Episode two frames polyp management as a reading task that begins before the snare opens: has the lesion grown horizontally along the mucosa or vertically into the submucosa, because vertical growth is what carries cancer risk. Paris morphology, the NICE and JNET optical patterns, Kudo pit pattern, and the lateral spreading granularity types are all ways of reading that same growth signal, and depressed or pseudodepressed surfaces are what deep submucosal invasion looks like from above. The optical read then dictates the resection plan. Cold snare wins on safety for diminutive and small lesions, hot snare is reserved for the vascularized pedunculated stalk, EMR is standard for larger sessile and lateral spreading lesions, and en bloc resection by ESD or band-ligation is reserved for when specimen integrity is needed for staging. Topics covered Horizontal versus vertical polyp growth Paris morphology classification NICE and JNET optical prediction Kudo pit pattern Lateral spreading lesion granularity types Cold snare and hot snare selection Endoscopic mucosal resection and the non-lifting sign Underwater EMR and margin ablation ESD and Japanese curative criteria Key decisions Depressed Paris zero-two-c and mixed zero-two-a-plus-c lesions carry disproportionately high submucosal invasion rates and go to en bloc resection or surgical referral, not piecemeal EMR. A NICE one or JNET one lesion can be confidently treated with cold-snare polypectomy, while a NICE three or JNET three lesion is a staging problem rather than an endoscopic one. Cold snare polypectomy is preferred for diminutive polyps and standard for four to ten millimeter polyps because pure mechanical transection avoids thermal injury, dropping delayed bleeding and electrocoagulation syndrome. Hot snare is reserved for pedunculated polyps over ten millimeters with a defined feeding artery, and thick stalks warrant a prophylactic clip or detachable loop before transection. For sessile and lateral spreading lesions ten millimeters or larger without high-risk features, submucosal-injection EMR is standard, and a non-lifting sign means biopsy and referral for surgery or ESD. Snare-tip soft coagulation of the EMR margin gives roughly a four-fold reduction in adenoma recurrence at first surveillance by killing microscopic adenomatous nests at the resection edge. Japanese ESD curative criteria require en bloc removal with negative vertical and lateral margins, well or moderate differentiation, no lymphovascular invasion, and intramucosal or submucosal invasion under one thousand microns, which drops nodal risk below one percent. For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com. Questions or feedback: [email protected].

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