Golo Ahlenstiel1, Luke F Hourigan2, Gregor Brown3, Simon Zanati4, Stephen J Williams5, Rajvinder Singh6, Alan Moss7, Rebecca Sonson5, Michael J Bourke1. 1. Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia. 2. Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia. 3. Department of Gastroenterology and Hepatology, The Alfred Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Victoria, Australia. 4. Department of Gastroenterology and Hepatology, The Alfred Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia. 5. Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia. 6. Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia. 7. Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia.
Abstract
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.
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.
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