Surveillance colonoscopy

First surveillance intervals following removal of large sessile or laterally spreading adenomas

From Cancer Guidelines Wiki

Definition[edit source]

Large sessile and laterally spreading lesions (LSLs) are defined as those that are broadly attached to the mucosa. In general, the height of the lesion does not exceed 50% of the base and is usually much less. The Paris system is the accepted international standard for the classification of lesion morphology (see Figure 1, Colonoscopic surveillance after polypectomy – Introduction).[1][2] LSLs ≥10mm are subdivided based on their height above the mucosa as 0–11a (flat <2.5mm above the mucosa), 1s (sessile >2.5mm above the mucosa) or 0–11a + 1s (lesions with a combination of both morphologies). The uncommon 0–11b lesions (not elevated and completely flat) are also within this subgroup. The surface features of LSLs are further characterised as granular and non-granular. This has important implications for the risk of submucosal invasive disease (cancer), presence of submucosal fibrosis and ease of resection.[3][2][4]

Back to top

Background[edit source]

The 2011 Australian national clinical practice guidelines for surveillance colonoscopy[5] recommended follow-up colonoscopy at 3–6 months and again at 12 months following piecemeal removal of large and sessile adenomas to ensure complete removal.

Approximately 5% of colonic polyps encountered during colonoscopy are LSLs ≥10 mm. They may exhibit extensive growth along the bowel wall before developing an invasive component.[6] Large (≥20 mm) LSLs are considered high-risk precursors of colorectal cancer (CRC). However, the majority are non-invasive and the absence of lymphatics in the colonic mucosa precludes lymph node metastasis enabling even very extensive LSLs to be completely resected and cured within a structured surveillance program, by endoscopic mucosal resection (EMR).[7] All LSLs are candidates for definitive management by EMR.

EMR is an outpatient day procedure, which is proven as a safe and effective alternative to surgery for most LSLs. Prospective multicentre studies have defined the therapeutic capacities and limitations and highlighted the dramatic mortality and cost reduction when compared to surgery.[8][9] Excellent long-term outcomes have been demonstrated[10][11][12] including an approximately 4% risk of late recurrence at 18 months in individuals with EMR scars that are clear at first colonoscopic surveillance at 4–6 months.

Adverse events have been reported. Post-EMR bleeding occurs in 5–6% of patients. It is rarely life-threatening, but can be managed by supportive measures alone in two thirds with endoscopic intervention reserved for those with ongoing bleeding.[13] The main risk factor is right colon location with an odds ratio of 3–4 compared with those in the left colon.[14] Perforation occurs in 1–2%, but if it or its stigmata are recognised intra-procedurally by validated imaging criteria then endoscopic closure can be effected without sequelae.[15][16]

The major limitation of colonic EMR is the high rate of adenoma recurrence of approximately 15–30% encountered at first surveillance colonoscopy.[7][11][12] This risk is closely related to the need for multi-piece excision. As size increases the possibility of single piece excision diminishes and it is rarely possible by EMR for LSLs >20mm. Endoscopic submucosal dissection (ESD) may achieve en-bloc resection, but is time-consuming, technically demanding, more expensive, mandates multiday hospital admission and in long term follow up offers no demonstrable clinical benefit over EMR for the overwhelming majority.[17][18] Fortunately, EMR recurrences are usually small, and easily treated at scheduled surveillance colonoscopy.[7][12] A structured surveillance protocol is a proven effective long-term strategy for eradication of recurrence.

Invisible, residual microscopic adenoma present at the resection margin may account for most recurrence encountered following EMR. The Complete Adenoma Resection (CARE) study clearly demonstrated that, even for smaller lesions, incomplete resection with biopsy proven residual adenoma at the edges occurs frequently (10%) and that increasing lesion size correlates with higher incomplete resection rates of up to 23.3% for lesions 15–20mm.[19] Extra-wide field EMR involves wider excision at the edges of the lesion including at least 5mm of normal-appearing tissue. This technique was not effective in reducing recurrence, most likely due to residual, endoscopically invisible microscopic adenoma at the lesion margin particularly in the areas between sequential snare placements.[20] Full publication of an Australian multicentre randomised controlled trial of complete thermal ablation of the entire EMR defect margin is awaited.[21]

Risk factors for recurrence after EMR include lesion size ≥40 mm, piecemeal resection and the presence of high-grade dysplasia (HGD) in the resected specimen.[7][11][22][23][24] Operator technique is also likely to be very important as can be inferred from the CARE study where there was a 4-fold difference in residual adenoma amongst endoscopists even though they knew their performance was being monitored.[19] Utilising a standardised imaging protocol incorporating narrow band imaging, even subtle recurrence is readily detected during follow-up.[25]

LSLs frequently have significant synchronous advanced pathology, including other LSLs, advanced adenomas, early cancers and serrated polyposis syndrome.[26] When an advanced lesion is found, a careful assessment of the entire mucosal surface of the colon is mandatory.

