Overutilization of surgical resection for benign colorectal polyps: analysis from a tertiary care center

Rayan Saade; Tyler Tsang; Michel Kmeid; David Miller; Zhiyan Fu; James Litynski; Patrick Young; Joseph C. Anderson; Hwajeong Lee; Micheal Tadros

doi:10.1055/a-1380-3017

Endoscopy International Open, Inhaltsverzeichnis

CC BY-NC-ND 4.0 · Endosc Int Open 2021; 09(05): E706-E712
DOI: 10.1055/a-1380-3017

Original article

Overutilization of surgical resection for benign colorectal polyps: analysis from a tertiary care center

Rayan Saade

¹Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York, United States

,

Tyler Tsang

²Albany Medical College, Albany, New York, United States

,

Michel Kmeid

¹Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York, United States

,

David Miller

²Albany Medical College, Albany, New York, United States

,

Zhiyan Fu

¹Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York, United States

,

James Litynski

³Gastroenterology, Albany Medical Center, Albany, New York, United States

,

Patrick Young

⁴Gastroenterology Service, Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, United States

,

Joseph C. Anderson

⁵Department of Veterans Affairs Medical Center, White River Junction, Vermont, United States, and The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, United States

⁶Division of Gastroenterology and Hepatology University of Connecticut School of Medicine, Farmington, Connecticut, United States

,

Hwajeong Lee

¹Pathology and Laboratory Medicine, Albany Medical Center, Albany, New York, United States

,

Micheal Tadros

³Gastroenterology, Albany Medical Center, Albany, New York, United States

› Institutsangaben

Abstract

Background and study aims Adequate removal of precancerous polyps is an independent factor in colorectal cancer prevention. Despite advances in polypectomy techniques, there is an increasing rate of surgery for benign polyps. We assessed whether surgical resection is properly utilized for benign colorectal polyps.

Patients and methods We identified 144 patients with surgical resection for benign colorectal polyps. Polyp location, size and the indication for and type of surgery were obtained. For the purposes of this analysis, we assumed that gastroenterologists should assess polyp size accurately, endoscopically resect polyps < 2 cm, and treat incompletely excised polyps on follow-up.

Results A total of 118 patients (82 %) were referred to surgery without attempted endoscopic removal. In 26 (22 %) of 118, the macroscopic polyp size was < 2 cm (23 in right, 3 in the left colon) and 18 (15 %; 14 in the right, four in the left colon) were found to have had size overestimation during endoscopy. Twenty-two (15 %) of 144 underwent surgical resection for incomplete endoscopic resection of adenomas (16 in the right, 6 in the left colon); 12 (54.5 %) had a residual polyp size of < 2 cm (10 in the right colon; 2 in the left colon). In-hospital mortality was 0.7 % and morbidity was 20.1 %.

Conclusions Of the patients, 41 % could have potentially avoided surgical intervention (37 polyps < 2 cm and/or size overestimations precluding endoscopic polypectomy and 22 incomplete resections). When including polyps with size ≥ 2 to < 4 cm, the percentage of patients with avoidable surgery reached 80 %. This confirms the need to develop standardized quality metrics for endoscopic polypectomies and for better overall training of endoscopists performing these procedures. Given the risks of surgery, referral to an experienced gastroenterologist should be considered as a first step.

