Pre and perioperative colonoscopy in patients with colorectal cancer undergoing resection

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Background

This section focuses specifically on the use of colonoscopy in surveillance following curative resection of colorectal cancer (CRCColorectal cancer). Complete, high-quality colonoscopy should be performed at the time of diagnosis of a CRCColorectal cancer, to check for synchronous cancer and to clear the colon of synchronous adenomatous polyps. Surveillance colonoscopy following resection of CRCColorectal cancer aims to improve patient outcomes by finding metachronous cancers at an early stage, detecting anastomotic or intraluminal recurrences and removing metachronous adenomas. Hence, understanding the rate of development of and risk factors associated with either metachronous neoplasia or locally recurrent cancer may be important for reducing mortality from CRCColorectal cancer.

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Evidence

What is the role of pre- or perioperative colonoscopy in CRCColorectal cancer patients? (COL1)

Systematic review evidence

A systematic review of studies published since 2010 was undertaken to update the evidence on which the 2011 version of these guidelines was based.[1]

The search strategy, inclusion and exclusion criteria, and quality assessment are described in detail in the Systematic review report).

Nine studies were identified, which included prospective[2][3][4] and retrospective[5][6][7] cohort studies, and two case-series.[8][9] Five studies[2][3][5][6][10] were level III-2, two studies[4][7] were level III-3 evidence, and two studies[9][8] were level IV evidence. Three studies were at high-risk of bias,[3][6] one study was at moderate risk of bias,[9] and five studies were at low risk of bias.[2][5][7][4][10]Back to top

Lesion localisation accuracy

Four studies[3][2][5][7] reported the accuracy of primary colorectal tumour identified by preoperative colonoscopy with the location of the primary tumour during surgical resection. All studies reported high accuracy, varying from 81% to 96%. However, accuracy is dependent on the colonoscopy success rate, which may be hindered by tumour obstruction.

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Preoperative imaging unable to locate tumour

Two studies[2][3] reported the percentage of patients in which preoperative imaging was unable to locate the primary colorectal tumour. Both studies reported rates of 22–23% across a combined total of 189 patients.

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Complications

Only a single study reported complications from preoperative colonoscopy, in a cohort of 48 patients who received a self-expendable metallic stent (SEMS) placement for luminal obstruction.[9] Complications including minor bleeding (16%) and perforation (2%) were reported, and were consist with any surveillance colonoscopy procedure in the average or symptomatic general populations.

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Surgery requiring modification intraoperatively due to preoperative non-concordance

Four studies reported the percentage of patients requiring a modification to planned surgery due to non-concordance with preoperative colonoscopy finding:[2][7][3][6]

  • In a cohort of 111 patients, 6.3% required an altered surgical management plan.[2]
  • In a large cohort of 374 patients, 2.9% required a modification of their planned operative procedure.[7]
  • In another large cohort of 715 patients, 8.9% required intraoperative on-table changes in their surgical procedure.[6]
  • In a small cohort of 79 patients,1.6% required an intraoperative surgical management change.[3]

Put together, there is consistent evidence across these studies that only a small percentage of patients (<10%) required a modification to their planned tumour surgery.

Successfully completed preoperative colonoscopy

Consistent evidence reported that preoperative colonoscopy was highly successful, and failure to complete colonoscopy was mainly due to obstructing/stenosing tumours, or poor bowel preparation. In the study by Kim et al,[9] a gastroscope was used instead of a colonoscope when the passage of colonoscope was not feasible due to a narrow expanded lumen. Johnstone et al[3] reported 79.7% success in a cohort of 79 patients. Kim et al[9] reported 62.5% success in a cohort of 48, and the 2013 study by Lim et al[4] reported 88.9% success in a cohort of 73 patients.

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Synchronous lesions

Five studies report synchronous lesions rates.[9][4][6][10][5]

Three studies reported adenomas rates varying from 22–42%, across a combined cohort of 800.[9][4][6] Only Lim et al reported a high-grade dysplasia rate of 2.2% in 45 patients.[4]

Synchronous carcinoma rates reported in three studies were relatively low at 2.2–4.1%.[9][4][6] Paik et al only reported polyp numbers and the percentage of patients.[10]

Put together, synchronous adenoma rate were up to 40% in these studies, but synchronous carcinoma rates were below 5%.

