Uptake and barriers for implementation of the resect and discard strategy: an international survey

Abstract

Background and study aims Optical real-time diagnosis (= resect-and-discard strategy) is an alternative to histopathology for diminutive colorectal polyps. However, clinical adoption of this approach seems sparse. We were interested in evaluating potential clinical uptake and barriers for implementation of this approach.

Methods We conducted an international survey using the “Google forms” platform. Nine endoscopy societies distributed the survey. Survey questions measured current clinical uptake and barriers for implementing the resect-and-discard strategy, perceived cancer risk associated with diminutive polyps and potential concerns with using CT-colonography as follow-up, as well as non-resection of diminutive polyps.

Results Eight hundred and eight endoscopists participated in the survey. 84.2 % (95 % CI 81.6 %–86.7 %) of endoscopists are currently not using the resect-and-discard strategy and 59.9 % (95 % CI 56.5 %–63.2 %) do not believe that the resect-and-discard strategy is feasible for implementation in its current form. European (38.5 %) and Asian (45 %) endoscopists had the highest rates of resect-and-discard practice, while Canadian (13.8 %) and American (5.1 %) endoscopists had some of the lowest implementation rates. 80.3 % (95 % CI 77.5 %–83.0 %) of endoscopists believe that using the resect-and-discard strategy for diminutive polyps will not increase cancer risk. 48.4 % (95 % CI 45.0 %–51.9 %) of endoscopists believe that leaving diminutive polyps in place is associated with increased cancer risk. This proportion was slightly higher (54.7 %; 95 % CI 53.6 %–60.4 %) when asked if current CT-colonography screening practice might increase cancer risks.

Conclusion Clinical uptake of resect-and-discard is very low. Most endoscopists believe that resect-and-discard is not feasible for clinical implementation in its current form. The most important barriers for implementation are fear of making an incorrect diagnosis, assigning incorrect surveillance intervals and medico-legal consequences.

