Summary of recommendations

From Clinical Guidelines Wiki


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The guideline recommendations were approved by the Chief Executive Officer of the National Health and Medical Research Council (NHMRC) on 7 December 2018 under section 14A of the National Health and Medical Research Council Act 1992. expand arrow

In approving the guideline recommendations, NHMRC considers that they meet the NHMRC standard for clinical practice guidelines. This approval is valid for a period of five years.

NHMRC is satisfied that the guideline recommendations are systematically derived, based on the identification and synthesis of the best available scientific evidence, and developed for health professionals practising in an Australian health care setting.

This publication reflects the views of the authors and not necessarily the views of the Australian Government.

Summary of recommendations

This is a summary of the recommendations in these guidelines, please note that some sections do not have associated recommendations.

For explanation of recommendations types, levels of evidence and grades for recommendations, see #NHMRC approved recommendation types and definitions and #Levels of evidence and grades for recommendations below.

Summary of recommendations

Advances in colonoscopy, CT colonographyAlso known as virtual colonoscopy. and other methods

Bowel preparation

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High-quality bowel preparation is a crucial pre-requisite for successful colonoscopy. Optimal preparation is achieved with split-dose or same-day preparation timing.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Bowel preparation#Practice_point_1
  • High-quality bowel preparation is a crucial pre-requisite for successful colonoscopy. Optimal preparation is achieved with split-dose or same-day preparation timing.
  • Good practice point
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PEG-based bowel preparations are safer for those with co-morbidities and the elderly.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Bowel preparation#Practice_point_2
  • PEG-based bowel preparations are safer for those with co-morbidities and the elderly.
  • Good practice point
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A low-residue diet can be used on the days prior to colonoscopy with appropriate preparation timing.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Bowel preparation#Practice_point_3
  • A low-residue diet can be used on the days prior to colonoscopy with appropriate preparation timing.
  • Good practice point
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Factors associated with poor preparation should be assessed and patients at high risk of poor preparation should be offered additional preparation volume and split-dose timing.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Bowel preparation#Practice_point_4
  • Factors associated with poor preparation should be assessed and patients at high risk of poor preparation should be offered additional preparation volume and split-dose timing.
  • Good practice point
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Preparation quality should be documented on the colonoscopy report using a validated preparation scale.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Bowel preparation#Practice_point_5
  • Preparation quality should be documented on the colonoscopy report using a validated preparation scale.
  • Good practice point
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Where the preparation is inadequate, repeat colonoscopy should normally be offered within 12 months.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Bowel preparation#Practice_point_6
  • Where the preparation is inadequate, repeat colonoscopy should normally be offered within 12 months.
  • Good practice point
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Successful bowel preparation should be achieved in ≥90% of all colonoscopies.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Bowel preparation#Practice_point_7
  • Successful bowel preparation should be achieved in ≥90% of all colonoscopies.
  • Good practice point

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Advances in technique

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Fundamental colonoscopic inspection technique should ensure systematic exposure of the proximal sides of folds and flexures, intensive intraprocedural cleansing and adequate distension of the colon.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Technique advances#Practice_point_1
  • Fundamental colonoscopic inspection technique should ensure systematic exposure of the proximal sides of folds and flexures, intensive intraprocedural cleansing and adequate distension of the colon.
  • Good practice point
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Colonoscopists should undergo training in the fundamentals of mucosal exposure and inspection techniques, and in the endoscopic appearance of adenomas and serrated lesions to increase detection rates and improve clinical outcomes of colonoscopy.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Technique advances#Practice_point_2
  • Colonoscopists should undergo training in the fundamentals of mucosal exposure and inspection techniques, and in the endoscopic appearance of adenomas and serrated lesions to increase detection rates and improve clinical outcomes of colonoscopy.
  • Good practice point
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Water exchange should be considered to improve adenoma detection through an effect on mucosal cleansing and higher rates of adequate bowel preparation.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Technique advances#Practice_point_3
  • Water exchange should be considered to improve adenoma detection through an effect on mucosal cleansing and higher rates of adequate bowel preparation.
  • Good practice point
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A second examination of the proximal colon in either the forward view or in retroflexion is recommended to improve lesion detection, particularly in patients with an expected higher prevalence of neoplasia.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Technique advances#Practice_point_4
  • A second examination of the proximal colon in either the forward view or in retroflexion is recommended to improve lesion detection, particularly in patients with an expected higher prevalence of neoplasia.
  • Good practice point
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Sessile polyps under 10mm in size should be removed using cold snare polypectomy. This is preferred over hot snare, which is unnecessary in most situations. Hot biopsy forceps should not be used because they are associated with unacceptably high rates of incomplete resection and deep mural injury.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Technique advances#Practice_point_5
  • Sessile polyps under 10mm in size should be removed using cold snare polypectomy. This is preferred over hot snare, which is unnecessary in most situations. Hot biopsy forceps should not be used because they are associated with unacceptably high rates of incomplete resection and deep mural injury.
  • Good practice point

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Technological advances

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High-definition colonoscopes should be used routinely, as the mainstay of colonoscopy is a careful white-light examination of the well prepared colon.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Technological advances#Practice_point_1
  • High-definition colonoscopes should be used routinely, as the mainstay of colonoscopy is a careful white-light examination of the well prepared colon.
  • Good practice point
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Electronic chromoendoscopyAn endoscopic procedure using a specialised endoscope that provides a detailed contrast enhancement image of the musical surface of the colon, and includes NBI, FICE or i-SCAN. should be used for lesion characterisation, but has limited value in lesion detection.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Technological advances#Practice_point_2
  • Electronic chromoendoscopyAn endoscopic procedure using a specialised endoscope that provides a detailed contrast enhancement image of the musical surface of the colon, and includes NBI, FICE or i-SCAN. should be used for lesion characterisation, but has limited value in lesion detection.
  • Good practice point

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Adjunct technologies

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Chromoendoscopy should be considered for routine colonoscopy to improve the detection and characterisation of colorectal polyps.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Adjunct technologies#Practice_point_1
  • Chromoendoscopy should be considered for routine colonoscopy to improve the detection and characterisation of colorectal polyps.
  • Good practice point
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Chromoendoscopy should be considered for patients undergoing surveillance for inflammatory bowel disease, although a recent study has shown equivalence with high resolution white-light endoscopy.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Adjunct technologies#Practice_point_2
  • Chromoendoscopy should be considered for patients undergoing surveillance for inflammatory bowel disease, although a recent study has shown equivalence with high resolution white-light endoscopy.
  • Good practice point
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CO2 insufflation should be used routinely to improve patient tolerability of colonoscopy.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Adjunct technologies#Practice_point_3
  • CO2 insufflation should be used routinely to improve patient tolerability of colonoscopy.
  • Good practice point

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Quality of colonoscopy

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Accurate and sufficient information about the procedure (and optimally consent) should be provided to patients prior to the commencement of bowel preparation for colonoscopy.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_1
  • Accurate and sufficient information about the procedure (and optimally consent) should be provided to patients prior to the commencement of bowel preparation for colonoscopy.
  • Good practice point
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Colonoscopy should be performed only for accepted indications, which should be clearly documented.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_2
  • Colonoscopy should be performed only for accepted indications, which should be clearly documented.
  • Good practice point
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Less than 10% of patients should require a repeat procedure due to poor bowel preparation, this should be offered within 12 months.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_3
  • Less than 10% of patients should require a repeat procedure due to poor bowel preparation, this should be offered within 12 months.
  • Good practice point
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Unadjusted rates for caecal intubation should be ≥90%.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_4
  • Unadjusted rates for caecal intubation should be ≥90%.
  • Good practice point
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Photo-documentation, that terminal ileum or the base of the caecum (appendix orifice and ileocaecal valve) has been reached, should be performed to confirm completeness of the examination.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_5
  • Photo-documentation, that terminal ileum or the base of the caecum (appendix orifice and ileocaecal valve) has been reached, should be performed to confirm completeness of the examination.
  • Good practice point
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Withdrawal times of >6 minutes for examinations without polypectomy are a surrogate marker for adenoma detection rates, but cannot be relied on as an independent quality indicator.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_6
  • Withdrawal times of >6 minutes for examinations without polypectomy are a surrogate marker for adenoma detection rates, but cannot be relied on as an independent quality indicator.
  • Good practice point
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Individual proceduralists should routinely document and maintain their adenoma detection rateThe proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas, or polyps, detected. at >25% in patients over the age of 50-years and without a diagnosis of inflammatory bowel disease.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_7
  • Individual proceduralists should routinely document and maintain their adenoma detection rateThe proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas, or polyps, detected. at >25% in patients over the age of 50-years and without a diagnosis of inflammatory bowel disease.
  • Good practice point
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Serrated polyp detection rates are likely to be an equally valid marker of quality as adenoma detection rateThe proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas, or polyps, detected., and increasing evidence suggests that maintaining a rate of >10% in patients over age 50 years without a diagnosis of inflammatory bowel disease may prove to be an additional, useful quality indicator in the future.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_8
  • Serrated polyp detection rates are likely to be an equally valid marker of quality as adenoma detection rateThe proportion of individuals undergoing a complete screening colonoscopy who have one or more adenomas, or polyps, detected., and increasing evidence suggests that maintaining a rate of >10% in patients over age 50 years without a diagnosis of inflammatory bowel disease may prove to be an additional, useful quality indicator in the future.
  • Good practice point
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Perforation rates post colonoscopy should be <1/1000. This is more relevant for population programs and large endoscopy units rather than individual colonoscopists.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_9
  • Perforation rates post colonoscopy should be <1/1000. This is more relevant for population programs and large endoscopy units rather than individual colonoscopists.
  • Good practice point
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All colonoscopists should have their training certified by the Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy and undergo regular recertification through an endorsed program.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_10
  • All colonoscopists should have their training certified by the Conjoint Committee for the Recognition of Training in Gastrointestinal Endoscopy and undergo regular recertification through an endorsed program.
  • Good practice point
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Comprehensive computer-generated colonoscopy reports with embedded photo-documentation should be generated at the time of the procedure, and provided to patients and relevant clinicians.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Quality of colonoscopy#Practice_point_11
  • Comprehensive computer-generated colonoscopy reports with embedded photo-documentation should be generated at the time of the procedure, and provided to patients and relevant clinicians.
  • Good practice point

