EMR Is a Safe and Well Tolerated Means of Large Polyp Removal in Geriatric Patients

Colonoscopy is an examination that allows direct visualization of the entire large intestine and also, if necessary, the final part of the small intestine. It is used as a diagnostic test, allows biopsy extraction and endoscopic therapy.
Investigators evaluated the safety and outcomes of colorectal endoscopic mucosal resection in patients aged 80 years and older.

Endoscopic mucosal resection (EMR) was found to be a safe and well tolerated method of large (≥20 mm) nonpedunculated polyp removal in patients aged 80 years and older, according to findings from a study published in Gastrointestinal Endoscopy.

The researchers of this retrospective study compared the rates of follow-up, recurrence, adverse events, and synchronous neoplasia detection in older (≥80 years) and younger patients (<80 years) who were referred for large nonpedunculated polyp removal between 2000 and 2019. The study population included 167 patients 80 years and older (mean patient age, 83.3; 54.5% female) and 1686 participants younger than 80 years (mean patient age, 63.8; 48.1% female; P <.001).

During the study period, 1852 patients underwent EMR, the first-line treatment standard for large sessile and flat colorectal lesions, for 2191 colorectal polyps. Of the 1989 colonoscopies performed for the initial removal of the large lesions, most (1805) were initiated in patients younger than 80 years of age.

The older patient population returned for surveillance less frequently (67.1% vs 75.1%, P =.024) and had greater first follow-up recurrence rates (27.5% vs 13.8%, P <.001) compared with the younger patient population, but had similar adverse event rates (1.8% vs 2.8%, P =.619). “We demonstrate that EMR in patients 80 years and older is associated with a higher recurrence rate,” the study authors stated. Notably, the higher recurrence rate observed at the first follow-up in the older patient population “was not expected,” the investigators said.

Regarding the patient follow-up findings, they added, “The exact reasons for being less likely to return for follow-up are unclear, but could include factors such as more comorbidities, poor tolerance of prep, more difficulty arranging transportation from substantial distances, or a difference in patient attitude toward follow-up.”

The rate of synchronous disease in patients 80 years and older was similar to that of patients less than 80 years of age but was notably high in both groups (85.6% vs 80.4%; P =.339). The rate of residual polyps present at the first follow-up was 27.5% and 13.8% in the older and younger patient subsets, respectively (P <.001).

Limitations to the study included its retrospective design and the method of EMR performance. All EMRs were executed by a single endoscopic expert, which could limit the generalizability of the results, according to the study authors.

“These results suggest that in patients 80 years and older, where mortality from surgical resection is about 3% in the United States, EMR is safe and well tolerated,” the researchers concluded. “Because of higher recurrence rates, lower follow-up rates, and higher rates of synchronous neoplasia, special measures are appropriate to encourage follow-up in patients 80 years and older undergoing EMR. When feasible, patients undergoing EMR at referral centers should have their colons cleared of synchronous disease at the index examination, particularly if they are elderly.”

Disclosures: One of the study authors reported affiliations with medical device companies. Please see the original reference for a full list of the author’s disclosures.

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Lee CJ, Vemulapalli KC, Rex DK. Colorectal endoscopic mucosal resection outcomes in octogenarians versus younger patients referred for removal of large (≥20 mm) nonpedunculated polyps. Gastrointest Endosc. Published online October 16, 2020. doi: 10.1016/j.gie.2020.10.014