impossible to excise the lesion in its entirety, or to disseminate the lesion in the setting of ulcerative colitis. A recent systematic evaluation and meta-analysis showed that ESD is highly effective in treating lesions larger than 2 cm and recurrence after EMR, with R0 resection rates of up to 88% and zero recurrence after R0 ESD resection. The R0 clearance rate was higher in Asia than in Europe, possibly reflecting cultural and technological differences. Two studies compared EMR versus ESD for the treatment of large colorectal lesions. The first study found higher block resection and cure rates and lower recurrence rates with ESD, but longer treatment times and possibly an increased incidence of perforation.The low recurrence rate in the ESD group was associated with a high block resection rate, as the recurrence rate was 13% in patients who did not receive a block resection, which was similar to that with fractional resection for EMR.There was an increase in the rate of recurrence in the fractional versus block resection group in the EMR group, but the effects of block and fractional resection were the same for preservation of the colon.The ESD group had an increased rate of recurrence in the ESD group, but the rate was not as high in patients who did not receive block resection. The second trial was a large multicenter prospective trial. A second trial, a large multicenter prospective observational study, demonstrated that the ESD group had a higher rate of gross resection, especially for lesions larger than 4 cm, and that ESD was preferred for large lesions, especially those that were flat or had mixed morphology. In other cases, EMR/EMD can safely resect the lesion, even if it is located in the colon where manipulation is difficult, such as close to the dentate line, the ileocecal valve, or the appendiceal inlet, and should be considered when the lesion extends through the ileocecal valve into the ileum or appendix. Large pedunculated polyps can be resected with a conventional thermotome. Endoscopic resection of deeply located large polyps can be performed laparoscopically through a tissue deposition system with a full suture in the resection location, which is a new technique that is under investigation. Recently combined laparoscopic and endoscopic techniques have been used selectively to resect large colonic lesions. Other hybrid and full-layer techniques are being tested in animal models. These developments are associated with rapid advances in therapeutic devices. Complications General Principles Although colonoscopy or colonoscopic polypectomy is generally safe, there are certain risks associated with complications including, for example, bleeding, perforation, and post-resection syndrome. Most of these complications are self-limiting and easily treated conservatively or endoscopically. Rarely, they are life-threatening or require surgery. The complication rate for diagnostic colonoscopy is extremely low, and all complications are related to colonoscopic procedures, especially polypectomy. The majority of complications during polypectomy are related to electrocoagulation, which is included in all maneuvers to remove large polyps. Submucosal injection of fluids produces a protective layer just to prevent temperature paramedical injury, however, electrocoagulation is not necessary for the removal of small or micropolyps, with the exception of pedunculated polyps. In fact, in the era of thermal biopsy forceps or thermal leukotomy, injuries such as perforation and bleeding were common. Recent studies have concluded that cold biopsy forceps and cold strangulation polypectomy are associated with fewer complications, so that these two methods should be standardized for small and micropolypectomy in terms of safety and quality of resection. Risk factors include multiple polypectomies, large lesions, right-sided colonic location, advanced age, and inexperience of the endoscopist. Nearly 1/3 of patients experience mild gastrointestinal symptoms after colonoscopic polypectomy, including abdominal pain, bloating, diarrhea, and nausea, which usually resolve in 24-48 hours. Other rare but more risky complications include splenic hemangioma tears leading to shortness of breath, acute appendicitis, diverticulitis, hernia, intramucosal hematoma, bacteremia, and colonic rupture. Bleeding, which can be immediate (at the time of polypectomy) or delayed (within 1 week or sometimes 3-4 weeks after surgery), is the most common complication. Small polyps and micropolyps Small polyps and micropolyps have an immediate hemorrhage rate of 0.5-2.2%, and delayed hemorrhage is less common, about 0.3-0.6%. Most bleeding is self-limiting and is easily managed endoscopically or with