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Postoperative metachronous lesions

Two studies reported postoperative lesions detected during surveillance scopes following tumour resection.[10][8] In a study of 116 patients, polyp rates of 53% during 3–15 month follow-up were reported, and 26% of patients with neoplastic polyps detected during follow-up.[10] In a large study including over 850 patients, Couch et al[8] reported adenoma and carcinoma detection rates in two cohorts, with one cohort (Cohort 1) having up to 5 years of follow-up. Adenoma rates were higher in those who had no preoperative colonoscope, but never reached more than 17% per year, per cohort. Carcinoma rates were much lower in both cohorts, and were below 3% per year in the 36% of patients that had a surveillance scope. The mean time to polyp detection in this cohort ranged from 12 to 40 months, depending on the cohort, or preoperative intervention.[8]

Postoperative lesions detected after surgical resection were substantial in these two studies. Adenoma rates were much greater than carcinoma rates, and were still detected up to 5 years post-surgery in those who had a surveillance colonoscopy. As not all participants had a surveillance scope, the exact recurrence rates are difficult to establish.

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Evidence summary and recommendations

Evidence summary Level References
Lesion localisation accuracy

Preoperative colonoscopy was highly accurate, but is dependent on its success rate, which may be hindered by tumour obstruction.

III-2, III-3 [2], [3], [5], [7]
Preoperative imaging unable to locate tumour

Primary colorectal tumour could not be located during preoperative imaging in as many as 1 in every 4 or 5 patients.

III-2 [2], [3]
Complications

Only minor complications were reported on preoperative colonoscopy, consistent with any surveillance scoping in the average or symptomatic general populations.

IV [9]
Surgery requiring modification intraoperatively due to preoperative non-concordance

There was consistent evidence that a small percentage of patients (<10%) will require a modification to their planned tumour surgery.

III-2, III-3 [2], [7], [3], [6]
Successfully completed preoperative colonoscopy

Consistent evidence reported that preoperative colonoscopy was highly successful, and failure to complete colonoscopy was mainly due to obstructing/stenosing tumours or poor bowel preparation.

III-2, III-3, IV [3], [9], [4]
Synchronous lesions

Synchronous adenoma rates were up to 40% in these studies, but synchronous carcinoma rates were below 5%.

III-2, III-3, IV [9], [4], [5], [10], [6]
Postoperative lesions

Rates of lesions detected on postoperative colonoscopy following surgical resection were substantial in the two studies that reported this outcome. Adenomas rates were much greater than carcinoma rates, and were still detected up to 5 years post surgery in those who had a surveillance colonoscopy. As not all participants had surveillance colonoscopy exact recurrence rates are difficult to establish.

III-2, IV [10], [8]
Evidence-based recommendationA recommendation formulated after a systematic review of the evidence, indicating supporting references.Question mark transparent.png Grade
A preoperative colonoscopy should be attempted in all patients with a newly diagnosed colorectal cancer.
C
Evidence-based recommendationA recommendation formulated after a systematic review of the evidence, indicating supporting references.Question mark transparent.png Grade
ColonoscopyAn examination of the large bowel using a camera on a flexible tube, which is passed through the anus. should be performed 3–6 months after resection for patients with obstructive colorectal cancer in whom a complete perioperative colonoscopy could not be performed and in whom there is residual colon proximal to the location of the pre-operatively obstructing cancer.
C
Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

In cases of a colorectal cancer that may be difficult to identify at surgery, particularly using the laparoscopic approach, submucosal tattoo should be placed in three places approximately 2 cm distal to the lesion at the time of colonoscopy. This should be clearly documented in the colonoscopy report.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

If the index colorectal cancer (CRCColorectal cancer) obstructs the lumen and prevents passage of a colonoscope, consideration should be given to specific pre-operative assessment of the proximal colon by alternative means. CT colonographyAlso known as virtual colonoscopy, a medical imaging procedure that uses low dose radiation computerised tomography (CT) scanning to obtain an interior view of the colon (the large bowel) that is otherwise only seen with a more invasive procedure such as colonoscopy where an endoscope is inserted into the rectum and passed through the entire colon. (CTC) can be considered. However, its role in this clinical scenario requires further analysis. It is safe to perform same-day CTC following an incomplete colonoscopy, including in patients who have had a biopsy or simple polypectomy. CTC should be delayed in patients with complex endoscopic intervention and in patients at high risk of perforation, such as those with active colitis or high-grade stricture.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

Proximal visualisation is unnecessary if the colon proximal to the cancer is to be included in the resection specimen. In patients with residual un-visualised colon, colonoscopy should be performed 3–6 months after surgery, providing no non-resectable distant metastases are found.

