Introduction
Large and complex colorectal polyps were traditionally managed using surgical resection.
The shift to endoscopic management was primarily due to improvements in procedural
risks, safety and cost-effectiveness of endoscopic polypectomy over surgical resection
[1 ]
[2 ]
[3 ]
[4 ]. More importantly, endoscopic resection showed comparable efficacy to surgery in
preventing colorectal cancer [5 ]. Specialized approaches to endoscopic resection, such as endoscopic mucosal resection
(EMR) and endoscopic submucosal dissection (ESD), initially used in the treatment
of gastric cancer, have made it possible to safely resect large (> 2 cm) sessile and
flat neoplastic colonic polyps as well as superficially invasive malignant polyps
in some instances. According to the US Multi-Society Task Force’s (USMSTF) most recent
guidelines on endoscopic removal of colorectal lesions, nonpedunculated lesions that
are 10 to 19 mm in size can be resected with hot or cold snare polypectomy with consideration
for EMR in cases of nonpolypoid or serrated morphology, while nonpedunculated lesions
≥ 20 mm should preferably be managed by EMR with a provision that these procedures
be performed by endoscopists experienced in advanced polypectomy [6 ]. Despite the apparent efficacy and wide availability of endoscopic polypectomy,
the rate of surgical resection for non-malignant colorectal polyps has increased from
5.9/100,000 in 2004 to 9.4/100,000 in 2014 [7 ]. Over the same time period, the morbidity and mortality rates were 25 % and 0.8 %,
respectively, in a nationwide sample consisting of over 260,000 surgeries for surgical
resections of benign colorectal polyps [8 ].
Factors responsible for this unexpected trend are not well studied. Potential contributors
include the expansion in colorectal screening programs leading to improved polyp detection,
the lack of well-defined indications for surgical referral, and the underutilization
of advanced endoscopists who are better suited to remove complex polyps. Moreover,
factors related to the polypectomy procedure itself should also be evaluated.
The technical aspects of endoscopic polypectomy have been well described. Critical
factors include high quality polyp assessment (Paris classification, NICE or KUDO
classification, and size estimate,) recognition of features suggestive of submucosally
invasive cancer (SMIC), and completeness of resection/recurrence rate. These criteria
in conjunction with accessibility (i. e. difficult endoscopic positioning) and morphologic
features such as flat and complex polyps with their associated complication risks
may lead to variability in defining a “surgical polyp” among different endoscopists
[9 ].
Recently published data show nonadherence to specific polypectomy guidelines by gastroenterologists,
sometimes even using inadequate polypectomy techniques [10 ]. Moreover, incomplete resections of neoplastic polyps are not uncommon, which is
concerning, given that incomplete polypectomy has been shown to account for up to
20 % of colorectal cancers detected after the colonoscopy [11 ]
[12 ]. While quality metrics regarding polyp detection (adenoma detection rate, ADR) have
been formalized, no widely applied measures exist for polypectomy competency. It has
also been demonstrated that informal quality measures of adequate polypectomy are
an independent factor in colorectal cancer prevention and do not correlate with adenoma
detection rates (ADR) [13 ].
Our study aim is to analyze the different patterns and indications of surgery for
non-malignant polyps with failed endoscopic resection and assess the appropriateness
of these surgical referrals. We judged the appropriateness of surgical referral based
on the most recent USMSTF guidelines on endoscopic removal of colorectal lesions [6 ]. The primary objective of the study is to determine the percentage of patients with
non-malignant colorectal polyps who could have avoided surgical resection and explore
the reasons behind it. We also sought to define the characteristics of polyps with
failed endoscopic polypectomy which might serve as guidance for focused endoscopist
training and developing standardized quality metrics for endoscopic polypectomy.
Patients and methods
The study was approved by the Institutional Review Board with a waiver of consent.
Archived pathology materials from consecutive surgical resections of benign colorectal
polyps (2003–2018) in our tertiary referral center were retrieved and reviewed. Clinicopathologic
characteristics including age, gender, polyp location, endoscopic and macroscopic
polyp size, type and indication of surgery were obtained from electronic medical records
(EMR). Two pathologists, including a gastrointestinal pathologist evaluated archived
pathology slides from these resections for polyp type and presence of high-grade dysplasia
(HGD). Exclusion criteria included patients undergoing surgery for inflammatory bowel
disease and emergency surgeries. We excluded polyps with reported invasive adenocarcinoma
on preoperative biopsy. A total of 154 cases of surgically removed benign colorectal
polyps from 2003 to 2018 were identified and retrieved. Of 154, 10 cases had reported
invasive adenocarcinoma on preoperative biopsy and were excluded from the study. All
the remaining cases satisfied our inclusion criteria ([Fig. 1 ]).
