1. Should colonoscopy be performed one year out from colorectal cancer resection? Alexandra Kent, Philip Thompson, Prof Alan Horgan, Mr Paul Hainsworth Newcastle NHS Trust

2. 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.

3. 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.

4. 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 guidelines (2004) NICE. Guidance on cancer services. Improving outcomes in colorectal cancer. 2004.

5. 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

6. Patients undergoing curative resection. Complete colonoscopy pre-operatively or within 6 months of discharge Surveillance colonoscopy at 1 year Newcastle Colorectal MDT Guidelines

7. Aims To assess compliance with local guidelines in patients undergoing curative colorectal cancer resection: Complete colonoscopy pre-op or within 6 months Follow up colonoscopy at one year Incidence of synchronous / metachronous lesions Record interventions resulting from colonoscopy

8. Colorectal cancer resections 2008-2012 PJH/AFH (total=347) Sub-set selected commencing 2008 Retrospective electronic chart review Endoscopy database Endoscopic outcomes recorded Method

9. Sample 115 patients 53 female, 62 male Age range 39-92, median 71 Dukes A 23; B 33; C39; D20.

10. Other: - 1 pelvic exanteration and 1 enbloc resection Colonic resection53 Anterior resection38 AP resection + Hartmann’s 16 Local excision6 Other2 Resections performed

11. 115 patients Complete Colonoscopy 59 Incomplete 28 Obstructing 12 Flexi sig 4 CT colonography 4 Unknown 8 No NUTH colonoscopy 28 Emergency admission 2 Complete colonoscopy pre-op or by 6 months

12. 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

13. Patients eligible for 1 year follow up colonoscopy

14. Reasons for failure to perform 1 year follow up colonoscopy Patient refused6 Lost to follow up5 Alt. surveillance7 Private patient4 Awaiting5 Frailty1 60/ 88 patients had surveillance colonoscopy 28 eligible patients did not have colonoscopies

15. Timing of ‘1 year’ colonoscopy Range 6-30 months post-op

16. 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

17. Interventions and complications resulting from colonoscopy 24 patients cleared of polyps 1 vasovagal episode - delayed discharge

18. Surveillance Polyps (24 patients) 24 patients Size (mm) 6 ( ˃ 10) 18 ( ˂ 10) Grade 21 low grade 3 benign

19. 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

20. 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