New ESGE Recommendations for Management of Polyposis Syndromes

Douglas K. Rex, MD, FASGE reviewing van Leerdam ME, et al. Endoscopy 2019 July 23.

This is a comprehensive document from the European Society of Gastrointestinal Endoscopy. Following are some of the key recommendations:

For familial adenomatous polyposis (FAP)/MUTYH-associated polyposis

  • Polyposis syndromes should be managed in dedicated units.
  • Start colonoscopy in FAP at 12 to 14 years of age and in MUTYH at 18 years, with 1- to 2-year intervals for both.
  • Timing and type of surgery in FAP and MUTYH should consider sex (fertility), polyp burden, rectal involvement, desmoids in patient and family, and mutation site.
  • After colectomy, intervals for the rectum or pouch should be 1 to 2 years.
  • All lesions pre- and post-colectomy >5 mm should be resected.
  • Start duodenal surveillance in FAP at 25 years of age, and resect all lesions ≥10 mm in FAP/MUTYH

For serrated polyposis syndrome (SPS)

  • Remove all lesions ≥5 mm.
  • One-year intervals are recommended if there is ≥1 advanced polyp (advanced adenoma or sessile serrated polyps ≥10 mm or with cytological dysplasia) or ≥5 nonadvanced, clinically relevant polyps (any polyp that is not advanced and not a hyperplastic polyp <5 mm); otherwise 2-year intervals are recommended.
  • Screen first-degree relatives by colonoscopy every 5 years starting at 45 years of age.

There are also detailed recommendations for Peutz-Jeghers syndrome and juvenile polyposis syndrome.


Comment:

The evidence base to support most of the recommendations is low quality. In my own practice, I tend to remove all the adenomas in FAP patients by cold snaring pre-colectomy (if we intend to delay colectomy) and post-colectomy and count the total number of lesions and those ≥10 mm. The goal is to lower the number of polyps removed in successive examinations, with shortening of the interval if lesion numbers go up in successive examinations. In SPS, I tend to expand to 2-year intervals when there are still slightly greater polyp burdens than described here, but this is only after detailed clearing of the whole colon, usually with Endocuff.


Douglas K. Rex, MD, FASGE
Bio and Disclosures

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Citation(s):
van Leerdam ME, Roos VH, van Hooft JE, et al. Endoscopic management of polyposis syndromes: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019 July 23. (Epub ahead of print) (https://doi.org/10.1055/a-0965-0605)