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Introduction In March 2021, J Gastroenterol updated and released the Japanese Society of Gastroenterology (JSGE) guidelines for the management of colorectal polyps (2020 revision).
The JSGE expert team created 18 clinical questions (CQs) on the diagnosis and treatment of colorectal polyps, and put forward corresponding guidance.
This article mainly describes 13 CQs related to the treatment of colorectal polyps, as described below.
CQ1: In terms of the size and shape of the adenoma, what are the indications for endoscopic resection? (1) For lesions ≥ 6 mm, endoscopic resection should be performed (Strength of recommendation: strong; 100% agree; level of evidence: B).
(2) For micropolypoid adenomas ≤5 mm, endoscopic resection should also be performed in principle, but colonoscopy follow-up observation is also feasible (Strength of recommendation: weak; 82% agree; Level of evidence: D).
(3) For flat and sunken tumor lesions, endoscopic resection should be performed even if ≤5 mm (Strength of recommendation: strong; 100% agree; level of evidence: D).
CQ2: How to manage hyperplastic polyps (HP)? For HP ≤5 mm detected in the rectum and sigmoid region, follow-up is recommended (Strength of recommendation: weak; 100% agree; Level of evidence: B).
CQ3: What are the indications for cold snare polypectomy (CSP)? (1) CSP is suitable for sessile benign adenomas <10 mm (Strength of recommendation: weak; 100% agree; Level of evidence: B).
(2) It is recommended that CSP be used for small lesions ≤5 mm, and can also be used for lesions of 6-9 mm (Strength of recommendation: strong; 100% agree; level of evidence: B).
(3) For "flat and sunken" lesions and lesions suspected of being cancerous by colonoscopy, CSP should be avoided even if ≤5 mm (Strength of recommendation: weak; 100% agree; Level of evidence: B).
CQ4: How to diagnose and treat colorectal serrated lesions? Colorectal serrated lesions include sessile serrated adenoma/polyp (SSA/P), traditional serrated adenoma (TSA) and HP.
The observation of the location, shape and surface characteristics of the lesion (including the performance under magnifying endoscopy) is of great significance for endoscopic diagnosis.
SSA/P and TSA may develop into cancer, so it is recommended to treat them (Strength of recommendation: weak; 100% agree; Level of evidence: C).
CQ5: What treatment is suitable for laterally developing tumors (LST)? For larger LST, you should choose endoscopic submucosal dissection (ESD) or split endoscopic mucosal resection (EMR) according to the subtype of LST (through the appropriate use of magnifying endoscopy and ultrasound endoscopy) (recommended strength) : Strong; 100% agree; Evidence level: C).
CQ6: Which colorectal tumors are feasible for fragmented EMR? Fractional EMR is feasible for adenomas or Tis carcinomas with a clear preoperative diagnosis.
However, the local recurrence rate of fragment resection is high, so it is recommended to use it with caution (Strength of recommendation: weak; 100% agree; Level of evidence: C).
CQ7: How should colonoscopy be performed after endoscopic resection of colorectal adenoma? Colonoscopy should be followed up within 3 years after polypectomy (Strength of recommendation: weak; 100% agree; Level of evidence: B).
CQ8: After endoscopic resection of T1 (SM) colorectal cancer, how should we monitor it? Local recurrence and lymph node metastasis and distant metastasis must be closely monitored.
After endoscopic resection, careful follow-up should be performed for at least 3 years (Strength of recommendation: weak; 100% agree; Level of evidence: C).
CQ9: What is the diagnosis and management method of colorectal neuroendocrine tumors? When a submucosal tumor (SMT) is detected in the rectum (especially the lower rectum), it is most likely a neuroendocrine tumor (NET).
It is strongly recommended to use the dye spray method to determine that the tumor surface is covered with normal mucosa, and to determine whether endoscopic or surgical resection is necessary according to the size and surface characteristics of the tumor (Strength of recommendation: strong; 100% agree; level of evidence: B).
CQ10: How to manage non-tumor polyps? (1) It is recommended to divide non-tumor colorectal polyps into three categories: hamartoma, inflammatory, and proliferative (Strength of recommendation: strong; 100% agree; level of evidence: D).
(2) Although most non-tumor colorectal polyps are not suitable for endoscopic resection, if they have bleeding, cause intussusception or suspected cancer, it is recommended to remove symptomatic polyps (Strength of recommendation: strong; 100% agree; evidence) Grade: D).
