ORIGINAL ARTICLE: Clinical Endoscopy

Setting up a regional expert panel for complex colorectal

polyps
Liselotte W. Zwager, MD, Barbara A. J. Bastiaansen, MD, Evelien Dekker, MD, PhD, Paul Fockens, MD, PhD,
on behalf of the Expert Panel Group*

Amsterdam, the Netherlands

GRAPHICAL ABSTRACT

Background and Aims: Advanced endoscopic resection techniques for complex colorectal polyps have evolved
significantly over the past decade, leading to a management shift from surgical to endoscopic resection as the
preferred treatment. However, in practice, interhospital consultation and appropriate referral management
remain challenging, leading to unnecessary surgical resections. To support regional care for patients with complex
colorectal polyps, facilitate peer consultations, and lower thresholds for referrals, an expert panel consultation
platform was initiated in the northwestern region of the Netherlands.
Methods: We initiated a regional expert panel in the northwestern region of the Netherlands for patients with com-
plex colorectal polyps and studied the implementation, adaption, and clinical impact. All panel consultations between
June 2019 and May 2021 were retrospectively analyzed, and user satisfaction among panel members was evaluated.
Results: Eighty-eight patients with complex colorectal polyps from 11 of 15 participating centers (73.3%) were
discussed in our panel. The most common reason for panel consultation was suspicion of invasive cancer in
36.4% (n Z 32). After panel consultation, 43.2% of the consulting endoscopists (n Z 38) changed their initial
treatment strategy, and in 63.6% (n Z 56) patients were referred to another endoscopy center. Of 26 cases sub-
mitted with a primary proposal for surgical treatment, surgery was avoided in 7 (26.9%). User satisfaction was
rated high in most participating centers (91.7%).
Conclusions: Our study shows that implementation of and consultation with a regional expert panel can be a
valuable tool for endoscopists to guide and optimize treatment of complex colorectal polyps and facilitate inter-
hospital referrals in a regional network. (Gastrointest Endosc 2022;96:84-91.)

(footnotes appear on last page of article)

Endoscopic polypectomy reduces incidence and mortal-
ity of colorectal cancer (CRC).1 Most colorectal polyps are
small and can be readily removed by conventional snare
resection methods by every endoscopist with low
adverse event rates.2,3 However, for a subset of colorectal
polyps, advanced endoscopic resection techniques are
required. These so-called complex colorectal polyps are
either large, located at a difficult anatomic location, have
had a previous failed attempt at endoscopic resection,
look suspicious for malignancy, or have a combination of

