Outcomes of Colonic Endoscopic Mucosal Resection for Large Polyps in Elderly Patients

Abstract

Objective:

The aim of this study is to investigate the short-term outcomes of endoscopic mucosal resection (EMR) for large colonic polyps in elderly patients (≥80 years) compared with those in younger patients (<80 years).

Patients and Methods:

Results:

The median age in Group A was 83.5 years (range 80–91 years) and 66 years in Group B (range 26–79 years, P < .001). The proportion of patients with American Society of Anesthesiologists class III was significantly high in Group A (39.1% versus 17.7%, P = .001). There was no significant difference in sex ratio, body mass index, tumor size, and tumor distribution between the two groups. Median operating time was similar between the two groups (30 versus 30 minutes, P = .839). En bloc resection rate was 33.8% in Group A and 29.2% in Group B (P = .445). No anesthesia-associated adverse events or deaths occurred in both groups. Complication rate was similar between the two groups, perforation rate was 2.2% in Group A and 1.7% in Group B (P = .823), and delayed bleeding rate was 4.3% versus 3.1% (P = .650), respectively.

Conclusions:

Colon EMR is feasible and safe in very elderly patients.

Introduction

Colorectal cancer is the third most common cancer and the fourth leading cause of cancer-related death worldwide.^1,2 More than 1.2 million new cases occur annually and nearly 50% patients will ultimately die from it.¹ The majority of colorectal cancers are thought to arise from adenomatous polyps.³ According to the adenoma–carcinoma sequence theory, early detection and resection of colorectal polyps are essential for improving cancer survival rate.^4,5 Endoscopic resection, including biopsy forceps, electrocautery snares, and endoscopic mucosal resection (EMR), has been widely applied for colorectal polyps.^6,7 However, the safety and outcomes of EMR in very elderly patients with large polyps are unknown. The aim of this study is to investigate the short-term outcomes of EMR for large colonic polyps in elderly patients (≥80 years) and to compare the outcomes with those of younger patients (<80 years).

Patients and Methods

Patients

From January 2007 to December 2014, patients who underwent EMR at our institution were retrospectively reviewed from our prospectively entered database. To provide a stricter definition of EMR, patients with small polyps (<2 cm) were excluded from our study. Finally, a total of 339 patients with 466 lesions were included. Sixty-five colon EMRs were performed on 46 patients ≥80 years (Group A) and 401 resections were performed on 293 patients <80 years.

Preoperative mechanical bowel preparation was performed 24 hour before the procedure. The EMR procedures used were inject and cut technique. A solution (usually normal saline dyed with methylene blue) was preinjected into the submucosal layer. The lesions were removed by the snare.

All specimens were fixed in 10% formalin and carefully examined by at least two pathologists. The following parameters were reported: tumor size, histological type, depth of invasion, and lateral and vertical resection margins.

Follow-up

Follow-up endoscopies were performed 3–6 months after the initial EMR and annually thereafter to assess the healing, residue, and local recurrence of the disease.

Statistical analysis

Statistical analysis was performed by Statistical Package for the Social Science (SPSS) 18.0 (SPSS, Inc. Chicago, IL). Categorical data are given as number and percentage, and were analyzed by chi-square test or Fisher's exact test as appropriate. Quantitative variables are presented as median and range, and Student's t-test was used for comparisons. All the tests were two sided, a P < .05 was considered significant.

Results

Patient characteristics

A total of 339 patients who underwent colon EMR ≥2 cm were included. Sixty-five colon EMRs were performed on 46 patients ≥80 years (Group A) and 401 resections were performed on 293 patients <80 years. The median age in Group A was 83.5 years (range 80–91 years) and 66 years in Group B (range 26–79 years, P < .001). The American Society of Anesthesiologists (ASA) score was significantly different between the two groups (P = .001). The proportion of patients with ASA class III was significantly high in Group A (39.1% versus 17.7%) than in Group B. Sexual ratio, median body mass index, and tumor distribution were not significantly different between the two groups (Table 1).

Table 1.

Demographics and Clinical Characteristics

Characteristic	Group A (n = 46)	Group B (n = 293)	P
Female/male	20/26	133/160	0.808
Median age (year; range)	83.5 (80–91)	66 (26–79)	<0.001
Median BMI (kg/m²; range)	23.8 (19.6–29.4)	23.8 (17.4–33.2)	0.519
ASA score (%)			0.001
I	1 (2.2)	50 (17.1)
II	26 (56.5)	189 (64.5)
III	18 (39.1)	52 (17.7)
IV	1 (2.2)	2 (0.7)
No. of lesions	65	401
Distribution (%)			0.797
Ascending colon	19 (29.2)	134 (33.4)
Transverse colon	5 (7.7)	36 (9.0)
Descending colon	8 (12.3)	41 (10.2)
Sigmoid colon	25 (38.5)	157 (39.2)
Rectum	8 (12.3)	33 (8.2)

ASA, American Society of Anesthesiologists; BMI, body mass index.

