Trending Topics in Gastroenterology | GastroAGI

Remimazolam Improves Sedation Safety During ERCP : GIE | Jun 2026

Introduction: Deep sedation is essential for successful endoscopic retrograde cholangiopancreatography (ERCP), a technically complex procedure frequently performed in elderly patients and those with significant comorbidities. Propofol remains the most commonly used sedative agent because of its rapid onset and effectiveness; however, cardiopulmonary adverse events such as hypotension and respiratory instability remain important limitations. Problem Statement: As the complexity and volume of therapeutic endoscopic procedures continue to increase, safer sedation strategies are needed. Remimazolam, an ultra-short-acting benzodiazepine with rapid recovery, predictable metabolism, and the availability of reversal with flumazenil, has emerged as a promising alternative. However, prospective randomized evidence supporting its use specifically during ERCP has been limited. Summary: This multicenter randomized controlled trial compared remimazolam with propofol for deep sedation during ERCP. The study demonstrated that remimazolam provided effective procedural sedation while maintaining procedural success and high operator satisfaction. Importantly, remimazolam was associated with a lower incidence of cardiopulmonary adverse events compared with propofol, highlighting a potential safety advantage in a population often characterized by advanced age and multiple medical comorbidities. Despite its improved safety profile, remimazolam maintained adequate sedation quality and did not compromise procedural performance. These findings are particularly relevant for advanced therapeutic endoscopy, where prolonged and stable sedation is required while minimizing hemodynamic and respiratory complications. The pharmacologic characteristics of remimazolam, including rapid onset, short duration of action, organ-independent metabolism, and reversibility with flumazenil, further support its suitability for use outside the operating room environment. As one of the largest prospective randomized studies evaluating remimazolam specifically in the ERCP setting, this trial provides important real-world evidence supporting its clinical adoption. Overall, the results suggest that remimazolam may represent a safer alternative to propofol for deep sedation during ERCP, especially in patients at increased risk for sedation-related complications. Future studies should further define optimal dosing strategies, cost-effectiveness, and outcomes in higher-risk patient populations.

Sustainability Cuts Endoscopy Carbon Footprint and Costs : GIE | Jun 2026

Introduction: Endoscopy services generate substantial amounts of healthcare waste due to high procedural volumes, extensive use of disposable accessories, and stringent infection-control requirements. As healthcare systems increasingly focus on environmental sustainability, reducing the ecological impact of endoscopy has become an important priority. However, evidence demonstrating the effectiveness of practical sustainability interventions in routine endoscopy practice remains limited. Problem Statement: Endoscopy is among the largest contributors to hospital hazardous waste, resulting in significant environmental and financial burdens. Whether simple interventions such as staff education, improved waste segregation, and recycling initiatives can meaningfully reduce carbon emissions and waste-processing costs has not been well established. Summary: This prospective study evaluated the impact of a structured sustainability intervention within an endoscopy unit, focusing on waste segregation, recycling promotion, and staff education. Following implementation of the intervention, the investigators observed a significant reduction in the unit’s carbon footprint, accompanied by a meaningful decrease in waste-processing expenses. These improvements were achieved despite only a modest reduction in the overall volume of waste generated, suggesting that appropriate waste classification and diversion from regulated medical waste streams were the primary drivers of benefit. The findings highlight the importance of behavioural and organizational changes rather than solely reducing procedural waste production. By improving staff awareness and encouraging correct disposal practices, the intervention successfully reduced both environmental impact and operational costs without requiring major infrastructure changes or compromising clinical care. Given the increasing emphasis on environmentally responsible healthcare delivery, these results demonstrate that relatively simple and low-cost sustainability measures can produce measurable benefits in endoscopy practice. The study provides a practical framework for endoscopy units seeking to improve environmental performance while simultaneously reducing expenditure. Overall, the findings support broader adoption of structured waste-management programs as an achievable strategy to advance sustainable endoscopy and reduce the environmental footprint of gastrointestinal healthcare services.