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Zwager et al
these 4 factors.4 Historically, these complex nonmalignant
polyps were managed by colorectal surgery.5,6 However,
colorectal surgery for nonmalignant polyps is associated
with higher morbidity and mortality rates compared with
more recently introduced advanced endoscopic resection
techniques.7-9
Over the past decade, a management shift has
occurred from surgery to minimally invasive resection
techniques such as piecemeal EMR, endoscopic submuco-
sal dissection (ESD), and endoscopic full-thickness resec-
tion (eFTR).5 These advanced endoscopic alternatives are
proven to be safe and effective for complex colorectal
polyps.10-12 However, additional training and expertise
are necessary, and a limited number of expert endoscop-
ists perform these complex resections. A prospective
study showed that after endoscopic reassessment by an
expert endoscopist, surgery could be avoided in 70% of
patients with complex colonic polyps without biopsy sam-
ple–proven cancer.13 Therefore, the most recent
guidelines advise that advanced colorectal polyps that
are assessed as nonmalignant should not be referred for
surgery without consultation with an expert endoscopist
for assessment of endoscopic treatment possibilities.5,6
However, at many centers, patients with complex
colorectal polyps are rarely referred to an expert
endoscopist.14 Multiple studies have shown that the rate
of referrals for surgery is only slowly decreasing.7,14-16 Po-
tential reasons for these low referral rates are that not
every endoscopist is aware of the available advanced tech-
niques or may also have a high threshold to consult
expert endoscopists.
Initiation of a digital expert panel that can be consulted
by sharing clinical details of patients and their endoscopic
images may facilitate structured peer consultation, increase
knowledge on therapeutic possibilities, and potentially
reduce the number of unnecessary surgical interventions
or inappropriate endoscopic interventions for complex
colorectal polyps. This could have an important impact
on the care for these patients both by assisting physicians
to have informed discussions with their patients with
regard to optimal management selection and to ease
referral pathways. In other areas of medicine, expert
panels have resulted in improved patient care and
demonstrated their effectiveness.17-19 For example, the
expert panel launched by the Dutch Pancreatitis Study
Group was shown to be a valuable tool for clinicians of
patients with pancreatitis.19 However, experiences and
the potential benefits for implementation of a regional
expert panel for complex colorectal polyps have not
been studied. To aid peer consultation and optimize
management for patients with complex colorectal polyps
in our region, we have designed and implemented a
regional complex polyp expert panel. This study aims to
describe the implementation and adaption of this regional
expert panel.
www.giejournal.org
Setting up a regional expert panel for complex colorectal polyps
METHODS
Set up and methodology of the expert panel
In June 2019, a secure online regional expert panel was
launched that was freely accessible to all endoscopists in
the northwestern region of the Netherlands. This area
covers 2 academic and 10 regional hospitals and 3 private
endoscopy services. Gastroenterologists of all centers (ac-
ademic and regional) with special interest in treating com-
plex colorectal polyps were invited to participate. In total,
16 gastroenterologists from 13 centers confirmed their
participation in the expert panel. All gastroenterologists
participated voluntarily.
All regional endoscopists were encouraged to submit
their cases online for advice from the expert panel. To obtain
information on the complexity of the colorectal polyps and
patients’ general health status, the following data were
collected: patient characteristics (eg, year of birth, gender,
American Society of Anesthesiologists class), previous
colonic interventions, colonoscopy characteristics, lesion
characteristics, recent endoscopic attempts, and available
histology. The consulting endoscopist was asked which
treatment would have been proposed when panel consulta-
tion was not available. Based on the submitted information,
the SMSA score (size, morphology, site, access) was auto-
matically calculated by allocating points. The points were
added to grade the lesion into 1 of 4 SMSA levels, with level
1 being very easy and level 4 being very difficult to resect.20
Finally, a minimum of 3 high-quality endoscopic images of
the lesion were requested. All these items were submitted
through an online form downloaded from our website
(www.poliepadvies.nl; Appendix 1, available online at
www.giejournal.org). Because data were collected for
standard patient health care, the Institutional Review
Board decided that this study did not fall under the Dutch
Legislation on Medical Research Involving Human Subjects
Act, and ethical review was deemed unnecessary. No
patient identification items were requested, and informed
consent was waived by our local ethics committee.
Collected data and images were stored in a secure on-
line database provided by a cloud-based clinical data plat-
form (Castor Electronic Data Capture) by the study
coordinator.21 Each time a new case was uploaded, the
members of the expert panel received an email with a
request to login and enter their advice. The panelists
were blinded to the opinion of other panelist and the
