QUALITY OF PRE- AND POST-RESECTION PHOTODOCUMENTATION OF LARGE COLORECTAL POLYPS

Background
Polypectomy decreases colorectal cancer (CRC) incidence and mortality. 19% of post-colonoscopy colorectal cancers (PCCRC) are found due to incomplete polypectomy. Recently the US Multi-Society Task Force strongly recommended photodocumentation (PD) of colorectal polyps > 10mm (LP) pre-resection and suggested PD after polypectomy confirming resection of all polyp tissue. The Task Force stated that pre-resection PD of LPs should include an open snare or open biopsy forceps of known size to improve accuracy of polyp size estimation. We recently reported that pre- and post-resection PD occurred in 82% and 52% of 1693 resected LPs respectively; however, the quality of PD was not ascertained. Our aim was to assess the quality of pre- and post-resection PD of LPs.

Methods
Images of a random subset of 1693 LPs resected between 2016-2021 with both pre- and post-resection photos were reviewed by 4 gastroenterologists: a 3^rd year GI fellow and gastroenterologists with 2, 8 and 33 years in practice. We assessed the frequency of 1) complete visualization of the LP in pre-excision photos, 2) presence of an open snare or open biopsy forceps in apposition to the LP in pre-resection photos, and 3) PD of a clean base with no visible polyp tissue post-resection. High-quality PD was defined as: entire polyp visualized pre-resection and clean base with no visible polyp tissue post-resection. Additionally, polyp size estimates (<10mm or ≥10mm) were provided. Reviewers cited their level of confidence in grading the quality post-resection PD and estimating polyp size. Reviewers’ agreement on size was assessed using free-marginal kappa.

Results
201 LPs were included (Table 1). Reviewers reported 52-84.6% fully visible polyps pre-resection and 70.1-74.6% had no visible polyp tissue post-resection. 42.3-64.2% of LPs were reported to have both high-quality PD pre- and post-resection. All reviewers agreed on polyp size category in 123 (61%) polyps. Kappa indicated moderate agreement on size estimation: 0.56 [95% CI 0.48, 0.64]. High-level confidence in size estimates was lowest in the trainee compared to experienced endoscopists and in polyps ≥10mm vs. <10mm. 1/201 pre-resection photos included open snare or open biopsy forceps.

Conclusions
Despite guideline recommendations for PD of LPs pre- and post-resection, high quality PD was reported in 52-64% of lesions. Only 56% of LPs were agreed by reviewers to be ≥10mm and 22-62% of LP sizes were estimated with high confidence, lowest in the trainee. A measuring standard was rarely used pre-resection which, if used, will likely decrease the variability in size estimation. Metrics for quality polypectomy PD are needed to assure accurate polyp size estimation and complete polyp eradication which impacts colonoscopy resource utilization and may decrease PCCRC. Providing feedback to providers on PD quality should be considered.