Fig. 1 Patient identification flow chart
Patients included both those initially seen at our institution as well as outside
referrals. Indications for surgery were retrieved from surgeons’ notes and/or operative
reports. A gastroenterologist and two pathologists carefully reviewed these indications.
The gastroenterologist was blinded to the referring gastroenterologist. Both pathology
residents who retrieved medical records data and reviewed the indications had no knowledge
of the referring gastroenterologists. A clear definition of appropriate polypectomy
was developed, reviewed with and confirmed by two outside gastroenterologists. For
the purposes of our evaluation, we assumed that a general gastroenterologist should
be able to assess polyp size accurately, endoscopically resect polyps < 2 cm, and
only attempt to remove polyps they can fully excise or follow-up and treat appropriately.
Surgical referrals were subcategorized into appropriate (colorectal polyp size ≥ 2 cm,
multiple polyps) and inappropriate. The latter category included polyp size < 2 cm,
size overestimation precluding endoscopic polypectomy, or incomplete resection. Size
overestimation was defined as a reported endoscopic size that was at least one- third
or 1 cm greater than the macroscopic size on final resection.
We analyzed the cohort based on polyp size < 2 cm versus ≥ 2 cm and compared characteristics
of these two groups. We also compared polyps based on their location. Right or left
colon polyps include those either proximal or distal to the splenic flexure, respectively.
Polyps were also assessed based on histology (adenoma vs serrated lesion). Statistical
analysis was done using chi-square test. All original slides of resected polyps were
reviewed by two pathologists, including a gastrointestinal pathologist. The polyps
were classified as tubular adenoma (TA), tubulovillous adenoma (TVA), sessile serrated
lesion (SSL) or traditional serrated adenoma (TSA). The presence of high-grade dysplasia
was also assessed.
The primary objective of the study is to determine the percentage of patients with
non-malignant colorectal polyps who could have avoided surgical resection and explore
the reasons behind it. We also sought to define the characteristics of polyps with
failed endoscopic polypectomy which might serve as guidance for focused endoscopist
training and developing standardized quality metrics for endoscopic polypectomy.
Results
Between January 1, 2003 and December 31, 2018, a total of 57,441 colonoscopies were
performed in our institution and affiliated hospitals and ambulatory centers. Our
annual number of colonoscopies consistently ranges between 3,000 and 4,000. A total
of 144 cases of surgically removed benign colorectal polyps during that same time
period were identified and retrieved. Surgical procedures included right hemicolectomy
(n = 101), partial cecectomy (n = 1), left hemicolectomy (n = 10), colonic segmental
resection (n = 21, out of which 10 were sigmoid colectomies), low anterior resection
(n = 6) and transanal mucosal excision (n = 5). Polyp size ranged from 0.5 cm up to
11.0 cm. The mean patient age was 65 (range = 34–94) years with slight male predilection
(male:female = 77:67) ([Table 1 ]). One hundred eighteen patients were referred to surgery without attempted endoscopic
removal, 22 patients had recurrence or incomplete polypectomy, and 4 patients had
> 10 adenomas or met criteria for serrated polyposis syndrome ([Fig. 1 ]).
Table 1
Patient demographics.
N = 144
Age (years), mean (range)
65 (34–94)
Gender, n (%)
77 (53.5 %)
67 (46.5 %)
Diabetes mellitus, n (%)
29 (20 %)
Hyperlipidemia, n (%)
69 (48 %)
Hypertension, n (%)
74 (51 %)
Smoking, n (%)
70 (49 %)
Body mass index (kg/m2 ), median (range)
26.9 (16.4–46.9)
Patients with benign polyps referred to surgery without attempted endoscopic polypectomy
In 26 (22 %, 95 % CI [15.5–30.3]) of 118 polyps, the macroscopic polyp size was < 2 cm,
and 56 (48 %, 95 % CI [38.7–56.4]) polyps were ≥ 2 to < 4 cm. Thirty-six (31 %) polyps
were > 4 cm ([Table 2 ]). The vast majority of polyps without attempted endoscopic polypectomy were adenomas
(97 %; 25 TAs, 88 TVAs, 1 TSA, 4 SSLs). Polyps ≥ 2 cm were significantly more likely
to be TVAs compared to polyps < 2 cm (81 of 92; 88 %, 95 % CI [86–93] vs 7 of 26;
27 %, 95 % CI [13.7–46.1]) (P < 0.01). Of the 26 polyps that were < 2 cm, 15.4 % were serrated polyps (4 SSLs;
95 % CI [6.2 %-33.5 %]) while only 1.1 % (1 TSA; 95 % CI [0.2–5.9]) of 92 polyps ≥ 2 cm
were serrated (P < 0.05). No statistical significance was shown when comparing the presence of high-grade
dysplasia between the 2 groups.