consulting physician. Panelists could provide multiple
treatment options and have a free text field for additional
comments. Within 1 week after submission, the bundled
panelists’ advice was sent to the consulting endoscopist
(Fig. 1). The identity of the responding panelist was
disclosed to the consulting endoscopist. After a
reasonable period of time, the consulting endoscopist
was asked to report the chosen treatment, clinical
outcome, and pathology results.
Volume 96, No. 1 : 2022 GASTROINTESTINAL ENDOSCOPY 85
Setting up a regional expert panel for complex colorectal polyps
Figure 1. Workflow of the expert panel. First, the consulting endoscopist from a center in the province of Noord-Holland or Flevoland filled out a form
downloaded from www.poliepadvies.nl. Then, the provided data were inserted into a secured database in less than 48 hours and an email was sent to the
participating experts. Third, all experts independently filled in their advice. Finally, within 1 week, bundled expert advice was forwarded to the consulting
endoscopist.
At bimonthly intervals all panelist received feedback on
the decisions and treatment results of recent patients. In
this feedback the different opinions of each panelist were
provided to the entire panel. Finally, approximately 1
year after the start of the panel, an evaluation form about
the satisfaction of the expert panel was sent to all panelists.
Aim, outcome measures, and statistical analysis
This study aimed to describe the implementation, adap-
tion, and clinical impact of our newly developed regional
expert panel. Outcome measures were the number of pa-
tients submitted to the expert panel, number of panelist re-
sponding per submitted case, initially proposed treatment
strategy by the consulting endoscopists, change in treat-
ment strategy after panel consultation (ie, between endos-
copy and surgery, treating in own hospital vs referral and
between different endoscopic treatment options), and
number of patients referred to another hospital after panel
consultation. Finally, we assessed user satisfaction among
the members of the expert panel.
Standard descriptive statistics were used. Variables are
reported as mean with standard deviation for continuous
and normally distributed variables, as median and inter-
quartile range for non-normally distributed continuous var-
iables, and as percentages for counts or categorical
variables. Statistical analysis was performed using SPSS 24
(SPSS, Chicago, Ill, USA).
RESULTS
From June 2019 to May 2021, the expert panel was con-
sulted for a total of 88 patients with complex colorectal
polyps. Of all 15 participating centers, endoscopists from
11 centers (73.3%) consulted the expert panel. Most consul-
tations was received from regional centers (95.5%, n Z 84).
During the first year, the panel was consulted for 23 cases,
which increased to 65 cases in the second year (Fig. 2).
The main reasons for panel consultation were suspicion of
malignancy in 36.4% (n Z 32), large size in 11.4% (n Z
10), location in 10.2% (n Z 9), and a combination of
those in 30.7% (n Z 27).
86 GASTROINTESTINAL ENDOSCOPY Volume 96, No. 1 : 2022
Zwager et al
Patient and lesion characteristics of the cases that
were submitted to the panel are shown in Table 1. Of
all 88 lesions, 43.2% (n Z 38) were located in the
proximal colon. The median diameter was 30 mm
(interquartile range, 20-40 mm), and 46.6% (n Z 41)
were submitted because of a suspicion for
adenocarcinoma. Fifty percent of lesions (n Z 44) had
the highest SMSA score of 4 (>12 points), 28.4% (n Z
25) had a score of 3 (9-12 points), 15.9% (n Z 14) had
a score of 2 (6-9 points), and in 5.7% (n Z 5) the
SMSA score was missing. Diagnostic biopsy specimens
had been taken in 48.9% of lesions (n Z 43), and
endoscopic resection had been attempted in 4.5% (n Z
4). At submission, histology of endoscopic biopsy
samples or resection attempts was supplied in 36 of 47
lesions and showed adenoma with low-grade dysplasia
in 50.0% (18/36), high-grade dysplasia in 19.4% (7/36),
and adenocarcinoma in 27.8% (10/36).
Of the 16 participating panelists, 12 (75.0%) submitted a
recommendation at least once. The mean number of panel-
ists submitting their recommendation per consultation was
6
2, which was lower during the first year of our panel
with a mean of 3
1 in comparison with a mean of 7
2 dur-
ing the second year. These panelists reached more than 50%
agreement in 51.1% of cases (n Z 45), whereas in 9.1% (n Z
8) non-unanimous treatment advice (ie, <50% consensus)
was given. Furthermore, in 27.3% consensus was reached
(n Z 24) and in 12.5% “50:50” advice (n Z 11) was given.
In 38 patients (43.2%) presented to the panel consultations,
the consulting endoscopists changed their initial treatment
strategy after receiving the panel’s advice, and 63.6% of pa-
tients (n Z 56) were referred to another center for further
treatment, (For an example of a consulted cases with the
final treatment strategy, see Appendix 2, available online at
www.giejournal.org.)
To evaluate the clinical impact of our regional expert
panel, we assessed whether panel consultation changed
the initially proposed treatment strategy between endo-
scopic resection and surgery (Fig. 3). In 5 of 88 submitted
cases (5.7%), the proposed treatment strategy was
missing. Of the remaining 83 cases, endoscopic resection
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Zwager et al Setting up a regional expert panel for complex colorectal polyps

