Reply to Heresbach & Pienkowski
28 May 2014 (online)
We read with great interest the letter from Heresbach & Pienkowski on the recent French recommendations for post-polypectomy endoscopic surveillance  . We agree with the authors that the main differences between the latter and the recent guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) are represented by the surveillance interval for the low-risk group and – to a lesser extent – by the inclusion of patients with villous histology in the high risk group  .
The French guidelines indeed recommend endoscopic surveillance at 5 years after polypectomy in the low risk group (i. e. 1 – 2 < 10 mm tubular adenomas), whilst the ESGE Guideline recommends for the same group: “participation in existing national screening programmes 10 years after the index colonoscopy. If no screening programme is available, repetition of colonoscopy 10 years after the index colonoscopy” . Although I might agree with the authors that “there are no existing meta-analyses that might support the cessation of follow-up after diagnosis of a low risk polyp,” it is also true that we have robust evidence of a non-increased risk of colorectal cancer (CRC) incidence in the low risk group. In particular, two epidemiological studies did not show any long-term increase in CRC in the low risk group without surveillance, as compared with the general population  . Similarly, clinical studies showed an overall very low prevalence of advanced neoplasia at 5-year endoscopic surveillance in the low risk group, that was not increased as compared with those with no neoplasia at baseline  . Thus, we did not find compelling evidence to recommend endoscopic surveillance in these patients.
There is also a methodological difference that may account for this discrepancy between the two recommendations. Apparently, the main criteria on which French recommendations are based is the estimate of the actual risk of advanced neoplasia or CRC in each of the selected groups . On the other hand, in the ESGE Guideline, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology that was adopted included not only evaluation of the expected benefit, but also of risk and burden. When dealing with the low risk group, the endoscopic burden related to a policy of 5-year surveillance may be massive, when one considers the very high prevalence of low risk adenomas found by current high definition endoscopy, coupled with the dissemination of organized CRC screening programs throughout Europe  . Thus, there is a credible risk that an intensive policy of surveillance in a low risk group could displace a significant amount of endoscopic resources from individuals who are never screened or who are at high risk of advanced neoplasia because of high risk endoscopic findings or alarm symptoms.
Regarding the definition of the high risk group, we agree with the authors that the role of the villous component is at least controversial. However, all the available data mainly come from retrospective evaluation of previous studies where the association between villous component and metachronous risk of advanced neoplasia/CRC was not a primary end point. Thus, prospective studies dedicated to confirming the lack of such an association are needed to exclude this feature from our current recommendation.
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