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ESTABLISHMENT OF STANDARDS FOR THE REFERRAL OF LARGE COMPLEX COLORECTAL POLYPS: AN INTERNATIONAL EXPERT CONSENSUS USING A MODIFIED DELPHI PROCESS

Kareem Khalaf 1, Samir Seleq 1, Nikko Gimpaya 1, Katarzyna Pawlak 1, Akiko Ohno 2, Asma AA Alkandari 3, Amol Bapaye 4, Michael John Bourke 5, Evgeny Dmitrievich Fedorov 6, Cesare Hassan 7, Mirjana Kalauz 8, Takahisa Matsuda 9, Klaus Mönkemüller 10, Tajana Pavic 11, Maria Pellisé Urquiza 12, Zoe Raos 13, Alessandro Repici 14, Douglas Kevin Rex 15, Payal Saxena 16, Cameron Schauer 13, Amrita Sethi 17, Prateek Sharma 18, Aasma Shaukat 19, Uzma D. Siddiqui 20, Rajvinder Singh 21, Lesley-Ann Smith 22, Mayo Tanabe 23, Daniel von Renteln 24, Natalia Causada Calo 1, Jeffrey D. Mosko 1, Christopher Teshima 25, Gary R. May 1, Samir C. Grover 1

Affiliations

1 Division of Gastroenterology, St. Michael's Hospital, Toronto, Canada

2 Kyorin University School of Medicine, Tokyo, Japan

3 Alamiri Hospital, Kuwait, Kuwait

4 Deenanath Mangeshkar Hospital and Research Center, Maharashtra, India

5 Westmead Hospital Sydney, Westmead, NSW, Australia

6 Pirogov Russia National Research Medical University, Moscow, Russian Federation

7 Humanitas University, Rome, Italy

8 Clinical Hospital Center Zagreb, Zagreb, Croatia

9 National Cancer Center Hospital, Tokyo, Japan

10 Frankenwald Klinikum, Braulage, Germany

11 University Hospital Center “Sestre milosrdnice”, Zagreb, Croatia

12 Hospital Clinic, Barcelona, Spain

13 Te Whatu Ora,, Waitemata, New Zealand

14 Ist. Clinico Humanitas Rozzano Dept. of Gastroenterology, Milano, Italy

15 IUPUI, Indiana, United States

16 Royal Prince Alfred Hospital, Camperdown, Australia

17 Columbia University Medical Center, New York, United States

18 University of Kansas School of Medicine Dept. of Gastroenterology, Leawood, United States

19 NYU Grossman School of Medicine, New York, United States

20 University of Chicago, Chicago, United States

21 NALHN & the University of Adelaide, Lyell McEwin Hospital, Adelaide, Australia

22 Auckland City Hospital, Auckland, New Zealand

23 Showa University Koto Toyosu Hospital, Tokyo, Japan

24 CHUM, Montreal, Canada

25 University of Toronto, Toronto, Canada

Summary

AI Generated

An international Delphi study involving 24 experts from four continents established minimum referral standards for large colorectal polyps, achieving consensus on 18 of 44 proposed items to improve care planning for endoscopic resection.

Many current referrals for large polyps lack sufficient information to properly characterize lesions, leading to delayed care, mismanagement, and suboptimal selection of resection techniques.
The study used a three-round Delphi methodology with 24 international experts in advanced endoscopy, with equal gender representation, to generate and vote on 44 referral standard statements covering patient demographics, anamnesis, previous endoscopy findings, lesion findings, and outcomes.
Only 18 of the 44 proposed statements achieved consensus after the second round, with consensus rates varying slightly among continents.
Experts emphasized balancing comprehensive information with practicality, prioritizing relevant and objective parameters while avoiding unnecessary burden on referring physicians.
This work provides evidence-based guidance for general gastroenterologists referring large complex polyps and for advanced endoscopists developing referral protocols.

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Abstract

Introduction

When it comes to removing large polyps during screening colonoscopies, general gastroenterologists often lack the necessary training and expertise. As a result, they will typically refer patients with large polyps to advanced endoscopists who have the required skill set to remove them. However, with the increasing number of techniques and approaches for removing large polyps, it is crucial for advanced endoscopists to have accurate information about the polyp in question in order to plan the best approach for its removal. Advanced endoscopists heavily rely on the referring doctor's information to begin this planning process, but unfortunately, many referrals for large polyps do not provide enough information to properly characterize the lesion. This can result in delayed care, mismanagement of the lesion, and may negatively impact the endoscopist's decisions in selecting the most appropriate resection technique and preparing the patient accordingly. Therefore, it is essential to establish standard guidelines regarding the necessary information to include in a referral for large polyps to ensure the best possible care is provided.