hemostatic forceps or epinephrine. Some methods of bleeding prevention, such as prophylactic use of hemostatic forceps or prophylactic argon ion electrocoagulation, have been proposed, but they seem to be ineffective in preventing delayed bleeding in resection scars. Most studies do not consider antiplatelet drugs to have an effect, such as starting aspirin and nonsteroidal anti-inflammatory drugs, so international guidelines do not recommend routine discontinuation before colonoscopy or removal of small polyps or micropolyps. Clopidogrel appears to be associated with a high incidence of postoperative bleeding. Anticoagulation has been reported to be a risk factor for bleeding on diagnostic and therapeutic colonoscopy, but recent studies have shown that continued anticoagulation does not increase bleeding after removal of small or micropolyps by cold strangulation, so discontinuation is not warranted, especially in patients at high risk of thrombosis. Polyp size is an independent predictor of bleeding, but the relationship between location and bleeding remains controversial. Intraoperative and delayed bleeding rates for EMR/ESD of large lesions are similar, 1-10%. A recent analysis found that the overall bleeding rate for ESD is 2% and can be successfully treated endoscopically. Lesion size, right-sided colonization, and aspirin use are risk factors for delayed bleeding. Split resection and previous resection history were not risk factors for delayed bleeding, and placement of hemostatic clips after EMR appeared to have some protective effect. The vascular supply of a pedunculated polyp is usually multiple, so increasing the risk of bleeding. Epinephrine injection into the root and head of the polyp, along with the loop-clamp technique, can successfully reduce the risk of bleeding after thermodilator polypectomy. Even injection of epinephrine only prevents immediate bleeding and has no effect on delayed bleeding. Injection of epinephrine is the most widely used method to prevent bleeding, and many authors prefer to use other techniques only in high-risk patients. Some predictive factors such as large pedunculated polyps, older age, type of current, type of polyp histology, diameter of the stem, and the use of anticoagulants or not increase the risk of bleeding. Perforation Perforation, either immediate or delayed, is the second most common complication of polypectomy. The risk of perforation is virtually nil for small or micropolyps when cold polypectomy is used. Most perforations are actually related to electrocoagulation, so this technique is no longer used. The risk of perforation is higher, as expected, when large lesions are removed by EMR or EMD. Of the two methods, EMR is somewhat safer, with a perforation rate of 0-1.5%. Recent studies have found a perforation rate of about 4% after ESD, with a range of 1.5-10%.The most important factor in the development of perforation in ESD is the lack of experience of the surgeon. Various authors have observed that all complications, especially perforation, decrease with experience and improved technical equipment. Lesions larger than 5 cm or non-particulate LST are the two main alterations that predispose to perforation in ESD, proximal colonic location especially ileum is also a factor that predisposes to perforation because of the thinner colonic wall in these locations, whereas rectal location is less prone to perforation because of the thicker wall and the location in the posterior peritoneum. Recent risk stratification scoring systems have shown good predictive features such as the success of the operation and the likelihood of complications after EMR resection of lesions larger than 2 cm. Future studies are needed to further validate this scoring system. Most EMR or EMD perforations can be successfully treated by endoscopic placement of hemostatic clips, and only a small percentage require surgery. The use of hemostatic clips and endoscopic suturing for the treatment of ESD-related perforations also requires further evaluation. Postpolypectomy Electrocoagulation Syndrome Postpolypectomy Electrocoagulation syndrome is a very rare complication that manifests itself primarily as abdominal irritability caused by electrocoagulation, but there is no CT evidence of perforation. It occurs in 1.35-3.7% of large polypectomies and requires hospitalization in only 0.07%. It is characterized by fever, abdominal pain, and increased inflammatory markers (CRP and leukocytes), which have a good prognosis and require only conservative pharmacological treatment. Mortality associated with stenosis formation Mortality associated with polypectomy is almost nil, even with operations such as EMR or ESD. Stenosis is rarely induced by ESR or ESD