Advances in endoscopy field allows most patients with complex colon polyps to avoid surgery, MD Anderson study finds

Using the latest advances in endoscopic resection techniques, more than 75 percent of patients with complex colon polyps could avoid surgery for their polyp removal, according to new research from The University of Texas MD Anderson Cancer Center.

The findings, published in Gastrointestinal Endoscopy, show that endoscopic mucosal resection (EMR) is safe and effective for those with complex polyps and could allow more patients to avoid surgery and its associated risks and costs.

Complex colon polyps are large or often flat lesions thought too difficult to remove endoscopically based on size or location. Patients therefore are often referred for surgical polyp removal. Fears of adverse events, high recurrence rates after piecemeal resection, and the potential for medical or legal risk associated with cancers after incomplete resection also contribute to surgical referrals.

During the last decade, improvements in resection procedures and technology to manage bleeding and perforation have allowed specialized, trained endoscopists to remove complex polyps with gastrointestinal EMR. However, the procedure requires specialized training which is not always accessible in the general medical community, said Gottumukkala S.Raju, M.D., professor, Gastroenterology, Hepatology & Nutrition.

The EMR procedure is a delicate colonoscopy technique performed with an endoscope to remove polyps, while avoiding the need to make surgical incisions in the abdominal wall. Lesions are first lifted from the colon by carefully injecting fluid into the colon wall underneath the lesion. They are then carefully shaved off, along with superficial layers of colon, without damaging deeper layers.

“Complete resections of these complex colon polyps are technically challenging, yet are too often referred to surgery. Surgery comes with substantial risk and cost to the patient. Our research shows that this is not medically necessary. With proper training, the majority of patients could be treated with an endoscopic mucosal resection,” said Raju, the study’s corresponding author.

For the study, data was collected on 203 patients with complex colon polyps referred to MD Anderson’s colon polyp clinic and EMR center as an alternative to surgery between 2009 and 2014. The study’s primary endpoint was complete resection rate; secondary endpoints were safety, residual adenoma rate and incidence of missed polyps. 

Of those 203 patients, more than 75 percent (155 patients) underwent a protocol-driven EMR, and 48 underwent surgery. In those that received an EMR, 149 patients were found to have benign polyps, and six had cancer. EMR-associated adverse events occurred in seven patients (4.5 percent) and residual tumor was found in 4 percent. Five patients required hospitalization. None of the patients died from their adverse events.

In 137 patients, surveillance colonoscopy four to six months after resection of their benign lesion found residual adenoma at the scar site in six patients and additional precancerous lesions in 117 patients. These findings understate the need for careful, repeat examination of the entire colon at the time of referral to an EMR center, said Raju. No patients underwent surgery for failure of the EMR.

Also in the study, the MD Anderson authors reference a previously published cost-effective comparative analysis of endoscopic and surgical resection of complex colon polyps: $5,570 per patient, and $18,717 per patient, respectively. Raju and his colleagues plan to follow up with their own cost analysis of their research.

Long-term outcomes for patients will need to be studied, with the hope of improving on the percentage of this patient population able to avoid surgery.

“There is still room for improvement, both in terms of outcomes for patients and education of endoscopists,” said Raju. “With the American Society of Gastrointestinal Endoscopy, we have created educational materials to share our knowledge and techniques with the endoscopic community, and we plan to build on our outreach efforts. It’s also vital that we educate patients with complex colon polyps so that they know that they may have another medical option and to seek out a facility with experience with EMR expertise if their physician immediately recommends surgery.”

In addition to Raju, other authors on the all-MD Anderson study include: Phillip Lum; William Ross, M.D.; Selvi Thirumurthi, M.D.; Ethan Miller, M.D.; Patrick Lynch, M.D.; Jeffrey Lee, M.D.; Maoop Bhutani, M.D.; Brian Weston, M.D.; Mala Pande M.B.B.S., Ph.D.; Asif Rashid, M.D.; Lopa Mishra, M.D.; Marta Davila, M.D. and John Stroehlein, M.D., all of Gastroenterology, Hepatology and Nutrition.

The study was financially supported by the John Stroehlein Distinguished Professorship. None of the authors have relevant financial disclosures to declare.