Outcomes of surgical resections for benign colon polyps: a systematic review

Abstract

Background Not all benign colonic polyps are suitable for endoscopic resection, although criteria for endoscopic non-resectability vary worldwide. Clinical decision-making largely depends on endoscopic treatment options, as well as postoperative risks after surgical resection. This systematic review aimed to determine postoperative outcomes and the characteristics of surgically resected benign colonic polyps.

Methods MEDLINE, EMBASE, and the Cochrane Library were searched for studies investigating the outcomes of surgical resection for benign colonic polyps since 1980. Studies were considered eligible when at least one postoperative outcome (morbidity and/or mortality) was reported. Meta-analyses were conducted for the primary outcome measures (morbidity and mortality) for studies that included patients only after the year 2000.

Results Of the 4210 studies retrieved, 26 studies describing 139 897 patients were included. The most common indications for surgical resection were polyp location in the right-sided colon, non-pedunculated morphology, and large polyp size. The pooled 1-month complication and mortality rates of studies that included patients after the year 2000 were 24 % (95 % confidence interval [CI] 15 % – 36 %) and 0.7 % (95 %CI 0.6 % – 0.8 %), respectively.

Conclusion The postoperative morbidity and mortality after colonic resection for benign polyps are substantial. Referral to an advanced interventional endoscopist should be considered before referral for surgery to evaluate the possibilities for endoscopic treatment of large, non-pedunculated, and/or colonic polyps in difficult locations without suspicion of submucosal malignant invasion.

