Introduction Complex NPRP (non pedunculated rectal polyp) is defined as the polyp which has an increased risk of malignancy, increased risk of incomplete resection/recurrence, increased risk of adverse event or SMSA level 4 polyp.1
Complex rectal polyps are managed by endoscopic (EMR, ESD, hybrid ESD) techniques or by various surgical techniques (TEMS, TAMIS, TART, TASER), depending on the endoscopic lesion assessment and the local expertise.
Methods The aim of this study was to describe the outcomes of the endoscopic management of complex rectal polyps in a large tertiary hospital (single operator).
Results Over a period of 33 months (May 2013 to Jan 2016), 77 complex rectal polyps including 10 rectosigmoid polyps were encountered. The size of the polyp varied from 1 cm to 14 cms (median - 3.5 cm). The age of the patient varied from 50 to 92 (median age - 60).
29 polyps (37.6%) was confirmed to have cancer. The pre resection endoscopic accuracy of malignancy was 94%. Frank malignancy was suspected and confirmed in 7 cases and deemed not suitable for endoscopic resection. A small subpedunculated pT1 polyp cancer was resected enbloc, but was not suspected to be a cancer prior to resection.21 polyps were noted to have features suggestive of high risk of malignancy. All had attempted endoscopic resection, including EMR and/or hybrid ESD. Of these, 7 polyps was confirmed to have cancer.
The surgery rate for complex rectal polyps (including lesions with endoscopic resections for cancer) is 4.2%. None of the benign polyps (including polyps with EMR/Hybrid ESD for recurrence at previous TEMS/EMR site, post surgery anastomosis site) had surgery. Of the data available for 54 polyps with post endoscopic resection, 46 polyps (85%) did not have any residual lesion at 3 months. Of the available data for 26 polyps at 12 months, no recurrence/residual lesion was noted.
None of the resection had perforation. 2 polyp cancers had significant bleeding during attempted hybrid ESD and had surgical resection of the polyp cancer. Another benign polyp with hybrid ESD had significant bleeding controlled with haemospray.
The average time of combined EMR/hybrid ESD procedures is 11.4 mins for every cm of polyp resected.
Considering the age, co-morbidity, size, location and final histology, ESD or alternative micro surgical techniques would have made a difference to the final outcome in only one patient.
Conclusion The pre resection endoscopic accuracy rate for malignancy is significantly high in a high volume centre. EMR and Hybrid ESD in experienced hands is an effective technique in managing complex rectal polyps.
Reference 1 British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps.
Disclosure of Interest None Declared
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