Quality Matters: Improving the Quality of Care for Patients With Complex Colorectal Polyps

Grimm, Ian S.; Peery, Anne F.; Kaltenbach, Tonya; Crockett, Seth D.

doi:10.1038/ajg.2017.409

Cited by 14 publications

(19 citation statements)

References 17 publications

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“…Endoscopic resection has replaced surgical resection as the primary treatment for large colon polyps because of a lower morbidity and less need for hospitalization. [1][2][3][4] Postprocedure bleeding is the most common severe complication, occurring in 2% to 24% of patients. [5][6][7][8][9][10][11][12][13] Proximal polyp location in the colon, polyp size, and use of antithrombotic medications are factors that have been associated with an increased risk of postprocedure bleeding.…”

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confidence: 99%

Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

et al. 2019

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BACKGROUND & AIMS: Bleeding is the most common severe complication after endoscopic mucosal resection of large colon polyps and is associated with significant morbidity and cost. We examined whether prophylactic closure of the mucosal defect with hemoclips after polyp resection reduces the risk of bleeding. METHODS: We performed a multicenter, randomized trial of patients with a large nonpedunculated colon polyp (!20 mm) at 18 medical centers in North America and Spain from April 2013 through October 2017. Patients were randomly assigned to groups that underwent endoscopic closure with a clip (clip group) or no closure (control group) and followed. The primary outcome, postprocedure bleeding, was defined as a severe bleeding event that required hospitalization, a blood transfusion, colonoscopy, surgery, or another invasive intervention within 30 days after completion of the colonoscopy. Subgroup analyses included postprocedure bleeding with polyp location, polyp size, or use of periprocedural antithrombotic medications. We also examined the risk of any serious adverse

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confidence: 99%

Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

et al. 2019

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“…Supplementary material is available under https://doi.org/10.1055/a-1220-6261 curve, are more resource-intense, carry a higher risk of adverse events (AEs), and their long-term advantages over surgery are still debated [4][5][6][7][8].…”

Section: Introductionmentioning

confidence: 99%

“…Technological improvements (e. g. endoscopic submucosal dissection [ESD]) and a deeper comprehension of the biological behavior of cancer precursors have enabled endoscopists to consider ER for lesions of increasing complexity. However, these procedures have a longer training curve, are more resource-intense, carry a higher risk of adverse events (AEs), and their long-term advantages over surgery are still debated 4 5 6 7 8 .…”

Section: Introductionmentioning

confidence: 99%

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Improving assessment and management of large non-pedunculated colorectal lesions in a Western center over 10 years: lessons learned and clinical impact

et al. 2020

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Background and study aims Outcomes of endoscopic assessment and management of large colorectal (CR) non-pedunculated lesions (LNPLs) are still under evaluation, especially in Western settings. We analyzed the clinical impact of changes in LNPL management over the last decade in a European center. Patients and methods All consecutive LNPLs ≥ 20 mm endoscopically assessed (2008–2019) were retrospectively included. Lesion, patient, and resection characteristics were compared among clinically relevant subgroups. Multivariate logistic regression (for predictors of submucosal invasion [SMI] and recurrence), Kaplan-Meier curves and ROC curves (for temporal cut-offs in trends analyses) were used. Results A total of 395 LNPLs were included (30 mm [range 20–40]; SMI = 9.6 %; primary endoscopic resection [ER] = 88.4 %). Pseudo-depression and JNET classification independently predicted SMI beyond single morphologies/location. After complete ER, involvement of ileocecal valve/dentate line, piece-meal resection and high-grade dysplasia independently predicted recurrence. Rates of 5-year recurrence-free, surgery-free and cancer-free survival were 77.5 %, 98.6 % and 100 %, respectively, with 93.8 % recurrences endoscopically managed and no death attributable to ER or CR cancer (versus 3.4 % primary surgery mortality).ROC curves identified the period ≥ 2015 (following Endoscopic Submucosal Dissection [ESD] introduction and education on pre-resective lesion assessment) as associated with improved lesions’ characterization, increased en-bloc resection of SMI lesions (87.5 % vs 37.5 %; p = 0.0455), reduced primary surgery (7.5 % vs 16.7 %; p = 0.0072), surgical referral of benign lesions (5.1 % vs 14.8 %; p = 0.0019), and recurrences. Conclusions ESD introduction and educational interventions allowed ER of more complex lesions, offset by increased complementary surgery for complications or intrinsic histological risk. Nevertheless, overall, they have reduced surgery demand and increased appropriateness and safety of LNPL management in our center.

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“…Strategies for diverting cases from surgery to ER have been proposed, but in practice, vested interests, perverse incentives, and habitual behaviors have remained formidable obstacles. 5,6 A better understanding of the conditions associated with surgical referrals for benign polyps could provide a foundation for reversing over-reliance on surgery and improving quality of care.…”

mentioning

confidence: 99%

Quality Matters: Improving the Quality of Care for Patients With Complex Colorectal Polyps

Cited by 14 publications

References 17 publications

Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

Improving assessment and management of large non-pedunculated colorectal lesions in a Western center over 10 years: lessons learned and clinical impact

Increasing the use of endoscopic resection for complex polyps: quality improvement begins with us

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