Modern Endoscopic Management of Flat Colonic Neoplasia : Endoscopy | June 2026

Introduction: Non-pedunculated colonic neoplasia (NPCN), including flat and sessile colorectal lesions, is being detected with increasing frequency due to widespread colorectal cancer screening and advances in high-definition endoscopy. Compared with pedunculated polyps, these lesions present greater challenges because of their higher risk of submucosal invasion, incomplete resection, and recurrence. Consequently, accurate lesion characterization and appropriate selection of resection technique are essential for optimal patient outcomes. Problem Statement: The expanding range of endoscopic imaging technologies and resection techniques has created increasing complexity in the management of NPCN. Clinicians must determine which lesions can be safely treated with cold resection techniques, which require advanced endoscopic interventions, and which should be referred for surgery. Clear guidance is needed to integrate evolving evidence into routine clinical practice. Summary: This review provides a contemporary overview of the diagnosis and management of NPCN, highlighting major advances that have reshaped endoscopic practice over the past decade. Modern optical diagnosis systems, including NICE, JNET, and Kudo pit pattern classifications, now enable more accurate real-time assessment of lesion histology and invasion depth, facilitating informed therapeutic decision-making. Cold snare polypectomy and cold EMR have emerged as preferred approaches for small and intermediate-sized lesions because of their excellent safety profile and high rates of complete resection. For lesions measuring 20 mm or larger, piecemeal EMR combined with systematic margin ablation using snare-tip soft coagulation has become the standard approach, substantially reducing recurrence rates. The review also discusses the growing role of underwater EMR, cap-assisted EMR, and endoscopic full-thickness resection for challenging fibrotic or non-lifting lesions. ESD remains an important technique when en bloc resection is required, particularly in lesions with suspected superficial submucosal invasion, although its adoption varies according to local expertise and service infrastructure. Looking ahead, artificial intelligence-assisted optical diagnosis, standardized training pathways, and robust quality metrics are expected to further improve outcomes. Overall, the review reinforces a lesion-specific, evidence-based approach to NPCN, emphasizing accurate optical diagnosis and tailored resection strategies as the foundation of high-quality colorectal endoscopic care.

EUS-GJ Preferred for Malignant Gastric Outlet Obstruction : GIE | Feb 2026

Introduction: Malignant gastric outlet obstruction (GOO) is a debilitating complication of advanced gastrointestinal and pancreatobiliary cancers, leading to nausea, vomiting, poor oral intake, malnutrition, and impaired quality of life. Palliation aims to restore enteral intake rapidly while minimizing complications, hospital stay, and need for repeat procedures. Available options include enteral stenting, surgical gastrojejunostomy, stomach-partitioning gastrojejunostomy, and EUS-guided gastrojejunostomy (EUS-GJ). Problem Statement: Despite multiple available approaches, the optimal palliative strategy for malignant GOO remains uncertain. Enteral stenting is widely available and less invasive but may be limited by recurrent obstruction and need for reintervention. Surgical bypass offers durability but is associated with longer hospitalization and perioperative burden. Comparative evidence across all modalities has remained fragmented. Summary: This systematic review and network meta-analysis compared major treatment options for malignant GOO using randomized trial data. EUS-GJ emerged as the most favorable strategy, demonstrating superior clinical success compared with surgical gastrojejunostomy, stomach-partitioning gastrojejunostomy, and enteral stenting. Importantly, technical success and severe adverse events were broadly comparable across approaches, suggesting that the advantage of EUS-GJ lies mainly in more durable symptom relief rather than increased procedural risk. Enteral stenting remained an important alternative because it is less invasive, widely available, and generally less expensive; however, it carried a substantially higher need for reintervention, reflecting the risk of stent dysfunction or recurrent obstruction. Surgical approaches were associated with longer hospital stay, which may be particularly relevant in patients with limited life expectancy or poor performance status. Overall, the findings support EUS-GJ as the preferred palliative treatment for malignant GOO when local expertise is available. Treatment selection should still be individualized based on expected survival, tumor anatomy, procedural expertise, patient fitness, and resource availability.

