Specialty endoscopy teams offer consults and interventions for difficult polyps

Most practiced endoscopists can safely remove small, low-risk gastrointestinal (GI) lesions. Polyps that are larger than 1 cm, difficult to elevate or adhere to underlying structures pose greater challenges and demand additional training and skill. Difficult polyps — those that are circumferential, involve more than one-third of the lumen, are close to critical areas, or have a high risk of bleeding or perforation — require the highest level of expertise.

At Mayo Clinic, specialists carefully assess all GI lesions and then refer patients to the providers best equipped to treat them. Central to this approach are advanced multidisciplinary teams that focus exclusively on difficult-to-resect lesions and post-procedural or post-surgical complications.

Gastroenterologist Navtej (Nav) S. Buttar, M.D., a member of the specialty endoscopic intervention team at Mayo's campus in Rochester, Minnesota, explains: "Most polyps that are easily removed in terms of size and location don’t reach us as referral cases. Within our own practice, however, we have many patients with low-risk lesions that any of our 50 consultants are well-trained to remove. Cases with a greater than average risk of complications are seen by one of 10 specialty consultants. And patients with a high risk of complications, existing post-procedural complications or very complex lesions are seen by my colleague Louis M. Wong Kee Song, M.D., or me."

At Mayo's campus in Jacksonville, Florida, a similar endoscopic team is led by Timothy A. Woodward, M.D., Michael B. Wallace, M.D., Massimo Raimondo, M.D., and Ernest P. Bouras, M.D., in partnership with surgical specialists.

Douglas O. Faigel, M.D., director of therapeutic endoscopy at Mayo's campus in Scottsdale, Arizona, leads the specialty endoscopy team there.

Polyp assessment

Case difficulty is determined by size, morphology, site and access to polyps. Endoscopic removal of polyps 2 cm or larger, for instance, is generally associated with a greater risk of bleeding and perforation and the possibility of inadequate polypectomy. Other difficult-to-resect lesions include sessile polyps that spread laterally and circumferentially along the colon wall, and polyps located in the duodenum or near the gastroesophageal junction, dentate line in the rectum or appendicular orifice.

Mayo Clinic specialists stress that highly trained luminal and biliary endoscopists with the ability to immediately address complications can remove most difficult polyps, even those larger than 2 cm, using novel devices and specialized endoscopic procedures.

"The lateral size is no longer a significant limitation as long as the polyp has not turned into a more invasive cancer, although very early cancers can be removed without surgery by the same techniques," Dr. Wallace explains. "Even the most advanced lesions such as early cancer can be removed using endoscopic mucosal dissection, a technique developed in Japan. Several Mayo Clinic physicians, including Dr. Wong Kee Song and myself have built strong collaborations for training with the Japanese developers."

24/7 access for complications

Specialty endoscopic intervention teams are available on a round-the-clock basis for consultations and referrals.

"Physicians whose patients have complications such as perforation can page us any time," say Drs. Buttar and Wallace. "We consult with our surgical and anesthesiology colleagues for potential backup, and then, if we can offer help, we will transfer the patient to Mayo. If it is not feasible to correct the problem endoscopically, surgery may be needed, but about 70 to 80 percent of cases can be treated with an endoscopic approach. This is particularly important for patients with comorbidities that make surgery risky and for those who have already had multiple surgeries because every time you operate, you increase the risk of complications."

When surgery is needed, surgeons perform minimally invasive procedures, thereby avoiding the major operations of the past.

Although endoscopic resection reduces hospitalization and recovery time, it has its own complications and risks. "We have specialists with great expertise in certain endoscopic procedures and surgeons and anesthesiologists as backup, so we are very confident managing difficult cases," Dr. Buttar says. "Nonetheless, we have extensive and candid discussions with patients and families. We inform them that the procedure we're considering carries a higher risk of complications than regular endoscopy, about 5 percent compared with 1 percent. On the other hand, surgery has a much higher risk of serious complications and mortality."

Multidisciplinary approaches

For certain challenging cases, an endoscopist and surgeon may operate in tandem. This novel approach is an option for lesions in areas that are anatomically challenging for surgery or endoscopy alone. Mayo Clinic specialists perform one or two of these hybrid procedures each week. More rarely, an interventional radiologist is also involved.

"Working in multidisciplinary teams with our surgeons and interventional radiologists, many complications such as perforation and abscesses as well as complications of pancreatitis can be managed with minimal invasiveness, shortening hospitalizations and improving outcomes," Dr. Faigel says.

Success rates for difficult polypectomies vary, depending on the size and location of lesions and underlying comorbidities, but even in the most complicated cases, the numbers are constantly improving. At Mayo Clinic's campus in Florida, the success rate for more than 2,000 cases is greater than 95 percent.