The notion that it can be justified as it gives an immediate diagnosis needs no further comment. There may also be opposition from gastroenterology/endoscopy groups who doubt that those who are more academic or better equipped can do this with 95%+ success or better than they or their own group can.
Are we assuming that the lower diagnostic standards of endoscopy are acceptable as they will not impact significantly on patient management? Why do we need to know precisely the pathology of polyps? Important differential diagnoses that really change follow-up include detecting the third adenoma, distinguishing adenomas from serrated polyps, hyperplastic polyps from sessile serrated polyps/adenomas (SSP/As), which can be difficult histologically, and especially dysplastic SSP/As from nondysplastic ones. Endoscopists need to demonstrate their competence at these skills for accreditation when this may not currently be possible, and identifying adenomas and SSP/As with early invasive cancer, which may not be resectable. Although uncommon, these are sometimes less than 5 mm.
Third, the issue is that it is one thing to say that a specific endoscopist can be accurate in studies based on less than 500 polyps, but when this is translated to an entire unit – after 10,000+ polyps, or a state, or the entire country. When 25 missed diagnoses become 1000, or 100,000. What gets missed that matters? Other tumors presenting as lower bowel polyps include carcinoids (low grade neuroendocrine tumors), metastatic carcinoma, metastatic melanomas, and lymphomas. While all of these are indicative of widespread disease, many are treatable.
There are intangibles at work in my argument as well. You never really know what you are dealing with when you discard the polyp. Even if accredited, are you really comfortable doing this? Would you be happy having your own polyps thrown out?
So where does this leave us? There are many issues, some of which are obvious but others less so, and there may even be some that have not yet to come to light. This summarizes the state of the art regarding the field of surveillance endoscopy and pathology. There are far too many challenges and hurdles to seriously consider implementing this policy now. It is not ready for prime time.
Dr. Robert H. Riddell is professor of laboratory medicine and pathobiology, University of Toronto, and Mount Sinai Hospital, Toronto.
Both Dr. Rex and Dr. Riddell made their comments during the ASGE and AGA joint Presidential Plenary at the annual Digestive Disease Week.
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