Back to top

Evidence[edit source]

What is the appropriate colonoscopic surveillance after the removal of large sessile or laterally spreading adenomas? (SAD3)?

Systematic review evidence[edit source]

The systematic review reported outcomes from 13 studies over 16 articles [10][7][24][27][28][29][30][31][32][33][34][35][36][37][38][39] examining surveillance colonoscopy for patients with large (≥20 mm) sessile and/or laterally spreading adenomas. There were seven prospective cohort studies and six retrospective cohort studies. Study types differed based on outcome.

For surveillance, there were 11 studies that were of aetiological type with all seven level II prospective studies and all six level III-2 retrospective studies, and level III-3 retrospective prognostic study. For cohort study outcomes, nine studies were at low risk of bias, no studies were at moderate risk of bias, and three studies were at high risk of bias.

For cohort study risk factor outcomes, only a single study had a low risk of bias, three studies had a moderate risk of bias, and the remaining nine studies were at high risk of bias.

Generalisability to the Australian population and healthcare environment varied between studies. Interpretation of the outcomes is genuinely uncertain due to a lack of consistency in the studies.

In summary, the systematic review did not demonstrate any additional information to guide decision-making. Accordingly the recommendations and practice points are based on consensus expert opinion.

Back to top

Evidence summary and recommendations[edit source]

Evidence summary Level References
Three-month residual/recurrent adenoma incidence by patient varied between 9.86% and 30.13%, and residual/recurrent neoplasm incidence was 31.91%. By adenoma, 3 month residual/recurrent adenoma incidence was 22.22%. Incidence based on resection type was either not consistent or could not be determined, while patient numbers between studies varied in size. II, III-2 [27], [34], [40], [39], [29]
The incidence of residual/recurrent adenoma within 4–6 months varied between three studies reporting by patient with incidences of 4.92% and 28.00% for those undergoing piecemeal resection and 0.00% and 18.75% for those undergoing en bloc resection. All three studies had fewer than 100 patients. In one study that reported by adenoma, the incidence at 4–6 months was 11.11% for those that underwent piecemeal resection and 9.09% (n=342) for those that underwent en bloc resection (n=55). II, III-2 [36], [28], [33], [41]
For other studies with dissimilar surveillance times or that could not be compared, residual/recurrent adenoma incidences by patient were 25.00% at >6 months and 0.00% at ≥9 months. The incidence of residual/recurrent neoplasm was 23.53% at 15 months. By adenoma, incidences at 12 and 36 months were 11.11% and 0.00%. II, III-2 [28], [38], [42]
There was no significant difference between <12 and >12 months surveillance for residual/recurrent adenoma (by patient; p=0.266) nor when adenoma size was adjusted (OR=0.42, 95% CI=0.11–1.65, p=0.213).

Similarly, there was no evidence to suggest significant differences between en bloc and piecemeal resection for residual/recurrent adenoma, nor when adjusted for adenoma size (OR=1.70; 95% CI 0.46–6.27; p=0.423) as well as location, shape, histology and ablation used (OR=1.13; 95% CI 0.4–3.3; p=0.82).

This was also the case when EMR and ESD were compared (OR=2.14; 95% CI 0.18–24.74; p=0.544).

II, III-2, III-3 [31], [37], [29]
The risk between en bloc and piecemeal resection types was found to be almost 3.5 times greater for patients undergoing piecemeal (compared to en bloc) resection at minimum 4–6 months, which was statistically significant when adjusted (HR=3.4; 1.5-7.6; p=0.002). II [35]
Cumulative incidence of residual/recurrent adenoma was reported to be 16.1%, 20.4%, 23.4% and 28.4% at 6, 12, 18 and 24 months and for those with sessile serrated adenomas/polyps this was 6.3% at 6 months and 7.0% at 12, 18 and 24 months. The overall cumulative incidence of sessile serrated adenomas/polyps were found to be significantly lower than adenomas over time (p<0.001). II [35]
There were no studies that reported cancer incidence relating to the population of interest.

Consensus-based recommendationQuestion mark transparent.png

Large sessile and laterally spreading lesions

First surveillance interval should be approximately 12 months in individuals who have undergone en-bloc excision of large sessile and laterally spreading lesions.

