Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon

Golo Ahlenstiel; Luke F Hourigan; Gregor Brown; Simon Zanati; Stephen J Williams; Rajvinder Singh; Alan Moss; Rebecca Sonson; Michael J Bourke; Australian Colonic Endoscopic Mucosal Resection (ACE) Study Group

doi:10.1016/j.gie.2014.04.015

Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon

Gastrointest Endosc. 2014 Oct;80(4):668-676. doi: 10.1016/j.gie.2014.04.015. Epub 2014 Jun 7.

Authors

Golo Ahlenstiel¹, Luke F Hourigan², Gregor Brown³, Simon Zanati⁴, Stephen J Williams⁵, Rajvinder Singh⁶, Alan Moss⁷, Rebecca Sonson⁵, Michael J Bourke¹; Australian Colonic Endoscopic Mucosal Resection (ACE) Study Group

Affiliations

¹ Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia.
² Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; Department of Gastroenterology and Hepatology, Greenslopes Private Hospital, Brisbane, Queensland, Australia.
³ Department of Gastroenterology and Hepatology, The Alfred Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Epworth Hospital, Melbourne, Victoria, Australia.
⁴ Department of Gastroenterology and Hepatology, The Alfred Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia.
⁵ Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.
⁶ Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia; Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Adelaide, South Australia, Australia.
⁷ Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Department of Gastroenterology and Hepatology, Western Hospital, Melbourne, Victoria, Australia.

PMID: 24916925
DOI: 10.1016/j.gie.2014.04.015

Abstract

Background: EMR of advanced mucosal neoplasia (AMN) (ie, sessile or laterally spreading lesions of ≥20 mm) of the colon has become an increasingly popular alternative to surgical resection. However, data regarding safety and mortality of EMR in comparison to surgery are limited.

Objective: To compare actual endoscopic with predicted surgical mortality.

Design: Prospective, observational, multicenter cohort study.

Setting: Academic, high-volume, tertiary-care referral center.

Patients: Consecutive patients referred for EMR.

Intervention emr main outcome measurements: To predict hypothetical surgical mortality, the Association of Coloproctology of Great Britain and Ireland score, composed of physiological and surgical components, was calculated for each patient. Predicted surgical mortality was then compared with actual outcomes of EMR. The results were validated by an unselected subcohort by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity.

Results: Among 1050 patients with AMN treated by EMR, including patients with a predicted mortality rate of greater than 5% (13.8% of cohort), no deaths occurred within 30 days after the procedure. The predicted surgical mortality rate was 3.3% with the Association of Coloproctology of Great Britain and Ireland score (P < .0001). This suggests a significant advantage of EMR over surgery. The results were validated by using the Colorectal Physiologic and Operative Severity Score for Enumeration of Mortality and Morbidity in 390 patients predicting a surgical mortality rate of 3.2% (P = .0003).

Limitations: Nonrandomized study.

Conclusion: In this large multicenter study of EMR for colonic AMN, the predicted surgical mortality rate was significantly higher than the actual endoscopic mortality rate. Given that endoscopic therapy is less morbid and less expensive than surgery and can be performed as an outpatient treatment, it should be considered as the first line of treatment for most patients with these lesions.

Publication types

Comparative Study
Multicenter Study
Observational Study

MeSH terms

Adult
Aged
Aged, 80 and over
Australia
Cause of Death*
Cohort Studies
Colonic Neoplasms / mortality*
Colonic Neoplasms / pathology
Colonic Neoplasms / surgery*
Colonoscopy / methods
Colonoscopy / mortality*
Disease-Free Survival
Education, Medical, Continuing
Female
Humans
Intestinal Mucosa / pathology
Intestinal Mucosa / surgery*
Male
Middle Aged
Neoplasm Invasiveness / pathology
Neoplasm Staging
Predictive Value of Tests
Prospective Studies
Risk Assessment
Survival Analysis