THE INCIDENCE AND IMPACT OF INCIDENTAL POLYPS FOUND AT THE TIME OF EVALUATION FOR ESD/EMR OF A KNOWN LARGE SESSILE BENIGN POLYP.
Dasuni Niyagama Gamage*1, Neil Mitra1, Jaspreet Sandhu2, Tianyi Lu1, Vesna Cekic1, Shantha Kumara HMC1, Xiaohong Yan1, Richard L. Whelan1
1Surgery, Mount Sinai West Hospital, New York, NY; 2Surgery, Brookdale Hospital Medical Center, Brooklyn, NY
Introduction: ESD and EMR are the gold standard treatments for large sessile benign colon polyps and are preferable to colectomy. When doing colonoscopy to evaluate for and possibly perform ESD/EMR, other neoplasms may be found that require endoscopic removal or that, rarely, may alter the overall treatment plan altogether. This retrospective review of colonoscopy findings in patients sent for ESD/EMR consideration was undertaken to determine how often additional neoplasms were found and how they were treated.
Methods: An IRB approved prospective data base of large polyp patients sent for consideration for ESD/EMR to be done by a surgical endoscopist in the OR setting (with MIS wedge partial circumference or segmental resection as backup treatments) was reviewed. Hospital, office, operative, and pathology records were reviewed.
Results: A total of 120 patients were evaluated for ESD/EMR in the OR. A total of 296 previously undetected polyps were found in 62 of the 120 patients (51.6%) taken to the OR for possible ESD/EMR. The mean number of polyps per patient was 4.8 (296/62). The location of the added polyps in regards to the segment containing the index lesion was as follows: same segment, 51.6%; immediately adjacent segment, 40.3%, distal segment, 50.0%. Of note, 22/62 pts had polyps in 2 or more segments. The size breakdown of the polyps was as follows: <0.5 cm, 76.4%; 0.6-1.0 cm, 16.9%; 1.1-2.0 cm, 5.1%; and >2 cm, 1.5%. The fate of the additional polyps was as follows: cold biopsy forceps removal, 136 (45.9%); hot snare polypectomy, 19 (6.4%); biopsy only, 3 (1%); removed via segmental resection of index polyp, 118 (39.9%); and no treatment or biopsy, 20 (6.8%). In 7 cases (5.8%) where the extra polyps were in the same segment as the index polyp, the overall polyp burden contributed to the decision to resect the colon. Also, in 5 colectomy patients (4.2%) the added polyps led to a different type of resection than would otherwise have been done: extended right vs right colectomy, 3; wedge to right colectomy, 1; and segmental to total abdominal colectomy, 1.
Conclusion: In about half of the large polyp patients considered for ESD/EMR additional polyps, not previously noted, were found on repeat colonoscopy carried out in the operating room. More than half (52.3%) the additional polyps were removed endoscopically while 39.9% were removed by colectomy done to remove the index polyp. In 7% the polyp burden in the index polyp segment contributed to the decision to do a segmental resection and in 4.2% the extent of the resection done was altered by the additional polyps found. Endoscopists doing ESD/EMR must be prepared to remove polyps encountered during the exam and, in a small percentage of patients, to change to overall treatment plan.
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