From the Journals

Nonendoscopic nonmalignant polyp surgery increasing despite greater risk


Key clinical point: Surgical resections for nonmalignant colorectal polyps are increasing while safer endoscopic procedures are available.

Major finding: Incidence rate of surgery for nonmalignant polyps has increased from 5.9 to 9.4 per 100,000 adults from 2000 to 2014.

Study details: A retrospective study of 1,230,458 surgeries recorded in the Healthcare Cost and Utilization Project National Inpatient Sample from 2000 to 2014.

Disclosures: The authors reported no relevant financial disclosures.

Source: Peery A et al. Gastroenterology. 2018 Jan 6. doi: 10.1053/j.gastro.2018.01.003.

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Management of complex colon polyps 

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.



Rate of nonendoscopic surgeries for nonmalignant colorectal polyps significantly increased from 5.9 to 9.4 per 100,000 people from 2000 to 2014, according to a study in Gastroenterology.

These surgeries are not only associated with a much higher risk to patients than endoscopic procedures, but they are significantly less cost effective, confusing investigators as to the cause of the increase.

“The literature to date is clear that endoscopic resection is the preferred management of nonmalignant colorectal polyps,” Anne Peery, MD, gastroenterologist at the University of North Carolina at Chapel Hill, and colleagues explained. “Among patients who have surgery for a nonmalignant colorectal polyp, 14% will have at least one major short-term postoperative event.”

Data from 1,230,458 surgeries conducted during 2000-2014 and recorded in the Healthcare Cost and Utilization Project National Inpatients Sample were included in this study. Patients who underwent a nonendoscopic procedure for nonmalignant polyps were predominantly non-Hispanic white, covered by Medicare, from the highest household income range, and an average age of 66 years.

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