Work and resources needed for endoscopic resection of large sessile colorectal polyps

Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends

Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.

Effect of time of day and daily endoscopic workload on outcomes of endoscopic mucosal resection for large sessile colon polyps

Background

Endoscopic mucosal resection of large non-pedunculated colon polyps is challenging.

Objective

To determine if the time of day or daily endoscopic workload play a role in outcomes of endoscopic mucosal resection for large non-pedunculated colon polyps greater than 20 mm.

Methods

This is a retrospective study of patients who underwent endoscopic mucosal resection of large non-pedunculated colon polyps. The time of day and endoscopic workload were compared across the following outcomes: the rate of complete resection of the polyp, the rate of referral for surgery, and the rate of residual neoplasia on follow-up.

Results

One hundred and three endoscopic mucosal resection procedures were performed. There were no differences in the rates of complete resection (80.8% vs. 70.0%; P = 0.25), the need for surgery (27.4% vs. 33.3%; P = 0.55), and rate of residual neoplasia (24.5% vs. 50.0%; P = 0.07) when comparing the time of day. Colon polyps greater than 40 mm were less likely to be completely resected versus polyps sized 20-39 mm (56.8% vs. 91.9%; P < 0.001). In cases with no residual neoplasia on follow-up, the mean duration for the index procedure was 45.6 minutes versus 60.7 minutes when there was residual neoplasia (P < 0.01).

Conclusion

The time of day and endoscopic workload does not affect outcomes for endoscopic mucosal resection of large non-pedunculated colon polyps, but the size of large non-pedunculated colon polyps and resection times do.

Facilitating endoscopic submucosal dissection: double balloon endolumenal platform significantly improves dissection time compared with conventional technique (with video)

BACKGROUND

Flexible endoscopes ability to manipulate the intestinal environment is limited. As a result, complex endolumenal procedures are often technically demanding and result in long procedure times, impacting institutional resources. Single- and double-balloon add-on endoscopic devices have been employed throughout the GI tract to facilitate tissue control e.g., small bowel enteroscopy, with recent reports suggesting a possible colonic utility for complex procedures e.g., ESD. Our objective was to objectively analyze the efficacy of a new double-balloon device in performing ESD.

METHODS

Ex vivo-12 simulated colonic lesions were created in porcine rectum using a standard 40 mm diameter template. Two categories were evaluated, standard cap technique ESD and double-balloon assisted ESD with retraction (ESD-R). Cases were performed sequentially. In vivo-Six, 40 mm lesion ESD-R's were performed in a porcine model. The primary outcomes of this study were total procedure and dissection times.

RESULTS

In ex vivo studies, the median total procedure time with the double-balloon platform was significantly shorter than the traditional ESD technique (29 ± 18 vs. 57 ± 21 min, p = 0.03). In the in vivo studies, lesions were successfully removed in a mean time of 48 min, with a dissection time of 20 min with no significant complications. Balloon-clip retraction and specimen retrieval capabilities were used in all double-balloon assisted cases. After 6 cases, times were significantly shorter (ex vivo 47 vs. 17 min; in vivo 57 vs. 27 min).

CONCLUSIONS

We have demonstrated the development of a unique technical ESD method facilitated by a new double-balloon device. Ex and in vivo investigation demonstrated superiority of ESD-R over the conventional ex vivo method. The DB device provided increased stability, improved visualization and tissue traction, which significantly reduced dissection time. Such an approach may increase safety, improve patient outcomes, and may prevent unnecessary surgeries for benign conditions.

Carbon dioxide insufflation during endoscopic resection of large colorectal polyps can reduce post-procedure abdominal pain: A prospective, double-blind, randomized controlled trial

Background

Studies of the use of CO₂ insufflation during endoscopic resection of large colorectal polyps (LCPs) are lacking.

Objective

We evaluated the effect of CO₂ insufflation on pain after endoscopic resection of LCPs.

Methods

In a prospective randomized controlled trial (RCT), 132 patients were randomly assigned to groups who underwent endoscopic resection with CO₂ insufflation (CO₂ group, n = 66) or air insufflation (air group, n = 66). The primary outcome was abdominal pain post-procedure (PP). The secondary outcomes were abdominal distension, rates of technical success, amounts of sedatives prescribed, use of analgesics, and adverse events.