^* Equal first authors

• References

• 1 Manne U, Shanmugam C, Katkoori VR. et al. Development and progression of colorectal neoplasia. Cancer Biomark 2010; 9: 235-265
• 2 Zauber AG, Winawer SJ, O'Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. NEJM 2012; 366: 687-696
• 3 Shaukat A, Mongin SJ, Geisser MS. et al. Long-term mortality after screening for colorectal cancer. NEJM 2013; 369: 1106-1114
• 4 Vermeer NC, Snijders HS, Holman FA. et al. Colorectal cancer screening: Systematic review of screen-related morbidity and mortality. Cancer Treat Rev 2017; 54: 87-98
• 5 Hewitson P, Glasziou P, Irwig L. et al. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev 2007; Cd001216
• 6 Rutter MD, Chattree A, Barbour JA. et al. British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut 2015; 64: 1847-1873
• 7 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
• 8 Gietelink L, Wouters MW, Bemelman WA. et al. Reduced 30-Day mortality after laparoscopic colorectal cancer surgery: a population based study from the Dutch Surgical Colorectal Audit (DSCA). Ann Surg 2016; 264: 135-140
• 9 Henneman D, Ten Berge MG, Snijders HS. et al. Safety of elective colorectal cancer surgery: non-surgical complications and colectomies are targets for quality improvement. J Surg Oncol 2014; 109: 567-573
• 10 Henneman D, Snijders HS, Fiocco M. et al. Hospital variation in failure to rescue after colorectal cancer surgery: results of the Dutch Surgical Colorectal Audit. Ann Surg Oncol 2013; 20: 2117-2123
• 11 Ma MX, Bourke MJ. Complications of endoscopic polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection in the colon. Best Pract Res Clin Gastroenterol 2016; 30: 749-767
• 12 Moher D, Liberati A, Tetzlaff J. et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg 2010; 8: 336-341
• 13 Wells G, Shea B, O'Connell D. et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available from: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp , Accessed: 10 June 2019
• 14 Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205-213
• 15 Viechtbauer W. Conducting meta-analyses in R with the metafor package. J Stat Software 2010;
• 16 Church J, Erkan A. Scope or scalpel? A matched study of the treatment of large colorectal polyps. ANZ J Surg 2018; 88: 177-181
• 17 Le Roy F, Manfredi S, Hamonic S. et al. Frequency of and risk factors for the surgical resection of nonmalignant colorectal polyps: a population-based study. Endoscopy 2016; 48: 263-270
• 18 Lee TJ, Rees CJ, Nickerson C. et al. Management of complex colonic polyps in the English Bowel Cancer Screening Programme. Br J Surg 2013; 100: 1633-1639
• 19 Lascarides C, Buscaglia JM, Denoya PI. et al. Laparoscopic right colectomy vs laparoscopic-assisted colonoscopic polypectomy for endoscopically unresectable polyps: a randomized controlled trial. Colorectal Dis 2016; 18: 1050-1056
• 20 Church JM. Avoiding surgery in patients with colorectal polyps. Dis Colon Rectum 2003; 46: 1513-1516
• 21 Eijsbouts QA, Heuff G, Sietses C. et al. Laparoscopic surgery in the treatment of colonic polyps. Br J Surg 1999; 86: 505-508
• 22 Brigic A, Cahill RA, Bassett P. et al. A prospective case controlled study of the short-term outcome following hemicolectomy for benign compared with malignant colonic polyps. Colorectal Dis 2014; 16: 179-185
• 23 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). Dig Surg 2013; 30: 394-400
• 24 Loungnarath R, Mutch MG, Birnbaum EH. et al. Laparoscopic colectomy using cancer principles is appropriate for colonoscopically unresectable adenomas of the colon. Dis Colon Rectum 2010; 53: 1017-1022
• 25 Gorgun E, Benlice C, Church JM. Does cancer risk in colonic polyps unsuitable for polypectomy support the need for advanced endoscopic resections?. J Am Coll Surg 2016; 223: 478-484
• 26 Lipof T, Bartus C, Sardella W. et al. Preoperative colonoscopy decreases the need for laparoscopic management of colonic polyps. Dis Colon Rectum 2005; 48: 1076-1080
• 27 Cruz RA, Ragupathi M, Pedraza R. et al. Minimally invasive approaches for the management of "difficult" colonic polyps. Diagn Ther Endosc 2011; 2011: 682793
• 28 Itah R, Greenberg R, Nir S. et al. Laparoscopic surgery for colorectal polyps. JSLS 2009; 13: 555-559
• 29 Blumberg D. Laparoscopic colon resection of benign polyps: high grade dysplasia on endoscopic biopsy and polyp location predict risk of cancer. Surg Laparosc Endosc Percutan Tech 2009; 19: 255-257
• 30 Hauenschild L, Bader FG, Laubert T. et al. Laparoscopic colorectal resection for benign polyps not suitable for endoscopic polypectomy. Int J Colorectal Dis 2009; 24: 755-759
• 31 Benedix F, Kockerling F, Lippert H. et al. Laparoscopic resection for endoscopically unresectable colorectal polyps: analysis of 525 patients. Surg Endosc 2008; 22: 2576-2582
