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Post-Polypectomy Colonoscopy Surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2020

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Post-Polypectomy Colonoscopy Surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2020 Guideline Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2020 Authors Cesare Hassan1, Giulio Antonelli1, Jean-Marc Dumonceau2, Jaroslaw Regula3, Michael Bretthauer4,Stanislas Chaussade5, Evelien Dekker6, Monika Ferlitsch7, Antonio Gimeno-Garcia8,RodrigoJover9,MetteKalager4,Maria Pellisé10,ChristianPox11, Luigi Ricciardiello12, Matthew Rutter13, Lise Mørkved Helsingen4, Arne Bleijenberg6,Carlo Senore14, Jeanin E. van Hooft6, Mario Dinis-Ribeiro15, Enrique Quintero8 Institutions 13 Gastroenterology, University Hospital of North Tees, 1 Gastroenterology Unit, Nuovo Regina Margherita Stockton-on-Tees, UK and Northern Institute for Hospital, Rome, Italy Cancer Research, Newcastle University, Newcastle 2 Gastroenterology Service, Hôpital Civil Marie Curie, upon Tyne, UK Charleroi, Belgium 14 Epidemiology and screening Unit – CPO, Città della 3 Centre of Postgraduate Medical Education and Maria Salute e della Scienza University Hospital, Turin, Italy Sklodowska-Curie Memorial Cancer Centre, Institute of 15 CIDES/CINTESIS, Faculty of Medicine, University of Oncology, Warsaw, Poland Porto, Porto, Portugal 4 Clinical Effectiveness Research Group, Oslo University Hospital and University of Oslo, Norway Bibliography 5 Gastroenterology and Endoscopy Unit, Faculté de DOI https://doi.org/10.1055/a-1185-3109 Médecine, Hôpital Cochin, Assistance Publique- Published online: 22.6.2020 | Endoscopy 2020; 52: 1–14 Hôpitaux de Paris (AP-HP), Université Paris Descartes, © Georg Thieme Verlag KG Stuttgart · New York France ISSN 0013-726X 6 Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Corresponding author Amsterdam, The Netherlands C. Hassan, MD, Nuovo Regina Margherita Hospital, Via 7 Department of Internal Medicine III, Division of E. Morosini 53, 00159, Rome, Italy Gastroenterology and Hepatology, Medical University Fax: +39-06-58446608 Vienna, and Quality Assurance Working Group, [email protected] Austrian Society for Gastroenterology and Hepatology, Vienna, Austria Appendix 1s – 3s 8 Gastroenterology Department, Hospital Universitario Online content viewable at: de Canarias, Instituto Universitario de Tecnologías https://doi.org/10.1055/a-1185-3109 Biomédicas (ITB) & Centro de Investigación Biomédica de Canarias (CIBICAN), Universidad de La Laguna, MAIN RECOMMENDATIONS Tenerife, Spain The following recommendations for post-polypectomy 9 Service of Digestive Medicine, Alicante Institute for colonoscopic surveillance apply to all patients who had Health and Biomedical Research (ISABIAL Foundation), one or more polyps that were completely removed during Alicante, Spain a high quality baseline colonoscopy. 10 Gastroenterology Department, Endoscopy Unit, 1 ESGE recommends that patients with complete removal of ICMDiM, Hospital Clinic, CIBEREHD, IDIBAPS, 1 – 4 < 10 mm adenomas with low grade dysplasia, irrespec- University of Barcelona, Catalonia, Spain tive of villous components, or any serrated polyp < 10mm 11 Department of Medicine, St. Joseph Stift, Bremen, without dysplasia, do not require endoscopic surveillance Germany and should be returned to screening. 12 Department of Medical and Surgical Sciences, Strong recommendation, moderate quality evidence. S. Orsola-Malpighi Hospital, Bologna, Italy If organized screening is not available, repetition of colonos- copy 10 years after the index procedure is recommended. Strong recommendation, moderate quality evidence. Hassan Cesare et al. Post-polypectomy colonoscopy surveillance: ESGE Guideline Update 2020 … Endoscopy 2020; 52 Guideline 2 ESGE recommends surveillance colonoscopy after 3 years 4 If no polyps requiring surveillance are detected at the first for patients with complete removal of at least 1 adenoma surveillance colonoscopy, ESGE suggests to perform a sec- ≥ 10mm or with high grade dysplasia, or ≥ 5adenomas,or ond surveillance colonoscopy after 5 years. any serrated polyp ≥ 10mm or with dysplasia. Weak recommendation, low quality evidence. Strong recommendation, moderate quality evidence. After that, if no polyps requiring surveillance are detected, 3 ESGE recommends a 3– 6-month early repeat colonos- patients can be returned to screening. copy following piecemeal endoscopic resection of polyps 5 ESGE suggests that, if polyps requiring surveillance are ≥ 20mm. detected at first or subsequent surveillance examinations, Strong recommendation, moderate quality evidence. surveillance colonoscopy may be performed at 3 years. A first surveillance colonoscopy 12 months after the repeat Weak recommendation, low quality evidence. colonoscopy is recommended to detect late recurrence. A