Structured Closure Improves Safety of Duodenal ESD and EFTR : GIE | April 2026

Introduction: Endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR) have expanded the therapeutic options for duodenal epithelial and sub epithelial lesions, allowing organ-preserving treatment of lesions that previously required surgery. However, the duodenum remains one of the most technically challenging locations for advanced endoscopic resection because of its thin wall, narrow lumen, rich vascularity, and exposure to bile and pancreatic secretions. These anatomical factors increase the risk of bleeding, perforation, and delayed adverse events. Problem Statement: Although ESD and EFTR are increasingly performed in expert centers, data regarding real-world outcomes, predictors of complications, and strategies to reduce delayed adverse events remain limited. Identifying high-risk lesions and optimizing defect closure techniques are critical to improving procedural safety. Summary: This real-world study demonstrates that both ESD and free-hand EFTR can be performed with high technical success and excellent oncologic outcomes for carefully selected duodenal lesions. The investigators achieved high rates of complete resection while maintaining low recurrence rates during follow-up. Importantly, all intraprocedural bleeding and perforation events were successfully managed endoscopically, highlighting the feasibility of advanced endoscopic therapy in experienced hands. A key finding of the study was the identification of severe fibrosis as the strongest predictor of procedural adverse events in sub epithelial lesions, particularly when associated with ulceration. These features may therefore serve as valuable markers for procedural complexity and risk stratification before intervention. The study also underscores the importance of meticulous defect management. By implementing a structured closure protocol that incorporated stepwise closure techniques, intraoperative assessment, and selective postprocedural imaging, the investigators achieved near-complete defect closure and remarkably low rates of delayed complications. This finding is particularly relevant because delayed perforation and bleeding remain major concerns after duodenal resection. Overall, the study supports ESD and EFTR as effective minimally invasive alternatives to surgery for selected duodenal lesions and suggests that a systematic closure strategy may be a critical factor in enhancing procedural safety. These results provide a practical framework for optimizing outcomes in advanced duodenal endoscopic resection.

Bariatric Endoscopy in the GLP-1 Era : Frontline Gastroenterol | June 2026

Introduction: Introduction: Obesity affects more than one billion individuals globally and is a major driver of type 2 diabetes, cardiovascular disease, metabolic dysfunction–associated steatotic liver disease (MASLD), and multiple obesity-related cancers. While incretin-based therapies such as GLP-1 and dual agonists have transformed medical obesity management, concerns remain regarding long-term adherence, treatment costs, access, and weight regain following discontinuation. These limitations have renewed interest in metabolic and bariatric endoscopy (MBE) as a minimally invasive treatment modality positioned between pharmacotherapy and bariatric surgery. Problem Statement: Problem Statement: The rapid success of highly effective anti-obesity medications has raised questions about the future role of endoscopic bariatric therapies. Determining how endoscopic interventions can complement pharmacotherapy, provide durable weight loss, and address metabolic disease remains a critical challenge for obesity care pathways. Summary: Summary: This review examines the evolving role of bariatric metabolic endoscopy and its future position within modern obesity management. Current endoscopic therapies target multiple components of the gut–metabolic axis and can be broadly classified into gastric-directed, small bowel-directed, and pancreatic-directed interventions. Among gastric therapies, endoscopic sleeve gastroplasty (ESG) remains the most established procedure. By reducing gastric volume through endoscopic suturing, ESG promotes early satiety, delays gastric emptying, and induces clinically meaningful weight loss with a favorable safety profile. Long-term studies continue to demonstrate sustained metabolic benefits, particularly when combined with multidisciplinary lifestyle interventions. Intragastric balloons remain an option for selected patients requiring temporary weight reduction, although durability and tolerability limitations have restricted their long-term role. Newer generation devices and swallowable balloon technologies aim to improve patient acceptance and safety. Small bowel-directed therapies focus on modifying nutrient exposure and enteroendocrine signaling. Techniques such as duodenal mucosal resurfacing and other endoscopic duodenal interventions seek to improve insulin sensitivity and glycemic control by altering proximal intestinal nutrient sensing. These approaches are particularly attractive for patients with obesity-associated type 2 diabetes. Emerging pancreatic-directed endoscopic therapies are based on the concept of modifying neurohormonal pathways involved in appetite regulation, glucose homeostasis, and energy metabolism. Although still largely investigational, these technologies may represent future therapeutic targets within the gut–brain–pancreas axis. A major theme of the review is the integration of endoscopic therapies with incretin-based pharmacotherapy rather than viewing them as competing strategies. Combination approaches may offer synergistic benefits by enhancing weight loss magnitude, improving durability, reducing medication requirements, and minimizing weight regain after drug discontinuation. The future of obesity treatment is increasingly moving toward personalized therapy selection. Patients with moderate obesity, inadequate response to pharmacotherapy, medication intolerance, or reluctance to undergo surgery may represent ideal candidates for bariatric endoscopy. The review also highlights the expanding relevance of metabolic endoscopy beyond weight reduction alone. Improvements in diabetes control, MASLD, cardiovascular risk factors, and obesity-related quality of life are becoming important therapeutic targets and may ultimately drive patient selection. As obesity is increasingly recognized as a chronic relapsing disease, bariatric endoscopy is expected to become an integral component of comprehensive obesity care pathways, functioning alongside lifestyle modification, pharmacotherapy, and surgery within a multidisciplinary precision medicine framework. Overall, bariatric metabolic endoscopy is evolving from a niche intervention into a key pillar of obesity management, with future success likely to depend on strategic integration with incretin therapies, individualized patient selection, and continued innovation across the gut–metabolic axis.

