Roel Bogie

Chapter 7

Abstract Several gastrointestinal societies strongly recommend colonoscopy surveillance after endoscopic and surgical resection of colorectal neoplasms. Common denominators to these recommendations include: high-quality baseline colonoscopy before inclusion in a surveillance program; risk stratification based on clinicopathologic profiles to guide surveillance intervals; and endoscopist responsibility for providing surveillance advice. Considerable variability also exists between guidelines (i.e. regarding risk classification and surveillance intervals). In this review, we examine key factors for quality of post-polypectomy surveillance practice, in particular bowel preparation, endoscopic findings at baseline examination and adherence to surveillance recommendations. Frequently asked questions by the practicing endoscopist are addressed. Introduction The vastmajority of gastrointestinal professional societies recommend colonoscopy surveillance after endoscopic and surgical resection of colorectal neoplasms, to diagnose synchronous and metachronous advanced neoplasms and early colorectal cancer (CRC). 1-9 In the West, up to one fourth of the total number of colonoscopies are carried out for surveillance. 10, 11 As population-based screening has been adopted in many European countries, the economic burden of colonoscopy surveillance will expand in the future. 1 It is thus critical to optimize the utilization of colonoscopy resources in practice. Previous post-polypectomy surveillance studies identified risk subgroups, based on endoscopic (number, location, size) and histological (villosity, high-grade dysplasia or CRC) features of colorectal neoplasms at baseline examination. 12-16 Such studies could not provide details on the quality of examination (e.g. bowel preparation, cecal intubation, adenoma detection and resection rates). Joint efforts to optimize quality in colonoscopy performance have now shifted to the forefront of surveillance practice. 1, 2 To establish optimal surveillance intervals, randomized controlled trials are needed using robust endpoints, such as reduction of interval CRC rate and mortality fromCRC. In real-life, it is cumbersome to generate such data: large sample sizes and long term follow-up are required. Using the detection of advanced adenoma and early CRC as alternative is easier and allows immediate intervention. Ongoing randomized controlled trials 17, 18 will inform about evidence-based surveillance intervals. Furthermore, standardizing the nomenclature for an interval CRC will facilitate surveillance-specific benchmarking. 19, 20 Several preconditions should be met to ensure the quality and effectiveness of colonoscopy surveillance. Foremost of which are optimal bowel preparation, the ability of the endoscopist to detect adenomatous and serrated polyps, and to effectively resect them, the clinician’s adherence to surveillance guidelines, and certain patient-related factors (age, comorbidity) affecting participation. Monitoring quality measures at all these levels is critical to identify room for potential improvements. 21 In this review, we outline key principles for improving the quality of post polypectomy surveillance in routine practice.We briefly summarize evidence of the appropriateness and frequency of surveillance intervals. We specifically address the following questions: 1. How does quality of bowel preparation affect surveillance intervals? 2. How do findings at baseline colonoscopy influence surveillance intervals? 3. How to improve adherence to surveillance recommendations?

A practical guide is proposed to assist the application of surveillance recommendations in clinical practice.

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