Dear colleagues,
In past issues of Perspectives, we have explored some of the most important controversies in gastrointestinal endoscopy, including the management of large colorectal polyps and Barrett's esophagus. These discussions highlighted evolving evidence, areas of ongoing debate, and the clinical decisions that often extend beyond guideline recommendations. In this issue, we continue that theme by shifting from controversy to practicality, inviting experts in the field to share the technical pearls, procedural strategies, and real-world approaches that have shaped their practices. Gottumukkala S. Raju, MD, outlines a structured approach to endoscopic mucosal resection of large colorectal polyps, emphasizing the importance of planning, lesion assessment, scope control, and meticulous resection technique. In a complementary article, Arvind Trindade, MD, reviews his recommendations for Barrett’s esophagus management, offering practical guidance on screening, endoscopic eradication techniques, specialized referral centers, and the nuanced management of low-grade dysplasia. Together, these contributions build upon the tradition established in the AGA Perspectives series — bringing expert insight to everyday clinical challenges and providing actionable recommendations that can be readily incorporated into practice.
Gyanprakash A. Ketwaroo, MD, MSc, is associate professor of medicine, Yale University, New Haven, and chief of endoscopy at West Haven VA Medical Center, both in Connecticut. He is an associate editor for GI & Hepatology News.
Beyond ablation: Contemporary challenges in the management of dysplastic Barrett’s
By Arvind Trindade, MD
The management of Barrett’s esophagus (BE) changed dramatically following publication of the landmark AIM Dysplasia Trial in 2009, led by Nicholas Shaheen and colleagues. Today, from a distance, the treatment paradigm appears straightforward: surveillance for nondysplastic BE, endoscopic resection of visible lesions, and radiofrequency ablation (RFA) for flat dysplastic disease. Yet after 14 years managing a high-volume Barrett’s referral practice, I have come to appreciate that successful treatment is rarely this simple. Important nuances remain regarding screening, lesion recognition, selection of eradication modalities, referral patterns, and the management of low-grade dysplasia (LGD). In this commentary, I discuss several of the most relevant controversies and practical considerations facing clinicians today.
Why is the incidence of esophageal adenocarcinoma not declining despite highly effective endoscopic eradication therapy?
The remarkable success of endoscopic eradication therapy has shifted the focus of BE research and clinical practice toward screening and early detection. While we now possess highly effective tools to eradicate dysplastic BE, these advances can only benefit patients whose disease is identified before progression to cancer.
Gastroenterologists performing screening colonoscopy should strongly consider performing upper endoscopy during the same session in patients who meet established BE screening criteria. Equally important is obtaining a thorough family history. A history of BE or esophageal adenocarcinoma in a first-degree relative is a significant risk factor and, by itself, qualifies many patients for screening according to current American Society for Gastrointestinal Endoscopy recommendations.
Unfortunately, most patients who meet screening criteria in primary care settings are never evaluated for BE. This represents a major missed opportunity for cancer prevention. To address this gap, several nonendoscopic screening tools and molecular-based screening strategies have been developed and are now clinically available. These technologies have the potential to expand screening beyond the endoscopy suite and into primary care practices, reducing the need for referral-based screening paradigms.
Gastroenterologists practicing within large health care systems, academic centers, multispecialty groups, and integrated private practices should actively partner with their primary care colleagues to improve identification of at-risk individuals. Without greater emphasis on screening and early detection, even the most effective eradication therapies will have only a limited impact on the overall incidence of esophageal adenocarcinoma.
When eradicating dysplastic BE, which tools should I use?
Successful endoscopic eradication therapy begins with meticulous lesion recognition. Before considering any ablative modality, I perform endoscopic resection of all nodular lesions and any areas suspicious for high-grade dysplasia (HGD), even when subtle or non-nodular in appearance. In experienced hands, HGD is frequently endoscopically visible, although the findings may be nuanced.
A careful examination is essential. The esophagus should be thoroughly cleansed, inspected under high-definition white light and virtual chromoendoscopy, and systematically evaluated for subtle mucosal abnormalities before resection is performed. Endoscopic resection serves not only as definitive therapy for visible lesions but also provides critical histologic staging information that may alter management. Whether endoscopic mucosal resection (EMR) or endoscopic submucosal dissection is preferred remains an area of ongoing debate and is beyond the scope of this commentary. Following resection, I typically allow two to three months for healing before initiating eradication therapy for the remaining flat Barrett’s segment.
