Personalized endoscopic surveillance and intervention protocols for patients with familial adenomatous polyposis: the European FAP Consortium strategy

Abstract

Background and aims Patients with familial adenomatous polyposis (FAP) undergo colectomy and lifelong endoscopic surveillance to prevent colorectal, duodenal and gastric cancer. Endoscopy has advanced importantly in the past years, including both detection technology as well as treatment options. For the lower gastrointestinal (GI) tract, current guidelines do not provide clear recommendations for surveillance intervals. Furthermore, the Spigelman staging system for duodenal polyposis has its limitations. We present a newly developed personalized endoscopic surveillance strategy for the lower and upper GI tract, aiming to improve the care for patients with FAP. We aim to inform centers caring for FAP patients and encourage the discussion on optimizing endoscopic surveillance and treatment in this high-risk population. Methods The European FAP Consortium, consisting of endoscopists with expertise in FAP, collaboratively developed new surveillance protocols. The proposed strategy was consensus-based and a result of several consortium meetings, discussing current evidence and limitations of existing systems. This strategy provides clear indications for endoscopic polypectomy in the rectum, pouch, duodenum and stomach and defines new criteria for surveillance intervals. This strategy will be evaluated in a 5-year prospective study in 9 FAP expert centers in Europe. Discussion We present a newly developed personalized endoscopic surveillance and endoscopic treatment strategy for patients with FAP aiming to prevent cancer, optimize endoscopic resources and limit the number of surgical interventions. Following this new strategy, prospectively collected data in a large cohort of patients will inform us on the efficacy and safety of the proposed approaches. Trial registration: NCT04678011, NCT04677998

Endoscopic indicators in patients with familial adenomatous polyposis undergoing duodenal resections – a nationwide Danish cohort study with long-term follow-up

“…The evolving role of endoscopic interventions, particularly polypectomy, EMR and endoscopic papillectomy in managing duodenal lesions in FAP cannot be understated 20 31 32 . While they offer signi cant advantages over surgical modalities, a comprehensive, individualized approach is crucial to ensure optimal patient outcomes 12 . Further studies, preferably comparative, that focus on long-term outcomes and newer endoscopic techniques, are eagerly awaited.…”

“…Although the Spigelman classi cation has been validated, it tends to underestimate the importance of ampullary lesions and does not closely correlate with the risk of duodenal cancer [8][9][10][11] . Additionally, it requires obtaining biopsies from duodenal lesions that many endoscopists would prefer to remove completely, either by simple polypectomy or endoscopic mucosal resection (EMR) [12][13][14] .…”

Outcomes following duodenectomy in patients with familial adenomatous polyposis

“…Currently, endoscopic upper gastrointestinal surveillance protocols exist only for patients who have not undergone duodenectomy [22,23]. Centers use a "neo-Spigelman stage" for jejunum assessment after surgery, which does not take into account gastric findings.…”

Cold snare polypectomy for duodenal adenomas in familial adenomatous polyposis: a prospective international cohort study

“…Numbers are too small to further study this in the present series. In our current endoscopic surveillance protocol, we do not advise taking routine biopsies to prevent submucosal scarring [26]. Another factor that might increase the adverse event risk is the morphology of the adenoma.…”