Opinion Review
Copyright ©The Author(s) 2022.
World J Gastroenterol. Dec 21, 2022; 28(47): 6619-6631
Published online Dec 21, 2022. doi: 10.3748/wjg.v28.i47.6619
Table 1 Main recent series on the morbidity and mortality of surgery for benign colorectal lesions
Data source
Mortality (%)
Colostomy/ Ileostomy (%)
Major adverse event (%)
Readmission (%)
Surgical re-intervention (%)
Peery et al[7]2018USANational Inpatient Sample112.7320.
Zogg et al[8]2016USANational Inpatient Sample168.4622--14.7-1.0
de Neree et al[9]2019NetherlandsSystematic Review139.8970.7-24.0-0-8.9
Ma et al[10]2019USANational Inpatient Sample1262.8430.825.3--
Table 2 Cost-effectiveness studies, endoscopic therapy vs surgery
Endoscopic technique
Costs analyzed
Swan et al[19]2009AustraliaEMRObservational monocentricEndoscopy vs surgery, Considering surgery without major complicationsDirect costs including a 1-day hospital stay for EMR, Loss of utility not consideredEAC: $2051 pp, SAC: $9041
Jayanna et al[16]2016AustraliaEMRObservational multicentricEndoscopy vs surgery, Considering surgery with and without complicationsDirect costs including hospital stay and adverse events, 1st surveillance endoscopyEAC: $4668 pp, SAC: $12720, If surgery 7.5% complications -> SAC: $45530
Law et al[17]2016USAEMRDecision analysis tree (hybrid Markov model)Endoscopy (resection + surveillance, surgery if recurrence at 12 mo) vs laparoscopic surgery, Considering complications in both armsDirect costs, Loss of utility considered, QALY, Sensitivity analysisEAC: $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]2019FranceESDObservational monocentricEndoscopy vs surgery, Considering complications in both armsDirect costs including hospital stay and endoscopy costsEAC: €3190, SAC: €8490
Buskermolen et al[13]2022NetherlandsNon-specifiedMicrosimulation screening analysis (MISCAN-colon)Surgery vs attempted removal by an expert endoscopist, Considering complications in both armsDirect costs, Loss of utility considered, QALY, Sensitivity analysisEAC: €60.200, SAC: €72.700, Endoscopy QALY: 33.1/1000 individuals, Surgery QALY: 32.9/1000 individuals
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 colonoscopiesEnsure that endoscopists undertake a sufficient number of procedures a year to maintain acceptable standards4
Increased risk of malignancy100-125 EMR to obtain competence
Kudo´s pit pattern VA non-defined number1 of EMR procedures to maintain competence
Paris 0-IIc/0-IIa+IIcTime from referral to definitive management: < 8 wk
LST-NG/LST-Gm (dominant nodule)Fulfilling key performance indicators
NICE 3/Sano IIIPresence of recurrence/residual polyp at 12 mo < 10%Geraghty et al[40]
Increased risk of incomplete resection/recurrenceProvided endoscopy list time for the additional workload with a dedicated list
Size ≥ 40 mmEMR 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
Within an inflamed segment of the colonESGE3 curriculum for optical diagnosis[59]
Prior failed resection attemptAssessing 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 yearEquipment: including necessary snares and hemostatic devices
Non-lifting sign
Increased risk of adverse eventsSurgeons for discussion in the MDT and case of operative treatment of adverse events
Endoscopist´s expertiseRobust 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