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Setting up a regional expert panel for complex colorectal polyps

Open AccessPublished:February 09, 2022DOI:https://doi.org/10.1016/j.gie.2022.02.003

      Background and Aims

      Advanced endoscopic resection techniques for complex colorectal polyps have evolved significantly over the past decade, leading to a management shift from surgical to endoscopic resection as the preferred treatment. However, in practice, interhospital consultation and appropriate referral management remain challenging, leading to unnecessary surgical resections. To support regional care for patients with complex colorectal polyps, facilitate peer consultations, and lower thresholds for referrals, an expert panel consultation platform was initiated in the northwestern region of the Netherlands.

      Methods

      We initiated a regional expert panel in the northwestern region of the Netherlands for patients with complex colorectal polyps and studied the implementation, adaption, and clinical impact. All panel consultations between June 2019 and May 2021 were retrospectively analyzed, and user satisfaction among panel members was evaluated.

      Results

      Eighty-eight patients with complex colorectal polyps from 11 of 15 participating centers (73.3%) were discussed in our panel. The most common reason for panel consultation was suspicion of invasive cancer in 36.4% (n = 32). After panel consultation, 43.2% of the consulting endoscopists (n = 38) changed their initial treatment strategy, and in 63.6% (n = 56) patients were referred to another endoscopy center. Of 26 cases submitted with a primary proposal for surgical treatment, surgery was avoided in 7 (26.9%). User satisfaction was rated high in most participating centers (91.7%).

      Conclusions

      Our study shows that implementation of and consultation with a regional expert panel can be a valuable tool for endoscopists to guide and optimize treatment of complex colorectal polyps and facilitate interhospital referrals in a regional network.

      Graphical abstract

      Abbreviations:

      CRC (colorectal cancer), eFTR (endoscopic full-thickness resection), ESD (endoscopic submucosal dissection), SMSA (size, morphology, site, access)
      Endoscopic polypectomy reduces incidence and mortality of colorectal cancer (CRC).
      • Zauber A.G.
      • Winawer S.J.
      • O'Brien M.J.
      • et al.
      Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.
      Most colorectal polyps are small and can be readily removed by conventional snare resection methods by every endoscopist with low adverse event rates.
      • Vermeer N.C.
      • Snijders H.S.
      • Holman F.A.
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      Colorectal cancer screening: systematic review of screen-related morbidity and mortality.
      ,
      • Winawer S.J.
      • Zauber A.G.
      • Ho M.N.
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      Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.
      However, for a subset of colorectal polyps, advanced endoscopic resection techniques are required. These so-called complex colorectal polyps are either large, located at a difficult anatomic location, have had a previous failed attempt at endoscopic resection, look suspicious for malignancy, or have a combination of these 4 factors.

      Nederlandse Vereniging van Maag- D-eL. Nederlandse richtlijn Endoscopische poliepectomie van het colon. 2019. Available at: https://mdl.nl. Accessed June 1, 2022.

