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Evidence-Based Clinical Practice Guidelines for Management of Colorectal Polyps

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Evidence-Based Clinical Practice Guidelines for Management of Colorectal Polyps J Gastroenterol https://doi.org/10.1007/s00535-021-01776-1 REVIEW Evidence-based clinical practice guidelines for management of colorectal polyps 1,2 1 1 1 Shinji Tanaka • Yusuke Saitoh • Takahisa Matsuda • Masahiro Igarashi • 1 1 1 1 Takayuki Matsumoto • Yasushi Iwao • Yasumoto Suzuki • Ryoichi Nozaki • 1 1 1 1 Tamotsu Sugai • Shiro Oka • Michio Itabashi • Ken-ichi Sugihara • 1 1 1 1 Osamu Tsuruta • Ichiro Hirata • Hiroshi Nishida • Hiroto Miwa • 1 1 1 Nobuyuki Enomoto • Tooru Shimosegawa • Kazuhiko Koike Received: 14 December 2020 / Accepted: 27 February 2021 Ó The Author(s) 2021 Abstract searched for relevant articles published in English from Background The Japanese Society of Gastroenterology 1983 to October 2018 and articles published in Japanese (JSGE) published ‘‘Daicho Polyp Shinryo Guideline 20140’ from 1983 to November 2018. The Japan Medical Library in Japanese and a part of this guideline was published in Association was also commissioned to search for relevant English as ‘‘Evidence-based clinical practice guidelines for materials. Manual searches were performed for questions management of colorectal polyps’’ in the Journal of Gas- with insufficient online references. troenterology in 2015. A revised version of the Japanese- Results The professional committee created 18 CQs and language guideline was published in 2020, and here we statements concerning the current concept and diagnosis/ introduce a part of the contents of revised version. treatment of various colorectal polyps, including their Methods The guideline committee discussed and drew up epidemiology, screening, pathophysiology, definition and a series of clinical questions (CQs). Recommendation classification, diagnosis, management, practical treatment, statements for the CQs were limited to items with multiple complications, and surveillance after treatment, and other therapeutic options. Items with established conclusions that colorectal lesions (submucosal tumors, nonneoplastic had 100% agreement with previous guidelines (background polyps, polyposis, hereditary tumors, ulcerative colitis-as- questions) and items with no (or old) evidence that are sociated tumors/carcinomas). topics for future research (future research questions: FRQs) Conclusions After evaluation by the moderators, evidence- were given descriptions only. To address the CQs and based clinical practice guidelines for management of col- FRQs, PubMed, ICHUSHI, and other sources were orectal polyps were proposed for 2020. This report addresses the therapeutic related CQs introduced when formulating these guidelines. The members of the Guidelines Committee are listed in the Appendix. The original version of these guidelines from the Japanese Society of Keywords Colorectal polyp Á Colorectal tumor Á Gastroenterology was published in 2020 as ‘‘Daicho Polyp Sinryo Polyposis Á Treatment Á Minds guidelines Guideline 2020 (2nd version)’’ by Nankodo (Tokyo, Japan). Please see the article on the standards, methods, and process used to develop the guidelines (https://doi.org/10.1007/s00535-014-1016-1). Introduction & Shinji Tanaka [email protected] The morbidity and mortality rates associated with col- orectal cancer have increased in Japan with increasing 1 Guidelines Committee for Creating and Evaluating the westernization of diet and an aging society. The colon has ‘‘Evidence-Based Clinical Practice Guidelines for become a prominent factor in health during the twenty-first Management of Colorectal Polyps’’, the Japanese Society of Gastroenterology (JSGE), 6F Shimbashi i-MARK Bldg., 2-6- century. Against this background, the Japanese Society of 2 Shimbashi, Minato-ku, Tokyo 105-0004, Japan Gastroenterology (JSGE) published the second edition of 2 Department of Endoscopy, Hiroshima University Hospital, 1- ‘‘Daicho Polyp Shinryo Guidelines’’ (PG) in 2020 [1] 2-3 Minami-ku, KasumiHiroshima 734-8551, Japan following publication of the English version of the first 123 J Gastroenterol edition [2]. Although the title indicates ‘‘colorectal surveillance after treatment underlying the contents of the polyps,’’ the PG covers all lesions located in the colon, PG. including superficial and other neoplastic lesions, early- stage cancers, and polyposis. In preparation for drafting the PG, we first set up an Clinical questions and statements editorial committee and an evaluation committee. The committee members were recommended by the Japanese CQ. What are the indications for endoscopic Gastroenterological Association, Japanese Society of Gas- resection with respect to the size and shape trointestinal Cancer Screening, Japanese Gastroenterolog- of adenomas? ical Endoscopy Society, Japan Society of