A staged hybrid technique for large benign colorectal polyps with severe fibrosis: a retrospective cohort study

Background and aims: Severe submucosal fibrosis presents a major challenge during endoscopic resection (ER) of large colorectal polyps, often precluding standard endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). This challenge is particularly relevant in elderly or comorbid patients when procedural safety is paramount. We describe the safety and efficacy of the novel PETAL (Polyp Excision with Thermal Ablation and AvuLsion) technique, a staged hybrid approach combining widefield EMR, thermal ablation, and avulsion. Methods: This retrospective cohort study included consecutive patients undergoing PETAL for benign-appearing colorectal polyps >20mm with severe fibrosis between January 2015 and December 2024. Primary outcomes included adverse events and recurrence at follow-up. Secondary outcomes included eradication rates and need for surgery. Results: Sixty-nine patients were included (median age 71 years; 38% ASA III-IV; 20% on antithrombotics). Median lesion size was 50mm, with 13.0% recurrent lesions. Delayed bleeding occurred in 2.9%, with no perforations or deep mural injury. Follow-up data were available in 61 patients (88%), with median duration 40 months. Recurrence at first follow-up was 45.9%, but typically small and amenable to repeat endoscopic therapy. Cumulative eradication rates were 91.1% and 98.2% at second and third follow-up, respectively. One patient required surgery. Conclusions: PETAL is a safe and effective strategy for large colorectal polyps with severe fibrosis, achieving high rates of eventual eradication despite frequent early recurrence. Its staged, low-risk profile makes it particularly suitable for elderly or comorbid patients, and may represent an alternative to higher-risk techniques such as ESD and full-thickness resection.