Advanced polyps in patients over 85: 5 years’ experience from a tertiary complex polyp meeting

Aims Colonoscopy and polypectomy carries significant risk in the elderly. Previous reports suggest polypectomy greater than 2cm should only be undertaken by experienced endoscopists following appropriate patient discussion. There remain no consensus guidelines. We reviewed all patients aged over 85 years referred to our complex polyp meeting over a 5 year period.

Methods Data was analysed from all patients over the age of 85 years referred to our complex polyp meeting from 2017 to 2022. Referrals, patient notes and endoscopy reports were reviewed. Elixhauser Comorbidity Indices were retrospectively applied. Mortality and cause of death were analysed from GP records.

Results 54 patients (median age 88; range 85-95) were identified. Data was incomplete for 3 patients. 37 were local referrals; 14 tertiary referrals. Median lesion size was 30mm (range 12-100mm). The most common sites were the caecum (28%) and rectum (24%). SMSA score was reported in only 6/39 (15%) of endoscopic referrals. Only 1 patient referral reported a prognostication or functional assessment score. The complex polyp meeting advised consideration of endoscopic resection (ER) in 36 cases (mean Elixhauser Comorbidity Index (MECI) 5.0). 11 cases (22%) were referred straight to ER, and discussion with the patient in a specialist polyp clinic was recommended for 25 (49%). 10 (40%) of those reviewed in specialist polyp clinic proceeded to ER, with the most common indications symptoms (60%) and patient choice (30%). 10 (40%) were managed conservatively due to excess procedural risk (70%) or patient choice (30%). 5 (20%) were referred for surgical assessment for polyps not amenable to ER. There was no difference in MECI between patients proceeding to ER or those for conservative management (4.9 v 5.3). ER was attempted in 20 cases: 12 endoscopic mucosal resection (EMR), 3 underwater EMR, 2 endoscopic submucosal dissection (ESD), 1 hybrid procedure, 1 trans-anal submucosal endoscopic resection (TASER) procedure, and 1 abandoned ER due to poor access. In those patients undergoing ER, 2 (11%) suffered complications with post-polypectomy bleeding. Both required admission, with 1 requiring a further therapeutic endoscopy. Both patients were on anti-coagulation. Histopathology showed high grade dysplasia in 3 (16%) and adenocarcinoma in 1 patient. 1 and 3 year mortality was 0% and 11% respectively for those undergoing ER, and 16% and 69% for those managed conservatively. There were no deaths secondary to colorectal cancer.

Conclusions Advanced polypectomy in patients over 85 is safe for the selected cohort, although risks of complications are increased in this group. Advanced polypectomy should only be considered after clear discussion of the risks and benefits with the patient. Although a comorbidity index did not differentiate patient outcomes, selection of patients for ER vs conservative management appeared appropriate. Further evaluation is required to identify appropriate prognostication tools to aid patient decision making. [1]

Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Baker G, Valori R, Brooklyn T.. Learning from adverse outcomes: guidelines colonoscopic polypectomy in patients aged 85 years and older. Frontline Gastroenterology 2016; 7: 199-201

Publication History

Article published online:
15 April 2024