      Historically, these complex nonmalignant polyps were managed by colorectal surgery.
      • Ferlitsch M.
      • Moss A.
      • Hassan C.
      • et al.
      Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
      ,
      • Rutter M.D.
      • Chattree A.
      • Barbour J.A.
      • et al.
      British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps.
      However, colorectal surgery for nonmalignant polyps is associated with higher morbidity and mortality rates compared with more recently introduced advanced endoscopic resection techniques.
      • Vermeer N.C.A.
      • de Neree Tot Babberich M.P.M.
      • Fockens P.
      • et al.
      Multicentre study of surgical referral and outcomes of patients with benign colorectal lesions.
      • de Neree Tot Babberich M.P.M.
      • Bronzwaer M.E.S.
      • Andriessen J.O.
      • et al.
      Outcomes of surgical resections for benign colon polyps: a systematic review.
      • Peery A.F.
      • Shaheen N.J.
      • Cools K.S.
      • et al.
      Morbidity and mortality after surgery for nonmalignant colorectal polyps.
      Over the past decade, a management shift has occurred from surgery to minimally invasive resection techniques such as piecemeal EMR, endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (eFTR).
      • Ferlitsch M.
      • Moss A.
      • Hassan C.
      • et al.
      Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
      These advanced endoscopic alternatives are proven to be safe and effective for complex colorectal polyps.
      • Zwager L.W.
      • Bastiaansen B.A.J.
      • Bronzwaer M.E.S.
      • et al.
      Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry.
      • Hassan C.
      • Repici A.
      • Sharma P.
      • et al.
      Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis.
      • Arezzo A.
      • Passera R.
      • Marchese N.
      • et al.
      Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions.
      However, additional training and expertise are necessary, and a limited number of expert endoscopists perform these complex resections. A prospective study showed that after endoscopic reassessment by an expert endoscopist, surgery could be avoided in 70% of patients with complex colonic polyps without biopsy sample–proven cancer.
      • Friedland S.
      • Banerjee S.
      • Kochar R.
      • et al.
      Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer.
      Therefore, the most recent guidelines advise that advanced colorectal polyps that are assessed as nonmalignant should not be referred for surgery without consultation with an expert endoscopist for assessment of endoscopic treatment possibilities.
      • Ferlitsch M.
      • Moss A.
      • Hassan C.
      • et al.
      Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
      ,
      • Rutter M.D.
      • Chattree A.
      • Barbour J.A.
      • et al.
      British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps.
      However, at many centers, patients with complex colorectal polyps are rarely referred to an expert endoscopist.
      • Bronzwaer M.E.S.
      • Koens L.
      • Bemelman W.A.
      • et al.
      Volume of surgery for benign colorectal polyps in the last 11 years.
      Multiple studies have shown that the rate of referrals for surgery is only slowly decreasing.
      • Vermeer N.C.A.
      • de Neree Tot Babberich M.P.M.
      • Fockens P.
      • et al.
      Multicentre study of surgical referral and outcomes of patients with benign colorectal lesions.
      ,
      • Bronzwaer M.E.S.
      • Koens L.
      • Bemelman W.A.
      • et al.
      Volume of surgery for benign colorectal polyps in the last 11 years.
      • van Nimwegen L.J.
      • Moons L.M.G.
      • Geesing J.M.J.
      • et al.
      Extent of unnecessary surgery for benign rectal polyps in the Netherlands.
      • Peery A.F.
      • Cools K.S.
      • Strassle P.D.
      • et al.
      Increasing rates of surgery for patients with nonmalignant colorectal polyps in the United States.
      Potential reasons for these low referral rates are that not every endoscopist is aware of the available advanced techniques or may also have a high threshold to consult expert endoscopists.
      Initiation of a digital expert panel that can be consulted by sharing clinical details of patients and their endoscopic images may facilitate structured peer consultation, increase knowledge on therapeutic possibilities, and potentially reduce the number of unnecessary surgical interventions or inappropriate endoscopic interventions for complex colorectal polyps. This could have an important impact on the care for these patients both by assisting physicians to have informed discussions with their patients with regard to optimal management selection and to ease referral pathways. In other areas of medicine, expert panels have resulted in improved patient care and demonstrated their effectiveness.
      • de Swart M.E.
      • Kouwenhoven M.C.M.
      • Hellingman T.
      • et al.
      A multidisciplinary neuro-oncological triage panel reduces the time to referral and treatment for patients with a brain tumor.
      • Hellingman T.
      • de Swart M.E.
      • Joosten J.J.A.
      • et al.
      The value of a dedicated multidisciplinary expert panel to assess treatment strategy in patients suffering from colorectal cancer liver metastases.
      • van Grinsven J.
      • van Brunschot S.
      • van Santvoort H.C.
      • et al.
      The value of a 24/7 online nationwide multidisciplinary expert panel for acute necrotizing pancreatitis.
      For example, the expert panel launched by the Dutch Pancreatitis Study Group was shown to be a valuable tool for clinicians of patients with pancreatitis.
      • van Grinsven J.
      • van Brunschot S.
      • van Santvoort H.C.
      • et al.
      The value of a 24/7 online nationwide multidisciplinary expert panel for acute necrotizing pancreatitis.
      However, experiences and the potential benefits for implementation of a regional expert panel for complex colorectal polyps have not been studied. To aid peer consultation and optimize management for patients with complex colorectal polyps in our region, we have designed and implemented a regional complex polyp expert panel. This study aims to describe the implementation and adaption of this regional expert panel.

