Table Of Content166 Colonoscopic Polypectomies and Recommendations on the Colonoscopy Follow-up Intervals Depending on Endoscopic and Histopathological Findings
ACTA INFORM MED. 2013 Sep; 21(3): 166-169 doi: 10.5455/aim.2013.21.166-169
Received: 15 May 2013 • Accepted: 20 July 2013
conflict of interest: none declared
© AVICENA 2013
Colonoscopic Polypectomies and Recommendations
on the Colonoscopy Follow-up Intervals Depending on
Endoscopic and Histopathological Findings
Miroslav Simunic1, Nikola Perkovic1, Bruna Rosic-Despalatovic1, Ante Tonkic1,
Zarko Ardalic1, Marina Titlic2, Marina Maras-Simunic3
Department of Internal Medicine, University Hospital Center Split, Split, Croatia1
Department of Neurology, University Hospital Center Split, Split, Croatia2
Department of Diagnostic and Interventional Radiology, University Hospital Center Split, Split, Croatia3
Corresponding author: Prof. Miroslav Simunic, PhD. Department of Internal Medicine, Split University Hospital, Spinciceva 1, Split, Croatia.
Tel: +385/98/371-888. Fax: +385/21/556-002. Email: [email protected]
Original paper 2009 in KBC Split, out of a total of 2842 Colonoscopies with polypectomy decreased
ABSTRACT colonoscopies, 350 patients underwent the risk of the formation of colorectal cancer
The Aim: To show histopathological diag- colonoscopic polypectomy, whereby 618 in these patients almost to the level of risk in
noses after colonoscopic polypectomy in polyps were removed (1-8 polyps in individual patients who have not even had a polyp dur-
the University Hospital Center (KBC) Split patients), while in 163 patients only biopsy ing colonoscopy. Arguably the best method of
with recommendations on further follow-up specimens were sampled. Out of the total prevention and early detection of colorectal
colonoscopy depending on the endoscopic of 557 polyps sent for histological analysis, cancer are already widely established national
and histological findings. Patients and Meth- 236 were hyperplastic (42%), 193 were programs. The next qualitative level is con-
ods: The study included 2842 patients who identified as tubular adenoma (35%), 84 stantly improving the quality of colonoscopy
underwent colonoscopy in a two-year period were tubulovillous (15%), 18 villous (3%), with clear criteria and the establishment of
(2008-2009), followed by a detailed analysis 9 were adenocarcinoma (2%) and other a body to evaluate the performers and the
of 350 patients in which one or more polyps 17 (3%). In 35 (15.4%) polyps high-grade equipment, and making recommendations on
were simultaneously removed and 163 pa- dysplasia was found. The largest number the colonoscopy follow-up intervals depending
tients who were only sampled for histological of nonpolypectomized changes confirmed on endoscopic and histopathological findings
analysis. Patients from the National Program the presence of adenocarcinoma (76-47%), of patients who for any reason underwent
for Colorectal Cancer Prevention and patients adenomas and hyperplastic polyps were 37 colonoscopy.
in which colonoscopy is indicated as part of (22%) and regular findings 23 (14%). Mu- Key words: colonoscopic polipectomy, surveil-
daily outpatient or inpatient treatment were cosal high-grade dysplasia was demonstrated lance, quality of endoscopy.
included as well. Results: During 2008 and in 35 (23.1%) biopsied changes. Conclusion:
1. INTRODUCTION
as much as 95% of carcinomas grow (2008-2009), with special emphasis on
Colorectal cancer (CRC) was out of polyps (polis=many, pous=foot), polypectomies, the histological classi-
the second leading cancer-related neoplasms which grow due to the fication of polyps and complications
cause of death both in men (N=1063; proliferation of the mucous mem- following colonoscopic polypectomy.
