Pronostic des polypes gastriques ( pith61iaux Etude d'une s6rie de 89 patients trait6s

par polypectomie per-endoscopique

J.P. H E Y R A U D *, B. M O U L I N I E R **, L. D E S C O S *, R. L A M B E R T **, R. T R U C H O T *** M. D E C H A V A N N E *

�9 S e r v i c e d ' H ( p a t o - G a s t r o e n t d r o l o g i e , C e n t r e H o s p i t a l i e r , L y o n - S u d �9 * S e r v i c e d ' H ( p a t o - G a s t r o e n t d r o l o g i e , H O p i t a l E d o u a r d - H e r r i o t L y o n

�9 ** L a b o r a t o i r e d ' A n a t o m i e P a t h o l o g i q u e , H O p i t a l E d o u a r d - H e r r i o t L y o n

Prognosis of the epithelial gastric polyps Study of a series of 89 patients treated by per-endoscopic polypectomy

RESUMi~

L'ex6r~se per-endoscopique d'un polype gastrique a gtO effectu6 chez 150 patients de 1971 ~ 1982.

Chez 89 patients, le polype 6tait de type 6pith61ial : hyperplasique et/ou hyperplasiog6nique dans 88,6 % des cas, adgnomateux dans 13,4 % des cas.

La surveillance au long cours des polypes 6pith61iaux permet de proposer des modalit6s de surveillance adaptge au type histologique initial (gtant entendu que tout polype doit faire l'objet d'une ex6r~se pour 6tude anatomopatbologique compl&te) :

- - les polypes byperplasiques et/ou hyperplasiog6niques ne d6gOnOrent que tr&s exceptionnellement. La rgcidive se fait toujours sur le mgme mode histologique, b6nin. De r fait, un contrOle endoscopique tous les 5 ans apparait suffisant ;

- - les polypes ad6nomateux peuvent d6gOn6rer (dans 17 ~ 40 % des cas). Un contrOle endoscopique apparait n6cessaire 6 mois apr~s leur ex6r~se, pour effectuer des biopsies syst6matiques au niveau de la cicatrice. De nouveaux contrOles sont ~ conseiller par la suite tousles deux ans.

Dans tous les cas, des biopsies sont ~ effectuer ~ titre syst6matique, h distance du polype, en territoire muqueux apparemment sain.

S U M M A R Y

The perendoscopic exeresis o f a gastric polyp was performed on 150 patients f rom 1971 to 1982.

In 89 patients, the polyp was o f epithelial type : hyperplastic and~or hyperplasiogenic in 88.6 % o f the cases, adenomatous in 13.4 % o f the cases.

The long term follow-up o f epithelial polyps allows to propose modalities adapted to the initial histological type (keeping in mind that all polyps must be submitted to exeresis in order to obtain a complete pathological study) :

- - the hyperplastic and~or hyperplasiogenic polyps degenerate very exceptionally. The recurrence always occurs in the histological way and benignly. Therefore, a 5 year endoscopic follow-up appears to be sufficient ;

- - the adenomatous polyps may degenerate (in 17 to 40 % o f cases). An endoscopic follow-up appears necessary 6 months after the exeresis in order to perform systematic biopsies at the level o f the scar. Other follow-up examinations are to be advised every 2 years.

In all cases, biopsies must be performed systematically, around the polyp, on an apparently healthy mucosa.

La p ra t ique r6gul i6re de la f ibroscopie c o m m e exp lora t ion de p r e m i 6 r e i n t e n t i o n du tube digestif sup6r ieur a p e r m i s de d6couvr i r avec une fr6- q u e n c e insoupcjonn6e des polypes gas t r iques de p lus ieurs types , n o t a m m e n t des polypes 6pi th6- l iaux. Bien que les po lypes gast r iques so ient mo i ns f r6quents que les po lypes in tes t inaux et q u ' a u n iveau de I ' e s tomac les po lypes 6pith61iaux so ien t

en p o u r c e n t a g e m o i n s n o m b r e u x q u ' a u n i v e a u du r e c t u m et du c61on, il se pose h leur su je t le p r o b l 6 m e de leur ex6r6se sy s t6ma t ique et celui de la surve i l lance au long cour s de la m u q u e u s e gas- t r ique oO ils son t n6s. C e t t e 6 tude r6 t rospec t ive a p o u r ob je t d ' a p p o r t e r des 616ments de r6ponses ces diverses ques t ions .

