Postpolypectomy Guidelines Research Articles

Adherence to Recommendations for Repeat Surveillance After Publication of New Postpolypectomy Guidelines.

The 2012 and 2020 US Multi-Society Task Force postpolypectomy guidelines have recommended progressively longer surveillance intervals for patients with low-risk adenomas (LRAs). These guidelines require data from past colonoscopies. We examined the impact of the 2012 guidelines for second surveillance on clinical practice, including the availability of prior colonoscopy data, with the aim of informing the implementation of the 2020 guidelines. We identified surveillance colonoscopies at Stanford Health Care and the Palo Alto Veterans Affairs Health Care System in 3 periods: preguideline (March-August 2012), postguideline (January-June 2013), and delayed postguideline (July-September 2017). We collected data on the most recent previous colonoscopy, findings at the study entry surveillance colonoscopy, and recommendations for subsequent surveillance. Among 977 patients, the most recent prior colonoscopy data were available in 78% of preguideline, 78% of postguideline, and 61% of delayed postguideline cases (P < .001). The fraction of surveillance colonoscopy reports that deferred recommendations awaiting pathology increased from 6% to 11% in preguideline and postguideline to 59% in delayed postguideline cases (P < .001). Overall adherence to guidelines for subsequent surveillance was similar in all 3 periods (54%-67%; P= .089). In the postguideline and delayed postguideline periods combined, a 10-year subsequent surveillance interval was recommended in 0 of 29 cases with LRA followed by normal surveillance colonoscopy. In patients undergoing surveillance, prior colonoscopy data were not always available and recommendations were often deferred awaiting pathology. Adherence to subsequent surveillance guidelines was suboptimal, especially for LRA followed by normal colonoscopy. Strategies addressing these gaps are needed to optimize implementation of the updated 2020 postpolypectomy guidelines.

Transanal minimally invasive surgery - A single-center experience.

Transanal minimally invasive surgery (TAMIS) was described in the literature 10 years ago. This procedure requires laparoscopic technical skills. It has been well accepted widely worldwide. TAMIS has been applied to multiple procedures, including excision for rectal polyps and cancer, with acceptable outcomes. The study aimed to assess the outcomes of TAMIS in a large district general hospital. A retrospective study on prospectively collected data on 52 consecutive patients of TAMIS performed in a single unit was conducted between May 2014 and February 2020. Data were collected on patient demographics, clinical diagnosis, peri-operative findings, pathological findings, adequacy of excision and complications. Patients were followed up as per the trust and national post-polypectomy guidelines. Among the 52 patients, TAMIS procedures were completed in 50 patients, of which 31 were female. The procedure was successful in 96.5% but had to abandon in two cases. There was no conversion to another procedure. Pre-operative indications were rectal polyps and one case was an emergency TAMIS in a patient who was bleeding following incomplete colonoscopic polypectomy. The final histology reported that the majority were benign polyps (46), and only 11 cases were malignant. The median distance of the lesion from the anal verge was 6 cm (3-10 cm). The median operative time was 55 min (8-175 min). A total of 45 (77.5%) lesions were completely excised and had negative microscopic margins. Most patients (64%) were discharged home the same day. No complications were observed at a median follow-up of 20 months (6-48 months). There was no mortality. Our data suggest that TAMIS can be safely performed in a district general hospital for both benign and early rectal cancer. TAMIS was also able to control post-polypectomy bleeding and completion of rectal polypectomy. In selected cases, day-case TAMIS is safe and feasible.

Risk of developing metachronous colorectal neoplasia after the resection of proximal versus distal adenomas.

Current post-polypectomy guidelines do not consider adenoma location. We compared the risk of metachronous colorectal neoplasia (CRN) according to adenoma location. We collected data from 9710 patients who underwent follow-up colonoscopy after adenoma removal. Patients were classified according to baseline adenoma location: distal only (n=4665), proximal only (n=3827), and both sides (n=1218). The risk of metachronous CRN in patients with proximal only adenomas was higher than that in those with distal only adenomas (adjusted hazard ratio [aHR]=1.12, 95% confidence interval [CI]=1.04-1.21), while the risk of metachronous advanced CRN (ACRN) was not different between the two groups. Among patients aged <50 years, the risk of metachronous CRN in those with proximal only non-advanced adenomas (NAAs) was higher than that in those with only distal NAAs, while among patients aged ≥50 years, the risk in those with proximal only advanced adenomas (AAs) was higher than that in those with distal only AAs. However, the risk of metachronous ACRN did not differ based on adenoma location in patients aged <50 and ≥50 years. Proximal adenoma was associated with an increased risk of metachronous CRN, but not with an increased risk of metachronous ACRN, supporting the current guidelines recommending the same surveillance interval for distal and proximal adenoma without discrimination by adenoma location.

