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DOI: 10.1055/a-1964-7965
Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy Cascade Guideline
Colorectal cancer (CRC) is a major contributor to morbidity and cancer death globally with an increasing incidence also in low- and middle-income countries [1] [2]. However, CRC is preventable if precursor lesions are detected and treated [3] [4]. Throughout the world, national screening programs have been established that are aimed at the endoscopic detection and removal of polyps, as well as the diagnosis of cancers at an early stage [5] [6]. In addition to screening, diagnostic colonoscopy is crucial for investigation of symptoms. However, in resource-limited settings, screening programs might be absent, and the availability of colonoscopy might be limited by costs, travel distance, and lack of trained endoscopists. Furthermore, to achieve the full benefit of colonoscopy, detected lesions should be optimally removed to prevent recurrence and subsequent development of CRC, while avoiding adverse events (AEs) such as bleeding and perforation. This can be ensured with suitable training and mentoring programs and accompanied by guidelines developed with a generally high level of evidence [7] [8] [9] [10]. Nevertheless, some recommendations within these guidelines include utilization of accessories that are costly and additionally require appropriate training to use safely. Hence, in a resource-limited setting, adherence to current guidelines for colonoscopy and polypectomy may be challenging.
In 2018, the European Society of Gastrointestinal Endoscopy (ESGE) and the World Endoscopy Organization (WEO) established an international working group with the aim of creating a set of guidelines amenable also in resource-sensitive communities [11]. Consequently, a cascade methodology was introduced developing adapted recommendations for different levels of available resources. The cascade methodology has already been applied to guidelines for non-variceal upper gastrointestinal bleeding, esophageal stenting, endoscopic treatment of variceal upper gastrointestinal bleeding, as well as a guideline in conjunction with the World Gastroenterology Organization for resuming endoscopy after the COVID pandemic [12] [13] [14] [15]. Based on the ESGE guideline by Ferlitsch et al, the aim of this cascade guideline is to propose recommendations for colorectal polypectomy and endoscopic mucosal resection (EMR) in resource-limited settings [7].
Methods
The cascade methodology has previously been described in detail in the ESGE position paper [11]. Briefly, five colleagues from Ethiopia, Ghana, and Nigeria reviewed the recommendations from the ESGE guidelines and commented on resource-limitations in relation to each statement. Guided by this review, five members (AE, PB, CS, LA, GA) of the International Affairs Working Group (IAWG) independently categorized the statements as either resource-sensitive or not. The statements that more than 50 % of the IAWG members agreed were resource-sensitive were then revised according to the cascade methodology into recommendations for four predefined resource levels ([Table 1]) after extensive discussion and consultation between IAWG and the external panel of African colleagues. The modified statements were then subject to a Delphi process with local doctors invited by a dedicated mailing list representative of gastroenterology specialists in different areas of Africa, as well as members of the GI-Echo WhatsApp group. Finally, the statements were subject to a Delphi survey in which African doctors were invited to participate [16]. If an agreement of 75 % or higher was reached, the recommendations were accepted. If not, the recommendations were modified according to the comments by the survey participants.
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Results
Statement selection
In the selection process, 36 of the 57 statements from the original guideline were selected. For each of the 36 statements, three cascade recommendations were suggested according to basic, limited, and enhanced resource settings. The maximal setting was equal to the statements in the original guideline and was not included in the process.
The Delphi process
The 108 adapted cascade statements were subsequently included in a Delphi process. Thirty-nine participants contributed to the Delphi process. Geographically, the areas most represented were Northern Africa (38.4 %) and Eastern Africa (33.3 %), while no participants from Southern Africa participated ([Table 2]). The participants were asked to indicate the socioeconomic status of their institution ([Table 2]), which was mainly assessed as low (42.6 %) or middle (41.0 %). Of the 36 adapted statements, 32 reached agreements in the Delphi process while four statements that reached between 68 % and 71 % agreement were subject to minor modifications according to comments from the Delphi participants. The four revised statements were related to endoscopic mucosal resection (EMR), tattooing, and use of CO2, which required adjustment of the resource level for the specific cascade statements.