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CT colonography

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Due to its excellent safety profile and high accuracy for detecting colonic carcinoma, CT colonographyAlso known as virtual colonoscopy. is an alternative for patients unable to have colonoscopy. Bowel preparation is still required prior to the examination.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/CT Colonography#Practice_point_1
  • Due to its excellent safety profile and high accuracy for detecting colonic carcinoma, CT colonographyAlso known as virtual colonoscopy. is an alternative for patients unable to have colonoscopy. Bowel preparation is still required prior to the examination.
  • Good practice point
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In patients at risk of colorectal carcinoma who have had an incomplete colonoscopy, CT colonographyAlso known as virtual colonoscopy. should be performed to allow assessment of the entire colonic mucosa.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/CT Colonography#Practice_point_2
  • In patients at risk of colorectal carcinoma who have had an incomplete colonoscopy, CT colonographyAlso known as virtual colonoscopy. should be performed to allow assessment of the entire colonic mucosa.
  • Good practice point
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It is safe to perform same-day CT colonographyAlso known as virtual colonoscopy. following incomplete colonoscopy, including in patients who have had a biopsy or simple polypectomy. However, CT colonographyAlso known as virtual colonoscopy. should be delayed in patients with complex endoscopic intervention and in patients at high risk of perforation such as active colitis or high-grade stricture.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/CT Colonography#Practice_point_3
  • It is safe to perform same-day CT colonographyAlso known as virtual colonoscopy. following incomplete colonoscopy, including in patients who have had a biopsy or simple polypectomy. However, CT colonographyAlso known as virtual colonoscopy. should be delayed in patients with complex endoscopic intervention and in patients at high risk of perforation such as active colitis or high-grade stricture.
  • Good practice point
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CT colonographyAlso known as virtual colonoscopy. should only be interpreted by radiologists who have undergone specialist training and are accredited by RANZCR.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/CT Colonography#Practice_point_4
  • CT colonographyAlso known as virtual colonoscopy. should only be interpreted by radiologists who have undergone specialist training and are accredited by RANZCR.
  • Good practice point
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Patients with a CT colonographyAlso known as virtual colonoscopy. detected polyp over 10mm should be referred for polypectomy. Patients with polyps 6–9mm can be offered either polypectomy or repeat colonic examination at 3 years.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/CT Colonography#Practice_point_5
  • Patients with a CT colonographyAlso known as virtual colonoscopy. detected polyp over 10mm should be referred for polypectomy. Patients with polyps 6–9mm can be offered either polypectomy or repeat colonic examination at 3 years.
  • Good practice point

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Colonoscopic surveillance after polypectomy

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Endoscopists and pathologists need to be aware of serrated polyps and be able to recognise and endoscopically manage them.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Colonoscopic surveillance after polypectomy#Practice_point_1
  • Endoscopists and pathologists need to be aware of serrated polyps and be able to recognise and endoscopically manage them.
  • Good practice point
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Hyperplastic polyps should be clearly distinguished from sessile serrated adenomas and traditional serrated adenomas. Although hyperplastic polyps are classified amongst serrated polyps, they do not have malignant potential when they are diminutive, confined to the rectosigmoid colon and not associated with proximal serrated polyps.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Colonoscopic surveillance after polypectomy#Practice_point_2
  • Hyperplastic polyps should be clearly distinguished from sessile serrated adenomas and traditional serrated adenomas. Although hyperplastic polyps are classified amongst serrated polyps, they do not have malignant potential when they are diminutive, confined to the rectosigmoid colon and not associated with proximal serrated polyps.
  • Good practice point
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Consistently high quality colonoscopy is imperative for optimal cost-effectiveness and for implementation of uniform surveillance guidelines.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Colonoscopic surveillance after polypectomy#Practice_point_3
  • Consistently high quality colonoscopy is imperative for optimal cost-effectiveness and for implementation of uniform surveillance guidelines.
  • Good practice point

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First surveillance intervals following removal of low-risk conventional adenomas only

Evidence-based recommendationQuestion mark transparent.png Grade
Low-risk individuals – conventional adenomas only

First surveillance intervals should be no sooner than 5 years following the complete removal of low-risk conventional adenomas only (1–2 small [<10mm] tubular adenomas without high-grade dysplasia).

D
  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Recommendation_1
  • Low-risk individuals – conventional adenomas only

First surveillance intervals should be no sooner than 5 years following the complete removal of low-risk conventional adenomas only (1–2 small [<10mm] tubular adenomas without high-grade dysplasia).

  • Recommendation
Consensus-based recommendationQuestion mark transparent.png

Low-risk individuals – conventional adenomas only

First surveillance interval of 10 years is appropriate for most individuals following complete removal of low-risk conventional adenomas only (1–2 small [<10mm] tubular adenomas without high-grade dysplasia).

  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Practice_point_1
  • Low-risk individuals – conventional adenomas only

First surveillance interval of 10 years is appropriate for most individuals following complete removal of low-risk conventional adenomas only (1–2 small [<10mm] tubular adenomas without high-grade dysplasia).

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

  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Practice_point_2
  • Consistently high-quality colonoscopy is imperative for optimal cost effectiveness and for implementation of uniform surveillance guidelines.
  • Good practice point
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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).

  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Practice_point_3
  • 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).
  • Good practice point
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Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known and in the context of individualised assessment of benefit to the patient.

  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Practice_point_4
  • Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known and in the context of individualised assessment of benefit to the patient.
  • Good practice point
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A shorter surveillance interval of 5 years could be considered for men who fit the criteria for the metabolic syndromeMetabolic syndrome is a collection of conditions that often occur together and increase the risk of diabetes, stroke and heart disease., because they may have increased risk of metachronous advanced neoplasia following removal of low-risk adenomas.

  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Practice_point_5
  • A shorter surveillance interval of 5 years could be considered for men who fit the criteria for the metabolic syndromeMetabolic syndrome is a collection of conditions that often occur together and increase the risk of diabetes, stroke and heart disease., because they may have increased risk of metachronous advanced neoplasia following removal of low-risk adenomas.
  • Good practice point
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Return to the National Bowel Cancer Screening Program with a faecal occult blood testA test that can detect microscopic amounts of blood in stools. after 4 years, is an appropriate option and should be discussed with the patient.

  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Practice_point_6
  • Return to the National Bowel Cancer Screening Program with a faecal occult blood testA test that can detect microscopic amounts of blood in stools. after 4 years, is an appropriate option and should be discussed with the patient.
  • Good practice point
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Patients with 1–2 diminutive (<6mm) low-risk adenomas have a very low risk of metachronous neoplasia and should be returned to the NBCSP after 4 years unless there are significant extenuating factors.

  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Practice_point_7
  • Patients with 1–2 diminutive (<6mm) low-risk adenomas have a very low risk of metachronous neoplasia and should be returned to the NBCSP after 4 years unless there are significant extenuating factors.
  • Good practice point
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Individuals with a significant family history of colorectal cancer should be assessed according to current Australian clinical practice guidelines for the prevention, early detection and management of colorectal cancer (see Risk and screening based on family history) in addition to these recommendations, and the shorter interval used.

  • Clinical question:What should be the surveillance colonoscopy for patients at low risk?#Practice_point_8
  • Individuals with a significant family history of colorectal cancer should be assessed according to current Australian clinical practice guidelines for the prevention, early detection and management of colorectal cancer (see Risk and screening based on family history) in addition to these recommendations, and the shorter interval used.
  • Good practice point

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First surveillance intervals following removal of high-risk conventional adenomas only

Evidence-based recommendationQuestion mark transparent.png Grade
High-risk individuals – conventional adenomas only

First surveillance intervals should be within 5 years following removal of high-risk conventional adenomas only, i.e. those with one or more of the following features:

  • size ≥10mm
  • high-grade dysplasia
  • villosityThe state of being villous, a histopathological feature of some tubular adenomas. Villous adenoma is a type of polyp found in the colon or rectum that appear as a cauliflower-like mass.
  • 3–4 adenomas.
D
  • Clinical question:What should be the surveillance colonoscopy for patients at high risk?#Recommendation_1
  • High-risk individuals – conventional adenomas only

First surveillance intervals should be within 5 years following removal of high-risk conventional adenomas only, i.e. those with one or more of the following features:

  • size ≥10mm
  • high-grade dysplasia
  • villosityThe state of being villous, a histopathological feature of some tubular adenomas. Villous adenoma is a type of polyp found in the colon or rectum that appear as a cauliflower-like mass.
  • 3–4 adenomas.
  • Recommendation
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High-risk individuals – conventional adenomas only

First surveillance intervals following removal of high-risk conventional adenomas only should be stratified according to the type and number of high-risk features (size ≥10mm, high-grade dysplasia (HGD), villosityThe state of being villous, a histopathological feature of some tubular adenomas. Villous adenoma is a type of polyp found in the colon or rectum that appear as a cauliflower-like mass., 3–4 adenomas):

A surveillance interval of 5 years is recommended for patients with either of the following:

  • 1–2 tubular adenomas with HGD or tubulovillous or villous adenomas (with or without HGD), all of which are <10mm
  • 3–4 tubular adenomas without HGD, all of which are <10mm

A surveillance interval of 3 years is recommended for patients with any of the following:

  • 1–2 tubular adenomas with HGD or tubulovillous or villous adenomas (with or without HGD), where the size of one or both is ≥10mm
  • 3–4 tubular adenomas, where the size of one or more is ≥10mm
  • 3–4 tubulovillous and/or villous adenomas and/or HGD, all <10mm
  • Clinical question:What should be the surveillance colonoscopy for patients at high risk?#Practice_point_1
  • High-risk individuals – conventional adenomas only

First surveillance intervals following removal of high-risk conventional adenomas only should be stratified according to the type and number of high-risk features (size ≥10mm, high-grade dysplasia (HGD), villosityThe state of being villous, a histopathological feature of some tubular adenomas. Villous adenoma is a type of polyp found in the colon or rectum that appear as a cauliflower-like mass., 3–4 adenomas):

A surveillance interval of 5 years is recommended for patients with either of the following:

  • 1–2 tubular adenomas with HGD or tubulovillous or villous adenomas (with or without HGD), all of which are <10mm
  • 3–4 tubular adenomas without HGD, all of which are <10mm

A surveillance interval of 3 years is recommended for patients with any of the following:

  • 1–2 tubular adenomas with HGD or tubulovillous or villous adenomas (with or without HGD), where the size of one or both is ≥10mm
  • 3–4 tubular adenomas, where the size of one or more is ≥10mm
  • 3–4 tubulovillous and/or villous adenomas and/or HGD, all <10mm
  • Consensus based recommendation
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Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known, and in the context of individualised assessment of benefit to the patient.