Post-polypectomy follow-up recommendations by practicing academic gastroenterologists-does number of years in practice matter?

Colorectal cancer (CRC) is the third most deadly and fourth most common cancer worldwide. Early detection, resection, and appropriate surveillance of precursor polyps result in better outcomes. Colonoscopy is a safe, accurate, and effective tool for surveillance and follow-up of premalignant polyps. Recommended surveillance intervals are based on polyp, procedural, and patient-related factors. The United States Multi-Society Task Force (MSTF) on CRC publishes guidelines with periodic updates on surveillance. We sought to evaluate adherence to post-polypectomy surveillance guidelines by academic gastroenterologists at a high-volume center. One-year retrospective study evaluating compliance with post-polypectomy recommendations after average risk adult screening colonoscopies. Data was collected on number and size of polyps, quality of bowel prep, initial follow-up recommendations, polyp pathology, and follow-up recommendations. Correlation with the 2012 MSTF guidelines was also evaluated. Endoscopist experience was categorized as greater or less than 10years of practice experience. Binomial regression was used to model the association between the providers' years of experience (<10 vs. >10) and the likelihood of agreement between initial assessment and post-pathology assessment. There was a greater than 85% adherence to post-polypectomy surveillance guidelines, independent of endoscopist experience. There is a high level of adherence to post-polypectomy guidelines by practicing academic gastroenterologists independent of post-fellowship clinical experience.

S237 Validation of Machine Learning Tool to Determine Post-Polypectomy Surveillance Intervals After Screening Colonoscopy in a Large Health System

Introduction: Accurate determination and documentation of post-polypectomy surveillance intervals after screening colonoscopy is essential to reduce colorectal cancer (CRC) incidence and mortality. However, this remains clinically challenging particularly in light of recent post-polypectomy guidelines that increase the number of surveillance intervals. In order to improve guideline-concordant surveillance after CRC screening, we sought to validate a previously developed natural language processing (NLP) algorithm that automates determination of post-polypectomy colonoscopy surveillance intervals. Methods: UCLA Health is a large, academic healthcare system performing over 15,000 screening colonoscopies per year. We previously developed an automated NLP pipeline to extract and analyze relevant polyp features from free-text colonoscopy (polyp number, size, location) and pathology reports (polyp histology) to determine appropriate post-polypectomy surveillance interval based on 2020 USMSTF guidelines (Figure 1). To validate the algorithm, we used a random selection of screening colonoscopies performed between 6/2/2020 and 2/2/2021 for individuals at average-risk for CRC. We determined the performance (sensitivity, specificity, PPV, F-score, accuracy) of the NLP algorithm to identify guideline-concordant surveillance intervals compared to manual chart review and characterized common errors made by the algorithm. Results: Our validation cohort (n = 469) was 50.3% female and mean age was 57.9 (SD = 7.3). The most common surveillance interval per chart review was 10-years (60.1%), followed by 7-10 years (22.8%) (Table 1). The NLP pipeline identified the appropriate surveillance interval after screening colonoscopy with an overall 82.6% sensitivity (range: 68.8-99.6%), 98.3% specificity (95.7-99.8%), 82.4% PPV (42.3-97.2%), 81.6% F-score (52.4-98%), and 97.6% accuracy (95.5-99.8%) (Table 1). Among the 58 cases misclassified by the NLP algorithm, 14 (25.9%) were allocated a longer surveillance interval than the manual gold standard. Conclusion: We developed an automated NLP algorithm that is moderately sensitive and highly specific at identifying appropriate surveillance intervals after screening colonoscopy. Future work will refine the algorithm to increase sensitivity and specificity. This tool will help providers and health systems achieve the ASGE/ACG Taskforce screening colonoscopy quality indicator goal that > 90% screening colonoscopies document a guideline-concordant surveillance interval.Figure 1.: Automated NLP Pipeline to Determine Guideline-Concordant Post-Polypectomy Surveillance Intervals (Gupta et al. 2020; US Multi-Society Task Force (MSTF)). HP, hyperplastic polyp; TA, tubular adenoma; SSP, sessile serrated polyp; TSA, total serrated polyp; TVA, tubulovillous adenoma; HGD, high-grade dysplasia.Table 1.: A) Surveillance colonoscopy interval determination from manual chart review versus NLP pipeline, N=469. B) Performance of the NLP algorithm to identify appropriate surveillance interval after screening colonoscopy, N=469

Development and clinical validation of a blood test for early detection of colorectal adenomas and cancer.