in very large lesions. Stenosis can be prevented by postoperative tissue placement or decellularized biologic scaffolding, which is currently being tested in animal studies. In short, the removal of small or micropolyps is very safe, and the removal of larger lesions is associated with acceptable complications, especially in terms of avoiding surgery and its associated complications and mortality, as well as reducing costs. Surveillance after polypectomy Missed or incomplete removal of polyps has been associated with heterogeneous colorectal cancer, thus suggesting an important role for adequate surveillance. Two principles that have influenced clinical practice worldwide were published by the ESEG and the MSTF. Both guidelines recommend stratifying patients according to colonoscopic findings: 1. If no polyps or adenomas are found, or if only small distal hyperproliferative polyps are found, a control colonoscopy needs to be performed in 10 years (MSTF). 2. 2. If a low-risk adenoma (LRA, 1-2 tubular adenomas, 10 mm, low-grade heterogeneous hyperplasia) is found, a control colonoscopy should be performed at 10 years (ESGE) or 5 years (MSTF). 3. If high-risk adenomas (HRA, ≥3 adenomas or ≥10 mm, villous histologic changes, or high-grade heterogeneous hyperplasia) are detected, a control colonoscopy should be performed at 3 years (ESGE, MSTF), and in the case of large lesions that are resected in separate stages, a control colonoscopy should be performed within 1 year (MSFT) or at 6 months (ESGE). 4. If more than 10 or more adenomas are found, they should be considered HRA, control colonoscopy should be performed within 3 years (MSFT), and the patient should be referred for genetic counseling (ESGE). 5. In the case of serrated, non-tipped polyps, 10 mm and without heterogeneous proliferation, control colonoscopy should be performed at 5 years (MSTF) or at 10 years (ESGE). If ≥10 mm or heterogeneous hyperplasia is present, control colonoscopy should be performed at 3 years (ESGE, MSTF); if serrated polyposis hyperplasia syndrome is present, control colonoscopy should be performed at 1 year (MSTF), and the patient should also undergo genetic counseling (ESGE). Therefore recommendations for surveillance endoscopy are based on the results of the first surveillance endoscopy and are summarized as follows: 1. LRA detected at screening colonoscopy, negative first surveillance colonoscopy, control colonoscopy at 10 years (MSTF) 2. LRA detected at screening colonoscopy and first surveillance colonoscopy, control colonoscopy at 5 years (MSTF) or 10 years (ESGE) 3, LRA detected at screening colonoscopy, HRA detected at first surveillance colonoscopy, control colonoscopy at 3 years (MSTF) 4. HRA detected at screening colonoscopy, negative first surveillance colonoscopy, control colonoscopy at 5 years (ESGE, MSTF) 5. HRA detected at screening colonoscopy, LRA detected at first surveillance colonoscopy, control colonoscopy at 5 years (MSTF) 6. HRA at screening colonoscopy and first surveillance colonoscopy with LRA, control colonoscopy at 3 years (ESGE, MSTF) Neither guideline recommends the use of interrupted FOBTs, and both agree that these recommendations should be consistent with clinical practice. The final recommendations are based on the hypothesis that a high-quality colonoscopy and complete removal of all malignant tissue from the baseline level are valid. If the screening colonoscopy is of very poor quality, the interval between other colonoscopies should be shortened. Summary Colonoscopic polypectomy has been successful in stopping colorectal cancer over the past few decades, cold strangler polypectomy appears to be the optimal treatment for small or micropolyps, and hot biopsy forceps resection should no longer be used. Relatively high polyp leakage rates and incomplete polypectomy rates are the most important problems endoscopists have to deal with.Endoscopic resection of large colonic polyps by EMR or ESD or its variants is feasible, with high success rates and acceptable complications, and reduces the chances of surgery, so this type of treatment should be preferred. Efforts are needed to develop teaching procedures, endoscopic tools, and adjuncts to improve colonoscopic quality, increase adenoma detection rates, improve means of gross and microscopic evaluation of lesions, and improve complete resection rates of small or micropolyps.EMR and ESD are relatively technically difficult to perform, and the development of new resection techniques by improving those that are already in existence would be beneficial in expanding the indications for endoscopic resection. Reducing the need for surgery to prevent colorectal cancer is a reality but requires further implementation.