Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA.
Division of Gastroenterology and Hepatology, University of Colorado and Veterans Affairs Medical Center, Denver, Colorado, USA.
Am J Gastroenterol. 2014 Sep;109(9):1312-24. doi: 10.1038/ajg.2014.95. Epub 2014 Jul 8.
The management of complex colorectal polyps varies in practice. Accurate descriptions of the endoscopic appearance by using a standardized classification system (Paris classification) and size for complex colon polyps may guide subsequent providers regarding curative endoscopic resection vs. need for surgery. The accuracy of this assessment is not well defined. Furthermore, the factors associated with decisions for endoscopic vs. surgical management are unclear. To characterize the accuracy of physician assessment of polyp morphology, size, and suspicion for malignancy among physician subspecialists performing colonoscopy and colon surgery. In addition, we aimed to assess the influence of these polyp characteristics as well as physician type and patient demographics on recommendations for endoscopic vs. surgical resection of complex colorectal polyps.
An online video-based survey was sent to gastroenterologists (GIs) and gastrointestinal surgeons affiliated with six tertiary academic centers. The survey consisted of high-definition video clips (30-60 s) of six complex colorectal polyps (one malignant) and clinical histories. Respondents were blinded to histology. Respondents were queried regarding polyp characteristics, suspicion for malignancy, and recommendations for resection.
The survey response rate was 154/317 (49%). Seventy-eight percent of respondents were attending physicians (91 GIs and 29 surgeons) and 22% were GI trainees. Sixteen percent of respondents self-identified as specialists in complex polypectomy. Accurate estimation of polyp size was poor (28.4%) with moderate interobserver agreement (k=0.52). Accuracy for Paris classification was 47.5%, also with moderate interobserver agreement (k=0.48). Specialists in complex polypectomy were most accurate, whereas surgeons were the least accurate in assigning Paris classification (66.0 vs. 28.7%, P<0.0001). Specialists in complex polypectomy were most likely to correctly identify the malignant lesion compared with other physicians (87.5 vs. 56.2%, P=0.008). Surgical removal of colon adenomas was recommended least frequently by specialists in complex polypectomy (3.1%) compared with nonspecialists in complex polypectomy (13.3%); surgeons were most likely to recommend surgical resection (17.2%, P=0.009). There were no differences in recommendations for endoscopic vs. surgical resection observed on the basis of years in practice, polyp morphology (polypoid vs. nonpolypoid), polyp location (right vs. left colon), or patient ASA class.
In this large survey of GIs and surgeons, physician specialty was strongly associated with accurate polyp characterization and a recommendation for endoscopic resection of complex polyps. Surgeons were most likely to recommend surgical resection of complex nonmalignant colorectal polyps compared with specialists in complex polypectomy who were the least likely. Therefore, collaboration with specialists in complex polypectomy may be helpful in determining the appropriate management of complex colon polyps. Further teaching is needed among all specialists to improve accurate communication and ensure optimal management of these lesions.
复杂结直肠息肉的处理方式存在差异。使用标准化分类系统（巴黎分类）准确描述息肉的内镜下表现和大小，可能有助于后续提供者确定是否进行有治愈可能的内镜下切除或需要手术。然而，这种评估的准确性尚未明确。此外，关于内镜治疗与手术治疗决策的相关因素也不清楚。本研究旨在描述行结肠镜检查和结肠手术的医师亚专科医生对息肉形态、大小和恶性怀疑的评估准确性。此外，我们还旨在评估这些息肉特征以及医生类型和患者人口统计学特征对复杂结直肠息肉内镜与手术切除建议的影响。
向 6 家三级学术中心的胃肠病学家（GI）和胃肠外科医生发送了一项基于在线视频的调查。该调查由 6 个复杂结直肠息肉（1 个恶性）和临床病史的高清视频片段（30-60 秒）组成。调查对象对组织病理学结果不知情。调查对象被询问有关息肉特征、恶性怀疑和切除建议。
调查回复率为 154/317（49%）。78%的调查对象为主治医生（91 名 GI 和 29 名外科医生），22%为 GI 培训医生。16%的调查对象自认为是复杂息肉切除术的专家。对息肉大小的准确估计较差（28.4%），观察者间一致性中等（k=0.52）。巴黎分类的准确性为 47.5%，观察者间一致性也中等（k=0.48）。复杂息肉切除术专家对巴黎分类的评估最准确，而外科医生的评估最不准确（66.0%比 28.7%，P<0.0001）。与其他医生相比，复杂息肉切除术专家更有可能正确识别恶性病变（87.5%比 56.2%，P=0.008）。复杂息肉切除术专家推荐结肠腺瘤切除的频率最低（3.1%），而非复杂息肉切除术专家的推荐频率最高（13.3%）；外科医生最有可能推荐手术切除（17.2%，P=0.009）。在实践年限、息肉形态（息肉样与非息肉样）、息肉位置（右结肠与左结肠）或患者 ASA 分级方面，内镜与手术切除建议均无差异。
在这项对胃肠病学家和外科医生的大型调查中，医生的专业领域与准确的息肉特征描述和对复杂息肉的内镜切除建议强烈相关。与复杂息肉切除术专家相比，外科医生最有可能推荐对复杂非恶性结直肠息肉进行手术切除，而复杂息肉切除术专家最不可能。因此，与复杂息肉切除术专家合作可能有助于确定复杂结肠息肉的适当治疗方法。所有专家都需要进一步接受教育，以提高准确沟通的能力，并确保这些病变的最佳管理。