  • Clinical question:What should be the surveillance colonoscopy for patients at high risk?#Practice_point_2
  • Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known, and in the context of individualised assessment of benefit to the patient.
  • Good practice point
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Consistently high-quality colonoscopy is imperative for optimal cost effectiveness and for implementation of uniform surveillance guidelines.

  • Clinical question:What should be the surveillance colonoscopy for patients at high risk?#Practice_point_3
  • Consistently high-quality colonoscopy is imperative for optimal cost effectiveness and for implementation of uniform surveillance guidelines.
  • Good practice point
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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).

  • Clinical question:What should be the surveillance colonoscopy for patients at high risk?#Practice_point_4
  • 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).
  • Good practice point
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Polyps removed at colonoscopy should be sent separately for histology to guide surveillance recommendations.

  • Clinical question:What should be the surveillance colonoscopy for patients at high risk?#Practice_point_5
  • Polyps removed at colonoscopy should be sent separately for histology to guide surveillance recommendations.
  • Good practice point
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Clinicians should accurately include features relevant to surveillance intervals in their procedure reports so that individualised surveillance recommendations can be made.

  • Clinical question:What should be the surveillance colonoscopy for patients at high risk?#Practice_point_6
  • Clinicians should accurately include features relevant to surveillance intervals in their procedure reports so that individualised surveillance recommendations can be made.
  • Good practice point

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First surveillance intervals following removal of ≥5 conventional adenomas only

Evidence-based recommendationQuestion mark transparent.png Grade
≥5 conventional adenomas only

First surveillance intervals following complete removal of ≥5 conventional adenomas only, should be no longer than 3 years.

D
  • Clinical question:What should be the surveillance colonoscopy for patients with adenoma multiplicity with or without polyposis syndrome?#Recommendation_1
  • ≥5 conventional adenomas only

First surveillance intervals following complete removal of ≥5 conventional adenomas only, should be no longer than 3 years.

  • Recommendation
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≥5 conventional adenomas only

First surveillance intervals should be within 3 years and stratified based on the number, size and histology following complete removal of ≥5 adenomas only.
For those with 5–9 adenomas, recommended surveillance intervals are:

  • 3 years if all tubular adenomas <10mm without high grade dysplasia (HGD)
  • 1 year if any adenoma ≥10mm or with HGD and/or villosityThe state of being villous, a histopathological feature of some tubular adenomas. Villous adenoma is a type of polyp found in the colon or rectum that appear as a cauliflower-like mass.

For those with ≥10 adenomas, the recommended surveillance interval is 1 year, regardless of size or histology.

  • Clinical question:What should be the surveillance colonoscopy for patients with adenoma multiplicity with or without polyposis syndrome?#Practice_point_1
  • ≥5 conventional adenomas only

First surveillance intervals should be within 3 years and stratified based on the number, size and histology following complete removal of ≥5 adenomas only.
For those with 5–9 adenomas, recommended surveillance intervals are:

  • 3 years if all tubular adenomas <10mm without high grade dysplasia (HGD)
  • 1 year if any adenoma ≥10mm or with HGD and/or villosityThe state of being villous, a histopathological feature of some tubular adenomas. Villous adenoma is a type of polyp found in the colon or rectum that appear as a cauliflower-like mass.

For those with ≥10 adenomas, the recommended surveillance interval is 1 year, regardless of size or histology.

  • Consensus based recommendation
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Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known, and in the context of individualised assessment of benefit to the patient.

  • Clinical question:What should be the surveillance colonoscopy for patients with adenoma multiplicity with or without polyposis syndrome?#Practice_point_2
  • Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known, and in the context of individualised assessment of benefit to the patient.
  • Good practice point
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Consistently high-quality colonoscopy is imperative for optimal cost effectiveness and for implementation of uniform surveillance guidelines.

  • Clinical question:What should be the surveillance colonoscopy for patients with adenoma multiplicity with or without polyposis syndrome?#Practice_point_3
  • Consistently high-quality colonoscopy is imperative for optimal cost effectiveness and for implementation of uniform surveillance guidelines.
  • Good practice point
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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).

  • Clinical question:What should be the surveillance colonoscopy for patients with adenoma multiplicity with or without polyposis syndrome?#Practice_point_4
  • 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).
  • Good practice point
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Polyps removed at colonoscopy should be sent separately for histology to guide surveillance recommendations.

  • Clinical question:What should be the surveillance colonoscopy for patients with adenoma multiplicity with or without polyposis syndrome?#Practice_point_5
  • Polyps removed at colonoscopy should be sent separately for histology to guide surveillance recommendations.
  • Good practice point
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Clinicians should accurately record adenoma features relevant to surveillance intervals so that individualised surveillance recommendations can be made.

  • Clinical question:What should be the surveillance colonoscopy for patients with adenoma multiplicity with or without polyposis syndrome?#Practice_point_6
  • Clinicians should accurately record adenoma features relevant to surveillance intervals so that individualised surveillance recommendations can be made.
  • Good practice point
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An underlying familial predisposition to colorectal cancer should be considered in all individuals with ≥10 polyps removed. Referral to a familial cancer clinic should be considered, along with appropriate psychological support.

Separate screening and surveillance recommendations apply to patients with diagnosed or likely familial syndromesGenetic disorders in which inherited genetic mutations in one or more genes predispose a person to developing cancer, particularly at an early age. (see Should family history affect surveillance intervals?).

  • Clinical question:What should be the surveillance colonoscopy for patients with adenoma multiplicity with or without polyposis syndrome?#Practice_point_7
  • An underlying familial predisposition to colorectal cancer should be considered in all individuals with ≥10 polyps removed. Referral to a familial cancer clinic should be considered, along with appropriate psychological support.

Separate screening and surveillance recommendations apply to patients with diagnosed or likely familial syndromesGenetic disorders in which inherited genetic mutations in one or more genes predispose a person to developing cancer, particularly at an early age. (see Should family history affect surveillance intervals?).

  • Good practice point

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Table 3. Summary of recommendations for first surveillance intervals following removal of conventional adenomas only

Table 3 Removal conventional adenomas.PNGBack to top

First surveillance intervals following removal of serrated polyps (with or without conventional adenoma)

Evidence-based recommendationQuestion mark transparent.png Grade
Sessile and traditional serrated adenomas (with or without conventional adenomas)

First surveillance intervals should be no greater than 5 years and should be based on features of synchronous conventional adenomas (if present) following complete removal of sessile and traditional serrated adenomas.

D
  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Recommendation_1
  • Sessile and traditional serrated adenomas (with or without conventional adenomas)

First surveillance intervals should be no greater than 5 years and should be based on features of synchronous conventional adenomas (if present) following complete removal of sessile and traditional serrated adenomas.

  • Recommendation
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Sessile and traditional serrated adenomas (with or without conventional adenomas)

First surveillance intervals should be based on the number, size and presence of dysplasia in the serrated polyps and synchronous conventional adenomas (if present) following complete removal of sessile and traditional serrated adenomas.


Clinically significant serrated polyps only
5 years for:

  • 1–2 sessile serrated adenomas all <10mm without dysplasia.

3 years for:

  • 3–4 sessile serrated adenomas, all <10mm without dysplasia
  • 1–2 sessile serrated adenomas ≥10mm or with dysplasia, or hyperplastic polyp ≥10mm
  • 1–2 traditional serrated adenomas, any size.

1 year for:

  • ≥5 sessile serrated adenomas <10mm without dysplasia
  • 3–4 sessile serrated adenomas, one or more ≥10mm or with dysplasia
  • 3–4 traditional serrated adenomas, any size.


Clinically significant serrated polyps and synchronous conventional adenomas
5 years for:

  • 2 in total, sessile serrated adenoma <10mm without dysplasia.

3 years for:

  • 3–9 in total, all sessile serrated adenomas <10mm without dysplasia
  • 2–4 in total, any serrated polyp ≥10mm and/or dysplasia
  • 2–4 in total, any traditional serrated adenoma.

1 year for:

  • ≥10 in total, all sessile serrated adenomas <10mm without dysplasia
  • ≥5 in total, any serrated polyp ≥10mm and/or dysplasia
  • ≥5 in total, any traditional serrated adenoma.


Synchronous high-risk conventional adenoma (tubulovillous or villous adenoma, with or without HGD and with or without size ≥10mm)
3 years for:

  • 2 in total, sessile serrated adenoma <10mm, without dysplasia
  • 2 in total, serrated polyp ≥10mm and/or dysplasia
  • 2 in total, any traditional serrated adenoma.

1 year for:

  • ≥3 total adenomas, sessile serrated adenoma any size with or without dysplasia
  • ≥3 total adenomas, one or more traditional serrated adenoma.
  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_1
  • Sessile and traditional serrated adenomas (with or without conventional adenomas)

First surveillance intervals should be based on the number, size and presence of dysplasia in the serrated polyps and synchronous conventional adenomas (if present) following complete removal of sessile and traditional serrated adenomas.


Clinically significant serrated polyps only
5 years for:

  • 1–2 sessile serrated adenomas all <10mm without dysplasia.

3 years for:

  • 3–4 sessile serrated adenomas, all <10mm without dysplasia
  • 1–2 sessile serrated adenomas ≥10mm or with dysplasia, or hyperplastic polyp ≥10mm
  • 1–2 traditional serrated adenomas, any size.

1 year for:

  • ≥5 sessile serrated adenomas <10mm without dysplasia
  • 3–4 sessile serrated adenomas, one or more ≥10mm or with dysplasia
  • 3–4 traditional serrated adenomas, any size.


Clinically significant serrated polyps and synchronous conventional adenomas
5 years for:

  • 2 in total, sessile serrated adenoma <10mm without dysplasia.

3 years for:

  • 3–9 in total, all sessile serrated adenomas <10mm without dysplasia
  • 2–4 in total, any serrated polyp ≥10mm and/or dysplasia
  • 2–4 in total, any traditional serrated adenoma.

1 year for:

  • ≥10 in total, all sessile serrated adenomas <10mm without dysplasia
  • ≥5 in total, any serrated polyp ≥10mm and/or dysplasia
  • ≥5 in total, any traditional serrated adenoma.


Synchronous high-risk conventional adenoma (tubulovillous or villous adenoma, with or without HGD and with or without size ≥10mm)
3 years for:

  • 2 in total, sessile serrated adenoma <10mm, without dysplasia
  • 2 in total, serrated polyp ≥10mm and/or dysplasia
  • 2 in total, any traditional serrated adenoma.

