Transcript Should colonoscopy be performed one year from colorectal cancer

Should colonoscopy be
performed one year out from
colorectal cancer resection?
Newcastle NHS
Trust
Alexandra Kent, Philip Thompson,
Prof Alan Horgan, Mr Paul Hainsworth
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.
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.
NICE guidelines (2004)
•
•
•
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. Guidance on cancer services. Improving outcomes in colorectal cancer. 2004.
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
Newcastle Colorectal
MDT Guidelines
Patients undergoing curative resection.
• Complete colonoscopy pre-operatively or within
6 months of discharge
• Surveillance colonoscopy at 1 year
Aims
To assess compliance with local
guidelines in patients undergoing
curative colorectal cancer resection:
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•
•
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Complete colonoscopy pre-op or within 6 months
Follow up colonoscopy at one year
Incidence of synchronous / metachronous lesions
Record interventions resulting from colonoscopy
Method
• Colorectal cancer resections 2008-2012
PJH/AFH (total=347)
• Sub-set selected commencing 2008
• Retrospective electronic chart review
• Endoscopy database
• Endoscopic outcomes recorded
Sample
• 115 patients
• 53 female, 62 male
• Age range 39-92, median 71
• Dukes A 23; B 33; C39; D20.
Resections performed
Colonic resection
53
Anterior resection
38
AP resection +
Hartmann’s
Local excision
16
Other
2
Other: - 1 pelvic exanteration and 1 enbloc resection
6
Complete colonoscopy pre-op or by 6 months
115 patients
Complete
Colonoscopy 59
Incomplete 28
Obstructing
12
Flexi sig
4
CT colonography 4
Unknown
8
No NUTH
colonoscopy 28
Emergency
admission 2
Completion
colonoscopy
Failure to establish clean
colon pre-op
56
Clean colon post-op
23
Mean time 16.6 months
Range
10-27months
Clean colon not
established
33
Mets
14
Deceased
6
Missing data 11(4PP)
Frailty
2
Patients eligible for 1 year
follow up colonoscopy
115 patients
Deceased
12
Metastatic disease
12
Eligible patients
88
Panproctocolectomy
3
Reasons for failure to perform
1 year follow up colonoscopy
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60/ 88 patients had surveillance colonoscopy
28 eligible patients did not have colonoscopies
Patient refused
6
Lost to follow up
5
Alt. surveillance
7
Private patient
4
Awaiting
5
Frailty
1
Timing of ‘1 year’ colonoscopy
Range 6-30 months post-op
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
Interventions and complications
resulting from colonoscopy
• 24 patients cleared of polyps
• 1 vasovagal episode - delayed
discharge
Surveillance Polyps (24 patients)
24
patients
Size (mm)
6 (˃10)
18(˂10)
Grade
21 low
grade
3 benign
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
Discussion
Should 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