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Cascade adaptation
Adequate training of personnel in each technique is imperative and independent of the resources available to carry out the procedures. The selected resource-sensitive statements and the accepted cascade modifications are presented in [Table 3]. The modifications are focused mainly on three areas.
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Indications
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Polypectomy techniques
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EMR
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Indications
For the majority of the previous cascade guidelines, the focus was on emergency situations, such as endoscopic treatment of variceal upper gastrointestinal bleeding [14]. Colorectal polypectomy and EMR, however, are mostly carried out in an elective setting. At a basic resource level, referral to a tertiary care center might be preferable if there is a lack of trained personal or limited access to accessories needed to perform a safe and adequate procedure. The risk of advanced histological features is extremely low for diminutive polyps (< 5 mm) [17]. Therefore, diminutive polyps could be removed and discarded, or even not removed, in a setting with a basic resource level. It is not recommended to attempt treatment of more advanced lesions without access to injection therapy or mechanical hemostasis with clips.
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Polypectomy techniques
In many centers, CO2 is not available; however, air insufflation might be an acceptable alternative. In general, cold snare polypectomy is widely available and recommend for polyps up to 10 mm in size. With larger polyps for which submucosal injection is recommended, normal saline might be used. However, with polyps larger than 20 mm for which more extensive resection is required and the risk of AEs is higher, in settings with basic and limited resource levels, referral is recommended to centers that have clips and injectors available.
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EMR
Access to EMR is limited at all three resource levels, which is reflected in a recommendation to carry out surgical resections in cases in which referral to an advanced endoscopy center is impossible and in cases in which there is a high suspicion of submucosal invasion. In cases with a need for tattooing either before surgery or for a follow-up colonoscopy after endoscopic removal of a lesion, sterile carbon particle or Indian Ink is strongly recommended. If these are not available, we recommend carefully describing the location of the lesion.
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Conclusions
In conclusion, the need for safe and adequate polypectomy and EMR for colorectal lesions is increasing even in resource-limited settings. This cascade guideline proposes a set of recommendations for colorectal polypectomy and EMR applicable in resource-sensitive regions and offers recommendations for minimal requirements at each resource level in order to carry out procedures safely.
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Competing interests
The authors declare that they have no conflict of interest.
Acknowledgments
Participants of the Delphi panel: Khaled Hallouly, Sidahmed Allal, Olusegun Alatise, Dorra Trad, Nanelin Alice Guingane, Sofia Oubaha, Hamdene Ziaya, Mouna Salihoun, Aissat Yakhlef, Suliman Hussein Suliman, Dafr-allah Benajah, Bendjaballah Azzedine, Aboudou Raïmi, Kpossou, Gideon Anigbo, Uchenna Ijoma, Mohamed Borahma, Babatunde Duduyemi, Mohamed Tayeb Bounnah, Chukwuemeka Osuagwu, Hailemichael Desalegn Mekonnen, Hanna Aberra, Chinwe Onyia, Getachew Reta, Berhane Meshesha, Henok Fisseha, Ayele Hailu, Berecha Alemu, Mersha Mamo, Rahel Admassu, Eskinder Tesfaye Negussie, Ganiyat Oyeleke, Paulos Shume, Yonas Gedamu, Ahmed Hussen, Levi Ayogu, Mbarek Azouaoui, Meriam Sabbah, Lamine Hamzaoui, Amal Khsiba.
