Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer

doi:10.1016/j.gie.2013.06.034

Gastrointestinal Endoscopy

Volume 79, Issue 1, January 2014, Pages 101-107

https://doi.org/10.1016/j.gie.2013.06.034 Get rights and content

Background

Despite advances in endoscopic treatment, many colonic adenomas are still referred for surgical resection. There is a paucity of data on the suitability of these lesions for endoscopic treatment.

Objective

To analyze the results of routine repeat colonoscopy in patients referred for surgical resection of colon polyps without biopsy-proven cancer.

Design

Retrospective review.

Setting

University hospital.

Patients

Patients referred to a colorectal surgeon for surgical resection of a polyp without biopsy-proven cancer.

Interventions

Repeat colonoscopy.

Main Outcome Measurements

The rate of successful endoscopic treatment.

Results

There were 38 lesions in 36 patients; 71% of the lesions were noncancerous and were successfully treated endoscopically. In 26% of the lesions, previous removal was attempted by the referring physician but was unsuccessful. The adenoma recurrence rate was 50%, but all recurrences were treated endoscopically and none were cancerous. Two patients were admitted for overnight observation. There were no major adverse events.

Limitations

Single center, retrospective.

Conclusions

In the absence of biopsy-proven invasive cancer, it is appropriate to reevaluate patients referred for surgical resection by repeat colonoscopy at an expert center.

Section snippets

Methods

The study was approved by the Stanford University Institutional Review Board. Electronic records of all patients referred to a colorectal surgery practice and an interventional colonoscopy clinic between December 2010 and March 2013 were reviewed. During this period, our standard practice was to schedule all patients referred for colorectal surgery of colon polyps without biopsy-confirmed cancer for a repeat colonoscopy because our colorectal surgery team believes strongly that surgical

Results

During the study period, 36 patients were referred for surgical resection of colon polyps without biopsy-demonstrated invasive cancer. Two of the patients were referred for surgical resection of 2 separate lesions (each patient had a rectal lesion and a synchronous right colon lesion), so a total of 38 lesions were included in the study. Patient and lesion characteristics are summarized in Table 1. The median patient age was 68 ± 9 years, and 47% of the patients were male; 28% of the patients

Discussion

In our study, 71% of lesions referred for surgical resection without biopsy proven invasive cancer were amenable to endoscopic resection with modern EMR technique. This rate compares favorably with the experience of Voloyiannis et al⁷ who successfully treated 40% of 252 patients by using polypectomy without submucosal injection referred to their surgical practice between 1999 and 2004. Several advances in endoscopic resection techniques and technology likely contributed to the higher success

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Cited by (46)

