Nonendoscopic nonmalignant polyp surgery increasing despite greater risk

In this comprehensive analysis, Peery et al. found a rising incidence of surgery for nonmalignant colorectal polyps despite relatively stable colorectal cancer screening rates and with decreasing incidence of colorectal cancer surgery.

In a separate study, the authors found that 14% of patients who underwent surgical resection of nonmalignant colorectal polyps had a major postoperative event. Other population-based studies have reported similar incidence of surgical complications.

This report thus raises concern for inappropriate surgical referral. While reimbursement models may play a role, many factors are involved with surgical referral. Complex polypectomy, often using endoscopic mucosal resection techniques to remove large polyps, is associated with higher rates of bleeding, perforation, and incomplete resection, compared with standard polypectomies. The decision to refer to surgery or to attempt endoscopic resection is based on provider experience and polyp characteristics, including suspicion for malignancy. Current literature suggests that surgical removal is recommended less frequently by specialists in complex polypectomy, compared with nonspecialists.

Given this study’s findings, health systems should consider including surgical referral rates in their quality measures. Thus, high-quality endoscopy centers would ensure that complex polyps are appropriately characterized and initially managed by endoscopists experienced in complex polypectomy. This is especially important with the increasing repertoire of endoscopic alternatives to surgery that we can offer our patients.

Gyanprakash A. Ketwaroo, MD, MSc, is an an assistant professor, division of gastroenterology and hepatology, Baylor College of Medicine, Houston. He has no conflicts.