Large pedunculated colorectal polyps: more than meets the eye

The effectiveness of screening-related colonoscopy in the prevention of colorectal cancer (CRC) hinges on the identification and removal of precancerous polyps [1]. It is now firmly established that the overwhelming majority of all colorectal polyps can be resected endoscopically, thereby avoiding surgery, which is associated with greater risks and is more costly [2]. Nevertheless, post-colonoscopy colorectal cancers occur among patients who have undergone one or more colonoscopies, where both missed and incompletely resected polyps are recognized risk factors for this undesirable outcome [3].

“…there may be a tendency for endoscopists to “miss the forest for the trees” once a large lesion is identified, by inadvertently overlooking the bigger picture of high synchronous polyp burden, including advanced neoplasia.”

An expansion of advanced endoscopic tissue resection techniques requiring additional training, along with a rising expectation among both practitioners and patients that surgery can be avoided, has driven referral-based practices. Patients seen at tertiary centers with large (≥ 20 mm) nonpedunculated colorectal polyps are known to have a high prevalence of synchronous polyps, including advanced lesions, that were either unrecognized or not described at the index colonoscopy [4]. It is less certain whether similar observations exist among referred patients with large pedunculated polyps.

In this issue of Endoscopy, El Rahyel and colleagues [5] report on the prevalence of synchronous screen-relevant neoplasia among patients with large pedunculated colorectal polyps through a retrospective analysis of a large single-center database of patients referred for endoscopic management of large colorectal polyps. Patients with large nonpedunculated colorectal polyps were used as controls. The findings of this study demonstrate high rates of synchronous neoplasia among those with both pedunculated and nonpedunculated index lesions, with means of 4.8 and 4.5 synchronous conventional adenomas per patient, respectively, and 1.7 synchronous sessile serrated lesions per patient in both groups. Those with pedunculated index lesions had similar rates of at least one synchronous high risk lesion (advanced adenoma or advanced serrated lesion; 56.4 % vs. 47.8 %, respectively) and at least one synchronous large (≥ 20 mm) neoplasm of any type (19.2 % vs. 17.1 %, respectively).

It is worth highlighting that all patients with large nonpedunculated polyps underwent early surveillance at 6–12 months at the study center, compared with only a minority of the patients with large pedunculated polyps. If anything, this would have led to an underestimation of the synchronous polyp burden among patients with large pedunculated colorectal polyps.

Study limitations include its single-center setting and retrospective design. In addition, all the procedures were performed by a single expert, potentially limiting the study’s generalizability. While the authors acknowledge their results may be more reflective of patients seen at referral centers, this presents an opportunity to discuss these findings within that context.

The findings of this study highlight several important implications for clinical practice. First, endoscopists should pay close attention when large nonpedunculated or pedunculated polyps are encountered, given the high likelihood of there being “more than meets the eye.” As suggested by others [6], there may be a tendency for endoscopists to “miss the forest for the trees” once a large lesion is identified, by inadvertently overlooking the bigger picture of high synchronous polyp burden, including advanced neoplasia. Second, as the authors have recommended, short-term follow-up appears warranted in patients with large pedunculated colorectal polyps, especially when a thorough examination becomes compromised following the removal of a more time-consuming large index lesion. Third, when an endoscopist makes the decision to refer a patient with a large polyp (nonpedunculated or pedunculated), they must still recognize the importance of completing a high quality colonoscopy in the overall care of their patient. Being aware of the increased risk of synchronous lesions, the index endoscopist should make every effort to meticulously examine the entire colon, removing all polyps that are within their comfort zone. Moreover, all polyps, including any not removed, should be carefully described in the index procedure report to assist the accepting physician in planning the second procedure. The benefits of this collaborative practice are cascading. A carefully performed and reported index procedure serves only to instill greater confidence in the referring endoscopist, increasing the likelihood of the patient being returned to the index practitioner for follow-up. This can have significant benefits to patients, many of whom are required to travel to receive subspecialized care at tertiary referral centers.

In conclusion, while additional studies are warranted, El Rahyel et al. should be congratulated on their study highlighting the high burden of synchronous neoplasia among patients with large pedunculated colorectal polyps. High quality colonoscopy among this cohort of patients requires a meticulous eye, adequate time, and, not uncommonly, effective communication and collaboration among endoscopists.

Publikationsverlauf

Artikel online veröffentlicht:
02. Mai 2023

• References

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• 2 Heitman SJ, Tate DJ, Bourke MJ. Optimizing resection of large colorectal polyps. Curr Treat Options Gastroenterol 2017; 15: 213-229
• 3 Rutter MD, Beintaris I, Valori R. et al. World Endoscopy Organization Consensus Statements on post-colonoscopy and post-imaging colorectal cancer. Gastroenterology 2018; 155: 909-925 e3
• 4 Bick BL, Ponugoti PL, Rex DK. High yield of synchronous lesions in referred patients with large lateral spreading colorectal tumors. Gastrointest Endosc 2017; 85: 228-233
• 5 El Rahyel A, Lahr R, Rex DK. Prevalence of synchronous neoplasia in patients with large pedunculated colorectal polyps. Endoscopy 2023; 55: 537-543
• 6 Tate DJ, Burgess NG, Bourke MJ. Endoscopic detection of large and advanced colonic lesions: Are we missing the forest for the trees?. Gastrointest Endosc 2017; 85: 234-236