Cumulative number of expert panel consultations

18 100

16 90
88
Number of consultations 14 80

76 70
12
65 60
10
50
8
48 40
6 40
30
4 27 20
22 23 23
2 19
10
9
0 0
Ju 019

g 9
p 9
t2 9
v 9
c2 9
Ja 019

b 0
ar 0

r 0
ay 0
n 0
Ju 20

g 0
p 0
t 0
v 0
c2 0
n 0
b 1
ar 1
r 1
ay 1
21
Au 01
Se 201
Oc 01
No 0 1
D e 201

Fe 02
M 202
Ap 202
M 202
Ju 02

Au 202
Se 202
Oc 202
No 2 0 2
D e 202
Ja 02
Fe 02
M 202
Ap 202
M 202
20

20
2
l2

2
n

l
Ju

Hospital 1 Hospital 2 Hospital 3

Hospital 4 Hospital 5 Hospital 6
Hospital 7 Hospital 8 Hospital 9
Hospital 10 Hospital 11 Total

Figure 2. Cumulative number of expert panel consultations per regional hospital between June 2019 and May 2021.

was proposed in 57 cases (68.7%). After panel consultation,
this treatment did not change in 39 cases (68.4%). In 17
cases (29.8%) the treatment plan changed to surgery, and
in 1 case (1.8%) no treatment was performed because of
patient preference. In most cases where panel
consultation changed the proposed treatment to surgery
(14/17, 82.4), the suggested endoscopic treatment was
deemed not feasible because of the suspicion of deep
submucosal invasion. The final histology of the surgical
specimen in 13 of these cases did show advanced CRC
justifying radical surgery. In the other patient no further
treatment was performed because of comorbidity reasons.
In the remaining 3 cases, 1 patient preferred surgery and
2 patients were not amenable to endoscopic treatment
because of a nonlifting sign or size of the lesion. Primary
surgery was proposed by the consulting endoscopist in 26
of 83 cases (31.3%). After panel consultation, in 17 cases
(65.4%) treatment did not change, whereas in 7 cases
(26.9%) the treatment plan changed to endoscopic
treatment. In all 7 cases, endoscopic resection was
feasible and followed by surveillance. No additional
surgeries were performed. In the 2 remaining cases
(7.7%) a conservative treatment approach was followed
because of patient preference.
All performed treatment procedures after panel consul-
tation are shown in Supplementary Table 1 (available
online at www.giejournal.org). Of all 36 cases with
supplied histology at submission, the final histology of 29
cases was available. Of those, in 12 (41.4%) the initial
biopsy sample was underestimated in the final histology.
Regarding the brief survey that was sent out to the
members of the expert panel after 1 year, 12 of 16 panelists
(75.0%) completed the survey, and 11 of 12 panelists
(91.7%) were satisfied about the expert panel
(Supplementary Table 2, available online at www.
giejournal.org). Five of 12 panelists (41.7%) actively
encouraged their colleagues to use the panel.
DISCUSSION
This study assessed the implementation, adaption, and
clinical impact of a regional expert panel for complex colo-
rectal polyps in the northwestern region of the
Netherlands. After 2 years, 73% of the participating centers
had consulted our expert panel for treatment advice
regarding complex colorectal polyps. The most common
reason for consulting the panel was a suspicion of invasive
growth. In 43% of submitted cases, consulting endoscop-
ists changed their initial treatment strategy and in 64%
the patient was referred to another center with more
expertise. Furthermore, in 27% of cases where surgical
resection was initially proposed, panel consultation led to
an endoscopic procedure, all treated successfully without
additional surgery. On the other hand, in 30% of cases in
which endoscopic treatment was initially proposed, the
expert panel advised a surgical treatment. Nearly all these
cases indeed showed an advanced CRC. We conclude
that our regional expert panel for complex colorectal
polyps has proven to be an accessible and valuable tool

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Setting up a regional expert panel for complex colorectal polyps Zwager et al

TABLE 1. Patient and lesion characteristics TABLE 1. Continued

Characteristics Value Characteristics Value

Consultations 88 (100) Pedunculated 2 (2.3)

Regional centers 84 (95.5) Missing 3 (3.4)
Patients SMSA score
Male sex 57 (64.8) Level 1 (4-5 points) 0 (0)
Age, y 67
10 Level 2 (6-9 points) 14 (15.9)
American Society of Anesthesiologists class Level 3 (9-12 points) 25 (28.4)
I: healthy 23 (26.1) Level 4 (>12 points) 44 (50.0)
II: mild systemic disease 58 (65.9) Missing 5 (5.7)
III: severe systemic disease 7 (8.0) Treatment performed
IV: severe systemic disease that is a 0 (0) Diagnostic biopsy sampling 43 (48.9)
constant threat to life
Submucosal lifting attempt 9 (10.2)
Indication first colonoscopy
Endoscopic resection attempt 4 (4.5)
Screening colonoscopy 45 (51.1)
Histology*
Surveillance after polypectomy 7 (8.0)
Adenoma with low-grade dysplasia 18 (50.0)
Surveillance after colorectal cancer 1 (1.1)
Adenoma with high-grade dysplasia 7 (19.4)
Positive family history for colorectal cancer 1 (1.1)
(Suspicion of) adenocarcinoma 10 (27.8)
Rectal blood loss 12 (13.6)
Sessile serrated lesion 0 (0)
Changed bowel habits 6 (6.8)
Hyperplastic polyp 0 (0)
Abdominal discomforts 2 (2.3)
Other 1 (2.8)
Anemia 2 (2.3)
Reasons for expert panel consultation
Unknown 2 (2.3)
Location 9 (10.2)
Other 8 (9.1)
Size 10 (11.4)
Median lesion diameter, mm 30 (20-40)
Suspicion of adenocarcinoma 32 (36.4)
Location lesion
Nonlifting 6 (6.8)
Proximal (cecum to splenic flexure) 38 (43.2)
Irradical resection 1 (1.1)
Cecum 5 (5.7)
Combination 27 (30.7)
Appendiceal orifice 5 (5.7)
Other 3 (3.4)
Ascending colon 13 (14.8)
Expert panel responses per case 6
2
Hepatic flexure 4 (4.5)
Expert panel advicey
Transverse colon 5 (5.7)
Consensus 24 (27.3)
Splenic flexure 0 (0)
50:50 11 (12.5)
Distal (descending colon to rectum) 50 (56.8)
50% consensus 45 (51.1)
Descending colon 0 (0)
<50% consensus 8 (9.1)
Sigmoid 22 (25.0)
Treatment strategy adjusted after panel consultation
Rectum 28 (31.8)
Yes 38 (43.2)
Macroscopic aspect
Not reported 5 (5.7)
Adenomatous 43 (48.9)
Referral to another center
Sessile serrated lesion 1 (1.1)
Yes 56 (63.6)
Hyperplastic polyp 0 (0)
Not reported 1 (1.1)
Adenocarcinoma 41 (46.6) Values are n (%), mean
standard deviation, or median (interquartile range).
Subepithelial lesion 0 (0) SMSA, Size, morphology, site, access.
*Histological findings provided after a biopsy sampling or attempt at endoscopic
Other 3 (3.4) removal.
Lesion morphology yWith consensus we mean that all panelists reported unanimous treatment
advice, 50% consensus means that panelists reached more than 50% consensus,
Flat 17 (19.3) and <50% consensus means non-unanimous treatment advice.
Sessile 66 (75.0)