Advanced Endoscopy Enhances Celiac Atrophy Detection : GIE | May 2026

Introduction Celiac Disease remains dependent on histological confirmation of villous atrophy for diagnosis. However, endoscopic recognition of subtle mucosal abnormalities has become increasingly important for improving biopsy targeting and reducing missed disease. Problem Statement Conventional White-Light Endoscopy often underdetects patchy or mild villous atrophy, particularly in patients with early or atypical celiac disease. Multiple advanced imaging techniques have emerged, but comparative diagnostic performance across modalities has remained uncertain. Summary This systematic review and meta-analysis evaluated the diagnostic accuracy of multiple endoscopic techniques for detecting duodenal villous atrophy in celiac disease. More than 22,000 studies were screened, with 52 eligible studies included, making this one of the largest comparative analyses of endoscopic imaging modalities in celiac disease. Standard white-light endoscopy demonstrated excellent specificity but only moderate sensitivity, confirming its limitation as a standalone tool for excluding villous atrophy. While classic findings such as scalloping, mosaic patterning and reduced folds remain highly suggestive, subtle disease continues to be frequently overlooked. Among all evaluated modalities, the water-immersion technique showed the best overall diagnostic performance, achieving both very high sensitivity and specificity. This approach likely improves visualization of villous architecture by reducing luminal collapse and enhancing mucosal detail. Narrow-Band Imaging also demonstrated excellent performance, supporting its increasing role in high-definition upper GI assessment. Enhanced mucosal contrast likely facilitates identification of subtle villous abnormalities and patchy disease distribution. Dye-based chromoendoscopy similarly achieved high sensitivity and specificity, reinforcing the value of enhanced mucosal surface characterization in suspected celiac disease. White-light magnification endoscopy improved sensitivity but suffered from lower specificity, potentially increasing false-positive interpretation of nonspecific mucosal irregularities. Other advanced techniques including Confocal Laser Endomicroscopy also showed promising diagnostic performance, although their availability and procedural complexity may currently limit routine use. Importantly, heterogeneity across studies remained low, strengthening the reliability of the pooled diagnostic estimates. Clinically, the findings support a shift from purely random duodenal biopsy strategies toward image-enhanced targeted sampling. Advanced endoscopic imaging may improve detection of patchy atrophy, reduce sampling error and potentially lower the number of biopsies required. The study is especially relevant in contemporary practice, where increasing recognition of non-classical and serology-positive celiac disease requires more sensitive endoscopic assessment strategies. These techniques may also become particularly valuable in patients with mild histologic abnormalities, seronegative celiac disease, partial gluten restriction or equivocal mucosal changes. From a practical perspective, water immersion and NBI appear especially attractive because they can be integrated into routine upper GI endoscopy without substantial procedural burden. The review additionally highlights an important educational point for endoscopists: high-quality duodenal inspection should extend beyond rapid biopsy acquisition and include careful mucosal pattern analysis. Limitations include variability in operator expertise, differences in endoscopic platforms and inconsistent histologic reference standards across studies. Future directions will likely involve integration of high-definition imaging with artificial intelligence-assisted mucosal recognition to improve real-time identification of villous abnormalities during routine gastroscopy. Overall, this meta-analysis demonstrates that advanced endoscopic imaging techniques, particularly water immersion, narrow-band imaging and dye-based chromoendoscopy, substantially improve the detection of villous atrophy compared with standard white-light endoscopy and may enhance diagnostic precision in celiac disease.