1 year for:

  • ≥3 total adenomas, sessile serrated adenoma any size with or without dysplasia
  • ≥3 total adenomas, one or more traditional serrated adenoma.
  • Consensus based recommendation
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Surveillance is recommended for ‘clinically significant’ serrated polyps:

  • sessile serrated adenomas
  • traditional serrated adenomas
  • hyperplastic polyps ≥10mm.
  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_2
  • Surveillance is recommended for ‘clinically significant’ serrated polyps:
  • sessile serrated adenomas
  • traditional serrated adenomas
  • hyperplastic polyps ≥10mm.
  • Good practice point
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High-quality endoscopy is imperative to identify accurately and to completely remove sessile and traditional serrated adenomas and synchronous conventional adenomas.

  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_3
  • High-quality endoscopy is imperative to identify accurately and to completely remove sessile and traditional serrated adenomas and synchronous conventional adenomas.
  • Good practice point
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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).

  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_4
  • 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).
  • Good practice point
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Polyps removed should be submitted separately for histologic assessment to inform surveillance recommendations.

  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_5
  • Polyps removed should be submitted separately for histologic assessment to inform surveillance recommendations.
  • Good practice point
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High-quality pathology interpretation is critical to correctly diagnose sessile and traditional serrated lesions and advanced serrated polyps.

  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_6
  • High-quality pathology interpretation is critical to correctly diagnose sessile and traditional serrated lesions and advanced serrated polyps.
  • Good practice point
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High-quality reporting from endoscopists and pathologists is required to allow accurate risk stratification for surveillance interval recommendations.

  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_7
  • High-quality reporting from endoscopists and pathologists is required to allow accurate risk stratification for surveillance interval recommendations.
  • Good practice point
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Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known and in the context of individualised assessment of benefit to the patient.

  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_8
  • Surveillance intervals should be determined after the colon has been cleared of all significant neoplasia, once histology is known and in the context of individualised assessment of benefit to the patient.
  • Good practice point
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Small, particularly distal, true hyperplastic polyps do not require surveillance.

  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_9
  • Small, particularly distal, true hyperplastic polyps do not require surveillance.
  • Good practice point
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Clinicians should be aware of the cumulative serrated polyp count and diagnostic criteria for serrated polyposis syndrome and recommend surveillance. See Clinical practice guidelines for the prevention, early detection and management of colorectal cancer, Serrated polyposis syndrome for diagnostic criteria and recommended surveillance.

  • Clinical question:What should be the surveillance colonoscopy following resection of serrated adenomas (SA) and sessile serrated adenomas (SSA)?#Practice_point_10
  • Clinicians should be aware of the cumulative serrated polyp count and diagnostic criteria for serrated polyposis syndrome and recommend surveillance. See Clinical practice guidelines for the prevention, early detection and management of colorectal cancer, Serrated polyposis syndrome for diagnostic criteria and recommended surveillance.
  • Good practice point

Table 9. Summary of recommendations for first surveillance intervals following removal of clinically significant serrated polyps (± conventional adenomas)

Table 9 1st surveillance removal serrated.PNGBack to top

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

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.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_1
  • 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 recommendation
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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.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_2
  • 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.

  • Consensus based recommendation
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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.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_3
  • 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.
  • Good practice point
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Patients with large sessile and laterally spreading lesions should be informed of the requirement for scheduled surveillance before proceeding to EMR.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_4
  • Patients with large sessile and laterally spreading lesions should be informed of the requirement for scheduled surveillance before proceeding to EMR.
  • Good practice point
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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.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_5
  • 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.
  • Good practice point
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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.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_6
  • 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.
  • Good practice point
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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.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_7
  • 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.
  • Good practice point
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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.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_8
  • 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.
  • Good practice point
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Consistently high-quality colonoscopy is imperative for optimal cost effectiveness and for implementation of uniform surveillance guidelines.

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_9
  • Consistently high-quality colonoscopy is imperative for optimal cost effectiveness and for

implementation of uniform surveillance guidelines.

  • Good practice point
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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).

  • Clinical question:What should be the surveillance colonoscopy following sessile and laterally spreading adenomas?#Practice_point_10
  • 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).
  • Good practice point

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Should family history affect surveillance intervals?

Evidence-based recommendationQuestion mark transparent.png Grade
Family history of CRC

First surveillance intervals following adenoma removal in those with a family history of colorectal cancer should be based on patient factors and the adenoma history, unless a genetic syndrome is known or suspected.

D
  • Clinical question:What should be the surveillance colonoscopy for patients with previous neoplasia history?#Recommendation_1
  • Family history of CRC

First surveillance intervals following adenoma removal in those with a family history of colorectal cancer should be based on patient factors and the adenoma history, unless a genetic syndrome is known or suspected.

  • Recommendation
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To identify those who may have an increased familial risk of colorectal cancer, a family history of colorectal cancer and associated malignancies including number of affected relatives, relatedness and age of onset should be taken and updated every 5 to 10 years.

  • Clinical question:What should be the surveillance colonoscopy for patients with previous neoplasia history?#Practice_point_1
  • To identify those who may have an increased familial risk of colorectal cancer, a family history of colorectal cancer and associated malignancies including number of affected relatives, relatedness and age of onset should be taken and updated every 5 to 10 years.
  • Good practice point
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In individuals who are undergoing screening colonoscopy for colorectal cancer based on family history, adenoma surveillance and screening recommendations should be compared and the shorter interval used. Refer to Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (2017) (see Recommendations for risk and screening based on family history of colorectal cancer).

  • Clinical question:What should be the surveillance colonoscopy for patients with previous neoplasia history?#Practice_point_2
  • In individuals who are undergoing screening colonoscopy for colorectal cancer based on family history, adenoma surveillance and screening recommendations should be compared and the shorter interval used. Refer to Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (2017) (see Recommendations for risk and screening based on family history of colorectal cancer).
  • Good practice point
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To address individual’s concerns, clinicians should take adequate time to explain the relationship of family history to recommended surveillance intervals and refer for counselling where appropriate.

  • Clinical question:What should be the surveillance colonoscopy for patients with previous neoplasia history?#Practice_point_3
  • To address individual’s concerns, clinicians should take adequate time to explain the relationship of family history to recommended surveillance intervals and refer for counselling where appropriate.
  • Good practice point

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Subsequent surveillance intervals

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The findings of the previous two colonoscopies predict high-risk findings on the subsequent colonoscopy and should be considered when recommending subsequent surveillance intervals.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Second and subsequent surveillance colonoscopies#Practice_point_1
  • The findings of the previous two colonoscopies predict high-risk findings on the subsequent colonoscopy and should be considered when recommending subsequent surveillance intervals.
  • Good practice point
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For individuals who have undergone two or more colonoscopies, the surveillance interval for the next (3rd) colonoscopy should be based on the reports and histology from the two most recent procedures (1st and 2nd colonoscopies) as per Tables 14–16 (see Table 13 as a quick reference guide).

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Second and subsequent surveillance colonoscopies#Practice_point_2
  • For individuals who have undergone two or more colonoscopies, the surveillance interval for the next (3rd) colonoscopy should be based on the reports and histology from the two most recent procedures (1st and 2nd colonoscopies) as per Tables 14–16 (see Table 13 as a quick reference guide).
  • Good practice point

(Table 13 is provided at the end of this section as a reference guide to Tables 14-16)


Table 14. Recommended surveillance intervals for 3rd colonoscopy - conventional adenomas only at 1st and 2nd colonoscopy Table 14 Conventional adenoma 3rdcol.PNGTable 15. Recommended surveillance intervals for 3rd colonoscopy. a. (top) clinically significant serrated polyps only at 2nd colonoscopy. b. (bottom) clinically significant serrated polyps with synchronous conventional adenomas at 2nd colonoscopy.

Table 15ab 3rd col clinical serrated.PNGTable 16. Recommended surveillance intervals for 3rd colonoscopy – clinically significant serrated polyps at 1st colonoscopy, no adenomas or conventional adenomas only at 2nd colonoscopy

Table 16 3rdcol no ad or conventional ad.PNGBack to top


The elderly and stopping rules

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Careful assessment and shared decision-making should be utilised when considering surveillance colonoscopy in the elderly, most of whom will have no significant findings and will not benefit.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/The elderly and stopping rules#Practice_point_1
  • Careful assessment and shared decision-making should be utilised when considering surveillance colonoscopy in the elderly, most of whom will have no significant findings and will not benefit.
  • Good practice point
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Surveillance colonoscopy in those ≥75 years should be considered based on age, co-morbidity and the preferences of the patient. The reproducible and validated Charlson score is useful to assess life expectancy and could be implemented to assist decision-making (see Tables 17 and 18 below).

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/The elderly and stopping rules#Practice_point_2
  • Surveillance colonoscopy in those ≥75 years should be considered based on age, co-morbidity and the preferences of the patient. The reproducible and validated Charlson score is useful to assess life expectancy and could be implemented to assist decision-making (see Tables 17 and 18 below).
  • Good practice point
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In obtaining consent for colonoscopy for an elderly patient, complication rates should reflect the individual risk based on age and comorbidity rather than ‘standard’ figures.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/The elderly and stopping rules#Practice_point_3
  • In obtaining consent for colonoscopy for an elderly patient, complication rates should reflect the individual risk based on age and comorbidity rather than ‘standard’ figures.
  • Good practice point


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Malignant polyps

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Endoscopists should be familiar with endoscopic appearances suggestive of a malignant polyp.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_1
  • Endoscopists should be familiar with endoscopic appearances suggestive of a malignant polyp.
  • Good practice point
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Removal of polyps likely to be malignant should be en-bloc or patients should be referred to a centre specialising in endoscopic excision of large and flat polyps.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_2
  • Removal of polyps likely to be malignant should be en-bloc or patients should be referred to a centre specialising in endoscopic excision of large and flat polyps.
  • Good practice point
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Tattoos should be applied 2–3cm distal to the polypectomy site if future site localisation or surgery is necessary.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_3
  • Tattoos should be applied 2–3cm distal to the polypectomy site if future site localisation or surgery is necessary.
  • Good practice point
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Malignant polyps should be reviewed by a second pathologist with a specialist gastrointestinal interest where histological diagnosis is unclear or difficult. Multidisciplinary review and management (endoscopist, pathologist and surgeon as a minimum) is appropriate in public and private settings although the nature may differ.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_4
  • Malignant polyps should be reviewed by a second pathologist with a specialist gastrointestinal interest where histological diagnosis is unclear or difficult. Multidisciplinary review and management (endoscopist, pathologist and surgeon as a minimum) is appropriate in public and private settings although the nature may differ.
  • Good practice point
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Standardised synoptic reporting should be used to assist clinical decision making (structured reporting protocols are available at the Royal College of Pathologists of Australasia website).