Coloproctology, and Japanese Society for Cancer of the Colon and Rectum. • Endoscopic resection should be performed for lesions To create the PG, the editorial committee met face-to-face C 6 mm in size (recommendation strong [agreement and communicated by e-mail to discuss and draw up rate 100%], level of evidence B). clinical questions (CQ). Recommendation statements for • Endoscopic resection should also be performed in the CQ were limited to items with multiple therapeutic principle for diminutive polypoid adenomas B 5mm options. Items with established conclusions that had 100% in size; however, follow-up observation by colono- agreement with previous guidelines (background ques- scopy is also acceptable (recommendation weak [agree- tions) and items with no (or old) evidence that are topics ment rate 82%], level of evidence D). for future research (future research questions: FRQs) were • Endoscopic resection should be performed for flat and given descriptions only. Next, the evaluation committee depressed neoplastic lesions even if B 5 mm in size was asked to examine and approve the questions to be (recommendation strong [agreement rate 100%], level included in the drafted CQs. A literature search formula of evidence D). was created for each CQ. PubMed, ICHUSHI, and other Comment: In line with the widely accepted findings of the sources searched for relevant English-language articles US National Polyp Study that colonoscopic removal of from 1983 to October 2018 and for Japanese-language precancerous adenomas can prevent 76–90% of the mor- articles from 1983 to November 2018 for CQs and FRQs. bidity associated with colorectal cancer and reduce the The Japan Medical Library Association was also com- mortality rate by 53% [5, 6], total colonoscopy (TCS) and missioned to search for relevant materials. Manual searches endoscopic resection of neoplastic lesions is now widely were performed for questions with insufficient online ref- performed in Japan. erences. Finally, we created a structured abstract and It is strongly recommended that endoscopic resection be completed the statements and descriptions. The recom- performed for lesions C 6 mm in size because the inci- mendation grades and evidence levels were determined by dence of carcinoma is higher in lesions C 6 mm than in the editorial committee following deliberations using the those B 5 mm (taking the relative risk of carcinoma for Delphi method. A draft of the guidelines was examined by lesions B 5 mm as 1, it increases to 7.2, 12.7, and 14.6 for the evaluation committee and then released to members of lesions measuring 6–10 mm, 11–20 mm, and 20 mm, the participating societies for comment. The responses respectively) [7] and because it is often difficult to distin- were discussed to finalize the PG. The PG contains sections guish between benign adenoma and carcinoma by colo- on epidemiology, screening, pathophysiology, defini- noscopy alone [7–9]. tion/classification, diagnosis, treatment and management, Based on the results of meta-analyses, endoscopic complications, and post-treatment surveillance, and polypectomy [7] and endoscopic mucosal resection (EMR) includes other colorectal lesions (submucosal tumors, non- [10, 11]/endoscopic submucosal dissection (ESD) [12] are neoplastic polyps, polyposis, hereditary tumors, ulcerative now the preferred as optimal, less invasive treatments for colitis-associated tumors/cancers). The PG were created by colorectal neoplasia [13, 14]. However, 70–80% of all incorporating the ideas in the Minds Handbook for Clinical polyps detected in routine practice are diminutive Practice Guideline Development 2014 [3] and the JSGE (B 5mm) [15], and the incidence of carcinoma in clinical practice guidelines [4]. diminutive colorectal lesions in Western countries is Finally, although the PG is to be used by general clin- reported to be exceedingly rare, ranging from 0.03% to icians treating colorectal lesions; it is ultimately only a 0.3% [9, 16]. standard reference and should be used in conjunction with Regarding the natural history of diminutive colorectal careful consideration of each patient’s preferences, age, lesions, Western researchers detected recurrences of complications, and social situation. This paper introduces advanced lesions (invasive cancers, intramucosal cancers, the CQs for the treatment of colorectal polyps including the adenomas measuring C 10 mm, and villous or 123 J Gastroenterol tubulovillous lesions) by follow-up colonoscopy in 4.2% of association of these lesions with adenoma [28] and (2) cases within 3 years after complete removal of all lesions there have been reports on precise endoscopic diagnosis of [17]. Furthermore, a meta-analysis reported that 6% of these lesions with combined use of dye spraying and/or 1,034 lesions measuring 1–9 mm in diameter progressed to narrow-band imaging (NBI) [29]. This statement
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