CQ11: Is there a difference between the management of familial adenomatous polyposis (FAP) and mild familial adenomatous polyposis (AFAP)? (1) For both FAP and AFAP, colonoscopy monitoring is recommended from adolescence (Strength of recommendation: strong; 100% agree; level of evidence: C).
(2) Preventive colorectal resection is recommended for AFAP, because AFAP can complicate colorectal cancer (Strength of recommendation: strong; 100% agree; level of evidence: C).
CQ12: What are the candidate groups for ulcerative colitis and appropriate cancer surveillance methods? (1) For patients with extensive left colitis 8-10 years after the onset of disease, it is recommended to perform colonoscopy for the first time (Strength of recommendation: strong; 100% agree; level of evidence: B).
(2) It is recommended that patients whose remission is not confirmed by endoscopy should be monitored earlier (Strength of recommendation: weak; 100% agree; Level of evidence: B).
(3) It is recommended to use stained endoscopy and/or narrow band imaging (NBI) combined with targeted biopsy in total colonoscopy, and attention should be paid to raised lesions and any changes in mucosal structure or color that are different from the surrounding area (recommended strength: Strong; 100% agree; Evidence level: B).
(4) A step-by-step biopsy is recommended for each segment of the colon (Strength of recommendation: weak; 100% agree; Level of evidence: B).
CQ13: If dysplasia or cancer is detected in ulcerative colitis, should all the lesions be surgically removed? Is low-grade dysplasia (LGD) an indication for surgery? (1) If LGD is detected in the flat mucosa, it is recommended to consult several experienced pathologists (Strength of recommendation: weak; 100% agree; Level of evidence: C).
(2) If LGD is detected in elevated lesions and the possibility of sporadic adenoma is high, endoscopic resection and detailed pathological examination are recommended (Strength of recommendation: strong; 100% agree; level of evidence: C).
(3) However, if cancer or high-grade dysplasia is found, and it is determined that it is related to colitis, total rectocolectomy is recommended (Strength of recommendation: strong; 100% agree; level of evidence: C).
Literature index: Tanaka S, Saitoh Y, Matsuda T, et al.
Evidence-based clinical practice guidelines for management of colorectal polyps[J].
J Gastroenterol.
2021 Apr;56(4):323-335.
Contribution email: tougao@ medlive.
cn
The JSGE expert team created 18 clinical questions (CQs) on the diagnosis and treatment of colorectal polyps, and put forward corresponding guidance.
This article mainly describes 13 CQs related to the treatment of colorectal polyps, as described below.
CQ1: In terms of the size and shape of the adenoma, what are the indications for endoscopic resection? (1) For lesions ≥ 6 mm, endoscopic resection should be performed (Strength of recommendation: strong; 100% agree; level of evidence: B).
(2) For micropolypoid adenomas ≤5 mm, endoscopic resection should also be performed in principle, but colonoscopy follow-up observation is also feasible (Strength of recommendation: weak; 82% agree; Level of evidence: D).
(3) For flat and sunken tumor lesions, endoscopic resection should be performed even if ≤5 mm (Strength of recommendation: strong; 100% agree; level of evidence: D).
CQ2: How to manage hyperplastic polyps (HP)? For HP ≤5 mm detected in the rectum and sigmoid region, follow-up is recommended (Strength of recommendation: weak; 100% agree; Level of evidence: B).
CQ3: What are the indications for cold snare polypectomy (CSP)? (1) CSP is suitable for sessile benign adenomas <10 mm (Strength of recommendation: weak; 100% agree; Level of evidence: B).
(2) It is recommended that CSP be used for small lesions ≤5 mm, and can also be used for lesions of 6-9 mm (Strength of recommendation: strong; 100% agree; level of evidence: B).
(3) For "flat and sunken" lesions and lesions suspected of being cancerous by colonoscopy, CSP should be avoided even if ≤5 mm (Strength of recommendation: weak; 100% agree; Level of evidence: B).
CQ4: How to diagnose and treat colorectal serrated lesions? Colorectal serrated lesions include sessile serrated adenoma/polyp (SSA/P), traditional serrated adenoma (TSA) and HP.
The observation of the location, shape and surface characteristics of the lesion (including the performance under magnifying endoscopy) is of great significance for endoscopic diagnosis.
SSA/P and TSA may develop into cancer, so it is recommended to treat them (Strength of recommendation: weak; 100% agree; Level of evidence: C).