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_5
  • Standardised synoptic reporting should be used to assist clinical decision making (structured reporting protocols are available at the Royal College of Pathologists of Australasia website).
  • Good practice point
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Low-risk malignant polyps have all of the following features: superficial submucosal invasion (<1000 microns), moderate or well differentiated histology, no lymphovascular invasion, clear margins and no other risk features. In these cases, where the endoscopist is certain that the lesion has been completely removed, then the neoplasm should be considered cured by endoscopic polypectomy.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_6
  • Low-risk malignant polyps have all of the following features: superficial submucosal invasion (<1000 microns), moderate or well differentiated histology, no lymphovascular invasion, clear margins and no other risk features. In these cases, where the endoscopist is certain that the lesion has been completely removed, then the neoplasm should be considered cured by endoscopic polypectomy.
  • Good practice point
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Polyps that do not satisfy low risk criteria or have other histological risk features (often not routinely reported) including: malignant invasion depth >2mm, invasion width >3mm, tumour budding and cribriform architecture, should be considered at risk of harbouring residual bowel wall cancer or lymph node metastases. A magnitude of the risk should be estimated and the need for formal surgical resection considered.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_7
  • Polyps that do not satisfy low risk criteria or have other histological risk features (often not routinely reported) including: malignant invasion depth >2mm, invasion width >3mm, tumour budding and cribriform architecture, should be considered at risk of harbouring residual bowel wall cancer or lymph node metastases. A magnitude of the risk should be estimated and the need for formal surgical resection considered.
  • Good practice point
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Cases considered for surgery must have an assessment of surgical risk using validated surgical risk scoring systems, e.g. Risk Prediction in Surgery.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_8
  • Cases considered for surgery must have an assessment of surgical risk using validated surgical risk scoring systems, e.g. Risk Prediction in Surgery.
  • Good practice point
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A discussion of risk of residual cancer balanced against risk of surgery must occur with the patient to determine ultimate management choice.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_9
  • A discussion of risk of residual cancer balanced against risk of surgery must occur with the patient to determine ultimate management choice.
  • Good practice point
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Multi-disciplinary management and audit are important.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_10
  • Multi-disciplinary management and audit are important.
  • Good practice point
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Surveillance recommendations for a T1 adenocarcinomaA type of cancerous tumour that forms from glandular structures in epithelial tissue. as per 2017 Australian Clinical practice guidelines for the prevention, early detection and management of colorectal cancer should be followed for completely resected malignant polyps.

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A patient who has had potential incomplete endoscopic resection of a malignant polyp not undergoing surgery should undergo repeat colonoscopy to assess recurrence at an interval of 3 months.

  • Guidelines:Colorectal cancer/Colonoscopy surveillance/Malignant polyps#Practice_point_12
  • A patient who has had potential incomplete endoscopic resection of a malignant polyp not undergoing surgery should undergo repeat colonoscopy to assess recurrence at an interval of 3 months.
  • Good practice point

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Role of surveillance colonoscopy after curative resection for colorectal cancer

Pre and perioperative colonoscopy in patients with colorectal cancer undergoing resection

Evidence-based recommendationQuestion mark transparent.png Grade
A preoperative colonoscopy should be attempted in all patients with a newly diagnosed colorectal cancer.
C
  • Clinical question:What is the role of pre or peri-operative colonoscopy in CRC patients?#Recommendation_1
  • A preoperative colonoscopy should be attempted in all patients with a newly diagnosed colorectal cancer.
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
Colonoscopy 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
  • Clinical question:What is the role of pre or peri-operative colonoscopy in CRC patients?#Recommendation_2
  • Colonoscopy 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.
  • Recommendation
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In cases of a colorectal cancer that may be difficult to identify at surgery, particularly using the laparoscopic approachA procedure where small multiple incisions are made to perform an operation, rather than making a large open incision., 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.

  • Clinical question:What is the role of pre or peri-operative colonoscopy in CRC patients?#Practice_point_1
  • In cases of a colorectal cancer that may be difficult to identify at surgery, particularly using the laparoscopic approachA procedure where small multiple incisions are made to perform an operation, rather than making a large open incision., 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.
  • Good practice point
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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 colonographyAlso known as virtual colonoscopy. (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.

  • Clinical question:What is the role of pre or peri-operative colonoscopy in CRC patients?#Practice_point_2
  • 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 colonographyAlso known as virtual colonoscopy. (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.
  • Good 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.

  • Clinical question:What is the role of pre or peri-operative colonoscopy in CRC patients?#Practice_point_3
  • 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.
  • Good practice point
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In patients with a defunctioning loop ileostomy, it is preferable to undertake colonoscopy after this is reversed to enable adequate bowel preparation.

  • Clinical question:What is the role of pre or peri-operative colonoscopy in CRC patients?#Practice_point_4
  • In patients with a defunctioning loop ileostomy, it is preferable to undertake colonoscopy after this is reversed to enable adequate bowel preparation.
  • Good practice point

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Follow-up colonoscopy after colorectal cancer resection

Evidence-based recommendationQuestion mark transparent.png Grade
Colonoscopy should be performed 1 year after the resection of a sporadic cancer, unless a complete postoperative colonoscopy has been performed sooner.

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

C
  • Clinical question:What should be the follow-up colonoscopy for patients after CRC resection?#Recommendation_1
  • Colonoscopy should be performed 1 year after the resection of a sporadic cancer, unless a complete postoperative colonoscopy has been performed sooner.

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

  • Recommendation
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If the perioperative colonoscopy or the colonoscopy performed at 1 year reveals advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia., then the interval before the next colonoscopy should be guided by recommended surveillance intervals according to polyp features.

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

C
  • Clinical question:What should be the follow-up colonoscopy for patients after CRC resection?#Recommendation_2
  • If the perioperative colonoscopy or the colonoscopy performed at 1 year reveals advanced adenomaAn adenoma that measures 10mm or more in size. Includes adenomatous polyps greater than or equal to 10 mm in size or with a significant villous component or with high-grade dysplasia., then the interval before the next colonoscopy should be guided by recommended surveillance intervals according to polyp features.

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

  • Recommendation
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If the colonoscopy performed at 1 year is normal or identifies no advanced adenomas, then the interval before the next colonoscopy should be five 5 years (i.e. colonoscopies at 1, 6, and 11 years after resection).

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

C
  • Clinical question:What should be the follow-up colonoscopy for patients after CRC resection?#Recommendation_3
  • If the colonoscopy performed at 1 year is normal or identifies no advanced adenomas, then the interval before the next colonoscopy should be five 5 years (i.e. colonoscopies at 1, 6, and 11 years after resection).

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

  • Recommendation
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If surveillance colonoscopy reveals adenoma, then the interval before the next colonoscopy should be guided by polyp features (evidence-based recommendation, Grade C). However, if subsequent colonoscopy is normal, then surveillance should revert back to the intervals recommended for initial cancer surveillance (colonoscopy at 6 and 11 years post resection).

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

  • Clinical question:What should be the follow-up colonoscopy for patients after CRC resection?#Practice_point_1
  • If surveillance colonoscopy reveals adenoma, then the interval before the next colonoscopy should be guided by polyp features (evidence-based recommendation, Grade C). However, if subsequent colonoscopy is normal, then surveillance should revert back to the intervals recommended for initial cancer surveillance (colonoscopy at 6 and 11 years post resection).

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

  • Consensus based recommendation
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If all colonoscopies performed at 1, 6 and 11 years post resection are normal, follow-up can be with either of the following options:

  • faecal occult blood testA test that can detect microscopic amounts of blood in stools. every 2 years
  • colonoscopy at 10 years (i.e. 21 years post resection)

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

  • Clinical question:What should be the follow-up colonoscopy for patients after CRC resection?#Practice_point_2
  • If all colonoscopies performed at 1, 6 and 11 years post resection are normal, follow-up can be with either of the following options:
  • faecal occult blood testA test that can detect microscopic amounts of blood in stools. every 2 years
  • colonoscopy at 10 years (i.e. 21 years post resection)

Recommendation unchanged from 2011 edition of clinical practice guidelines for surveillance colonoscopy.

  • Consensus based recommendation
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Patients undergoing either local excision (including transanal endoscopic microsurgery) of rectal cancer or advanced adenomas or ultra-low anterior resectionA surgical procedure to remove cancer in the rectum with the bowel being re-joined to leave a functioning anus. for rectal cancer should be considered for periodic examination of the rectum at 6-monthly intervals for 2 or 3 years using either digital rectal examination, rigid proctoscopy, flexible proctoscopy, and/or rectal endoscopic ultrasoundAn imaging procedure where a probe is inserted into the rectum and high frequency sound waves (ultrasound waves) are generated to look for abnormalities in the rectum and nearby structures.. These examinations are considered to be independent of the colonoscopic examination schedule described above

  • Clinical question:What should be the follow-up colonoscopy for patients after CRC resection?#Practice_point_3
  • Patients undergoing either local excision (including transanal endoscopic microsurgery) of rectal cancer or advanced adenomas or ultra-low anterior resectionA surgical procedure to remove cancer in the rectum with the bowel being re-joined to leave a functioning anus. for rectal cancer should be considered for periodic examination of the rectum at 6-monthly intervals for 2 or 3 years using either digital rectal examination, rigid proctoscopy, flexible proctoscopy, and/or rectal endoscopic ultrasoundAn imaging procedure where a probe is inserted into the rectum and high frequency sound waves (ultrasound waves) are generated to look for abnormalities in the rectum and nearby structures.. These examinations are considered to be independent of the colonoscopic examination schedule described above
  • Good practice point
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Patients with incomplete colonoscopy pre-operatively (e.g. impassable distal lesion) should have a semi-urgent elective post-operative colonoscopy when feasible, independent of surveillance intervals.

  • Clinical question:What should be the follow-up colonoscopy for patients after CRC resection?#Practice_point_4
  • Patients with incomplete colonoscopy pre-operatively (e.g. impassable distal lesion) should have a semi-urgent elective post-operative colonoscopy when feasible, independent of surveillance intervals.
  • Good practice point
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Surveillance colonoscopy in those age ≥75 years should be based on age and comorbidity as assessed by the reproducible and validated Charlson score. Charlson score is useful to assess life expectancy and could be implemented to stratify benefits of surveillance colonoscopy in the elderly (see Table 18. Charlson score for colonoscopy benefit).

