Guidelines of the French Society of Digestive Endoscopy: Total Colonoscopy Indications

• Introduction by Michel Greff M.D., International Secretary of the French Society of Digestive Endoscopy (SFED)
• The Guidelines
• Total Colonoscopy As A First Intention
• Total Colonoscopy As A Second Intention After Another Imaging Procedure
• Total Follow-Up Colonoscopy
• Acknowledgements
• References

Introduction by Michel Greff M.D., International Secretary of the French Society of Digestive Endoscopy (SFED)

Since 1998 the French Council of Digestive Endoscopy Society has published standards for good practice in endoscopy. These recommendations appear to be the best way to arrive at the most optimal practice in medicine at the moment. Written by a group of experts and corrected by an even larger expert group, they are regularly updated in a written form in order to help with decision making.

The “Total Colonoscopy Indications” document was prepared by P. Carayon and The Council of the SFED, according to the Medical Recommendations and References of the Agence Nationale pour le Développement de l'Evaluation Médicale (ANDEM) and Sickness Insurance [1] and the conclusions of the Consensus Conference on cancers of the colon [2].

The Guidelines

Total Colonoscopy As A First Intention

A total colonoscopy is indicated as first intention in cases of:

• Symptoms indicating altered bowel habit in patients over 50 years (patients with an increased risk of colorectal cancer).

• Clinical signs suggesting bowel pathology.

• Discovery of occult blood in the stools.

• Patients with a high genetic risk for colorectal cancer, i.e. a first-degree relative (father, mother, brother, sister) who had colorectal cancer before the age of 60, or two first-degree relatives who have suffered from colorectal cancer regardless of their age. Identification colonoscopy must therefore be performed: - 5 years before the age of onset of cancer in the relative affected, if the latter was under 60, - from 45 years in the other cases.

• The presence of a very high genetic colorectal cancer risk factor, i.e. in patients belonging to a family with familial polyadenomatous polyposis (FAP), or with hereditary nonpolyp colorectal cancer (HNPCC) syndrome, fulfilling the three Amsterdam criteria: - Number criterion (at least three subjects with colon or rectal cancer) - Kinship criterion (first-degree relationship over two generations), - Age criterion (at least one of the cancers detected before age 50). Subjects having undergone a genetic test and not carrying the familial mutation should be excluded from the screening process. The colonoscopy should be performed: 1. FAP: - From puberty (total colonoscopy could possibly be replaced by a sigmoidoscopy) 2. HNPCC syndrome: - 5 years before the age of the earliest onset of cancer in the family, if it appeared before age 25 years; - From age 20 in other cases.

• History of an emergency resection operation, for example a tumor, without prior exploration. Total colonoscopy should be performed in 3 to 6 months following the surgery.

*On the basis of current data, a screening strategy for subjects with a first-degree family history of adenomas, even if they are greater than 1 cm in size, is not recommended.

Total Colonoscopy As A Second Intention After Another Imaging Procedure

A total colonoscopy is indicated as second intention after another morphological examination in the following situations.

• Findings, during the use of a radiographic contrast medium, of abnormal images suggesting polyp or tumor lesions, regardless of their size, in order to confirm the presence of lesions. Biopsies should be performed, and if possible a resection in the absence of a contraindication on account of age and/or associated pathology.

• The discovery, during a rectosigmoidoscopy, of an adenoma when investigating other colon lesions.

Total Follow-Up Colonoscopy

A total follow-up colonoscopy is indicated in the following situations.

• When there is a change of the clinical symptomatology and/or appearance of clinical signs suggesting bowel pathology.

