Treatment of large and giant colorectal polyps in the real world

S. Husson*1, G. Ventre2, F. Vagne3, J. Vies4, M. Musso3, J. Colson5, J. Picot5, J. Boyaval3, D. Sondag6, F. Khachoyan5, I. Gendre6, P. Perrin7, B. Denis7
1Gastroenterology, Hôpitaux civils de Colmar, Strasbourg, 2Gastroenterology, ADECA, Saint-Louis, 3Gastroenterology, ADECA, Colmar, 4Gastroenterology, ADECA, Guebwiller, 5Gastroenterology, ADECA, 6Gastroenterology, CH Mulhouse, Mulhouse, 7ADECA, Hôpitaux civils de Colmar, Colmar, France


Introduction        

Some authors reported success rates of endoscopic resection (ER) of large (>20mm) (LP) and giant (>30mm) (GP) colorectal polyps close to 100% but their series were performed in referral centers.

Aims & methods        

To assess the success rate of ER of LP in a population-based setting. Retrospective study of all LP detected over a 3 year period within a colorectal cancer screening program with FOBT in the Haut-Rhin area.

Results        

2968 colonoscopic procedures were performed by the 34 endoscopists practicing. They detected 325 LP in 279 people (237 LP in 197 men) of witch 110 GP (33.8%) in 101 people. 69.5% were pedunculated, 24.3% sessile, 3.4% flat and 2.8% had a malignant appearance. 14.8% were located in the rectum and 13.8% in the proximal colon. 54% were tubulovillous, 37% tubular and 8.4% villous adenomas. 66.8% displayed high-grade dysplasia and 9.5% were T1 carcinomas. 244 LP (75.1%) including 61 GP were treated by ER in 218 patients (78.1%)(mean polyp size 25mm). The ER rate varied according to the endoscopist, shape, size, location and malignancy of the polyp: expert (86.4%), not expert (68.6%), pedunculated polyps (86.3%), sessile and flat lesions (52.2%), GP (55.5%), rectum (64.6%), distal colon (80.2%), proximal colon (60%), T1 carcinomas (25.8%) (p<0.01). En bloc ER was performed in 67.2% of cases, using endoscopic mucosal resection in 8.6% of cases. ER was performed during a single session in 76.8 and at a 2nd procedure by the same endoscopist (18.6%) and by a 2nd expert (5.8%). Surgical resection (SR) was required for 81 polyps (24.9%) (including 49 GP) in 61 patients (21.9%)(mean polyp size 35mm). The main reasons for SR were the failure of ER (44%) and the malignancy (46.7%). 16.3% of SR were transanal, 39.3% laparoscopic and 44.3% open resections. A follow-up colonoscopy was performed in 99 patients (35.6%) after a mean follow-up time of 19.7 months. A recurrence was detected in 26 patients after ER (34.2%), treated by ER, and in 3 patients after SR (17.4%), treated by surgery.

Conclusion        

Our series shows that in the real world one patient with a benign large polyp out of 5 is operated on (2 out of 5 with a benign giant polyp). Referral to surgery is related to the sessile or flat shape of the adenoma, its size, its proximal or rectal location, its malignancy and to the lack of referral to an expert endoscopist. Endoscopic mucosal resection is only performed by a minority of endoscopists and the referral to an expert endoscopist remains rare.



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