Tir6s h part : pr L. DESCOS, Centre Hospitalier, Lyon Sud, 69310 Pierre B6nite (France).

Mots-Cl(s: polypectomie per-endoscopique, polypes gastri- ques, surveillance.

Key-words : follow-up, gastric polyps, perendoscopic polypec- tomy.

Acta Endoscopica Volume 16 - N" 3 - 1986 169

ME, T H O D E D E T R A V A I L

L'ex6rbse per-endoscopique d'un polype gastri- que a 6t6 r6alis6e chez 150 patients, de 1971 1982, dans le service d'H6pato-Gastro-Ent6rologie de l'H6pital Edouard Herriot, principalement, et dans celui du Centre Hospitalier Lyon Sud. 89 patients sur ces 150 pr6sentaient un polype 6pith6- lial: 54 femmes et 35 hommes fig6s en moyenne de 62 ans (figes extr6mes 29 et 85 ans). 53 fois des biopsies ont 6t6 effectu6es au niveau du polype avant son ex6r6se h l'anse diathermique et son 6tude anatomo-pathologique apr6s coupe r6alis6e suivant son grand axe. 65 fois des biopsies syst6- matiques ont 6t6 pratiqu6es en muqueuse saine. T o u s l e s examens anatomo-pathologiques ont 6t6 interpr6t6s par le m6me anatomo-pathologiste.

43 patients pr6sentant un polype 6pith61ial ont 6t6 recontr616s par fibroscopie dans un d61ai de six mois & huit ans.

R E S U L T A T S

- - Les polypes hyperplasiques et hyperplasiog6- niques concernaient 77 des 89 patients pr6sentant un ou des polypes 6pith61iaux (86,6 %). I1 s'agis- sait trois fois sur quatre d'un polype unique. 8 fois seulement plus de trois polypes 6taient compt6s sans qu'aucune polypose diffuse ne soit observ6e. 59 polypes furent mesur6s avec pr6cision: 8 avaient une taille qui d6passait 2 cm ; aucun n'at- teignait 3 cm. T o u s l e s polypes pr61ev6s 6taient b6nins. Les biopsies r6alis6es avant l'ex6r6se n'avaient conduit au diagnostic d6finitif que seize fois sur quarante-quatre (36 %). Celles effectu6es

distance du polype permettaient de d6couvrir une muqueuse gastrique atrophique dans 82 % des cas.

Lors du contr61e endoscopique effectu6 chez 36 patients, 4, 3 ans en moyenne apr6s l'ex6r6se, un ou plusieurs polypes furent d6couverts chez 13 d'entre eux, d'histologie identique et toujours b6- nins.

- - L e s polypes ad6nomateux concernaient 12 patients (13,4 %). 6 6taient de structure tubulaire, 6 6taient de structure tubulo-villeuse. Uniques 9 fois sur 12, 6 des 8 polypes mesur6s d6passaient une taille de 2 cm de diam6tre ; Fun deux attei- gnait 4 cm. Sur le plan anatomo-pathologique, des contingents hyperplasiog6niques cotoyaient des contingents ad6nomateux au sein du m6me polype dans quatre observations. Une zone de d6g6n6res- cence fut observ6e sur trois polypes de structure tubulo-villeuse. Les biopsies r6alis6es avant l'ex6- r~se n'avaient conduit au diagnostic d6finitif d'ad6- home que 7 fois sur 9 et ~ celui de d6g6n6res- cence qu' l fois sur 3. Les biopsies faites ~ distance du polype indiquaient dans tous les cas l'existence d'une muqueuse gastrique atrophique.