Table 2
Surgical referral patterns.
N = 144
No attempted endoscopic polypectomy, n (%)
118 (82 %)
Polyp < 2 cm, n (%)
26 (18 %)
23 (16 %)
3 (2 %)
Polyp ≥ 2 cm, n (%)
92 (64 %)
66 (46 %)
26 (18 %)
Polyp ≥ 2 cm – < 4 cm
56 (39 %)
Polyp ≥ 4 cm
36 (25 %)
Size overestimation, n (%)
18 (13 %)
Polyp < 2 cm with size overestimation, n (%)
7 (5 %)
Polyp ≥ 2 cm with size overestimation, n (%)
11 (8 %)
Incomplete endoscopic resection, n (%)
22 (15 %)
Residual polyp < 2 cm, n (%)
12 (8 %)
10 (7 %)
2 (1 %)
Residual polyp ≥ 2 cm, n (%)
10 (7 %)
6 (4 %)
4 (3 %)
Serrated polyposis or multiple polyposis syndromes, n (%)
4 (3 %)
In this group, two polyps (1.7 %) were located at the appendiceal orifice (sizes 0.6 cm
and 1.2 cm) and 8 (6.8 %) were located at the ileocecal valve (range 1.7 cm–5.8 cm).
Two (1.7 %) polyps were either ulcerated or depressed and did not raise after saline
lift (sizes were ≥ 2 cm in both).
Potentially avoidable surgery for patients without attempted endoscopic polypectomy
Twenty-six of 118 polyps (22 %; 23 in the right, 3 in the left colon) < 2 cm, macroscopically.
In 92 of 118 polyps (78 %; 66 in right, 26 in the left colon) of 118 polyps, the macroscopic
size was ≥ 2 cm. Polyps that were < 2 cm were mostly located in the right colon (89 %,
95 % CI [71–96] versus 72 %, 95 % CI [61.8–79.9] for polyps ≥ 2 cm) ([Table 2 ]). However, no statistical significance (P > 0.05) was demonstrated with regard to location (right versus left colon) between
the two groups.
Eighteen of 118 polyps (15 %) polyps were found to have had size overestimation during
endoscopy as previously defined. The majority of polyps with size overestimation were
in the right colon (78 %; 14 polyps) ([Table 2 ]). There were seven surgical resections that met both criteria of size < 2 cm and
size overestimation.
Surgery for incomplete endoscopic resection or recurrent polyps
Of the 144 patients, 22 (15 %) underwent surgical resection for incomplete endoscopic
polypectomy of adenomas (10 TAs; 12 TVAs). Among these, 12 (54.5 %) polyps had a residual
polyp diameter of < 2 cm (10 in the right colon; 83.3 %, 95 % CI [55.2–95.3] and two
in the left colon; 16.7 %, 95 % CI [4.7–44.8]) and 10 polyps (45.5 %) had a residual
diameter of ≥ 2 cm (6 in the right colon; 60 %, 95 % CI [31.3–83.2] and 4 in the left
colon, 40 %, 95 % CI [16.8–68.7]). The mean of the residual polyp diameter was 1.9 cm
([Table 2 ]). There was no statistical difference (P > 0.05) between the diameters of residual polyp in the right and left colon.
Surgery for serrated polyposis syndrome or multiple polyposis syndrome
Of the 144 cases, four (2.8 %) were referred to surgery for having > 10 adenomas or
met the definition of serrated polyposis syndrome [14 ].
