should colonoscopy be performed one year out from colorectal cancer resection? alexandra kent,...
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Should colonoscopy be performed one year out from colorectal cancer resection?
Alexandra Kent, Philip Thompson, Prof Alan Horgan, Mr Paul Hainsworth
Newcastle NHS Trust
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ACPGBI: Guidelines for the Management of Colorectal Cancer
Staging investigation for potentially curable colorectal cancer
•Complete visualisation of colon required either pre- or post-operatively.
•If complete colonic imaging is not possible before surgery, it is important this is done within six months, or as soon as possible after closure of a temporary ileostomy.
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ACPGBI Guidelines
Colonoscopic follow-up
• If such a policy is pursued, it is recommended that a “clean” colon should be examined by colonoscopy at 5 yearly intervals.
•Patients should be counselled about the potential complications of colonoscopy.
ACPGBI. Guidelines for the management of colorectal cancer 3rd edition 2007.
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• Patients who did not have a complete colonoscopy pre-op should be offered colonoscopy within 6 months of discharge.
•MDTs in each network should agree follow up guidelines.
• 5 yearly intervals for patients with a ‘clean’ colon.
NICE guidelines (2004)
NICE. Guidance on cancer services. Improving outcomes in colorectal cancer. 2004.
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NICE guidelines (2011)
•Offer a surveillance colonoscopy at 1 year after initial treatment. If this is normal consider colonoscopy at 5 years.
•Two Systematic reviews - potential benefit in identifying recurrence of disease at an earlier stage - Low-moderate evidence base.
NICE. CG131 Colorectal cancer - the diagnosis and management of colorectal cancer 2011
Jeffery M, Hickey BE, Hider PN. Follow-up strategies for patients treated for non-metastatic colorectal cancer (Review), The Cochrane Library 2007, Issue 4
Tiandra J, Chan MK..Follow-up after curative resection of colorectal cancer: a meta-analysis. Dis Colon Rectum. 2007 Nov;50(11):1783-99
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Patients undergoing curative resection.
• Complete colonoscopy pre-operatively or within 6 months of discharge
• Surveillance colonoscopy at 1 year
Newcastle Colorectal MDT Guidelines
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AimsTo assess compliance with local guidelines in patients undergoing curative colorectal cancer resection:•Complete colonoscopy pre-op or within 6 months
•Follow up colonoscopy at one year
• Incidence of synchronous / metachronous lesions
•Record interventions resulting from colonoscopy
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• Colorectal cancer resections 2008-2012 PJH/AFH (total=347)
• Sub-set selected commencing 2008
• Retrospective electronic chart review
• Endoscopy database
• Endoscopic outcomes recorded
Method
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Sample
•115 patients
•53 female, 62 male
•Age range 39-92, median 71
•Dukes A 23; B 33; C39; D20.
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Other: - 1 pelvic exanteration and 1 enbloc resection
Colonic resection 53
Anterior resection 38
AP resection + Hartmann’s
16
Local excision 6
Other 2
Resections performed
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Complete colonoscopy pre-op or by 6 months
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Completion colonoscopy
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Patients eligible for 1 year follow up colonoscopy
Deceased12
Eligible patients88
Metastatic disease12
Panproctocolectomy3
115 patients
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Reasons for failure to perform
1 year follow up colonoscopy
Patient refused 6
Lost to follow up 5
Alt. surveillance 7
Private patient 4
Awaiting 5
Frailty 1
•60/ 88 patients had surveillance colonoscopy
•28 eligible patients did not have colonoscopies
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Timing of ‘1 year’ colonoscopy
Range 6-30 months post-op
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Incidence of metachronous lesions at ‘1 year’ scope
(n=60)
•Normal 35
•Polyps 24
•1 patient had a TEMS procedure, local reoccurrence at 17 months on colonoscopy - anterior resection
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Interventions and complications
resulting from colonoscopy
•24 patients cleared of polyps
•1 vasovagal episode - delayed discharge
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Surveillance Polyps (24 patients)
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Conclusion
•Failure to establish clean colon within 6 months
•1 year colonoscopy performed in 68% range 6 - 30 months
•Significant incidence of lesions leading to interventions in 24
•Low complication rate from colonoscopy
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DiscussionShould colonoscopy be performed one year out from colorectal cancer resection?
Benefits
• Ensures clean colon in patients missed by pre-op/ 6month colonoscopy.
• Acknowledged aversion to removing polyps by surgeons when suspected cancer discovered
Drawbacks
• Cost• Invasive Procedure
Limitations Small study size Missing data