Follow-up after colonic polypectomy in 2014: is there a French paradox?
28 May 2014 (online)
We have read the Guideline on post-polypectomy colonoscopy surveillance recently published by the European Society of Gastrointestinal Endoscopy (ESGE) . A corresponding French guideline was published in November 2013 . The working group, convened by the Haute Autorité de Santé (HAS), included representatives from the Société Française d’Endoscopie Digestive (SFED), the Fédération des Spécialistes des Maladies de l’Appareil Digestif (FSMAD), and the Conseil National Professionnel d’Hépato Gastro Entérologie (CNP-HGE), and the summarized findings are available online .
In order to examine differences between the ESGE and our own guidelines we have extracted data from previous meta-analyses especially regarding factors linked to recurrence of adenoma or advanced adenoma after polypectomy   : an odds ratio of recurrence risk was considered to be statistically significant if its 95 % confidence interval did not extend below 1 and to be usually clinically pertinent when it did not extend below 1.5.
Retrospective comparison of the two guidelines reassuringly shows five areas of agreement: the definitions of groups with low or high risk polyps (LRPs or HRPs); the follow-up schedule for patients with HRP; the definition and classification of serrated adenomas/polyps; the lack of impact of a familial history of colorectal cancer (CRC) on the follow-up schedule; and the strategy in the case of interval symptoms or positive fecal occult blood test (FOBT) findings. However there are three points of difference: in the ESGE guideline, patients with adenomas with villous histology are included in the high risk group; and for patients with low risk polyps it is recommended that 10 years after the index colonoscopy they should participate in national screening programmes or have a surveillance endoscopy if no programme is available.
The discrepancies require some discussion:
In the current French guideline, villous histology is not a factor that is taken into account in the definition of a high risk polyp. Multivariate analysis shows an inconsistent association of villous histology with risk of recurrence, and either a high heterogeneity coefficient or an odds ratio < 1.5 is shown in meta-analysis. Although this odds ratio is statistically significant, it is largely lower than those for adenoma number ≥ 3 or for the presence of high grade dysplasia
Proximal location is at present not included as factor that indicates a shorter time to follow-up (i. e., 3 years), notably in international US , UK , or European guidelines . However, the three recent meta-analyses show a recurrence risk in this case of ≥ 1.5 without heterogeneity. Although they show a significant odds ratio, these meta-analyses are based on studies that had technical drawbacks regarding detection of proximal and/or flat polyps, and this finding needs confirmation in studies with more accurate colonoscopy and with push-button chromography.
The French guidelines recommend that the first surveillance colonoscopy should be scheduled 3 or 5 years after the index colonoscopy for the high risk and low risk groups, respectively. Then, if a high or low risk polyp is diagnosed at the first surveillance colonoscopy, then the next surveillance colonoscopy should also be either 3 or 5 years later, respectively. In the specific case of an individual with a low risk polyp diagnosed at index colonoscopy but with no lesion found at the first or second surveillance examination, any familial history of CRC or adenoma should be taken into account; given the frequency of missed adenoma, found even in recent studies , follow-up should be stopped only after two negative colonoscopies performed 5 years apart.
Considering the crucial role of colonoscopy in decreasing CRC incidence and mortality and the possible timescale for the adenoma – CRC sequence of 5 to 10 years, polypectomy is the best tool for reducing CRC mortality because up to 20 % to 30 % of patients with polyps can be shown to have recurring (or missed?) lesions during the next 5 years. However there are no existing meta-analyses that might support the cessation of follow-up after diagnosis of a low risk polyp. The optimal surveillance schedules for first-degree relatives of individuals with CRC, and the definition of the group at high risk for CRC, are issues that require further work, aimed at a better specification for the time of the first colonoscopy.
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