Operative outcomes and complications

Operative outcomes and complications are detailed in Table 2. Median operating time was similar between the two groups (30 minutes versus 30 minutes, P = .839). En bloc resection rate was 33.8% in Group A and 29.2% in Group B (P = .445). R0 resection rate was also similar between the two groups (92.3% versus 92.5%, P = .952). The pathological results were not significantly different between the two groups (Table 2).

Table 2.

Clinical Outcomes

Variable	Group A (n = 46)	Group B (n = 293)	P
Median tumor size (mm; range)	32.5 (20–110)	30 (20–120)	0.430
Median operating time (minute; range)	30 (5–100)	30 (5–130)	0.839
En bloc resection (%)	22 (33.8)	117 (29.2)	0.445
R0 resection (%)	60 (92.3)	371 (92.5)	0.952
Pathological results (%)			0.109
Adenoma	42 (64.6)	287 (71.6)
Intramucosal cancer	14 (21.5)	88 (21.9)
Submucosal cancer	9 (13.8)	26 (6.5)
Complication (%)
Delayed bleeding	2 (4.3)	9 (3.1)	0.650
Perforation	1 (2.2)	5 (1.7)	0.823
Emergency surgical operation (%)	1 (2.2)	6 (2.0)	0.955
Additional surgery (%)	3 (6.5)	25 (8.5)	0.645

The complication rate was similar between the two groups, perforation rate was 2.2% in Group A and 1.7% in Group B (P = .823), and delayed bleeding rate was 4.3% versus 3.1% (P = .650), respectively. Seven patients underwent emergency surgical operation: 1 in Group A and 6 in Group B (P = .955). The proportion of patients who underwent additional surgery was 6.5% in Group A and 8.5% in Group B (P = .645).

Long-term results

The median follow-up was 32.5 months (range 6–88 months) in Group A and 33 months (range 6–89 months) in Group B (P = .365). Residual disease and local recurrence rates were similar between the two groups. In Group A, 6 patients (13.0%) developed local recurrence and 3 patients received additional EMR, 1 patient received laparoscopic colectomy, and 2 patients refused additional treatment. In Group B, 25 patients (10.5%) developed local recurrence, 18 patients received additional EMR, 6 patients underwent laparoscopic colectomy, and 1 patient refused surgical treatment. During follow-up, 5 patients (10.9%) in Group A died; however, none of them died of colorectal disease. A total of 6 patients (2.0%) in Group B died: 2 patients died of colon cancer and 4 patients died of other diseases.

Discussion

The incidence of colorectal cancer increases with age, older age is associated with a high risk of colorectal cancer and adenomas.^8–10 According to the Surveillance Epidemiology End Results registry data of 2007, the incidence of colorectal cancer per 100,000 persons is 120 in persons aged 50–64 years of age, 186 in those aged 65–74, and 290.1 in those aged ≥75.¹¹ Most of the colorectal cancers are thought to rise from adenomatous polyps. It is well established that endoscopic screening and resection of colorectal polyps significantly decrease the incidence of colorectal cancer and improve survival. Several studies showed that older patients also could benefit from colonoscopy.^12–17 However, little is known about the safety and clinical outcomes of EMR for large polyps in the elderly patient population. To the best of our knowledge, this is the first study to investigate the short-term outcomes of EMR for large colonic polyps in elderly patients (≥80 years) compared with those in younger patients (<80 years).

In our study, a total of 339 patients who underwent colon EMR ≥2 cm were included. Sixty-five colon EMRs were performed on 46 patients ≥80 years, and 401 resections were performed on 293 patients <80 years. Although the median age was significantly higher in Group A and the proportion of patients with ASA class III was significantly high in Group A, the median operating time, en bloc resection, and R0 resection rate were similar between the groups. Furthermore, the complication rate was low in both groups, and the risk of bleeding or perforation did not increase in older patients when compared with that in younger patients. Our results indicate that EMR in patients aged ≥80 is safe and feasible, age alone should not be considered as a contraindication for EMR. Several studies also found similar results.^18–20 Lippert et al.¹⁸ analyzed the outcomes and complications of colonoscopy in patients aged 75 and older. A total of 735 colonoscopies were performed, and therapeutic steps were taken in 316 cases. In all the colonoscopies, the complication rate was 0.95% and the complication rate did not increase with age. Gómez et al.¹⁹ retrospectively evaluated patients ≥80 years of age who underwent colon EMR ≥2 cm; 131 colon EMRs were performed on 99 patients. En bloc resection rate was 26.7% and the complication rate was 6.1% (8/131).

There are several limitations in this study. The main limitation of our study is the retrospective collection of the data, selection bias may exist. It was difficult to elucidate how age of a patient influenced a doctor's decision to perform or not to perform an EMR. Perspective randomized controlled trials are needed to confirm our results. Despite these limitations, our study was the first to investigate the short-term outcomes of EMR for large colonic polyps in elderly patients (≥80 years) and compared with those of younger patients (<80 years).

Conclusions

In experienced hands, colon EMR is safe and feasible for patients aged ≥80 years. The complication rate is not increased in elderly patients compared with that in the younger patients.

Footnotes

Disclosure Statement

No competing financial interests exist.

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