50 Background: Many of the 50,000 annual colorectal cancer (CRC) deaths can be attributed to 1/3 eligible Americans not following screening guidelines or approximately 1/2 of the population not adherent to the follow-up post-polypectomy guidelines. The new understanding of the natural history and shared etiology of adenomas and CRC inform integration of clinically relevant biomarkers. The two objectives of CRC screening and surveillance are early detection to improve survival and prevention of CRC through removal of adenomas using colonoscopy. Adenomas account for 98% of actionable colonoscopies. Stool tests have low sensitivity for advanced adenomas (AA, 24-42%). Methods: A prospective, blinded study was conducted at the VA Palo Alto Health Care System. Patients had blood drawn prior to colonoscopy. The test analyzes two biomarkers: circulating gastrointestinal epithelial cells and somatic mutations of cell-free DNA. The probability of advanced neoplasia was obtained by ordinal/nominal logistic regression methods together with SEER-incidence rate and prior history of AA on a training set of 346 subjects. The cutpoint for the quantitative score was fixed and the remaining 112 subjects were tested. Results: Interim results for 458 patients with no prior diagnosis of colorectal cancer (CRC) are presented. The cohort included both screening (239) and surveillance (219) subjects. Indications for colonoscopy were 86% asymptomatic and 14% with symptoms or positive-FIT. Balanced distribution of roughly 3/4th subjects in each disease category were randomly selected for training and algorithm development and the remaining 1/4th subjects were used for validation. A cutpoint was selected to obtain a test specificity (non-neoplastic finding or negative colonoscopy) of 90% resulting in a sensitivity of 100% and 80.0% for detection of CRC and advanced neoplasia (AN = CRC+AA), respectively, on the training subjects. The area under the ROC curve is 0.91. Validation using the fixed cutpoint and 112 test subjects achieved 91.4% specificity and 100% and 75.0% sensitivity for CRC and AN. Conclusions: This blood test has high sensitivity for colorectal advanced neoplasia while retaining high specificity. The quantitative nature of the score has the potential to enable stratification of patients for screening or post-polypectomy surveillance colonoscopy. [Table: see text]

Post-polypectomy surveillance colonoscopy: are we following the guidelines?

Polyps are a common finding on colonoscopy procedures. After completing polypectomy, patients are to be followed up with endoscopy. The purpose of the study was to assess the adherence of gastroenterologists to international post-polypectomy guidelines. Israeli gastroenterologists answered a questionnaire, consisting of 30 items, regarding the recommendation for post-polypectomy surveillance following colonoscopy. One hundred and twelve gastroenterologists, representing 23% of the total number of Israeli gastroenterologists, participated in this study, by responding to the web-based questionnaire (mean age is 47 ± 10years, males, 74 (66%)). From the total responses, 57.4% were compatible with the updated European post-polypectomy guidelines. The recommendations appeared remarkably inappropriate when applied to polyps that were identified as having low-risk tubular adenoma, tubular adenoma with high-grade dysplasia, and small serrated adenoma. In 37.2% of questionnaires, the recommended time to follow-up colonoscopy was shorter than currently stated in the guidelines. The appropriate polypectomy technique was chosen by 62% of the responses. Gastroenterologists younger than 45years of age adhered more strongly to the international guidelines, particularly in cases of piecemeal polypectomy or high-risk adenoma polypectomy. Gastroenterologists follow the clinical guidelines for post-polypectomy surveillance intervals partially. 57.4% of the recommendations were compatible with the guidelines, whereas 37% of the recommendations were for shorter interval.

