Treatment of large and giant colorectal polyps in the real

world

Stéphanie HUSSON, Guy VENTRE, Frédéric VAGNE, Jean François VIES, Marjorie MUSSO, Jean Louis COLSON, Jacques PICOT, Jean Marc BOYAVAL, Daniel SONDAG, François KHACHOYAN, Isabelle

GENDRE, Philippe PERRIN, Bernard DENIS

Association pour le dépistage du cancer colorectal dans le Haut-Rhin (ADECA 68), Colmar, France

B. Denis - DDW 2007 – Washington DC

background

large polyps ≥ 20 mm / giant ≥ 30 mm

endoscopic resection effective and safe Walsh RM 1992, Dell’Abate P 2001, Brooker JC 2002, Seitz

U 2003, Conio M 2004, Katsinelos P 2006

success rates ~ 1OO% Binmoeller KF 1996, Kanamori T 1996, Iishi H 2000,

Stergiou N 2002, Doniec JM 2003, Bories E 2006,

how about the real world?

B. Denis - DDW 2007 – Washington DC

aim

to assess the success rate of endoscopic resection of

large colorectal polyps in a population-based setting

B. Denis - DDW 2007 – Washington DC

methods

population-based CRC screening program with guaiac based FOBT

23 pilot areas

Haut-Rhin: 190 000 residents aged 50-74 y

(Denis B et al. Gut 2007 in press)

B. Denis - DDW 2007 – Washington DC

methods

retrospective study all large polyps detected CRC screening program in the Haut-

Rhin

3 year period (sept. 2003 - sept. 2006)

B. Denis - DDW 2007 – Washington DC

results

34 endoscopists (21 private practice)

2968 colonoscopic procedures

325 large polyps in 279 people (82

women)

prevalence = 9.4%

B. Denis - DDW 2007 – Washington DC

results – polyps characteristics

n (%)

size20 – 29 mm 215 (66.2)

≥ 30 mm 110 (33.8)

B. Denis - DDW 2007 – Washington DC

results – polyps characteristics

n (%)

shape

pedunculated 226 (69,5)

sessile 79 (24,3)

flat 11 (3,4)

B. Denis - DDW 2007 – Washington DC

results – polyps characteristics

n (%)

shape

pedunculated 226 (69,5)

sessile 79 (24,3)

flat 11 (3,4)

B. Denis - DDW 2007 – Washington DC

results – polyps characteristics

n (%)

location

rectum 48 (14,8)

distal colon 232 (71,4)

proximal colon 45 (13,8)

B. Denis - DDW 2007 – Washington DC

results – polyps characteristics

n (%)

location

rectum 48 (14,8)

distal colon 232 (71,4)

proximal colon 45 (13,8)

B. Denis - DDW 2007 – Washington DC

results – polyps characteristics

n (%)

type

tubular 119 (37,0)

tubulo-villous 174 (54,0)

villous 27 (8,4)

serrated 1 (0,3)

hyperplastic 1 (0,3)

B. Denis - DDW 2007 – Washington DC

results – polyps characteristics

n (%)

dysplasia

high-grade 217 (66,8)

T1 carcinoma 31 (9,5)

B. Denis - DDW 2007 – Washington DC

results – endoscopic resection

247 polyps (76%) in 220 people

resection during single session: 76.8%

2nd procedure other expert endoscopist: 4.6%

En bloc resection: 67.2%

EMR: 8.6%

2 bleeding / endoscopic treatment

B. Denis - DDW 2007 – Washington DC

results – surgical resection

78 polyps (24%) in 61 people

reasons endoscopic resection failure: 44.0%

polyposis: 9.3%

malignant polyp: 46.7%

no complication

B. Denis - DDW 2007 – Washington DC

endoscopic resection rate

85,1% 86,3%

52,2%55,5%

P<0.001 P<0.001

20–29 mm >30 mm pedunc. sessile / flat

B. Denis - DDW 2007 – Washington DC

endoscopic resection rate

P=0.02 P<0.001

64,6%

80,2%

60,0%

rectum distal colon proximal

colon

80,3%

25,8%

benign cancer

P<0.01

B. Denis - DDW 2007 – Washington DC

endoscopic resection rate

P<0.001

86,4%

68,6%

expert endoscopist non expert

B. Denis - DDW 2007 – Washington DC

conclusions (1)

largest series

1st in a population-based setting

in the real world 1 / 5 patients with a benign large polyp is operated on 2 / 5 with a benign giant polyp

B. Denis - DDW 2007 – Washington DC

conclusions (2)

referral to surgery related to sessile or flat shape size, proximal or rectal location, malignancy and lack of referral to an expert endoscopist

EMR performed by a minority (41.2%)

referral to an expert is rare (4.6%)

B. Denis - DDW 2007 – Washington DC

future

need for

teaching (spreading) endoscopic techniques

for the management of large polyps

promoting referral of difficult large polyps to expert endoscopists to avoid unnecessary surgery

B. Denis - DDW 2007 – Washington DC

acknowledgements

all the 34 endoscopists practicing in the Haut-Rhin