Gastroenterology

Gastroenterology

Volume 144, Issue 1, January 2013, Pages 74-80.e1
Gastroenterology

Original Research
Clinical—Alimentary Tract
Incomplete Polyp Resection During Colonoscopy—Results of the Complete Adenoma Resection (CARE) Study

https://doi.org/10.1053/j.gastro.2012.09.043Get rights and content

Background & Aims

Although the adenoma detection rate is used as a measure of colonoscopy quality, there are limited data on the quality of endoscopic resection of detected adenomas. We determined the rate of incompletely resected neoplastic polyps in clinical practice.

Methods

We performed a prospective study on 1427 patients who underwent colonoscopy at 2 medical centers and had at least 1 nonpedunculated polyp (5–20 mm). After polyp removal was considered complete macroscopically, biopsies were obtained from the resection margin. The main outcome was the percentage of incompletely resected neoplastic polyps (incomplete resection rate [IRR]) determined by the presence of neoplastic tissue in post-polypectomy biopsies. Associations between IRR and polyp size, morphology, histology, and endoscopist were assessed by regression analysis.

Results

Of 346 neoplastic polyps (269 patients; 84.0% men; mean age, 63.4 years) removed by 11 gastroenterologists, 10.1% were incompletely resected. IRR increased with polyp size and was significantly higher for large (10–20 mm) than small (5–9 mm) neoplastic polyps (17.3% vs 6.8%; relative risk = 2.1), and for sessile serrated adenomas/polyps than for conventional adenomas (31.0% vs 7.2%; relative risk = 3.7). The IRR for endoscopists with at least 20 polypectomies ranged from 6.5% to 22.7%; there was a 3.4-fold difference between the highest and lowest IRR after adjusting for size and sessile serrated histology.

Conclusions

Neoplastic polyps are often incompletely resected, and the rate of incomplete resection varies broadly among endoscopists. Incomplete resection might contribute to the development of colon cancers after colonoscopy (interval cancers). Efforts are needed to ensure complete resection, especially of larger lesions. ClinicalTrials.gov Number: NCT01224444.

Section snippets

Participants

Adults (aged 40 through 85 years) who presented for an outpatient colonoscopy at 2 academic medical centers (ie, Dartmouth-Hitchcock Medical Center, Lebanon, NH and VA Medical Center, White River Junction, VT) without a history of inflammatory bowel disease or a coagulopathy (international normalized ratio ≥1.8) were asked to participate. Those who agreed provided informed consent and were subsequently included into the study cohort if at least one polyp of eligible size (≥5 mm to ≤20 mm) was

Patient Characteristics

An eligible polyp was found in 269 patients of the 1427 individuals who were consented for the study (Figure 1). The mean age in the study cohort was 63.4 years (±9.1 standard deviation) and 84.0% were men. Most colonoscopies were performed either for screening (36.8%) or surveillance (33.1%) (Table 1).

Polyp Characteristics

A total of 418 study polyps were resected by 11 endoscopists; 346 polyps (82.8%) were neoplastic (Table 2), of which 286 (68.4%) were classified as tubular, tubulovillous, or villous adenomas.

Discussion

Our 2-center multi-endoscopist study showed that approximately 10% of all neoplastic polyps between 5 and 20 mm are incompletely resected, ie, neoplastic tissue was left behind, as proven by biopsies from resection margins. Incomplete resection was more frequent for large polyps (≥ 10 mm) and for SSA/P. We observed a broad variation in the resection rate between individual endoscopists.

The occurrence of post-colonoscopy CRC4, 5, 6, 7 is well described and 3 main reasons have been implicated in

Conclusions

We found that 10% of neoplastic polyps between 5 and 20 mm were incompletely removed. Incomplete resection increased with polyp size, was significantly higher for SSA/P (both factors are associated with increased risk of malignant degeneration of adenomas), and varied broadly between endoscopists. To date, quality measures have predominantly focused on polyp detection (eg, adenoma detection rates). Our results suggest a need for quality metrics evaluating polyp resection. The performance of

References (28)

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Conflicts of interest The authors disclose no conflicts.

Funding This material is the result of work supported with resources and the use of facilities at the VA Medical Center, White River Junction, Vermont. The contents of this article do not represent the views of the Department of Veterans Affairs or the United States Government.

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