2022+韩国指南：息肉切除术后结肠镜监测（修订版）.pdf

Korean guidelines for postpolypectomy colonoscopic surveillance:2022 revised editionSu Young Kim1,*,Min Seob Kwak2,*,Soon Man Yoon3,Yunho Jung4,Jong Wook Kim5,Sun-Jin Boo6,Eun Hye Oh7,Seong Ran Jeon8,Seung-Joo Nam9,Seon-Young Park10,Soo-Kyung Park11,Jaeyoung Chun12,Dong Hoon Baek13,Mi-Young Choi14,Suyeon Park15,16,Jeong-Sik Byeon17,Hyung Kil Kim18,Joo Young Cho19,Moon Sung Lee20,Oh Young Lee21,Korean Society of Gastrointestinal Endoscopy,Korean Society of Gastroenterology,Korean Association for the Study of Intestinal Diseases 1Department of Gastroenterology,Wonju Severance Christian Hospital,Yonsei University Wonju College of Medicine,Wonju;2Department of Internal Medicine,Kyung Hee University Hospital at Gangdong,Kyung Hee University School of Medicine,Seoul;3Department of Gastroenterology,Chungbuk National University Hospital,Chungbuk National University College of Medicine,Cheongju;4Department of Internal Medicine,Soonchunhyang University College of Medicine,Cheonan;5Department of Gastroenterology,Inje University Ilsan Paik Hospital,Goyang;6Department of Internal Medicine,Jeju National University School of Medicine,Jeju;7Department of Gastroenterology,Hanyang University Guri Hospital,Hanyang University College of Medicine,Guri;8Digestive Disease Center,Institute for Digestive Research,Soonchunhyang University College of Medicine,Seoul;9Department of Internal Medicine,Kangwon National University School of Medicine,Chuncheon;10Department of Internal Medicine,Chonnam National University Medical School,Gwangju;11Department of Internal Medicine,Kangbuk Samsung Hospital,Sungkyunkwan University School of Medicine,Seoul;12Department of Gastroenterology,Gangnam Severance Hospital,Yonsei University College of Medicine,Seoul;13Department of Internal Medicine,Pusan National University School of Medicine,Busan;14National Evidence-Based Healthcare Collaborating Agency,Seoul;15Department of biostatistics,Soonchunhyang University College of Medicine,Seoul;16Department of Applied Statistics,Chung-Ang University,Seoul;17Department of Gastroenterology,Asan Medical Center,University of Ulsan College of Medicine,Seoul;18Department of Gastroenterology,Inha University Hospital,Inha University School of Medicine,Incheon;19Department of Gastroenterology,CHA Gangnam Medical Center,Seoul;20Digestive Disease Center,Institute for Digestive Research,Soonchunhyang University College of Medicine,Bucheon;21Department of Internal Medicine,Hanyang University School of Medicine,Seoul,Korea REVIEW2022 October 13 Epub ahead of printhttps:/doi.org/10.5946/ce.2022.136pISSN:2234-2400 eISSN:2234-2443Received:April 26,2022 Revised:June 12,2022 Accepted:June 22,2022Correspondence:Jeong-Sik Byeon Department of Gastroenterology,Asan Medical Center,University of Ulsan College of Medicine,88 Olympic-ro 43-gil,Songpa-gu,Seoul 05505,Korea E-mail:jsbyeonamc.seoul.kr Correspondence:Oh Young Lee Department of Internal Medicine,Hanyang University School of Medicine,222 Wangsimni-ro,Seongdong-gu,Seoul 04763,Korea E-mail:leeoyhanyang.ac.kr*Su Young Kim and Min Seob Kwak contributed equally to this work as first authors.These guideline is being co-published in Clinical Endoscopy,Intestinal Research,and the Korean Journal of Gastroenterology(in Korean)for the facilitated distribution.Open AccessColonoscopic polypectomy is effective in decreasing the incidence and mortality of colorectal cancer(CRC).Premalignant polyps discovered during colonoscopy are associated with the risk of metachronous advanced neoplasia.Postpolypectomy surveillance is the most important meth-od for the management of advanced metachronous neoplasia.A more efficient and evidence-based guideline for postpolypectomy surveillance is required because of limited medical resources and concerns regarding colonoscopy complications.In these consensus guidelines,an analytic ap-proach was used to address all reliable evidence to interpret the predictors of CRC or advanced neoplasia during surveillance colonoscopy.The key recommendations state that the high-risk findings for metachronous CRC following polypectomy are as follows:(1)adenoma 10 mm in size;(2)3 to 5(or more)adenomas;(3)tubulovillous or villous adenoma;(4)adenoma containing high-grade dysplasia;(5)traditional serrated adeno-ma;(6)sessile serrated lesion(SSL)containing any grade of dysplasia;(7)serrated polyp of at least 10 mm in size;and(8)3 to 5(or more)SSLs.More studies are needed to fully comprehend the patients most likely to benefit from surveillance colonoscopy and the ideal surveillance interval to prevent metachronous CRC.Keywords:Colonoscopy;Colorectal cancer;Guidelines;Polypectomy;Surveillance This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License(http:/creativecommons.org/licenses/by-nc/4.0/)which permits unrestricted non-commercial use,distribution,and reproduction in any medium,provided the original work is properly cited.1Copyright 2022 Korean Society of Gastrointestinal