Endoscopists should remove colorectal polyps smaller than 20 mm with at least a 1-mm margin, carefully inspect the resection defect, and document the result, according to an international expert consensus published online in Clinical Gastroenterology and Hepatology.
The Standardized Assessment of Complete Colorectal Polyp Resection, or SCOPE, initiative also recommended that endoscopists know their incomplete resection rate (IRR) for polyps measuring 10-19 mm. The IRR is the proportion of polyps with histologically confirmed residual neoplastic tissue after resection, and the panel said it should not exceed 10% and preferably should remain below 5%.
The consensus addresses what the authors described as a lack of standardized methods for assessing whether colorectal polyps have been completely removed. Incomplete removal may lead to polyp recurrence and is estimated to account for 7%-19% of colorectal cancers diagnosed after colonoscopy, the authors wrote.
“The most important change is to make assessment of the resection defect a deliberate, standardized procedure rather than a quick visual check,” first author Querijn van Bokhorst, MD, a research fellow at Amsterdam University Medical Center, the Netherlands, told GI & Hepatology News. “Until now, guidelines have provided extensive advice on which resection technique to use, but relatively little guidance on how to confirm that the polyp has actually been removed completely. The recommendations provided may serve as a valuable starting point.”
Dr. van Bokhorst and colleagues surveyed gastrointestinal endoscopy experts in a modified Delphi process — three rounds of anonymous online surveys conducted from March to December 2025. A steering committee of four endoscopists drafted the questions and statements. The surveys covered resection margins, visual inspection of the resection defect, photo documentation, histopathologic margin assessment, and IRR measurement.
The researchers invited 103 experts. Of those, 67 from 18 countries completed the first survey, 54 completed the second, and 53 from 16 countries completed all three. Consensus was reached when at least 80% of participants agreed or strongly agreed with a statement.
Of the 53 who completed all three rounds, 42 reported more than 10 years of endoscopy experience, 41 had performed more than 5,000 colonoscopies, and nearly four in five worked in academic hospital-based practices. Most were based in Europe or North America.
After three rounds, the panel agreed on 18 of 20 statements. Among the experts, 89% agreed with a recommendation to include at least a 1-mm margin of normal tissue when using a cold snare on polyps measuring 1-19 mm. For polyps measuring 10-19 mm removed with a hot snare, 93% agreed that a margin of at least 1 mm was acceptable.
The panel agreed that careful visual inspection is the cornerstone of assessing resection completeness in daily practice. However, the authors cautioned that visual inspection alone is often insufficient to confirm complete resection, even for polyps smaller than 10 mm. The lateral margin (89% agreement) and base (96%) of a resection defect can be presumed clear if they are fully visualized and no residual polyp tissue is seen, according to the panel; at the base, the submucosa should be visible without “islands” or “bridges” of mucosal tissue.
The panel recommended using a water jet to make the resection defect easier to see after cold snare resection, with 94% agreement. The experts also encouraged using magnification endoscopy, if available, when a polyp may not have been completely removed (85%).
The panel fell just short of consensus on routine virtual chromoendoscopy for polyps 10-19 mm (79% agreement). Panelists cited its presumed limited feasibility on coagulated or bleeding defects and the absence of strong evidence of superiority over high-definition white-light endoscopy. It did agree on two stepwise protocols, one for daily practice and one for quality assurance and research. Under the daily practice protocol, high-definition white-light inspection alone is sufficient for polyps 1-9 mm, while inspection of polyps 10-19 mm should add image enhancement — magnification endoscopy, virtual chromoendoscopy, or both (93% agreement). The authors said the apparent discrepancy may reflect the broader scope of image enhancement, which includes magnification.
The panel recommended taking adequate images before and after removing all polyps, with 82% agreement. Under the daily practice protocol, photos of the resection defect are standard for polyps 10-19 mm. The authors said documentation should include at least one high-quality image of the polyp before removal and one of the resection defect afterward.