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Zwager et al
for endoscopists to discuss and optimize further treatment
and referral strategies.
Our study showed that most panelists were satisfied with
the panel with a relatively high participation rate. During the
second year of our panel, panel consultation increased
significantly, possibly because of repeated presentations at
regional meetings and pamphlets in endoscopic depart-
ments of regional centers. In agreement, we observed a
similar trend in experts submitting their recommendation
per consultation. During the first year of our expert panel,
relatively few panelists participated per case. Therefore, it
is difficult to assess if experts also learned from each other
and reached more consensus during the second year. How-
ever, by discussing cases of complex colorectal polyps,
participating gastroenterologists may become more aware
of the array of available endoscopic options and their
respective indications. Moreover, our study showed that in
almost one-fourth of consultations, the provided advice
largely varied among experts (ie, non-unanimous treatment
advice or 50:50 advice). This implies some discrepancy ex-
ists in recommended management options, even among en-
doscopists with special interest in complex colorectal
polyps. Because all members of the expert panel received
feedback forms including decisions and final treatment re-
sults of every discussed case, the members of the expert
panel should have been able to learn from each other.
Future evaluations are needed to evaluate a possible
learning curve in recommendations of participating experts.
The main goal in the treatment of complex colorectal
polyps is to provide an optimal treatment and prevent un-
necessary surgical or endoscopic resection, with its concur-
rent burden and adverse event risk. Colorectal surgery is
associated with increased morbidity and mortality rates as
compared with endoscopic treatment methods.7,9,14,22-24
Judging whether colorectal polyps are complex remains largely
subjective and depends mostly on endoscopic skills, equip-
ment, and experience of the performing endoscopist.20 To
support determining the optimal management strategy,
classification systems have been developed to grade the
complexity of a lesion to assess whether endoscopic or
surgical resection is more appropriate.16,21 Most polyps
consulted in our expert panel were classified as complex
(SMSA score level 4). For these complex polyps, guidelines
recommend referral to an expert endoscopist for
comprehensive assessment of the optimal treatment strategy
as suggested by the European Society of Gastrointestinal
Endoscopy guideline.5 In the present study, most patients
(63%) for whom consultation was sought were referred to
another center with expertise in advanced endoscopic
resection. This seems an important step forward compared
with the results of our previous study in the same region,
demonstrating that only 2.4% of patients with polyps
considered too complex for endoscopic resection were
referred to another endoscopy center before surgical
resection.12 However, it is unknown which percentage of all
complex colorectal polyps have been submitted to our
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Setting up a regional expert panel for complex colorectal polyps
regional expert panel. Nevertheless, our high referral rate
between centers implies that there might be a lower
threshold to consult dedicated endoscopists with special
interest in complex colorectal polyps in the region.
Although endoscopic resection seems to have multiple
advantages, it is not always the preferred treatment for com-
plex colorectal polyps. For polyps with suspected malignant
invasion, complete en-bloc resection is mandatory. Despite
the fact that advanced endoscopic resection techniques
allow complete resection of some of these polyps, colorectal
surgery remains the preferred treatment strategy for a subset
of more advanced polyps. Thus, avoiding surgery should not
be a goal by itself.25 During endoscopy, optical diagnosis
with high-definition virtual chromoendoscopy techniques
can be used to predict the depth of submucosal invasion
by using classification systems as the Japan Narrow Band Im-
aging Expert Team (JNET), Narrow Band Imaging Interna-
tional Colorectal Endoscopic (NICE), and/or Kudo
classification.26 In daily practice, however, real-time endo-
scopic recognition of submucosal invasive cancer is chal-
lenging.27 We showed that in 30% of cases in which the
consulting endoscopist suggested an endoscopic
resection, panel consultation eventually led to the advice
for a surgical resection. This is comparable with the results
of Friedland et al,13 who showed that 29% of complex
colorectal polyps were not amenable for endoscopic
treatment after reassessment.
In our study, most cases were sent for surgery because
of the suspicion of deeper submucosal invasion. In nearly
all cases, final histopathology showed an advanced CRC,
and surgery seemed the appropriate treatment strategy.
Notably, in most cases the consulting endoscopist pro-
posed an ESD. In addition to a suspicion of deeper inva-
sion, these lesions were also located in the right-sided
colon, larger than 20 mm, and therefore not amenable
for a safe and complete resection by colorectal ESD or
eFTR. For lesions with a suspicion of deep invasive cancer,
ESD is not the preferred treatment strategy to achieve a
radical resection.28 On the other hand, our study showed
that surgery could be avoided in 27% of consultations.
For all cases initially considered not amenable to
endoscopic resection by consulting physicians and
judged as amenable for endoscopic resection by our
panelists, a successful endoscopic procedure could be
performed. Therefore, our expert panel seems to aid in
selecting the most optimal treatment strategy.
To further improve our expert panel, we should optimize
the quality of provided endoscopic images. Currently, a min-
imum of 3 images is requested. However, to optimally assess
a lesion, it is important that endoscopists provide high-
quality pictures with advanced imaging techniques such as
white-light endoscopy and/or narrow-band imaging. Several
studies have shown that these techniques improve optical
diagnosis.26 For better assessment, the consulting
endoscopists should be able to provide an endoscopic
video of the lesion. This may help the panelist to
Volume 96, No. 1 : 2022 GASTROINTESTINAL ENDOSCOPY 89
Setting up a regional expert panel for complex colorectal polyps Zwager et al