Consensus-based recommendationQuestion mark transparent.png

Large sessile and laterally spreading lesions

First surveillance interval should be approximately 6 months in individuals who have undergone piecemeal excision of large sessile and laterally spreading lesions.

Practice pointQuestion mark transparent.png

Consideration should be given to referring large sessile and laterally spreading lesions to experienced clinicians trained in and regularly undertaking high quality EMR to reduce the risk of recurrence.

Practice pointQuestion mark transparent.png

Patients with large sessile and laterally spreading lesions should be informed of the requirement for scheduled surveillance before proceeding to EMR.

Practice pointQuestion mark transparent.png

At surveillance following piecemeal or en-bloc excision of large sessile and laterally spreading lesions, the EMR scar should be identified, photodocumented and systematically evaluated for recurrence, including biopsies. These individuals are at high risk for synchronous and/or metachronous lesions and require very careful evaluation of the remaining colon at the same time.

Practice pointQuestion mark transparent.png

Endoscopic mucosal resection (EMR) of large sessile and laterally spreading lesions (>20mm) is usually piecemeal and all lesions that undergo piecemeal excision are at higher risk of recurrence and require scheduled surveillance. Risk factors for recurrence after EMR are piecemeal excision, larger lesion size (>40mm) and the presence of high-grade dysplasia in the resected specimen.

Practice pointQuestion mark transparent.png

In patients who have undergone piecemeal excision of large sessile and laterally spreading lesions (in whom the first surveillance colonoscopy at 6 months is clear), the next surveillance colonoscopy should be considered around 12–18 months, especially in those who had large lesions (>40mm) or high-grade dysplasia at index EMR.

Practice pointQuestion mark transparent.png

Consideration should be given to tattooing all lesions which may need to be identified subsequently. Those that may need surgical resection should be tattooed distal to the lesion in three locations around the circumference of the bowel to facilitate recognition.

Practice pointQuestion mark transparent.png

Consistently high-quality colonoscopy is imperative for optimal cost effectiveness and for implementation of uniform surveillance guidelines.

Practice pointQuestion mark transparent.png

Polyp/adenoma size as per the endoscopist documentation should be used for determining surveillance intervals. All endoscopists should ensure size measurements are accurate using a reference standard (eg an open biopsy forceps or snare).

Back to top

Notes on the recommendations[edit source]

High-quality scientific evidence to determine the optimal surveillance interval following removal of large sessile and LSLs is limited. There are no randomised controlled trials comparing one surveillance interval with another.

There is no high-quality evidence to guide the timing of second surveillance colonoscopy. Back to top

Health system implications[edit source]

Clinical practice[edit source]

Implementation of these recommendations would not significantly affect current practice.

Resourcing[edit source]

Implementation of these recommendations would not require additional resources.

Barriers to implementation[edit source]

No barriers to the implementation of these recommendations are envisaged.

Back to top

References[edit source]