49.77/100.000) and in women (N=803; brane into the lumen of the colon Various factors which determine
34.89/100.000) (1) in Croatia in 2009. and the rectum. Even though mostly the current follow-up recommenda-
As much as 30-40% of patients are in benign, some of them possess a lower tions for patients who underwent
the stage of a metastatic disease at the or higher malignancy potential and colonoscopy have been analyzed as
time the diagnosis is set, since even therefore need to be removed by a well. Of these, the findings obtained
the advanced CRC can present almost procedure called polypectomy. Fol- by colonoscopy are most important
none or very few non-specific symp- lowing removal, the polyps need to be in epidemiological and clinical terms.
toms. In this case, the only way of sent for histological analysis, and ac-
2. PATIENTS AND METHODS
identifying the condition is colonos- cording to the findings (type and size
copy, which makes it the diagnostic of the polyp, grade of dysplasia, resec- The patients’ data have been gath-
method of choice in CRC screening.1 tion margins) colonoscopy follow-up ered by a retrospective analysis of the
In accordance with this, a National intervals need to be recommend (4). database and the discharge letters of
program of early CRC diagnostics was The aim of this study was to an- the Department of Internal Medi-
introduced in Croatia in 2007 (2, 3). alyze colonoscopies performed in cine KBC Split, as well as by the in-
Today it is known for a fact that KBC Split within a two-year period sight into the pathohistological diag-
Original paper / aCTa inFOrM MeD. 2013 Sep; 21(3): 166-169
Colonoscopic Polypectomies and Recommendations on the Colonoscopy Follow-up Intervals Depending on Endoscopic and Histopathological Findings 167
noses of the Department of Clinical Year 2008 2009 Total 2008 2009 Total
Pathology KBC Split. The study in- Men 105 117 222 (63%) Perforation 0 1 1
cluded all patients who underwent Women 67 61 128 (37%) Bleeding 5 4 9
colonoscopy at the Department for Age <40 8 8 16 (4%) Post-procedure 4 2 6
Gastroenterology and Hepatology of 40-55 50 42 92 (26%) observation
55-70 78 78 156 (45%) Total complications 9 7 16/350 (4.6%)
the Department of Internal Medicine
>70 36 50 86 (25%)
KBC Split from Jan. 1st 2008 to Dec. Table 6. Complications following polypectomy
Number of
31st 2009, as well as those patients in polyps 1 75 85 160 During and following colono-
86 79 165
which during the same period only 2-5 scopic polypectomy 16 patients (4.6%)
11 14 25
biopsy specimens were sampled from >5 developed a complication. One pa-
new formations without performing Table 2. Demographic data of patients who underwent tient suffered bowel perforation and
polypectomy. polypectomy was successfully operated on. 9 pa-
Patients from the National Pro- patients. A total of 618 polyps were tients who were bleeding were all
gram for Colorectal Cancer Preven- removed, with 557 of them sent to hospitalized and treated conserva-
tion and patients in which colonos- histological analysis (Table 3). Polyps tively. 6 patients were hospitalized
copy is indicated as part of daily not sent to analysis were deemed for a period of 2-3 days due to subjec-
outpatient or inpatient treatment clinically insignificant by the endos- tive difficulties, such as stomach pain,
were included as well. Along with copist, with the polypectomy itself as flatulence and general weakness.
demographic data, we analyzed the the undoubtedly final solution. Total number of pathohistological tests 163
number of performed colonoscopies Pathohistological Women 62 (38%)
2008 2009 Total
and removed polyps, the histological diagnosis Men 101 (62%)
structure of the polyp, complications Hyperplastic polyp 101 135 236 (42%) Adenocarcinoma 76 (47%)
and problems following the proce- Tubular adenoma 89 104 193 (35%) Clean results 23 (14%)
dure, and finally pathohistological Tubulovillous adenoma 39 45 84 (15%) Other 27 (16%)
findings of biopsies taken from neo- Villous adenoma 6 12 18 (3%) Adenoma tubulare 6 (4%)
plasms without performing polypec- Adenocarcinoma 4 5 9 (2%) Adenoma tubulovillosum 14 (8%)
tomy. Others 9 8 17 (3%) Adenoma villosum 3 (2%)
Total 557 Polypus hyperplasticus 14 (8%)
3. RESULTS Table 3. Histological structure of the polyp Dysplasia 22 (13%)
Between January 1st 2008 and De- Out of the total of 557 polyps sent Table 7. Biopsy results of nonpolypectomized neoplasms
cember 31st 2009, a total of 2842 colo- to histological analysis, 236 were hy- The largest number of pathohis-
noscopies were performed at the De- perplastic (42%), 193 were identified tological results confirmed the exis-
partment for Gastroenterology and as tubular adenoma (35%), 84 were tence of adenocarcinomas, as much
Hepatology of the Department of tubulovillous (15%), 18 villous (3%), 9 as 76 (47%). The other results iden-
Internal Diseases KBC Split, during were adenocarcinoma (2%) and other tify the growths as adenomas and hy-
which 350 patients underwent colo- 17 (3%), which includes mostly the perplastic polyps, while there were
noscopic polypectomy and whereby nonneoplastic mucous tumors (juve- 23 clean results. Mucosal high-grade
618 polyps were removed (1-8 polyps nile, inflammatory and hamartoma- dysplasia was proven in 22 (13%) bi-
in individual patients), while in 163 tous polyps) and submucous lipomas opsied changes. (Table 5,6,7).