Lors du contr61e endoscopique effectu6 chez 6 patients apr~s l'ex6r6se, un cancer fut d6couvert

chez trois d'entre eux au niveau de la cicatrice d'ex6r6se dans un d61ai inf6rieur ~ un an (2 lois apr6s ex6r6se d'un ad6nome b6nin ; 1 fois apr6s celle d'un ad6nome dEgEn6r6). Dans ce dernier cas, des biopsies effectu6es un mois apr6s l'exEr~se 6talent normales ; huit mois plus tard elles per- mettaient de conclure ~ une d6g6n6rescence n6o- plasique). Chez deux autres patients, un cancer gastrique fut d6couvert deux ans apr6s la polypec- tomie (Fun d'eux pr6sentait une maladie de Peutz Jeghers, Fautre avait subi une gastro-ent6ro-anas- tomose voici 25 ans). Chez un dernier patieni enfin, un polype hyperplasiog6nique fut enlev6 deux ans apr6s la premi6re polypectomie.

D I S C U S S I O N

Bien que cette 6tude r6trospective appelle de par sa nature quelques remarques : insuffisance num6rique des patients revus, recul de surveillance insuffisant, elle porte sur un total de 150 malades et repose sur des donn6es homog6nes d'explora- tion endoscopique et d'anatomie pathologique. Elle permet, confort6e par d'autres s6ries interna- tionales, de situer la place des polypes gastriques 6pith61iaux parmi les autres types de polypes et de proposer pour ce qui les concerne un plan de surveillance.

Endoscopiquement, il est impossible de faire la distinction entre polypes 6pith61iaux et autres polypes : fibro-inflammatoires, brunneromes ; il peut 6tre malais6 de distinguer un polype d'une formation sous muqueuse : myome, tumeur carci- noide, pancr6as aberrant. Les biopsies r6alis6es au niveau des polypes sont plus souvent positives lorsqu'il s'agit de polypes 6pith61iaux. Elles n'ap- portent des renseignements pr6cis, pour les autres polypes, que dans 10 % des cas. Seule l'6tude anatomo-pathologique faite apr6s polypectomie per-endoscopique permet r6guli6rement de porter un diagnostic de certitude.

Histologiquement, pour ce qui concerne les polypes 6pith61iaux, une distinction a 6t6 6tablie par Elster [4] et Seifert et Elster [14] entre polypes hyperplasiques et polypes hyperplasiog6ni- ques d'une part, et ad6nomes d'autre part. Les premiers sont constitu6s de cellules mucipares bien diff6renci6es, les seconds de cellules d6diff6ren- ci6es, basophiles, ayant perdu leur caract~re muco- s6cr6tant. L'architecture des polypes hyperplasio- g6niques et des ad6nomes est semblable, avec une prolif6ration h la fois de l'6pith61ium de surface et des glandes, tandis que dans les polypes hyperpla- siques la prolif6ration n'int6resse que l'6pith61ium de surface et les cryptes. Ces caract6ristiques font a priori pr6voir que les ad6nomes pr6sentent un plus grand risque de d6g6n6rescence.

Aucun des 77 polypes hyperplasiques ou hyper- plasiog6niques de la s6rie 6tudi6e n'6tait le si~ge d'une transformation maligne. Des constatations analogues sont faites par la plupart des auteurs [8,