Endoscopic submucosal dissection for removal of large colorectal neoplasias in an outpatient setting: a single-center series of 660 procedures in Sweden
2022, Gastrointestinal Endoscopy
Citation Excerpt :
It is crucial that advanced endoscopic resection services are available to patients to minimize the number of patients with benign lesions referred for unnecessary surgical resection. Studies have shown that 15% to 25% of all surgical resections are performed on benign lesions,22,23 where most of those probably were amendable for endoscopic resection.24 Endoscopic treatment is associated with lower mortality and morbidity rates compared with laparoscopic and open surgery.25-28
Endoscopic submucosal dissection (ESD) is a technique developed in Japan for the removal of large lesions in the GI tract. Because of the complexity of the technique, implementation in Western health care has been slow. An ESD procedure is usually followed by hospital admission. Our aim was to investigate if ESD of colorectal lesions can be performed in an outpatient setting.
Six hundred sixty colorectal ESD procedures between 2014 and 2020 were evaluated retrospectively. All patients referred to the unit with an early colorectal neoplasm >20 mm without signs of deep invasion were considered eligible for an ESD procedure.
Of 660 lesions, 323 (48.9%) were localized in the proximal colon, 102 (15.5%) in the distal colon, and 235 (35.6%) in the rectum. Median lesion size was 38 mm (interquartile range, 30-50) and median procedure duration 70 minutes (interquartile range, 45-115). En-bloc resection was achieved in 620 cases (93.9%). R0 resection was achieved in 492 en-bloc resections (79.4%), whereas the number of Rx and R1 resections was 124 (20.0%) and 4 (.6%), respectively. Low-grade dysplasia was found in 473 cases (71.7%), high-grade dysplasia in 144 (21.8%), and adenocarcinoma in 34 (5.1%). Six hundred twelve procedures (92.7%) were scheduled as outpatient, and 33 of these underwent unplanned admission. Forty-eight cases (7.3%) were planned as inpatient procedures. The rate of full wall perforation was 38 (5.8%), in which 35 (92.1%) were managed endoscopically and 3 patients (7.9%) required emergency surgery. Forty-six patients (7.0%) sought medical attention within 30 days because of bleeding (21 [3.2%]), abdominal tenderness (16 [2.4%]), and other reasons (9 [1.4%]). Twenty-four of these patients were admitted for observation for a median of 2 days (range, 1-7). Ten of these patients were treated with antibiotics, and 6 patients required blood transfusion. None required additional surgery.
ESD of colorectal lesions can be safely performed in an outpatient setting in a well-selected patient.
Setting up a regional expert panel for complex colorectal polyps
2022, Gastrointestinal Endoscopy
Citation Excerpt :
We showed that in 30% of cases in which the consulting endoscopist suggested an endoscopic resection, panel consultation eventually led to the advice for a surgical resection. This is comparable with the results of Friedland et al,13 who showed that 29% of complex colorectal polyps were not amenable for endoscopic treatment after reassessment. In our study, most cases were sent for surgery because of the suspicion of deeper submucosal invasion.
Advanced endoscopic resection techniques for complex colorectal polyps have evolved significantly over the past decade, leading to a management shift from surgical to endoscopic resection as the preferred treatment. However, in practice, interhospital consultation and appropriate referral management remain challenging, leading to unnecessary surgical resections. To support regional care for patients with complex colorectal polyps, facilitate peer consultations, and lower thresholds for referrals, an expert panel consultation platform was initiated in the northwestern region of the Netherlands.
We initiated a regional expert panel in the northwestern region of the Netherlands for patients with complex colorectal polyps and studied the implementation, adaption, and clinical impact. All panel consultations between June 2019 and May 2021 were retrospectively analyzed, and user satisfaction among panel members was evaluated.
Eighty-eight patients with complex colorectal polyps from 11 of 15 participating centers (73.3%) were discussed in our panel. The most common reason for panel consultation was suspicion of invasive cancer in 36.4% (n = 32). After panel consultation, 43.2% of the consulting endoscopists (n = 38) changed their initial treatment strategy, and in 63.6% (n = 56) patients were referred to another endoscopy center. Of 26 cases submitted with a primary proposal for surgical treatment, surgery was avoided in 7 (26.9%). User satisfaction was rated high in most participating centers (91.7%).
Our study shows that implementation of and consultation with a regional expert panel can be a valuable tool for endoscopists to guide and optimize treatment of complex colorectal polyps and facilitate interhospital referrals in a regional network.
Effect of implementing a regional referral network on surgical referral rate of benign polyps found during a colorectal cancer screening program: A population-based study
2021, Clinics and Research in Hepatology and Gastroenterology
Surgical management is too often performed as the first-line treatment for large, benign colorectal polyps. We report the management of benign lesions detected by organised colorectal cancer (CRC) screening.
Population-based study in 2012, 2016, and 2017, analyzing the evolution of surgical management of benign polyps of ≥ 2 cm diameter discovered in the context of organised CRC screening after the implementation of a regional referral network for the management of superficial colorectal lesions.
A total of 1571 patients underwent colonoscopy following a positive test during the study period, among which 981 colonoscopies yielded at least one lesion. The adenoma detection rate was lower in 2012 (Guaiac test) than in 2016 and 2017 (fecal immunochemical test) (40% vs. 60% vs. 57%, P < 0.0001). The surgery rate for benign lesions decreased from 14.6% in 2012 to 7.7% in 2016 and 5% in 2017 (P = 0.017). The risk factors for surgery for benign lesions were year 2012 (odds ratio [OR] = 3.35, P = 0.022), high-grade dysplasia (OR = 2.49, P = 0.04), in situ carcinoma (OR = 5, P = 0.003), size ≥ 20 mm (OR = 17.39, P < 0.0001), and private sector (OR = 6.6, P = 0.0002). The morbidity rate of surgery for benign polyp ≥ 2 cm was 20.4% at 1 month and its cost was sixfold higher than that of endoscopy.
The establishment of a regional referral network for the management of large colorectal polyps reduces the rate of surgical management of such lesions.
Trends in EMR for nonmalignant colorectal polyps in the United States
2020, Gastrointestinal Endoscopy