patients only biopsy specimens were and leiomyomata (Table 4).
4. DISCUSSION
sampled from nonpolypectomized Others 2008 2009 Total
neoplasms (Tables 1 and 2). Leiomyoma 1 0 1 Hereditary and environmental fac-
Lipoma submucosum 2 2 4 tors play an important role in CRC
Year 2008 2009 Total
Adenoma iuvenilis 2 0 2 occurrence. With the advancement
Colonoscopy 1428 1414 2842 Polypus inflammatus 3 4 7 of genetic research, a genetic predis-
Polypectomy (1-8 polyps) 172 178 350
Polyp hamartomatous 1 2 3 position can be accurately identified
Number of removed polyps 284 334 618 Total 9 8 17 in one third of CRCs, implying that
Histological analysis 248 309 557 Table 4. Rare pathohistological diagnoses the family members of the patients
also need to take genetic tests, fol-
Table 1. Colonoscopies between January 1st 2008 and Dysplasia
December 31st 2009 lowed by colonoscopies at precisely
Grade of dysplasia 2008 2009 Total
determined intervals (5). A diet con-
Low 81 69 150 (76.9%)
Out of the total number of patients taining large amounts of animal fats
High 18 17 35 (23.1%)
which underwent polypectomy, 222 and industrially processed meats is
TOTAL 99 86 195
were men (63%), and 128 (37%) were considered to be an important en-
Table 5. Grade of cell dysplasia
women. The average age of patients vironmental factor affecting polyp
was 57, with 71% of them being be- growth (6).
tween 40 and 70 years old. A single Cell dysplasia was described in 195 Polyps of the colon usually grow
polyp was found in 160 patients, 2-5 analyzed polyps, whereof 150 (76.9%) without symptoms, which clari-
were found in 165 of them, whereas of low grade and 35 (23.1%) of high fies why without a widely accepted
more than 5 polyps were found in 25 grade. screening strategy some of them are
aCTa inFOrM MeD. 2013 Sep; 21(3): 166-169 / Original paper
168 Colonoscopic Polypectomies and Recommendations on the Colonoscopy Follow-up Intervals Depending on Endoscopic and Histopathological Findings
not found for too long, i.e. until they also to always improving therapy op- unreached cecum, the fact that there
turn malignant. If the polyps are tions, the CRC mortality has been are more sessile polyps in this area,
big, they can induce stomach pains slowly decreasing in the last 3-4 years. with the biggest problems being of
and spasms. Big villous polyps can An additional important factor are course the overlooked polyps (up to
also induce persistent diarrhea. Early the possible lifestyle changes in pol- 17%!) and an incomplete resection
carcinomas are found in only 18% ypectomized patients, who very often (up to 27% of new polyps are diag-
of patients, which is precisely why change their diets, intensify physical nosed in the same segment).
screening programs have been initi- activity, stop smoking, and often Complications which can occur
ated.7 take multivitamin preparations and during and following polypectomy
Polyps can grow at any age in both NSAIDs in order to prevent adenoma are bleeding and colon perforation
sexes, but are more common in per- reoccurrence and CRC development (14, 15). The endoscopist can stop
sons over 50. In almost one third of (11). the bleeding during the exam itself,
this group, routine and screening The risk of malignant alteration is and even smaller perforations can
colonoscopies show regular results. bigger if the polyps are larger in size be successfully solved by endoscopic
Pedunculated polyps present a much and villous in build, if there are more methods. Sometimes the patients still
smaller problem than the large ses- polyps and if cell atypia or dysplastic have to be surgically treated, which
sile polyps, which demand a polypec- changes are present. The National happened only once in two years in
tomy with a mucosectomy to be per- Programs of CRC Prevention are our Clinic, due to perforation.