      Methods

      Set up and methodology of the expert panel

      In June 2019, a secure online regional expert panel was launched that was freely accessible to all endoscopists in the northwestern region of the Netherlands. This area covers 2 academic and 10 regional hospitals and 3 private endoscopy services. Gastroenterologists of all centers (academic and regional) with special interest in treating complex colorectal polyps were invited to participate. In total, 16 gastroenterologists from 13 centers confirmed their participation in the expert panel. All gastroenterologists participated voluntarily.
      All regional endoscopists were encouraged to submit their cases online for advice from the expert panel. To obtain information on the complexity of the colorectal polyps and patients’ general health status, the following data were collected: patient characteristics (eg, year of birth, gender, American Society of Anesthesiologists class), previous colonic interventions, colonoscopy characteristics, lesion characteristics, recent endoscopic attempts, and available histology. The consulting endoscopist was asked which treatment would have been proposed when panel consultation was not available. Based on the submitted information, the SMSA score (size, morphology, site, access) was automatically calculated by allocating points. The points were added to grade the lesion into 1 of 4 SMSA levels, with level 1 being very easy and level 4 being very difficult to resect.
      • Gupta S.
      • Miskovic D.
      • Bhandari P.
      • et al.
      A novel method for determining the difficulty of colonoscopic polypectomy.
      Finally, a minimum of 3 high-quality endoscopic images of the lesion were requested. All these items were submitted through an online form downloaded from our website (www.poliepadvies.nl; Appendix 1, available online at www.giejournal.org). Because data were collected for standard patient health care, the Institutional Review Board decided that this study did not fall under the Dutch Legislation on Medical Research Involving Human Subjects Act, and ethical review was deemed unnecessary. No patient identification items were requested, and informed consent was waived by our local ethics committee.
      Collected data and images were stored in a secure online database provided by a cloud-based clinical data platform (Castor Electronic Data Capture) by the study coordinator.
      Each time a new case was uploaded, the members of the expert panel received an email with a request to login and enter their advice. The panelists were blinded to the opinion of other panelist and the consulting physician. Panelists could provide multiple treatment options and have a free text field for additional comments. Within 1 week after submission, the bundled panelists’ advice was sent to the consulting endoscopist (Fig. 1). The identity of the responding panelist was disclosed to the consulting endoscopist. After a reasonable period of time, the consulting endoscopist was asked to report the chosen treatment, clinical outcome, and pathology results.
      Figure thumbnail gr1
      Figure 1Workflow of the expert panel. First, the consulting endoscopist from a center in the province of Noord-Holland or Flevoland filled out a form downloaded from www.poliepadvies.nl. Then, the provided data were inserted into a secured database in less than 48 hours and an email was sent to the participating experts. Third, all experts independently filled in their advice. Finally, within 1 week, bundled expert advice was forwarded to the consulting endoscopist.
      At bimonthly intervals all panelist received feedback on the decisions and treatment results of recent patients. In this feedback the different opinions of each panelist were provided to the entire panel. Finally, approximately 1 year after the start of the panel, an evaluation form about the satisfaction of the expert panel was sent to all panelists.

      Aim, outcome measures, and statistical analysis

      This study aimed to describe the implementation, adaption, and clinical impact of our newly developed regional expert panel. Outcome measures were the number of patients submitted to the expert panel, number of panelist responding per submitted case, initially proposed treatment strategy by the consulting endoscopists, change in treatment strategy after panel consultation (ie, between endoscopy and surgery, treating in own hospital vs referral and between different endoscopic treatment options), and number of patients referred to another hospital after panel consultation. Finally, we assessed user satisfaction among the members of the expert panel.
      Standard descriptive statistics were used. Variables are reported as mean with standard deviation for continuous and normally distributed variables, as median and interquartile range for non-normally distributed continuous variables, and as percentages for counts or categorical variables. Statistical analysis was performed using SPSS 24 (SPSS, Chicago, Ill, USA).