  1. The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003 Dec;58(6 Suppl):S3-43 Available from:
  2. 2.0 2.1 Holt BA, Bourke MJ. Wide field endoscopic resection for advanced colonic mucosal neoplasia: current status and future directions. Clin Gastroenterol Hepatol 2012 Sep;10(9):969-79 Available from:
  3. Moss A, Bourke MJ, Williams SJ, Hourigan LF, Brown G, Tam W, et al. Endoscopic mucosal resection outcomes and prediction of submucosal cancer from advanced colonic mucosal neoplasia. Gastroenterology 2011 Jun;140(7):1909-18 Available from:
  4. Burgess NG, Hourigan LF, Zanati SA, Brown GJ, Singh R, Williams SJ, et al. Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort. Gastroenterology 2017 Sep;153(3):732-742.e1 Available from:
  5. 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.
  6. Rotondano G, Bianco MA, Buffoli F, Gizzi G, Tessari F, Cipolletta L. The Cooperative Italian FLIN Study Group: prevalence and clinico-pathological features of colorectal laterally spreading tumors. Endoscopy 2011 Oct;43(10):856-61 Available from:
  7. 7.0 7.1 7.2 7.3 7.4 Moss A, Williams SJ, Hourigan LF, Brown G, Tam W, Singh R, et al. Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 2015 Jan;64(1):57-65 Available from:
  8. Ahlenstiel G, Hourigan LF, Brown G, Zanati S, Williams SJ, Singh R, et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 2014 Oct;80(4):668-76 Available from:
  9. Jayanna M, Burgess NG, Singh R, Hourigan LF, Brown GJ, Zanati SA, et al. Cost Analysis of Endoscopic Mucosal Resection vs Surgery for Large Laterally Spreading Colorectal Lesions. Clin Gastroenterol Hepatol 2016 Feb;14(2):271-8.e1-2 Available from:
  10. 10.0 10.1 Moss A, Bourke MJ, Hourigan LF, Gupta S, Williams SJ, Tran K, et al. Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit. Am J Gastroenterol 2010 Jun;105(6):1276-83 Available from:
  11. 11.0 11.1 11.2 Belderbos TD, Leenders M, Moons LM, Siersema PD. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014 May;46(5):388-402 Available from:
  12. 12.0 12.1 12.2 Knabe M, Pohl J, Gerges C, Ell C, Neuhaus H, Schumacher B. Standardized long-term follow-up after endoscopic resection of large, nonpedunculated colorectal lesions: a prospective two-center study. Am J Gastroenterol 2014 Feb;109(2):183-9 Available from:
  13. Burgess NG, Williams SJ, Hourigan LF, Brown GJ, Zanati SA, Singh R, et al. A management algorithm based on delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014 Sep;12(9):1525-33 Available from:
  14. Burgess NG, Metz AJ, Williams SJ, Singh R, Tam W, Hourigan LF, et al. Risk factors for intraprocedural and clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014 Apr;12(4):651-61.e1-3 Available from:
  15. Burgess NG, Bassan MS, McLeod D, Williams SJ, Byth K, Bourke MJ. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut 2017 Oct;66(10):1779-1789 Available from:
  16. Swan MP, Bourke MJ, Moss A, Williams SJ, Hopper A, Metz A. The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection. Gastrointest Endosc 2011 Jan;73(1):79-85 Available from:
  17. Bahin FF, Heitman SJ, Rasouli KN, Mahajan H, McLeod D, Lee EYT, et al. Wide-field endoscopic mucosal resection versus endoscopic submucosal dissection for laterally spreading colorectal lesions: a cost-effectiveness analysis. Gut 2017 Oct 7 Available from:
  18. Ma MX, Bourke MJ. Endoscopic submucosal dissection in the West: Current status and future directions. Dig Endosc 2017 Sep 7 Available from:
  19. 19.0 19.1 Pohl H, Srivastava A, Bensen SP, Anderson P, Rothstein RI, Gordon SR, et al. Incomplete polyp resection during colonoscopy-results of the complete adenoma resection (CARE) study. Gastroenterology 2013 Jan;144(1):74-80.e1 Available from:
  20. Bahin FF, Pellise M, Williams SJ, Bourke MJ. Extended endoscopic mucosal resection does not reduce recurrence compared with standard endoscopic mucosal resection of large laterally spreading colorectal lesions. Gastrointest Endosc 2016 Dec;84(6):997-1006.e1 Available from:
  21. Klein A, Jayasekeran V, Hourigan LF, Tate DJ, Singh R, Brown GL et. 812b A Multi-Center Randomized Control Trial of ThermalAablation of the Margin of the Post Endoscopic Mucosal Resection (EMR) Mucosal Defect in the Prevention of Adenoma Recurrence Following EMR: Preliminary Results from the “SCAR” Study. Gastroenterology 2016 Available from:
  22. Kim HH, Kim JH, Park SJ, Park MI, Moon W. Risk factors for incomplete resection and complications in endoscopic mucosal resection for lateral spreading tumors. Dig Endosc 2012 Jul;24(4):259-66 Available from:
  23. Seo JY, Chun J, Lee C, Hong KS, Im JP, Kim SG, et al. Novel risk stratification for recurrence after endoscopic resection of advanced colorectal adenoma. Gastrointest Endosc 2015 Mar;81(3):655-64 Available from:
