Guidelines British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps Matthew D Rutter,1,2 Amit Chattree,2 Jamie A Barbour,3 Siwan Thomas-Gibson,4 Pradeep Bhandari,5 Brian P Saunders,4 Andrew M Veitch,6 John Anderson,7 Bjorn J Rembacken,8 Maurice B Loughrey,9 Rupert Pullan,10 William V Garrett,11 Gethin Lewis,12 Sunil Dolwani12 For numbered affiliations see ABSTRACT radiologists and pathologists. These guidelines refer end of article. These guidelines provide an evidence-based framework specifically to lesions considered benign at the time Correspondence to for the management of patients with large non- of assessment and/or lesions without biopsy-proven Professor MD Rutter, pedunculated colorectal polyps (LNPCPs), in addition to malignancy. The management of malignant lesions Department of identifying key performance indicators (KPIs) that permit is detailed in a recent position statement by the Gastroenterology, University the audit of quality outcomes. These are areas not Association of Coloproctologists of Great Britain Hospital of North Tees, previously covered by British Society of Gastroenterology and Ireland (ACPGBI) and updated National Stockton on Tees TS19 8PE, (BSG) Guidelines. Institute of Health and Care Excellence (NICE) UK; [email protected] – A National Institute of Health and Care Excellence guidelines for colorectal carcinoma.1 3 MDR and AC are joint first (NICE) compliant BSG guideline development process LNPCPs carry an increased risk of colorectal name authors. was used throughout and the Appraisal of Guidelines for cancer, can be challenging lesions to resect endo- Received 13 March 2015 Research and Evaluation (AGREE II) tool was used to scopically and are associated with an increased risk Revised 25 May 2015 structure the guideline development process. A of incomplete excision and complications. The UK Accepted 29 May 2015 systematic review of literature was conducted for English incidence of LNPCPs is unknown and no previous language articles up to May 2014 concerning the framework exists for the management of these assessment and management of LNPCPs. Quality of lesions. evaluated studies was assessed using the Scottish Key questions we sought to cover included: Intercollegiate Guidelines Network (SIGN) Methodology 1. What are the key definitions and terms asso- Checklist System. Proposed recommendation statements ciated with LNPCPs? were evaluated by each member of the Guideline 2. What are the available management options? Development Group (GDG) on a scale from 1 (strongly 3. What are the key principles for optimal man- agree) to 5 (strongly disagree) with >80% agreement agement, including both assessment and required for consensus to be reached. Where consensus therapy? was not reached a modified Delphi process was used to 4. Which are the most complex lesions and how re-evaluate and modify proposed statements until should they be managed? consensus was reached or the statement discarded. 5. What histopathological considerations are A round table meeting was subsequently held to finalise important in the management of LNPCPs? recommendations and to evaluate the strength of 6. When is surgical or conservative management evidence discussed. The GRADE tool was used to more appropriate than endoscopic therapy? assess the strength of evidence and strength of 7. Can multidisciplinary input into assessment recommendation for finalised statements. and therapy improve management? KPIs, a training framework and potential research 8. What information should patients be given questions for the management of LNPCPs were also about their management? developed. It is hoped that these guidelines will improve 9. How should anticoagulant and antiplatelet the assessment and management of LNPCPs. drugs be managed before and after procedure? 10. How should patients be followed up after endoscopic removal of LNPCPs? OBJECTIVE 11. What are the most appropriate key perform- To provide a structured framework for the manage- ance indicators for monitoring the quality of ment of large non-pedunculated colorectal polyps management of LNPCPs? (LNPCPs). 