Endoscopic mucosal resection of large colorectal adenomas: Only for expert centers?

Extent of unnecessary surgery for benign rectal polyps in the Netherlands

BACKGROUND AND AIMS

Minimally invasive techniques are available to safely and efficaciously remove even the largest rectal polyps. This study aimed to investigate the magnitude of cases still referred for radical rectal surgery and the reasons for these referrals and to perform a re-evaluation of cases potentially suitable for endoscopic therapy.

METHODS

A retrospective analysis of data from the Dutch Pathology Registry (Pathologic Anatomic Nationwide Automated Archive) was performed using the records of patients who underwent major surgical treatment for a histologically proven benign rectal polyp between 2005 and 2014 in the Netherlands. In a representative subset of 7 hospitals, detailed analysis was performed. An expert panel of 3 endoscopists reassessed all patient data to judge whether endoscopic treatment would have been a reasonable alternative.

RESULTS

In the last decade 575 patients, and 56 patients in the subset of hospitals, were referred for major rectal surgery for a benign rectal polyp in the Netherlands. The number of radical resections declined over the years but stabilized in the last years. The main reasons for surgery were polyp size (34%), suspicion of malignancy (34%), and transanal endoscopic microsurgery failures (20%). In community hospitals, referrals for surgery were relatively more prevalent compared with academic hospitals (P < .01). Thirty-nine percent of patients had perioperative adverse events, and 1 patient (1.8%) died. Seventy-three percent of cases were assessed as "probably feasible" for endoscopic therapy.

CONCLUSIONS

Over the last 10 years the rate of radical rectal surgery for a benign polyp declined. However, a significant subgroup of patients was still referred for invasive surgery at the cost of high morbidity and mortality. Referral to an expert endoscopist may avoid unnecessary surgery in most cases.

Outcome of EMR as an alternative to surgery in patients with complex colon polyps

BACKGROUND AND AIMS

Patients with complex colon polyps were traditionally referred for surgery to avoid adverse events associated with endoscopic resection. Recent advances in endoscopic imaging as well as endoscopic hemostasis and clip closure allow for the use of EMR as an alternative to surgery for such lesions. To determine the outcome of treatment of complex colon polyps with EMR as an alternative to surgery, we conducted a retrospective observational study.

METHODS

Two hundred three patients with complex colon polyps were referred to an EMR center as an alternative to surgery. Patients underwent a protocol-driven EMR. The primary endpoint was the complete resection rate. Secondary endpoints were safety, residual adenoma rate, and incidence of missed synchronous polyps.

RESULTS

EMR was performed in 155 patients and was deferred in 48 patients who were referred to surgery. EMR specimens revealed benign polyps in 149 and cancer in 6 patients. EMR adverse events occurred in 7 patients, requiring hospitalization in 5 of them. None of the patients died as a result of their adverse events. Surveillance colonoscopy at 4 to 6 months after resection of a benign lesion in 137 patients revealed residual adenoma at the scar site in 6 patients and additional synchronous precancerous lesions in 117 patients that were not removed by the referring endoscopist. None underwent surgery for failure of EMR. The overall precancerous lesion burden was 2.83 per patient, the adenoma burden was 2.13 per patient, and the serrated polyp burden was .69 per patient.

CONCLUSIONS

EMR can be used instead of surgery for complex colon polyps in 75% of patients with few adverse events and few residual adenomas at resection sites. In addition, careful repeat examination of the entire colon for synchronous lesions overlooked by the referring endoscopist is required for most patients. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01827241.).