In a series of interviews, guest reporter Owen Haskins from Dendrite Clinical Systems, will be previewing this year's ACPGBI annual meeting in Edinburgh, Scotland, July 4-6. He talked to Mr Chris Cunningham (Oxford, UK) who will examine 'The Adenoma - Techniques of transanal excision'.
Mr Cunningham began by stating that the causes of colorectal adenomas are multifactorial including genetic predisposition, as well as dietary and environmental factors. He added that the risk of colorectal adenomas increases with age and at least 20% of population will develop polyps at some point.
“Endoscopic removal of smaller polyps has been practised for many years, but technology and expertise are improving so larger more complex polyps may be removed effectively without major surgery,” he explained. “For polyps and early cancers arising in the rectum, there is the additional option of transanal surgery with access through the anus, which means more extensive endoscopic surgery can be performed, compared to sites higher in the bowel. This is just a feature of access and the fact that much of the rectum is surrounded by fatty tissue and lies outside of the peritoneal cavity, so risks of bowel perforation are reduced”
Before considering polyp removal Mr Cunningham said it was important to consider and assess the polyp and patient very carefully. Location of the polyp, risk of cancer, skill set and expertise of the surgeon and endoscopist are all important factors to be considered along with the wishes and general health and condition of the patient.
He added that if the polyp is thought to be a benign adenoma then survival should only be affected by mortality related to the procedure, which should be extremely low. However, he cautioned that up to 20% of ‘benign’ adenomas may contain foci of cancer, which may impact survival.
The management of early stage cancer arising within polyps can be challenging and opens a very difficult discussion of the impact of treatment, particularly radical surgery versus less invasive approaches which may offer patients better quality of life at the expense of increased risk of disease recurrence. This “trade-off” between oncological excellence with radical surgery versus quality of life is a controversial area, and increasingly relevant in our aging population particularly for rectal cancer.
“If an endoscopist sees a significant adenoma they must stop and think. They must assess the adenoma for risk of malignancy, determine if they can remove it completely or consider if they should refer for discussion at a polyp MDT within an expert centre. Do not be afraid to leave a polyp and bring the patient back for a therapeutic procedure. You get one chance to remove a adenoma effectively and that is the first attempt,” he concluded. “My presentation in Edinburgh will discuss rectal adenoma and techniques for removing them, which means patients may avoid major life changing surgery and still be offered cure. It is a complex decision-making process and truly reflects modern practice in personalising treatment. One size does not fit all!”
Chris Cunningham’s lecture is on Tuesday 5th July at 11:05am.