Remove or Refer Before Resection: The Case for Endoscopic Management of Most Large Polyps

New study calls for paradigm shift

When physicians detect a large colorectal polyp during colonoscopy, they often make the call on endoscopic versus surgical removal based on a number of factors. Before choosing surgery, researchers of a matched control study argue, consider referral to a second endoscopist given resection’s larger risk of complications, longer length of stay and potential for greater detriment to patient quality of life.

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“Patients keep getting sent in for surgical resection of polyps are potentially removable endoscopically,” says James Church, MD, Director of the Sanford R. Weiss, MD, Center for Hereditary Colon Cancer. “If you do a colonoscopy and see a polyp, and it’s obviously a precancerous polyp, and you feel uncomfortable taking it out, send it to an endoscopist who is more expert and more comfortable — before you send them right to surgery.”

Dr. Church and colleague Arman Erkan compared outcomes between 78 people with large polyps from an endoscopy database and a matched cohort of 78 others from a pathology database. Mean polyp size was approximately 33mm.

Complication apprehension

Potential complications, especially bleeding, are a main reason many endoscopists remain reluctant to snare a large polyp, Dr. Church says. In other cases, the clinician belie
ves the polyp is too large or its position too awkward, “and they don’t know all the tricks of the trade.” In these cases, a colleague more adept at tackling these challenging cases may be able to16-ddi-2083-polyp-cqd-inset remove the polyp endoscopically.

In the study, eight colonoscopy patients (10.3%) experienced complications versus 42 surgery patients (56.0%). Postpolypectomy hemorrhage was most common in the endoscopy group versus a prolonged ileus in the surgery group.

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In addition, patients may experience a diminished quality of life postsurgery, Dr. Church says. “If there are complications that lead to unintended bowel resection or the need for reoperation, patients may experience repeated adhesion-related obstructions, may need a stoma, or may even develop short bowel syndrome.”

Length of stay surprise

As expected, length of hospital stay was significantly shorter between the colonoscopy patients (mean 0 days) and the surgical patients (7.3 days, P < 0.001). “I was a little bit surprised by the long length of stay after surgery,” Dr. Church says, “and that there wasn’t much difference between laparoscopic and open surgery.”

Patients spent a mean of 5.8 days in the hospital after laparoscopy versus 8.4 days following open surgery, but this difference was not statistically significant (P = 0.17). Similarly, complication rates favored less invasive laparoscopy, but not significantly: 42.4% versus 53.5% (P = 0.46).

“Some people might say that resecting a polyp with surgery is okay because with minimally invasive techniques there is less pain, they recover faster and do not stay as long, so what is all the fuss about?” Dr. Church says. “You can see here the complication rate was the same, the length of stay was the same, so that settles that.”

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Colonoscopy is cheaper

Another advantage of colonoscopic polypectomy over surgical resection is cost. Although this was not specifically measured in the current study, other authors show that open surgery costs
approximately five times more than colonoscopic polypectomy.

The message from the study is not that surgery is never indicated, Dr. Church says. The standard of care at Cleveland Clinic is to manage a large polyp in the most effective and least complicated way. “When you get referred a patient with a big polyp, it
’s your responsibility to make sure it gets removed. And if it needs surgery, it needs surgery. You discuss that with the patient.”

The study findings were published online August 3, 2016 in ANZ Journal of Surgery (EPub Ahead of Print).