12. Appropriateness of Colonoscopy: Surveillance After Polypectomy [1]

Introduction

A colorectal polyp is a circumscribed mass of tissue that projects above the surface of the intestinal mucosa, which may be classified as either pedunculated or sessile depending on whether or not it contains a discrete stalk [1] , and according to size and type (neoplastic-adenomas; non-neoplastic, e.g. inflammatory, hyperplastic). Adenomas are the most significant type of colorectal polyps because of their alleged role in the natural history of colorectal cancer development. Indeed, several studies support the concept that colorectal neoplasia develops most often through a continuous process from normal mucosa to benign adenoma and then to carcinoma [2] [3] [4] . In addition, the importance of adenomatous polyps is emphasized by their frequent occurrence. In several cross-sectional and autopsy studies involving various populations (community- and hospital-based, referral for colonoscopy), the prevalence of adenomas ranged from 25 to 35 %, and the prevalence of hyperplastic polyps from 10 to 35 % [3] [5] [6] [7] [8] [9] [10] [11] [12] . The objective of using colonoscopy for post-polypectomy surveillance is to reduce the risk of development and death from colorectal cancer.

In November 1998, a multidisciplinary European expert panel convened in Lausanne, Switzerland, to discuss and develop criteria for the appropriate use of gastrointestinal endoscopy, a widely-used procedure, regarded as highly accurate and safe. The RAND appropriateness method was chosen for this purpose, because it allows the development of appropriateness criteria based on published evidence and supplemented by explicit expert opinion. A detailed description of the RAND appropriateness method, including the literature search process [13], and of the whole process, as well as the global results of the panel [14], are published as separate articles in this issue of the Journal. The literature review was based on a systematic search of Medline, Embase and the Cochrane Library conducted up to the end of 1997 and completed with some key articles published in 1998. Updating and revision of the literature review is currently ongoing.

This article contains three parts; 1. the review of the literature that was used by the panelists to support their ratings of appropriateness of use of colonoscopy for surveillance after endoscopic polypectomy; 2. an overview of the main panel results; 3. a summary of the published evidence and of the panel based appropriateness criteria.

1 The European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE, Lausanne, Switzerland)

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1 The European Panel of Appropriateness of Gastrointestinal Endoscopy (EPAGE, Lausanne, Switzerland)