  • Clinical question:What should be the follow-up colonoscopy for patients after CRC resection?#Practice_point_5
  • Surveillance colonoscopy in those age ≥75 years should be based on age and comorbidity as assessed by the reproducible and validated Charlson score. Charlson score is useful to assess life expectancy and could be implemented to stratify benefits of surveillance colonoscopy in the elderly (see Table 18. Charlson score for colonoscopy benefit).
  • Good practice point

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Patient selection for surveillance colonoscopy following resection

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Patients with hereditary colorectal cancer syndromes should have surveillance colonoscopy performed post-operatively as per the Clinical practice guidelines for the prevention, early detection and management of colorectal cancer.

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Other clinically high-risk patients should be considered for more frequent surveillance colonoscopy after surgery than would otherwise be recommended (e.g. initial post-operative colonoscopy at 1 year and then 1–3 yearly depending on personalised estimate of risk). These include patients:

  • whose initial diagnosis was made younger than age 40 years
  • with suspected but un-identified hereditary colorectal cancer syndromes
  • with multiple synchronous cancers or advanced adenomas at initial diagnosis.
  • Clinical question:Which CRC patients should be followed up with surveillance colonoscopy?#Practice_point_2
  • Other clinically high-risk patients should be considered for more frequent surveillance colonoscopy after surgery than would otherwise be recommended (e.g. initial post-operative colonoscopy at 1 year and then 1–3 yearly depending on personalised estimate of risk).

These include patients:

  • whose initial diagnosis was made younger than age 40 years
  • with suspected but un-identified hereditary colorectal cancer syndromes
  • with multiple synchronous cancers or advanced adenomas at initial diagnosis.
  • Good practice point

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Colonoscopic surveillance and management of dysplasia in inflammatory bowel disease (IBD)

Initiation of surveillance in IBD

Evidence-based recommendationQuestion mark transparent.png Grade
Surveillance colonoscopy should commence after 8 years of onset of inflammatory bowel disease symptoms in those with at least distal (left-sided) ulcerative colitis or Crohn’s colitis with involvement of at least one third of the colon.
C
  • Clinical question:When should surveillance colonoscopy be initiated for UC and Crohn’s patients, for UC and Crohn’s patients who have PSC detection, for UC and Crohn’s patients with a strong family history?#Recommendation_1
  • Surveillance colonoscopy should commence after 8 years of onset of inflammatory bowel disease symptoms in those with at least distal (left-sided) ulcerative colitis or Crohn’s colitis with involvement of at least one third of the colon.
  • Recommendation
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In the presence of primary sclerosing cholangitis (PSC), surveillance colonoscopy should commence upon the diagnosis of PSC.
B
  • Clinical question:When should surveillance colonoscopy be initiated for UC and Crohn’s patients, for UC and Crohn’s patients who have PSC detection, for UC and Crohn’s patients with a strong family history?#Recommendation_2
  • In the presence of primary sclerosing cholangitis (PSC), surveillance colonoscopy should commence upon the diagnosis of PSC.
  • Recommendation
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A family history of colorectal cancer in a first degree relative represents an intermediate risk factor. Surveillance colonoscopy may begin after 8 years of the onset of symptoms of inflammatory bowel disease, or 10 years before the age of the youngest relative with colorectal cancer,whichever is earliest.

  • Clinical question:When should surveillance colonoscopy be initiated for UC and Crohn’s patients, for UC and Crohn’s patients who have PSC detection, for UC and Crohn’s patients with a strong family history?#Practice_point_1
  • A family history of colorectal cancer in a first degree relative represents an intermediate risk factor. Surveillance colonoscopy may begin after 8 years of the onset of symptoms of inflammatory bowel disease, or 10 years before the age of the youngest relative with colorectal cancer,whichever is earliest.
  • Good practice point
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Those with isolated proctitis or small bowel Crohn’s disease do not require surveillance colonoscopy.

  • Clinical question:When should surveillance colonoscopy be initiated for UC and Crohn’s patients, for UC and Crohn’s patients who have PSC detection, for UC and Crohn’s patients with a strong family history?#Practice_point_2
  • Those with isolated proctitis or small bowel Crohn’s disease do not require surveillance colonoscopy.
  • Good practice point

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Surveillance interval for IBD patients

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Patients with IBD at high risk of CRC (those with PSC, ongoing chronic active inflammation, prior colorectal dysplasia, evidence of intestinal damage with colonic stricture, pseudopolyps or foreshortened tubular colon or family history of CRC at age ≤50 years) should undergo yearly surveillance colonoscopy.

  • Clinical question:What is the most appropriate time interval for surveillance in IBD patients?#Practice_point_1
  • Patients with IBD at high risk of CRC (those with PSC, ongoing chronic active inflammation, prior colorectal dysplasia, evidence of intestinal damage with colonic stricture, pseudopolyps or foreshortened tubular colon or family history of CRC at age ≤50 years) should undergo yearly surveillance colonoscopy.
  • Consensus based recommendation
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Patients with IBD at intermediate risk of CRC (those with quiescent disease, no high risk features or family history of CRC in a first-degree relative) should undergo surveillance colonoscopy every 3 years.

  • Clinical question:What is the most appropriate time interval for surveillance in IBD patients?#Practice_point_2
  • Patients with IBD at intermediate risk of CRC (those with quiescent disease, no high risk features or family history of CRC in a first-degree relative) should undergo surveillance colonoscopy every 3 years.
  • Consensus based recommendation
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Patients with IBD at low risk of CRC (those with quiescent disease and no other risk factors, and with inactive disease on consecutive surveillance colonoscopies) may undergo surveillance colonoscopy every 5 years.

  • Clinical question:What is the most appropriate time interval for surveillance in IBD patients?#Practice_point_3
  • Patients with IBD at low risk of CRC (those with quiescent disease and no other risk factors, and with inactive disease on consecutive surveillance colonoscopies) may undergo surveillance colonoscopy every 5 years.
  • Consensus based recommendation
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Consider increased frequency of surveillance (intervals less than 3 years) in patients with a family history of CRC in a first-degree relative <50 years of age because this may be an additional risk factor for CRC.

  • Clinical question:What is the most appropriate time interval for surveillance in IBD patients?#Practice_point_4
  • Consider increased frequency of surveillance (intervals less than 3 years) in patients with a family history of CRC in a first-degree relative <50 years of age because this may be an additional risk factor for CRC.
  • Good practice point

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Recommended surveillance techniques in IBD patients

Evidence-based recommendationQuestion mark transparent.png Grade
Chromoendoscopy should be incorporated into surveillance procedures, especially in high-risk patients.
A
  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Recommendation_1
  • Chromoendoscopy should be incorporated into surveillance procedures, especially in high-risk patients.
  • Recommendation
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Taking targeted, rather than random, biopsies is the recommended method of identifying dysplasia in patients with inflammatory bowel disease.
B
  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Recommendation_2
  • Taking targeted, rather than random, biopsies is the recommended method of identifying dysplasia in patients with inflammatory bowel disease.
  • Recommendation
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Random biopsies are recommended in IBD patients with PSC, prior dysplasia, and intestinal damage (colonic stricture or foreshortening).
C
  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Recommendation_3
  • Random biopsies are recommended in IBD patients with PSC, prior dysplasia, and intestinal damage (colonic stricture or foreshortening).
  • Recommendation
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Standard-definition colonoscopy is not recommended for surveillance procedures, especially in the absence of chromoendoscopy
B
  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Recommendation_4
  • Standard-definition colonoscopy is not recommended for surveillance procedures, especially in the absence of chromoendoscopy
  • Recommendation
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Proceduralists performing surveillance colonoscopy in patients with IBD should be familiar with and adhere to surveillance guidelines.

  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Practice_point_1
  • Proceduralists performing surveillance colonoscopy in patients with IBD should be familiar with and adhere to surveillance guidelines.
  • Consensus based recommendation
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IBD surveillance requires high-quality colonoscopy:

  • performing the colonoscopy when the patient is in clinical and endoscopic remission
  • excellent bowel preparation
  • the use of high-definition colonoscopes
  • ensuring optimal and full visualisation of the mucosal surface during slow withdrawal.
  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Practice_point_2
  • IBD surveillance requires high-quality colonoscopy:
  • performing the colonoscopy when the patient is in clinical and endoscopic remission
  • excellent bowel preparation
  • the use of high-definition colonoscopes
  • ensuring optimal and full visualisation of the mucosal surface during slow withdrawal.
  • Good practice point
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Dye spray chromoendoscopy can be applied with a spray catheter or by incorporating dye in the reservoir of the water pump.

  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Practice_point_3
  • Dye spray chromoendoscopy can be applied with a spray catheter or by incorporating dye in the reservoir of the water pump.
  • Good practice point
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Either methylene blue or indigo carmine is an appropriate dye for chromoendoscopy.

  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Practice_point_4
  • Either methylene blue or indigo carmine is an appropriate dye for chromoendoscopy.
  • Good practice point
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Upon identification of invisible dysplasia on random biopsies, confirmation of diagnosis and grade is required by at least two GI pathologists. Chromoendoscopy is then recommended to determine if there is multifocal dysplasia.

  • Clinical question:What is the recommended technique for surveillance in IBD patients?#Practice_point_5
  • Upon identification of invisible dysplasia on random biopsies, confirmation of diagnosis and grade is required by at least two GI pathologists. Chromoendoscopy is then recommended to determine if there is multifocal dysplasia.
  • Good practice point

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Management of elevated dysplastic lesions in patients with IBD

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Raised lesions containing dysplasia may be treated endoscopically provided that the entire lesion is removed and there is no dysplasia in flat mucosa elsewhere in the colon.
C
  • Clinical question:What should be the protocol to manage elevated dysplasia in IBD?#Recommendation_1
  • Raised lesions containing dysplasia may be treated endoscopically provided that the entire lesion is removed and there is no dysplasia in flat mucosa elsewhere in the colon.
  • Recommendation
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If a raised dysplastic lesion cannot be completely removed, surgical intervention is strongly recommended.
D
  • Clinical question:What should be the protocol to manage elevated dysplasia in IBD?#Recommendation_2
  • If a raised dysplastic lesion cannot be completely removed, surgical intervention is strongly recommended.
  • Recommendation
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In the presence of multifocal low-grade dysplasia that cannot be removed endoscopically, at least frequent surveillance colonoscopy is required. Surgical management is an alternative based on case-by-case discussion.

Surveillance colonoscopy with chromoendoscopy within 3–12 months should be carried out after endoscopic resection of an elevated dysplastic lesion in inflammatory bowel disease.