Aims & Methods

Our study aimed to determine the minimum standards for referring large colorectal polyps for endoscopic resection by utilizing the Delphi methodology to obtain expert consensus. We recruited 24 international experts in endoluminal advanced endoscopy from various continents. Experts were selected based on their publication record in the last decade, recognition as key opinion leaders in relevant endoscopic societies, and their willingness to disclose self-identification data for recruitment equity and diversity. The study comprised three rounds of surveys to achieve consensus. The first round involved generating research-related items or claims to establish minimum expected standards for referral of large complex (>20mm) colorectal polyps for potential endoscopic resection. In the second round, the experts voted on the statements using a 5-point Likert Scale to reach consensus. Statements that did not achieve consensus were abandoned, and the remaining statements were presented again for voting. In the third round, the experts ranked the items on a scale of 1 to 10 to allow an overall gradation of importance for each individual item.

Results

A total of 24 experts from four continents (Oceania, North America, Europe, and Asia) participated in the Delphi study, with equal representation of female and male experts. After the first round, 44 item statements were generated and sent for voting in the second round, grouped as follows: Patient Demographics (3 questions), Patient Anamnesis (13 statements), Previous Endoscopy Findings (7 statements), Lesion Findings (10 statements), Conclusion and Outcomes (7 statements). Out of the 44 statements, only 18 achieved consensus after the second round. The consensus rates for the accepted statements varied slightly among the different continents, with some statements achieving variable consensus rates in the different regions.

Conclusion

Overall, our study highlighted the need for a balance between providing comprehensive information and ensuring the practicality and simplicity of the referral report. The experts emphasized the importance of relevant and objective parameters while avoiding unnecessary burden on referring physicians. The feedback provided valuable insights and considerations for refining the standards for the referral of large colorectal polyps, ultimately improving the quality of care for patients undergoing endoscopic resection.

References

Zauber AG, Winawer SJ, O’Brien MJ, et al. Colonoscopic Polypectomy and Long-Term Prevention of Colorectal-Cancer Deaths. http://dx.doi.org/101056/NEJMoa1100370 2012;366:687–696.
Gupta N, Bansal A, Rao D, et al. Prevalence of advanced histological features in diminutive and small colon polyps. Gastrointestinal Endoscopy 2012;75:1022–1030.
Burgess NG, Hourigan LF, Zanati SA, et al. Risk Stratification for Covert Invasive Cancer Among Patients Referred for Colonic Endoscopic Mucosal Resection: A Large Multicenter Cohort. Gastroenterology 2017;153:732-742.e1.
Peery AF, Cools KS, Strassle PD, et al. Increasing Rates of Surgery for Patients With Non-Malignant Colorectal Polyps in the United States. Gastroenterology 2018;154:1352.
Hassan C, Repici A, Sharma P, et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016;65:806–820.
Ahlenstiel G, Hourigan LF, Brown G, et al. Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointestinal Endoscopy 2014;80:668–676.
Kaltenbach T, Anderson JC, Burke CA, et al. Endoscopic Removal of Colorectal Lesions Recommendations by the US Multi-Society Task Force on Colorectal Cancer. 2020.
Monika Ferlitsch A, Moss A, Hassan C, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. | Endoscopy 2017;49:270–297.

Disclosure

DVR, CS, ZR, MT, TM, RS, AR, AO, CH, LAS, AS, AB, EDF, MK, MP, AA, KM, KK, SS, NG, KMP, JDM, CWT, GRM, SCG - The authors have no financial disclosures or conflicts of interest to declare.
AS - Consultant: Boston Scientific, Interscope, Medtronic, Olympus; Research Support: Boston Scientific, Fujifilm; Advisory board: Endosound
MJB - Research support for ethics approved studies from Cook Medical, Olympus medical and Boston scientific
PS – Consultant: Boston Scientific, Ambu, Erbe
DKR - Consultant: Olympus, Boston Scientific, Sabela, Norgine, Acacia, GI Supply; Ownership interest in Satisfai Health
UDS - Research, Consultant and Speaker: Olympus and Boston Scientific; Consultant and Speaker: Conmed, Cook, Medtronic

Conference

UEG Week Copenhagen 2023

Topics

Colorectal

Submission format

Abstract

Session

Lower GI endoscopic polypectomy (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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When is the time to call the surgeon?

