Surgical management of endoscopically unresectable colorectal polyps

Abstract

Objective: To define the management of colorectal polyps that were technically unsuitable for endoscopic removal. Materials and Methods: Between May 2010 and January 2019, 4886 polyps from 3822 of 16,996 colorectal endoscopies were analyzed. Of the total colorectal polyps, 135 (2.8%) were identified as endoscopically unresectable single polyps and examined in detail. Result: The rate of invasive colorectal cancer (CRC) in unresectable and resectable polyps was 26.7% and 1.7%, respectively (p<0.001). Unresectable polyps were more common in the ascending colon and cecum (p<0.001), but the potential to contain invasive CRC was greater in the sigmoid colon and rectum-located polyps (p=0.001). In addition, advancing age (p=0.014), increased polyp size (p=0.012), deep submucosal invasion (p<0.001), and the presence of lymphovascular invasion (p<0.001) were associated with the development of CRC. Unresectable polyps requiring surgery after non-curative endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) were found to have a significantly higher risk of containing CRC compared with polyps that underwent surgical resection primarily (p=0.002). In the multivariate model, advancing age (p=0.010) and detected deep submucosal invasion (p=0.002) were more associated with the development of CRC. Conclusion: The study suggests that oncologic surgery for polyps with deep submucosal invasion (particularly by EMR or ESD) that cannot be endoscopically resected in older patients should be considered carefully and, perhaps, without delay, primarily by abandoning repeated endoscopic resection attempts.