Burden and trends of endoscopically unresectable polyps requiring surgical intervention: A systematic review and meta-analysis
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Background
Colorectal polyps judged endoscopically unresectable are conventionally referred for colectomy, carrying substantial morbidity for a lesion that is usually benign. Advanced endoscopic techniques have made many such lesions resectable, but the burden and temporal trends of surgery remain unclear.
Methods
PubMed, Scopus, Embase, Web of Science, and Cochrane CENTRAL were searched from inception to 1 September 2026 for studies reporting surgery for endoscopically unresectable polyps against a population or health-system denominator. Estimates were assigned a priori to four denominator classes: population at risk (N1), colorectal resections (N2), polyps detected (N3), or colonoscopies/screening episodes (N4). Estimates were analysed within class and never combined across classes. Within denominator sub-definitions containing at least three independent data sources, proportions were pooled using random-effects models on the logit scale with restricted maximum likelihood estimation of between-study variance, Hartung-Knapp adjusted confidence intervals and 95% prediction intervals. Risk of bias was assessed using the JBI checklist for prevalence studies and certainty using an adapted GRADE approach.
Results
Eighteen studies contributed 122 burden estimates; 105 of 130 full texts were excluded for lacking a population or health-system denominator. Seventy-five distinct denominator definitions were identified. Estimates ranged from 1.09%–38.38% of colorectal resections and 0.09%–52.38% of polyps detected. Seven studies reported one numerator against multiple denominators, producing within-study differences of up to 88.3-fold. When denominators matched, estimates converged: 12 values from two national datasets spanned only 0.20%–0.37% of unselected colonoscopy volume. Unresectability criteria were reported in 7 of 17 assessable studies; only one satisfied all five reporting items. Three sub-definitions contained enough independent sources to pool, and every pooled estimate carried a wide prediction interval: 23.79% (95% CI 12.27-41.06; 95% prediction interval 3.22-74.55) of resections for colorectal neoplasia, 1.15% (0.31-4.21; 0.02-37.19) of all detected polyps and 17.11% (4.36-48.30; 0.31-93.22) of large or complex lesions. Restricting estimates to a single denominator sub-definition reduced between-study variance by 53% among polyp-based denominators.
Conclusions
The burden of surgery for endoscopically unresectable colorectal polyps cannot presently be expressed as a single figure. Published disagreement is primarily definitional, with estimates converging when denominators match. Surgical volume appears to have peaked around 2012–2014 and subsequently declined. A minimum reporting standard is needed to measure this burden reliably.