  24. 24.0 24.1 Tate DJ, Desomer L, Klein A, Brown G, Hourigan LF, Lee EY, et al. Adenoma recurrence after piecemeal colonic EMR is predictable: the Sydney EMR recurrence tool. Gastrointest Endosc 2017 Mar;85(3):647-656.e6 Available from:
  25. Desomer L, Tutticci N, Tate DJ, Williams SJ, McLeod D, Bourke MJ. A standardized imaging protocol is accurate in detecting recurrence after EMR. Gastrointest Endosc 2017 Mar;85(3):518-526 Available from:
  26. Bick BL, Ponugoti PL, Rex DK. High yield of synchronous lesions in referred patients with large lateral spreading colorectal tumors. Gastrointest Endosc 2017 Jan;85(1):228-233 Available from:
  27. 27.0 27.1 Albuquerque W, Arantes VN, Coelho LG, Dias CA, Savassi-Rocha PR. Complementation by argon plasma coagulation after endoscopic piecemeal resection of large colorectal adenomas. Rev Col Bras Cir 2013 Sep;40(5):404-8 Available from:
  28. 28.0 28.1 28.2 Barendse RM, van den Broek FJ, van Schooten J, Bemelman WA, Fockens P, de Graaf EJ, et al. Endoscopic mucosal resection vs transanal endoscopic microsurgery for the treatment of large rectal adenomas. Colorectal Dis 2012 Apr;14(4):e191-6 Available from:
  29. 29.0 29.1 29.2 Carvalho R, Areia M, Brito D, Saraiva S, Alves S, Cadime AT. Endoscopic mucosal resection of large colorectal polyps: prospective evaluation of recurrence and complications. Acta Gastroenterol Belg 2013 Jun;76(2):225-30 Available from:
  30. Cipolletta L, Rotondano G, Bianco MA, Buffoli F, Gizzi G, Tessari F, et al. Endoscopic resection for superficial colorectal neoplasia in Italy: a prospective multicentre study. Dig Liver Dis 2014 Feb;46(2):146-51 Available from:
  31. 31.0 31.1 Kim B, Choi AR, Park SJ, Cheon JH, Kim TI, Kim WH, et al. Long-Term Outcome and Surveillance Colonoscopy after Successful Endoscopic Treatment of Large Sessile Colorectal Polyps. Yonsei Med J 2016 Sep;57(5):1106-14 Available from:
  32. Lee TJ, Rees CJ, Nickerson C, Stebbing J, Abercrombie JF, McNally RJ, et al. Management of complex colonic polyps in the English Bowel Cancer Screening Programme. Br J Surg 2013 Nov;100(12):1633-9 Available from:
  33. 33.0 33.1 Liu S, Li Y, Yang H, Li A, Han Z, Wang X, et al. Retroflexion-assisted endoscopic mucosal resection: a useful and safe method for removal of low rectal laterally spreading tumors. Surg Endosc 2016 Jan;30(1):139-46 Available from:
  34. 34.0 34.1 Moss A, Bourke MJ, Metz AJ. A randomized, double-blind trial of succinylated gelatin submucosal injection for endoscopic resection of large sessile polyps of the colon. Am J Gastroenterol 2010 Nov;105(11):2375-82 Available from:
  35. 35.0 35.1 35.2 Pellise M, Burgess NG, Tutticci N, Hourigan LF, Zanati SA, Brown GJ, et al. Endoscopic mucosal resection for large serrated lesions in comparison with adenomas: a prospective multicentre study of 2000 lesions. Gut 2017 Apr;66(4):644-653 Available from:
  36. 36.0 36.1 Raju GS, Lum PJ, Ross WA, Thirumurthi S, Miller E, Lynch PM, et al. Outcome of EMR as an alternative to surgery in patients with complex colon polyps. Gastrointest Endosc 2016 Aug;84(2):315-25 Available from:
  37. 37.0 37.1 Rex KD, Vemulapalli KC, Rex DK. Recurrence rates after EMR of large sessile serrated polyps. Gastrointest Endosc 2015 Sep;82(3):538-41 Available from:
  38. 38.0 38.1 Seo GJ, Sohn DK, Han KS, Hong CW, Kim BC, Park JW, et al. Recurrence after endoscopic piecemeal mucosal resection for large sessile colorectal polyps. World J Gastroenterol 2010 Jun 14;16(22):2806-11 Available from:
  39. 39.0 39.1 Urban O, Kijonkova B, Kajzrlikova IM, Vitek P, Kliment M, Fojtik P, et al. Local residual neoplasia after endoscopic treatment of laterally spreading tumors during 15 months of follow-up. Eur J Gastroenterol Hepatol 2013 Jun;25(6):733-8 Available from:
  40. Lee TJ, Nickerson C, Goddard AF, Rees CJ, McNally RJ, Rutter MD. Outcome of 12-month surveillance colonoscopy in high-risk patients in the National Health Service Bowel Cancer Screening Programme. Colorectal Dis 2013 Aug;15(8):e435-42 Available from:
  41. Rex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, et al. Quality indicators for colonoscopy. Am J Gastroenterol 2015 Jan;110(1):72-90 Available from:
  42. Carvalho R, Areia M, Brito D, Saraiva S, Alves S, Cadime AT. Diagnostic accuracy of lugol chromoendoscopy in the oesophagus in patients with head and neck cancer. Rev Esp Enferm Dig 2013 Feb;105(2):79-83 Available from:

Back to top

Appendices[edit source]

Jutta's magnifying glass icon.png PICO question SAD 3 View Evidence statement form SAD3 Evidence statement form SAD3 View Systematic review report SAD3 Systematic review report SAD3

Back to top