OVERTREATMENT IN THE PREVENTION OF COLORECTAL CANCER. COMPARISON BETWEEN SURGICAL AND ENDOSCOPIC TREATMENT OF BENIGN COLONIC POLYPS

INTRODUCTION: Most premalignant lesions detected at colonoscopy are treated endoscopically, but an increasing number classified as complex undergo surgical treatment, leading to overtreatment.
AIMS: Describe adverse events according to the AGREE (endoscopic group) and Clavien-Dindo (surgical group) classification and to compare the rates of serious complications, hospital stay and mortality in both groups. Describe the characteristics of benign complex lesions treated endoscopically and surgically, and determine the prevalence of early and late recurrence within the endoscopic treatment group.
METHODS: Single-centre case-control study. Benign colonic lesions treated surgically between 2004-2021 were included and compared with a control cohort of complex lesions (SMSA≥3) treated endoscopically between 2018-2022. One case per control matched by sex, age (+/-1 year), SMSA level and size was included. Severe surgical adverse events were defined as: suture dehiscence, infections and collections, ostomy, eventration/evisceration or paralytic ileus; and endoscopic: haemorrhage with admission or perforation. They were described using the AGREE (endoscopic group) and Clavien-Dindo (surgical group) classification.
RESULTS: 196 patients with benign lesions were included, 98 in each group, the majority being adenomas (88.8%). In the endoscopic group, with a mean age of 67.5 years(± 9.7), 53.1% of the lesions were flat (0-IIa), with a mean size of 40(±17.3) mm. In the surgical group, the mean age was 66.8 years(±11.4), 41.8% were sessile (0-Is), with a mean size of 41(±17.0) mm. There were no differences between groups in the level of difficulty estimated according to the "SMSA" system. Complications were more frequent in the surgical treatment group, OR=4.90 (95%CI 2.58- 9.26). The need for reoperation (34.7% vs. 1.0%) and the mean length of stay (10 vs. 0 days) were also higher in the surgical vs. endoscopic group (p<0.001). Three (3.1%) patients in the surgical group and one (1.0%) in the endoscopic group died (p=0.19) due to procedural complications. Twelve cases of recurrence were detected, eight cases in the first revision (66.6%) and four cases in the second revision.
CONCLUSIONS: Endoscopic treatment of benign complex colonic lesions (SMSA≥3) is associated with fewer complications, need for surgical reoperation and shorter hospital stay compared with surgery. The prevalence of recurrence of endoscopically removed colonic lesions is low and most are detected at the first colonoscopy.