Post written by Dennis Yang, MD, from the Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA.

The incidence of surgery for nonmalignant colorectal polyps has continued to rise. We aimed to evaluate referral patterns and factors associated with surgery for nonmalignant colorectal polyps at a large tertiary care center.

Endoscopic resection should be the first-line treatment for most nonmalignant colorectal polyps. When compared with surgery, endoscopic resection has been shown to be more cost-effective and associated with fewer adverse events and higher patient quality of life. Yet, despite the evidence favoring endoscopic resection, surgery has remained a common practice in the United States. 

In our study, surgeons were more likely to advise patients to undergo surgery rather than a second attempt at endoscopic resection (OR: 2.5) if the referral came from academic gastroenterologists. This is consistent with a review of a national representative sample demonstrating that the rate of surgery was highest among teaching hospitals. Hence, surgery may not be driven by a lack of local expertise in endoscopic resection, but rather an underutilization of these services.

In our study, a baseline pathology of intramucosal adenocarcinoma was associated with higher odds for surgery (OR 5.72), even though this term is synonymous with high-grade dysplasia in the colorectum. These findings reiterate the stigma of the word “carcinoma,” which is often mistaken by providers as equivalent to invasive cancer. GI pathologists should review these cases to avoid unnecessary surgery for endoscopically curable lesions. Lastly, similar to prior studies, endoscopic resection was associated with shorter hospital stay and lower rate of adverse events when compared to surgery.

We need to raise awareness among patients, gastroenterologists, and surgeons of the spectrum of colorectal polyps amenable to endoscopic resection. This begins by developing relationships with our referring physicians, streamlining the referral process so that all non-malignant polyps are reviewed by expert endoscopists prior to surgery, and assisting in the follow-up care of these patients in a multi-disciplinary approach.

Figure 1. Flowchart of patients. CRS, Colorectal surgery.

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