Volltext

Referenzen

References
1 Law R, Das A, Gregory D. et al. Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis. Gastrointest Endosc 2016; 83: 1248-1257
2 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: 271-8 e1-2
3 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
4 Peery AF, Shaheen NJ, Cools KS. et al. Morbidity and mortality after surgery for nonmalignant colorectal polyps. Gastrointest Endosc 2018; 87: 243-250 e2
5 Winawer SJ, Zauber AG, Ho MN. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
6 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions-recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91: 486-519
7 Peery AF, Cools KS, Strassle PD. et al. Increasing rates of surgery for patients with nonmalignant colorectal polyps in the United States. Gastroenterology 2018; 154: 1352-1360 e3
8 Ma C, Teriaky A, Sheh S. et al. Morbidity and mortality after surgery for nonmalignant colorectal polyps: a 10-year nationwide analysis. Am J Gastroenterol 2019; 114: 1802-1810
9 Gallegos-Orozco JF, Gurudu SR. Complex colon polypectomy. Gastroenterol Hepatol (N Y) 2010; 6: 375-382
10 Pedersen IB, Loberg M, Hoff G. et al. Polypectomy techniques among gastroenterologists in Norway – a nationwide survey. Endosc Int Open 2018; 6: E812-E820
11 Robertson DJ, Lieberman DA, Winawer SJ. et al. Colorectal cancers soon after colonoscopy: a pooled multicohort analysis. Gut 2014; 63: 949-956
12 Pohl H, Srivastava A, Bensen SP. et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology 2013; 144: 74-80 e1
13 Duloy AM, Kaltenbach TR, Wood M. et al. Colon polypectomy report card improves polypectomy competency: results of a prospective quality improvement study (with video). Gastrointest Endosc 2019; 89: 1212-1221
14 Dekker E, Bleijenberg A, Balaguer F. et al. Update on the World Health Organization Criteria for Diagnosis of Serrated Polyposis Syndrome. Gastroenterology 2020; 158: 1520-1523
15 Zogg CK, Najjar P, Diaz AJ. et al. Rethinking priorities: cost of complications after elective colectomy. Ann Surg 2016; 264: 312-322
16 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
17 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 e1-3
18 Kaminski MF, Wieszczy P, Rupinski M. et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology 2017; 153: 98-105
19 Duloy A, Keswani R, Yadlapati R. et al. Polypectomy competency does not adequately correlate with colonoscopy inspection quality: the need for a polypectomy quality metric: 138. A J Gastroenterol 2017; 112: S66
20 Gupta S, Anderson J, Bhandari P. et al. Development and validation of a novel method for assessing competency in polypectomy: direct observation of polypectomy skills. Gastrointest Endosc 2011; 73: 1232-1239 e2
21 Patel SG, Duloy A, Kaltenbach T. et al. Development and validation of a video-based cold snare polypectomy assessment tool (with videos). Gastrointest Endosc 2019; 89: 1222-1230 e2
22 Siau K, Dunckley P, Valori R. et al. Changes in scoring of Direct Observation of Procedural Skills (DOPS) forms and the impact on competence assessment. Endoscopy 2018; 50: 770-778
23 Gamaleldin M, Benlice C, Delaney CP. et al. Management of the colorectal polyp referred for resection: A case-matched comparison of advanced endoscopic surgery and laparoscopic colectomy. Surgery 2018; 163: 522-527
24 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
25 Ruhl C, Sayer B, Byrd-Holt D. et al. Costs of digestive diseases. The burden of digestive diseases in the United States. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. 9-6443. Washington, DC: US Government Printing Office; 2008: 137-147
26 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
27 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
28 Rex DK, Bond JH, Winawer S. et al. Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2002; 97: 1296-1308
29 Rex DK, Schoenfeld PS, Cohen J. et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015; 81: 31-53
30 Voloyiannis T, Snyder MJ, Bailey RR. et al. Management of the difficult colon polyp referred for resection: resect or rescope?. Dis Colon Rectum 2008; 51: 292-295
31 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
32 Leung K, Pinsky P, Laiyemo AO. et al. Ongoing colorectal cancer risk despite surveillance colonoscopy: the Polyp Prevention Trial Continued Follow-up Study. Gastrointest Endosc 2010; 71: 111-117
33 Farrar WD, Sawhney MS, Nelson DB. et al. Colorectal cancers found after a complete colonoscopy. Clin Gastroenterol Hepatol 2006; 4: 1259-1264
34 Robertson DJ, Lieberman DA, Winawer SJ. et al. 795 Interval Cancer After Total Colonoscopy: Results from a Pooled Analysis of Eight Studies. Gastroenterology 2008; 134: A-111-A-112

Zusatzmaterial

Zusatzmaterial