SURGICAL MANAGEMENT OF ENDOSCOPICALLY UNRESECTABLE COLORECTAL POLYPS

Öz

Objective: To define the management of colorectal polyps that were technically unsuitable for endoscopic removal. Materials and Methods: Between May 2010 and January 2019, 4886 polyps from 3822 of 16,996 colorectal endoscopies were analyzed. Of the total colorectal polyps, 135 (2.8%) were identified as endoscopically unresectable single polyps and examined in detail. Result: The rate of invasive colorectal cancer (CRC) in unresectable and resectable polyps was 26.7% and 1.7%, respectively (p<0.001). Unresectable polyps were more common in the ascending colon and cecum (p<0.001), but the potential to contain invasive CRC was greater in the sigmoid colon and rectum-located polyps (p=0.001). In addition, advancing age (p=0.014), increased polyp size (p=0.012), deep submucosal invasion (p<0.001), and the presence of lymphovascular invasion (p<0.001) were associated with the development of CRC. Unresectable polyps requiring surgery after non-curative endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) were found to have a significantly higher risk of containing CRC compared with polyps that underwent surgical resection primarily (p=0.002). In the multivariate model, advancing age (p=0.010) and detected deep submucosal invasion (p=0.002) were more associated with the development of CRC. Conclusion: The study suggests that oncologic surgery for polyps with deep submucosal invasion (particularly by EMR or ESD) that cannot be endoscopically resected in older patients should be considered carefully and, perhaps, without delay, primarily by abandoning repeated endoscopic resection attempts.

Anahtar Kelimeler

• Colorectal Neoplasms
• Polyps
• Endoscopy
• Endoscopic Mucosal Resection
• Endoscopic Submucosal Dissection

ENDOSKOPİK OLARAK ÇIKARILAMAYAN KOLOREKTAL POLİPLERE CERRAHİ YAKLAŞIM

Öz

Amaç: Bu çalışma, endoskopik olarak çıkarılması teknik olarak uygun olmayan kolorektal poliplerin tedavisini tanımlamayı amaçladı. Gereç ve Yöntem: Mayıs 2010 ile Ocak 2019 tarihleri arasında 16,996 kolorektal endoskopiden 3,822’sinde 4,886 polip analiz edildi. Total kolorektal poliplerin 135’i (%2,8) endoskopik olarak çıkarılamayan tekli polip olarak tanımlandı ve detaylı olarak incelendi. Bulgular: Rezeke edilemeyen bir polipte invaziv kolorektal kanser (KRK) oranı %26,7 iken, rezeke edilebilir bir polipte bu oran %1,7 idi (p<0,001). Rezeke edilemeyen polipler çıkan kolon ve çekumda daha yaygındı (p<0,001), ancak invaziv KRK içerme potansiyeli sigmoid kolon ve rektum yerleşimli poliplerde daha fazlaydı (p=0,001). Ayrıca ilerleyen yaş (p=0,014), artmış polip boyutu (p=0,012), derin submukozal invazyon (p<0,001) ve lenfovasküler invazyon varlığı (p<0,001) KRK gelişimi ile ilişkiliydi. Küratif olmayan endoskopik mukozal rezeksiyon (EMR) veya endoskopik submukozal diseksiyon (ESD) sonrası ameliyat gerektiren rezeke edilemeyen poliplerin, primer olarak cerrahi rezeksiyon uygulanan poliplere kıyasla anlamlı derecede daha yüksek KRK içerme riskine sahip olduğu bulundu (p=0,002). Çok değişkenli modelde ilerleyen yaş (p=0,010) ve saptanan derin submukozal invazyon (p=0,002) KRK gelişimi ile daha fazla ilişkiliydi. Sonuç: Çalışma, yaşlı hastalarda endoskopik olarak rezeke edilemeyen derin submukozal invazyonlu (özellikle EMR veya ESD ile) polipler için onkolojik cerrahinin dikkatli bir şekilde düşünülmesi gerektiğini ve belki de gecikmeden, öncelikle tekrarlanan endoskopik rezeksiyon girişimlerinden vazgeçilmesi gerektiğini önermektedir.

Anahtar Kelimeler

• Kolorektal Neoplazmalar
• Polipler
• Endoskopi
• Endoskopik Mukozal Rezeksiyon
• Endoskopik submukozal diseksiyon

Kaynakça

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