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References
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- 2 Arnold M, Sierra MS, Laversanne M. et al. Global patterns and trends in colorectal cancer incidence and mortality. Gut 2017; 66: 683-691
- 3 Zauber AG, Winawer SJ, O'Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
- 4 Winawer SJ, Zauber AG, Ho MN. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
- 5 Shaukat A, Kahi CJ, Burke CA. et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol 2021; 116: 458-479
- 6 Cardoso R, Guo F, Heisser T. et al. Proportion and stage distribution of screen-detected and non-screen-detected colorectal cancer in nine European countries: an international, population-based study. Lancet Gastroenterol Hepatol 2022; 8: 711-712
- 7 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
- 8 Walsh CM, Scaffidi MA, Khan R. et al. Non-technical skills curriculum incorporating simulation-based training improves performance in colonoscopy among novice endoscopists: Randomized controlled trial. Dig Endosc 2020; 32: 940-948
- 9 Siau K, Crossley J, Dunckley P. et al. Colonoscopy direct observation of procedural skills assessment tool for evaluating competency development during training. Am J Gastroenterol 2020; 115: 234-243
- 10 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions-recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158: 1095-1129
- 11 Hassan C, Aabakken L, Ebigbo A. et al. Partnership with African Countries: European Society of Gastrointestinal Endoscopy (ESGE) - Position Statement. Endosc Int Open 2018; 6: E1247-E1255
- 12 Karstensen JG, Ebigbo A, Aabakken L. et al. Nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2018; 6: E1256-E1263
- 13 Ebigbo A, Karstensen JG, Aabakken L. et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2019; 7: E833-E836
- 14 Karstensen JG, Ebigbo A, Bhat P. et al. Endoscopic treatment of variceal upper gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2020; 8: E990-E997
- 15 Antonelli G, Karsensten JG, Bhat P. et al. Resuming endoscopy during COVID-19 pandemic: ESGE, WEO and WGO Joint Cascade Guideline for Resource Limited Settings. Endosc Int Open 2021; 9: E543-E551
- 16 Milholland AV, Wheeler SG, Heieck JJ. Medical assessment by a Delphi group opinion technic. N Engl J Med 1973; 288: 1272-1275
- 17 Gupta N, Bansal A, Rao D. et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc 2012; 75: 1022-1030
Corresponding author
Publication History
Received: 19 October 2022
Accepted: 19 October 2022
Article published online:
15 November 2022
© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Sung H, Ferlay J, Siegel RL. et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin 2021; 71: 209-249
- 2 Arnold M, Sierra MS, Laversanne M. et al. Global patterns and trends in colorectal cancer incidence and mortality. Gut 2017; 66: 683-691
- 3 Zauber AG, Winawer SJ, O'Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
- 4 Winawer SJ, Zauber AG, Ho MN. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993; 329: 1977-1981
- 5 Shaukat A, Kahi CJ, Burke CA. et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol 2021; 116: 458-479
- 6 Cardoso R, Guo F, Heisser T. et al. Proportion and stage distribution of screen-detected and non-screen-detected colorectal cancer in nine European countries: an international, population-based study. Lancet Gastroenterol Hepatol 2022; 8: 711-712
- 7 Ferlitsch M, Moss A, Hassan C. et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2017; 49: 270-297
- 8 Walsh CM, Scaffidi MA, Khan R. et al. Non-technical skills curriculum incorporating simulation-based training improves performance in colonoscopy among novice endoscopists: Randomized controlled trial. Dig Endosc 2020; 32: 940-948
- 9 Siau K, Crossley J, Dunckley P. et al. Colonoscopy direct observation of procedural skills assessment tool for evaluating competency development during training. Am J Gastroenterol 2020; 115: 234-243
- 10 Kaltenbach T, Anderson JC, Burke CA. et al. Endoscopic removal of colorectal lesions-recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158: 1095-1129
- 11 Hassan C, Aabakken L, Ebigbo A. et al. Partnership with African Countries: European Society of Gastrointestinal Endoscopy (ESGE) - Position Statement. Endosc Int Open 2018; 6: E1247-E1255
- 12 Karstensen JG, Ebigbo A, Aabakken L. et al. Nonvariceal upper gastrointestinal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2018; 6: E1256-E1263
- 13 Ebigbo A, Karstensen JG, Aabakken L. et al. Esophageal stenting for benign and malignant disease: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2019; 7: E833-E836
- 14 Karstensen JG, Ebigbo A, Bhat P. et al. Endoscopic treatment of variceal upper gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open 2020; 8: E990-E997
- 15 Antonelli G, Karsensten JG, Bhat P. et al. Resuming endoscopy during COVID-19 pandemic: ESGE, WEO and WGO Joint Cascade Guideline for Resource Limited Settings. Endosc Int Open 2021; 9: E543-E551
- 16 Milholland AV, Wheeler SG, Heieck JJ. Medical assessment by a Delphi group opinion technic. N Engl J Med 1973; 288: 1272-1275
- 17 Gupta N, Bansal A, Rao D. et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointest Endosc 2012; 75: 1022-1030