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Gastric polyps and polypectomy: rationale, technique, and complications
0016-5107/84/3002-0101$02.00/0
GASTROINTESTINAL ENDOSCOPY Copyright © 1984 by the American Society for Gastrointestinal Endoscopy
Symposium Gastrointestinal endoscopy in clinical practice AISIGIE National Postgraduate Course May 26 and 27, 1983, Washington, D.C. Editor: Michael V. Sivak, Jr., MD Cleveland, Ohio
Gastric polyps and polypectomy: rationale, technique, and complications Rollin W. Hughes, Jr., MD
With improved fiberoptic technique, diagnostic as well as therapeutic endoscopy is playing a more important role in the management of gastrointestinal polyps.1-4 Although the incidence of gastric polyps is low, 0.4%5 to 0.7%,6 recent experience has led to classification schemes based on topographic, 7 histologic,8-11 and vital staining 12 criteria. The most frequently encountered gastric polyps, hyperplastic or regenerative polyps, are reported to contain malignancy rarely. Adenomatous gastric polyps that are greater than 2 cm in diameter have been reported to contain foci of in situ or invasive malignancy 43%13 to 59%8 of the time. Occasional cases of adenomatous gastric polyps cont~ining malignancy have been reported in a polyp· less than 2 cm. 14 Histological classification of gastric polyps by endoscopic biopsy is not sufficient to screen for polyps with malignant potential. Seifert and Elster 15 reported a series of 24 gastric polyps removed endoscopically where the histological classification was modified in 75% once the entire polyp was available for tissue sectioning. Kozuka et al. 16 observed that regenerative polyps underwent malignant change through secondary involvement with metaplasia. When regenerative polyps had severe invasive metaplasia, it became difficult to distinguish them from adenomatous polyps and the highest incidence of cancerous change was found in the metaplastic type polyp. OhruP7 has extended the
From the Mayo Graduate School of Medicine, Mayo Foundation, Rochester, Minnesota. VOLUME 30, NO.2, 1984
concept further by showing the correlation between atypical changes of intestinal metaplasia and carcinogenesis in the human stomach mucosa. A retrospective review of all endoscopic gastric polypectomies performed at the Mayo Clinic between 1974 and 1979 was undertaken. Forty-eight polyps were removed from 43 patients, ranging in age from 43 to 86 with a mean of 66 years. Patients were offered endoscopic polypectomy if the gastric polyp had been diagnosed and they met one of the following criteria: (1) unchanged or enlarging gastric polyp on serial upper gastrointestinal contrast studies; (2) expected noncompliant patient follow-up; (3) previous gastric surgical procedure with the presence of a new polyp; and (4) a gastric polyp in a patient known to have pernicious anemia. The most frequent presenting symptoms initiating the diagnostic workup were epigastric discomfort or indigestion (44%) and anemia (21 %). The presence of a gastric polyp was established by upper gastrointestinal contrast studies in 39 of 43 cases (91 %) and by endoscopy because of melena (two), persistent epigastric discomfort despite a negative upper gastrointestinal series (one), and previous gastric surgery (one). The most frequent location for the polyp was in the antrum (67.2%) followed by the fundus (30%), one was found in the cardia (2.3%). Seventy-seven percent of the polyps were pedunculated, although the width of the stalk varied considerably. The size of the polyps removed ranged from 0.3 to 3.5 cm with a mean of 1.4 cm in diameter. Multiple polyps were noted in 35% of the patients. Endoscopic gastric polypectomy was performed uneventfully in 45 (94%) procedures. Bleeding was noted from the polyp site in two cases (4.2%). Both were transfused and, despite attempts at endoscopic electrocoagulation, required surgical ligation of the site 1 101
and 11 days after undergoing endoscopic polypectomy. Poor patient cooperation complicated one procedure (2%). As a result of the endoscopic polypectomy findings, laparotomy with gastric wedge resection was performed on four patients in whom three carcinoid tumors and one leiomyoma were found. Follow-up examinations in over 50% of patients revealed no new polyp formation or change in existing polyps in 92%. Hyperplastic polyps without associated malignancy recurred twice in the same patient. No adenomatous polyps recurred. Complications that can ensue from endoscopic gastric polypectomy are perforation, hemorrhage, and the development of a symptomatic ulcer. In one study, 15 all patients were submitted to follow-up endoscopy and 18% had a residual ulcer 1 week postpolypectomy; all ulcers healed by the eighth week of follow-up. Lanza et al. 18 has recommended an ulcer therapy program for 2 weeks following an upper gastrointestinal polypectomy, and we routinely prescribe an Hz antagonist for 2 weeks after polypectomy.
