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Repeat Colonoscopy

Repeat Colonoscopy

Best Practice Guidance

Summary

Colorectal carcinoma (CRC) is one of the most common cancers in the UK with more than 40,000 new cases diagnosed each year. Polyps are extremely common and certain types (colorectal adenomas and serrated lesions) have the potential to progress into CRC.

Colonoscopy can assist in the diagnosis of CRC and several other pathologies, including colonic polyps. Polyp removal (or polypectomy) can be performed endoscopically and is an effective way to treat pre-malignancy polyps (which includes both serrated polyps (excluding diminutive [1-5mm] rectal hyperplastic polyps) and adenomatous polyps. It does not include other polyps such as post inflammatory polyps) before they progress to cancer. Colonoscopy with or without polypectomy is a safe procedure however there is a small risk of complications – including pain, intestinal perforation or major haemorrhage as well as issues related to any sedative used.

Colorectal carcinoma is often treated by surgical resection, especially for people with potentially curative disease. Individuals who have had treatment for colorectal carcinoma and adenomas are known to be at high-risk of recurrence.

While reducing colorectal mortality is an important aim of colonoscopic surveillance, the main aim is to prevent colorectal cancer by resecting premalignant polyps. Many patients benefit from this alone and do not require subsequent surveillance.

 

This guidance applies to adults aged 19 years and over.

Recommendation

Follow the British Society of Gastroenterology surveillance guidelines for post-polypectomy and post-colorectal cancer resection.

 

Risk Surveillance Criteria for Colonoscopy

Either of the following put individuals at high-risk for future colorectal cancer following polypectomy:

  • 2 or more premalignant polyps including at least one advanced colorectal polyp (defined as a serrated polyp of at least 10mm in size or containing any grade of dysplasia, or an adenoma of at least 10mm in size or containing high-grade dysplasia); OR
  • 5 or more premalignant polyps.

 

Surveillance colonoscopy after polypectomy

For individuals at high-risk and under the age of 75 and whose life expectancy is greater than 10 years:

  • Offer one-off surveillance colonoscopy at 3 years.

For individuals with no high-risk findings:

  • No colonoscopic surveillance should be undertaken
  • Individuals should be strongly encouraged to participate in their national bowel screening programme when invited.

For individuals not at high-risk who are more than 10 years younger than the national bowel screening programme lower age-limit, consider for surveillance colonoscopy after 5 or 10 years, individual to age and other risk factors.

 

Surveillance colonoscopy after potentially curative CRC resection

  • Offer a clearance colonoscopy within a year after initial surgical resection
  • Then offer a surveillance colonoscopy after a further 3 years
  • Further surveillance colonoscopy to be determined in accordance with the post-polypectomy high-risk criteria.

 

Surveillance after pathologically en bloc R0 EMR or ESD of LNPCPs or early polyp cancers:

  • No site-checks are required
  • Offer surveillance colonoscopy after 3 years
  • Further surveillance colonoscopy to be determined in accordance with the post-polypectomy high-risk criteria.

 

Surveillance after piecemeal EMR or ESD of LNPCPs (large nonpedunculated colorectal polyps of at least 20mm in size)

  • Site-checks at 2-6 months and 18 months from the original resection

Once no recurrence is confirmed, patients should undergo postpolypectomy surveillance after 3 years

  • Further surveillance colonoscopy to be determined in accordance with the post-polypectomy high-risk criteria.

 

Surveillance where histological completeness of excision cannot be determined in patients with: (i) a non-pedunculated polyps of 10-19mm in size, or (ii) an adenoma containing high-grade dysplasia, or (iii) a serrated polyp containing any dysplasia:

  • Site-check should be considered within 2-6 months
  • Further surveillance colonoscopy to be determined in accordance with the post-polypectomy high-risk criteria

 

Ongoing colonoscopic surveillance:

  • To be determined by the findings at each surveillance procedure, using the high-risk criteria to stratify risk
  • Where there are no high-risk findings, colonoscopic surveillance should cease but individuals should be encouraged to participate in the national bowel screening programme when invited.

 

 

Rationale for recommendation

This recommendation is based on the 2019 guidelines published by the British Society of Gastroenterology, the Association of Coloproctology of Great British and Ireland and Public Health England.

Premalignant polyps are common, occurring in a quarter to a half of all people of screening age, yet only about 5% of the population will develop CRC during their life. As such, only a minority of people with polyps will develop CRC, meaning that most people will not benefit from post-polypectomy surveillance.

It is an increasingly held view that the greatest benefit in terms of CRC prevention is derived from the initial polypectomy, rather than from subsequent surveillance. It is possible to stratify individuals according to future risk and identify cohorts of patients with persistently elevated CRC risk beyond index polypectomy, yet even with current risk stratification, surveillance places a considerable burden on patients and endoscopy services: approximately 15% of the half a million colonoscopies performed each year in the UK are performed for polyp surveillance.

