Compounding factors influence polypectomy risk, adverse outcomes
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Polypectomy entails a “higher risk” with factors such as polyp, patient and physician characteristics as well as polyp indication influencing procedure outcomes, according to a speaker.
“The reason we have this talk is because we think of polypectomy as entailing higher risk, of course,” Thomas Attard, MD, pediatric gastroenterologist at Children’s Mercy Kansas City, said at the North American Society for Pediatric Gastroenterology, Hepatology & Nutrition Annual Meeting. “Adult data suggests that bleeding happens as often as 1% and from the adult data as well we get perforation risks in the order of 1.1%; in that group of patients, we also find a fatality rate of up to 5%.”
Among pediatric patients, small studies have demonstrated polypectomy-associated perforations occurred in 0.07% to 6.7%, with all therapeutic endoscopy outcomes yielding a complication rate of 0.7% and a mortality rate of 0.01%, Attard said. Though in gastroenterology practice 10% to 15% of polyps are deemed “difficult” due to polyp size, location, morphology and quantity, factors that influence post-procedure complications go beyond the polyp itself.
According to Attard, polypectomy entails an increased risk of 2.67 (95% CI, 1.01-7.03) for bleeding compared with routine colonoscopy, which only increases to a 3.23 times higher risk for bleeding among pediatric patients aged 0 to 10 years compared with patients aged 11 to 17 years (95% CI, 1.52-6.83).
Another high-risk factor are the physicians themselves, where high-volume polypectomy rates ( 300 per year) correlated with a decreased rate of adverse events (OR = 1-1.4). Further, additional physician variability factors that impact performance are positioning and poly view, the ability to determine the full extent of the polyp, stable endoscopy position, remnant polyp examination and accurate snare placement for sessile polyps.
“Polyp risk can be defined by the type of syndrome that you’re dealing with. With familial adenomatous polyposis, thankfully, we’re dealing with an older patient with smaller polyps, but they do tend to be multiple and entail an adenoma risk,” Attard said. “Peutz-Jeghers syndrome really, nothing on the positive side, any age and usually a difficult location in the small intestine. Juvenile polyposis syndrome: younger patients tending to have a lot larger polyps but ones that you can come back and second time or third time to remove as the as the months or years go by.”
Attard’s take-home points for optimal polypectomy procedure follow.
- Define the indication for polypectomy.
- Anticipate and prepare for the technique you will use.
- Assess the polyp histology as well as the polypectomy stalk.
- Determine any and all prophylactic measures.
- Know your limits and ask for help.
Perspective
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Deborah A. Goldman, MD
Endoscopic procedures have been safely performed in children for decades with a relatively low rate of complications. However, there are certain clinical scenarios that can potentially increase the risks for adverse events, such as perforation and bleeding. In general, when performing colonoscopy in both adults and children, the major complications include bleeding and perforation, the incidence of which increases significantly when a polypectomy is performed. Clinical judgment and experience are essential in performing a polypectomy and treating these complications.
The majority of colonoscopy with polypectomy in adults is performed for colorectal screening. However, in children a colonoscopy with polypectomy is often performed for juvenile polyps or as part of hereditary polyposis syndrome. The majority of pediatric polyps are benign and often present with hematochezia. In a report from Pediatric Endoscopy Database System-Clinical Outcomes Research Initiative, the overall rate of complications during colonoscopy in children was 1.1% with most adverse events associated with polypectomy. To minimize this risk, the pediatric endoscopist needs to be cognizant of several procedural elements to ensure that the procedure is performed safely. These factors include:
- A well-prepped colon, devoid of fecal debris;
- Assessment of the patient’s inherent risk for bleeding, which may include a CBC and INR;
- Good endoscopic technique with avoidance of excessive insufflation, looping and torque on the scope;
- Positioning the polyp in the 5-7 o’clock position to allow ease of polypectomy snare placement;
- Placement of the snare close to the polyp head or mid-stalk region to avoid thermal injury to the bowel wall;
- Lifting the stalk prior to electrocautery with appropriate passage of current through the stalk; and
- Having readily available epinephrine (1:10,000) and hemostatic clips, which may reduce post-polypectomy risks.
In conclusion, the pediatric endoscopist needs to be aware of requisites for quality and safety for all endoscopic procedures, and proactive steps should be taken before, during and after the procedure to minimize risks. The incidence of complications is highest with polypectomy and therefore knowledge, judgment and procedural skills are of paramount importance.
Reference:
Kay M, et al. J Pediatr Gastroenterol Nutr. 2020;doi:10.1097/MPG.0000000000002591.
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Attard T. The difficult polyps: Too big, too flat, too many. Presented at: North American Society for Pediatric Gastroenterology, Hepatology & Nutrition Annual Meeting; Dec. 12-18, 2021 (virtual meeting).
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