Endoscopy Surgery

Initial proposed 1 (2%) No 2 (8%)

treatment
treatment performed*
57 26

21 (37%) 8 (31%)
9 (16%) 4 (15%)

Reassessment1
26 (46%) 12 (46%)

13 (62%) 5 (63%)

3 (38%) 8 (38%)

Treatment after
panel consultation
46 34

Final treatment with endoscopy

Final treatment with surgery

Figure 3. Description of the initial proposed treatment by the consulting endoscopist without panel consultation and performed treatment after panel
consultation. Of all 88 submitted cases, in 5 cases the consulting endoscopist did not register a proposed treatment strategy. *After panel consultation no
treatment was performed because of patient preference or a watch-and-wait approach (n Z 3). 1Reassessment is defined as a second look by a dedicated
endoscopist.

optimally assess the complexity. Furthermore, we should
encourage all experts to actively participate in our panel,
because 25% of experts never assessed a case. To support
the use of our regional panel by all endoscopists in the
region, we should promote our panel during regional
meetings. Finally, adding a colorectal surgeon to our
expert panel will enhance decision-making by critically as-
sessing the indication for surgery.
This study has limitations to address. At first, the num-
ber of consultations in our expert panel was relatively
low. This may have resulted in a potential selection bias
of cases submitted for panel consultation and may not
reflect the true number of complex colorectal polyp
cases that may have been discussed or referred to expert
centers without consultation of this panel. However, the
significant increase of panel consultations during our sec-
ond year may be a reflection of increased awareness and
acknowledgement, and we expect the number of consul-
tations will only increase in the following years. Second,
although we showed that patients may have received a
more appropriate treatment strategy, either changing
from surgery to endoscopy or vice versa, it remains diffi-
cult to interpret the true impact of all panel consulta-
tions. Panelists were blinded to each other’s opinion.
Because opinions varied on most consultations,
completely uniform treatment advice could not be given,
and all individual opinions were transferred back to the
consulting endoscopist. For this reason, it remains un-
clear how the decision process exactly was influenced
by our expert panel to either perform endoscopic or sur-
gical treatment depending on multiple factors including
age, comorbidity, and patient preference. However,
because in most consultations patients were referred to
a center with more expertise, this possibly supported
optimal treatment selection.
In conclusion, our study shows that implementation of a
regional expert panel for complex colorectal polyp cases fa-
cilitates peer consultation, could lower thresholds for inter-
hospital referrals, and decreases the number of
inappropriate surgical or endoscopic interventions. Access
to the required expertise on complex colorectal polyp
cases can support physicians in optimizing treatment and
can aid appropriate referral management. Similar regional
initiatives or multidisciplinary referral networks are
strongly encouraged to be implemented.
ACKNOWLEDGMENT
We thank the members of the Expert Panel Group: M. I.
E. Appels, G. J. de Bruin, A. C. T. M. Depla, I. L. Huibregtse,
T. Kuiper, B. I. Liberov, R. Ch. Mallant-Hent, W. A. Mars-
man, D. Ramsoekh, B. W. van der Spek, M. S. Vlug, S. J.
B. van Weyenberg, and C. A. Wientjes.
REFERENCES
1. Zauber AG, Winawer SJ, O'Brien MJ, et al. Colonoscopic polypectomy
and long-term prevention of colorectal-cancer deaths. N Engl J Med
2012;366:687-96.