EndoscopyINTRODUCTION Colonoscopy is currently a key diagnostic modality for colorec-tal cancer(CRC)screening and the establishment of a treatment strategy.CRC remains one of the leading causes of cancer-relat-ed deaths worldwide,despite a decreasing trend in its incidence and mortality owing to the development of screening meth-ods and prevention programs.1 Screening methods to prevent CRC have been presented in various national cohort studies.Among the various methods,colonoscopic polypectomy,which involves the removal of colorectal polyps by colonoscopy,is re-portedly the most effective method for reducing CRC incidence and CRC-related mortality.2,3 Patients with colorectal polyps are at a high risk of developing colorectal polyps and CRC in the future;thus,appropriate surveillance using colonoscopy after colorectal polyp resection is instrumental.4,5 Additionally,the significance of colonoscopic surveillance lies not only in detect-ing metachronous polyps but also in the detection of colorectal lesions not detected by index colonoscopy.In Korea,fecal occult blood test has been adopted as a na-tional test to screen for CRC.However,colonoscopy has already been considered for CRC screening because of the character-istics of the healthcare environment in Korea,defined by its high accessibility and utility of health services,leading to a remarkable increase in the diagnosis and resection of colorectal polyps.6 Although there is no doubt regarding the importance of postpolypectomy colonoscopic surveillance,the method may have a marginal effect on prevention compared to a screening colonoscopy;the likelihood of complications from colonoscopy is also present.Therefore,guidelines for the optimal practice of postpolypectomy colonoscopic surveillance,which max-imizes the benefits and minimizes the possible damage,are required.2,7,8 To establish Korea-specific guidelines,the Korean Society of Gastroenterology,Korean Society of Gastrointesti-nal Endoscopy,Korean Association for the Study of Intestinal Diseases,and Korean Society of Abdominal Radiology jointly organized a multi-society Taskforce Committee to develop national guidelines for colorectal polyp treatment.The Korean Guidelines for Postpolypectomy Colonoscopic Surveillance were first published in 2012 and distributed to health professionals for use in clinical practice.9 Since establishing the first Korean guidelines,many studies have reported postpolypectomy colonoscopic surveillance,ne-cessitating a revision of the existing Korean guidelines to reflect and incorporate additional evidence and reports.The revised edition of the Korean Guidelines for Postpolypectomy Colonos-copic Surveillance was developed by adapting three internation-al guidelines that have been recently revised and released.10-12 In this way,we aimed to present revised evidence-based guidelines that can be used as a useful reference to determine the timing and interval of colonoscopic surveillance,based on the assump-tion that the patient underwent a high-quality index colonos-copy conducted by a specialist in treating colorectal polyps.For the major recommendations in the revised guidelines,CRC incidence and mortality are set as the primary endpoints.The risk of developing metachronous advanced neoplasia,which was set as a key endpoint in previous guidelines,is considered a secondary endpoint.The estimates of benefits and risks are comprehensively considered in the revised guidelines.However,the revised guidelines exclude recommendations for follow-up of hereditary CRC(for example,hereditary non-polyposis CRC and familial adenomatous polyposis),inflammatory bowel disease,and serrated polyposis syndrome.Additionally,these guidelines do not take precedence over clinical evaluations made by physicians,taking into consideration various factors related to patients and the healthcare environment in real-world clinical practice.Nevertheless,these guidelines are expected to serve as useful and complementary references in the clinical setting.PROCESS OF GUIDELINE DEVELOPMENT The guidelines are applicable to all patients(both men and women,including those with comorbidities)who have under-gone colonoscopy and had polyps removed.The Guidelines Development Committee and Taskforce Committee include gastroenterologists and methodological experts as members to develop a revised edition of existing guidelines(Appendix 1).By selecting reference guidelines through a systematic literature review and meta-analysis using a systematic process,the final guidelines were adapted for the development of this guideline.The guidelines developed in this study will be revised within the next 5 years,although early revision may be necessary in case of significant changes in the evidence base for the condi-tion.Development procedure The guidelines were developed based on the Guidance for the Development of Clinical Practice guidelines ver.1.0,as pub-lished by the National Evidence-Based Healthcare Collaborat-2ing