Water-Assisted Colonoscopy: Endoscopy| May 2026

Water-assisted colonoscopy (WAC), also known as hydrocolonoscopy, is an evolving insertion technique in which water is used instead of, or alongside, gas insufflation during colonoscope advancement. Over recent years, growing evidence has shown that WAC not only improves patient comfort but may also enhance adenoma detection and procedural quality. Conventional air or CO₂ insufflation can elongate the colon, promote loop formation, increase angulations, and contribute to procedural discomfort. In addition, inadequate mucosal cleansing may impair adenoma detection. The challenge is to achieve: Less painful colonoscopy Better loop control Improved mucosal visualization Higher adenoma detection rates (ADR) without compromising procedural efficiency. The principle behind WAC is maintaining the lumen minimally distended using water during insertion. Water exerts a gravitational effect that helps straighten the colon, reduces angulations, and minimizes loop formation. This translates into reduced patient discomfort and lower sedation requirements. Two major forms are commonly used: 1. Water immersion 2. Water exchange Among these, water exchange appears superior for reducing pain and improving ADR because residual stool and debris are aggressively washed away during insertion. An additional benefit is improved mucosal visualization. Continuous irrigation cleans the mucosal surface, enhancing detection of subtle lesions and adenomas. Water also has therapeutic advantages during endoscopic resection. During underwater polypectomy or EMR, water dissipates thermal energy and may reduce deep electrosurgical injury to the muscularis propria. Many experienced endoscopists now use a hybrid dynamic approach, combining water and CO₂ selectively during insertion and withdrawal. Water helps traverse difficult angulations and clean the mucosa, while CO₂ is used strategically to expand folds during detailed inspection. Overall, WAC represents a practical, low-cost technique that improves colonoscopy ergonomics, patient tolerance, mucosal visualization, and potentially adenoma detection without prolonging procedure time.

Optimizing Barrett’s Endoscopy Quality to Reduce Missed Neoplasia : FG | May 2026

Introduction Barrett's Esophagus is the principal precursor lesion for Esophageal Adenocarcinoma. Surveillance endoscopy aims to detect dysplasia and early neoplasia at a curable stage; however, post-endoscopy upper gastrointestinal cancers remain a significant problem. Contemporary UK data suggest particularly high rates of missed neoplasia in Barrett’s surveillance compared with upper gastrointestinal endoscopy overall, emphasizing the urgent need for improved examination quality. Problem Statement Despite widespread Barrett’s surveillance programs, substantial rates of missed dysplasia and early cancer persist, largely due to variability in endoscopic examination quality, lesion recognition and adherence to optimal imaging and biopsy protocols. Summary This video review provides a practical and clinically focused framework for improving the quality of Barrett’s endoscopy, emphasizing meticulous mucosal inspection, advanced imaging utilization and standardized biopsy techniques to enhance neoplasia detection. The review begins by reinforcing the importance of accurate endoscopic landmark recognition and Barrett’s segment characterization. Proper identification of the gastroesophageal junction, diaphragmatic pinch and squamocolumnar junction is essential for reliable Prague classification and longitudinal surveillance consistency. A major emphasis is placed on careful mucosal inspection using high-definition white light endoscopy combined with image-enhanced technologies. Modalities such as Narrow Band Imaging, blue light imaging and i-scan are highlighted as critical adjuncts for identifying subtle vascular and mucosal abnormalities associated with dysplasia. The review additionally emphasizes the growing role of acetic acid chromoendoscopy, which can accentuate dysplastic mucosal patterns and improve targeted lesion recognition. This reflects the broader evolution of Barrett’s surveillance from random biopsy-driven protocols toward increasingly targeted optical diagnosis approaches. Importantly, the article highlights that many dysplastic lesions in Barrett’s esophagus are extremely subtle and easily overlooked during rapid or low-quality examinations. Careful slow inspection, adequate mucosal cleansing and optimized insufflation are therefore fundamental components of high-quality surveillance. The authors also stress adherence to systematic biopsy protocols following targeted lesion assessment. Although advanced imaging improves lesion detection, systematic four-quadrant biopsies remain important because flat dysplasia may still be endoscopically occult. Clinically, the work reinforces that Barrett’s surveillance quality is operator dependent. Variability in withdrawal time, familiarity with dysplastic morphology and use of enhanced imaging likely contribute substantially to the persistently elevated post-endoscopy cancer rates observed in Barrett’s patients. The review also aligns with increasing evidence supporting dedicated Barrett’s surveillance expertise and centralization of complex neoplasia management. High-quality surveillance requires not only technical proficiency but also advanced lesion recognition skills and familiarity with endoscopic resection strategies. An important practical implication is the need for structured training in Barrett’s neoplasia recognition. As endoscopic eradication therapies increasingly replace surgery for early neoplasia, accurate detection and delineation of visible lesions become even more critical. The article further reflects the broader movement within gastrointestinal endoscopy toward quality metric-driven practice. Similar to adenoma detection rates in colonoscopy, Barrett’s surveillance may increasingly adopt formal quality indicators including inspection time, adherence to biopsy protocols and use of advanced imaging. From a therapeutic perspective, improved detection directly influences patient outcomes because early Barrett’s neoplasia can often be managed endoscopically using Endoscopic Mucosal Resection and ablative therapies, avoiding esophagectomy. Overall, this review emphasizes that high-quality Barrett’s endoscopy requires a structured, meticulous and technology-enhanced approach. Careful landmark identification, prolonged mucosal inspection, advanced imaging utilization and systematic biopsy acquisition are central to reducing missed dysplasia and improving early esophageal cancer detection in Barrett’s surveillance programs.