Today, several effective options exist for eradication of flat dysplastic BE, including RFA, nitrous oxide cryoballoon therapy, liquid nitrogen spray cryotherapy, and hybrid argon plasma coagulation (APC). Prospective data support the use of each modality, making treatment selection increasingly individualized.
When discussing treatment options with patients, I emphasize that RFA possesses the longest track record and the most robust evidence base. At the same time, cryotherapy has accumulated high-quality multicenter prospective data demonstrating outcomes comparable to RFA in treatment-naive patients. Because postprocedural discomfort remains a common limitation of RFA, cryotherapy can be an attractive alternative for patients who experience significant pain or are hesitant to continue treatment after an initial RFA session.
Hybrid APC is another valuable addition to the therapeutic armamentarium. While effective, its focal treatment pattern and need for repeated submucosal lifting can make treatment of long Barrett’s segments more labor-intensive. For this reason, I most commonly reserve hybrid APC for refractory or residual disease rather than as a first-line therapy.
Does Barrett’s endoscopic eradication therapy belong in specialized referral centers?
The ultimate goal of Barrett’s endotherapy is prevention of esophageal adenocarcinoma through complete eradication of intestinal metaplasia (CE-IM). To maximize the likelihood of achieving this outcome, patients should receive care in environments that possess the expertise, experience, and procedural resources necessary to manage the full spectrum of Barrett’s neoplasia.
Multiple studies have demonstrated that patients referred from community practices to specialized Barrett’s centers are frequently found to have previously unrecognized HGD or visible lesions. In some series, expert evaluation identifies advanced pathology in up to one-quarter of referred patients. Similarly, lesion detection rates are consistently higher among experienced Barrett’s endoscopists than among lower-volume operators. Procedural volume also matters. Data from the U.S. suggest that outcomes improve significantly with operator experience, with the learning curve for RFA plateauing after approximately 30 cases — a volume more commonly encountered in dedicated referral programs.
In my view, these data support a strong argument for centralization of Barrett’s endoscopic eradication therapy. Ideally, procedures should be performed in centers with dedicated Barrett’s expertise, high procedural volumes, and access to a full range of resection and ablative technologies. The treatment plan must remain adaptable. An endoscopist who intends to perform RFA should be prepared to perform endoscopic resection if a previously unrecognized lesion is encountered. Likewise, if multiple ablation sessions fail to produce meaningful regression, the operator should be comfortable transitioning to alternative modalities such as cryotherapy or hybrid APC.
Endoscopic eradication therapy should not be viewed as a series of isolated procedures. Rather, it is a longitudinal treatment strategy aimed at achieving CE-IM. Maintaining focus on this endpoint — and possessing the tools and expertise required to reach it — is what ultimately distinguishes specialized Barrett’s programs.
Should all LGD be endoscopically eradicated?
LGD remains one of the most challenging and controversial diagnoses in BE. A substantial proportion of LGD diagnosed in the community is downgraded following expert gastrointestinal pathology review, with studies demonstrating that only approximately 15–30% of cases are ultimately confirmed as true LGD. As a result, the most important initial step in management is confirmation of the diagnosis by an expert GI pathologist. Many academic centers with dedicated Barrett’s programs offer streamlined outside pathology review services, making expert reassessment readily accessible.
When there is concern that the histologic findings may represent reactive atypia rather than true dysplasia, optimization of acid suppression followed by repeat endoscopy with systematic biopsies is often appropriate. Confirming the diagnosis before embarking on long-term surveillance or endoscopic eradication therapy is critical.
Once LGD has been confirmed, management should be individualized. Although randomized data have demonstrated that endoscopic eradication therapy reduces progression to HGD and esophageal adenocarcinoma, not all patients with LGD carry the same risk of progression. In my practice, patients with focal LGD identified on a single examination are generally offered surveillance following a thorough discussion of risks and benefits. In contrast, I strongly favor endoscopic eradication therapy for patients who are appropriate procedural candidates and have features associated with higher risk, including multifocal LGD, persistent LGD on sequential examinations, long-segment BE, or visible lesions that have required endoscopic resection.