      Results

      From June 2019 to May 2021, the expert panel was consulted for a total of 88 patients with complex colorectal polyps. Of all 15 participating centers, endoscopists from 11 centers (73.3%) consulted the expert panel. Most consultations was received from regional centers (95.5%, n = 84). During the first year, the panel was consulted for 23 cases, which increased to 65 cases in the second year (Fig. 2). The main reasons for panel consultation were suspicion of malignancy in 36.4% (n = 32), large size in 11.4% (n = 10), location in 10.2% (n = 9), and a combination of those in 30.7% (n = 27).
      Figure thumbnail gr2
      Figure 2Cumulative number of expert panel consultations per regional hospital between June 2019 and May 2021.
      Patient and lesion characteristics of the cases that were submitted to the panel are shown in Table 1. Of all 88 lesions, 43.2% (n = 38) were located in the proximal colon. The median diameter was 30 mm (interquartile range, 20-40 mm), and 46.6% (n = 41) were submitted because of a suspicion for adenocarcinoma. Fifty percent of lesions (n = 44) had the highest SMSA score of 4 (>12 points), 28.4% (n = 25) had a score of 3 (9-12 points), 15.9% (n = 14) had a score of 2 (6-9 points), and in 5.7% (n = 5) the SMSA score was missing. Diagnostic biopsy specimens had been taken in 48.9% of lesions (n = 43), and endoscopic resection had been attempted in 4.5% (n = 4). At submission, histology of endoscopic biopsy samples or resection attempts was supplied in 36 of 47 lesions and showed adenoma with low-grade dysplasia in 50.0% (18/36), high-grade dysplasia in 19.4% (7/36), and adenocarcinoma in 27.8% (10/36).
      Table 1Patient and lesion characteristics
      CharacteristicsValue
      Consultations88 (100)
      Regional centers84 (95.5)
      Patients
       Male sex57 (64.8)
       Age, y67 ± 10
      American Society of Anesthesiologists class
       I: healthy23 (26.1)
       II: mild systemic disease58 (65.9)
       III: severe systemic disease7 (8.0)
       IV: severe systemic disease that is a constant threat to life0 (0)
      Indication first colonoscopy
       Screening colonoscopy45 (51.1)
       Surveillance after polypectomy7 (8.0)
       Surveillance after colorectal cancer1 (1.1)
       Positive family history for colorectal cancer1 (1.1)
       Rectal blood loss12 (13.6)
       Changed bowel habits6 (6.8)
       Abdominal discomforts2 (2.3)
       Anemia2 (2.3)
       Unknown2 (2.3)
       Other8 (9.1)
      Median lesion diameter, mm30 (20-40)
      Location lesion
       Proximal (cecum to splenic flexure)38 (43.2)
      Cecum5 (5.7)
      Appendiceal orifice5 (5.7)
      Ascending colon13 (14.8)
      Hepatic flexure4 (4.5)
      Transverse colon5 (5.7)
      Splenic flexure0 (0)
       Distal (descending colon to rectum)50 (56.8)
      Descending colon0 (0)
      Sigmoid22 (25.0)
      Rectum28 (31.8)
      Macroscopic aspect
       Adenomatous43 (48.9)
       Sessile serrated lesion1 (1.1)
       Hyperplastic polyp0 (0)
       Adenocarcinoma41 (46.6)
       Subepithelial lesion0 (0)
       Other3 (3.4)
      Lesion morphology
       Flat17 (19.3)
       Sessile66 (75.0)
       Pedunculated2 (2.3)
       Missing3 (3.4)
      SMSA score
       Level 1 (4-5 points)0 (0)
       Level 2 (6-9 points)14 (15.9)
       Level 3 (9-12 points)25 (28.4)
       Level 4 (>12 points)44 (50.0)
       Missing5 (5.7)
      Treatment performed
       Diagnostic biopsy sampling43 (48.9)
       Submucosal lifting attempt9 (10.2)
       Endoscopic resection attempt4 (4.5)
      Histology
      Histological findings provided after a biopsy sampling or attempt at endoscopic removal.
       Adenoma with low-grade dysplasia18 (50.0)
       Adenoma with high-grade dysplasia7 (19.4)
       (Suspicion of) adenocarcinoma10 (27.8)
       Sessile serrated lesion0 (0)
       Hyperplastic polyp0 (0)
       Other1 (2.8)
      Reasons for expert panel consultation
       Location9 (10.2)
       Size10 (11.4)
       Suspicion of adenocarcinoma32 (36.4)
       Nonlifting6 (6.8)
       Irradical resection1 (1.1)
       Combination27 (30.7)
       Other3 (3.4)
      Expert panel responses per case6 ± 2
      Expert panel advice
      With consensus we mean that all panelists reported unanimous treatment advice, ≥50% consensus means that panelists reached more than 50% consensus, and <50% consensus means non-unanimous treatment advice.
       Consensus24 (27.3)
       50:5011 (12.5)