The panel recommended histopathologic margin assessment for all polyps in which it is feasible (87% agreement). Nonpedunculated polyps qualify when resected en bloc and not fragmented during retrieval (93%), and pedunculated polyps when resected en bloc with a clearly identifiable stalk (91%). For polyps that do not meet those criteria, the authors wrote, margin assessment may be unreliable. When high-grade dysplasia or cancer is suspected, they advised considering submitting specimens in an oriented manner, such as pinned or in a tissue cassette.
The panel agreed that routine biopsy sampling of resection defects is not recommended in daily practice (96% agreement). For quality assurance and research, the protocol applies the daily practice standards for polyps 10-19 mm to polyps of all sizes. It prefers confirming complete removal with extended resection — using a cold snare to remove a rim of normal-appearing mucosa around the defect. If this approach is unsafe or impractical, the protocol recommends two biopsies from opposite edges for polyps measuring 1-9 mm. For polyps measuring 10-19 mm, it recommends four biopsies, one from each quadrant of the defect’s lateral margin. For pedunculated polyps resected en bloc, the panel agreed that careful visual inspection combined with histopathologic margin assessment is sufficient to determine complete resection, with no extended resection or biopsy needed (98%).
Standardized IRR measurement could help identify endoscopists with high rates early and enable targeted training, the authors wrote. They added that an IRR above 10% for polyps 10-19 mm may signal a need for more detailed review of an endoscopist’s resection practices. However, the panel fell short of the 80% threshold on intermittent IRR measurement in daily practice (79% agreement), mainly because of concerns about time, logistics, and cost. The steering committee wrote that it nonetheless views the overall findings as supportive of monitoring and encouraged endoscopy units to set their own schedules. The 10% target reflects expert opinion rather than evidence derived directly from clinical data, the authors acknowledged.
Limitations included the 65% response rate in the first round, the loss of participants in later rounds, and possible selection bias. Some experts were identified through the steering committee’s professional network, and the study did not use formal selection criteria or set targets for geographic or gender representation. The recommendations apply only to polyps smaller than 20 mm, may be difficult to follow where magnification endoscopy is unavailable, and have not been formally endorsed by endoscopy societies. The panel included only gastroenterologists, and the authors said future evaluations should involve pathologists.
The recommendations “are based on expert consensus rather than definitive outcome evidence and do not represent formal society guidelines,” Dr. van Bokhorst said. “Future studies should evaluate the clinical feasibility of proposed protocols, validate the proposed incomplete resection rate (IRR) threshold, determine how often IRR should be measured, develop training for defect inspection and demonstrate whether implementation ultimately reduces recurrence and post-colonoscopy colorectal cancer.”
Multiple authors disclosed research support, consulting or speaking fees, equipment loans, royalties, stock interests or advisory roles involving medical device, diagnostic and pharmaceutical companies.
Expert Insight
Senior author Aasma Shaukat, MD, MPH, a gastroenterologist at NYU Langone Health, discussed the consensus recommendations with GI & Hepatology News.
What are the most important changes endoscopists should make in daily practice based on these recommendations?
Dr. Shaukat: Endoscopists should consider ways to evaluate their polypectomy completeness. This can be done by close exam of the site after resection using near magnification or narrow-band imaging, photos documenting the before and after pictures or other ways.
Why should endoscopists know their incomplete resection rate for 10-19 mm polyps, and how should they use that information to improve care?
Dr. Shaukat: IRRs are higher than we think, and a common source of post colonoscopy colon cancers. IRRs can be as high as 30%. Measuring and improving these will improve the effectiveness of colonoscopy
What should physicians do when they are unsure whether a polyp has been completely removed?
Dr. Shaukat: We recommend respecting the margins of the polyp area and doing close inspection or biopsies. If there's residual tissue repeat resection is important.
Is there anything else you'd like to say about this work?
Dr. Shaukat: As a next step we will be evaluating the polypectomy technique and the safety of different techniques to be able to guide endoscopists.