Percentage of cases with potentially avoidable surgical resections
In total, 59 patients (41 %) could have potentially avoided surgical intervention
([Table 2 ]). 22 polyps had incomplete resections, 26 polyps were < 2 cm, seven of which also
had size overestimation precluding endoscopic polypectomy. The remaining 11 polyps
with size overestimation had sizes ranging from 2.0 to 3.5 cm, only two of which had
a size > 3 cm (3.2 and 3.5 cm). Moreover, of the 56 polyps/adenomas ≥ 2 to < 4 cm,
23 (16 %) had a polyp size < 3 cm (18 in the right, 5 in the left colon) and 33 (23 %)
had a polyp size < 4 cm (23 in the right and 10 in the left colon) which is likely
to increase the number of cases that could have benefited from expert referral with
ability to remove larger polyps, prior to surgery. When including polyps ≥ 2 to < 4 cm,
the percentage of patients that could have potentially avoided surgical resection
reaches up to 80 %.
Adverse events
The median hospital stay was 4.5 days (range 3.0–14.0 days). Nine patients (6.3 %)
were admitted to the intensive care unit (ICU) after surgery with a median duration
of 3.0 days (range 1.0–10.5 days). A total of 29 patients (20.1 %, 95 % CI [14.4–27.4])
had postoperative adverse events (AEs), which are further specified in [Table 3 ]. Mortality related to the SR was 0.7 % (95 % CI [0.4–3.8]).
Table 3
Surgical adverse events.
N = 144
Hospital stay (days), median (range)
4.5 (3.0–14.0)
Patients admitted to the intensive care unit, n (%, 95 % CI)
9 (6.3 %;3.3–11.5)
Intensive care unit stay (days), median (range)
3.0 (1.0–10.5)
Patients with postoperative adverse events, n (%, 95 % CI)
29 (20.1 %; 14.4–27.4)
Postoperative adverse events type, n (%, 95 % CI)
4 (2.8 %;1.1–6.9)
4 (2.8 %1.1–6.9)
11 (7.6 %)
2 (1.4 %)
3 (2.1 %; 0.7–6.0)
1 (0.7 %; 0.1–3.8)
3 (2.1 %; 0.7–6.0)
1 (0.7 %; 0.1–3.8)
Mortality, n (%, 95 % CI)
1 (0.7 %; 0.1–3.8)
Discussion
Despite its efficacy and the strong evidence favoring endoscopic resection, partial
colectomies for benign colorectal polyps are on the rise in the United States [15 ]. An analysis of a large data sample from Healthcare Cost and Utilization Project
National Inpatient Sample (NIS) showed a concerning significant increase in the incidence
of surgery for non-malignant colorectal polyps from 5.9 in 2000 to 9.4 in 2014 per
100,000 individuals [7 ]. This increase was observed in both men and women and across different races and
age groups, especially among adults 50 to 79 years old. Certainly, these shifting
trends in management do not come without costs, both financial and safety-related.
Several studies have shown that major adverse postoperative events are relatively
common in patients undergoing surgery for a non-malignant colorectal polyp. In one
study, the risk of at least one major postoperative event was as high as 14 % [4 ]. In addition, a nationwide analysis of > 260,000 surgeries for non-malignant colorectal
polyps from the National Inpatient Sample (NIS) over a 10-year period (2005–2014)
showed an overall in-hospital mortality rate of 0.8 % and a morbidity rate as high
as 25 % [8 ] both in line and comparable to the rates from our institution. Not surprisingly,
this substantial risk of postoperative AEs was associated with a 106 % increase in
mean hospital length of stay and a 91 % increase in mean hospitalization cost. Although
multivariable logistic regression analysis established an association between postoperative
morbidity risk with increasing age, male sex, black race, open surgical technique,
and the presence of comorbidities, the study provided additional support for attempting
endoscopic resection prior to surgical referral. In comparison, the complications
most commonly associated with advanced endoscopic resection include intra-procedural
bleeding (11 %) [16 ], delayed bleeding (6 %) [17 ] and perforation (1.5 %) for large polypectomies [3 ]. Mortality directly related to endoscopy or subsequent surgery after endoscopy is
rare (0.08 %) [3 ].