Practice pointA recommendation on a subject that is outside the scope of the search strategy for the systematic review, based on expert opinion and formulated by a consensus process.Question mark transparent.png

In patients with a defunctioning loop ileostomy, it is preferable to undertake colonoscopy after this is reversed to enable adequate bowel preparation.

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Health system implications

Clinical practice

No significant effects on clinical practice are anticipated, because the evidence-based recommendations and consensus-based recommendations have not changed.

Resourcing

No significant effects on resource requirements are anticipated, because the evidence-based recommendations and consensus-based recommendations have not changed.

Barriers to implementation

No significant barriers to the implementation of these recommendations have been identified.

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References

  1. Cancer Council Australia ColonoscopyAn examination of the large bowel using a camera on a flexible tube, which is passed through the anus. Surveillance Working Party. Clinical Practice Guidelines for Surveillance Colonoscopy – in adenoma follow-up; following curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease. Sydney: Cancer Council Australia; 2011 Dec.
  2. 2.02.12.22.32.42.52.62.72.82.9 Bryce AS, Johnstone MS, Moug SJ. Improving lesion localisation at colonoscopy: an analysis of influencing factors. Int J ColorectalReferring to the large bowel, comprising the colon and rectum. Dis 2015 Jan;30(1):111-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25376334.
  3. 3.003.013.023.033.043.053.063.073.083.093.103.11 Johnstone MS, Moug SJ, West of Scotland Surgical Research Network.. The accuracy of colonoscopic localisation of colorectal tumours: a prospective, multi-centred observational study. Scott Med J 2014 May;59(2):85-90 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/24659380.
  4. 4.04.14.24.34.44.54.64.74.84.9 Lim SG, Lee KJ, Suh KW, Oh SY, Kim SS, Yoo JH, et al. Preoperative colonoscopy for detection of synchronous neoplasms after insertion of self-expandable metal stents in occlusive colorectal cancer: comparison of covered and uncovered stents. Gut Liver 2013 May;7(3):311-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23710312.
  5. 5.05.15.25.35.45.55.6 Louis MAMetachronous adenoma, Nandipati K, Astorga R, Mandava A, Rousseau CP, Mandava N. Correlation between preoperative endoscopic and intraoperative findings in localizing colorectal lesions. World J Surg 2010 Jul;34(7):1587-91 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20054542.
  6. 6.06.16.26.36.46.56.66.76.86.9 Sasaki K, Kazama S, Sunami E, Tsuno NH, Nozawa H, Nagawa H, et al. One-stage segmental colectomy and primary anastomosis after intraoperative colonic irrigation and total colonoscopy for patients with obstruction due to left-sided colorectal cancer. Dis ColonThe main part of the large bowel, which absorbs water and electrolytes from undigested food (solid waste). Its four parts are the ascending colon, transverse colon, descending colon and sigmoid colon. RectumThe final section of the large bowel, ending at the anus. 2012 Jan;55(1):72-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22156870.
  7. 7.07.17.27.37.47.57.67.7 Vaziri K, Choxi SC, Orkin BA. Accuracy of colonoscopic localization. Surg Endosc 2010 Oct;24(10):2502-5 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/20333403.
  8. 8.08.18.28.38.48.5 Couch DG, Bullen N, Ward-Booth SE, Adams C. What interval between colorectal cancer resection and first surveillance colonoscopy? An audit of practice and yield. ColorectalReferring to the large bowel, comprising the colon and rectum. Dis 2013 Mar;15(3):317-22 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/22845696.
  9. 9.009.019.029.039.049.059.069.079.089.099.109.11 Kim JS, Lee KM, Kim SW, Kim EJ, Lim CH, Oh ST, et al. Preoperative colonoscopy through the colonic stent in patients with colorectal cancer obstruction. World J Gastroenterol 2014 Aug 14;20(30):10570-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/25132777.
  10. 10.010.110.210.310.410.510.610.7 Paik JH, Jung EJ, Ryu CG, Hwang DY. Detection of Polyps After Resection of Colorectal Cancer. Ann Coloproctol 2015 Oct;31(5):182-6 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26576396.

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Appendices

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