formed, in order to avoid an incom- therefore today a generally accepted Due to all of the above it is neces-
plete resection and prevent the neo- strategy, however with growing at- sary to insist on the one hand on the
plastic tissue from remaining in the tention redirected to further moni- quality of colonoscopy, since endos-
colon wall (8). toring of polypectomized patients, copists with more discovered polyps
It is an undivided opinion that since they are under greater risk of and >95% cecum intubations have
screening for colon cancer decreases the growth of new polyps, and there less cases of CRC in control colo-
its fatality in two ways: by an early is always a possibility of overlooked noscopies, and on the other hand
discovery of malignant lesions, as or partially resected polyps. This ex- on monitoring polypectomized pa-
well as by removing polyps in their plains “new” polyps found in control tients according to the guidelines of
benign phase, thus preventing a pos- colonoscopies of 20-50% of patients competent operative groups (16). A
sible malignant alteration of some of who underwent polypectomy 3-5 situation similar to a published re-
them. The confirmation of the first years before that, with even 10% of search in the field of family medicine
claim was obtained relatively easy, in them being diagnosed also with CRC should not happen, where excessive
a shorter time period and on a smaller („interval CRCs”). Risk stratification monitoring of low risk patients after
number of patients, as patients tend has thus been defined depending on polypectomy was proven (20% those
to live significantly longer with CRC the number, size and histological without polyps and even 40% those
being discovered at an early stage. structure of the polyp (villous compo- with small tubular adenomas under-
Since the finding of adenomatous nent, high-grade dysplasia). In the re- went colonoscopy already after 1-3
polyps is a much more frequent search of Lieberman et al., a polyp >10 years), whereas as much as 40% of pa-
finding than CRC, the significance of mm increased the risk of new polyp tients with a high risk either did not
polypectomy on a later development growth after 5 years from 2.4 to 15.5% undergo colonoscopy in 5 years or it
of CRC, and the fatality it causes has (RR, 5.01; 95% CI, 2.10 –11.96) (12). was not even suggested to them (17)!
been analyzed. In both cases polyp- Similar results have been calculated Following a regular finding or a
ectomy had a distinctly protective ef- for the risk carried by 3 or more ade- finding of small hyperplastic polyps
fect (9, 10) which was visible already nomas (RR 2.52; 95% CI1.07-5.97) and during a high-quality first colonos-
after the first 10 years of monitoring, high-grade dysplasia (RR 1.84; 95% CI copy, and if there is no family burden,
since colonoscopies with polypec- 1.06-3.19). This is why the US Multi- a 10-year interval until the control
tomies had lowered the risk of CRC Society Task Force on Colorectal colonoscopy is enough. CRC diag-
development to the risk level of pa- Cancer has divided polypectomized nosed in a member of close family
tients who did not even have polyps patients into low (up to 2 polyps <10 who is under 60 years of age shortens
at colonoscopy! The authors explain mm) and high risk groups (polyp >10 that interval to two years.
such a good result also by the excel- mm and/or 3 or more polyps and/ High risk polyps need to be con-
lent conditions in which controlled or more pronounced villous compo- trolled in 3-year intervals. After the
randomized studies are usually per- nent and/or high-grade dysplasia) (1). resection of big polyps, controls are
formed (most experienced endosco- In the United Kingdom an additional best performed already after one
pists, enough time for bowel explora- group of medium risk has been strati- year. Patients should be monitored
tion, insisting on a total colonoscopy, fied with only one polyp >10 mm or according to guidelines up to the age
good patient preparation, and so on), 3-4 smaller ones (13). of 75, then up to the age of 85 single
which cannot always be achieved on CRCs discovered only 6 months to out only those patients which carry a
the conditions in actual clinical prac- 3 years after polypectomies are usu- higher risk, whereas monitoring pa-
tice. Precisely owing to early CRC de- ally in the proximal colon, which is tients over 85 is mostly not recom-
tection, polypectomies, but certainly explained by a poorer preparation, mended. If new symptoms charac-
Original paper / aCTa inFOrM MeD. 2013 Sep; 21(3): 166-169
Colonoscopic Polypectomies and Recommendations on the Colonoscopy Follow-up Intervals Depending on Endoscopic and Histopathological Findings 169
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aCTa inFOrM MeD. 2013 Sep; 21(3): 166-169 / Original paper
