Pre and perioperative colonoscopy in patients with colorectal cancer undergoing resection
Background[edit source]
This section focuses specifically on the use of colonoscopy in surveillance following curative resection of colorectal cancer (CRC). Complete, high-quality colonoscopy should be performed at the time of diagnosis of a CRC, to check for synchronous cancer and to clear the colon of synchronous adenomatous polyps. Surveillance colonoscopy following resection of CRC 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 CRC.
Evidence[edit source]
What is the role of pre- or perioperative colonoscopy in CRC patients? (COL1)
Systematic review evidence[edit source]
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]
Lesion localisation accuracy[edit source]
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.
Preoperative imaging unable to locate tumour[edit source]
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.
Complications[edit source]
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.
Surgery requiring modification intraoperatively due to preoperative non-concordance[edit source]
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[edit source]
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.
Synchronous lesions[edit source]
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%.
Postoperative metachronous lesions[edit source]
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.
Evidence summary and recommendations[edit source]
| 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 recommendation
|
Grade |
|---|---|
 |
C |
| Evidence-based recommendation
|
Grade |
|---|---|
|
C |
| Practice point
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|---|
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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 point
|
|---|
|
If the index colorectal cancer (CRC) 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 colonography (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 point
|
|---|
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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 point
|
|---|
|
In patients with a defunctioning loop ileostomy, it is preferable to undertake colonoscopy after this is reversed to enable adequate bowel preparation. |
Health system implications[edit source]
Clinical practice[edit source]
No significant effects on clinical practice are anticipated, because the evidence-based recommendations and consensus-based recommendations have not changed.
Resourcing[edit source]
No significant effects on resource requirements are anticipated, because the evidence-based recommendations and consensus-based recommendations have not changed.
Barriers to implementation[edit source]
No significant barriers to the implementation of these recommendations have been identified.
References[edit source]
- ↑ Cancer Council Australia Colonoscopy 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.
- ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Bryce AS, Johnstone MS, Moug SJ. Improving lesion localisation at colonoscopy: an analysis of influencing factors. Int J Colorectal Dis 2015 Jan;30(1):111-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25376334.
- ↑ 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24659380.
- ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 4.9 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/23710312.
- ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Louis MA, 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20054542.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 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 Colon Rectum 2012 Jan;55(1):72-8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22156870.
- ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Vaziri K, Choxi SC, Orkin BA. Accuracy of colonoscopic localization. Surg Endosc 2010 Oct;24(10):2502-5 Available from: http://www.ncbi.nlm.nih.gov/pubmed/20333403.
- ↑ 8.0 8.1 8.2 8.3 8.4 8.5 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. Colorectal Dis 2013 Mar;15(3):317-22 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22845696.
- ↑ 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 9.11 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 Available from: http://www.ncbi.nlm.nih.gov/pubmed/25132777.
- ↑ 10.0 10.1 10.2 10.3 10.4 10.5 10.6 10.7 Paik JH, Jung EJ, Ryu CG, Hwang DY. Detection of Polyps After Resection of Colorectal Cancer. Ann Coloproctol 2015 Oct;31(5):182-6 Available from: http://www.ncbi.nlm.nih.gov/pubmed/26576396.
Appendices[edit source]
 PICO question COL1
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 Evidence statement form COL1
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Systematic review report COL1
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