  • Clinical question:What should be the protocol to manage elevated dysplasia in IBD?#Practice_point_1
  • In the presence of multifocal low-grade dysplasia that cannot be removed endoscopically, at least frequent surveillance colonoscopy is required. Surgical management is an alternative based on case-by-case discussion.

Surveillance colonoscopy with chromoendoscopy within 3–12 months should be carried out after endoscopic resection of an elevated dysplastic lesion in inflammatory bowel disease.

  • Consensus based recommendation
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The important objective for the endoscopist performing surveillance procedures is to identify lesions that are safely and completely resectable endoscopically. This is based on endoscopic features of the identified lesion and elsewhere in the colon.

  • Clinical question:What should be the protocol to manage elevated dysplasia in IBD?#Practice_point_2
  • The important objective for the endoscopist performing surveillance procedures is to identify lesions that are safely and completely resectable endoscopically. This is based on endoscopic features of the identified lesion and elsewhere in the colon.
  • Good practice point
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Nomenclature should reflect the SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. The term 'dysplasia associated lesion or mass (DALM)' should not be used.

  • Clinical question:What should be the protocol to manage elevated dysplasia in IBD?#Practice_point_3
  • Nomenclature should reflect the SCENIC international consensus statement on surveillance and management of dysplasia in inflammatory bowel disease. The term 'dysplasia associated lesion or mass (DALM)' should not be used.
  • Good practice point
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Consider referral to an experienced endoscopist to perform surveillance for inflammatory bowel disease using chromoendoscopy to exclude multi-focal dysplasia followed by endoscopic resection of the dysplastic lesion.

  • Clinical question:What should be the protocol to manage elevated dysplasia in IBD?#Practice_point_4
  • Consider referral to an experienced endoscopist to perform surveillance for inflammatory bowel disease using chromoendoscopy to exclude multi-focal dysplasia followed by endoscopic resection of the dysplastic lesion.
  • Good practice point
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Close colonoscopic surveillance is required following endoscopic resection of dysplasia given the risk of multifocal dysplasia and metachronous dysplasia.

  • Clinical question:What should be the protocol to manage elevated dysplasia in IBD?#Practice_point_5
  • Close colonoscopic surveillance is required following endoscopic resection of dysplasia given the risk of multifocal dysplasia and metachronous dysplasia.
  • Good practice point

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High-grade dysplasia in IBD

Evidence-based recommendationQuestion mark transparent.png Grade
Patients with endoscopically non-resectable high-grade dysplasia should undergo colectomyThe surgical removal of all or part of the colon..
C
  • Clinical question:What should be the protocol to manage high grade dysplasia in IBD?#Recommendation_1
  • Patients with endoscopically non-resectable high-grade dysplasia should undergo colectomyThe surgical removal of all or part of the colon..
  • Recommendation
Evidence-based recommendationQuestion mark transparent.png Grade
For patients with endoscopically resectable high grade dysplasia, whether polypoid or non-polypoid, continued colonoscopic surveillance after complete resection of the lesion is recommended rather than referral for colectomyThe surgical removal of all or part of the colon..
C
  • Clinical question:What should be the protocol to manage high grade dysplasia in IBD?#Recommendation_2
  • For patients with endoscopically resectable high grade dysplasia, whether polypoid or non-polypoid, continued colonoscopic surveillance after complete resection of the lesion is recommended rather than referral for colectomyThe surgical removal of all or part of the colon..
  • Recommendation
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Patients with resected high-grade dysplasia should undergo further surveillance in 3–12 months. Subsequent surveillance intervals depend on the findings of each subsequent surveillance colonoscopy.

  • Clinical question:What should be the protocol to manage high grade dysplasia in IBD?#Practice_point_1
  • Patients with resected high-grade dysplasia should undergo further surveillance in 3–12 months. Subsequent surveillance intervals depend on the findings of each subsequent surveillance colonoscopy.
  • Consensus based recommendation
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Patients with invisible high-grade dysplasia (HGD) should undergo more intensive colonoscopic surveillance than patients with visible HGD.

  • Clinical question:What should be the protocol to manage high grade dysplasia in IBD?#Practice_point_2
  • Patients with invisible high-grade dysplasia (HGD) should undergo more intensive colonoscopic surveillance than patients with visible HGD.
  • Consensus based recommendation

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Low-grade dysplasia in IBD

Evidence-based recommendationQuestion mark transparent.png Grade
Unifocal low-grade dysplasia should be followed by ongoing surveillance using high-definition white-light endoscopy and chromoendoscopy at 6 months. If 6-month surveillance colonoscopy is normal, surveillance should be repeated annually.
C
  • Clinical question:What should be the protocol to manage low grade dysplasia in IBD?#Recommendation_1
  • Unifocal low-grade dysplasia should be followed by ongoing surveillance using high-definition white-light endoscopy and chromoendoscopy at 6 months. If 6-month surveillance colonoscopy is normal, surveillance should be repeated annually.
  • Recommendation
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Low-grade dysplasia in flat mucosa should be evaluated for multifocal dysplasia by an endoscopist with expertise in inflammatory bowel disease surveillance using high-definition white-light endoscopy and/or chromoendoscopy.
C
  • Clinical question:What should be the protocol to manage low grade dysplasia in IBD?#Recommendation_2
  • Low-grade dysplasia in flat mucosa should be evaluated for multifocal dysplasia by an endoscopist with expertise in inflammatory bowel disease surveillance using high-definition white-light endoscopy and/or chromoendoscopy.
  • Recommendation
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Visible dysplasia should be resected endoscopically and then followed up with surveillance colonoscopy with high-definition white-light endoscopy and chromoendoscopy within 3–12 months.

  • Clinical question:What should be the protocol to manage low grade dysplasia in IBD?#Practice_point_1
  • Visible dysplasia should be resected endoscopically and then followed up with surveillance colonoscopy with high-definition white-light endoscopy and chromoendoscopy within 3–12 months.
  • Consensus based recommendation
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Consider shorter surveillance intervals for flat dysplasia located in the distal colon, as this is associated with higher risk of progression.

  • Clinical question:What should be the protocol to manage low grade dysplasia in IBD?#Practice_point_2
  • Consider shorter surveillance intervals for flat dysplasia located in the distal colon, as this is associated with higher risk of progression.
  • Consensus based recommendation
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When determining an individual’s appropriate surveillance frequency, the risk factors for progression of low-grade dysplasia (LGD) towards high-grade dysplasia (HGD) or colorectal cancer are: older age at diagnosis of LGD (age >55 years), male sex and inflammatory bowel disease duration of >8 years at diagnosis of LGD.

  • Clinical question:What should be the protocol to manage low grade dysplasia in IBD?#Practice_point_3
  • When determining an individual’s appropriate surveillance frequency, the risk factors for progression of low-grade dysplasia (LGD) towards high-grade dysplasia (HGD) or colorectal cancer are: older age at diagnosis of LGD (age >55 years), male sex and inflammatory bowel disease duration of >8 years at diagnosis of LGD.
  • Good practice point
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Multifocal low-grade dysplasia is associated with a sufficiently high risk of future cancer that colectomyThe surgical removal of all or part of the colon. is usually recommended. Patients who elect to avoid surgery require follow-up surveillance at 3 months, preferably with chromoendoscopy and high-definition white-light endoscopy. If 3-month surveillance colonoscopy is normal, surveillance should be repeated annually.

  • Clinical question:What should be the protocol to manage low grade dysplasia in IBD?#Practice_point_4
  • Multifocal low-grade dysplasia is associated with a sufficiently high risk of future cancer that colectomyThe surgical removal of all or part of the colon. is usually recommended. Patients who elect to avoid surgery require follow-up surveillance at 3 months, preferably with chromoendoscopy and high-definition white-light endoscopy. If 3-month surveillance colonoscopy is normal, surveillance should be repeated annually.
  • Good practice point

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Indefinite dysplasia in IBD

Evidence-based recommendationQuestion mark transparent.png Grade
Indefinite dysplasia in flat mucosa does not require surgery, but follow-up colonoscopic surveillance is recommended, preferably with chromoendoscopy, at more frequent intervals.
D
  • Clinical question:What should be the protocol to manage indefinite dysplasia in IBD?#Recommendation_1
  • Indefinite dysplasia in flat mucosa does not require surgery, but follow-up colonoscopic surveillance is recommended, preferably with chromoendoscopy, at more frequent intervals.
  • Recommendation
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Indefinite dysplasia should be reviewed by a second gastro-intestinal pathologist.

  • Clinical question:What should be the protocol to manage indefinite dysplasia in IBD?#Practice_point_1
  • Indefinite dysplasia should be reviewed by a second gastro-intestinal pathologist.
  • Consensus based recommendation
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After detecting indefinite dysplasia, inflammation (if present) should be treated and colonoscopy should be repeated.

  • Clinical question:What should be the protocol to manage indefinite dysplasia in IBD?#Practice_point_2
  • After detecting indefinite dysplasia, inflammation (if present) should be treated and colonoscopy should be repeated.
  • Consensus based recommendation
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If indefinite dysplasia is detected at random biopsy, repeat colonoscopy with enhanced imaging techniques may assist in defining an endoscopically resectable lesion, or a lesion amenable to further targeted biopsies.

  • Clinical question:What should be the protocol to manage indefinite dysplasia in IBD?#Practice_point_3
  • If indefinite dysplasia is detected at random biopsy, repeat colonoscopy with enhanced imaging techniques may assist in defining an endoscopically resectable lesion, or a lesion amenable to further targeted biopsies.
  • Good practice point
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If there are features of active inflammation, repeat colonoscopy following escalation of therapy may assist in further defining indefinite dysplasia.

  • Clinical question:What should be the protocol to manage indefinite dysplasia in IBD?#Practice_point_4
  • If there are features of active inflammation, repeat colonoscopy following escalation of therapy may assist in further defining indefinite dysplasia.
  • Good practice point

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Anxiety in colonoscopy: approaches to minimise anxiety and its adverse effects

Anxiety and colonoscopy: approaches to minimise anxiety and its adverse effects

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Providing pre-colonoscopic advice to patients by means of educational material, video and clinical explanation can assist in improving the patient experience with the procedure, and in reducing decreasing anxiety and abdominal pain during the procedure.

  • Clinical question:What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?#Practice_point_1
  • Providing pre-colonoscopic advice to patients by means of educational material, video and clinical explanation can assist in improving the patient experience with the procedure, and in reducing decreasing anxiety and abdominal pain during the procedure.
  • Good practice point
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Endoscopists should aim to control pain and discomfort during a colonoscopy procedure in order to reduce patient anxiety.