170 Volume 16 - N ~ 3 - 1986 Acta Endoscopica

16, 17, 18, 19]. C e p e n d a n t , q u e l q u e s cas isol6s de d 6 g 6 n 6 r e s c e n c e son t r a p p o r t 6 s [2, 7, 10, 12]. D a n s u n e 6 tude m u l t i c e n t r i q u e r e g r o u p a n t p ros de 1 000 p o l y p e s de ce t y p e , K o c h e t V i e b a h n [6] ne d 6 n o m b r e n t q u ' u n seul p o l y p e h y p e r p l a s i o g 6 n i q u e d6g6n6r6 . L a su rve i l l ance au long cou r s de p o l y p e s h y p e r p l a s i q u e s et h y p e r p l a s i o g 6 n i q u e s laiss6s en p l a c e n ' a j a m a i s p e r m i s h la p l u p a r t de s au t eu r s d ' o b s e r v e r d e d 6 g 6 n 6 r e s c e n c e [3, 5, 7, 9]. L a ta i l le des p o l y p e s . r e s t a i en t g 6 n 6 r a l e m e n t s t ab l e ou aug- m e n t a i t j u s q u ' h un m a x i m u m de 2 cm. A p r ~ s ex6r~se , la r6c id ive es t f r 6 q u e n t e , a t t e i g n a n t 50 % p o u r L a x e n et coi l . [7], 40 % p o u r Se i fe r t e t coll . [15] sur un to ta l d e p lus d e 1 000 p o l y p e s . Pou r ces d e r n i e r s a u t e u r s , ii s ' ag i t en fa i t 5 fois p lus s o u v e n t de n o u v e a u x p o l y p e s q u e d e r6cid ives p r o p r e m e n t p a r l e r . D a n s t o u s les cas , les nou- v e a u x p o l y p e s son t h a b i t u e l l e m e n t b6n ins , de t ype h y p e r p l a s i q u e ou h y p e r p l a s i o g 6 n i q u e .

T r o i s p o l y p e s a d 6 n o m a t e u x sur d o u z e de la s6rie 6 tud i6e 6 t a i en t le s i~ge d ' u n e d 6 g 6 n 6 r e s c e n c e . U n e te l l e t r a n s f o r m a t i o n es t r a p p o r t 6 e d a n s 17 /a 40 % des cas se lon les a u t e u r s [7, 11, 16]. Les ad6- n o m e s , p a r t i c u l i ~ r e m e n t ceux d e t ype v i l leux , peu - ven t 6 t re cons id6 r6s c o m m e d e s 16sions pr6-canc6- reuses . L e u r ex6r~se es t pa r fo i s i n c o m p l e t e en l ' a b s e n c e de p 6 d i c u l e b i e n i nd iv idua l i s6 , ce qui e x p l i q u e la f r 6 q u e n c e des r6c id ives in-s i tu et jus t i - fie une s u r v e i l l a n c e u l t 6 r i e u r e r i g o u r e u s e .

E n p r a t i q u e s ' i l a p p a r a i t i n d i s p e n s a b l e d ' e f f e c - t u e r l ' e x 6 r ~ s e p e r - e n d o s c o p i q u e d e t o u t p o l y p e g a s t r i q u e p o u r c o n n a i t r e sa n a t u r e a n a t o m o - p a t h o - l o g i q u e e x a c t e , le p r o b l 6 m e d e la s u r v e i l l a n c e ~t l ong t e r m e ne c o n c e r n e que les su j e t s a y a n t p r6 - sen t6 d e s p o t y p e s 6pi th61iaux. P o u r les p o l y p e s h y p e r p l a s i q u e s e t h y p e r p l a s i o g 6 n i q u e s , un cont r61e e n d o s c o p i q u e r6al is6 t ous les c inq ans s e m b l e suf- f i san t . M 6 m e si ces p o l y p e s r 6 c i d i v e n t , la r6c id ive se fa i t s u r un m o d e h i s t o l o g i q u e s e m b l a b l e le p lu s s o u v e n t . L e s r a r e s cas oO s ' a s s o c i e n t les c o n t i n - g e n t s h y p e r p l a s i o g 6 n i q u e s et a d 6 n o m a t e u x , p o s a n t le p r o b l ~ m e d e la p a r e n t 6 6 v e n t u e l l e de ces d e u x t y p e s d e p o l y p e s , p l a i d e n t p o u r c e t t e c o n d u i t e [8].