Results

Baseline patient characteristics were similar between the groups. The mean abdominal pain score was 12.3 in the CO₂ group vs. 17.5 in the air group at 1 h PP (p  =  0.047). Also, the proportion of patients without pain was significantly higher in the CO₂ group at 1 h PP (p = 0.008). The pain score differed more in the endoscopic submucosal dissection group and long-time group. The secondary outcomes were not significantly different between the two groups.

Conclusions

The results of this RCT demonstrate the superiority of CO₂ insufflation for endoscopic resection of LCPs in terms of decreasing PP abdominal pain (KCT0001636).

The Difficult Colorectal Polyp

Difficult colorectal polyps represent lesions that pose a challenge to traditional endoscopic snare polypectomy. These polyps have historically been managed by surgical resection. Currently, several less invasive options are available to avoid colectomy. Repeat colonoscopy and snare polypectomy by an expert endoscopist, endoscopic mucosal resection, endoscopic submucosal dissection, and combined endoscopic and laparoscopic surgery have been developed to remove difficult polyps without the need for formal surgical resection. Patients with rectal polyps have the advantage of additional transanal minimally invasive techniques to enhance their resectability. Today, most colorectal polyps can be managed without the need for formal surgical resection.

Endoscopic resection is cost-effective compared with laparoscopic resection in the management of complex colon polyps: an economic analysis

BACKGROUND AND AIMS

Endoscopic resection (ER) is an efficacious treatment for complex colon polyps (CCPs). Many patients are referred for surgical resection because of concerns over procedural safety, incomplete polyp resection, and adenoma recurrence after ER. Efficacy data for both resection strategies are widely available, but a paucity of data exist on the cost-effectiveness of each modality. The aim of this study was to perform an economic analysis comparing ER and laparoscopic resection (LR) strategies in patients with CCP.

METHODS

A decision analysis tree was constructed using decision analysis software. The 2 strategies (ER vs LR) were evaluated in a hypothetical cohort of patients with CCPs. A hybrid Markov model with a 10-year time horizon was used. Patients entered the model after colonoscopic diagnosis at age 50. Under Strategy I, patients underwent ER followed by surveillance colonoscopy at 3 to 6 months and 12 months. Patients with failed ER and residual adenoma at 12 months were referred for LR. Under Strategy II, patients underwent LR as primary treatment. Patients with invasive cancer were excluded. Estimates regarding ER performance characteristics were obtained from a systematic review of published literature. The Centers for Medicare & Medicaid Services (2012-2013) and the 2012 Healthcare Cost and Utilization Project databases were used to determine the costs and loss of utility. We assumed that all procedures were performed with anesthesia support, and patients with adverse events in both strategies required inpatient hospitalization. Baseline estimates and costs were varied by using a sensitivity analysis through the ranges.

RESULTS

LR was found to be more costly and yielded fewer quality-adjusted life-years (QALYs) compared with ER. The cost of ER of a CCP was $5570 per patient and yielded 9.640 QALYs. LR of a CCP cost $18,717 per patient and yielded fewer QALYs (9.577). For LR to be more cost-effective, the thresholds of 1-way sensitivity analyses were (1) technical success of ER for complete resection in <75.8% of cases, (2) adverse event rates for ER > 12%, and (3) LR cost of <$14,000.

CONCLUSIONS

Our data suggest that ER is a cost-effective strategy for removal of CCPs. The effectiveness is driven by high technical success and low adverse event rates associated with ER, in addition to the increased cost of LR.

Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions

BACKGROUND & AIMS

Large laterally spreading lesions (LSL) in the colon and rectum can be safely and effectively removed by endoscopic mucosal resection (EMR). However, many patients still undergo surgery. Endoscopic treatment may be more cost effective. We compared the costs of endoscopic versus surgical management of large LSL.

METHODS

We performed a prospective, observational, multicenter study of consecutive patients referred to 1 of 7 academic hospitals in Australia for the management of large LSL (≥ 20 mm) from January 2010 to December 2013. We collected data on numbers of patients undergoing EMR, actual endoscopic management costs (index colonoscopy, hospital stay, adverse events, and first surveillance colonoscopy), characteristics of patients and lesions, outcomes, and adverse events, and findings from follow-up examinations 14 days, 4-6 months, and 16-18 months after treatment. We compared data from patients who underwent EMR with those from a model in which all patients underwent surgery without any complications. Event-specific costs, based on Australian refined diagnosis-related group codes, were used to estimate average cost per patient.