90 GASTROINTESTINAL ENDOSCOPY Volume 96, No. 1 : 2022 www.giejournal.org

Zwager et al Setting up a regional expert panel for complex colorectal polyps

2. Vermeer NC, Snijders HS, Holman FA, et al. Colorectal cancer screening: 20. Gupta S, Miskovic D, Bhandari P, et al. A novel method for determining
systematic review of screen-related morbidity and mortality. Cancer the difficulty of colonoscopic polypectomy. Frontline Gastroenterol
Treat Rev 2017;54:87-98. 2013;4:244-8.
3. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer 21. Castor Electronic Data Capture. Amsterdam, the Netherlands 2019.
by colonoscopic polypectomy. The National Polyp Study Workgroup. Available at: https://www.castoredc.com. Accessed June 1, 2022.
N Engl J Med 1993;329:1977-81. 22. Keswani RN, Law R, Ciolino JD, et al. Adverse events after surgery for
4. Nederlandse Vereniging van Maag- D-eL. Nederlandse richtlijn Endo- nonmalignant colon polyps are common and associated with increased
scopische poliepectomie van het colon. 2019. Available at: https:// length of stay and costs. Gastrointest Endosc 2016;84:296-303.
mdl.nl. Accessed June 1, 2022. 23. Le Roy F, Manfredi S, Hamonic S, et al. Frequency of and risk factors for
the surgical resection of nonmalignant colorectal polyps: a population-
5. Ferlitsch M, Moss A, Hassan C, et al. Colorectal polypectomy and
based study. Endoscopy 2016;48:263-70.
endoscopic mucosal resection (EMR): European Society of Gastroin-
24. Tholoor S, Tsagkournis O, Basford P, et al. Managing difficult polyps:
testinal Endoscopy (ESGE) clinical guideline. Endoscopy 2017;49:
techniques and pitfalls. Ann Gastroenterol 2013;26:114-21.
270-97.
25. Shaukat A, Kaltenbach T, Dominitz JA, et al. Endoscopic recognition
6. Rutter MD, Chattree A, Barbour JA, et al. British Society of Gastroenter-
and management strategies for malignant colorectal polyps: recom-
ology/Association of Coloproctologists of Great Britain and Ireland
mendations of the US Multi-Society Task Force on Colorectal Cancer.
guidelines for the management of large non-pedunculated colorectal
Gastrointest Endosc 2020;92:997-1015.
polyps. Gut 2015;64:1847-73.
26. Bisschops R, East JE, Hassan C, et al. Advanced imaging for detection
7. Vermeer NCA, de Neree Tot Babberich MPM, Fockens P, et al. Multi-
and differentiation of colorectal neoplasia: European Society of Gastro-
centre study of surgical referral and outcomes of patients with benign
intestinal Endoscopy (ESGE) guideline - update 2019. Endoscopy
colorectal lesions. BJS Open 2019;3:687-95.
2019;51:1155-79.
8. de Neree Tot Babberich MPM, Bronzwaer MES, Andriessen JO, et al.
27. Vleugels JLA, Koens L, Dijkgraaf MGW, et al. Suboptimal endoscopic
Outcomes of surgical resections for benign colon polyps: a systematic
cancer recognition in colorectal lesions in a national bowel screening
review. Endoscopy 2019;51:961-72.
programme. Gut 2020;69:977-80.
9. Peery AF, Shaheen NJ, Cools KS, et al. Morbidity and mortality after sur-
28. Fuccio L, Hassan C, Ponchon T, et al. Clinical outcomes after endo-
gery for nonmalignant colorectal polyps. Gastrointest Endosc 2018;87:
scopic submucosal dissection for colorectal neoplasia: a systematic re-
243-50 e2.
view and meta-analysis. Gastrointest Endosc 2017;86:74-86.
10. Zwager LW, Bastiaansen BAJ, Bronzwaer MES, et al. Endoscopic full-
thickness resection (eFTR) of colorectal lesions: results from the Dutch
colorectal eFTR registry. Endoscopy 2020;52:1014-23. Abbreviations: CRC, colorectal cancer; eFTR, endoscopic full-thickness
11. Hassan C, Repici A, Sharma P, et al. Efficacy and safety of endoscopic resection; ESD, endoscopic submucosal dissection; SMSA, size,
resection of large colorectal polyps: a systematic review and meta- morphology, site, access.
analysis. Gut 2016;65:806-20.
DISCLOSURE: The following authors disclosed financial relationships:
12. Arezzo A, Passera R, Marchese N, et al. Systematic review and meta-
B. A. J. Bastiaansen: Speaker for Olympus, Tillotts Pharma AG, and
analysis of endoscopic submucosal dissection vs endoscopic mucosal
Ovesco Endoscopy. E. Dekker: Research support and equipment loan
resection for colorectal lesions. United Eur Gastroenterol J 2016;4:
from FujiFilm; consultant for FujiFilm, Olympus, Tillotts Pharma AG,
18-29.
GI Supply, CPP-FAP, and PAION; speaker for Olympus, Roche, GI
13. Friedland S, Banerjee S, Kochar R, et al. Outcomes of repeat colonos-
Supply, Ambu, and Ipsen. P. Fockens: Consultant for Cook, Ethicon,
copy in patients with polyps referred for surgery without biopsy-
and Olympus; research support from Boston Scientific. All other
proven cancer. Gastrointest Endosc 2014;79:101-7.
authors disclosed no financial relationships.
14. Bronzwaer MES, Koens L, Bemelman WA, et al. Volume of surgery for
benign colorectal polyps in the last 11 years. Gastrointest Endosc
*See Acknowledgment for members of the Expert Panel Group.
2018;87:552-61.
15. van Nimwegen LJ, Moons LMG, Geesing JMJ, et al. Extent of unneces- Copyright ª 2022 by the American Society for Gastrointestinal Endoscopy.
sary surgery for benign rectal polyps in the Netherlands. Gastrointest Published by Elsevier, Inc. This is an open access article under the CC BY
Endosc 2018;87:562-70. license (http://creativecommons.org/licenses/by/4.0/).
16. Peery AF, Cools KS, Strassle PD, et al. Increasing rates of surgery for pa- 0016-5107
tients with nonmalignant colorectal polyps in the United States. https://doi.org/10.1016/j.gie.2022.02.003
Gastroenterology 2018;154:1352-60.
Received November 12, 2021. Accepted February 1, 2022.
17. de Swart ME, Kouwenhoven MCM, Hellingman T, et al.
A multidisciplinary neuro-oncological triage panel reduces the time Current affiliation: Department of Gastroenterology and Hepatology,
to referral and treatment for patients with a brain tumor. Neurooncol Amsterdam Gastroenterology & Metabolism, Amsterdam University
Pract 2021;8:559-68. Medical Centers, Amsterdam, the Netherlands.
18. Hellingman T, de Swart ME, Joosten JJA, et al. The value of a dedicated
Reprint requests: Paul Fockens, MD, PhD, Department of Gastroenterology
multidisciplinary expert panel to assess treatment strategy in patients
and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam
suffering from colorectal cancer liver metastases. Surg Oncol 2020;35:
University Medical Centers, University of Amsterdam, Meibergdreef 9,
412-7.
1105 AZ Amsterdam, The Netherlands.
19. van Grinsven J, van Brunschot S, van Santvoort HC, et al. The value of a
24/7 online nationwide multidisciplinary expert panel for acute necro- If you would like to chat with an author of this article, you may contact
tizing pancreatitis. Gastroenterology 2017;152:685-8. Dr Fockens at p.fockens@amsterdamumc.nl.