D e p lus , c o m m e la m u q u e u s e g a s t r i q u e avo i s i - n a n t e es t s o u v e n t d e t y p e a t r o p h i q u e , un c a n c e r p e u t s u r v e n i r h d i s t a n c e de la p o l y p e c t o m i e : c e t t e 6 v e n t u a l i t 6 s ' o b s e r v e d a n s 1 h 16 % des cas sui- v a n t les a u t e u r s , t ous p o l y p e s 6pi th61iaux c o n f o n - dus [1, 7, 13]. L ' e x p l o r a t i o n de la m u q u e u s e gas - t r i q u e s e r a fac i l i t6e p a r l ' u s a g e d ' u n c o l o r a n t ( i n d i g o - c a r m i n ) . L a p r a t i q u e d e b i o p s i e s m u l t i p l e s p e r m e t t r a d e r e c h e r c h e r d ' 6 v e n t u e l l e s p l a g e s de d y s p l a s i e . P o u r les p o l y p e s a d 6 n o m a t e u x , le r i sque d e d 6 g 6 n 6 r e s c e n c e loca le o u ~i d i s t a n c e a p p a r a i t b i e n p lu s g r a n d . U n e g a s t r o s c o p i e d e con t r61e es t n 6 c e s s a i r e six mo i s ap r~s l ' ex6 r~se p e r - e n d o s c o p i - q u e p o u r e f f e c t u e r des b i o p s i e s s y s t 6 m a t i q u e s au n i v e a u d e la c i ca t r i ce , pu i s t o u s l e s d e u x ans .

RI~FI~RENCES

1. BOTJ'ICHER R., BI]NTE H., HERMANEK P., ROSCH W. - - Magen Polypen - Prognose und Therapie. Dtsch. Med. Wschr., 1975, 100, 167-170.

BOSSECKERT H., RAABE G. - - Multiple polyps in the stomach. How many should be ectomized ? Endoscopy, 1983, 15, 150-151.

ELSBORG L., ANDERSEN D., MYRE-JENSEN O., BASTRUP MADSEN P. - - Gastric mucosal polyps in pernicious anemia. Scand., J. Gastroenterol, 1977, 12, 49- 52.

ELSTER K . - - A new approach to the classification of gastric polyps. Endoscopy, 1974, 6, 44-47.

5. HIROSHI M., SEIBI K., TATSUZO K. - - Endoscopic follow-up of gastric polyps. Gastrointest. Endosc., 1975, 21, 112-115.

6. KOCH H., VIEBAHN B. - - Gastrointestinal polyps - The significance of polypectomy in the stomach. En- doscopy, 1983, 15, 144-147.

7. LAXEN F., SIPPONEN P. IHAM,~KI T., HAKKI- LUOTO A., DORTSCHEVA Z. - - Gastric polyps ; their morphological and endoscopical characteristics and relation to gastric carcinoma. Acta. Pathol. MicrobioL Scand. Sect. C., 1982, 90, 221-228.

8. LESBROS F., LABADIE M., TRUCHOT R., BERGER F. - - Les polypes gastriques - Essai de classification anato- mo-pathologique portant sur 83 polypes. Arch. Anat. Cy- tol. Pathol., 1977, 25, 251-257.

9. MOULINIER B., GRENIER-BOLEY Ph., DE OLI- VEIRA C., RUET D., LAMBERT R. - - L'ex6r~se en-

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doscopique des polypes gastriques ou duod6naux. Nouv. Presse. M~d., 1974, 3, 740-742.

10. PAPP J.P. - - Adenocarcinoma occuring in a hyperplastic gastric polyp - Removal by electrosurgical polypectomy. Gastrointest. Endosc., 1976, 23, 38-39.

11. REMINE S.G., HUGUES R.W., WEILAND L.H. - - Endoscopic gastric polypectomies. Mayo. Clin. Proc. , 1981, 56, 371-375.

12. REMMELE W., KOLB E.F. - - Malignant transformation of hyperplasiogenic polyps of the stomach. Case report. Endoscopy, t978, 10, 63-65.

13. ROESCH W. - - Follow-up of risk-groups for gastric carci- nomas. Acta Endosc., 1980, Suppl. Abst.

14. SEIFERT E., ELSTER K. - - Gastric polypectomy. Am. J. gastroenterol., 1975, 63, 451-456.

15. SEIFERT E., GAlL K., WEISMI[ILLER J. - - Gastric polypectomy - Long term results (Survey of 23 centres in Germany). Endoscopy, 1983, 15, 8-11.