RESULTS

EMR was performed on 1489 lesions (mean size, 36 mm) in 1353 patients (mean age, 67 years; 52.1% male). Total costs involved in the endoscopic management of large LSL were US $6,316,593 and total inpatient hospitalization length of stay was 1180 days. The total cost predicted for the surgical management group was US $16,601,502, with a total inpatient hospitalization length of stay of 4986 days. Endoscopic management produced a potential total cost saving of US $10,284,909; the mean cost difference per patient was US $7602 (95% confidence interval, $8458-$9220; P < .001). Inpatient hospitalization length of stay was reduced by 2.81 nights per patient (95% confidence interval, 2.69-2.94; P < .001).

CONCLUSIONS

In a large multicenter study, endoscopic management of large LSL by EMR was significantly more cost-effective than surgery. Endoscopic management by EMR at an appropriately experienced and resourced tertiary center should be considered the first line of therapy for most patients with this disorder. This approach is likely to deliver substantial overall health expenditure savings. ClinicalTrials.gov, Number: NCT01368289.

Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions

BACKGROUND

Endoscopic resection of large colorectal lesions is associated with high complication rates.

OBJECTIVE

To evaluate the effect of prophylactic clip closure of polypectomy sites after resection of large (≥2 cm) sessile and flat colorectal lesions.

DESIGN

Retrospective study.

SETTING

Tertiary referral center.

PATIENTS AND INTERVENTIONS

Patients with lesions 2 cm or larger who underwent EMR performed by using low-power coagulation current between January 2000 and February 2012. Beginning in June 2006, polypectomy sites were prophylactically closed with clips when possible. Patients had telephone follow-up at 30 days or later to track complications.

MAIN OUTCOME MEASUREMENTS

Delayed hemorrhage, postpolypectomy syndrome, and perforation.

RESULTS

There were 524 lesions 2 cm or larger in 463 patients, of which 247 (47.1%) were not clipped, 52 (9.9%) were partially clipped, and 225 (42.9%) were fully clipped. There were 31 delayed hemorrhages, 2 perforations, and 6 cases of postpolypectomy syndrome. The delayed hemorrhage rate was 9.7% in the not clipped group versus 1.8% in the fully clipped group. Multivariate analysis showed that not clipping (odds ratio [OR] 6.0; 95% CI, 2.0-18.5), location proximal to the splenic flexure (OR 2.9; 95% CI, 1.05-8.1), and polyp size (OR 1.3; 95% CI, 1.1-1.7 for each 10-mm increase in size) were associated with delayed bleeding.

LIMITATION

Retrospective design.

CONCLUSIONS

Prophylactic clipping of resection sites after endoscopic removal of large (≥2 cm) colorectal lesions using low-power coagulation current reduced the risk of delayed postpolypectomy hemorrhage. A randomized, prospective trial of clipping large polypectomy sites is warranted.

Endoscopic resection of large colon polyps

Endoscopic resection, including polypectomy, endoscopic mucosal resection, and endoscopic submucosal dissection, is the preferred treatment method of large colorectal polyps. Its safety and efficacy have been shown. Endoscopic removal techniques are important because they provide a resection specimen for precise histopathologic staging to further direct diagnosis, prognosis, and management decisions. Used according to its indications, it provides curative resection and obviates the higher morbidity, mortality, and cost associated with alternative surgical treatment.

Failure to recognize serrated polyposis syndrome in a cohort with large sessile colorectal polyps

BACKGROUND

Serrated polyposis syndrome (SPS) is a rare condition of multiple serrated colorectal polyps and cancers. Colorectal cancer risk is increased in SPS.

OBJECTIVE

We determined the prevalence of SPS in a cohort of patients with large (≥ 2 cm) sessile colorectal polyps and the rate at which the diagnosis was made by the clinicians.

DESIGN

Review of patient care database. The 2010 World Health Organization (WHO) criteria were used to identify cases of SPS.

SETTING

Tertiary academic center.

PATIENTS

529 consecutive patients referred for endoscopic resection of a sessile colorectal polyp ≥ 2 cm.

MAIN OUTCOME MEASUREMENTS

Prevalence of SPS in the cohort and frequency with which the referring physician and the endoscopist recognized SPS.

