Post written by Maxime E.S. Bronzwaer, MD, from the Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.

Over the past decade endoscopic resection techniques, such as piecemeal endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), have progressed significantly to treat large and complex non-pedunculated colorectal polyps. Endoscopic resection is an attractive treatment option for these patients, as it is associated with acceptable adverse events rates, very low mortality, and significantly lower costs when compared with colonic surgery. Traditionally these large and complex non-pedunculated colorectal polyps were managed by surgical resection. Despite the increased performance of endoscopic resection accompanied with its important benefits, it remained largely unknown to what extend endoscopic resection of benign colorectal polyps has replaced surgical resection in the Netherlands.

Our study represents a multicenter, retrospective, cohort study which was performed to assess the total volume of colorectal surgery performed to resect benign colorectal polyps in the Netherlands and to evaluate its absolute and relative volume changes over the past decade. A total of 5937 patients who underwent surgical resection for a benign colorectal polyp between 2005 and 2015 were identified through the prospective nationwide Dutch Pathology Registry. The absolute (454-739 per year) and relative volumes (0.20%-0.37% per colonoscopy per year) of surgical resection remained stable over the study period (Figure 2). Over the past decade, nationwide volumes of colonoscopy have increased, suggesting that a higher number of complex colorectal polyps might have been found endoscopically. Keeping in mind that the volume of surgical resection remained stable over the study period, potentially more successful endoscopic resection procedures have been performed. Regrettably, no comparative data were available on the overall nationwide volumes of successful endoscopic resection procedures performed in order to confirm this.

Figure 2. A, Relative changes in SR plotted against the annual number of colonoscopies performed. B, Relative changes in SR plotted against the annual number of SRs performed.

In our study cohort, endoscopic resection attempts were performed in a small proportion (15.0%, 134/915) of patients, and only a minority (2.4%, 22/915) of cases had been referred to another endoscopy center for an additional endoscopic resection attempt before referral for surgical resection. An increasing body of evidence suggests that many lesions currently referred for surgical resection are eligible to endoscopic resection when performed in experienced hands.1-3 The study by Friedland et al showed that 71% of advanced colonic lesions without biopsy-proven colorectal cancer, which were already referred for surgical resection, could be treated endoscopically during a repeat colonoscopy performed by an experienced endoscopist in a tertiary endoscopy center.1 In these patients surgery, could directly be avoided. Therefore, we would like to make a plea that all patients with a benign colorectal polyp assessed ineligible for endoscopic resection, should be referred for repeat colonoscopy by a tertiary interventional endoscopist before surgical resection. In order to facilitate the increase of endoscopic resections and avoid surgical resection in a subset of patients, implementation of regional multidisciplinary referral networks should be considered, as these could result in advanced endoscopic treatment options becoming more widely available and accessible.

References

1. Friedland S, Banerjee S, Kochar R, Chen A, Shelton A. Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer. Gastrointestinal endoscopy. 2014;79(1):101-7.
2. Moss A, Bourke MJ, Williams SJ, Hourigan LF, Brown G, Tam W, et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology. 2011;140(7):1909-18.
3. Moss A, Williams SJ, Hourigan LF, Brown G, Tam W, Singh R, 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(1):57-65.

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