16. SI-CHUN MING, GOLDMANN H. - - Gastric polyps. A histogenetic classification and its relation to carcinoma. Cancer, 1965, 18, 721-726.

t7. SI-CHUN MING. - - The adenoma-carcinoma sequence in the stomach and colon II Malignant potential of gastric polyps. Gastrointest. Radiol., 1976, 1, 121.

18. SINGER M., BUSSE R., SEIB H.J., ELSTER K., OTFENJANN R . - - Endoscopic polypectomy in the up- per gastrointestinal tract. Endoscopy, 1975, 7, 216-221.

19. TOMASULO J . - - Gastric polyps - Histologic types and their relationship to gastric carcinoma. Cancer, 1971, 27, 1346-1355.

Acta Endoscopica Volume 16 - N ~ 3 - 1986 171

INTRODUCTION

The current use of fibroscopy as initial investiga- tion of the upper digestive tract lead to the disco- very of unsuspectedly frequent gastric polyps of several types - - among which epithelial polyps. Although gastric polyps are less frequent than intes- tinal polyps and though the percentage of epithelial polyps is lower in the stomach than in the rectum and the colon, a problem arises as to their systema- tic removal and the Iongterm follow-up of the gas- tric mucosa where they appeared. The aim of this retrospective work is to provide elements of answer to these questions.

METHODS

From 1971 to 1982, 150 patients have undergone the per-endoscopic removal of a gastric polyp, at the Hepato-Gastro-Enterology Departments of the Hospital Edouard Herriot, mainly, and of the Cen- tre Hospitalier Lyon Sud. 89 of these 150 patients presented an epithelial polyp: 54 women and 35 men, average age: 62 (range: 29 and 85). In 53 cases, biopsies were performed at the polyp level before its removal by diathermic snare and its ana- tomopathological study after section along its great axis. Systematic biopsies were performed on sur- rounding mucosa in 65 cases. Al l anatomopatholo- gical examinations were interpreted by the same pathologist.

43 patients with an epithelial polyp were control- led by fibroscopy after six months to eight years.

RESULTS

- - Hyperplastic and hyperplasiogenic polyps con- cerned 77 of the 89 patients with one or several epithelial polyps (86.6 %). Three times out of four, it was a single polyp. In 8 cases only, more than three polyps were counted without any diffuse poly- posis being observed. 59 polyps were measured with precision : 8 measured more than 2 cm, none reached 3 cm. All polyps taken were benign. Biop- sies performed before the excision had only lead to the definitive diagnosis in 16 cases out of 44 (36 %). Those performed at some distance of the polyp revealed an atrophic gastric mucosa in 82 % of the cases.

The control endoscopy performed on 36 patients, on average 4,3 years after the excision, showed one or several polyps in 13 of them, with a similar histology and always benign.

- -Adenomatous polyps concerned 12 patients (13,4 %). 6 had a tubular structure, 6 others a tubulo-villous structure. Being single 9 times out of 12, 6 out of the 8 measured polyps had a diameter higher than 2 cm ; one of them reached 4 cm. From an anatomopathological point of view, hyper-

plasiogenic structure mixed with adenomatous con- tingents inside the same polyp in four observations. A degenerescence zone was observed in three polyps with tubulo-villous structure. Biopsies per- formed before the excision had only lead to the definitive diagnosis of adenoma in 7 cases out of 9, and to that of degenerescence in one case out of 3. Biopsies carried out at some distance from the polyp showed an atrophic gastric mucosa in all the cases.

The control endoscopy performed on 6 patieitts after the excision lead in 3 of them to the discovery of a cancer at the excision scar level after less thail one year (twice after removal of a benign adenoma, once after removal of a degenerated adenoma). Ill the latter case, biopsies performed one month aJ?er the excision were normal, eight months later they undoubtedly indicated a neoplastic degenerescence. In two other patients, a gastric cancer was discove- red two years after the polypectomy (one of them presented a Peutz Jeghers' syndrome, the other had undergone a gastro-entero-anastomosis 25 years ear- lier). In a last patient finally, a hyperplasiogenic polyp was removed two years after the first poly- pectomy.