The question is therefore not whether all LGD should be eradicated, but rather which patients with confirmed LGD stand to benefit most from intervention. As our ability to risk stratify BE continues to improve, management of LGD will likely become increasingly personalized rather than uniformly procedural.
The field of BE continues to evolve at a rapid pace. Although remarkable advances in endoscopic eradication therapy have transformed outcomes for patients with dysplastic disease, important questions remain unanswered. How should we optimize screening to reduce the incidence of esophageal adenocarcinoma? Should all confirmed LGD be eradicated? Are Seattle protocol biopsies nearing obsolescence? What role should biomarkers and artificial intelligence play in risk stratification and treatment selection? As these questions are answered, the next decade of Barrett’s management will likely be defined not by new ablative technologies, but by our ability to identify the right patients, select the right therapies, and deliver care in the right settings.
A structured approach to endoscopic resection of large colorectal polyps
By Gottumukkala S. Raju, MD
Successful resection of large colorectal polyps (>10 mm) depends not only on technical skill, but also on planning, lesion selection, scope control, thoughtful submucosal injection, disciplined resection, and careful postprocedural management. EMR can achieve complete and safe removal of large polyps with low rates of complications and recurrence. Although variations such as cold EMR and underwater EMR are available, I continue to favor the traditional hot EMR protocol that I have followed consistently for nearly two decades. I reserve underwater resection mainly for selected cecal lesions when scope instability worsens with luminal distension and the instrument tends to slip backward. In the remainder of this discussion, I focus on practical tips for performing traditional EMR of large polyps measuring 20–30 mm.1-3
Planning is part of the procedure
Large polyps are encountered in two distinct settings: during screening or surveillance colonoscopy, or during a dedicated referral for EMR. During screening colonoscopy, the endoscopist must decide in real time whether the lesion can be removed completely and safely during that session or whether resection should be deferred and planned separately. Larger lesions should not be forced into a procedure that no longer has the time, preparation, or clinical setting needed for safe therapy.
Before undertaking resection, I routinely ask about upcoming travel, including international flights and cruises. Delayed bleeding remains one of the most important adverse events after EMR. A technically successful resection may still be poorly timed if the patient is about to travel far from medical care. In elderly patients, I also assess the support structure at home. Who will help if delayed bleeding or pain develops? These are not peripheral concerns; they are part of procedural safety.
If I decide to proceed with a large resection during a screening colonoscopy, I usually speak with the accompanying family member before proceeding. They should understand why the procedure may take longer and which delayed symptoms require attention after discharge.
In referred cases, I review the color photographs of the lesion with my team before the procedure and confirm that all necessary devices are ready, including the injection catheter, snares, clips, hot biopsy forceps, hemostatic forceps, a straight-fire APC catheter, the electrosurgical unit, and a functioning CO2 supply.
Scope control precedes resection
The first technical requirement is excellent endoscope control. I want the lesion positioned in the lower half of the visual field, the scope tip within a few centimeters of the target, and the ability to move, or “dance,” around the lesion in a stable and controlled fashion. This requires careful insertion, repeated loop reduction, and willingness to spend time in the left colon so that the cecum is reached with a short, stable scope position, usually at about 60–70 cm. Time invested in achieving that position is rarely wasted. It allows controlled and deliberate resection of the polyp.
Lesion selection and inspection
Inspection should be deliberate. Before committing to EMR, I assess morphology, location, access, lifting characteristics, and the possibility of deep submucosal invasion. I avoid EMR when a lesion shows overt mucosal or vascular features of cancer on electronic chromoendoscopy.
I also emphasize to trainees that prior manipulation can substantially alter the difficulty of later resection. If I decide to reschedule a patient for EMR of a large lesion, I avoid biopsies and partial snaring. When tattooing is needed, I place a small tattoo distal to the lesion into a submucosal saline bleb; placing the tattoo on the opposite wall may be even better.