flowchart showing the recommended surveillance inter- Strong recommendation, high quality evidence. vals is provided (▶ Fig.1). SOURCE AND SCOPE Introduction This Guideline is an official statement of the European This Guideline represents an update of the Guideline on post- Society of Gastrointestinal Endoscopy (ESGE). It is an up- polypectomy endoscopic surveillance published by the Europe- date of the previously published 2013 Guideline address- an Society of Gastrointestinal Endoscopy (ESGE) in 2013 [1]. ing the role of post-polypectomy colonoscopy surveil- Previous recommendations were primarily based on esti- lance. mates of the risk of metachronous advanced neoplasia (ad- vanced adenoma or colorectal cancer [CRC]) according to the endoscopic and histological features at the baseline colonosco- py that represented most of the available evidence. High quality colonoscopy According to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology adopted for ESGE guidelines [2,3], a hierarchy across outcomes must be Polyp requiring surveillance? created, and the main recommendations should be based on Yes No ABBREVIATIONS ADR adenoma detection rate ARR adjusted rate ratio 3-year surveillance CI confidence interval CRC colorectal cancer EMR endoscopic mucosal resection Polyp requiring Yes ESGE European Society of Gastrointestinal Endoscopy surveillance? FIT fecal immunochemical test FOBT fecal occult blood test No GRADE Grading of Recommendations Assessment, Development and Evaluation Hb hemoglobin 5-year surveillance HGD high grade dysplasia HR hazard ratio LST laterally spreading tumor Polyp requiring Yes OR odds ratio surveillance? PICO population, intervention, comparison/control, outcome No RCT randomized controlled trial RR risk ratio SD standard deviation Return to screening SERT Sydney EMR Recurrence Tool SIR standardized incidence ratio SSL sessile serrated lesion ▶ Fig.1 Colonoscopy surveillance intervals following polypectomy. Hassan Cesare et al. Post-polypectomy colonoscopy surveillance: ESGE Guideline Update 2020 … Endoscopy 2020; 52 the estimates of benefit and risk (burden) of the most clinically relevant outcomes. In this regard, risk of CRC incidence and Methods mortality was ranked as a more relevant outcome than the risk ESGE commissioned the update of this Guideline and appointed of metachronous advanced neoplasia for estimating the benefit a guideline leader (C.H.), who invited the listed authors to par- of post-polypectomy surveillance. Of note, this applies both to ticipate in the project development. The key questions were the stratification of baseline risk at index colonoscopy and to the prepared by the coordinating team (E.Q., J.M.D., J.R.) using assessment of the efficacy of endoscopic surveillance. PICO methodology (population, intervention, comparison/con- Recently, a series of cohort studies assessed the post- trol, outcome) [19] and were then approved by the other mem- polypectomy risk of CRC incidence/mortality with and without bers. The coordinating team formed task force subgroups, endoscopic surveillance. The overall long-term CRC risk follow- based on the statements of the 2013 guideline, each with its ing polypectomy appeared to be similar or slightly higher than own leader, and divided the key topics among these task forces for the general population or for patients without adenomas. In (Appendix 2s) with a specific focus on the update of literature detail, a 2% absolute long-term CRC risk for post-polypectomy and revision of the statements. patients without surveillance has been shown, ranging be- Recent ESGE Guidelines have addressed endoscopic surveil- tween 1.1% and 2.9% according to the baseline risk stratifica- lance after endoscopic or surgical resection of invasive carcino- tion [4]. These estimates were confirmed in a surveillance set- ma/malignant polyp [20] and of patients with hereditary syn- ting, with a 10-year CRC incidence risk between 0.44% and dromes or with polyposis syndromes [21,22], and these topics 1.24%, and mortality risk between 0.03% and 0.25% [5]. In ad- are not addressed in the present Guideline. dition, the efficacy of surveillance for patients at high risk of The work included telephone conferences, a face to face CRC appeared to be less than 1% [4], while it was ineffective in meeting and online discussions. patients at lower risk (Table1s;seeAppendix 1s, online-only The task forces conducted a literature search using Medline Supplementary Material). Of note, these estimates are much (via Pubmed) and the Cochrane Central Register of Controlled lower than the 3% long-term CRC risk required in one guideline Trials up to October 2019. New evidence on each key question for recommending CRC screening [6]. Overall, this new evidence wassummarizedintablesusingtheGRADEsystem[3](Appen- supports
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