REFERENCES 1. Tsuneoka K, Uchida T. Endoscopic polypectomy of the stomach. Second World Congress of Gastrointestinal Endoscopy, Copenhagen, 1970. 2. Burns D, Jacobs WHo Endoscopic electrosurgical polypectomies of the upper gastrointestinal tract. South Med J 1977;70:92630.
Upper gastrointestinal endoscopy in polyposis syndromes: familial polyposis coli and Gardner's syndrome Michael V. Sivak, Jr., MD David G. Jagelman, MD
A registry for patients and families with familial polyposis coli (FPC) and/or Gardner's syndrome (GS) was established at the Cleveland Clinic in 1979. Approximately 1800 individuals from 100 families have been registered, and about 14% of registrants have established FPC or GS. Cases of FPC and of GS were found within the same family in a little less than half of the kindreds. Esophagogastroduodenoscopy (EGD) was performed in 49 patients with FPC or GS from 35 families prior to colectomy. Polypoid lesions were found in the upper gastrointestinal tract in 43% of patients. Onehalf of the patients with FPC who underwent EGD had polyps, and polyps were encountered in 36% of
From the Cleveland Clinic, Cleveland, Ohio.
102
3. Gaisford W. Gastrointestinal polypectomy via the fiberendoscope. Arch Surg 1973;106:458-62. 4. Papp JP. Electrosurgical advances in upper gastrointestinal endoscopy. Am J Gastroenterol 1976;66:248-50. 5. Stewart MJ. Observations on the relation of malignant disease to benign tumors of the gastrointestinal tract. Br Med J 1929;2:267-9. 6. Lawrence JC. Gastrointestinal polyps-a statistical study of malignancy incidence. Am J Surg 1936;31:499-505. 7. Yamada T. Polypoid lesions of the stomach. Stomach Intestine 1966;1:145-50. 8. Tomasuco J. Gastric polyps. Cancer 1971;27:1346-55. 9. Morson BC. Pathology of the gastrointestinal tract. Curr Topics PathoI1976;63:77-93. 10. Si-Chun Ming. The classification and significance of gastric polyps. Monogr PathoI1977;18:149-75. 11. Elster K. Histologic classification of gastric polyps. Curr Topics PathoI1976;63:77-93. 12. Ida K, Kubota Y, Okuda J, Miyanaga M, Nishiwaki K. Differential diagnosis of gastric polypoid lesion by the application of methylene blue staining. J Kyoto Prof Univ Med 1979;88:2918. 13. Hay LJ. Surgical management of gastric polyps and adenocarcinoma. Surgery 1956;39:114-9. 14. Bowden L. Adenocarcinoma in a small gastric polyp: a case report. Cancer 1962;15:468-71. 15. Seifert E, Elster K. Gastric polypectomy. Am J Gastroenterol 1975;63:451-6. 16. Kozuka S, Masamoto K, Suzuki S, Kubota K, Yokoyama Y. Histogenic types and size of polypoid lesion in the stomach with special reference to cancerous change. Gann 1977;68:26774. 17. Ohrui T. Histopathological and morphometric study of relationship between atypical changes of intestinal metaplasia and carcinogenesis in human stomach mucosa (abstract 2529). 13th International Cancer Congress, 1982. 18. Lanza FL, Graham DY, Nelson RS, Godiness R, McKechnie JC. Endoscopic upper gastrointestinal polypectomy. Am J GastroenteroI1981;75:345-8.
