TABLE 1.

EMR protocol

Before the procedure	Clinic visit: evaluation and counseling for 1 hour in the clinic using figures and YouTube videos (https://www.youtube.com/user/GottumukkalaSRaju).
	Preparation: split-dose polyethylene glycol-electrolyte solution.
Procedure	Sedation: Conscious sedation/anesthesia.
	Endoscope: Cap-fitted high definition colonoscope.
	Submucosal injection: Saline with Indigo Carmine or methylene blue.
	Resection: A) Snare resection: en bloc resection ≤20 mm; piecemeal resection >20 mm; current setting: EndoCut Q 3-1-3. B) Cold biopsy avulsion of 2- to 3-mm residue at the edge that is not amenable to snare resection. C) Hot biopsy avulsion of residual polyp in the resection base not amenable to snare resection.
	Confirmation of complete resection: Close-up photographs of the entire resection edge every 5 mm to confirm a round mucosal pit pattern and, thus, complete resection.
	Argon plasma coagulation: Routine ablation of the edge. Settings: 0.8-L flow and 25-30 W; 0.8-L flow and 50-60 W for lesions with prior resections and tethering of the edges. All macroscopic disease removed prior to ablation with argon plasma coagulation. Repeat photo documentation of cleared resection edge.
	Clip closure: Complete clip closure or clip closure of a deep resection with exposure of the muscularis propria in large lesions (>3-4 cm). Photo documentation: Multiple photos are taken to document every step of the procedure – lesion, injection, resection, ablation, clip closure.
Recovery	Patients are discharged from the EMR center as soon as they meet the discharge criteria with instructions for diet, activity, medications, and follow-up.
After the procedure (0-5 days)	Diet: Full liquid diet on days 0-2, low-residue diet on days 3 and 4, regular diet on day 5. E-mail reports: Patients instructed to e-mail their progress daily for the first 5 days.
After the procedure (10-14 days)	Telephone call: Endoscopist checks for complications and reports pathology results to the patients.
Surveillance	Six and 18 months after EMR: Colonoscopy to check for residual polyp at the scar site and clear the colon of any polyps missed by the referring endoscopist. Biopsy the scar for residual tumor in patients with nodular scar and submit in different jars for larger scars; biopsies are deferred in patients with smooth scars with round pit patterns and innominate grooves.