1. Treatment of large and giant colorectal polyps in the real world Stéphanie HUSSON, Guy VENTRE, Frédéric VAGNE, Jean François VIES, Marjorie MUSSO, Jean Louis COLSON, Jacques PICOT, Jean Marc BOYAVAL, Daniel SONDAG, François KHACHOYAN, Isabelle GENDRE, Philippe PERRIN, Bernard DENIS Association pour le dépistage du cancer colorectal dans le Haut-Rhin (ADECA 68), Colmar, France

2. B. Denis - DDW 2007 – Washington DC background l large polyps ≥ 20 mm / giant ≥ 30 mm endoscopic resection effective and safe Walsh RM 1992, Dell’Abate P 2001, Brooker JC 2002, Seitz U 2003, Conio M 2004, Katsinelos P 2006 success rates ~ 1OO% Binmoeller KF 1996, Kanamori T 1996, Iishi H 2000, Stergiou N 2002, Doniec JM 2003, Bories E 2006, l how about the real world?

3. B. Denis - DDW 2007 – Washington DC aim to assess the success rate of endoscopic resection of large colorectal polyps in a population-based setting

4. B. Denis - DDW 2007 – Washington DC methods l population-based CRC screening program with guaiac based FOBT l 23 pilot areas l Haut-Rhin: 190 000 residents aged 50-74 y (Denis B et al. Gut 2007 in press)

5. B. Denis - DDW 2007 – Washington DC methods l retrospective study l all large polyps detected l CRC screening program in the Haut-Rhin l 3 year period (sept. 2003 - sept. 2006)

6. B. Denis - DDW 2007 – Washington DC results l 34 endoscopists (21 private practice) l 2968 colonoscopic procedures l 325 large polyps in 279 people (82 women) prevalence = 9.4%

7. B. Denis - DDW 2007 – Washington DC results – polyps characteristics n (%) size 20 – 29 mm215 (66.2) ≥ 30 mm 110 (33.8)

8. B. Denis - DDW 2007 – Washington DC results – polyps characteristics n (%) shape pedunculated226 (69,5) sessile79 (24,3) flat11 (3,4)

9. B. Denis - DDW 2007 – Washington DC results – polyps characteristics n (%) shape pedunculated226 (69,5) sessile79 (24,3) flat11 (3,4)

10. B. Denis - DDW 2007 – Washington DC results – polyps characteristics n (%) location rectum48 (14,8) distal colon232 (71,4) proximal colon45 (13,8)

11. B. Denis - DDW 2007 – Washington DC results – polyps characteristics n (%) location rectum48 (14,8) distal colon232 (71,4) proximal colon45 (13,8)

12. B. Denis - DDW 2007 – Washington DC results – polyps characteristics n (%) type tubular119 (37,0) tubulo-villous174 (54,0) villous27 (8,4) serrated1 (0,3) hyperplastic1 (0,3)

13. B. Denis - DDW 2007 – Washington DC results – polyps characteristics n (%) dysplasia high-grade217 (66,8) T1 carcinoma31 (9,5)

14. B. Denis - DDW 2007 – Washington DC results – endoscopic resection l 247 polyps (76%) in 220 people l resection during u single session: 76.8% u 2nd procedure other expert endoscopist: 4.6% l En bloc resection: 67.2% l EMR: 8.6% l 2 bleeding / endoscopic treatment

15. B. Denis - DDW 2007 – Washington DC results – surgical resection l 78 polyps (24%) in 61 people l reasons u endoscopic resection failure: 44.0% u polyposis: 9.3% u malignant polyp: 46.7% l no complication

16. B. Denis - DDW 2007 – Washington DC endoscopic resection rate P<0.001 20–29 mm >30 mmpedunc. sessile / flat

17. B. Denis - DDW 2007 – Washington DC endoscopic resection rate P=0.02 P<0.001 P<0.01

18. B. Denis - DDW 2007 – Washington DC endoscopic resection rate P<0.001

19. B. Denis - DDW 2007 – Washington DC conclusions (1) l largest series l 1 st in a population-based setting l in the real world u 1 / 5 patients with a benign large polyp is operated on u 2 / 5 with a benign giant polyp

20. B. Denis - DDW 2007 – Washington DC conclusions (2) l referral to surgery related to u sessile or flat shape u size, u proximal or rectal location, u malignancy and u lack of referral to an expert endoscopist l EMR performed by a minority (41.2%) l referral to an expert is rare (4.6%)

21. B. Denis - DDW 2007 – Washington DC future l need for u teaching (spreading) endoscopic techniques for the management of large polyps u promoting referral of difficult large polyps to expert endoscopists to avoid unnecessary surgery

22. B. Denis - DDW 2007 – Washington DC acknowledgements l all the 34 endoscopists practicing in the Haut-Rhin