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

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 saving 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, pendunculated 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. (Gastrointest Enclosc 2009;70:1128-36.)