       ≥50% consensus45 (51.1)
       <50% consensus8 (9.1)
      Treatment strategy adjusted after panel consultation
       Yes38 (43.2)
       Not reported5 (5.7)
      Referral to another center
       Yes56 (63.6)
       Not reported1 (1.1)
      Values are n (%), mean ± standard deviation, or median (interquartile range).
      SMSA, Size, morphology, site, access.
      Histological findings provided after a biopsy sampling or attempt at endoscopic removal.
      With consensus we mean that all panelists reported unanimous treatment advice, ≥50% consensus means that panelists reached more than 50% consensus, and <50% consensus means non-unanimous treatment advice.
      Of the 16 participating panelists, 12 (75.0%) submitted a recommendation at least once. The mean number of panelists submitting their recommendation per consultation was 6 ± 2, which was lower during the first year of our panel with a mean of 3 ± 1 in comparison with a mean of 7 ± 2 during the second year. These panelists reached more than 50% agreement in 51.1% of cases (n = 45), whereas in 9.1% (n = 8) non-unanimous treatment advice (ie, <50% consensus) was given. Furthermore, in 27.3% consensus was reached (n = 24) and in 12.5% “50:50” advice (n = 11) was given. In 38 patients (43.2%) presented to the panel consultations, the consulting endoscopists changed their initial treatment strategy after receiving the panel’s advice, and 63.6% of patients (n = 56) were referred to another center for further treatment, (For an example of a consulted cases with the final treatment strategy, see Appendix 2, available online at www.giejournal.org.)
      To evaluate the clinical impact of our regional expert panel, we assessed whether panel consultation changed the initially proposed treatment strategy between endoscopic resection and surgery (Fig. 3). In 5 of 88 submitted cases (5.7%), the proposed treatment strategy was missing. Of the remaining 83 cases, endoscopic resection was proposed in 57 cases (68.7%). After panel consultation, this treatment did not change in 39 cases (68.4%). In 17 cases (29.8%) the treatment plan changed to surgery, and in 1 case (1.8%) no treatment was performed because of patient preference. In most cases where panel consultation changed the proposed treatment to surgery (14/17, 82.4), the suggested endoscopic treatment was deemed not feasible because of the suspicion of deep submucosal invasion. The final histology of the surgical specimen in 13 of these cases did show advanced CRC justifying radical surgery. In the other patient no further treatment was performed because of comorbidity reasons. In the remaining 3 cases, 1 patient preferred surgery and 2 patients were not amenable to endoscopic treatment because of a nonlifting sign or size of the lesion. Primary surgery was proposed by the consulting endoscopist in 26 of 83 cases (31.3%). After panel consultation, in 17 cases (65.4%) treatment did not change, whereas in 7 cases (26.9%) the treatment plan changed to endoscopic treatment. In all 7 cases, endoscopic resection was feasible and followed by surveillance. No additional surgeries were performed. In the 2 remaining cases (7.7%) a conservative treatment approach was followed because of patient preference.
      Figure thumbnail gr3
      Figure 3Description of the initial proposed treatment by the consulting endoscopist without panel consultation and performed treatment after panel consultation. Of all 88 submitted cases, in 5 cases the consulting endoscopist did not register a proposed treatment strategy. ∗After panel consultation no treatment was performed because of patient preference or a watch-and-wait approach (n = 3). 1Reassessment is defined as a second look by a dedicated endoscopist.
      All performed treatment procedures after panel consultation are shown in Supplementary Table 1 (available online at www.giejournal.org). Of all 36 cases with supplied histology at submission, the final histology of 29 cases was available. Of those, in 12 (41.4%) the initial biopsy sample was underestimated in the final histology.
      Regarding the brief survey that was sent out to the members of the expert panel after 1 year, 12 of 16 panelists (75.0%) completed the survey, and 11 of 12 panelists (91.7%) were satisfied about the expert panel (Supplementary Table 2, available online at www.giejournal.org). Five of 12 panelists (41.7%) actively encouraged their colleagues to use the panel.

