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Are difficult colon polyps still being operated on?

Thomas Rösch, Hamburg

Endoscopy 2016;48:263-70

Frequency of and risk factors for the surgical resection of nonmalignant colorectal polyps: A population-based study
Florence Le Roy1, Sylvain Manfredi1,2, Stéphanie Hamonic3, Christine Piette2, Guillaume Bouguen1, Francoise Riou3, Jean-Francois Bretagne1,2

  1. Service des Maladies de l‘Appareil Digestif, Hôpital Pontchaillou, Centre Hospitalo- Universitaire, Rennes, France
  2. Association pour le Dépistage des Cancers en ille-et-Vilaine (ADECI 35), Rennes, France
  3. Service d‘Epidémiologie et de Santé publique, Hôpital Pontchaillou, Centre Hospitalo- Universitaire, Rennes, France

Background and study aims

The management of patients with colon polyps who are referred to surgery remains uncharacterized in a population-based setting. The aims of this study were to determine the frequency, risk factors, and outcomes of patients referred for surgical resection
of colorectal polyps.

Patients and methods

All patients who underwent a colonoscopy for positive fecal occult blood test in the setting of a population-based colorectal cancer screening program in France between 2003 and 2012 were analyzed. The primary outcome was the proportion of patients undergoing colorectal surgery for polyps without invasive carcinoma. Logistic regression analysis was applied to identify risk factors for surgical resection.

Results

Among 4251 patients with at least one colorectal polyp, 175 (4.1 %) underwent colorectal surgery. Risk factors for surgery included size, proximal polyp location, advanced histology (villous or high grade dysplasia), the endoscopy center, and colonoscopy performed during the first half of the study period. Subgroup analysis of 3475 colonoscopies performed by 22 endoscopists who performed at least 50 colonoscopies during the study period, identified the endoscopist as an additional risk factor. The adjusted proportions of referrals to surgery ranged from 0 to 46.6% per endoscopist for polyps≥ 20mm (median 20.2 %). Overall, surgical complications occurred in 24.0 %, and one patient died following surgery (0.5 %). None of the 175 patients who underwent surgery were referred to a tertiary endoscopic center prior to surgery.

Conclusions

In this population-based study, 4.1% of patients with nonmalignant polyps were referred for surgical resection. The endoscopist was one important factor that was associated with surgical referral. To further decrease the proportion of inappropriate surgery in patients, endoscopists should refer their patients with large or difficult polyps to expert endoscopists prior to surgery.

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The current standard is that when polyps or adenomas are identified on (screening) colonoscopies, they should be either directly removed or, if not, patients should be referred to reference centers for endoscopic resection of the lesions. Data from several studies have shown that what are known as difficult or allegedly unresectable polyps can indeed be resected endoscopically in more than 90% of cases when the patients are transferred to reference centers [1–7]. Although there are differing opinions regarding (selected) adenomas with high-grade dysplasia [8], the efficacy and cost–benefit ratio are clearly in favor of endoscopic resection in nearly all adenomas, particularly when the procedures are carried out by experienced endoscopists [9]. Endoscopic resection should therefore be the method of choice for polyps with no endoscopic suspicion of malignancy.

The present study originated in France’s colorectal carcinoma screening program and addresses the issue of how many patients with polyps are still being referred for surgery, even when there is no suspicion or evidence of malignancy in the polyp. The data were obtained from France’s colon carcinoma screening database, which records all colonoscopies prospectively — in this case from the French Department of Ille-et-Vilaine, one of the first in France to initiate a screening program. The data are from 2003–2012. Only polyps with nonmalignant histology were selected. Among these 8663 polyps in 4251 patients, 65% had high-grade dysplasia or “mucosal carcinoma” (which are histologically identical in any case). It should be noted that in the colon, the definition of carcinoma only starts with submucosal infiltration. It should also be borne in mind that screening colonoscopy in France means colonoscopy following a positive fecal occult blood test (FOBT).

The results show that the rate of referral for surgery continued to be around 4%, and that this rate varied substantially among the endoscopists. Some endoscopists referred for surgery up to 47% of patients with polyps larger than 2 cm. The most noticeable factor in favor of surgical referral was a polyp size larger than 2 cm. However, it should be noted that during the study period, the rate of referral for surgery declined from an initial 4.8% to 2.8% in the second half of the study. In a subgroup analysis of 22 endoscopists who carried out at least 50 colonoscopies, the endoscopist was also identified as a “risk factor” for referral to a surgical center. One of the 175 patients who underwent surgery died, and the overall complication rate was 24%, mainly with severe postoperative pain and transient colonic dysfunction. Approximately 30% of the complications were grade 3 or 4 in the Clavien–Dindo classification.

Since it is already known that even complex polyps can be resected endoscopically, at least when the procedure is in expert hands, surgery should be reserved for cases in which this is not successful or for polyps that are in fact malignant and are diagnosed before or after the endoscopic resection. Referral to so-called reference centers would certainly be helpful here if it were generally accepted, but this differs from country to country. Better dissemination of information about the histology of polyps might also be helpful — one should avoid diagnosing so-called “mucosal” colon carcinomas if the cellular changes are limited to the mucosa (in contrast to the upper gastrointestinal tract), as it is known that mucosal carcinomas in the colorectum are equivalent to high-grade dysplasia. In this way, the shock term “carcinoma” would not automatically lead to referral for surgery, as evidently still appears to be the case.

References

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  2. Aziz Aadam A, Wani S, Kahi C, Kaltenbach T, Oh Y, Edmundowicz S, Peng J, Rademaker A, Patel S, Kushnir V, Venu M, Soetikno R, Keswani RN. Physician assessment and management of complex colon polyps: a multicenter video-based survey study. The American journal of Gastroenterology. 2014;109:1312-1324.
  3. Lipof T, Bartus C, Sardella W, Johnson K, Vignati P, Cohen J. Preoperative colonoscopy decreases the need for laparoscopic management of colonic polyps. Diseases of the Colon and Rectum. 2005;48:1076-1080.
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  7. Swan MP, Bourke MJ, Alexander S, Moss A, Williams SJ. Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos). Gastrointestinal Endoscopy. 2009;70:1128-1136.
  8. Jang JH, Balik E, Kirchoff D, Tromp W, Kumar A, Grieco M, Feingold DL, Cekic V, Njoh L, Whelan RL. Oncologic colorectal resection, not advanced endoscopic polypectomy, is the best treatment for large dysplastic adenomas. Journal of Gastrointestinal Surgery 2012;16(1):165-171; discussion 171-162.
  9. Ahlenstiel G, Hourigan LF, Brown G, Zanati S, Williams SJ, Singh R, Moss A, Sonson R, Bourke MJ. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointestinal endoscopy. 2014;80(4):668-676.
  10. Ikard RW, Snyder RA, Roumie CL. Postoperative morbidity and mortality among Veterans Health Administration patients undergoing surgical resection for large bowel polyps (bowel resection for polyps). Digestive surgery. 2013;30(4-6):394-400.

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