Patient information

There is no specific EBI patient guidance for this intervention.

However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.

Further information on patient involvement in EBI can be found on the EBI for patients section.

 

 

Coding

This coding is relevant to appropriate colonoscopy in the management of hereditary colorectal cancer and repeat colonoscopy.

 

Estimated activity

  • 415,262 episodes during 2018/19
  • Age/sex std rate per 100,000 – 699.0
  • Reduction opportunity based on 25th percentile of activity across CCGs: not calculated.
  • Variation (age/sex std rates):
    • N-fold – 1.6
    • 10th percentile – 543.6
    • 25th percentile – 612.4
    • 50th percentile – 698.1
    • 90th percentile – 850.1

 

Codes

Procedure codes

H22.1 Diagnostic fibreoptic endoscopic examination of colon and biopsy of lesion of colon

H22.8 Other specified diagnostic endoscopic examination of colon

H22.9 Unspecified diagnostic endoscopic examination of colon

H68.2 Diagnostic endoscopic examination of colonic pouch using colonoscope NEC

H68.4 Diagnostic endoscopic examination of ileoanal pouch using colonoscope NEC

H68.8 Other specified diagnostic endoscopic examination of enteric pouch using colonoscope

H68.9 Unspecified diagnostic endoscopic examination of enteric pouch using colonoscope

Exclusions:

H68.1 Diagnostic endoscopic examination of colonic pouch and biopsy of colonic pouch using colonoscope

H68.3 Diagnostic endoscopic examination of ileoanal pouch and biopsy of ileoanal pouch using colonoscope

Diagnosis codes

Exclusions:

Z12.1 Encounter for screening for malignant neoplasm of intestinal tract

(Note – cancer diagnoses are a global exclusion)

 

Any other criteria (e.g. patient age)

Adult (aged >=19 years)

Exclude any patients admitted as a non-elective admission

[APC extract only]

 

Will the procedure be carried out in OP or as APC?

Outpatient and Admitted Patient Care

 

Coding logic

APC:

Where procedure code in any position is:

H22.1 OR

H22.8 OR

H22.9 OR

H68.2 OR

H68.4 OR

H68.8 OR

H68.9

AND

Procedure code in any position is not:

H68.1 OR

H68.3

AND

Diagnosis code in any position is not:

Z121

AND

Patient age >=19 years

AND

APCS.Admission_Method not like (‘2%’)

OPA:

Where procedure code in any position is:

H22.1 OR

H22.8 OR

H22.9 OR

H68.2 OR

H68.4 OR

H68.8 OR

H68.9

AND

Procedure code in any position is not:

H68.1 OR

H68.3

AND

Diagnosis code in any position is not:

Z121

AND

Patient age >=19 years

 

SQL code

WHEN (opa.Der_Procedure_All like '%H22[189]%' OR opa.Der_Procedure_All like '%H68%')
AND ISNULL(opa.der_diagnosis_all,'') not like '%Z121%'
AND ISNULL(opa.Age_at_Start_of_Episode_SUS,opa.Der_Age_at_CDS_Activity_Date) between 19 AND 120
AND opa.Der_Procedure_All NOT like '%H68[13]%'
THEN '2NO_UnnecColonoscopy'

Global cancer exclusion

APC
WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (apcs.der_diagnosis_all not like '%C[0-9][0-9]%'
AND apcs.der_diagnosis_all not like '%D0%'
AND apcs.der_diagnosis_all not like '%D3[789]%'
AND apcs.der_diagnosis_all not like '%D4[012345678]%'
OR apcs.der_diagnosis_all IS NULL)

OPA
-- Cancer Diagnosis Exclusion Codes
AND (( opa.der_diagnosis_all not like '%C[0-9][0-9]%'
AND opa.der_diagnosis_all not like '%D0%'
AND opa.der_diagnosis_all not like '%D3[789]%'
AND opa.der_diagnosis_all not like '%D4[012345678]%')
OR opa.Der_Diagnosis_All IS NULL)

Additional Exclusions

-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

WHERE 1=1
-- Patient Has Attended Appointment
AND Attendance_Status IN (5,6)

-- Private Appointment Exclusion
AND opa.Administrative_Category<>'02'

References

  1. Rutter MD, et al. (2019) BSG/ACPGBI/PHE Post-polypectomy and post-colorectal cancer resection surveillance guidelines: Gut 2020;69:201–223. doi:10.1136/gutjnl-2019-319858.
  2. NICE Guideline (2020) Colorectal cancer [NG151].
  3. NICE Guideline (2011) Colorectal cancer prevention: Colonoscopic surveillance in adults with ulcerative colitis, Crohn’s disease or adenomas guideline [CG118].
  4. Cancer Research UK. Colonoscopy.

How up to date is this information?

August 2022


Changes

August 2022 - Coding updated