Evaluation of a progressive algorithmic approach for the treatment of unresectable colon polyps using colon conservation techniques

BACKGROUND The majority of endoscopically unresectable colon polyps (EUCP) are treated by segmental colectomy. However, up to 90% of EUCP do not harbor malignancy, making colectomy an unnecessary procedure. To minimize unnecessary segmental colectomy, we established a progressive treatment algorithm utilizing colon conservation techniques (CCT). In our progressive CCT algorithm, patients with EUCP first underwent endoscopic submucosal dissection (ESD). If unsuccessful, they progressed to combined endo-laparoscopic surgery (CELS) and ultimately to segmental colectomy, if necessary. METHODS We performed a retrospective analysis of all patients treated by our progressive CCT algorithm from August 2015 to April 2019. Demographic information, polyp characteristics, and clinical outcomes were analyzed. We also compared the outcomes of our CCT algorithm group to 156 patients undergoing segmental colectomy for EUCP at related institutions from August 2015 to August 2018. RESULTS A total of 102 EUCP in 97 patients were treated with our progressive CCT algorithm. Of these, 76 of 102 (75.5%) EUCP were removed without requiring segmental colectomy, with 42 EUCP removed via ESD and 34 via CELS. Interval surveillance colonoscopy confirmed that 72 of 97 (74.2%) patients with EUCP treated by CCT completely avoided segmental colectomy. Polyps > 5 cm in size was a significant predictor of CCT failure (OR 3.83, P = 0.03). When compared to an external cohort of patients undergoing segmental colectomy for EUCP, the CCT algorithm was associated with longer operative time, but shorter length of stay, with no difference in postoperative complications. The estimated total healthcare cost of the CCT algorithm was lower than segmental colectomy ($10,956.77 versus $16,692.94), with more dramatic cost savings seen in ESD ($4,492.70) and CELS ($8,507.06). CONCLUSIONS An established progressive CCT algorithm can result in high colon conservation rate and decrease associated health care costs compared to segmental colectomy. It is a reasonable treatment strategy for patients with EUCP.