Risk of developing metachronous advanced colorectal neoplasia after resection of low-risk diminutive versus small adenomas

Current postpolypectomy guidelines classify 1 to 2 diminutive (1-5mm) nonadvanced adenomas (NAAs) and 1 to 2 small (6-9mm) NAAs as low-risk adenomas and recommend the same surveillance interval for both lesions. We compared the risk of metachronous advanced colorectal neoplasia (ACRN) for both groups. We studied 8602 patients who underwent removal of≥1 NAA and follow-up colonoscopic surveillance. Patients were categorized into 4 groups based on size and number of baseline NAAs: group 1,≤2 diminutive NAAs (n= 6379); group 2,≤2 small NAAs (n= 1672); group 3,≥3 diminutive NAAs (n= 293); and group 4,≥3 small NAAs (n= 258). Size was classified based on the largest NAA. The 5-year cumulative incidence rates of metachronous ACRN in groups 1, 2, 3, and 4 were 2.7%, 5.1%, 10.7%, and 15.1%, respectively. Groups 2, 3, and 4 had a higher risk of metachronous ACRN than group 1. Compared with group 1, the adjusted hazard ratios for metachronous ACRN were 2.06 (95% confidence interval [CI], 1.46-2.91) for group 2, 2.75 (95% CI, 1.53-4.96) for group 3, and 4.49 (95% CI, 2.62-7.70) for group 4. However, the risk of metachronous ACRN was not significantly different between groups 3 and 4 (adjusted hazard ratio, 1.62; 95% CI, .76-3.44). Among patients with≤2 NAAs, patients with 1- to 5-mm NAAs had a lower risk of metachronous ACRN than those with 6- to 9-mm NAAs. The guidelines should consider extending surveillance intervals in patients with≤2 diminutive NAAs.

The predictive value of small versus diminutive adenomas for subsequent advanced neoplasia

Patients with previous colorectal adenomas are at increased risk of colorectal cancer. Current guidelines for postpolypectomy surveillance intervals treat all tubular adenomas 1 to 9mm in size with low-grade dysplasia as carrying the same level of risk. We evaluated whether 6 to 9mm adenomas detected at colonoscopy are associated with greater risk of advanced neoplasia at follow-up compared with baseline 1 to 5mm adenomas. We retrospectively evaluated a colonoscopy database at a single U.S. academic center. Patients with baseline examinations demonstrating tubular adenomas 1 to 9mm in size with low-grade dysplasia and no advanced adenomas were included. Follow-up colonoscopies were performed at least 200 days later and were assessed for incident advanced neoplasia (cancer, high-grade dysplasia, adenoma≥10mm in size, or villous elements). There were 2477 qualifying baseline colonoscopies. The absolute risk of metachronous advanced neoplasia increased from 3.6% in patients with 1 to 5mm adenomas to 6.9% in patients with at least 1 adenoma of 6 to 9mm (P= .001). Patients with 5 or more adenomas 1 of which was at least 6 to 9mm had the highest risk of advanced neoplasia at follow-up (10.4%, P= .006). When only screening colonoscopies were considered, all baseline groups (1-2 adenomas, 3-4 adenomas,≥5 adenomas) with adenomas 6 to 9mm in size had an increased risk for metachronous advanced neoplasia (odds ratio [OR], 4.07; 95% confidence interval [CI], 1.50-11.04; OR, 4.91; 95% CI, 1.44-16.75; OR, 4.71; 95% CI, 1.30-17.05, respectively). Patients with baseline small (6-9mm) adenomas have an increased risk of advanced lesions on follow-up compared with patients with only diminutive (1-5mm) adenomas. Postpolypectomy guidelines should consider risk stratification based on small versus diminutive adenomas.

Risk of Developing Metachronous Advanced Colorectal Neoplasia After Polypectomy in Patients With Multiple Diminutive or Small Adenomas.

Current post-polypectomy guidelines recommend a 3-year surveillance interval for ≥3 nonadvanced adenomas (NAAs) without discrimination between diminutive (1-5 mm) and small (6-9 mm) adenomas. We compared the risk of metachronous advanced colorectal neoplasia (ACRN) among these groups. We studied 9,733 patients who underwent ≥1 adenoma removal and follow-up colonoscopic surveillance. Patients were classified based on baseline adenoma characteristics: group 1, 1-2 NAAs (n = 8,051); group 2, ≥3 diminutive NAAs (n = 293); group 3, ≥3 small NAAs (n = 258); and group 4, advanced adenomas (AAs) (n = 1,131). The mean age of the study population was 45.8 ± 8.2 years. In group 4, most patients (94.5%) had 1 AA. The 3- and 5-year cumulative incidence rates of metachronous ACRN in groups 1, 2, 3, and 4 were 0.9%, 2.8%, 3.5%, and 4.0% and 3.1%, 10.7%, 15.1%, and 8.5%, respectively. Groups 2, 3, and 4 had a higher risk of metachronous ACRN than group 1. Compared with those for group 1, adjusted hazard ratios (95% confidence interval) for metachronous ACRN were 2.07 (1.16-3.68), 3.29 (1.94-5.56), and 2.73 (2.00-3.72) for groups 2, 3, and 4, respectively. However, this relationship was statistically insignificant between groups 2, 3, and 4. Compared with those for group 2, adjusted hazard ratios (95% confidence intervals) for groups 3 and 4 were 1.59 (0.76-3.30) and 1.32 (0.72-2.42), respectively, and 0.83 (0.47-1.46) for group 4 compared with group 3. The results of patients aged ≥50 years were identical to those of all patients. Risk of metachronous ACRN was not different between patients aged ≥50 years who underwent polypectomy of ≥3 diminutive NAAs, ≥3 small NAAs, and AA, thus supporting current guidelines that recommend a uniform surveillance interval for these lesions.

