Elective Colectomy for the Treatment of Benign Colon Polyps: National Surgical Trends, Outcomes and Cost Analysis

Introduction: Colonoscopy with polypectomy decreases the incidence and mortality of colon cancer. While endoscopic management for benign colon polyps has been demonstrated to be safer and more cost-effective than surgery, patients are routinely referred for surgical polyp removal. Little is known about this practice. We aimed to determine the trends, outcomes and costs of colectomy in the management of benign colon polyps. Methods: We queried the national Veterans Affairs Surgical Quality Improvement Program (VASQIP) database for colectomy procedures, using CPT codes, between 2000-2014. We linked this to the national VA Corporate Data Warehouse (CDW) to assess patient, pathology and hospital cost data. We measured rates, complications and costs associated with colectomy for benign polyps. We analyzed the pathology characteristics of a random sample (9.5%, n=642). Results: Of the 60,494 colectomies performed, we identified 7,102 Veterans who had a colectomy for benign polyps. Colectomy for benign polyps increased from 6% (n=213) in 2000 to 18% (n=614) in 2014, P<0.001. The number of colonoscopies tripled from 131,326 to 381,333, P<0.001. However, the percent of colectomies performed for colon cancer decreased from 40% (n=1,674) to 31% (n=1,065) (Figure 1). Patients had a mean age of 66 (SD 8.8, 27-92) years. The majority were men (97%) and ASA class III (71%) (Table 1). Based on pathology, 80% (n=514) of patients underwent a right hemicolectomy. The median polyp diameter was 25mm (IQR 15-35mm). Histology of the surgically resected polyps predominantly showed adenoma 63.4%, with only 6.4% of surgical specimens showing submucosal invasion and 27.6% high-grade dysplasia. 3.6% of specimens contained no residual lesion. The 30-day mortality was 1.2% and complication rate was 19.7% (Table 2). 5.4% of patients required repeat surgery. The median cost of colectomy was $22,712 (IQR: $16,621-32,508) for open and $20,697 (IQR: $14,905-29,268) for laparoscopic. Costs increased to $32,460(IQR: $20,842-54,665) and $27,639 (IQR: $19,752-45,748), respectively, if any complications.Figure: Comparison of aggregate colonoscopy procedures completed and percentage of colectomy cases completed by indication for surgery.Table: Patient Demographics.Table: Outcomes of patients who underwent colectomy for benign adenomas.Conclusion: In our large VA national cohort, the rates of colectomies for benign adenomas significantly increased by three-fold over a 15 year period, and were associated with significant mortality, morbidity and cost. In the most recent year, 2014, close to a fifth of colectomies were performed for benign polyps. Future efforts should focus on determining physician and patient factors that drive these practice patterns.