patients with GS. Carcinoma of the duodenum was found in one patient with FPC, but not as a result of screening in an asymptomatic patient. There were three distribution patterns for polyps: (1) fundic, (2) duodenal, and (3) fundic plus duodenal. The distribution of patients with polyps according to these patterns was approximately even for both FPC and GS. Polyps were found in the antrum in a few cases. Endoscopic biopsies were obtained of polyps in all cases, but these contained adenomatous tissue in only 38%, the majority of these being in the duodenum. Polyps, when present in the fundus, were usually numerous, hemispheric, sessile, orange-yellow in color, and from 2 to 7 mm in diameter. In the duodenum they were usually multiple, although less numerous than in the fundus, and usually small and white in color compared to surrounding mucosa. It is very difficult to arrive at an exact figure for the occurrence of polyps in the stomach and/or duodenum in patients with FPC. Halsted et aLl studied a single kindred with 15 living members in which gastric polyps were found in four individuals. Utsunomiya et al. z GASTROINTESTINAL ENDOSCOPY
GASTROINTESTINAL ENDOSCOPY Copyright © 1984 by the American Society for Gastrointestinal Endoscopy
Symposium Gastrointestinal endoscopy in clinical practice AISIGIE National Postgraduate Course May 26 and 27, 1983, Washington, D.C. Editor: Michael V. Sivak, Jr., MD Cleveland, Ohio
Gastric polyps and polypectomy: rationale, technique, and complications Rollin W. Hughes, Jr., MD
With improved fiberoptic technique, diagnostic as well as therapeutic endoscopy is playing a more important role in the management of gastrointestinal polyps.1-4 Although the incidence of gastric polyps is low, 0.4%5 to 0.7%,6 recent experience has led to classification schemes based on topographic, 7 histologic,8-11 and vital staining 12 criteria. The most frequently encountered gastric polyps, hyperplastic or regenerative polyps, are reported to contain malignancy rarely. Adenomatous gastric polyps that are greater than 2 cm in diameter have been reported to contain foci of in situ or invasive malignancy 43%13 to 59%8 of the time. Occasional cases of adenomatous gastric polyps cont~ining malignancy have been reported in a polyp· less than 2 cm. 14 Histological classification of gastric polyps by endoscopic biopsy is not sufficient to screen for polyps with malignant potential. Seifert and Elster 15 reported a series of 24 gastric polyps removed endoscopically where the histological classification was modified in 75% once the entire polyp was available for tissue sectioning. Kozuka et al. 16 observed that regenerative polyps underwent malignant change through secondary involvement with metaplasia. When regenerative polyps had severe invasive metaplasia, it became difficult to distinguish them from adenomatous polyps and the highest incidence of cancerous change was found in the metaplastic type polyp. OhruP7 has extended the
From the Mayo Graduate School of Medicine, Mayo Foundation, Rochester, Minnesota. VOLUME 30, NO.2, 1984
concept further by showing the correlation between atypical changes of intestinal metaplasia and carcinogenesis in the human stomach mucosa. A retrospective review of all endoscopic gastric polypectomies performed at the Mayo Clinic between 1974 and 1979 was undertaken. Forty-eight polyps were removed from 43 patients, ranging in age from 43 to 86 with a mean of 66 years. Patients were offered endoscopic polypectomy if the gastric polyp had been diagnosed and they met one of the following criteria: (1) unchanged or enlarging gastric polyp on serial upper gastrointestinal contrast studies; (2) expected noncompliant patient follow-up; (3) previous gastric surgical procedure with the presence of a new polyp; and (4) a gastric polyp in a patient known to have pernicious anemia. The most frequent presenting symptoms initiating the diagnostic workup were epigastric discomfort or indigestion (44%) and anemia (21 %). The presence of a gastric polyp was established by upper gastrointestinal contrast studies in 39 of 43 cases (91 %) and by endoscopy because of melena (two), persistent epigastric discomfort despite a negative upper gastrointestinal series (one), and previous gastric surgery (one). The most frequent location for the polyp was in the antrum (67.2%) followed by the fundus (30%), one was found in the cardia (2.3%). Seventy-seven percent of the polyps were pedunculated, although the width of the stalk varied considerably. The size of the polyps removed ranged from 0.3 to 3.5 cm with a mean of 1.4 cm in diameter. Multiple polyps were noted in 35% of the patients. Endoscopic gastric polypectomy was performed uneventfully in 45 (94%) procedures. Bleeding was noted from the polyp site in two cases (4.2%). Both were transfused and, despite attempts at endoscopic electrocoagulation, required surgical ligation of the site 1 101
and 11 days after undergoing endoscopic polypectomy. Poor patient cooperation complicated one procedure (2%). As a result of the endoscopic polypectomy findings, laparotomy with gastric wedge resection was performed on four patients in whom three carcinoid tumors and one leiomyoma were found. Follow-up examinations in over 50% of patients revealed no new polyp formation or change in existing polyps in 92%. Hyperplastic polyps without associated malignancy recurred twice in the same patient. No adenomatous polyps recurred. Complications that can ensue from endoscopic gastric polypectomy are perforation, hemorrhage, and the development of a symptomatic ulcer. In one study, 15 all patients were submitted to follow-up endoscopy and 18% had a residual ulcer 1 week postpolypectomy; all ulcers healed by the eighth week of follow-up. Lanza et al. 18 has recommended an ulcer therapy program for 2 weeks following an upper gastrointestinal polypectomy, and we routinely prescribe an Hz antagonist for 2 weeks after polypectomy.
