Roel Bogie

Chapter 7

colonoscopies (only 0.03 colonoscopies per patient per 5 years). 55 Vemulapalli et al. also found that application of the UK guidelines better predicts advanced neoplasms in the high risk group. 56 The recent post-polypectomy surveillance guidelines of the European guidelines for quality assurance in colorectal cancer screening and diagnosis recommend a similar risk stratification as the UK guidelines. 9 As several organized screening programs are now running in Europe, low-risk patients are recommended to return to such screening after 10 years. The revised Dutch post-polypectomy surveillance guidelines propose a personal risk score assessment, based on independent risk factors (e.g. number of adenomas, size ≥10mm, villous histology and proximal location). 7 Using such a score, patients can be stratified into three risk groups, with cut-off values derived from a cost-benefit analysis. 8, 15, 16 Patients who score 0, 1-2 or 3-5 are recommended to return to the screening program after 10 years (no surveillance colonoscopy), or to undergo surveillance colonoscopy after 5 years and after 3 years, respectively. Upon validation, such strategy may lead to personalized surveillance advice in practice. 7 With regard to signs of unfavorable histology, villosity and high-grade dysplasia are considered independent risk factors by some 1, 2, 4-6 but not other post-polypectomy surveillance guidelines. 3, 7 High-grade dysplasia does not seem to be an independent risk factor for advanced colorectal neoplasm diagnosis after polypectomy. 8, 16 Approximately 98% of adenomas with high-grade dysplasia are also large or villous. 16 Integrated risk profiles can be considered to personalize surveillance intervals. As such, Chiu et al. 57 showed that the metabolic syndrome is a risk factor for developing advanced neoplasms in patients at low-risk and those without neoplasms at baseline examination.

I

l

Surveillance interval r ill i r l

Surveillance colonoscopy† S r ill l

Surveillance interval r ill i r l

Index colonoscopy†

High risk neoplasm ● Advanced adenoma‡ ● ≥ 3 adenomas ● Serrated polyps ≥ 10mm or with dysplasia High risk neoplasm Advanced adeno a‡ ≥3 adenomas ● Serrated polyps ≥10 or with dyspla sia

3 years

High risk neoplasm Hi

3 years 3 years

5 years

Low risk neoplasm

Piecemeal resection neoplasms >10mm

<6 months

Low risk neoplasm ● 1-2 tubular adenomas, all <10mm, all with low grade dysplasia ● Serrated polyps <10mm, all without dysplasia Low ri lasm t l r adenomas, 10 , all with low grade dysplasia t polyps <10mm, all without dysplasia

3 years

i

High risk neoplasm

Surveillance colonoscopy or return to screening after 10 years Surveillance colonoscopy or return to screening after s

Surveillance colonoscopy or return to screening after 10 years Surveillance colonoscopy or return to screening after

Low risk neoplasm Low risk neoplasm

† Inadequate visualisation due to poor bowel preparation: reschedule colonoscopy †Inadequate vis alis ti e to poor bowel preparation: reschedule colon scopy i li Figure 7.2: Clinical decision algorithm for determining post-polypectomy surveillance intervals in practice | Based on the post-polypectomy colonoscopy surveillance guidelines of the European Society of Gastrointestinal Endoscopy [ESGE], 2013. 1 †The ESGE guidelines define sufficient visualization as allowing reasonable exclusion of the presence of lesions ≥5mm. ‡Advanced adenoma is defined as adenoma with villous histology, high grade dysplasia or a size ≥10mm. Based on the ESGE guideline Based on the ESGE

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