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Setting up a regional expert panel for complex colorectal polyps Zwager et al

APPENDIX

Supplementary Figure 1. A, B, C, D, E, F, G, Endoscopic images of the target lesion. H, Marked lesion with the full-thickness resection device marking
probe. I, The full-thickness resection site with the over-the-scope clip in place. J, The resected lesion pinned onto paraffin.

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Zwager et al Setting up a regional expert panel for complex colorectal polyps

SUPPLEMENTARY TABLE 1. Performed treatment after panel SUPPLEMENTARY TABLE 2. Survey of members of the expert panel
consultation (12/16 panelists)

Treatment Value Survey question Value

Consultations 88 (100) I am satisfied with the online expert panel

No treatment performed 3 (3.4) Totally disagree 0 (0)
Endoscopic treatment 50 (56.8) Disagree 0 (0)
Endoscopic mucosal resection 26 (29.5) Not agree or disagree 1 (8.3)
Endoscopic full-thickness resection 8 (9.1) Agree 10 (83.3)
Endoscopic submucosal dissection 11 (12.5) Fully agree 1 (8.3)
Endoscopic intermuscular dissection 5 (5.7) I am satisfied about the website
Surgical treatment 34 (38.6) Totally disagree 1 (8.3)
Ileocecal resection 2 (2.3) Disagree 0 (0)
Right hemicolectomy 11 (12.5) Not agree or disagree 1 (8.3)
Left hemicolectomy 1 (1.1) Agree 7 (58.3)
Sigmoid resection 9 (10.2) Fully agree 1 (8.3)
Low anterior resection 1 (1.1) I am satisfied with the format in Castor Electronic
Subtotal colectomy 1 (1.1) Data Capture

Partial mesorectal excision 1 (1.1) Totally disagree 0 (0)

Transanal total mesorectal excision 2 (2.3) Disagree 0 (0)

Transanal minimal invasive surgery local excision 5 (5.7) Not agree or disagree 2 (16.7)

Laparoscopic wedge resection 1 (1.1) Agree 7 (58.3)

Missing 1 (1.1) Fully agree 3 (25.0)

Values are n (%).

I think it is valuable to receive the advice of other
experts and final treatment strategy afterwards
Totally disagree 0 (0)
Disagree 0 (0)
Not agree or disagree 0 (0)
Agree 9 (75.0)
Fully agree 3 (25.0)
I advise my colleagues to use the online expert panel
Totally disagree 0 (0)
Disagree 2 (16.7)
Not agree or disagree 5 (41.6)
Agree 3 (25.0)
Fully agree 2 (16.7)
Values are n (%).

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