CQ5: What treatment is suitable for laterally developing tumors (LST)? For larger LST, you should choose endoscopic submucosal dissection (ESD) or split endoscopic mucosal resection (EMR) according to the subtype of LST (through the appropriate use of magnifying endoscopy and ultrasound endoscopy) (recommended strength) : Strong; 100% agree; Evidence level: C).
CQ6: Which colorectal tumors are feasible for fragmented EMR? Fractional EMR is feasible for adenomas or Tis carcinomas with a clear preoperative diagnosis.
However, the local recurrence rate of fragment resection is high, so it is recommended to use it with caution (Strength of recommendation: weak; 100% agree; Level of evidence: C).
CQ7: How should colonoscopy be performed after endoscopic resection of colorectal adenoma? Colonoscopy should be followed up within 3 years after polypectomy (Strength of recommendation: weak; 100% agree; Level of evidence: B).
CQ8: After endoscopic resection of T1 (SM) colorectal cancer, how should we monitor it? Local recurrence and lymph node metastasis and distant metastasis must be closely monitored.
After endoscopic resection, careful follow-up should be performed for at least 3 years (Strength of recommendation: weak; 100% agree; Level of evidence: C).
CQ9: What is the diagnosis and management method of colorectal neuroendocrine tumors? When a submucosal tumor (SMT) is detected in the rectum (especially the lower rectum), it is most likely a neuroendocrine tumor (NET).
It is strongly recommended to use the dye spray method to determine that the tumor surface is covered with normal mucosa, and to determine whether endoscopic or surgical resection is necessary according to the size and surface characteristics of the tumor (Strength of recommendation: strong; 100% agree; level of evidence: B).
CQ10: How to manage non-tumor polyps? (1) It is recommended to divide non-tumor colorectal polyps into three categories: hamartoma, inflammatory, and proliferative (Strength of recommendation: strong; 100% agree; level of evidence: D).
(2) Although most non-tumor colorectal polyps are not suitable for endoscopic resection, if they have bleeding, cause intussusception or suspected cancer, it is recommended to remove symptomatic polyps (Strength of recommendation: strong; 100% agree; evidence) Grade: D).
CQ11: Is there a difference between the management of familial adenomatous polyposis (FAP) and mild familial adenomatous polyposis (AFAP)? (1) For both FAP and AFAP, colonoscopy monitoring is recommended from adolescence (Strength of recommendation: strong; 100% agree; level of evidence: C).
(2) Preventive colorectal resection is recommended for AFAP, because AFAP can complicate colorectal cancer (Strength of recommendation: strong; 100% agree; level of evidence: C).
CQ12: What are the candidate groups for ulcerative colitis and appropriate cancer surveillance methods? (1) For patients with extensive left colitis 8-10 years after the onset of disease, it is recommended to perform colonoscopy for the first time (Strength of recommendation: strong; 100% agree; level of evidence: B).
(2) It is recommended that patients whose remission is not confirmed by endoscopy should be monitored earlier (Strength of recommendation: weak; 100% agree; Level of evidence: B).
(3) It is recommended to use stained endoscopy and/or narrow band imaging (NBI) combined with targeted biopsy in total colonoscopy, and attention should be paid to raised lesions and any changes in mucosal structure or color that are different from the surrounding area (recommended strength: Strong; 100% agree; Evidence level: B).
(4) A step-by-step biopsy is recommended for each segment of the colon (Strength of recommendation: weak; 100% agree; Level of evidence: B).
CQ13: If dysplasia or cancer is detected in ulcerative colitis, should all the lesions be surgically removed? Is low-grade dysplasia (LGD) an indication for surgery? (1) If LGD is detected in the flat mucosa, it is recommended to consult several experienced pathologists (Strength of recommendation: weak; 100% agree; Level of evidence: C).
(2) If LGD is detected in elevated lesions and the possibility of sporadic adenoma is high, endoscopic resection and detailed pathological examination are recommended (Strength of recommendation: strong; 100% agree; level of evidence: C).
(3) However, if cancer or high-grade dysplasia is found, and it is determined that it is related to colitis, total rectocolectomy is recommended (Strength of recommendation: strong; 100% agree; level of evidence: C).
Literature index: Tanaka S, Saitoh Y, Matsuda T, et al.
Evidence-based clinical practice guidelines for management of colorectal polyps[J].
J Gastroenterol.
2021 Apr;56(4):323-335.
Contribution email: tougao@ medlive.
cn
