How to avoid overtreatment of benign colorectal lesions: Rationale for an evidence-based management

Table 3 Objective parameters for assessing lesions, endoscopists, and units

Complex polyp			Expert endoscopist			Reference endoscopy unit
SMSA score ≥ 12 (Level 4)[41]			BSG criteria[42]			BSG criteria[42]
BSG criteria[42]				500 independent colonoscopies			Ensure that endoscopists undertake a sufficient number of procedures a year to maintain acceptable standards4
	Increased risk of malignancy			100-125 EMR to obtain competence
		Kudo´s pit pattern V		A non-defined number1 of EMR procedures to maintain competence
		Paris 0-IIc/0-IIa+IIc					Time from referral to definitive management: < 8 wk
		LST-NG/LST-Gm (dominant nodule)		Fulfilling key performance indicators
		NICE 3/Sano III			Presence of recurrence/residual polyp at 12 mo < 10%	Geraghty et al[40]
	Increased risk of incomplete resection/recurrence						Provided endoscopy list time for the additional workload with a dedicated list
		Size ≥ 40 mm			EMR perforation rate: < 2%
		Difficult location (ileocecal valve, appendix, diverticulum, dentate line)			Post-polypectomy bleeding rate: < 5%		Staff to include at least two endoscopists that can cover each other and endoscopy nurses with training in complex polypectomy
			DOPyS2
		Within an inflamed segment of the colon	ESGE3 curriculum for optical diagnosis[59]
		Prior failed resection attempt			Assessing competence: ≥ 80 % accuracy for identifying submucosal invasion in large (≥ 20 mm lesions), Maintaining competence: in vivo audit and review of at least 10 large (≥ 20 mm) lesions within a year		Equipment: including necessary snares and hemostatic devices
		Non-lifting sign
	Increased risk of adverse events						Surgeons for discussion in the MDT and case of operative treatment of adverse events
		Cecum
		Endoscopist´s expertise					Robust referral system including administrative staff support and tools for virtual MDT
ESGE criteria[21]
	Difficult location or poor access (ileocecal valve, periapendicular, anorectal junction)
	Prior failed resection attempts
	Non-lifting sign
	SMSA level 4

¹Enough to maintain quality standards.

²Direct Observation of Competence Skills (not specific for EMR).

³For achieving competence in optical diagnosis of early colorectal cancer.

⁴Review in conjunction with other key performance indicators.

BSG: British Society of Gastroenterology; EMR: Endoscopic mucosal resection; LST-NG: Non-granular lateral spreading tumor; LST-Gm: Granular mixed lateral spreading tumor; NICE: NBI International Colorectal Endoscopic classification; ESGE: European Society of Gastrointestinal Endoscopy; MDT: Multi-disciplinary team; DOPyS: Direct Observation of Competence Skills; SMSA: Site, Morphology, Size, Access.