Guidelines Gut: first published as 10.1136/gutjnl-2019-319858 on 27 November 2019. Downloaded from British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England post- polypectomy and post- colorectal cancer resection surveillance guidelines Matthew D Rutter ,1,2 James East,3 Colin J Rees,2,4 Neil Cripps,5 James Docherty,6 Sunil Dolwani,7 Philip V Kaye,8 Kevin J Monahan ,9,10 Marco R Novelli,11 Andrew Plumb,12 Brian P Saunders,13 Siwan Thomas- Gibson,14 Damian J M Tolan,15 Sophie Whyte,16 Stewart Bonnington,17 Alison Scope,16 Ruth Wong,16 Barbara Hibbert,18 John Marsh,18 Billie Moores,19 Amanda Cross,20 Linda Sharp21 ► Additional material is ABSTRact people die from the disease each year.1 The vast published online only. To view These consensus guidelines were jointly commissioned majority of CRCs arise from premalignant polyps, a please visit the journal online process that takes many years.2 Endoscopic polyp- (http:// dx. doi. org/ 10. 1136/ by the British Society of Gastroenterology (BSG), the gutjnl- 2019- 319858). Association of Coloproctology of Great Britain and ectomy is effective in reducing CRC incidence and Ireland (ACPGBI) and Public Health England (PHE). mortality.3 For numbered affiliations see Some patients who have premalignant polyps end of article. They provide an evidence-based framework for the use of surveillance colonoscopy and non-colonoscopic (adenomas or serrated polyps) detected at colo- Correspondence to colorectal imaging in people aged 18 years and over. noscopy are more likely to develop metachro- 4–6 Professor Matthew D Rutter, They are the first guidelines that take into account the nous polyps or CRC. Endoscopic follow- up of Gastroenterology, University introduction of national bowel cancer screening. For the patients with such polyps is referred to as a post- Hospital of North Tees, first time, they also incorporate surveillance of patients polypectomy surveillance colonoscopy. Likewise, Stockton- on- Tees TS19 8PE, UK; following resection of either adenomatous or serrated people who have had a CRC resection may develop matt. rutter@ nth. nhs. uk polyps and also post- colorectal cancer resection. They are a metachronous CRC and are offered post- CRC AC and LS are joint senior primarily aimed at healthcare professionals, and aim to resection colonoscopic surveillance. Surveillance http://gut.bmj.com/ authors. address: aims to detect and resect metachronous prema- 1. Which patients should commence surveillance post- lignant polyps and to detect lesions not identified Received 17 September 2019 Revised 14 October 2019 polypectomy and post-cancer resection? on the initial examination, thereby preventing Accepted 15 October 2019 2. What is the appropriate surveillance interval? cancer and reducing CRC mortality; however, no 3. When can surveillance be stopped? randomised trial has directly assessed the benefit The Appraisal of Guidelines for Research and Evaluation of post- polypectomy or post- cancer resection (AGREE II) instrument provided a methodological surveillance. on December 4, 2019 at UCL Library Services. Protected by copyright. framework for the guidelines. The BSG’s guideline Premalignant polyps are common, occurring in a development process was used, which is National quarter to a half of all people of screening age,7–10 Institute for Health and Care Excellence (NICE) yet only about 5% of the population will develop compliant. CRC during their life; thus, only a minority of The key recommendations are that the high-risk criteria people with polyps will develop CRC, meaning that for future colorectal cancer (CRC) following polypectomy most people will not benefit from post- polypectomy comprise either: surveillance. Indeed, it is an increasingly held view ► two or more premalignant polyps including at least that the greatest benefit in terms of CRC preven- one advanced colorectal polyp (defined as a serrated tion is derived from the initial polypectomy, rather polyp of at least 10 mm in size or containing any than from subsequent surveillance. It is possible to grade of dysplasia, or an adenoma of at least 10 mm stratify individuals according to future CRC risk in size or containing high- grade dysplasia); or and identify cohorts of patients with persistently 11 12 ► five or more premalignant polyps elevated CRC risk beyond index polypectomy, © Author(s) (or their This cohort should undergo a one- off surveillance yet even with current risk stratification, surveil- employer(s)) 2019. Re- use colonoscopy at 3 years. Post- CRC resection patients lance places a considerable burden on patients and permitted under CC BY- NC. No should undergo a 1 year clearance colonoscopy, then a endoscopy services; approximately 15% of the half commercial