title: Physician assessment and management of complex colon polyps: a multicenter video-based survey study.
abstract: OBJECTIVE
  The management of complex colorectal polyps varies in practice. Accurate descriptions of the endoscopic appearance by using a standardized classification system (Paris classification) and size for complex colon polyps may guide subsequent providers regarding curative endoscopic resection vs. need for surgery. The accuracy of this assessment is not well defined. Furthermore, the factors associated with decisions for endoscopic vs. surgical management are unclear. To characterize the accuracy of physician assessment of polyp morphology, size, and suspicion for malignancy among physician subspecialists performing colonoscopy and colon surgery. In addition, we aimed to assess the influence of these polyp characteristics as well as physician type and patient demographics on recommendations for endoscopic vs. surgical resection of complex colorectal polyps.
  
  
  METHODS
  An online video-based survey was sent to gastroenterologists (GIs) and gastrointestinal surgeons affiliated with six tertiary academic centers. The survey consisted of high-definition video clips (30-60 s) of six complex colorectal polyps (one malignant) and clinical histories. Respondents were blinded to histology. Respondents were queried regarding polyp characteristics, suspicion for malignancy, and recommendations for resection.
  
  
  RESULTS
  The survey response rate was 154/317 (49%). Seventy-eight percent of respondents were attending physicians (91 GIs and 29 surgeons) and 22% were GI trainees. Sixteen percent of respondents self-identified as specialists in complex polypectomy. Accurate estimation of polyp size was poor (28.4%) with moderate interobserver agreement (k=0.52). Accuracy for Paris classification was 47.5%, also with moderate interobserver agreement (k=0.48). Specialists in complex polypectomy were most accurate, whereas surgeons were the least accurate in assigning Paris classification (66.0 vs. 28.7%, P<0.0001). Specialists in complex polypectomy were most likely to correctly identify the malignant lesion compared with other physicians (87.5 vs. 56.2%, P=0.008). Surgical removal of colon adenomas was recommended least frequently by specialists in complex polypectomy (3.1%) compared with nonspecialists in complex polypectomy (13.3%); surgeons were most likely to recommend surgical resection (17.2%, P=0.009). There were no differences in recommendations for endoscopic vs. surgical resection observed on the basis of years in practice, polyp morphology (polypoid vs. nonpolypoid), polyp location (right vs. left colon), or patient ASA class.
  
  
  CONCLUSIONS
  In this large survey of GIs and surgeons, physician specialty was strongly associated with accurate polyp characterization and a recommendation for endoscopic resection of complex polyps. Surgeons were most likely to recommend surgical resection of complex nonmalignant colorectal polyps compared with specialists in complex polypectomy who were the least likely. Therefore, collaboration with specialists in complex polypectomy may be helpful in determining the appropriate management of complex colon polyps. Further teaching is needed among all specialists to improve accurate communication and ensure optimal management of these lesions.
authors.affiliation: Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA.
authors.forename: A
authors.initials: A
authors.lastname: Aziz Aadam
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado and Veterans Affairs Medical Center, Denver, Colorado, USA.
authors.forename: Sachin
authors.initials: S
authors.lastname: Wani
authors.affiliation: Division of Gastroenterology and Hepatology, Indiana University and Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Kahi
authors.affiliation: Division of Gastroenterology, Veteran's Affairs Palo Alto, Palo Alto, California, USA.
authors.forename: Tonya
authors.initials: T
authors.lastname: Kaltenbach
authors.affiliation: Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Young
authors.initials: Y
authors.lastname: Oh
authors.affiliation: Division of Gastroenterology, Washington University in St. Louis, Saint Louis, Missouri, USA.
authors.forename: Steven
authors.initials: S
authors.lastname: Edmundowicz
authors.affiliation: Department of Preventative Medicine, Northwestern University, Chicago, Illinois, USA.
authors.forename: Jie
authors.initials: J
authors.lastname: Peng
authors.affiliation: Department of Preventative Medicine, Northwestern University, Chicago, Illinois, USA.
authors.forename: Alfred
authors.initials: A
authors.lastname: Rademaker
authors.affiliation: Division of Gastroenterology and Hepatology, University of Colorado and Veterans Affairs Medical Center, Denver, Colorado, USA.
authors.forename: Swati
authors.initials: S
authors.lastname: Patel
authors.affiliation: Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Vladimir
authors.initials: V
authors.lastname: Kushnir
authors.affiliation: Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
authors.forename: Mukund
authors.initials: M
authors.lastname: Venu
authors.affiliation: Division of Gastroenterology, Veteran's Affairs Palo Alto, Palo Alto, California, USA.
authors.forename: Roy
authors.initials: R
authors.lastname: Soetikno
authors.affiliation: Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois, USA.
authors.forename: Rajesh N
authors.initials: RN
authors.lastname: Keswani
mesh_terms: D000236:Adenoma / Q000473:pathology* / Q000601:surgery*; D000368:Aged; D002983:Clinical Competence; D003111:Colonic Polyps / Q000145:classification / Q000473:pathology* / Q000601:surgery*; D003113:Colonoscopy; D015179:Colorectal Neoplasms / Q000473:pathology* / Q000601:surgery*; D003107:Colorectal Surgery; D003657:Decision Making; D005260:Female; D005762:Gastroenterology; D019538:Health Care Surveys / Q000379:methods; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010818:Practice Patterns, Physicians'; D016037:Single-Blind Method; D014741:Video Recording