Introduction Features that characterise polyp complexity should be clearly defined and recognised to avert suboptimal piecemeal endoscopic mucosal resection (p-EMR) strategies and need for salvage surgery.
Methods A prospective database of all colorectal polyps excised at our tertiary referral centre between Jan 2010 and August 2012 was collected. Standard p-EMR, p-EMR using a 20 mm spiral snare (sp-EMR), and hybrid p-EMR (hp-EMR; p-EMR plus endoscopic mucosal ablation or endoscopic submucosal dissection) were performed. Multinomial regression analysis was utilised to define characteristic features of complex polyps and factors associated with the chosen resection technique.
Results Of 330 patients with 341 polyps (mean size 3.7 cm), 81% (261/323, p < 0.001) were tertiary and 19% were local referrals. 94/261 (36%, p < 0.001) tertiary referrals mentioned one or more previous endoscopic resection attempts. Endoscopic polyp access was described as difficult in 174/341 (51%, p = 0.001), incomplete polyp lift in 179/341 (52%, p = 0.002) cases and polyp size ≥ 4 cm (median size 5 cm) in 123/341 (36%, p < 0.001) cases. Polyps ≥4 cm were more frequently in a difficult position (≥4 cm; 63% vs <4 cm; 37%, p < 0.001). Polyps <4 cm were more likely to be in the caecum or ascending colon (<4cm; 35% vs ≥4 cm; 16%, p < 0.001).Endoscopically complete polypectomy was achieved in one session in 336/341 (98%, p < 0.001) polyps. Procedural and delayed bleeding were significantly higher in the ≥ 4 cm group where 2 of the 3 micro-perforations also occurred (3/341, 0.9%, p < 0.001) that were all treated successfully with endoscopic clipping. The overall long-term recurrence at 24 months was 17% (28% for ≥4 cm/p = 0.02). Only eleven patients (4 benign recurrence/7 cancer at histology, 3%) in this cohort underwent surgery. Using multivariable analysis, factors associated with need for sp-EMR or hp-EMR were; i) tertiary referrals (sp-EMR, OR 3.41, p < 0.001), ii) incomplete polyp lift (hp-EMR, OR 8.3 > sp-EMR, OR 1.19 p < 0.001), iii) previous polypectomy attempt (hp-EMR, OR 2.77, p = 0.02), iv) larger polyp size (for an increase of 1 cm – hp-EMR (OR 1.37)/sp-EMR (OR 1.66,) p < 0.001, v) polyps in the rectosigmoid location (sp-EMR and hp-EMR, p < 0.001) and vi) Paris IIa+IIb polyps (sp-EMR, OR 5.01 and hp-EMR, OR 2.9, p –0.007).
Conclusion Complex colorectal polyps referred to this tertiary centre were characterised by polyp size ≥ 4 cm, caecal location, previous unsuccessful polypectomy, difficult endoscopic access, or incomplete polyp lift. Advanced techniques such as hybrid-pEMR and spiral p-EMR were required in 33% of tertiary referrals.
Disclosure of Interest None Declared
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