Management of the Pedunculated Polyp

Pedunculated polyps, characterized by a visible stalk on endoscopic examination, account for about 15-30% of all detected polyps, most commonly on the left side of the colon, typically measuring 10-30 mm. Due to their stalk, endoscopic resection is safer with a lower risk of intra- and postprocedureal events, and a generally low risk of lymph node metastasis and distant metastasis in early colorectal cancer. En bloc excision with clear margins is always advised, even and especially in suspected malignant cases. Most pedunculated polyps are in the sigmoid colon, where technical challenges arise form anatomic variations. Techniques such as repositioning, water filling of the lumen, and the use of a cap can facilitate snare placement. For small pedunculated polyps (<10 mm), cold snare polypectomy minimizes postprocedural bleeding but increase immediate bleeding managed during the procedure. For larger polyps (>10 mm head or > 5 mm stalk), hot snare polypectomy (HSP) with mechanical or injection-based prophylaxis is preferred due to the higher risk intraprocedural bleeding. Prophylactic tools (detachable snare, hemoclips, injections) mainly prevent immediate intraprocedural bleeding; mechanical methods are more effective when combined but should not compromise complete resection. Immediate bleeding is managed with contact coagulation, hemostatic forceps, or clips. This chapter provides a detailed overview of all considerations to make in order to achieve safety, margin clarity, and recurrence prevention through a tailored endoscopic approach.