LAUSR

There continues to be a steady increase in the incidence of significant polyps and early colorectal cancer (SPECC), largely driven by the implementation of bowel cancer screening programmes (BCSP) worldwide. Whilst there are substantial oncological benefits of detecting earlystage colorectal cancer and removing precancerous adenomatous polyps [1,2], new management dilemmas have arisen regarding the optimal treatment for complex polyps detected at colonoscopy, the majority of which are benign. Endoscopic resection has been reported to be safe, efficient [3] and cost effective [4] compared with surgical excision, which should ideally be reserved for patients in whom safe and complete polypectomy is not achievable, or for polyps deemed to be clinically malignant irrespective of negative histology at biopsy [5]. Despite these recommendations, significant variation exists in the treatment of SPECC, particularly in relation to the utilization of resectional surgery. In the English BCSP, a fivefold variation in the use of surgery has been observed, between screening units, for the treatment of complex colorectal polyps [6]. More recently, population-level data from North America suggest an increase in the rate of surgical resection for patients with benign colorectal polyps [7]. The underlying reasons for these disparities are complex and multifactorial, but often relate to suboptimal assessment and characterization of lesions at index colonoscopy, the lack of standardized treatment algorithms, deficiencies in interdisciplinary co-operation and the challenges of accurate histopathological evaluation of polyps. This paper discusses some of these aspects in greater detail, with the aim that a wider awareness of these pitfalls may help to stratify treatment decisions appropriately and minimize the potential for underor overtreatment in this patient group. Endoscopic polyp assessment