Clinical implications of decision making in colorectal polypectomy: an international survey of Western endoscopists suggests priorities for change

Abstract

Introduction Colonoscopy prevents colorectal cancer via the detection and resection of premalignant polyps. This effect may be attenuated by variations in polypectomy, with multiple techniques available and a wide range of experience amongst endoscopists. We assessed current practice against the best available contemporary evidence. Methods An online survey was distributed to members of the gastroenterological and surgical societies of seven countries during July 2017. Images of colorectal polyps were presented and respondents requested to provide the polypectomy technique they would employ in their daily practice. Responses were compared to the evidence-based techniques in the 2017 ESGE Colorectal Polypectomy Guideline. Results In total, 707 endoscopists (627 physicians, 71 surgeons, 9 nurse endoscopists, median practice duration 18 years) completed the survey. Of these, 3.1 % selected hot biopsy forceps and 5.2 % hot snare polypectomy (without submucosal lifting) to remove a 3 mm ascending colon polyp. Only 43.3 % selected cold snare polypectomy (CSP) to remove an 8 mm ascending colon polyp. Surgical referral was selected by 16.7 % of respondents for a 45 mm transverse colon polyp without endoscopic evidence of submucosal invasive cancer (SMIC). Endoscopic resection was selected by 12.0 % for an 80 mm sigmoid polyp with imaging consistent with deep SMIC, and a further 26.4 % selected tertiary endoscopist referral, suggesting they had not appreciated that it was endoscopically unresectable. Conclusion CSP is underutilized for small polyp resection despite its favorable safety and efficacy. Benign polyps are commonly referred for surgery and overt SMIC is underappreciated using endoscopic imaging. Addressing these issues may reduce diathermy-related adverse events, surgery, and unnecessary colonoscopic procedures for patients and reduce rates of post-colonoscopy colorectal cancer.

A Device for Polypectomy May Contribute to Safety in Bloodless Resection of a Small Hemangioma of the Tongue under Local Anesthesia

“…These treatments usually were performed under general anesthesia to control safety hemostasis. Polypectomy is underutilized for small polyp resection despite its favorable safety and efficacy [2]. A device of polypectomy made by Martin Co. Ltd. (Germany) automatically outputs small current for alternating incisions and coagulations for fast bloodless excision.…”

The low impact of the guidelines: does it concern only colorectal polypectomy?

“…A good example of where we stand is provided by the international survey on the attitude of endoscopists by over 700 endoscopists in seven countries reported in this issue of the Journal [3]. When considering the recent ESGE guidelines on polypectomy and endoscopic mucosal resection (EMR) as a template for an optimal standard [4], the authors inferred the technical and cultural approach, with quite controversial and somewhat disappointing results [3].…”

“…The evidence that less than 50 % of resections of small to diminutive polyps are appropriately performed by the recommended cold-snaring deserves some comments [3]. None of us would consider it as clinically relevant due to the remote, if any, chance that an incomplete resection of these tiny lesions would cause an interval CRC.…”

“…societies, including evidence-based courses, e-learning, translational and other activities. According to the published survey [3], such a step-up approach succeeded in persuading approximately 40 % of the endoscopists, suggesting that there are some major barriers for the remaining majority. Of course, we can see the glass half full, as usually a step-up approach is not so much demanding in terms of required resources, acting more as a tool than a formal strategy.…”

“…Is there variability among centers in safety of complex resections? According to the survey, these risks exist and affect a not negligible proportion of our community [3]. As shown by the authors, overuse or under-use of endoscopic resection for complex polyps depends not only on the same personal disbeliefs against evidence-based standard, but also on suboptimal competence in differentiating between early and deeply invasive CRC.…”