DISCUSSION

Though the very nature of this retrospective study calls for some critical remarks : insufficient number of reexamined patients and a too short follow-up period, it concerns 150 patients in total and is based on homogenous data of endoscopic investiga- tion and pathological anatomy. Reinforced by other international series, it permits to situate gastric epi- thelial polyps amongst the other types of polyps and to suggest for them a follow-up program.

From an endoscopic point of view, it is impossi- ble to distinguish epithelial polyps from other polyps : fibro-inflammatory, brunneroma ; it call be difficult to distinguish a polyp from a submuco- sal formation : myoma, carcinoid tumor, aberrant pancreas. Biopsies performed at the polyp level are more often positive when it goes on epithelial polyps. For other polyps, they only provide precice information in 10 % of the cases. Only the anato- mopathological study conducted after the per- endoscopic polypectomy regularly allows to give a sure diagnosis.

From an histological point of view, Elster [4] and Seifert and Elster [14] established a distinction among epithelial polyps: hyperplastic and hyper- plasiogenic polyps on one hand, adenoma on the other hand. The first ones are composed of well differentiated muciparous cells, the latters o f dedif- ferentiated, basophilic cells which lost their muco- secreting characteristic. The architecture of the hyperplasiogenic polyps is similar to that of the adenoma, with a proliferation both o f the surface epithelium and the glands, while in the case of the hyperplastic polyps, the proliferation only concerns

172 Volume 16 - iV" 3 - 1986 Acta Endoscopica

the surface epithelium and the crypts. A priori, those features make foresee a higher risk of degene- rescence for adenoma.

None of the 77 hyperplastic or hyperplasiogenic polyp of the studied series presented a malignant transformation. Most of the authors make similar constatations [8, 16, 17, 18, 19]. However, some isolated cases of degenerescence are reported [2, 7, 10, 12]. "In a multicentric study examining near to 1 000 such polyps, Koch and Viebahn [6] only count one degenerated hyperplasiogenic polyp. The long lasting follow-up of hyperplastic and hyperpla- siogenic polyps left in-situ has never allowed to observe any degenerescence [3, 5, 7, 9]. The size of the polyp generally remained stable or grew to a maximum of 2 cm. Recurrence is frequent after removal, reaching 50 % for Laxen and coll. [7], 40 % for Seifert and coll. [15] for more than 1 000 polyps in total. According to these latter authors, the polyps concerned are in fact, five times more often new polyps rather than real recurrence. In all cases, the new polyps usually are benign, hyper- plastic of hyperplasiogenic-type polyps.

Three adenomatous polyps out of twelve in the examined series presented a degenerescence. Such a transformation is reported in 17 to 40 % of the cases, according to the authors [7, 11, 16]. Ade- noma, particularly villous ones, can be considered as precancerous lesions. They sometimes are

uncompletely removed when there was no indivi- dualized pedicle, which explains the frequency of the recurrence in-situ and calls for a strict subse- quent follow-up.

In practice, if any gastric polyp appears to require a per-endoscopic excision in order to know its exact anatomopathological nature, only the patients with epithelial polyps require a long-term follow-up. For the hyperplastic and hyperplasioge- nic polyps, an endoscopic control every five years seems to be sufficient. Even if those polyps recur, the recurrence most often shows similar histological features. The rare cases where hyperplasiogenic and adenomatous contingents occur simultaneously, making thus wonder about the possible kinship of these two types of polyps, tend to confirm this attitude [8]. Moreover, as the remaining gastric mucosa is often atrophic, a cancer can appear at some distance from the polypectomy : this possibi- lity occurs in 1 to 16 % of the cases according to the authors, all epithelial polyps being taken into consideration [1, 7, 13]. The investigation of the gastric mucosa will be facilitated by the use of a stain (indigo-carmine). Multiple biopsies will allow to search for possible dysplasia areas. As to adeno- matous polyps, local or remote degenerescence is much more likely to appear. A control gastroscopy is needed six months after the per-endoscopic exci- sion in order to perform systematic biopsies at the scar level, and then every two years.

Acta Endoscopica Volume 16 - N" 3 - 1986 173