REFERENCES 1. Tsuneoka K, Uchida T. Endoscopic polypectomy of the stomach. Second World Congress of Gastrointestinal Endoscopy, Copenhagen, 1970. 2. Burns D, Jacobs WHo Endoscopic electrosurgical polypectomies of the upper gastrointestinal tract. South Med J 1977;70:92630.
Upper gastrointestinal endoscopy in polyposis syndromes: familial polyposis coli and Gardner's syndrome Michael V. Sivak, Jr., MD David G. Jagelman, MD
A registry for patients and families with familial polyposis coli (FPC) and/or Gardner's syndrome (GS) was established at the Cleveland Clinic in 1979. Approximately 1800 individuals from 100 families have been registered, and about 14% of registrants have established FPC or GS. Cases of FPC and of GS were found within the same family in a little less than half of the kindreds. Esophagogastroduodenoscopy (EGD) was performed in 49 patients with FPC or GS from 35 families prior to colectomy. Polypoid lesions were found in the upper gastrointestinal tract in 43% of patients. Onehalf of the patients with FPC who underwent EGD had polyps, and polyps were encountered in 36% of
From the Cleveland Clinic, Cleveland, Ohio.
102
3. Gaisford W. Gastrointestinal polypectomy via the fiberendoscope. Arch Surg 1973;106:458-62. 4. Papp JP. Electrosurgical advances in upper gastrointestinal endoscopy. Am J Gastroenterol 1976;66:248-50. 5. Stewart MJ. Observations on the relation of malignant disease to benign tumors of the gastrointestinal tract. Br Med J 1929;2:267-9. 6. Lawrence JC. Gastrointestinal polyps-a statistical study of malignancy incidence. Am J Surg 1936;31:499-505. 7. Yamada T. Polypoid lesions of the stomach. Stomach Intestine 1966;1:145-50. 8. Tomasuco J. Gastric polyps. Cancer 1971;27:1346-55. 9. Morson BC. Pathology of the gastrointestinal tract. Curr Topics PathoI1976;63:77-93. 10. Si-Chun Ming. The classification and significance of gastric polyps. Monogr PathoI1977;18:149-75. 11. Elster K. Histologic classification of gastric polyps. Curr Topics PathoI1976;63:77-93. 12. Ida K, Kubota Y, Okuda J, Miyanaga M, Nishiwaki K. Differential diagnosis of gastric polypoid lesion by the application of methylene blue staining. J Kyoto Prof Univ Med 1979;88:2918. 13. Hay LJ. Surgical management of gastric polyps and adenocarcinoma. Surgery 1956;39:114-9. 14. Bowden L. Adenocarcinoma in a small gastric polyp: a case report. Cancer 1962;15:468-71. 15. Seifert E, Elster K. Gastric polypectomy. Am J Gastroenterol 1975;63:451-6. 16. Kozuka S, Masamoto K, Suzuki S, Kubota K, Yokoyama Y. Histogenic types and size of polypoid lesion in the stomach with special reference to cancerous change. Gann 1977;68:26774. 17. Ohrui T. Histopathological and morphometric study of relationship between atypical changes of intestinal metaplasia and carcinogenesis in human stomach mucosa (abstract 2529). 13th International Cancer Congress, 1982. 18. Lanza FL, Graham DY, Nelson RS, Godiness R, McKechnie JC. Endoscopic upper gastrointestinal polypectomy. Am J GastroenteroI1981;75:345-8.
patients with GS. Carcinoma of the duodenum was found in one patient with FPC, but not as a result of screening in an asymptomatic patient. There were three distribution patterns for polyps: (1) fundic, (2) duodenal, and (3) fundic plus duodenal. The distribution of patients with polyps according to these patterns was approximately even for both FPC and GS. Polyps were found in the antrum in a few cases. Endoscopic biopsies were obtained of polyps in all cases, but these contained adenomatous tissue in only 38%, the majority of these being in the duodenum. Polyps, when present in the fundus, were usually numerous, hemispheric, sessile, orange-yellow in color, and from 2 to 7 mm in diameter. In the duodenum they were usually multiple, although less numerous than in the fundus, and usually small and white in color compared to surrounding mucosa. It is very difficult to arrive at an exact figure for the occurrence of polyps in the stomach and/or duodenum in patients with FPC. Halsted et aLl studied a single kindred with 15 living members in which gastric polyps were found in four individuals. Utsunomiya et al. z GASTROINTESTINAL ENDOSCOPY