RESULTS

Of the 529 patients, 20 (4%) met the WHO criteria for SPS. Only 1 of these cases was suspected by a referring physician. Twelve cases (60%) were either diagnosed or suspected by the endoscopist at our center. Compared with all other patients without SPS, those with SPS were more likely to have an index lesion (the lesion that led to referral) that was serrated (60% vs 3.8%), to have a cecal or ascending colon index lesion (70% vs 45%), and to be current smokers (42% vs 15%). Including the first colonoscopy to remove the index lesion and 26 follow-up colonoscopies, the endoscopist at our center removed 183 serrated polyps from the 20 patients with SPS; of those polyps, 68 were >1 cm. Three patients were referred for surgical resection of involved colon. Eighteen of the 20 patients with SPS met the WHO criterion of 5 serrated polyps proximal to the sigmoid, of which 2 are >1 cm. Failure to recognize SPS by the referring physician was at least partly related to unrecognized serrated lesions. Failure to recognize SPS by the endoscopist at our institution was the result of not systematically applying WHO criteria to the polyp findings.

LIMITATIONS

Retrospective study.

CONCLUSIONS

SPS was common in a cohort of patients with large sessile colorectal polyps, and it was frequently unrecognized. These data suggest the need for better detection of serrated lesions, better awareness of SPS, and more consistent application of SPS criteria to the polyp findings of individual patients.

Evolving techniques in colonoscopy

PURPOSE OF REVIEW

This review summarizes recent clinical studies of colonoscopy technique and new technologies.

RECENT FINDINGS

Water immersion reduces pain and sedation doses in unsedated and lightly sedated colonoscopy. Cap-fitted colonoscopy makes insertion faster and improves detection of lesions behind folds, but the latter effect is operator-dependent. A single controlled trial showed improved detection with the Third Eye Retroscope, but the two arms of the study were not controlled for withdrawal time. Chromoendoscopy increases detection of diminutive adenomas, but adds time to the colonoscopy procedure. Electronic chromoendoscopy methods (narrow band imaging, Fujinon Intelligent ChromoEndoscopy, i-scan, and autofluorescence) have been either unsuccessful in improving detection or require more study. However, these methods and several other methods (chromoendoscopy with magnification, confocal laser microscopy, and endocytoscopy) allow accurate real time determination of polyp histology.

SUMMARY

Water immersion is a clear advance in unsedated colonoscopy. Cap-fitted colonoscopy is a promising method for both practical and effective visualization of the proximal sides of haustral folds. Electronic chromoendoscopy has been largely ineffective at improving polyp detection, but is effective (as are confocal laser microscopy and endocytoscopy) for diagnosis of polyp histology.

Improving colonoscopy quality through health-care payment reform

Problems with the quality of colonoscopy are well recognized. Variation in colonoscopist performance is compounded by payment structures that reward volume rather than quality. Payment reform has emerged as one strategy to address these and more systemic problems in the quality of health care. Various forms of value-based purchasing might encourage a realignment of incentives, and allow reimbursement to be directly linked with clinically important goals of colonoscopy. This paper proposes criteria for the selection of quality measures, and three candidate indicators to define quality for the purpose of payment reform in colonoscopy: cecal intubation rate, adenoma detection rate, and recommended post-polypectomy surveillance interval. These measures represent valid, credible, and reliable indicators of the quality of colonoscopy for colorectal cancer screening and surveillance. Payment reform should explicitly link public reporting and performance on these quality measures to payment for colonoscopy.

Endoscopic mucosal resection of non-polypoid colorectal neoplasm

Endoscopic mucosal resection (EMR) is preferred to standard polypectomy for the resection of non-polypoid lesions because these lesions can be technically difficult to capture with a snare; furthermore, without submucosal injection the underlying muscularis propria may be excessively coagulated or even inadvertently resected. Because the resection plane of EMR is in the middle or deeper part of the submucosa, EMR allows the precise depth of the lesion to be evaluated. Although the majority of non-polypoid lesions are adenomatous, non-polypoid colorectal neoplasm has a high association with advanced pathology, irrespective of size. Using EMR, a complete pathologic specimen is obtained, the risk of lymph node metastasis can be accurately assessed based on the depth of invasion, and patients can be suitably managed. Used according to its indications, EMR provides curative resection, and obviates the higher morbidity, mortality, and cost associated with surgical treatment.

Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos)

BACKGROUND

Patients who have large, difficult, colorectal lesions not readily amenable to endoscopic resection are often referred directly to surgery. The application of advanced polypectomy and endoscopic mucosal resection (EMR) techniques undertaken by a tertiary referral colonic mucosal resection and polypectomy service (TRCPS) is not often considered but may be superior to surgery.

