How Clinical Guidelines on Polyp Removal are Evolving

Jo Roth, Staff Writer

It is very much in the interests of both patients and clinicians to avoid surgery where possible. This reduces the risk of complications and provides a minimal impact on a patient’s quality of life as well as financial resources

Reducing the need for surgery in the removal of colonic polyps plays an important role in delivering improved outcomes for patients, but it has to be done safely.

VERY YEAR, thousands of patients around the world will undergo a procedure to have non-malignant polyps removed. In themselves, they are relatively harmless but in a small minority of cases they could lead to bowel cancer. Removal is recommended, but when polyps are large or in an anatomically hard to reach position, managing the procedure can be challenging. This has significant safety issues for patients and also leads to increased intervention costs for health services.

Endoscopic Removal

A doctor will use an endoscopic procedure to remove polyps within the bowel in the least invasive way possible. However, problems grow when things get more complicated. Current NICE guidelines raise major safety concerns about the removal of full thickness non-lifting colonic polyps¹. NICE argues that current evidence is lacking in quality and quantity and, as such, the procedure should not be used unless there are special arrangement made for clinical governance, the patient has given full consent and an audit or research has been undertaken.

It makes the following recommendations for any clinicians wishing to do full thickness polyp removal:

  • Inform the clinical governance leads in their NHS Trusts.
  • Ensure that patients understand the uncertainty about the procedure’s safety and efficacy and provide them with clear written information. In addition, the use of NICE’s information for the public is recommended².
  • Audit and review clinical outcomes of all patients having endoscopic full thickness removal of non-lifting colonic polyps.

Patient selection, says the guidelines, “should only be done with polyp and early colorectal cancer multidisciplinary team, and the procedure should only be performed by clinicians with specific training.”

When cases become more complex, clinicians may veer towards the apparently safer option of surgery. This will normally involve a small incision into the side of the abdomen. Small tools will then be inserted laparoscopically into the abdomen which is expanded with carbon dioxide. Evidence from NICE suggests that this has a high success rate. They analysed a total of nine studies involving a total of 781 patients which showed that polyps were successfully removed in most patients. A study of 176 patients found no polyps had returned after five years. Another study of 146 patients found one polyp had returned after two years. However, there are risks.

  • 14 patients developed an infection at the laparoscopic wound site.
  • Four patients developed an abscess in the abdomen. Three of them managed to have this abscess drained while one required another operation.
  • Two patients had problems emptying their bladder and four struggled with their bowels.
  • Nine patients had a collapse of all or part of their lung, which may have been caused either by the anaesthetic or the carbon dioxide used as part of the laparoscopy.
  • One patient had bleeding which needed further treatment and three patients had a build-up of clear bodily fluid in the place where the polyp had been removed³.

The studies analysed by NICE also show that seven patients had to be switched to open surgery during the procedure. This may be necessary in more advanced cases which need a larger incision in the abdomen. The surgeon then removes part of the colon to fully ensure all of the polyps and any associated cancer have been removed.

The problem is that the greater the level of intervention, the more likely it is that complications will set in. Much depends on the experience of the surgeons. A 2013 study published by Digestive Surgery covering 126 patients over the course of ten years found post-operative complications in a third of cases4.

Recovery time can also vary depending on the extent of the procedure. A basic polypectomy should last between 30 and 60 minutes and most patients will be allowed to return home the same day. A larger polyp removal may require surveillance for three to six months to ensure there is no tissue remaining.

When surgery is required, patients may need several days of rest in the hospital to recover, but this may be significantly longer if complications set in. These can include paralysis of the gut resulting from the unnatural insertion of tools into the abdomen, which can take several days to resolve.

Deciding on the Best Course of Action

The more invasive the intervention, then, the greater the recovery time and the higher the impact on healthcare resources. When planning treatments, clinicians will have to weigh up multiple factors including the risks of an endoscopic procedure for larger non-lifting polyps, the pitfalls of surgery and the likely recovery time of patients.

In making this decision, clinicians may consider the wishes of the patient. It is natural for anyone to want to avoid the risks of open surgery so there is always likely to be a push, from the patient’s side, towards minimally invasive procedures which may allow them to return to their regular daily routines as soon as possible. However, all patients will have to be made aware of the risks each option poses.

It is very much in the interests of both patients and clinicians to avoid surgery where possible. This reduces the risk of complications and provides a minimal impact on a patient’s quality of life as well as financial resources. Even so, this must never put the health and wellbeing of patients at risk. The study published by Digestive Surgery recommends that all “clinical pathways chosen to treat colonoscopically unresectable polyps should be tailored to patients’ conditions and the characteristics of their colorectal lesions.” Patients and their families will need an in-depth discussion about the various options available to them.

Reducing the Need for Surgery

Increasingly, though, various procedures are coming to the fore which widen the range of situations in which less invasive procedures may work effectively. These make it possible to treat more complex and harder to reach cases without needing to revert to more invasive surgical procedures. They reduce the need for surgery, which in turn reduces the length of hospital stay and also improves outcomes. As these options become more widespread, they will help health services deliver top quality care in a way which reduces the strain on their budgets.

  1. Endoscopic Removal of Full Thickness Non-Lifting Colonic Polyps: https://www.nice.org.uk/guidance/ipg580/chapter/1-Recommendations
  2. Endoscopic Full Thickness Removal of Non-Lifting Colonic Polyps – information for the public: https://www.nice.org.uk/guidance/IPG580/InformationForPublic
  3. Combined Endoscopic and Laparoscopic Removal of Polyps. Benefits and Risks: https://www.nice.org.uk/guidance/ipg503/ifp/chapter/Benefits-and-risks
  4. Undergoing Surgical Resection for Large Polyps: https://www.ncbi.nlm.nih.gov/pubmed/24192456
Healthcare costs have risen dramatically over the past few years and are set to continue to do so. The next few decades, therefore, will be marked by a rapid and accelerating increase in the cost of care.