Management of Polyps

Part of the controversy regarding the management of polypoid lesions found in UC patients is embedded in the nomenclature associated with IBD neoplasia. Until recently, the finding of a dysplasia-associated lesion or mass (DALM) in the colon has been considered an indication for colec-tomy; however, the dilemma arises when trying to differentiate a sporadic adenoma (removed by polypectomy) from a DALM (requires colectomy). Many UC patients undergoing surveillance are in the age range to have a 30% probability of sporadic adenoma. There are many approaches to the problem of polypoid lesions in the IBD patient. One approach is to perform a polypectomy on lesions that arise in a field of normal colon (IBD-free) and a colectomy for dys-plastic lesions that arise in a field of colitis. This approach is based on the concern that occult cancer is present, either in the lesion itself or elsewhere in the colon. The problem of this approach is that colectomies will be performed on many patients who would otherwise have a benign course. The reason for this problem is, again, one of sampling error; if the endoscopist fails to remove the entire lesion for full histo-logic examination and/or fails to take sufficient biopsies to find dysplasia in the remaining colon, then a missed diagnosis of HGD or cancer can occur.

An alternative approach is the performance of a complete colonoscopic resection of sessile and pedunculated polyps, regardless of whether they occur in IBD-affected colon or not, while at the same time taking sufficient numbers of biopsies to evaluate the remaining colon (Figure 83-2). If the biopsies of the lesion reveal invasive adenocarcinoma (AC) or if biopsies of the flat mucosa reveal dysplasia, then a colectomy is warranted. If histologic examination of the polyp reveals a completely resected dysplastic lesion, and if the remaining colon is dysplasia-free, then the patient should have a repeat surveillance colonoscopy in 1 year. Two recent studies have

Polyp or nodule

Cannot be completely removed endoscopically due to size, location or technical problem

Completely excised endoscopically; biopsies taken throughout the remaining colon

Colectomy

Cancer present in lesion or margins not clear; HGD present in remaining colon

Dysplasia in lesion with clear margins; remaining colon shows no dysplasia or cancer

Repeat surveillance in 1 year

FIGURE 83-2. Management of polypoid lesions. HGD = high grade dysplasia.

used this paradigm. The studies involved 24 and 73 polypoid lesions, respectively, from colitic sites (Engelsgjerd et al, 1999; Rubin et al, 1992). A large number of the polypoid lesions were sessile. Approximately half of the patients had recurrent polyps on follow-up colonoscopy, often in the same location, which required repeated polypectomy. However, the patients had a benign course; no patients developed cancer and few patients developed flat dysplasia outside the polypoid lesion.

We use this strategy for management of polypoid lesions and have found it to be successful (ie, patients have not developed cancer and have avoided colectomy), provided that the entire lesion is excised with clean margins and the patient continues in annual surveillance. If patients have dysplasia both in a polyp and in flat mucosa, colectomy should be considered. Please refer to Chapter 6 "Endoscopic Mucosal Resection" which is relevant to this discussion.

Constipation Prescription

Constipation Prescription

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