Recurrent Colorectal Polyps Require Advanced, Structured Endoscopic Management : Frontline Gastroenterology | May 2026

Introduction Colorectal Polyps are identified in up to half of screening colonoscopies and represent key precursor lesions for Colorectal Cancer. Advances in endoscopic resection techniques have dramatically reduced the need for surgery; however, recurrence or residual neoplasia after initial polypectomy remains an important clinical challenge. Recurrence rates may approach 20%, particularly after piecemeal resection of large lesions. Problem Statement Optimal management strategies for recurrent or residual colorectal polyps remain incompletely standardized. Limited evidence exists regarding selection among repeat endoscopic therapy, advanced resection techniques and surgery, particularly in technically difficult or fibrotic lesions. Summary This review comprehensively evaluates current evidence regarding management of recurrent or residual colorectal polyps after initial polypectomy, with particular emphasis on advanced endoscopic approaches and strategies to minimize repeated interventions. The review highlights that recurrence is strongly influenced by the initial resection technique. Piecemeal endoscopic mucosal resection (EMR) carries substantially higher recurrence risk compared with en bloc resection because microscopic residual neoplastic tissue may remain at resection margins. Larger lesion size, difficult location, multiplicity and lesion morphology additionally contribute to recurrence risk. Several patient-related factors were also associated with recurrent neoplasia, including male sex, older age, obesity and smoking history. These observations reinforce the multifactorial biology underlying colorectal neoplasia persistence and recurrence. A key theme throughout the review is the importance of expert initial resection. Incomplete primary therapy frequently converts otherwise manageable lesions into technically complex recurrent polyps characterized by fibrosis, scar formation and distorted tissue planes. These recurrent lesions are often substantially more difficult to eradicate than treatment-naïve lesions. The review discusses a spectrum of advanced therapeutic options for recurrent lesions. Repeat EMR may remain feasible for smaller residual adenomas, whereas more advanced approaches such as Endoscopic Submucosal Dissection can facilitate en bloc excision of scarred or recurrent lesions. Avulsion techniques combined with thermal margin ablation have also emerged as valuable tools for fibrotic residual disease not amenable to standard snare capture. The role of full-thickness endoscopic resection is additionally emphasized for selected nonlifting or heavily scarred lesions. These techniques may help avoid surgery in carefully selected patients while still achieving definitive resection. Importantly, the review underscores that surgery remains necessary in selected circumstances, particularly when invasive malignancy is suspected, complete endoscopic excision is not feasible or repeated endoscopic attempts have failed. However, the authors strongly advocate referral to advanced endoscopy centers before surgical referral whenever possible, given the morbidity associated with colorectal resection. A major practical message is that recurrent polyp management should ideally occur in highly experienced, well-resourced tertiary centers. Advanced imaging, expert lesion characterization and availability of multiple resection platforms are critical for maximizing endoscopic cure rates and minimizing repeated procedures. The burden of recurrent procedures is also appropriately highlighted. Beyond technical complexity, repeated interventions increase patient anxiety, healthcare utilization, procedural risk and surveillance burden. Consequently, achieving high-quality definitive initial resection is likely the most effective recurrence-prevention strategy. The review also reflects the broader evolution of therapeutic colonoscopy toward organ-preserving minimally invasive management. Increasingly sophisticated endoscopic techniques are now allowing successful treatment of lesions previously referred directly for surgery. Overall, this review emphasizes that recurrent colorectal polyps represent a technically demanding but increasingly manageable clinical problem. Optimal outcomes depend on expert lesion assessment, advanced endoscopic resection capability and early referral to specialized centers, with the overarching goal of achieving definitive organ-preserving therapy while minimizing repeated interventions and unnecessary surgery.