OBJECTIVE

To evaluate the safety, efficacy, and cost savings of a TRCPS for colorectal lesions.

DESIGN

Prospective intention-to-treat analysis.

SETTING

Tertiary academic referral center.

PATIENTS

In a 21-month period ending in April 2008, consecutive patients with large or complex colorectal polyps referred by other specialist endoscopists were prospectively enrolled on an intention-to-treat basis.

INTERVENTION

For sessile lesions, a standardized EMR approach was used. Pedunculated lesions were removed with or without pretreatment with an Endoloop procedure.

MAIN OUTCOME MEASUREMENTS

Complete resection, complications, recurrence, and potential cost savings comparing actual outcome of the cohort with a hypothetical analysis of surgical management.

RESULTS

This study included 174 patients (mean age 68 years) who were referred with 193 difficult polyps (186 laterally spreading, mean size 30 mm [range 10-80 mm]). We totally excised 173 laterally spreading lesions by EMR (115 piecemeal, 58 en bloc). Invasive adenocarcinoma was found in 6 lesions-5 treated successfully with EMR. Eleven patients were referred directly to surgery without an endoscopic attempt due to suspected invasive carcinoma. Seven >30-mm, pedunculated polyps were removed. There were no perforations. A total of 20 bed days was used because of endoscopic complications. Among all patients referred, 90% avoided the need for surgery. Excluding patients who were treated surgically for invasive cancer, the procedural success was 95% (157 of 168). By using Australian cost estimates applied to the entire group and compared with cost estimates assuming all patients had undergone surgery, we calculated the total medical cost savings was $6990 (U.S.) per patient, or a total savings of $1,216,231 (U.S.).

LIMITATION

Not a randomized trial.

CONCLUSIONS

Colonoscopic polypectomy performed by a TRCPS on large or difficult polyps is technically effective and safe. This approach results in major cost savings and avoids the potential complications of colonic surgery. This type of clinical pathway should be developed to enhance patient outcomes and reduce health care costs.

Simulation of a colorectal polypoid lesion--a pilot porcine model

BACKGROUND

Large sessile polyps almost always contain villous tissue with appreciable premalignant potential and tend to recur locally after colonoscopic resection. Developing new endoscopic techniques for the removal of polyps requires a large animal model of colorectal polypoid lesions. So far, no appropriate large animal model of a colorectal or other GI polyp has been described in the English literature.

OBJECTIVE

Our purpose was to develop a large animal model simulating large, perfused and viable, sessile colorectal polypoid lesions, with distinct easily detectable histologic features.

SETTING

An animal laboratory.

INTERVENTIONS

Two simulated rectal polyps, using 2 different techniques, were created in each of 10 animals. The polyps were simulated by ovarian tissue that was introduced either intraluminally through the rectal wall or into a dissected submucosal space in the rectal wall. In 2 animals the created polyps were endoscopically resected.

RESULTS

All submucosal lesions were sessile-like polypoid lesions because the base of the polyp was the widest diameter of the lesion. All transmural polypoid lesions had short and thick pedicles. Resection by snaring and cutting was demonstrated to be feasible.

MAIN OUTCOME MEASUREMENTS

The mean measurements of the submucosal-simulated polyps were as follow: 1.74 cm (+/-0.32) x 2.07 cm (+/-0.42) x 1.51 cm (+/-0.27). The mean measurements of the transmural-simulated polyps were significantly larger: 2.55 cm (+/-0.52) x 3.57 cm (+/-1.1) x 2.7 cm (+/-0.64).

LIMITATION

This model does not simulate a real intestinal neoplasia.

CONCLUSION

Either method, the submucosal or the transmural, could be helpful in the research and development efforts of surgical and endoscopic treatments of intestinal polyps.

Colonoscopic polypectomy

Colonoscopic polypectomy is the most effective visceral cancer prevention tool in clinical medicine. In general, risks associated with the technique of polyp removal should match the likelihood that the polyp will become or already is malignant (eg, low-risk technique for low risk for malignant potential). Cold techniques are preferred for most diminutive polyps. Polypectomy techniques must be effective and minimize complications. Complications can occur even with proper technique, however. Aggressive evaluation and treatment of complications helps ensure the best possible outcome.