      Discussion

      This study assessed the implementation, adaption, and clinical impact of a regional expert panel for complex colorectal polyps in the northwestern region of the Netherlands. After 2 years, 73% of the participating centers had consulted our expert panel for treatment advice regarding complex colorectal polyps. The most common reason for consulting the panel was a suspicion of invasive growth. In 43% of submitted cases, consulting endoscopists changed their initial treatment strategy and in 64% the patient was referred to another center with more expertise. Furthermore, in 27% of cases where surgical resection was initially proposed, panel consultation led to an endoscopic procedure, all treated successfully without additional surgery. On the other hand, in 30% of cases in which endoscopic treatment was initially proposed, the expert panel advised a surgical treatment. Nearly all these cases indeed showed an advanced CRC. We conclude that our regional expert panel for complex colorectal polyps has proven to be an accessible and valuable tool for endoscopists to discuss and optimize further treatment and referral strategies.
      Our study showed that most panelists were satisfied with the panel with a relatively high participation rate. During the second year of our panel, panel consultation increased significantly, possibly because of repeated presentations at regional meetings and pamphlets in endoscopic departments of regional centers. In agreement, we observed a similar trend in experts submitting their recommendation per consultation. During the first year of our expert panel, relatively few panelists participated per case. Therefore, it is difficult to assess if experts also learned from each other and reached more consensus during the second year. However, by discussing cases of complex colorectal polyps, participating gastroenterologists may become more aware of the array of available endoscopic options and their respective indications. Moreover, our study showed that in almost one-fourth of consultations, the provided advice largely varied among experts (ie, non-unanimous treatment advice or 50:50 advice). This implies some discrepancy exists in recommended management options, even among endoscopists with special interest in complex colorectal polyps. Because all members of the expert panel received feedback forms including decisions and final treatment results of every discussed case, the members of the expert panel should have been able to learn from each other. Future evaluations are needed to evaluate a possible learning curve in recommendations of participating experts.
      The main goal in the treatment of complex colorectal polyps is to provide an optimal treatment and prevent unnecessary surgical or endoscopic resection, with its concurrent burden and adverse event risk. Colorectal surgery is associated with increased morbidity and mortality rates as compared with endoscopic treatment methods.
      • Vermeer N.C.A.
      • de Neree Tot Babberich M.P.M.
      • Fockens P.
      • et al.
      Multicentre study of surgical referral and outcomes of patients with benign colorectal lesions.
      ,
      • Peery A.F.
      • Shaheen N.J.
      • Cools K.S.
      • et al.
      Morbidity and mortality after surgery for nonmalignant colorectal polyps.
      ,
      • Bronzwaer M.E.S.
      • Koens L.
      • Bemelman W.A.
      • et al.
      Volume of surgery for benign colorectal polyps in the last 11 years.
      ,
      • Keswani R.N.
      • Law R.
      • Ciolino J.D.
      • et al.
      Adverse events after surgery for nonmalignant colon polyps are common and associated with increased length of stay and costs.
      • Le Roy F.
      • Manfredi S.
      • Hamonic S.
      • et al.
      Frequency of and risk factors for the surgical resection of nonmalignant colorectal polyps: a population-based study.
      • Tholoor S.
      • Tsagkournis O.
      • Basford P.
      • et al.
      Managing difficult polyps: techniques and pitfalls.
      Judging whether colorectal polyps are complex remains largely subjective and depends mostly on endoscopic skills, equipment, and experience of the performing endoscopist.
      • Gupta S.
      • Miskovic D.
      • Bhandari P.
      • et al.
      A novel method for determining the difficulty of colonoscopic polypectomy.
      To support determining the optimal management strategy, classification systems have been developed to grade the complexity of a lesion to assess whether endoscopic or surgical resection is more appropriate.
      • Peery A.F.
      • Cools K.S.
      • Strassle P.D.
      • et al.
      Increasing rates of surgery for patients with nonmalignant colorectal polyps in the United States.
      ,
      Most polyps consulted in our expert panel were classified as complex (SMSA score level 4). For these complex polyps, guidelines recommend referral to an expert endoscopist for comprehensive assessment of the optimal treatment strategy as suggested by the European Society of Gastrointestinal Endoscopy guideline.
      • Ferlitsch M.
      • Moss A.
      • Hassan C.
      • et al.
      Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
      In the present study, most patients (63%) for whom consultation was sought were referred to another center with expertise in advanced endoscopic resection. This seems an important step forward compared with the results of our previous study in the same region, demonstrating that only 2.4% of patients with polyps considered too complex for endoscopic resection were referred to another endoscopy center before surgical resection.
      • Arezzo A.
      • Passera R.
      • Marchese N.
      • et al.
      Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions.
      However, it is unknown which percentage of all complex colorectal polyps have been submitted to our regional expert panel. Nevertheless, our high referral rate between centers implies that there might be a lower threshold to consult dedicated endoscopists with special interest in complex colorectal polyps in the region.
