Daniel von Renteln1, Tonya Kaltenbach2, Amit Rastogi3, Joseph C Anderson4, Thomas Rösch5, Roy Soetikno6, Heiko Pohl4. 1. Division of Gastroenterology, University of Montreal Medical Center (CHUM) and Research Center (CRCHUM), Montreal, QC, Canada. Electronic address: renteln@gmx.net. 2. San Francisco Veterans Affairs Medical Center, University of California, San Francisco, Division of Gastroenterology and Hepatology, San Francisco, California. 3. Veterans Affairs Kansas City, Gastroenterology Section and Department of Medicine, Division of Gastroenterology, University of Kansas, Kansas City, Missouri. 4. Section of Gastroenterology, White River Junction VA Medical Center, White River Junction, Vermont, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire. 5. Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany. 6. Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, Palo Alto, California.
Abstract
BACKGROUND & AIMS: During endoscopy, the resect and discard strategy, if performed with high confidence, can be used to determine histologic features of diminutive colorectal polyps (5 mm or less). These polyps can then be removed and discarded without pathology assessment. However, the complexities of real-time optical assessment and follow-up management have provided challenges to widespread use of this approach. We aimed to determine the outcomes of simple alternative strategies, in which all diminutive polyps can be resected and discarded. METHODS: We collected data from 2 previous studies that used narrow-band imaging to assess polyps, performed at 5 medical centers (1658 patients with 2285 diminutive polyps; 15 endoscopists). We compared 3 resect and discard strategies: the currently used optical strategy, which relies on high confidence optical assessment of all diminutive polyps; a location-based strategy that classifies all recto-sigmoid diminutive polyps a priori as hyperplastic and all polyps proximal to the recto-sigmoid colon a priori as neoplastic; and a simplified optical strategy, in which all recto-sigmoid diminutive polyps are classified as hyperplastic unless confidently assessed as neoplastic, and all polyps proximal to the recto-sigmoid colon are classified as neoplastic unless confidently assessed as hyperplastic polyps. The primary outcome was the agreement of the surveillance interval calculated for each strategy with the surveillance interval determined by pathology analysis. RESULTS: The proportion of surveillance intervals that agreed with pathology-based surveillance recommendations was slightly higher when the optical strategy was used compared to the location-based strategy or simplified optical strategy (94% vs 89% and 90%, respectively; P < .001). When the 5-10 year recommendations for patients with low-risk polyps were applied as a 10-year surveillance interval, all 3 strategies resulted in surveillance interval agreement compared to pathology above 90% (the quality benchmark). Use of the simplified or location-based strategy could have avoided pathology analysis for 77% of all polyps, compared to 59% if the optical strategy was used (P < .001). In addition, a higher proportion of patients could receive recommendations immediately after colonoscopy with use of the simplified or location based strategy (65%) compared to the optical strategy (40%) (P < .001). CONCLUSION: A location-based and a simplified optical resect and discard strategy produced surveillance recommendations that were in agreement with those from pathology analysis for at least 90% of patients, assuming a 10-year surveillance interval for patients with low-risk polyps. These strategies could further reduce the number of pathology examinations and provide more patients with immediate surveillance recommendations. Optical assessment might be reduced or might not be required for resect and discard. Clintrials.gov no: NCT01935180 and NCT01288833.
BACKGROUND & AIMS: During endoscopy, the resect and discard strategy, if performed with high confidence, can be used to determine histologic features of diminutive colorectal polyps (5 mm or less). These polyps can then be removed and discarded without pathology assessment. However, the complexities of real-time optical assessment and follow-up management have provided challenges to widespread use of this approach. We aimed to determine the outcomes of simple alternative strategies, in which all diminutive polyps can be resected and discarded. METHODS: We collected data from 2 previous studies that used narrow-band imaging to assess polyps, performed at 5 medical centers (1658 patients with 2285 diminutive polyps; 15 endoscopists). We compared 3 resect and discard strategies: the currently used optical strategy, which relies on high confidence optical assessment of all diminutive polyps; a location-based strategy that classifies all recto-sigmoid diminutive polyps a priori as hyperplastic and all polyps proximal to the recto-sigmoid colon a priori as neoplastic; and a simplified optical strategy, in which all recto-sigmoid diminutive polyps are classified as hyperplastic unless confidently assessed as neoplastic, and all polyps proximal to the recto-sigmoid colon are classified as neoplastic unless confidently assessed as hyperplastic polyps. The primary outcome was the agreement of the surveillance interval calculated for each strategy with the surveillance interval determined by pathology analysis. RESULTS: The proportion of surveillance intervals that agreed with pathology-based surveillance recommendations was slightly higher when the optical strategy was used compared to the location-based strategy or simplified optical strategy (94% vs 89% and 90%, respectively; P < .001). When the 5-10 year recommendations for patients with low-risk polyps were applied as a 10-year surveillance interval, all 3 strategies resulted in surveillance interval agreement compared to pathology above 90% (the quality benchmark). Use of the simplified or location-based strategy could have avoided pathology analysis for 77% of all polyps, compared to 59% if the optical strategy was used (P < .001). In addition, a higher proportion of patients could receive recommendations immediately after colonoscopy with use of the simplified or location based strategy (65%) compared to the optical strategy (40%) (P < .001). CONCLUSION: A location-based and a simplified optical resect and discard strategy produced surveillance recommendations that were in agreement with those from pathology analysis for at least 90% of patients, assuming a 10-year surveillance interval for patients with low-risk polyps. These strategies could further reduce the number of pathology examinations and provide more patients with immediate surveillance recommendations. Optical assessment might be reduced or might not be required for resect and discard. Clintrials.gov no: NCT01935180 and NCT01288833.
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