Opinion Review
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 21, 2022; 28(47): 6619-6631
Published online Dec 21, 2022. doi: 10.3748/wjg.v28.i47.6619
How to avoid overtreatment of benign colorectal lesions: Rationale for an evidence-based management
Marco Bustamante-Balén
Marco Bustamante-Balén, Gastrointestinal Endoscopy Unit, Gastrointestinal Endoscopy Research Group, Hospital Universitari I Politècnic La Fe, Health Research Institute Hospital La Fe (IISLaFe), Valencia 46026, Spain
Author contributions: Bustamante-Balén M conceived the idea for the manuscript, performed the literature review, and drafted the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Marco Bustamante-Balén, MD, PhD, Doctor, Gastrointestinal Endoscopy Unit, Gastrointestinal Endoscopy Research Group, Hospital Universitari I Politècnic La Fe, Health Research Institute Hospital La Fe (IISLaFe), Avda. Fernando Abril Martorell, 106, Valencia 46026, Spain. bustamante_mar@gva.es
Received: September 13, 2022
Peer-review started: September 13, 2022
First decision: October 3, 2022
Revised: October 10, 2022
Accepted: November 27, 2022
Article in press: November 27, 2022
Published online: December 21, 2022

Implementing population-based screening programs for colorectal cancer has led to an increase in the detection of large but benign histological lesions. Currently, endoscopic mucosal resection can be considered the standard technique for the removal of benign lesions of the colon due to its excellent safety profile and good clinical results. However, several studies from different geographic areas agree that many benign colon lesions are still referred for surgery. Moreover, the referral rate to surgery is not decreasing over the years, despite the theoretical improvement of endoscopic resection techniques. This article will review the leading causes for benign colorectal lesions to be referred for surgery and the influence of the endoscopist experience on the referral rate. It will also describe how to categorize a polyp as complex for resection and consider an endoscopist as an expert in endoscopic resection. And finally, we will propose a framework for the accurate and evidence-based treatment of complex benign colorectal lesions.

Keywords: Colorectal polyps, Endoscopic mucosal resection, Colorectal surgery

Core Tip: Despite endoscopic treatment being of choice for the treatment of large benign colorectal neoplasms, many lesions are still being referred to surgery. Problems in identifying a polyp as complex to resect, too much self-confidence of the endoscopists, and the lack of a referral pathway may be causes underlying this situation. The organization of a structured referral network may be the main step to reducing the overtreatment of benign lesions. Decisive support from Medical Societies and Public Administration is warranted to set up this paradigm change.