• When there is a history of adenomas, excluding hyperplastic polyps. 1. If the adenoma is sessile and larger than 2 cm or if there are multiple adenomas (more than five) or if the adenoma is considered sufficient (intramucosal carcinoma or invasive carcinoma commensurate with the four accepted criteria; resection and total anatomy and pathology examination, grade I or II cancer well or moderately differentiated, absence of characteristic lymphatic emboli, safety margins greater than 1 mm). It is recommended that a follow-up colonoscopy be performed within 3 - 6 months to check that the outcome of the excision was successful, then after 3 years if findings are normal and then every 5 years. 2. In all other cases, a colonoscopy is performed after 3 years then every 5 years in case of a negative examination, until monitoring does not appear to prolong life expectancy (i.e. 75 years on average).

• In cases of cancer of the colon or degenerated invasive polyp treated by surgical resection with a curative aim, only involving patients capable of withstanding another surgical operation, it is recommended that a monitoring colonoscopy be performed after 3 years and then every 5 years if findings are normal, until monitoring does not appear to prolong life expectancy (i.e. 75 years on average). If there are multiple synchronous adenomas associated with cancer (three or more), one of which is larger than 1 cm or has a villous appearance, it is recommended that total monitoring be carried out after 1 year, then after 3 years, and then every 5 years in the case of negative findings.

• In cases of a high genetic risk of colorectal cancer. In patients with a first-degree family history of colorectal cancer, a total investigative colonoscopy should take place every 5 years after a negative examination.

• In cases of a very high risk of colorectal cancer, 1. For FAP (confirmed by genetic testing or suspected): - If the colonoscopy at puberty was negative, a full colonoscopy is recommended. Then rectosigmoid- oscopy should be performed every year. This diagnosis is generally made before age 40. 2. For HNPCC syndrome: - If colonoscopy has revealed a cancer, a total investiga- tive colonoscopy is recommended every year for life. - If the initial colonoscopy was negative, a total inves- tigative colonoscopy should be performed every 2 years up to 35 years and then every year. - In cases of pancolitis developing for more than 15 years, a total colonoscopy is recommended every 2 years.

All these cases imply that each colonoscopy is of “good quality”, i.e. that “the gastroenterologist believes that he has removed all the polyps without leaving behind any polypoid remnants. This term includes good quality preparation (absence of solid stercorous residues, at most, persistence of intestinal liquid that can be removed by suction). This implies that if the preparation is not of good quality, an early endoscopic investigation may be necessary” (ANDEM recommendation 1996 [1]).

Acknowledgements

We gratefully acknowledge the expert assistance in translation of Professor Colm O'Morain of Trinity College. We would also like to acknowledge the help and cooperation of Olympus-France.

References

• 1 Agence Nationale pour le Développement de l'Evaluation Médicale (ANDEM). Endoscopies digestives basses. Recommandations et références médicales.  Gastroentérol Clin Biol. 1996;  20 881-896
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• 2 Conférence de Consensus. Prévention, dépistage et prise en charge des cancers du côlon. Texte des experts et du groupe bibliographique. Conclusions et recommandations du jury.  Gastroentérol Clin Biol. 1998;  22 295-
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M.D. M. Greff

International Secretary French Society of Digestive Endoscopy Institut Arnault Tzanck

Av. du Dr Maurice Donat

06700 St Laurent du Var, France

Phone: +33-4-93078192

Email: mgreff001@rss.fr

References

• 1 Agence Nationale pour le Développement de l'Evaluation Médicale (ANDEM). Endoscopies digestives basses. Recommandations et références médicales.  Gastroentérol Clin Biol. 1996;  20 881-896
  PubMedSearch in Google Scholar
• 2 Conférence de Consensus. Prévention, dépistage et prise en charge des cancers du côlon. Texte des experts et du groupe bibliographique. Conclusions et recommandations du jury.  Gastroentérol Clin Biol. 1998;  22 295-
  PubMedSearch in Google Scholar

M.D. M. Greff

International Secretary French Society of Digestive Endoscopy Institut Arnault Tzanck

Av. du Dr Maurice Donat

06700 St Laurent du Var, France

Phone: +33-4-93078192

Email: mgreff001@rss.fr