Colonoscopy quality requisites for selecting surveillance intervals: A World Endoscopy Organization Delphi Recommendation.

Different post-polypectomy guidelines underscore the need for high-quality baseline colonoscopy before appropriate surveillance recommendations can be made. Standards for colonoscopy practice have been advocated by gastrointestinal societies. Our aims were to define standards for the procedural practice of colonoscopy in this particular setting of surveillance and to generate a colonoscopy procedural quality checklist that could be implemented in clinical practice. This study was based on the Delphi process methodology. The baseline questionnaire included 12 domains and 56 individual statements. A total of three rounds were carried out between September 2015 and March 2016 until consensus or lack of consensus was reached. In total, consensus was reached on 27 statements in nine domains. High levels of agreement and consensus were reached that: (i) colonoscopy should be considered complete only if the whole cecum has been inspected, including the ileocecal valve and the appendiceal orifice (agreement score 4.63; degree of consensus 82%); (ii) quality of the bowel preparation should always be reported (agreement score 4.9, degree of consensus 94%); and (iii) it is preferable to use a segmental validated scale (agreement score 4.36, degree of consensus 86%). Consensus was also reached regarding multiple statements related to documentation of polyps and their resection. Finally, a colonoscopy quality checklist was drafted. Consensus on different statements regarding quality of colonoscopy has been reached. Based on this consensus, we propose a colonoscopy quality checklist that would be helpful for post-polypectomy surveillance recommendations.

Surveillance colonoscopy in Austria: Are we following the guidelines?

The European guidelines for quality assurance in colorectal cancer screening and diagnosis contain postpolypectomy surveillance recommendations. They recommend follow-up intervals depending on the findings at index colonoscopy, and divide patients into a low-, intermediate- or high-risk group. The aim of this study was to assess the adherence of Austrian endoscopists to the European guidelines and to determine whether sending a reminder letter resulted in better adherence. A single reminder letter containing the guidelines was sent to all endoscopists who participated in the Certificate of Quality for Screening Colonoscopy program in Austria. Adherence was assessed before and after the letter had been sent. Factors associated with adherence were investigated. We found poor baseline adherence to the guidelines. After the reminder letter, the adherence slightly improved in the low-risk group, but did not change in the intermediate-risk or high-risk groups. An adenoma detection rate of at least 20 % was associated with higher adherence rates. Generally, internists and hospitals showed better adherence compared with surgeons and private practices, respectively, both before and after the reminder letter. A single reminder letter was not enough to improve the poor adherence to the European postpolypectomy surveillance guidelines. Thus, future studies are required to identify and eliminate all factors responsible for nonadherence to postpolypectomy guidelines in order to reach the goal of a safe, effective, and cost-effective colorectal cancer prevention tool in the near future.

Low ADR is associated with poor adherence to post polypectomy surveillance guidelines

The 2010 published European post polypectomy guidelines contain recommendations for surveillance intervals after screening colonoscopies. Depending on the histological findings, patients are divided into three groups: low risk group (surveillance interval: 7 – 10 years), intermediate risk group (36 months) and high risk group (within 1 year).