12. What can be done to improve formal training in the management of LNPCPs? AIMS AND METHODS 13. What aspects of LNPCP management have the To cite: Rutter MD, The purpose of the guideline is to provide an weakest evidence base and what are the key Chattree A, Barbour JA, et al. Gut Published Online evidence-based framework for the optimal manage- research questions which will help address First: [please include Day ment of LNPCPs for clinicians involved in their these? Month Year] doi:10.1136/ management, including gastroenterologists, nurse The Appraisal of Guidelines for Research and gutjnl-2015-309576 practitioners, physicians, colorectal surgeons, Evaluation (AGREE II) instrument provided a Rutter MD, et al. Gut 2015;0:1–27. doi:10.1136/gutjnl-2015-309576 1 Guidelines methodological framework for the development of the guide- informed consent for endoscopic procedures’, ‘diathermy in lines. In accordance with the British Society of Gastroenterology polypectomy’, ‘argon plasma coagulation for polypectomy’, (BSG) NICE-compliant guideline process, a Guideline ‘submucosal injection for endoscopic mucosal resection’, ‘malig- Development Group (GDG) including gastroenterologists, nant colonic polyps’, ‘piecemeal endoscopic mucosal resection’, endoscopists, colorectal surgeons, gastrointestinal pathologists ‘colorectal endoscopic submucosal dissection’, ‘surgical manage- and a patient representative was selected to ensure wide-ranging ment of colonic polyps’, ‘laparoscopic surgery of colonic expertise across all relevant disciplines. The surgical and histo- polyps’, ‘training in endoscopic polypectomy’ and ‘transanal pathological representatives were nominated by the ACPGBI endoscopic microsurgery’ and the Royal College of Pathologists, respectively. A writing Returned abstracts were reviewed for relevance. Additional subcommittee was formed to identify key search terms for a references were obtained by cross-referencing and by recom- comprehensive literature review of the management of LNPCPs mendation from the GDG. Relevant published national and and to develop draft recommendation statements. international guidelines were also scrutinised. The ‘Scottish A literature search for English language articles published up Intercollegiate Guidelines Network (SIGN) Methodology to the present was performed using PubMed. The term ‘colonic Checklist System’ was used to evaluate the quality of studies and polypectomy’ was entered into the PubMed MeSH database. studies considered of suboptimal quality were excluded.4 A total of 5989 articles were returned. The terms ‘therapy’ and Initial draft statements formulated by the writing committee ‘surgery’ were used to filter the results based on relevance, after were reviewed by the GDG to allow for modification and to which, 2230 articles were returned and scrutinised for relevant identify additional references. After a preliminary discussion, articles. Additional PubMed searches were performed using add- formal anonymous voting rounds were undertaken. Each state- itional search terms agreed by the writing subcommittee. The ment was scored by each member of the GDG using a five-point search terms used were ‘colorectal laterally spreading type scale. Consensus required at least 80% agreement. Where con- polyps’, ‘endoscopic mucosal resection’, ‘complex colonic sensus was not reached, feedback from the GDG members was polyps’, ‘difficult colonic polyps’, ‘surgical management of colo- disseminated after each round to allow members to reconsider rectal laterally spreading type polyps’, ‘endoscopic polypect- their original position. Where appropriate, revisions to state- omy’, ‘anticoagulation in endoscopic polypectomy’, ‘obtaining ments were made and a further voting round was undertaken. A final round of voting for statements where consensus had not been reached took place at a round table meeting at the BSG offices on 26 March 2014 (figure 1). Voting was anonymous throughout, with the final round of voting made using an elec- tronic keypad system. The GRADE tool was used to evaluate the strength of evi- dence and the strength of recommendations made (see below). The GRADE system specifically separates the strength of evi- dence from the strength of a recommendation. While the strength of a recommendation may often reflect the evidence base, the GRADE system allows for occasions where this is not the case—for example, where it seems good sense to make a recommendation despite the absence of high-quality scientific evidence such as a large randomised controlled trial (RCT) (table 1). Table 1 An overview of the GRADE system5 GRADE—strength of evidence GRADE—strength of recommendation High quality: The trade-offs: Further research is very unlikely to Taking into account the estimated size of change our confidence in the the effect for main outcomes, the estimate of effect confidence limits around those estimates and the relative value placed on each outcome Moderate quality: The quality of the evidence Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate Low quality: Translation of the evidence into practice Further research is very likely to in a particular setting: have an important impact on our Taking into consideration important confidence in the estimate of effect