Endoscopic resection of large anastomotic polyps is safe and effective

 

 Buy Article Permissions and Reprints

Abstract

Background Large (≥20mm) adenomatous anastomotic polyps (LAAPs) are uncommon. Data pertaining to their prevalence, characteristics, and the efficacy of endoscopic resection (ER) are absent. A safe and effective strategy for ER would reduce morbidity and healthcare costs.

Methods Large nonpedunculated colorectal polyps of ≥20mm (LNPCPs) referred for ER were prospectively studied. Multiple data points were recorded including anastomotic location, polyp morphology, resection modality, complications, and technical success.

Results Over 7 years until November 2022, 2629 lesions were referred. Of these, 10 (0.4%) were LAAPs (median size 35 mm [interquartile range (IQR) 30–40mm]). All LAAPs were removed by piecemeal endoscopic mucosal resection (EMR), most (n=9; 90%) in combination with cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST). On comparison of the LAAP group with the conventional LNPCP group, CAST was more commonly used (90% vs. 9%; P<0.001) and deep mural injury (DMI) type II was more frequent (40% vs. 11%, P=0.003); however, significant DMI (III–V) did not occur. At 6 month (IQR 5.25–6 months) surveillance, there was no recurrence in any of the 10 cases. There were no serious adverse events.

Conclusions LAAPs present unique challenges owing to their location overlying an anastomosis. Despite these challenges they can be safely and effectively managed endoscopically without recurrence at endoscopic follow-up.

Publication History

Received: 28 April 2023

Accepted after revision: 12 September 2023

Accepted Manuscript online:
12 September 2023

Article published online:
10 November 2023

© 2023. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• References

• 1 Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin 2017; 67: 7-30 DOI: 10.3322/caac.21387. (PMID: 28055103)
  CrossrefPubMedGoogle Scholar
• 2 Torre LA, Bray F, Siegel RL. et al. Global cancer statistics, 2012. CA Cancer J Clin 2015; 65: 87-108 DOI: 10.3322/caac.21262. (PMID: 25651787)
  CrossrefPubMedGoogle Scholar
• 3 Arnold M, Sierra MF, Laversanne M. et al. Global patterns and trends in colorectal cancer incidence and mortality. Gut 2017; 66: 683-691 DOI: 10.1136/gutjnl-2015-310912. (PMID: 26818619)
  CrossrefPubMedGoogle Scholar
• 4 Cancer Council Australia Clinical Guidelines. Clinical practice guidelines for surveillance colonoscopy. Accessed September 14, 2023 at: wiki.cancer.org.au/australia/Guidelines:Colorectal_cancer/Colonoscopy_surveillance
  PubMedGoogle Scholar
• 5 Cohen JF, Korevaar DA, Altman DG. et al. STARD 2015 guidelines for reporting diagnostic accuracy studies: explanation and elaboration. BMJ Open 2016; 6: e012799 DOI: 10.1136/bmjopen-2016-012799. (PMID: 28137831)
  CrossrefPubMedGoogle Scholar
• 6 von Elm E, Altman DG, Egger M. et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147: 573-577 DOI: 10.1016/j.ijsu.2014.07.013. (PMID: 25046131)
  CrossrefPubMedGoogle Scholar
• 7 Klein A, Bourke MJ. Advanced polypectomy and resection techniques. Gastrointest Endosc Clin N Am 2015; 25: 303-333 DOI: 10.1016/j.giec.2014.11.005. (PMID: 25839688)
  CrossrefPubMedGoogle Scholar
• 8 Jideh B, Bourke MJ. How to perform wide-field endoscopic mucosal resection and follow-up examinations. Gastrointest Endosc Clin N Am 2019; 29: 629-646 DOI: 10.1016/j.giec.2019.05.002. (PMID: 31445687)
  CrossrefPubMedGoogle Scholar
• 9 Burgess NG, Hourigan LF, Zanati SA. et al. Risk stratification for covert invasive cancer among patients referred for colonic endoscopic mucosal resection: a large multicenter cohort. Gastroenterology 2017; 153: 732-742.e1
  CrossrefPubMedGoogle Scholar
• 10 Fahrtash-Bahin F, Holt BA, Jayasekeran V. et al. Snare tip soft coagulation achieves effective and safe endoscopic hemostasis during wide-field endoscopic resection of large colonic lesions (with videos). Gastrointest Endosc 2013; 78: 158-163.e1
  CrossrefPubMedGoogle Scholar
• 11 Tate DJ, Desomer L, Klein A. et al. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc 2017; 85: 647-656.e6
  CrossrefPubMedGoogle Scholar
• 12 Sidhu M, Shahidi N, Gupta S. et al. Outcomes of thermal ablation of the mucosal defect margin after endoscopic mucosal resection: a prospective, international, multicenter trial of 1000 large nonpedunculated colorectal polyps. Gastroenterology 2021; 161: 163-170.e3
  CrossrefPubMedGoogle Scholar
• 13 Kumarasinghe M, Bourke MP, Brown I. et al. Pathological assessment of endoscopic resections of the gastrointestinal tract: a comprehensive clinicopathologic review. Mod Pathol 2020; 33: 986-1006 DOI: 10.1038/s41379-019-0443-1. (PMID: 31907377)
  CrossrefPubMedGoogle Scholar
• 14 Rex DK, Hassan C, Bourke MJ. The colonoscopist's guide to the vocabulary of colorectal neoplasia: histology, morphology, and management. Gastrointest Endosc 2017; 86: 253-263 DOI: 10.1016/j.gie.2017.03.1546. (PMID: 28396276)
  CrossrefPubMedGoogle Scholar
• 15 Burgess NG, Bassan MS, McLeod D. et al. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut 2017; 66: 1779-1789 DOI: 10.1136/gutjnl-2015-309848. (PMID: 27464708)
  CrossrefPubMedGoogle Scholar
• 16 Vleugels JLA, Hazewinkel Y, Fockens P. et al. Natural history of diminutive and small colorectal polyps: a systematic literature review. Gastrointest Endosc 2017; 85: 1169-1176.e1
  CrossrefPubMedGoogle Scholar
• 17 Vosko S, Shahidi N, Sidhu M. et al. Optical evaluation for predicting cancer in large nonpedunculated colorectal polyps is accurate for flat lesions. Clin Gastroenterol Hepatol 2021; 19: 2425-2434.e4
  CrossrefPubMedGoogle Scholar
• 18 Bahin FF, Heitman SJ, Rasouli KN. et al. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2018; 67: 1965-1973 DOI: 10.1136/gutjnl-2017-313823. (PMID: 28988198)
  CrossrefPubMedGoogle Scholar
• 19 Tate DJ, Bahin FF, Desomer L. et al. Cold-forceps avulsion with adjuvant snare-tip soft coagulation (CAST) is an effective and safe strategy for the management of non-lifting large laterally spreading colonic lesions. Endoscopy 2018; 50: 52-62
  PubMedGoogle Scholar
• 20 Shahidi N, Vosko S, Gupta S. et al. Previously attempted large nonpedunculated colorectal polyps are effectively managed by endoscopic mucosal resection. Am J Gastroenterol 2021; 116: 958-966 DOI: 10.14309/ajg.0000000000001096. (PMID: 33625125)
  CrossrefPubMedGoogle Scholar