Although most large nonpedunculated colorectal lesions can be safely and efficaciously removed using EMR, the use of colectomy for benign colorectal lesions appears to be increasing. The reason(s) is unclear. We aimed to determine the use and adverse events of EMR in the United States.
We used Optum’s de-identified Clinformatics Data Mart Database (2003-2016), a database from a large national insurance provider, to identify all colonoscopies performed with either EMR or simple polypectomy on adult patients from January 1, 2011 to December 31, 2015. We measured time trends, regional variation, and adverse event rates. We assessed risk factors for adverse events using multivariate logistic regression.
The rate of EMR use in the US increased from 1.62% of all colonoscopies in 2011 to 2.48% of colonoscopies in 2015 (P < .001). There were, however, significant regional differences in the use of EMRs, from 2.4% of colonoscopies in the western United States to 2.0% of colonoscopies in the southern United States. Between 2011 and 2015, we found stable rates of perforation, GI bleeding (GIB), infections, and cardiac adverse events and decreasing rates of admissions after EMR. In our multivariate model, EMR was an independent risk factor for adverse events, albeit the rates of adverse events were low (1.35% GIB, .22% perforation).
Use of EMR is rising in the United States, although there is significant regional variation. The rates of adverse events after EMR and polypectomies were low and stable, confirming the continued safety of EMR procedures. A better understanding of the regional barriers and facilitators may improve the use of EMR as the standard management for benign colorectal lesions throughout the United States.
Dissection-enabled scaffold-assisted resection (DeSCAR): a novel technique for resection of residual or non-lifting GI neoplasia of the colon (with video)
2018, Gastrointestinal Endoscopy
As a result of previous manipulation or submucosal invasion, GI lesions referred for EMR frequently have flat areas of visible tissue that cannot be snared. Current methods for treating residual tissue may lead to incomplete eradication or not allow complete tissue sampling for histologic evaluation. Our aim is to describe dissection-enabled scaffold-assisted resection (DeSCAR), a new technique combining circumferential ESD with EMR for removal of superficial non-lifting or residual “islands” with suspected submucosal involvement/fibrosis.
From 2015 to 2017, lesions referred for EMR were retrospectively reviewed. Cases were identified where lifting and/or snaring of the lesion was incomplete and the DeSCAR technique was undertaken. Cases were reviewed for location, previous manipulation, rates of successful hybrid resection, and adverse events.
Twenty-nine lesions underwent DeSCAR because of non-lifting or residual “islands” of tissue. Fifty-two percent of the patients were male and 48% were female; average age was 66 years (standard deviation ±9.9 years). Lesions were located in the cecum (n = 10), right side of the colon (n = 12), left side of the colon (n = 4), and rectum (n = 3). Average size was 31 mm (standard deviation ±20.6 mm). Previous manipulation had occurred in 28 of 29 cases (83% biopsy, 34% resection attempt, 52% tattoo). The technical success rate for resection of non-lifting lesions was 100%. There was one episode of delayed bleeding but no other adverse events.
DeSCAR is a feasible and safe alternative to argon plasma coagulation and avulsion for the endoscopic management of non-lifting or residual GI lesions, providing en bloc resection of tissue for histologic review. Further studies are needed to demonstrate long-term eradication and for comparison with other methods.
Volume of surgery for benign colorectal polyps in the last 11 years
2018, Gastrointestinal Endoscopy
Citation Excerpt :
An increasing body of evidence suggests that many lesions currently referred for SR are amenable to endoscopic treatment when performed in experienced hands. When performed by experienced endoscopists, over 90% of all large complex colorectal polyps can be removed by ER.10,13,36,37 In the study by Friedland et al,13 71% of advanced colonic lesions without biopsy-proven CRC, already referred for SR, could be treated by ER during a repeat colonoscopy performed in a tertiary center performed by an experienced endoscopist.
Traditionally large, complex colorectal polyps were managed by surgical resection (SR), and in recent years endoscopic resection (ER) has progressed significantly. However, to what extent ER has replaced SR remains largely unknown. We performed a multicenter retrospective cohort study to assess the volume and volume changes of SR for benign colorectal polyps over the past decade.
Patients who underwent SR for a benign colorectal polyp in the Netherlands between 2005 and 2015 were selected from the prospective nationwide Dutch Pathology Registry (PALGA database). Clinical characteristics were obtained from the charts of patients who underwent SR in the province of Noord-Holland.
A total of 5937 patients were treated with SR for a colorectal polyp and the absolute (454-739 per year) and relative volumes (0.20%-0.37% per colonoscopy per year) of SR remained stable. In the province of Noord-Holland, 928 patients (15.6%) underwent SR. In these patients, submucosal lifting and ER were attempted in 19.9% (n = 175) and 15.0% (n = 134). After 2010, patients were more likely to undergo lifting (27.7% vs 11.4%, P < .001) and ER attempts (18.8% vs 10.9%, P = .001) before definitive SR. Twenty-two patients (2.4%) had been referred to another endoscopy clinic.
SR for large, complex colorectal polyps is still frequently performed and has remained stable. A small percentage of patients underwent ER attempts before SR, and referral for an additional ER attempt only occurred in a minority of cases. To increase ER attempts, implementation of a regional multidisciplinary referral network should be considered.

View all citing articles on Scopus

: DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

: If you would like to chat with an author of this article, you may contact Dr Friedland at [email protected].

: See CME section; p. 135.

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Original articleClinical endoscopyOutcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer

Background

Objective

Design

Setting

Patients

Interventions

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

Methods

Results

Discussion

Gastroenterology

Clin Gastroenterol Hepatol

Gastrointest Endosc Clin N Am

Gastroenterology

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc Clin N Am

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc Clin N Am

Original article
Clinical endoscopy
Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer