Serrated Polyposis Syndrome Requires Improved Detection and Personalized Surveillance : Endoscopy | May 2026

Introduction

Serrated polyposis syndrome (SPS) is now recognized as the most common colorectal polyposis syndrome and an important precursor condition for colorectal cancer (CRC). The syndrome is characterized by multiple serrated colorectal lesions, including sessile serrated lesions and traditional serrated adenomas, which contribute substantially to colorectal carcinogenesis through the serrated neoplasia pathway.

Problem Statement

Despite its clinical importance, SPS remains significantly underdiagnosed because serrated lesions are frequently subtle, flat and historically misclassified during colonoscopy. In addition, uncertainty persists regarding optimal endoscopic resection techniques and long-term surveillance strategies, with most current recommendations still based on expert opinion rather than high-quality prospective evidence.

Summary

This review provides a contemporary overview of the evolving understanding and management of serrated polyposis syndrome, emphasizing the central role of improved endoscopic detection in reducing colorectal cancer risk. Advances in high-definition colonoscopy, chromoendoscopy, prolonged withdrawal times and refined lesion classification systems have substantially improved recognition of serrated lesions, particularly sessile serrated lesions that often present with indistinct borders and mucus caps. The review reinforces cold snare polypectomy as the preferred technique for most small nondysplastic serrated lesions because of its favorable safety profile and effective complete resection rates. For larger or dysplastic lesions, endoscopic mucosal resection remains the preferred strategy, although comparative evidence regarding cold, hot and underwater techniques specifically for serrated lesions remains limited. The article also highlights the growing shift toward individualized surveillance strategies in SPS. Although annual colonoscopy following colon clearance remains guideline standard, emerging evidence suggests that selected low-risk patients may safely undergo biennial surveillance, potentially reducing procedural burden without compromising cancer prevention. Overall, the review underscores that serrated neoplasia represents a major but still incompletely understood pathway in colorectal carcinogenesis and calls for further research to optimize detection, resection and surveillance strategies aimed at reducing interval and preventable colorectal cancers.