Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon

doi:10.1016/j.gie.2014.04.015

Gastrointestinal Endoscopy

Volume 80, Issue 4, October 2014, Pages 668-676

https://doi.org/10.1016/j.gie.2014.04.015 Get rights and content

Background

EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited.

Objective

To compare actual endoscopic with predicted surgical mortality.

Design

Prospective, observational, multicenter cohort study.

Setting

Academic, high-volume, tertiary-care referral center.

Patients

Consecutive patients referred for EMR.

Intervention

EMR.

Main Outcome Measurements

To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity.

Results

Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003).

Limitations

Nonrandomized study.

Conclusion

In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions.

Section snippets

Study design and patient selection

This study was part of a prospective, observational study of all patients referred for EMR of colonic AMNs 20 mm or larger at 7 Australian academic endoscopy units.¹² Ethics approval was obtained by institutional review board approval for each participating center, and all patients gave written informed consent. Consecutive patients were enrolled from July 2008 to April 2012.

A detailed description of the study protocol, including adverse events, was previously published.¹² In brief, all

Results

This cohort of 1061 patients had a total of 1129 lesions with a mean size of 35.6 mm, with 54% in the right side of the colon. The mean age was 68 years (range 29-95 years). EMR was technically successful in 997 patients (91.5%). In 37 of 1061 patients (3.5%) EMR was not performed because of malignant features of the lesion (n = 19, 1.8%) or technical difficulties (n = 18, 1.7%). Seventy patients (6.6%) with technically successful EMR required surgical review subsequently for invasive disease

Discussion

The relative distribution of colonic AMN to either surgical or endoscopic management is unknown; however, it seems likely that many patients who could be treated efficiently, safely, and cost-effectively by EMR are still being offered only surgery. For example in a recent retrospective review, 27 of 38 advanced colonic lesions without biopsy-proven cancer referred for surgical resection could be safely removed by endoscopic resection, avoiding surgery completely.²⁵ If it were not for an

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: DISCLOSURE: All authors disclosed no financial relationships relevant to this article.

: If you would like to chat with an author of this article, you may contact Dr Ahlenstiel at [email protected].

: See CME section; p. 679.

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Original articleClinical endoscopyActual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Study design and patient selection

Results

Discussion

Am J Gastroenterol

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Surg Oncol

Lancet Oncol

Clin Gastroenterol Hepatol

J Gastrointest Surg

Surgeon

Clin Gastroenterol Hepatol

Annual report to the nation on the status of cancer, 1975-2006, featuring colorectal cancer trends and impact of interventions (risk factors, screening, and treatment) to reduce future rates

Cancer

Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup

N Engl J Med

Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths

N Engl J Med

Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults

JAMA

Management of the difficult colon polyp referred for resection: resect or rescope?

Dis Colon Rectum

Colonoscopy results of a French regional FOBT-based colorectal cancer screening program with high compliance

Endoscopy

Original article
Clinical endoscopy
Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon