British Society of Gastroenterology position statement on serrated polyps in the colon and rectum

Abstract

Serrated polyps have been recognised in the last decade as important premalignant lesions accounting for between 15% and 30% of colorectal cancers. There is therefore a clinical need for guidance on how to manage these lesions; however, the evidence base is limited. A working group was commission by the British Society of Gastroenterology (BSG) Endoscopy section to review the available evidence and develop a position statement to provide clinical guidance until the evidence becomes available to support a formal guideline. The scope of the position statement was wide-ranging and included: evidence that serrated lesions have premalignant potential; detection and resection of serrated lesions; surveillance strategies after detection of serrated lesions; special situations—serrated polyposis syndrome (including surgery) and serrated lesions in colitis; education, audit and benchmarks and research questions. Statements on these issues were proposed where the evidence was deemed sufficient, and re-evaluated modified via a Delphi process until >80% agreement was reached. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool was used to assess the strength of evidence and strength of recommendation for finalised statements. Key recommendation: we suggest that until further evidence on the efficacy or otherwise of surveillance are published, patients with sessile serrated lesions (SSLs) that appear associated with a higher risk of future neoplasia or colorectal cancer (SSLs ≥10 mm or serrated lesions harbouring dysplasia including traditional serrated adenomas) should be offered a one-off colonoscopic surveillance examination at 3 years (weak recommendation, low quality evidence, 90% agreement).

The Serrated Polyp Pathway: Is It Time to Alter Surveillance Guidelines?

“…The main difference between these two is the treatment of large and/or proximal HPs, for which the International Consensus Panel recommends more frequent follow-up. Of note, many professional societies do not have detailed recommendations for SPs at this time, including the European Union (EU) and the Japanese Society of Gastroenterology (JSGE), amongst others [65–69, 76]. …”

Serrated polyposis syndrome may go undiagnosed even in structured colorectal cancer screening programmes performed by endoscopists with otherwise good quality indices

“…A 5-year cumulative incidence of CRC during surveillance after clearing of all relevant polyps of 1.5% has been reported 2. Recently published guidelines recommend resection of all clinically relevant lesions and starting annual colonoscopy surveillance thereafter 3. Therefore, early recognition and treatment of SPS is important to achieve low long-term risk of CRC 4…”

Serrated pathway: a paradigm shift in CRC prevention

“…To reduce the number of postcolonoscopy CRCs and to optimise current clinical care for patients with serrated polyps, several issues are at stake. The new British Society of Gastroenterology (BSG) position statement on serrated polyps in the colon and rectum is therefore timely as well as important 2. It discusses current knowledge on serrated polyps and provides recommendations for daily clinical practice as well as research.…”

“…Of the several subtypes, for now the sessile serrated lesions with or without dysplasia, and traditional serrated adenomas are considered to have neoplastic potential, whereas hyperplastic polyps are generally considered benign, especially when located in the rectosigmoid 2. There is uncertainty for the larger and/or proximal hyperplastic polyps.…”

“…However, for now we have to deal with circumstantial evidence. As many postcolonoscopy CRCs seem to arise from serrated polyps, and detection rates vary widely between endoscopists, implementation of a serrated polyp detection rate as a quality indicator seems a logical step forward and also supported by the BSG 2. As long as no data are available, the average detection rate of serrated polyps, as found in expert colonoscopy centres, could be used as a minimum standard 5.…”