Der angemessene Einsatz der Koloskopie in Europa (EPAGE II)

Zusammenfassung

Hintergrund und Studienziele: Ziel ist eine Zusammenfassung der veröffentlichten Literatur zum Thema angemessener Einsatz von Kolosko­pien in der Nachsorge nach Polypektomie oder kura­tiver Resektion von kolorektalem Karzinom (KRK). Es folgt ein Bericht über die erstellten ­Kriterien zum Thema angemesse­ner Einsatz der gastrointestinalen Endoskopie (EPAGE II) durch ein Exper­tengremium im Rahmen der euro­päischen Zusammenkunft 2008. Methoden: Es wurde eine systemische Suche nach Richtlinien, Reviews und primären Studien durchgeführt, die sich auf die Evaluation und das Management von Nachsorgeprogrammen mittels Koloskopie nach Polypektomie und nach Resektion von KRK konzentrieren. Die RAND / UCLA-Methode wurde angewendet, um Kriterien für den angemessenen Einsatz der Koloskopie unter diesen Konditionen zu erstellen. Ergebnis: Die meisten KRK entstehen aus adenomatösen Polypen. Die Merkmale der entfernten Polypen, besonders die Unterscheidung zwischen Adenomen mit niedrigem Risiko (Anzahl 1 bis 2, kleiner 1 cm, tubulär, keine höhergradige Dysplasie) und mit hohem Risiko (größer 1 cm, mehr als 3, höhergradige Dysplasien oder villöse Struktur) hat einen großen Einfluss auf die Wahrscheinlichkeit von Adenom Rezidiven. Die meisten Richtlinien empfehlen eine Nachsorge-Koloskopie in 3 Jahren bei Adenomen mit höherem Risiko und eine Koloskopie in 5 Jahren bei Adenomen mit niedrigem Risiko. Trotz fehlender Evidenz, dass es einen Überlebensvorteil gibt, eine Nachsorge-Koloskopie nach Polypektomie oder nach kura­tiver Resektion eines KRK zu unterstützen oder abzulehnen, wird in den meisten Richtlinien eine Nachsorge-Koloskopie empfohlen. Jedoch variieren die zeitlichen Abstände für die erste Nachsorge-Koloskopie. Das Expertengremium stimmte in 56 % der klinischen Indikationen für eine angemessene Nachsorge-Koloskopie überein. Der richtige Zeitpunkt für eine Koloskopie nach einer Resektion eines KRK wurde mit ­einem Jahr nach der Operation festgelegt. Zusammenfassung: Die Koloskopie wird als Diagnostik der ersten Wahl bei der Nachsorge nach Polypektomie in allen veröffentlichten Richtlinien und in den EPAGE-II-Kriterien empfohlen. Trotz unzureichender Information aus veröffentlichten Studien wird die Koloskopie zur Nachsorge nach der Resektion eines KRK ebenfalls von den meisten Richtlinien und in den EPAGE-II-Kriterien empfohlen.

Abstract

Background and study aims: To summarize the published literature on assessment of appro­priateness of colonoscopy for surveillance after ­polypectomy and after curative-intent resection of colorectal cancer (CRC), and report appropri­ate­ness criteria developed by an expert panel, the 2008 European Panel on the Appropriateness of Gastrointestinal Endoscopy, EPAGE II. Methods: A systematic search of guidelines, sys­tematic reviews and primary studies regarding the evaluation and management of surveillance colonoscopy after polypectomy and after resec­tion of CRC was performed. The RAND / UCLA ­Appropriateness Method was applied to develop appropriateness criteria for colonoscopy for these conditions. Results: Most CRCs arise from adenomatous ­polyps. The characteristics of removed polyps, ­especially the distinction between low-risk adenomas (1 or 2, small [< 1 cm], tubular, no high-grade dysplasia) vs. high-risk adenomas (large [≥ 1 cm], multiple [< 3], high-grade dysplasia or villous features), have an impact on advanced adenoma recurrence. Most guidelines recommend a 3-year follow-up colonoscopy for high-risk adenomas and a 5-year colonoscopy for low-risk adenomas. Despite the lack of evidence to support or refute any survival benefit for follow-up colonoscopy after curative-intent CRC resec­tion, surveillance colonoscopy is recommended by most guidelines. The timing of the first surveillance colonoscopy differs. The expert panel con­sidered that 56 % of the clinical indications for colo­noscopy for surveillance after polypectomy were appropriate. For surveillance after CRC resec­tion, it considered colonoscopy appropriate 1 year after resection. Conclusions: Colonoscopy is recommended as a first-choice procedure for surveillance after polyp­ectomy by all published guidelines and by the EPAGE II criteria. Despite the limitations of the published stud­ies, colonoscopy is also recommended by most of the guidelines and by EPAGE II criteria for surveillance after curative-intent CRC resection.

Schlüsselwörter

Koloskopie - kolorektales Karzinom - Nachsorge - Polypektomie

Key words

colonoscopy - surveillance - polypectomy - colorectal cancer - appropriateness

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