Modern endoscopic colorectal polyp assessment and management offers advantages over
surgical resection in terms of safety and decreased cost while maintaining efficacy
in diagnosis and definitive management of most benign colorectal neoplasms [1 ]
[2 ]
[3 ]
[4 ]. There is substantial evidence that endoscopic removal of a colonic adenomatous
polyp significantly reduces the risk of colorectal cancer development [5 ]. This is, however, contingent on optimizing the quality of colonoscopy which can
be monitored using adenoma detection rate (ADR), a surrogate marker that measures
combined personnel and technique-dependent factors. An endoscopist’s ADR is associated
with the subsequent interval cancer risk, with lower ADR predicting higher risk of
interval cancer [18 ]. To date, quality measures have predominantly focused on ADR in colorectal cancer
prevention, but polypectomy competency is rarely reported. A recent prospective study
that included a series of 120 polypectomies performed by 12 endoscopists showed that
polypectomy competency did not correlate with ADR or colonoscopy inspection quality
(CIQ) [19 ]. This highlighted the need to develop quality metrics that would independently evaluate
polypectomy competency. Reliable tools to assess an endoscopist’s technical skills
and competence have been developed but have not been widely adopted [20 ]
[21 ]. Gupta et al. initially introduced Direct Observation of Polypectomy Skills (DOPyS)
which uses a 4-tier grading system to score a set of parameters pertaining to the
polypectomy procedure with a subsequent overall rating, based on video observations
by expert assessors [20 ]. This method showed an agreement rate of up to 98 % when assessing the success of
the procedure and proved to be a reliable reflection of an endoscopist’s competence
when applied with a specific set of criteria, in more than one study [13 ]
[20 ]
[22 ].
Polyp size, especially those ≥ 2 cm, site and morphology are among the commonly reported
variables that would add to the complexity of the endoscopic procedure and lead to
surgical referral [7 ]. However, given the technical advancements in polypectomy techniques such as endoscopic
submucosal dissection (ESD) and the published data on safety and cost effectiveness
of endoscopic resection of advanced polyps [23 ], the guidelines set forth by the European Society of Gastrointestinal Endoscopy
(ESGE) and the United States Preventive Services Task Force (USPSTF) on colorectal
cancer recommend endoscopic resection as a preferred method to manage benign-appearing
colorectal polyps [3 ]
[4 ]
[24 ]
[25 ]. When dealing with complex polyps, referral to an advanced endoscopist for repeat
colonoscopy and attempted endoscopic resection, if appropriate, is recommended [6 ]
[26 ]
[27 ]
[28 ]
[29 ]. These recommendations are based on evidence that > 90 % of complex non-malignant
colorectal polyps can be safely resected endoscopically regardless of size. In a meta-analysis,
only 8.1 % of patients with polyps > 2 cm, predominantly laterally spreading sessile
lesions, required surgery [3 ]. Nearly 60 % of patients avoided surgical resection when repeat colonoscopy with
polypectomy was performed, and similarly, 71 % of lesions referred for surgery were
actually amenable to endoscopic resection [30 ]
[31 ].
When examining the parameters responsible for the observed increase in surgical resection
of non-malignant polyps, the role of endoscopists’ skills and subjectivity in defining
a complex polyp are an undeniable factor. This can be attributed, in part, to the
lack of standardized quality measures for adequate endoscopic polypectomy. The Complete
Adenoma Resection (CARE) study helped better characterize the rate of incompletely
resected neoplastic polyps in clinical practice and evaluated potential contributing
factors [12 ]. In this study, 346 endoscopically resected polyps were prospectively analyzed.
The incomplete resection rate (IRR) was 10.1 % and varied broadly among endoscopists.
Moreover, the rate increased significantly with larger polyp size (10–20 mm) and sessile
serrated histology. These findings could explain why incompletely resected polyps
are estimated to account for 10 % to 27 % of interval colorectal cancers [11 ]
[32 ]
[33 ]
[34 ]. Other factors accounting for incomplete polyp removal may include right-sided location,
lack of a contrast agent, intra-procedural bleeding, and endoscopist’s skill level
[10 ]. Another parameter that may contribute to surgical referrals in these cases is size
overestimation during endoscopy. Estimation of a polyp size in vivo is a unique, but
trainable skill set. For instance, one may use the width of an open forceps (~ 7–8 mm
depending on the model) or the diameter of an open snare to ascertain a more accurate
estimate of the size of the lesion.