Emma V. Carrington 1

Affiliations

1 University of North Carolina / NCRBSI, London, United Kingdom

Summary

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

Topics

Neurogastroenterology & Motility Surgery Primary Care Small Intestine & Nutrition

Session

Chronic constipation: How to diagnose and treat this frequent condition in clinical practice

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

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2026

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The role of behavioural treatments

Allison Malcolm 1

Affiliations

1 University Of Sydney, Sydney, Australia

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

Topics

Neurogastroenterology & Motility Surgery Primary Care Small Intestine & Nutrition

Session

Chronic constipation: How to diagnose and treat this frequent condition in clinical practice

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Allison Malcolm

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Marie-Anne Noreillie

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Christian Lambiase

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Hyunil Kim

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Michael John Bourke

UEG Presentation

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

ADVANCES IN COLORECTAL ENDOSCOPIC RESECTION HAVE ALTERED INCIDENCE AND RISK FACTORS FOR RECURRENCE: A COMPARATIVE STUDY OVER TWO TIME PERIODS

This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

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ADVANCES IN COLORECTAL ENDOSCOPIC RESECTION HAVE ALTERED INCIDENCE AND RISK FACTORS FOR RECURRENCE: A COMPARATIVE STUDY OVER TWO TIME PERIODS

Homira Ayubi 1, Olaolu Olabintan 1, Ali Eqbal 1, Marie-Anne Noreillie 1, Jemma Bhoday 1, Ademola Adeyeye 1, Manraj Anand 1, Bu Hayee 1, Shraddha Gulati 1, Sri Thrumurthy 1, Amyn Haji 1, Andrew Emmanuel 1

Affiliations

1 King's College Hospital, London, United Kingdom

Summary

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Abstract

Introduction

EMR remains the primary therapeutic option for LNPCP in western practice, but new procedures and techniques are increasingly employed. Large published series previously defined expected rates of, and risk factors for, residual/recurrent adenoma after endoscopic resection (ER). However, these may no longer be relevant.

Aims & Methods

We aimed to identify independent risk factors for recurrent/residual adenoma in a contemporary cohort of LNPCP treated by ER compared to a historical cohort. Patients with LNPCP treated by ER at a tertiary referral centre between January 2011 and September 2023 who had completed 6 month surveillance (SC1) were included. Patients were divided into contemporary (January 2018 – September 2023) and historical (January 2011 – December 2017) cohorts. Post-ER scars were examined using with magnification chromoendoscopy and NBI/BLI. Clinicopathological features significantly associated with recurrent/residual adenoma on univariate analysis were subjected to multiple logistic regression to identify independent risk factors.

Results

1517 ER were performed over the study period of which 946 met the inclusion criteria and had undergone SC1: 483 in the contemporary cohort and 463 in the historical cohort. In the contemporary cohort 313 (65%) were treated using ESD compared to 117 (25%) in the historical cohort (p<0.001). En bloc resection was more frequently achieved in the contemporary cohort compared to the historical cohort (70% versus 33%, p<0.001). Recurrent/residual adenoma at SC1 was detected in 2.5% in the contemporary cohort compared to 8.9% in the historical cohort (p<0.001). For the historical cohort, multivariate analysis revealed that previous failed attempt at resection (OR 2.80, 95% CI 1.14-6.88, p=0.02); piecemeal resection (OR 5.21, 95% CI 1.18-23.02, p=0.03) and involvement of >75% of the circumference of the lumen (OR 5.80, 95% CI 2.07-16.25, p<0.001) were independently associated with recurrent/residual adenoma: However, for the contemporary cohort, only difficult access to the lesion (OR 4.24, 95% CI 1.21-14.78) was independently associated with recurrent residual adenoma at SC1.

Conclusion

Significant changes have taken place in ER practice over the last decade. This study demonstrates this has led to a marked alteration in previously established expected outcomes and risk factors for recurrence. Furthermore, the increasing use of adjunctive measures and techniques such as ESD throughout the colorectum may help drive down recurrence rates with the advantage of producing high quality histopathological specimens and accurate diagnosis, leading to a reduction in surveillance requirements. These data should help define performance standards for advanced resection units as well as guide informed consent and decision making for patients.

