How to avoid overtreatment of benign colorectal lesions: Rationale for an evidence-based management

Table 1 Main recent series on the morbidity and mortality of surgery for benign colorectal lesions

Ref.	Year	Country	Data source	N	Mortality (%)	Colostomy/ Ileostomy (%)	Major adverse event (%)	Readmission (%)	Surgical re-intervention (%)
Peery et al[7]	2018	USA	National Inpatient Sample1	12.732	0.7	2.2	14.0	7.8	3.6
Zogg et al[8]	2016	USA	National Inpatient Sample1	68.4622	-	-	14.7	-	1.0
de Neree et al[9]	2019	Netherlands	Systematic Review	139.897	0.7	-	24.0	-	0-8.9
Ma et al[10]	2019	USA	National Inpatient Sample1	262.843	0.8		25.3	-	-

¹All-payer inpatient healthcare database.

²Overall colon surgery (not only colorrectal epithelial lesions): % of adverse events are specific for surgery of benign colorectal lesions.

Table 2 Cost-effectiveness studies, endoscopic therapy vs surgery

Ref.	Year	Country	Endoscopic technique	Design	Comparison	Costs analyzed	Results
Swan et al[19]	2009	Australia	EMR	Observational monocentric	Endoscopy vs surgery, Considering surgery without major complications	Direct costs including a 1-day hospital stay for EMR, Loss of utility not considered	EAC: $2051 pp, SAC: $9041
Jayanna et al[16]	2016	Australia	EMR	Observational multicentric	Endoscopy vs surgery, Considering surgery with and without complications	Direct costs including hospital stay and adverse events, 1st surveillance endoscopy	EAC: $4668 pp, SAC: $12720, If surgery 7.5% complications -> SAC: $45530
Law et al[17]	2016	USA	EMR	Decision analysis tree (hybrid Markov model)	Endoscopy (resection + surveillance, surgery if recurrence at 12 mo) vs laparoscopic surgery, Considering complications in both arms	Direct costs, Loss of utility considered, QALY, Sensitivity analysis	EAC: $5570 ppEndoscopy QALY: 9.64, SAC: $18717 pp, Surgery QALY: 9.58, Laparoscopy is cost-effective if complete EMR < 75.8%, EMR adverse events rate > 12% and laparoscopy cost < $14.000
Dahan et al[18]	2019	France	ESD	Observational monocentric	Endoscopy vs surgery, Considering complications in both arms	Direct costs including hospital stay and endoscopy costs	EAC: €3190, SAC: €8490
Buskermolen et al[13]	2022	Netherlands	Non-specified	Microsimulation screening analysis (MISCAN-colon)	Surgery vs attempted removal by an expert endoscopist, Considering complications in both arms	Direct costs, Loss of utility considered, QALY, Sensitivity analysis	EAC: €60.200, SAC: €72.700, Endoscopy QALY: 33.1/1000 individuals, Surgery QALY: 32.9/1000 individuals

EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosa dissection; QUALY: Quality adjusted life years; EAC: Endoscopy average cost; SAC: Surgical average cost; pp: Per patient.

Table 3 Objective parameters for assessing lesions, endoscopists, and units

Complex polyp			Expert endoscopist			Reference endoscopy unit
SMSA score ≥ 12 (Level 4)[41]			BSG criteria[42]			BSG criteria[42]
BSG criteria[42]				500 independent colonoscopies			Ensure that endoscopists undertake a sufficient number of procedures a year to maintain acceptable standards4
	Increased risk of malignancy			100-125 EMR to obtain competence
		Kudo´s pit pattern V		A non-defined number1 of EMR procedures to maintain competence
		Paris 0-IIc/0-IIa+IIc					Time from referral to definitive management: < 8 wk
		LST-NG/LST-Gm (dominant nodule)		Fulfilling key performance indicators
		NICE 3/Sano III			Presence of recurrence/residual polyp at 12 mo < 10%	Geraghty et al[40]
	Increased risk of incomplete resection/recurrence						Provided endoscopy list time for the additional workload with a dedicated list
		Size ≥ 40 mm			EMR perforation rate: < 2%
		Difficult location (ileocecal valve, appendix, diverticulum, dentate line)			Post-polypectomy bleeding rate: < 5%		Staff to include at least two endoscopists that can cover each other and endoscopy nurses with training in complex polypectomy
			DOPyS2
		Within an inflamed segment of the colon	ESGE3 curriculum for optical diagnosis[59]
		Prior failed resection attempt			Assessing competence: ≥ 80 % accuracy for identifying submucosal invasion in large (≥ 20 mm lesions), Maintaining competence: in vivo audit and review of at least 10 large (≥ 20 mm) lesions within a year		Equipment: including necessary snares and hemostatic devices
		Non-lifting sign
	Increased risk of adverse events						Surgeons for discussion in the MDT and case of operative treatment of adverse events
		Cecum
		Endoscopist´s expertise					Robust referral system including administrative staff support and tools for virtual MDT
ESGE criteria[21]
	Difficult location or poor access (ileocecal valve, periapendicular, anorectal junction)
	Prior failed resection attempts
	Non-lifting sign
	SMSA level 4

¹Enough to maintain quality standards.

²Direct Observation of Competence Skills (not specific for EMR).

³For achieving competence in optical diagnosis of early colorectal cancer.

⁴Review in conjunction with other key performance indicators.

BSG: British Society of Gastroenterology; EMR: Endoscopic mucosal resection; LST-NG: Non-granular lateral spreading tumor; LST-Gm: Granular mixed lateral spreading tumor; NICE: NBI International Colorectal Endoscopic classification; ESGE: European Society of Gastrointestinal Endoscopy; MDT: Multi-disciplinary team; DOPyS: Direct Observation of Competence Skills; SMSA: Site, Morphology, Size, Access.