Gastroenterology

Gastroenterology

Volume 130, Issue 6, May 2006, Pages 1872-1885
Gastroenterology

Special report and review
Guidelines for Colonoscopy Surveillance After Polypectomy: A Consensus Update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society

https://doi.org/10.1053/j.gastro.2006.03.012Get rights and content

Adenomatous polyps are the most common neoplastic findings discovered in people who undergo colorectal screening or who have a diagnostic work-up for symptoms. It was common practice in the 1970s for these patients to have annual follow-up surveillance examinations to detect additional new adenomas and missed synchronous adenomas. As a result of the National Polyp Study report in 1993, which showed clearly in a randomized design that the first postpolypectomy examination could be deferred for 3 years, guidelines published by a gastrointestinal consortium in 1997 recommended that the first follow-up surveillance take place 3 years after polypectomy for most patients. In 2003 these guidelines were updated and colonoscopy was recommended as the only follow-up examination, stratification at baseline into low risk and higher risk for subsequent adenomas was suggested. The 1997 and 2003 guidelines dealt with both screening and surveillance. However, it has become increasingly clear that postpolypectomy surveillance is now a large part of endoscopic practice, draining resources from screening and diagnosis. In addition, surveys have shown that a large proportion of endoscopists are conducting surveillance examinations at shorter intervals than recommended in the guidelines. In the present report, a careful analytic approach was designed to address all evidence available in the literature to delineate predictors of advanced pathology, both cancer and advanced adenomas, so that patients can be stratified more definitely at their baseline colonoscopy into those at lower risk or increased risk for a subsequent advanced neoplasia. People at increased risk have either 3 or more adenomas, high-grade dysplasia, villous features, or an adenoma 1 cm or larger in size. It is recommended that they have a 3-year follow-up colonoscopy. People at lower risk who have 1 or 2 small (<1 cm) tubular adenomas with no high-grade dysplasia can have a follow-up evaluation in 5–10 years, whereas people with hyperplastic polyps only should have a 10-year follow-up evaluation, as for average-risk people. There have been recent studies that have reported a significant number of missed cancers by colonoscopy. However, high-quality baseline colonoscopy with excellent patient preparation and adequate withdrawal time should minimize this and reduce clinicians concerns. These guidelines were developed jointly by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society to provide a broader consensus and thereby increase the use of the recommendations by endoscopists. The adoption of these guidelines nationally can have a dramatic impact on shifting available resources from intensive surveillance to screening. It has been shown that the first screening colonoscopy and polypectomy produces the greatest effects on reducing the incidence of colorectal cancer in patients with adenomatous polyps.

Section snippets

Methodology and Literature Review

We performed a Medline search of the postpolypectomy literature under the subject headings “colonoscopy” and “adenoma,” “polypectomy surveillance,” and “adenoma surveillance,” limited to English language articles from 1990 to 2005. This search identified 35 articles based on inclusion of data pertaining to baseline colonoscopy characteristics, advanced adenoma detection during follow-up surveillance, and advanced adenoma characteristics. Subsequently, we identified 12 additional articles from

Results of the Literature Review and Rationale for the Guidelines

Certain characteristics of colorectal adenomas at baseline colonoscopy are associated with the rate of adenoma detection and the histologic severity of subsequent adenomas. These data can be used as the basis for decisions about safe and effective postpolypectomy surveillance intervals by stratifying patients into lower-risk and higher-risk groups for future advanced adenomas. The available body of evidence is the basis for these recommendations.

Discussion

These guidelines are based on all of the available evidence, clinical experience, knowledge of the adenoma-carcinoma sequence, and expert opinion. They are intended to be used by clinicians as a guide in their approach to postpolypectomy surveillance, taking into consideration clinical judgment in patient comorbidities, patient preferences, and family history. The differences between these guidelines and prior ones are shown in Table 1. The detailed evidence for these guidelines are presented

Questions to Be Addressed

  • 1

    What are the reasons that guidelines are not followed more widely?

  • 2

    How can adherence to quality control indicators at baseline colonoscopy be encouraged to reduce the miss rate of advanced adenomas and colorectal cancers?

  • 3

    Will emerging studies with longer colonoscopy follow-up times support the safety of lengthening surveillance intervals?

  • 4

    What is the appropriate management and surveillance of the hyperplastic polyposis syndrome?

  • 5

    What is the appropriate surveillance of patients who have had an

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    This article is being published jointly in 2006 in CA: A Cancer Journal for Clinicians (online: May 30, 2006; print: May/June 2006) and Gastroenterology (online: May 2006; print: May 2006) by the American Cancer Society and the American Gastroenterology Association. ©2006 American Cancer Society, Inc. and American Gastroenterology Association, Inc. Copying with attribution allowed for any noncommercial use of the work.

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