Introduction Initial data from the UK BCSP demonstrated variation in referrals to surgery and management for complex polyps encountered in colonoscopy. Associated factors included local availability of operator skills and expertise with endoscopic resection, lack of a structure for discussion and standardised management at the Local assessment centres (LAC). Inappropriately high incomplete resection rates at colonoscopy was noted for such polyps at local units. We hence established a National Clinical Network of specialist expert advisors, meeting every fortnight via videoconference to review endoscopy, radiology, pathology and clinical data of cases referred through specific criteria for complex lesions. We also established a National referral centre (NRC) at Llandough with the requisite skills and expertise in complex Endoscopic Mucosal Resection and Dissection (EMR, ESD) where appropriate polyps that met the referral criteria after a Network Multidisciplinary Team meeting discussion (NMDT) could undergo advanced therapy. An NMDT and NRC pilot was established in Oct 2011 to offer the opportunity to access expert opinion and discussion of therapeutic options for Welsh participants of the BCSP. We present our preliminary results.
Methods Referral criteria for complex polyps were agreed based on a composite of site, size, morphology and accessibility. Polyps satisfying the criteria were referred to the NMDT electronically along with relevant images and video. Depending on outcomes of NMDT discussion participants were given the option of accessing local surgery or travelling to the NRC for therapeutic endoscopy. Over a 2 year period, 140 referrals were made from 14 different welsh BCS centres to the NMDT.
Results The various management decisions taken in 126 benign complex polyps and the 14 cancers detected is illustrated in fig 1. Polyps that had incomplete resection (22) often had piecemeal EMR or repeated attempts at EMR at LAC causing failure of lifting in polyps. It is noteworthy that in the first 1 year of NMDT and NRC establishment;16 such cases were referred in contrast to 6 in the subsequent year with most cases in the 1st year needing surgery. This is an encouraging trend as awareness through discussion in the NMDT has streamlined management and decreased the incidence of incomplete resections allowing definitive management in the first instance and reduction in inappropriate referral to surgery for benign disease.
Conclusion Establishing a clinical network for standardised decision making for complex polyps appears to have a significant effect on clinical outcomes.
Disclosure of Interest None Declared.
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