      Although endoscopic resection seems to have multiple advantages, it is not always the preferred treatment for complex colorectal polyps. For polyps with suspected malignant invasion, complete en-bloc resection is mandatory. Despite the fact that advanced endoscopic resection techniques allow complete resection of some of these polyps, colorectal surgery remains the preferred treatment strategy for a subset of more advanced polyps. Thus, avoiding surgery should not be a goal by itself.
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      • et al.
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      During endoscopy, optical diagnosis with high-definition virtual chromoendoscopy techniques can be used to predict the depth of submucosal invasion by using classification systems as the Japan Narrow Band Imaging Expert Team (JNET), Narrow Band Imaging International Colorectal Endoscopic (NICE), and/or Kudo classification.
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      In daily practice, however, real-time endoscopic recognition of submucosal invasive cancer is challenging.
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      • et al.
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      We showed that in 30% of cases in which the consulting endoscopist suggested an endoscopic resection, panel consultation eventually led to the advice for a surgical resection. This is comparable with the results of Friedland et al,
      • Friedland S.
      • Banerjee S.
      • Kochar R.
      • et al.
      Outcomes of repeat colonoscopy in patients with polyps referred for surgery without biopsy-proven cancer.
      who showed that 29% of complex colorectal polyps were not amenable for endoscopic treatment after reassessment.
      In our study, most cases were sent for surgery because of the suspicion of deeper submucosal invasion. In nearly all cases, final histopathology showed an advanced CRC, and surgery seemed the appropriate treatment strategy. Notably, in most cases the consulting endoscopist proposed an ESD. In addition to a suspicion of deeper invasion, these lesions were also located in the right-sided colon, larger than 20 mm, and therefore not amenable for a safe and complete resection by colorectal ESD or eFTR. For lesions with a suspicion of deep invasive cancer, ESD is not the preferred treatment strategy to achieve a radical resection.
      • Fuccio L.
      • Hassan C.
      • Ponchon T.
      • et al.
      Clinical outcomes after endoscopic submucosal dissection for colorectal neoplasia: a systematic review and meta-analysis.
      On the other hand, our study showed that surgery could be avoided in 27% of consultations. For all cases initially considered not amenable to endoscopic resection by consulting physicians and judged as amenable for endoscopic resection by our panelists, a successful endoscopic procedure could be performed. Therefore, our expert panel seems to aid in selecting the most optimal treatment strategy.
      To further improve our expert panel, we should optimize the quality of provided endoscopic images. Currently, a minimum of 3 images is requested. However, to optimally assess a lesion, it is important that endoscopists provide high-quality pictures with advanced imaging techniques such as white-light endoscopy and/or narrow-band imaging. Several studies have shown that these techniques improve optical diagnosis.
      • Bisschops R.
      • East J.E.
      • Hassan C.
      • et al.
      Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) guideline - update 2019.
      For better assessment, the consulting endoscopists should be able to provide an endoscopic video of the lesion. This may help the panelist to optimally assess the complexity. Furthermore, we should encourage all experts to actively participate in our panel, because 25% of experts never assessed a case. To support the use of our regional panel by all endoscopists in the region, we should promote our panel during regional meetings. Finally, adding a colorectal surgeon to our expert panel will enhance decision-making by critically assessing the indication for surgery.
      This study has limitations to address. At first, the number of consultations in our expert panel was relatively low. This may have resulted in a potential selection bias of cases submitted for panel consultation and may not reflect the true number of complex colorectal polyp cases that may have been discussed or referred to expert centers without consultation of this panel. However, the significant increase of panel consultations during our second year may be a reflection of increased awareness and acknowledgement, and we expect the number of consultations will only increase in the following years. Second, although we showed that patients may have received a more appropriate treatment strategy, either changing from surgery to endoscopy or vice versa, it remains difficult to interpret the true impact of all panel consultations. Panelists were blinded to each other’s opinion. Because opinions varied on most consultations, completely uniform treatment advice could not be given, and all individual opinions were transferred back to the consulting endoscopist. For this reason, it remains unclear how the decision process exactly was influenced by our expert panel to either perform endoscopic or surgical treatment depending on multiple factors including age, comorbidity, and patient preference. However, because in most consultations patients were referred to a center with more expertise, this possibly supported optimal treatment selection.
      In conclusion, our study shows that implementation of a regional expert panel for complex colorectal polyp cases facilitates peer consultation, could lower thresholds for interhospital referrals, and decreases the number of inappropriate surgical or endoscopic interventions. Access to the required expertise on complex colorectal polyp cases can support physicians in optimizing treatment and can aid appropriate referral management. Similar regional initiatives or multidisciplinary referral networks are strongly encouraged to be implemented.