To assess the quality of endoscopic resection in clinical practice, our study focused
on the characteristics of non-malignant polyps that are surgically resected as well
as the indications for surgical referral. To our knowledge, this is the first study
which included a large cohort from a tertiary care center that looked at the appropriateness
of surgical removal of non-malignant polyps based on polyp size, location, morphology,
histology and incomplete endoscopic resection rare. Unexpectedly, 22 % of polyps that
had no attempted endoscopic resection were < 2 cm which is not commensurate with the
evidence-based guidelines and recommendations. The majority (85 %) of these smaller
polyps were adenomas without depressed or ulcerated morphology in contrast with published
data showing an association between surgical referral and sessile serrated lesions
and/or complex configuration. Although not statistically significant, the majority
(89 %) of these polyps were located in the right colon, which could be a starting
point when trying to address the shortcomings and improve the quality of endoscopic
polypectomy.
Our data also suggest that overestimation of polyp size might preclude endoscopic
resection and contribute to surgical referral. Fifteen percent of polyps in our study
had size overestimation. Moreover, 27 % of polyps that were < 2 cm had been estimated
to be ≥ 2 cm endoscopically. Upon reviewing the indications for surgery on these polyps,
size was invariably the main indication listed. Interestingly, most (78 %) of the
polyps with size overestimation were located in the right colon possibly due to technical
difficulties in assessing proximal colon polyps. This also suggests that training
for accurate polyp size measurement needs to be focused on proximal colon polyps.
When examining incompletely resected polyps which accounted for 15 % of total cases,
the majority (73 %) were located in the right colon as well. All of these polyps were
either tubular or tubulovillous adenomas suggesting that adenomas, not just SSLs,
can be associated with a higher rate of incomplete endoscopic resection. Moreover,
over a half of the residual polyps measured < 2 cm in maximum diameter on follow-up. Nonetheless,
surgical resection was preferred over endoscopic re-excision attempt in these situations.
It is not entirely clear why these smaller sized residual polyps tended to be located
in the right colon rather than left, but this could be due to higher incidence of
incomplete resection rate in the right colon in general or physicians’ reluctance
to retreat polyp tissue in the right colon due to concerns about complications.
Our study shows that 59 patients (41 %) could have potentially avoided surgical intervention
given the size of the polyps/residual polyps that were < 2 cm. Furthermore, polyps
with size ≥ 2 to < 4 cm (48 % of polyps without attempted endoscopic polypectomy)
could potentially be removed by a more experienced endoscopist which could dramatically
increase the percentage of avoidable surgeries. It is important to emphasize that
our study design which included a polyp size cut-off of 2 cm was based on two expert
opinions from gastroenterologists in the field that proposed a minimum polyp size
that can be resected by the vast majority of practicing endoscopists given that there
are no standard guidelines for endoscopic management of colorectal polyps, nor are
there specific and updated guidelines for advanced endoscopy or surgical referral.
However, given the advancements in endoscopic polypectomy techniques and the overwhelming
evidence that the vast majority of benign colorectal polyps can and should be managed
endoscopically, a higher number of surgeries would have likely been avoided with expert
endoscopist referral of larger and more complex polyps. Moreover, polyps in special
locations such as the appendiceal orifice and ileocecal valve can also potentially
benefit from expert referral prior to surgery (i. e., one case with a 0.6 cm polyp
at the appendiceal orifice underwent surgical resection). This would be a justified
first step given the complication risks and costs associated with surgery [4 ]
[19 ]. It is worth mentioning that the surgical samples that we collected were from a
tertiary care referral center, and thus our observation brings out a speculation regarding
polypectomy practices in a community setting.
Our study has some limitations. Our data collection and interpretation were done retrospectively
potentially missing some pertinent information related to the outcomes we had defined.
In about 40 % of cases of incomplete polypectomy, original polyp size could not be
found in the EMR, as these were outside referrals, precluding establishing a meaningful
association between the size and location of incompletely resected polyps. Additionally,
the time period when the retrospective data were collected likely includes cases of
surgically resected polyps when endoscopic polypectomy techniques were not as readily
available or as advanced as present date although snare polypectomy has been around
for some time and is effective in removing most polyps with size ≤ 2 cm without the
need for surgery.
Conclusions
A large number of patients in this study underwent potential avoidable surgery for
colorectal polyps which were likely endoscopically resectable, placing them at undue
risks. Providing practicing endoscopists with tools for accurate polyp size estimation,
enhanced training in proper polypectomy technique, and increased awareness that experts
can safely remove the vast majority of benign colorectal polyps with emphasis on seeking
that expert referral as a first step prior to surgery would be helpful. For those
currently learning colonoscopy, standardized training in and documentation of proficiency
in polypectomy using Direct Observation of Polypectomy Skills (DOPyS) or a similar
system would be important.