re- use. See rights surveillance colonoscopy after 3 more years. a million colonoscopies performed each year in the and permissions. Published 13 by BMJ. UK are performed for polyp surveillance. To cite: Rutter MD, East J, AIMS AND OBJECTIVES Rees CJ, et al. Gut Epub ahead of print: [please INTRODUCTION These guidelines were jointly commissioned by include Day Month Year]. Colorectal cancer (CRC) is a major cause of the British Society of Gastroenterology (BSG), the doi:10.1136/ morbidity and mortality in the UK: more than Association of Coloproctology of Great Britain and gutjnl-2019-319858 40 000 people are diagnosed and more than 16 000 Ireland (ACPGBI) and the English Bowel Cancer Rutter MD, et al. Gut 2019;0:1–23. doi:10.1136/gutjnl-2019-319858 1 Guidelines Gut: first published as 10.1136/gutjnl-2019-319858 on 27 November 2019. Downloaded from Screening Programme (BCSP) (Public Health England; PHE) iv. Histological subtype (degree of villous component in and supported by NHS England (NHSE). adenomas) These guidelines consider the use of surveillance colonoscopy v. Dysplasia grade and non- colonoscopic colorectal imaging in people aged 18 and vi. Colonic location over and are an update of current BSG/ACPGBI post- polypectomy b. Which patient factors confer higher future risk of CRC? and post- CRC resection colorectal surveillance guidelines (first i. Age published in 2002, last revised in 2010 (containing evidence up ii. Sex to 2006))14 15 ; they are the first guidelines that take into account iii. Body mass index (BMI) the introduction of national bowel cancer screening. For the first iv. Smoking time, they also incorporate surveillance of patients following v. Family history of CRC resection of either adenomatous or serrated polyps, and serve as c. Which colonoscopic factors confer higher future risk of an update on the surveillance recommendations in the BSG 2017 CRC? position statement on serrated polyps in the colon and rectum.6 i. Completion to caecum They are primarily aimed at healthcare professionals contrib- ii. Bowel prep quality uting to the management of such patients. iii. Endoscopist quality The high- level aims of the guidelines are to address: iv. Enhanced detection technologies 1. Which patients should commence surveillance post- d. How should such factors be used to stratify risk and pro- polypectomy and post- cancer resection? duce a composite surveillance strategy? 2. What is the appropriate surveillance interval? e. Can a risk threshold be set to determine who requires 3. When can surveillance be stopped? surveillance? These guidelines do not address surveillance in patients 3. At what interval(s) should surveillance be performed? affected by hereditary colorectal syndromes, guidelines for which 4. Ongoing surveillance have also been updated recently16 ; however, care has been taken a. Can the findings at index and first surveillance (S1) colo- to ensure consistency, avoid overlap and ensure that all patient noscopies be used to determine who needs a second sur- cohorts are comprehensively covered by one of these guidelines. veillance (S2)? b. When (and in whom) can surveillance be stopped? i. Relating to patient age/comorbidity METHODS ii. Relating to colonoscopy findings The Appraisal of Guidelines for Research and Evaluation 5. Special situations (AGREE II) instrument provided a methodological framework 17 a. Are special considerations required for patients who are for the development of the guidelines. The BSG’s guideline below the national bowel cancer screening lower age lim- development process was used, which is National Institute for 18 it? Health and Care Excellence (NICE) compliant. b. How does the quality of index colonoscopy affect sur- http://gut.bmj.com/ veillance recommendations? Guideline development group 6. Other surveillance cohorts A guideline development group (GDG)—including epidemiol- a. How should surveillance be performed following surgical ogists, gastroenterologists, endoscopists, colorectal surgeons, resection of CRC? gastrointestinal (GI) pathologists, GI radiologists, patient repre- b. How should surveillance be performed following endo- scopic resection of CRC? sentatives, charity representatives, representatives from the on December 4, 2019 at UCL Library Services. Protected by copyright. English BCSP, a health economist and a methodologist—was c. How can serrated polyp follow- up be incorporated into selected in accordance with BSG/NICE criteria to ensure wide these guidelines? ranging expertise across all relevant disciplines. The surgical d. How should these guidelines integrate with the BSG/ ACPGBI Large Non- Pedunculated Colorectal Polyp (LN- and histopathological representatives were nominated by the 19 ACPGBI and the Royal College