Surveillance after colorectal polyp removal

Surveillance after colorectal polyp resection

Post-polypectomy surveillance has proven to reduce colorectal cancer (CRC) incidence in patients with high-risk polyps, but it implies a major burden on colonoscopy units. Therefore, it should be targeted to individuals with a higher risk. Different societies have published guidelines on surveillance after resection of polyps, with notable discrepancies among them, and many recommendations come from low-quality evidence based on surrogate measures, such as risk of advanced adenoma, and not CRC risk. In this review, we aimed to summarize the evidence supporting post-polypectomy surveillance, compare the recently updated major guidelines, and discuss the existing discrepancies on this topic. Briefly, patients with adenomas ≥10 mm or high-grade dysplasia and patients with serrated polyps ≥10 mm or dysplasia are generally considered to have an increased risk of metachronous CRC and require surveillance, whereas the indication of surveillance is not clearly established in patients without these high-risk features.

Incidence of colorectal cancer at different screening intervals after index colonoscopy and post-polypectomy: a meta-analysis of 811,181 participants

OBJECTIVES

To examine the evidence on the incidence of colorectal cancers (CRCs) at a follow-up screening colonoscopy (after index colonoscopy and post-polypectomy) in individuals with no adenoma, low-risk adenomas, and high-risk adenomas.

METHODS

We included studies reporting the incidence of CRCs at different screening intervals after index colonoscopy and post-polypectomy. The main outcome was pooled cumulative incidence rate of CRCs stratified by intervals of 3, 5, 10, and >10 years.

RESULTS

Fourteen studies with 811,181 participants were analyzed, including 10 multicenter studies and 3 national CRC screening programs. The cumulative incidence of CRCs was 0.63% (95% confidence interval [CI]: 0.30, 0.97) in the high-risk-adenoma group at 3 years, 0.37% (95% CI: 0.13, 0.61) and 0.67% (95% CI: 0.36, 0.99) in the low-risk-adenoma group at 5 and 10 years, respectively, and 0.32% (95% CI: 0.20, 0.45) and 0.50% (95% CI: 0.30, 0.69) in the no-adenoma-group at 10 and >10 years, respectively.

CONCLUSION

This meta-analysis summarizes the results of colonoscopy surveillance programs with detailed data support for different screening intervals. The data on date suggest that reasonable surveillance intervals are within 3 years for the high-risk-adenoma group, 5-10 years for the low-risk-adenoma group, and ≥10 years for the no-adenoma group.

Colonoscopy quality requisites for selecting surveillance intervals: A World Endoscopy Organization Delphi Recommendation

BACKGROUND AND AIMS

Different post-polypectomy guidelines underscore the need for high-quality baseline colonoscopy before appropriate surveillance recommendations can be made. Standards for colonoscopy practice have been advocated by gastrointestinal societies. Our aims were to define standards for the procedural practice of colonoscopy in this particular setting of surveillance and to generate a colonoscopy procedural quality checklist that could be implemented in clinical practice.

METHODS

This study was based on the Delphi process methodology. The baseline questionnaire included 12 domains and 56 individual statements. A total of three rounds were carried out between September 2015 and March 2016 until consensus or lack of consensus was reached.

RESULTS

In total, consensus was reached on 27 statements in nine domains. High levels of agreement and consensus were reached that: (i) colonoscopy should be considered complete only if the whole cecum has been inspected, including the ileocecal valve and the appendiceal orifice (agreement score 4.63; degree of consensus 82%); (ii) quality of the bowel preparation should always be reported (agreement score 4.9, degree of consensus 94%); and (iii) it is preferable to use a segmental validated scale (agreement score 4.36, degree of consensus 86%). Consensus was also reached regarding multiple statements related to documentation of polyps and their resection. Finally, a colonoscopy quality checklist was drafted.

CONCLUSION

Consensus on different statements regarding quality of colonoscopy has been reached. Based on this consensus, we propose a colonoscopy quality checklist that would be helpful for post-polypectomy surveillance recommendations.

The incidence of colorectal cancer in patients with previously removed polyp(s)-a cross-sectional study

Background

Years ago, it was established that removal of adenomas will lead to a lower incidence of colorectal cancer. This study aims to establish the occurrence of colorectal cancer in unselected patients after index colonoscopy with polyp removal.

Methods

A prospectively collected dataset on colonoscopy covering 25 consecutive years was used. Patients in who during the index (first) procedure a polyp(s) was removed were included. Excluded were patients with colorectal cancer and patients belonging to Lynch families. In case of cancer time after the index and previous procedure, tumor stage, histology of earlier removed polyps, localization of the tumor and demographics were noted.

Results

In 1,617 patients polyp(s) were removed. Thirty (1.9%) patients developed colorectal cancer. In 18 cases adenomas were removed during prior endoscopies. Five patients only had hyperplastic polyp(s). Nine patients with cancer already were older than 75 years when the previous endoscopy was done. Patients with adenomas prior to the cancer were older compared with patients with hyperplastic polyps [mean (SD): 71.6 (5.8) versus 64.2 (10.5) years, P=0.046]. The majority of cancers were located in the proximal colon (75%). The time between diagnosing cancer and the previous colonoscopy was mean 70.6 months with a median of 60.0 months (range, 12.0-167.0 months).

Conclusions

It is concluded that follow-up after removal of polyps in normal daily practice is associated with a low incidence of developing colorectal cancer.

The Serrated Polyp Pathway: Is It Time to Alter Surveillance Guidelines?

PURPOSE OF REVIEW

In this manuscript, we review current surveillance guidelines for serrated polyps (SPs) and discuss how recent studies inform the selection of appropriate surveillance intervals for patients with SPs.

RECENT FINDINGS

Large and/or proximal SPs, particularly sessile serrated polyps (SSPs), are associated with increased risk of both synchronous and metachronous neoplasia, including advanced adenomas and colorectal cancer (CRC). Persons harboring multiple SSPs or dysplastic SSPs are at the highest risk. Moreover, a high percentage of large and/or proximal SPs are reclassified as SSPs when read by trained gastrointestinal pathologists, even if they were originally reported as hyperplastic polyps. These findings support the adoption of surveillance guidelines that prescribe closer surveillance of large and/or proximal SPs, regardless of subtype. SSPs remain a challenge to reliably identify, resect, and diagnose via histology. The increased risk of future neoplasia in patients with SSPs is likely driven by a combination of underdetection, inadequate removal, misclassification, and biology. Until further evidence emerges, we support guidelines that recommend close surveillance of patients with a history of large and/or proximal SPs and SSPs specifically in order to mitigate the threat of interval CRC.