2939 Outcomes of Patients with Large Colonic Polyps Referred to a Tertiary Center for Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

INTRODUCTION: Large colonic polyps (>2 cm), flat or sessile, are difficult to remove by endoscopy. These difficult polyps are usually referred to experienced advanced endoscopists for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). There is no data regarding outcomes of referred polypectomies to a tertiary care center for endoscopic management. We aimed to examine outcomes of patients referred to a tertiary center for EMR and ESD and thereby provide feedback to referring physicians. METHODS: A retrospective study of patients with difficult polyps referred to an experienced advanced endoscopist at a large academic center for EMR and ESD between February 2016-August 2018 was completed. 141 referred patients were enrolled. Charts were reviewed for outcomes including: procedure setting, procedure type, need for surgical consult, duration, complete removal, complications, antibiotic use, hospital days, pathology, and repeat colonoscopy findings. RESULTS: The average size of referred polyps was 3.39 cm, with most being flat or sessile. Procedures were largely performed in the surgical ambulatory center. EMR constituted the majority of procedures, followed by ESD, and snare cautery polypectomy. Complete removal with first session colonoscopy was originally noted with 87% of polyps. For this group, mean procedure time was 47 minutes with a complication rate of 8.9%, consisting mainly of hematochezia. Of this subset of patients, 46.4% had a repeat colonoscopy/pathology at time of study with majority of findings unremarkable. When accounting for residual polyps on repeat colonoscopy, 62.4% of patients had complete removal at first colonoscopy. Overall, 7.8% required a surgical consult. Most patients did not require hospitalization after procedure or antibiotics. Comparative analysis revealed no significant difference between different techniques. CONCLUSION: Most polypectomies referred to an experienced advanced endoscopist for EMR and ESD can be performed in an outpatient ambulatory surgical center. Most of the polyps were removed by EMR. ESD was performed in a small percentage of patients. Currently there are no guide lines regarding what kind of polyps should be referred. The majority of referred difficult polyps were completed removed at the first colonoscopy within a relatively short procedure time. At least a portion of those polyps should be able to be resected at the index colonoscopy, without referral, to reduce health care cost and patient inconvenience.