Event

UEG Week Vienna 2024

Topics

Colorectal Digestive Oncology Endoscopy

Submission format

Abstract

Session

EMR or ESD for colon neoplasia

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Allison Malcolm

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Marie-Anne Noreillie

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Christian Lambiase

EFFECTIVENESS OF COLONOSCOPY ON EARLY ONSET COLORECTAL CANCER INCIDENCE AMONG PERSONS 40-49 YEARS

Hyunil Kim

For the endoscopist

Michael John Bourke

UEG Presentation

New

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Summary: What happened to the patient?

Christian Lambiase 1

Affiliations

1 Gastrointestinal Unit, Department of Translational Sciences and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy

Summary

AI Generated

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

Topics

Neurogastroenterology & Motility Surgery Primary Care Small Intestine & Nutrition

Session

Chronic constipation: How to diagnose and treat this frequent condition in clinical practice

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Emma V. Carrington

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Allison Malcolm

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Marie-Anne Noreillie

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Christian Lambiase

EFFECTIVENESS OF COLONOSCOPY ON EARLY ONSET COLORECTAL CANCER INCIDENCE AMONG PERSONS 40-49 YEARS

Hyunil Kim

For the endoscopist

Michael John Bourke

UEG Presentation

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

EFFECTIVENESS OF COLONOSCOPY ON EARLY ONSET COLORECTAL CANCER INCIDENCE AMONG PERSONS 40-49 YEARS

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EFFECTIVENESS OF COLONOSCOPY ON EARLY ONSET COLORECTAL CANCER INCIDENCE AMONG PERSONS 40-49 YEARS

Hyun-Soo Kim 1, Su-Young Kim 1, Hyunil Kim 1

Affiliations

1 Wonju Severance Christian Hospital, Wonju, Korea, Republic of

Summary

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Abstract

Introduction

Recently, some guidelines recommend conducting colorectal cancer (CRC) screening at ages younger than 50 years. However, there are few data on the preventive effect of colonoscopy at ages 40-49 years at the population level.

Aims & Methods

In this study, the risk of CRC according to the presence or absence of CSP in their 40s was evaluated in a retrospective cohort design using a nationwide database. Using the Korean National Health Insurance System data between 2004 and 2006, we constructed 1:5 colonoscopy cohort (CsC) and non-colonoscopy cohort (NCsC) at ages 40-49 years and followed through 2014. A total of 2,940,792 subjects were enrolled and CRC risk was evaluated after propensity score matching between CsC and NCsC based on age, sex, smoking, metabolic syndrome (MetS) and potentially relevant variables related CRC risk.

Results

Among 490,132 CsC subjects and 2,450,660 NCsC subjects at baseline periods in 40-49 ages, 689 (0.14%) and 9,440 (0.39%) cases of CRC were found during 10 years follow up period, respectively. According to age group, cumulative CRC incidences in early 40’s (40-44) were 0.10% in CsC and 0.25% in NCsC respectively. For late 40’s (45-49), those were 0.17% in CsC group and 0.49% in NCsC group, respectively. Compared with NCsC, the adjusted hazard ratios (aHRs) for CRC development in CsC group were 0.42 (men, 95% CI: 0.35-0.50) and 0.37 (women, 95% CI: 0.30-0.47) in early 40’s and 0.33 (men, 95% CI: 0.29-0.37) and 0.39 (women, 95% CI: 0.33-0.45) in late 40’s.

Conclusion

Overall, colonoscopy in their 40s significantly lowered the risk of colorectal cancer development by 58-67%. This cancer prevention effect of colonoscopy was different according to age and gender, and it was most effective in men in their late 40s, suggesting the rationales for optimization of age and gender to start colonoscopy.

Disclosure

Korea Health Technology R&D Project through the Korea Health Industry Development Institute, National Research Foundation of Korea grant and the National R&D Program for Cancer Control through the National Cancer Center funded by the Korea Ministry of Health & Welfare, Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Education.

Event

UEG Week Vienna 2024

Topics

Colorectal Digestive Oncology Endoscopy

Submission format

Abstract

Session

Fit for CRC screening

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Michael John Bourke

UEG Presentation

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For the endoscopist

Michael John Bourke 1

Affiliations

1 Westmead Hospital Sydney, Westmead, Australia

Summary

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Abstract

Event

UEG Week Berlin 2025

Topics

Digestive Oncology Endoscopy Surgery

Session

Game changers in lower GI over the past decade: Neoplasm

Citation

United European Gastroenterology Journal 2025; 13 (Supplement 8)

Published

2025

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