Publication History

Received: 21 November 2019

Accepted: 04 February 2019

Article published online:
17 April 2020

• References

• 1 Lieberman D, Moravec M, Holub J. et al. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography. Gastroenterology 2008; 135: 1100-1105
• 2 Gupta N, Bansal A, Rao D. et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc 2012; 75: 1022-1030
• 3 Kessler WR, Imperiale TF, Klein RW. et al. A quantitative assessment of the risks and cost savings of forgoing histologic examination of diminutive polyps. Endoscopy 2011; 43: 683-691
• 4 IJspeert JE, Bastiaansen BA, van Leerdam ME. et al. Development and validation of the WASP classification system for optical diagnosis of adenomas, hyperplastic polyps and sessile serrated adenomas/polyps. Gut 2016; 65: 963-970
• 5 Hewett DG, Kaltenbach T, Sano Y. et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology 2012; 143: 599-607.e591
• 6 Iacucci M, Trovato C, Daperno M. et al. Development and validation of the SIMPLE endoscopic classification of diminutive and small colorectal polyps. Endoscopy 2018; 50: 779-789
• 7 Sano Y, Tanaka S, Kudo SE. et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016; 28: 526-533
• 8 McGill SK, Evangelou E, Ioannidis JP. et al. Narrow band imaging to differentiate neoplastic and non-neoplastic colorectal polyps in real time: a meta-analysis of diagnostic operating characteristics. Gut 2013; 62: 1704-1713
• 9 Abu Dayyeh BK, Thosani N, Konda V. et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2015; 81: 502 e501-502 e516
• 10 Rex DK, Kahi C, O'Brien M. et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2011; 73: 419-422
• 11 Kaminski MF, Hassan C, Bisschops R. et al. Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2014; 46: 435-449
• 12 National Institute for Health Care and Excellence. Virtual chromoendoscopy to assess colorectal polyps during colonoscopy. Diagnostic Guidance [D628]. 2017 Available at (Accessed May 4th 2019): https://www.nice.org/uk/guidance/dg28
• 13 Eysenbach G. Improving the quality of web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res 2004; 6: e34
• 14 Soudagar AS, Nguyen M, Bhatia A. et al. Are gastroenterologists willing to implement the “predict, resect, and discard” management strategy for diminutive colorectal polyps? results from a national survey. J Clin Gastroenterol 2016; 50: e45-49
• 15 McGill SK, Soetikno R, Rastogi A. et al. Endoscopists can sustain high performance for the optical diagnosis of colorectal polyps following standardized and continued training. Endoscopy 2015; 47: 200-206
• 16 Vleugels JLA, Dijkgraaf MGW, Hazewinkel Y. et al. Effects of training and feedback on accuracy of predicting rectosigmoid neoplastic lesions and selection of surveillance intervals by endoscopists performing optical diagnosis of diminutive polyps. Gastroenterology 2018; 154: 1682-1693 e1681
• 17 Djinbachian R, Dube AJ, von Renteln D. Optical diagnosis of colorectal polyps: recent developments. Curr Treat Options Gastroenterol 2019; 17: 99-114
• 18 Atkinson NS, East JE. Optical biopsy and sessile serrated polyps: Is DISCARD dead? Long live DISCARD-lite!. Gastrointest Endosc 2015; 82: 118-121
• 19 von Renteln D, Kaltenbach T, Rastogi A. et al. Simplifying resect and discard strategies for real-time assessment of diminutive colorectal polyps. Clin Gastroenterol Hepatol 2018; 16: 706-714
• 20 Hammar C, Frenn M, Pohl H. et al. The polyp-based resect-and-discard strategy: a prospective study. Endoscopy 2019; 51: OP262
• 21 Duong A, Bouin M, Leduc R. et al. A7 The Polyp-based resect-and-discard strategy. J Can Assoc Gastroenterol 2019; 2: 15-16
• 22 Gellad ZF, Voils CI, Lin L. et al. Clinical practice variation in the management of diminutive colorectal polyps: results of a national survey of gastroenterologists. Am J Gastroenterol 2013; 108: 873-878
• 23 Johnson CD, Chen M-H, Toledano AY. et al. Accuracy of CT colonography for detection of large adenomas and cancers. N Engl J Med 2008; 359: 1207-1217
• 24 Halligan S, Altman DG, Taylor SA. et al. CT colonography in the detection of colorectal polyps and cancer: systematic review, Meta-analysis, and proposed minimum data set for study level reporting. Radiology 2005; 237: 893-904
• 25 Pickhardt PJ, Hassan C, Halligan S. et al. Colorectal cancer: CT colonography and colonoscopy for detection – systematic review and meta-analysis. Radiology 2011; 259: 393-405
• 26 Ijspeert JEG, Tutein Nolthenius CJ, Kuipers EJ. et al. CT-colonography vs. colonoscopy for detection of high-risk sessile serrated polyps. Am J Gastroenterol 2016; 111: 516
• 27 Mulhall BP, Veerappan GR, Jackson JL. Meta-analysis: computed tomographic colonography. Ann Intern Med 2005; 142: 635-650
• 28 Ponugoti PL, Cummings OW, Rex DK. Risk of cancer in small and diminutive colorectal polyps. Dig Liver Dis 2017; 49: 34-37
• 29 Vleugels JLA, Hazewinkel Y, Fockens P. et al. Natural history of diminutive and small colorectal polyps: a systematic literature review. Gastrointest Endosc 2017; 85: 1169-1176.e1161
• 30 Vleugels JLA, Hassan C, Senore C. et al. Diminutive polyps with advanced histologic features do not increase risk for metachronous advanced colon neoplasia. Gastroenterology 2019; 156: 623-634.e623
• 31 Djinbachian R, Dubé A-J, Durand M. et al. Adherence to post-polypectomy surveillance guidelines: a systematic review and meta-analysis. Endoscopy 2019; 51: 673-683