• 32 Pokala N, Delaney CP, Kiran RP. et al. Outcome of laparoscopic colectomy for polyps not suitable for endoscopic resection. Surg Endosc 2007; 21: 400-403
• 33 Dulskas A, Kuliesius Z, Samalavicius NE. Laparoscopic colorectal surgery for colorectal polyps: experience of ten years. Acta Med Litu 2017; 24: 18-24
• 34 Alder AC, Hamilton EC, Anthony T. et al. Cancer risk in endoscopically unresectable colon polyps. Am J Surg 2006; 192: 644-648
• 35 Keswani RN, Law R, Ciolino JD. et al. Adverse events after surgery for nonmalignant colon polyps are common and associated with increased length of stay and costs. Gastrointest Endosc 2016; 84: 296-303 e291
• 36 Jang JH, Balik E, Kirchoff D. et al. Oncologic colorectal resection, not advanced endoscopic polypectomy, is the best treatment for large dysplastic adenomas. J Gastrointest Surg 2012; 16: 165-171 ; discussion 171–162
• 37 Peery AF, Shaheen NJ, Cools KS. et al. Morbidity and mortality after surgery for nonmalignant colorectal polyps. Gastrointest Endosc 2018; 87: 243-250.e2
• 38 Young-Fadok TM, Radice E, Nelson H. et al. Benefits of laparoscopic-assisted colectomy for colon polyps: a case-matched series. Mayo Clin Proc 2000; 75: 344-348
• 39 Lee MK, Chen F, Esrailian E. et al. Combined endoscopic and laparoscopic surgery may be an alternative to bowel resection for the management of colon polyps not removable by standard colonoscopy. Surg Endosc 2013; 27: 2082-2086
• 40 Hernandez-Boussard TM, McDonald KM, Morrison DE. et al. Risks of adverse events in colorectal patients: population-based study. J Surg Res 2016; 202: 328-334
• 41 Joo JS, Amarnath L, Wexner SD. Is laparoscopic resection of colorectal polyps beneficial?. Surg Endosc 1998; 12: 1341-1344
• 42 Tholoor S, Tsagkournis O, Basford P. et al. Managing difficult polyps: techniques and pitfalls. Ann Gastroenterol 2013; 26: 114
• 43 Metz AJ, Bourke MJ, Moss A. et al. Factors that predict bleeding following endoscopic mucosal resection of large colonic lesions. Endoscopy 2011; 43: 506-511
• 44 Moss A, Williams SJ, Hourigan LF. et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015; 64: 57-65
• 45 Longcroft-Wheaton G, Duku M, Mead R. et al. Risk stratification system for evaluation of complex polyps can predict outcomes of endoscopic mucosal resection. Dis Colon Rectum 2013; 56: 960-966
• 46 Haas EM, Cruz RA, Ragupathi M. et al. Minimally invasive approaches for the management of difficult colonic polyps. Diagn Ther Endosc 2011; 2011: 682793
• 47 Church JM. Avoiding surgery in patients with colorectal polyps. Dis Colon Rectum 2003; 46: 1513-1516
• 48 Friedland S, Banerjee S, Kochar R. et al. Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer. Gastrointest Endosc 2014; 79: 101-107
• 49 Hassan C, Repici A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65: 806-820
• 50 Tate DJ, Desomer L, Klein A. et al. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc 2017; 85: 647-656.e646
• 51 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 52 Burgess NG, Metz AJ, Williams SJ. et al. Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12: 651-661.e651-e653
• 53 Fujiya M, Tanaka K, Dokoshi T. et al. Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection. Gastrointest Endosc 2015; 81: 583-595
• 54 Swan MP, Bourke MJ, Alexander S. et al. 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). Gastrointest Endosc 2009; 70: 1128-1136
• 55 Jayanna M, Burgess NG, Singh R. et al. Cost analysis of endoscopic mucosal resection vs surgery for large laterally spreading colorectal lesions. Clin Gastroenterol Hepatol 2016; 14: 271-278 e271–e272
• 56 Hayashi N, Tanaka S, Hewett DG. et al. Endoscopic prediction of deep submucosal invasive carcinoma: validation of the narrow-band imaging international colorectal endoscopic (NICE) classification. Gastrointest Endosc 2013; 78: 625-632
• 57 Kudo S, Hirota S, Nakajima T. et al. Colorectal tumours and pit pattern. J Clin Pathol 1994; 47: 880-885
• 58 Endoscopic Classification Review Group. Update on the Paris classification of superficial neoplastic lesions in the digestive tract. Endoscopy 2005; 37: 570-578
• 59 [Anonymous] The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-S43
• 60 Burgess NG, Hourigan LF, Zanati SA. et al. Risk stratification for covert invasive cancer among patients referred for colonic endoscopic mucosal resection: a large multicenter cohort. Gastroenterology 2017; 153: 732-742.e1
• 61 Lee MK, Chen F, Esrailian E. et al. Combined endoscopic and laparoscopic surgery may be an alternative to bowel resection for the management of colon polyps not removable by standard colonoscopy. Surg Endosc 2013; 27: 2082-2086
• 62 Lee TJ, Rees CJ, Nickerson C. et al. Management of complex colonic polyps in the English Bowel Cancer Screening Programme. Br J Surg 2013; 100: 1633-1639
• 63 Alder AC, Hamilton EC, Anthony T. et al. Cancer risk in endoscopically unresectable colon polyps. Am J Surg 2006; 192: 644-648