Agency(Appendix 2).The Guidelines Development Com-mittee held its first meeting on July 6,2020,and discussed the direction of revision for the existing guidelines.The guideline development process consisted of three stages:planning,development,and finalization.The planning stage consisted of(1)selecting the key themes of the guidelines;(2)reviewing the existing guidelines;(3)establishing a develop-ment plan;and(4)selecting key questions.The development stage consisted of(5)searching for evidence,quality assessment,and synthesis;(6)writing recommendations and determining the strength of recommendation;and(7)drawing consensus.The finalization stage consisted of an external review and publi-cation of the final guidelines.1)Selection of key questions The Task Force Committee,consisting of nine members,re-viewed three guidelines developed in the United States(US Multi-Society Task Force USMSTF),Europe(European So-ciety of Gastrointestinal Endoscopy ESGE),and the United Kingdom(UK)(British Society of Gastroenterology BSG).First,twelve related themes were selected.Detailed key ques-tions were determined considering the patient population(P),intervention(I),comparator(C),and outcome(O).Thus,the key questions that represent the building blocks of the recom-mendations are presented as PICO questions(Appendix 2).2)Search and selection of guidelines The search for related literature was conducted by two taskforce members,using keyword terms for the guidelines.The major sources used for literature search included the international search engines PubMed,Ovid-Embase,and Cochrane libraries.A total of 503 guidelines published after 2015 were retrieved,after excluding duplicates.After reviewing titles and abstracts,55 articles were selected.By reviewing the original texts of the articles,three guidelines that satisfied the following three con-ditions were finally selected:(1)guidelines including PICO that matched the key questions;(2)evidence-based guidelines that included the report of a systematic literature search and showed a clear connection between the recommendations and the sup-porting evidence;and(3)guidelines published in English(Ap-pendices 3,4).3)Final selection process of the guideline Through a systematic literature review and inclusion/exclusion criteria,a quality assessment was conducted for the three guide-lines published by USMSTF,ESGE,and BSG.All of them were selected as guidelines for adaptation(Appendix 5,6).10-12 Qual-ity assessment of the guidelines was performed based on the Korean Appraisal of Guidelines for Research and Evaluation II(K-AGREE II).In addition to comprehensive evaluation,scope and purpose,rigor of development,stakeholder involvement,clarity of presentation,applicability,and editorial independence were considered the key assessment domains.13 Quality assess-ment of the guidelines using the K-AGREE II was performed by three taskforce members per guideline,and items with a differ-ence of more than a specified score among taskforce members were refined through re-review and consensus discussion.For the final selection of the guidelines,rigor of development was considered with particular attention.4)Writing process of the guideline The recommendations and related evidence of the three guide-lines selected by the Task Force Committee were comprehen-sively reviewed to derive the primary recommendations for the key questions(Appendix 7),and the acceptance and applicabil-ity of these recommendations were evaluated(Appendix 8,9).Subsequently,the opinions of all the members were collected,and the final recommendations were compiled.For the level of evidence for each key question,major foreign grading method-ologies,such as the Scottish Intercollegiate Guidelines Network,Grading of Recommendations,Assessment,Development and Evaluation,and existing domestic clinical practice guidelines,were reviewed.14-17 After discussing with the Guidelines De-velopment Committee,the level of evidence was divided into four,as shown in Table 1.To consider the level of evidence,the study design and quality assessment results of the selected studies were evaluated,and the consistency of the outcomes and precision of the evidence(total number of subjects or con-fidence intervals CIs in the included articles)were considered to determine the level of evidence for each key question.The strength of the recommendations was divided into four levels:strong recommendation,conditional recommendation,not recommended,and inconclusive(Table 2).For content that lacked evidence or required clinical interpretation,the task force members held a consensus to reach an agreed conclusion.The level of evidence was divided into five,and the strength of the recommendation was determined by considering the level of evidence,benefits(such as clinical effects,increased patient satisfaction,and quality of life),and harm(such as adverse events,increased use of unnecessary resources,and decreased Kim et al.Postpolypectomy colonoscopic surveill