A retrospective review of 104 consecutive patients with large colorectal lesions, including 39 with carcinoma, found that “endoscopic excision of large colorectal polyps is a viable alternative to surgical resection in a select group of patients and can be performed safely with a good success rate.” The patients all had lesions “deemed not amenable to endoscopic resection at initial colonoscopy,” most commonly performed for screening (51%) and positive fecal occult blood test results (24%), and had initially been referred for surgical resection. In 68% of the patients the polyps were located in the colon, and the other 32% had rectal polyps. The results of the review were published in the Archives of Surgery.
Among the 104 patients brought to the endoscopy suite for endoscopic excision, 98 had excisions, which were performed by two interventional endoscopists. Most were complete excisions, although 20 patients had incomplete excision with residual disease. Six patients did not have excisions and were referred back for surgical evaluation.
“We found that most patients (83%) could be successfully treated endoscopically, with only a small number of patients (14%) requiring operative resection to treat complications, incomplete excision after index intervention, or long-term residual disease that could not be eradicated endoscopically,” the authors commented. Endoscopic reintervention was needed in 25 (27%) of 92 patients for reasons including residual disease in 12 patients and recurrence in 10 patients.
Reasons for Failure
“Despite a high overall endoscopic success rate in our group of patients, a diagnosis of carcinoma in situ or invasive carcinoma was associated with a lower success rate,” the authors noted. “Most of the lesions in our study were sessile. Although endoscopic polypectomy may be a suitable option for many pedunculated malignant polyps, its role may be limited in sessile lesions. This may be owing to technical factors, such as inability to safely obtain a deep margin, or because of the limitation of endoscopy in addressing the lymphatic spread in case of invasion. In our experience, the reasons for failure of endoscopic management of some of the cases harboring carcinoma were incomplete excision, long-term residual disease, and concern about the suitability of endoscopic excision in the setting of poor histologic features, such as lymphovascular invasion, or poor differentiation.”
The authors concluded that the involvement of surgeons is critical to determine which patients can benefit from endoscopic excision and which patients need surgical resection. “When counseling patients who may benefit from endoscopic excision, keep in mind that endoscopic reintervention or surgical resection is needed in approximately one-third of patients,” the authors cautioned. “Long-term surveillance is warranted for all lesions in view of the risk of recurrence, especially for lesions located in the rectum.”
Kao KT, et al: Arch Surg 146:690-696, 2011.