  • Clinical question:What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?#Practice_point_2
  • Endoscopists should aim to control pain and discomfort during a colonoscopy procedure in order to reduce patient anxiety.
  • Good practice point
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Physicians should be able to provide accurate and relevant information about colonoscopy for patients who are undergoing open access colonoscopy (without prior consultation with an endoscopist).

  • Clinical question:What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?#Practice_point_3
  • Physicians should be able to provide accurate and relevant information about colonoscopy for patients who are undergoing open access colonoscopy (without prior consultation with an endoscopist).
  • Good practice point
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Gastroenterology clinics are recommended to evaluate shifting towards a biopsychosocial approach to healthcare and encouraging patients to participate in decision-making in order to provide them with a greater sense of control, thus reducing anxiety.

  • Clinical question:What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?#Practice_point_4
  • Gastroenterology clinics are recommended to evaluate shifting towards a biopsychosocial approach to healthcare and encouraging patients to participate in decision-making in order to provide them with a greater sense of control, thus reducing anxiety.
  • Good practice point
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The use of neutral language around colonoscopy may be useful in order to break down the stigma and taboo surrounding the procedure and bowel health issues.

  • Clinical question:What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?#Practice_point_5
  • The use of neutral language around colonoscopy may be useful in order to break down the stigma and taboo surrounding the procedure and bowel health issues.
  • Good practice point
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Clinicians should ensure that patients understand the standard practice and convey information about the procedure as clearly as possible (e.g., whether they will be conscious, whether they will experience pain, etc.).

Note: Clinicians should also follow the Clinical Care Standards that apply to the preparation of patients for procedures, including informed consent (see Australian Commission on Safety and Quality in Health Care Colonoscopy Clinical Care Standards).

  • Clinical question:What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?#Practice_point_6
  • Clinicians should ensure that patients understand the standard practice and convey information about the procedure as clearly as possible (e.g., whether they will be conscious, whether they will experience pain, etc.).

Note: Clinicians should also follow the Clinical Care Standards that apply to the preparation of patients for procedures, including informed consent (see Australian Commission on Safety and Quality in Health Care Colonoscopy Clinical Care Standards).

  • Good practice point
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Patients who receive the amount of information consistent with their preferences (information seekers versus avoiders) report lower anxiety and more satisfaction with the intervention, and experience less pain and shorter time in recovery. Colonoscopists can assess patients’ desire for information by asking the patient directly, for example “how much information would you like about XX (this procedure)? Are you someone who prefers to get a lot of information or just the basics?”

  • Clinical question:What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?#Practice_point_7
  • Patients who receive the amount of information consistent with their preferences (information seekers versus avoiders) report lower anxiety and more satisfaction with the intervention, and experience less pain and shorter time in recovery. Colonoscopists can assess patients’ desire for information by asking the patient directly, for example “how much information would you like about XX (this procedure)? Are you someone who prefers to get a lot of information or just the basics?”
  • Good practice point
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Music provided to patients prior to and during colonoscopy may reduce their discomfort.

  • Clinical question:What approaches can be incorporated successfully into an efficient surveillance colonoscopy program to minimise anxiety and pain fall out?#Practice_point_8
  • Music provided to patients prior to and during colonoscopy may reduce their discomfort.
  • Good practice point

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Socio-economic factors

Impact of socioeconomic factors on surveillance colonoscopy

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Clinicians should advise patients that modification of lifestyle factors can reduce their risk of polyp recurrence and colorectal cancer.

  • Clinical question:What is the impact and nature of SES?#Practice_point_1
  • Clinicians should advise patients that modification of lifestyle factors can reduce their risk of polyp recurrence and colorectal cancer.
  • Good practice point
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Information and instructions for bowel preparation and colonoscopy need to be tailored to meet the needs of most Australians who have inadequate or poor health literacy.

  • Clinical question:What is the impact and nature of SES?#Practice_point_2
  • Information and instructions for bowel preparation and colonoscopy need to be tailored to meet the needs of most Australians who have inadequate or poor health literacy.
  • Good practice point

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Impact made by socioeconomic factors in treatment groups undergoing surveillance colonoscopy

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After curative resection for colorectal cancer, survival outcomes in disadvantaged patients may be improved by clinicians and health systems by addressing the barriers and access to optimal clinical care.

  • Clinical question:Does lower SES have to result in poorer outcome for curative resection for colonic cancer?#Practice_point_1
  • After curative resection for colorectal cancer, survival outcomes in disadvantaged patients may be improved by clinicians and health systems by addressing the barriers and access to optimal clinical care.
  • Good practice point

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Table 13 Colonoscopy findings and surveillance intervals: reference guide to Tables 14–16

1st colonoscopy findings 2nd colonoscopy findings 3rd colonoscopy

surveillance interval

Conventional adenomas only Normal colonoscopy or

conventional adenomas only

Table 14
Clinically significant serrated polyps

without synchronous

conventional adenomas

Table 15a
Clinically significant serrated polyps

with synchronous

conventional adenomas

Table 15b
Clinically significant serrated

polyps with or without

synchronous conventional

adenomas

Normal colonoscopy or

conventional adenomas only

Table 16
Clinically significant serrated polyps

without synchronous

conventional adenomas

Table 15a
Clinically significant serrated polyps

with synchronous

conventional adenomas

Table 15b
Table 17. Surveillance recommendations for individuals age ≥75 years
Age (years) Charlson scorea
≤4 >4
75–80 Surveillance colonoscopy to be considered b,c Surveillance colonoscopy not recommended
>80 Surveillance colonoscopy not recommended
aCharlson for colonoscopy benefit can be simplified as per Table 18; bcolonoscopy should be considered an option dependent on a clear conversation about the low risk of significant colorectal pathology, taking the patient’s wishes into consideration; cconsent for colonoscopy should include age appropriate statistics on risk.

Table 18. Charlson score for colonoscopy benefit
Age Medical conditions
75–79 years

(3 points for age)

May have one of these conditions only (1 point each):

Mild liver disease

Diabetes without end-organ damage

Cerebrovascular disease

Ulcer disease

Connective tissue disease

Chronic pulmonary disease

Dementia

Peripheral vascular disease

Congestive heart failure

Myocardial infarction

May not have any of these medical conditions

(≥1 point each):

Moderate/severe liver disease

Diabetes with end-organ damage

Hemiplegia

Moderate or severe renal disease

AIDS

MetastaticCancer that has spread from the primary site of origin (where it started) into different area(s) of the body. or non-metastaticCancer that has spread from the primary site of origin (where it started) into different area(s) of the body. solid organ or haematopoietic malignancy

80 years

(4 points for age)

May not have any of the above medical conditions

NHMRC approved recommendation types and definitions

This guideline includes evidence-based recommendations (EBR), consensus-based recommendations (CBR) and practice points (PP) as defined in the table below. Recommendations and practice points were developed by working party members and sub-committee members.

Each EBR was assigned a grade by the expert working group, taking into account the volume, consistency, generalisability, applicability and clinical impact of the body of evidence according to NHMRC Level and Grades for Recommendations for Guidelines Developers.[1]
Type of recommendation
Definition
Evidence-based recommendation
A recommendation formulated after a systematic review of the evidence, indicating supporting references
Consensus-based recommendation
A recommendation formulated in the absence of quality evidence, after a systematic review of the evidence was conducted and failed to identify admissible evidence on the clinical question
Practice point
A 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
Source: National Health and Medical Research Council. Procedures and requirements for meeting the NHMRC standard for clinical practice guidelines. Melbourne: National Health and Medical Research Council, 2011


Levels of evidence and grades for recommendations

These guidelines are intended for use by all practitioners and health workers who require information about surveillance colonoscopy - in adenoma follow-up, following curative resection of colorectal cancer, and for cancer surveillance in inflammatory bowel disease. They are specifically revising the colonoscopic surveillance sections of the Clinical Practice Guidelines for the prevention, early detection and management of colorectal cancer 2005 chapters 8, 9, 17, and introduce a new chapter on cancer surveillance in inflammatory bowel disease. They also cover psychosocial care (chapter 18 in the 2005 Guidelines), socio economic factors and cost effectiveness (chapters 23 and 22 in the 2005 Guidelines). The guidelines have been produced by a process of systematic literature review; critical appraisal and consultation encompassing all interested parties in Australia (see Appendices).

The following table provides a list of the evidence-based recommendations detailed in the text of each chapter. The table below provides details on the highest level of evidence identified to support each recommendation (I-IV). The Summary of Recommendations table includes the grade for each recommendation (A-D). The key references that underpin the recommendation are provided in the last column. Individual levels of evidence can be found in the Evidence Summaries for each recommendation in each chapter.

Each recommendation was assigned a grade by the expert working group taking into account the volume, consistency, generalisability, applicability and clinical impact of the body of evidence supporting each recommendation.

When no Level I or II evidence was available and in some areas, in particular where there was insufficient evidence in the literature to make a specific evidence-based recommendation, but also strong and unanimous expert opinion amongst the working group members about both the advisability of making a clinically relevant statement and its content, recommended best practice points were generated. Thus, the practice points relate to the evidence in each chapter, but are more expert opinion-based than evidence-based. These can be identified throughout the guidelines with the following: Practice point (PP).

Grade of Recommendation Description
A Body of evidence can be trusted to guide practice
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendations but care should be taken in its application.
D Body of evidence is weak and recommendation must be applied with caution
Source: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009. (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)


Levels of Evidence

Designations of levels of evidence for intervention research questions (NHMRC, 2009)

Level Intervention
I A systematic review of level II studies
II A randomised controlled trial
III-1 A pseudo-randomised controlled trial (ie alternate allocation or some other method)
III-2 A comparative study with concurrent controls:

• non-randomised, experimental trial

• cohort study

• case-control study

• interrupted time series with a control group

III-3 A comparative study without concurrent controls:

• historical control study

• two or more single-arm studies

• interrupted time series without a parallel control group

IV Case series with either post-test or pre-test/post-test outcomes
Source: National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for developers of guidelines. Canberra: NHMRC; 2009. (https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf)


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References

  1. National Health and Medical Research Council. NHMRC levels of evidence and grades for recommendations for guideline developers. Canberra: National Health and Medical Research Council; 2009 Available from: https://www.nhmrc.gov.au/_files_nhmrc/file/guidelines/developers/nhmrc_levels_grades_evidence_120423.pdf.

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