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Resect and discard strategy in clinical practice: a prospective cohort study
submitted 28 December 2011
accepted after revision 10 March 2012
02 August 2012 (online)
Background and study aims: Narrow-band imaging (NBI) has shown promising results in discriminating adenomatous from non-adenomatous colonic polyps. In patients with small polyps (< 10 mm), the application of NBI within a “resect and discard” strategy, might allow post-polypectomy surveillance intervals to be determined independently from histopathology. The aim of the present study was to assess the feasibility and safety of this approach in routine clinical practice.
Patients and methods: Consecutive colonoscopy outpatients with one or more polyps smaller than 10 mm were prospectively included. Each polyp was categorized by the endoscopist as adenoma or non-adenoma according to simplified NBI criteria, and future post-polypectomy surveillance interval was assigned accordingly. Following histopathology, post-polypectomy surveillance interval was subsequently re-assigned, and the accordance between endoscopy- and histology-directed surveillance strategies was calculated.
Results: Among 942 colonoscopy patients, 286 (30.4 %) with only small polyps were included. In total, 511 small polyps were evaluated; 350 (68.5 %) were adenomas and 18 of these (5.1 %) had histologic features of advanced neoplasia. For the in vivo diagnosis of adenoma, NBI sensitivity, specificity, accuracy, and positive and negative likelihood ratios were 94.9 %, 65.8 %, 85.7 %, 2.80, and 0.08, respectively. The endoscopy-directed surveillance strategy was in accordance with the histology-directed strategy in 237 of 286 patients (82.9 %). In 9.8 % and 7.3 % patients, the endoscopy-directed approach would have resulted in early and delayed surveillance, respectively.
Conclusions: The resect and discard strategy seems to be a viable, safe, and cost-effective approach for the management of patients with small polyps. However, caution in the application of the strategy should be advocated for patients with polyps 6 – 9 mm in size and those with right-sided lesions, due to their malignant potential.
The study was registered on Clinicaltrials.gov (NCT01462123).
- 1 Winawer SJ, Zauber AG, Ho MN. The National Polyp Study Workgroup et al. Prevention of colorectal cancer by colonoscopic polypectomy. N Engl J Med 1993; 329: 1977-1981
- 2 Citarda F, Tomaselli G, Capocaccia R et al. Efficacy in standard clinical practice of colonoscopic polypectomy in reducing colorectal cancer incidence. Gut 2001; 48: 812-815
- 3 Su MY, Hsu CM, Ho YP et al. Comparative study of conventional colonoscopy, chromoendoscopy, and narrow-band imaging systems in differential diagnosis of neoplastic and nonneoplastic colonic polyps. Am J Gastroenterol 2006; 101: 2711-2716
- 4 Winawer SJ, Zauber AG, Fletcher RH et al. Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society. CA Cancer J Clin 2006; 56: 143-159
- 5 de Jonge V, Sint Nicolaas J, van Leerdam ME et al. Systematic literature review and pooled analyses of risk factors for finding adenomas at surveillance colonoscopy. Endoscopy 2011; 43: 560-572
- 6 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
- 7 Rex DK. Narrow-band imaging without optical magnification for histologic analysis of colorectal polyps. Gastroenterology 2009; 136: 1174-1181
- 8 van den Broek FJ, Reitsma JB, Curvers WL et al. Systematic review of narrow-band imaging for the detection and differentiation of neoplastic and nonneoplastic lesions in the colon (with videos). Gastrointest Endosc 2009; 69: 124-135
- 9 Ignjatovic A, East JE, Suzuki N et al. Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect and Discard; DISCARD trial): a prospective cohort study. Lancet Oncol 2009; 10: 1171-1178
- 10 Cash BD. Narrow-band imaging for colorectal polyps: it can be taught but will it be used?. Gastrointest Endosc 2010; 72: 577-579
- 11 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
- 12 Aronchick CA, Lipshutz WH, Wright SH et al. A novel tableted purgative for colonoscopic preparation: efficacy and safety comparisons with Colyte and Fleet Phospho-Soda. Gastrointest Endosc 2000; 52: 346-352
- 13 Paggi S, Radaelli F, Amato A et al. The impact of narrow band imaging in screening colonoscopy: a randomized controlled trial. Clin Gastroenterol Hepatol 2009; 7: 1049-1054
- 14 Raghavendra M, Hewett DG, Rex DK. Differentiating adenomas from hyperplastic colorectal polyps: narrow-band imaging can be learned in 20 minutes. Gastrointest Endosc 2010; 72: 572-576
- 15 Radaelli F, Meucci G, Imperiali G et al. High-dose senna compared with conventional PEG-ES lavage as bowel preparation for elective colonoscopy: a prospective, randomized, investigator-blinded trial. Am J Gastroenterol 2005; 100: 2674-2680
- 16 Black ER, Panzer RJ, Mayewski RJ et al. Characteristics of diagnostic tests and principles for their use in quantitative decision making in diagnostic strategies for common medical problems. In: Black ER, Bordley DR, Tape TG, Panzer RJ, eds. Diagnostic strategies of common medical problems. Philadelphia: American College of Physicians; 1999: 1-17
- 17 Lijmer JG, Mol BW, Heisterkamp S et al. Empirical evidence of design-related bias in studies of diagnostic tests. JAMA 1999; 282: 1061-1066
- 18 Kuiper T, van den Broek FJ, Naber AH et al. Endoscopic trimodal imaging detects colonic neoplasia as well as standard video endoscopy. Gastroenterology 2011; 140: 1887-1894
- 19 European guidelines for quality assurance in colorectal cancer screening and diagnosis. Available from: http://ec.europa.eu/health/major_chronic_diseases/diseases/cancer/index_en.htm#fragment3 Accessed: 22 November 2011
- 20 Cairns SR, Scholefield JH, Steele RJ et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut 2010; 59: 666-689
- 21 Butterly LF, Chase MP, Pohl H et al. Prevalence of clinically important histology in small adenomas. Clin Gastroenterol Hepatol 2006; 4: 343-348
- 22 Schreiner MA, Weiss DG, Lieberman DA. Proximal and large hyperplastic and nondysplastic serrated polyps detected by colonoscopy are associated with neoplasia. Gastroenterology 2010; 139: 1497-1502
- 23 Terdiman JP, McQuaid KR. Surveillance guidelines should be updated to recognize the importance of serrated polyps. Gastroenterology 2010; 139: 1444-1447
- 24 Hassan C, Pickhardt PJ, Rex DK. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol 2010; 8: 865-869
- 25 Tadepalli US, Feihel D, Miller KM et al. A morphologic analysis of sessile serrated polyps observed during routine colonoscopy. Gastrointest Endosc 2011; 74: 1360-1368
- 26 Rondagh EJ, Masclee AA, Bouwens MW et al. Endoscopic red flags for the detection of high-risk serrated polyps: an observational study. Endoscopy 2011; 43: 1052-1058