Submucosal injection
After inspection, I proceed with submucosal injection, most often using saline mixed with indigo carmine or methylene blue, sometimes with epinephrine in bulky sessile polyps. I have preferred saline with dye for the past 20 years. Although saline is often criticized for providing a shorter-lived lift, that has not been a practical limitation in my experience. The key is preparation. Before injection, electrosurgery should already be powered on, the foot pedal positioned, and the selected snare opened and ready for immediate use as soon as the injection catheter is withdrawn.
My team prepares two or three syringes of 10 mL saline with a few drops of indigo carmine to create a Carolina blue color. The softer saline cushion helps avoid snare slippage, unlike the concerns I sometimes hear from colleagues using more viscous lifting agents, and it often allows deeper clip closure of the defect after resection.
Injection technique matters. I ask the technician to prime the catheter fully to the tip. Once the catheter is in the field, the needle is advanced and flushed once so I can observe where the fluid settles. If fluid pools around the lesion, the lesion is in a dependent position. In larger polyps, I may reposition the patient so that bleeding, if it occurs, drains away from the resection site rather than obscuring it.
I routinely ask the technician to demonstrate injection of small aliquots of saline by gently tapping the syringe plunger to confirm that these small volumes can be delivered in a controlled fashion. Once satisfied with the technique, I usually begin injection on the cecal side of the lesion and puncture the submucosa at an acute angle rather than a right angle, thereby reducing the risk of deep or transmural injection. I then ask the technician to continue delivering small aliquots while I watch for the initial submucosal lift. Once correct submucosal positioning is confirmed, I use a dynamic injection technique, adjusting the scope tip and slowly withdrawing the needle as the cushion develops. For lesions measuring 20–30 mm, I try to achieve most of the lift with one or two injections and avoid multiple punctures.
The lift improves safety, but it also provides information. A good lift is reassuring. A poor lift raises concern for fibrosis, prior intervention, or deeper invasion.
Hot snare resection
My preference is to use either a 10-mm or 15-mm stiff braided snare, with the 10-mm snare favored for cecal lesions or technically difficult resections. I always keep the snare parallel to the wall to avoid muscle entrapment and deep mural injury.
After the technician initially ensnares the lesion, I take over control of the snare handle and closely watch the tissue as the snare is closed. I pay particular attention to the movement of tissue above and below the snare. If excessive puckering is seen below the snare, I gently release the snare while distending the colon to free the deeper layers, then close the snare again tightly, nearly to the point of a cold cut, before favoring rapid transection with minimal energy. A large submucosal lift helps maintain the cut plane away from larger deep submucosal vessels, and tight snare closure combined with rapid cutting minimizes the heat energy required. This may reduce the risk of bleeding, muscle injury, and post-EMR complications.
Resection should be deliberate. After each cut, the base and margin should be reassessed before proceeding. Small amounts of residual polyp at the edges, or in the base of tethered lesions, that cannot be captured with the snare should be removed completely with hot biopsy avulsion.
Equally important, the procedure is not over when the polyp has been removed. The defect deserves close inspection. I take multiple photographs to document a clean base and a clean resection edge. The true endpoint is confidence that no visible neoplasia remains. Only then should margin treatment with APC or snare-tip soft coagulation, defect closure with clips, and postprocedural planning follow.
As part of my protocol, I use APC to treat the resection edge, followed by deep clip approximation and closure of the defect. Typically, I take 20–30 images as part of my documentation of large EMRs.
Large colorectal polyp resection is best understood as a discipline of planning, control, judgment, and completeness. That is the framework I use in teaching, and I believe it leads to safer and more durable outcomes. I hope you will also find my YouTube resource dedicated to EMR techniques helpful (search my name on YouTube and find the EMR Channel playlist).
References
Raju GS, Lum PJ, Ross WA, et al. Outcome of EMR as an alternative to surgery in patients with complex colon polyps. Gastrointest Endosc 2016; 84(2):315-25.
Raju GS, Lum P, Abu-Sbeih H, et al. Cap-fitted endoscopic mucosal resection of ≥20 mm colon flat lesions followed by argon plasma coagulation results in a low adenoma recurrence rate. Endosc Int Open 2020; 8(2):E115-E121.
Ferlitsch M, Hassan C, Bisschops R, et al. Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2024. Endoscopy 2024; 56:516-545.