Improving the management and outcomes of complex non-pedunculated colorectal polyps at a regional hospital in British Columbia

Background Colorectal cancer arises from precancerous lesions, primarily adenomatous and serrated polyps. Some polyps pose significant technical endoscopic challenges due to their size, location, and/or morphology. A standardized protocol for documentation and management of these polyps can optimize clinical outcomes. Methods A Quality Improvement project compared patients with a complex polyp (non-pedunculated, > 2 cm), for 12 months prior and 12 months after protocol introduction. Documentation and polyp management details were compared pre- and post-implementation using the Chi-square test. Results 69 patients were diagnosed with complex polyps prior to the protocol introduction and 72 after. 79% (112/141) of patients underwent endoscopic mucosal resections (EMR) locally, and 14.9% (21/141) underwent surgery locally. After protocol introduction, there was significant improvement in documentation of suspicious appearing polyps (21.7% to 47.2%, P = 0.001), luminal circumference (14.5% to 34.7%, P = 0.005), and management plans (87.0% to 97.2%, P = 0.023); other elements of documentation were similar. The number of patients reviewed at multidisciplinary conference (MDC) increased from 1 to 61% ( P < 0.005). Patients rebooked in a 1 h endoscopy time slot increased from 19 to 58% ( P < 0.005), as did specific consent for EMR from 22 to 57% ( P < 0.005). Among patients with polyps 3 cm or greater (23 pre, 36 post), MDC review increased from 4 to 67% ( P < 0.005), primary polypectomy decreased from 72 to 23% ( P = 0.001), patients rebooked in a double endoscopy slot increased from 33 to 75% ( P = 0.005), and specific consent increased from 39 to 75% ( P = 0.014). There were less polyp recurrences (12/42 pre and 1/50 post) among the post-protocol cohort ( P < 0.001). Conclusions The introduction of a formalized protocol for complex polyp adjudication and management has led to improved documentation, multidisciplinary discussion, and optimal complex polyp management with dedicated time for EMR, particularly for polyps over 3 cm. There is room for improvement, and this can be approached in a collaborative manner.