Awareness of Postpolypectomy Surveillance Guidelines: A Nationwide Survey of Colonoscopists in Canada

Due to the increasing demand for colonoscopy, adherence to postpolypectomy surveillance guidelines is important. Suboptimal compliance can lead to unnecessary risks and ineffective use of resources. To determine the awareness of and adherence to postpolypectomy surveillance guidelines among members of the Canadian Association of Gastroenterology (CAG). A survey describing 14 clinical cases was mailed to all physician members (n=411) of the CAG. Respondents were required to recommend a surveillance interval and a reason for his or her choice. A total of 150 colonoscopists (37%) completed the survey. Adherence to the guidelines varied from 23% to 96% per clinical scenario (median 63%). Recommended surveillance intervals were too short in 0% to 60% of the different cases (median 8%). The recommended interval was most often (60%) too short for a patient with one tubular adenoma with high-grade dysplasia. Surveillance intervals were too long in 4% to 75% of the cases (median 9%). The recommended interval was most often too long in a patient with a villous adenoma 15 mm in size and removed piecemeal (75%). Most often, recommendations were reported to be based on guidelines (median 74%; range 31% to 94%). However, in nine of 14 cases, more than 10% (median 18%; range 12% to 38%) of the respondents stated that their recommendation was based on guidelines, but did not provide the appropriate surveillance interval. Compliance to colonoscopy surveillance guidelines is suboptimal and reflects both overuse and underuse. The results show that awareness about the content of guidelines needs to be raised and strategies implemented to increase adherence.

A Nationwide Survey Evaluating Adherence to Guidelines for Follow-up After Polypectomy or Treatment for Colorectal Cancer

Endoscopic follow-up (FU) in patients treated for colorectal adenomas or cancer (CRC) is intended to reduce the incidence of CRC. In the Dutch postpolypectomy guidelines, the FU interval is solely determined by the number of previous adenomas, whereas in other countries size and histology are also taken into account. Whether this difference in policy is also reflected in clinical practice is unknown. Furthermore, FU guidelines after CRC are not standardized in The Netherlands, even though national recommendations are available. To assess the adherence to the current Dutch postpolypectomy guidelines and to evaluate the FU policy after CRC resection. A survey was sent to all Gastrointestinal Departments in The Netherlands. The survey consisted of questions on logistic organization of FU, postpolypectomy FU intervals, and FU after CRC. The response rate was 85%. In contrast to the national guidelines, size and histology of the adenomas were often taken into account, leading to shortening of the FU interval. With respect to the CRC cases, 52% of the respondents advised shorter FU intervals than advised by the national recommendations. Despite recent Dutch postpolypectomy guidelines, clinicians incorporate histology and size into their clinical strategy. Either further education on the guidelines is needed, or the guidelines need to be reconsidered. Furthermore, evidence-based guidelines for FU after CRC should be formulated.

Improving compliance with postpolypectomy surveillance guidelines: an interventional study using a continuous quality improvement initiative

Despite guidelines, physicians tend to perform postpolypectomy surveillance colonoscopies too frequently. The objective of the study was to determine the baseline compliance rate with postpolypectomy guidelines in our unit and to determine the influence of a continuous quality improvement (CQI) intervention on improving the compliance rate and on decreasing the potential additional costs because of the scheduling of postpolypectomy surveillance colonoscopies earlier than indicated. This was a single-arm, pretest-posttest design. This study took place at a tertiary care, academic medical center. The medical records of all patients who underwent colonoscopy with polypectomy in our unit retrospectively during 6 months preceding (baseline period) and prospectively for 6 months after an intervention (postintervention period) were reviewed for patient demographics, colonoscopy findings, and scheduling of repeat colonoscopies. We used 3 components: (1) distribution of a wallet-size card with a summary of postpolypectomy guidelines to all endoscopists, (2) placement of guideline charts near computers used for typing endoscopy reports, and (3) distribution and reinforcement of the guidelines in a monthly continuous quality improvement meeting. The main outcome measures were compliance rates, mean times to repeat colonoscopy, and additional costs from surveillance colonoscopies being scheduled earlier than indicated were compared between the two periods. There were 278 patients in the baseline period and 242 in the postintervention period, with similar patient and polyp characteristics. After the intervention, the compliance rate with guidelines improved from 57.2% to 81% (p < 0.001). The mean time to a repeat colonoscopy increased from 4.5 to 5.2 years (p = 0.003) (i.e., a 14% reduction in the number of postpolypectomy surveillance colonoscopies performed per year). This would result in a reduction of a total of 73 surveillance colonoscopies per year in our unit, with a projected cost savings of 171,331 dollars per year (cost of a colonoscopy assumed at 2347 dollars). The limitation of the study was possible enhanced performance secondary to being observed (Hawthorne effect). Because more than 1 intervention was used, we do not know which one is more effective. Relatively simple and easy-to-implement quality improvement initiatives can significantly enhance compliance with postpolypectomy guidelines and result in cost savings because of a reduction in the number of postpolypectomy surveillance colonoscopies being scheduled earlier than recommended guidelines.