      Acknowledgment

      We thank the members of the Expert Panel Group: M. I. E. Appels, G. J. de Bruin, A. C. T. M. Depla, I. L. Huibregtse, T. Kuiper, B. I. Liberov, R. Ch. Mallant-Hent, W. A. Marsman, D. Ramsoekh, B. W. van der Spek, M. S. Vlug, S. J. B. van Weyenberg, and C. A. Wientjes.

      Supplementary data

      Appendix

      Figure thumbnail fx2
      Supplementary Figure 1A, B, C, D, E, F, G, Endoscopic images of the target lesion. H, Marked lesion with the full-thickness resection device marking probe. I, The full-thickness resection site with the over-the-scope clip in place. J, The resected lesion pinned onto paraffin.
      Supplementary Table 1Performed treatment after panel consultation
      TreatmentValue
      Consultations88 (100)
      No treatment performed3 (3.4)
      Endoscopic treatment50 (56.8)
       Endoscopic mucosal resection26 (29.5)
       Endoscopic full-thickness resection8 (9.1)
       Endoscopic submucosal dissection11 (12.5)
       Endoscopic intermuscular dissection5 (5.7)
      Surgical treatment34 (38.6)
       Ileocecal resection2 (2.3)
       Right hemicolectomy11 (12.5)
       Left hemicolectomy1 (1.1)
       Sigmoid resection9 (10.2)
       Low anterior resection1 (1.1)
       Subtotal colectomy1 (1.1)
       Partial mesorectal excision1 (1.1)
       Transanal total mesorectal excision2 (2.3)
       Transanal minimal invasive surgery local excision5 (5.7)
       Laparoscopic wedge resection1 (1.1)
      Missing1 (1.1)
      Values are n (%).
      Supplementary Table 2Survey of members of the expert panel (12/16 panelists)
      Survey questionValue
      I am satisfied with the online expert panel
       Totally disagree0 (0)
       Disagree0 (0)
       Not agree or disagree1 (8.3)
       Agree10 (83.3)
       Fully agree1 (8.3)
      I am satisfied about the website
       Totally disagree1 (8.3)
       Disagree0 (0)
       Not agree or disagree1 (8.3)
       Agree7 (58.3)
       Fully agree1 (8.3)
      I am satisfied with the format in Castor Electronic Data Capture
       Totally disagree0 (0)
       Disagree0 (0)
       Not agree or disagree2 (16.7)
       Agree7 (58.3)
       Fully agree3 (25.0)
      I think it is valuable to receive the advice of other experts and final treatment strategy afterwards
       Totally disagree0 (0)
       Disagree0 (0)
       Not agree or disagree0 (0)
       Agree9 (75.0)
       Fully agree3 (25.0)
      I advise my colleagues to use the online expert panel
       Totally disagree0 (0)
       Disagree2 (16.7)
       Not agree or disagree5 (41.6)
       Agree3 (25.0)
       Fully agree2 (16.7)
      Values are n (%).

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      Linked Article

      • Second opinions foster better outcomes
        Gastrointestinal EndoscopyVol. 96Issue 1
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          Recent progress in the management of complex colorectal polyps has been rapid. Many lesions that would not have been treated endoscopically a decade ago are now regarded as good candidates for endoscopic resection. EMR has become safer and more effective, with diminished risks of post-EMR bleeding, deep mural injury, and recurrence.1-3 The use of endoscopic submucosal dissection (ESD) is increasing in the West because of training and improvements in technology, and endoscopic full-thickness resection (eFTR) can treat otherwise defiant lesions.
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