Second-Surveillance Risk Hinges on Results of Prior Colonoscopies
Risk estimates are more accurate when clinicians consider serial findings rather than just the most recent exam.
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09/26/2025
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by Kerri Miller
Findings from a new analysis of 5,912 participants showed that the prevalence of advanced neoplasia at second surveillance increased depending on the risk combinations observed at earlier examinations. In particular, incorporating results from the prior colonoscopy helped refine risk stratification, demonstrating that certain baseline and first-surveillance findings were strongly associated with a higher likelihood of advanced neoplasia at the subsequent follow-up.
Among those with no adenoma at baseline, 4% had advanced neoplasia after at first surveillance, 7.2% after nonadvanced neoplasia, and 11.4% after advanced neoplasia. For participants with baseline nonadvanced neoplasia, the proportions were 5.4% after no adenoma, 9.1% after nonadvanced neoplasia, and 20.2% after advanced neoplasia. The highest proportions were seen in those with baseline advanced neoplasia: 9.1% after no adenoma, 12.8% after nonadvanced neoplasia, and 26.1% after advanced neoplasia at first surveillance, according to Pooja Pandita, MD, of the Department of Medicine, University of California San Diego, La Jolla, California, and colleagues.
"Although recent guidelines have generally moved towards less aggressive and longer surveillance intervals, our results support the importance of classifying groups that may benefit from closer follow-up," Dr. Pandita and fellow investigators wrote. By identifying patients with persistently high-risk findings, clinicians can tailor surveillance strategies to optimize outcomes—offering less frequent colonoscopies for those at low risk while advocating for close monitoring for those at higher risk."
They conducted a comprehensive systematic review of multiple databases across 11 observational studies. The analysis included studies that reported neoplasia yield at three time points: baseline colonoscopy, first post‑polypectomy surveillance, and second surveillance. Studies were conducted in the United States (6 studies), Asia (4 studies), and Europe (1 study), with colonoscopies performed between 1985 and 2014. Nine of the studies received high-quality ratings on standardized assessment tools.
The findings generally support the 2020 recommendations from the US Multisociety Task Force for serial surveillance but also highlight areas where refinements may be warranted. Notably, two scenarios emerged that deserve further research: a 9.1% prevalence of advanced neoplasia among patients with baseline nonadvanced followed by first-surveillance nonadvanced neoplasia, who are currently recommended for a 7- to 10-year follow-up; and a 12.8% prevalence among those with baseline advanced disease followed by first-surveillance nonadvanced neoplasia, who are recommended for a 5-year follow-up. The authors suggest heuristic thresholds as research frameworks rather than formal clinical guidance, proposing “aggressive” follow-up when prevalence exceeds approximately 15%, “intermediate” surveillance around 10%, and “relaxed” intervals near 5%. These benchmarks align with the roughly 5% advanced neoplasia detection rate seen in average-risk screening populations.
Substantial between study heterogeneity affected several risk strata, reflecting variations in surveillance intervals, risk definitions, and study populations across the nearly 30-year span. Surveillance protocols were not consistently standardized across studies.
Reporting of quality factors, such as bowel preparation quality and adenoma detection rates, was inconsistent. Patient-level variables, including aspirin use, body mass index, and smoking status, were limited. The definitions of advanced neoplasia categories also varied, reducing comparability. Outcomes related to serrated lesions could not be adequately assessed because of inconsistent reporting. Finally, most of the available data were derived from retrospective cohort studies, which further constrained interpretation.
Sensitivity analyses excluding influential studies modestly reduced heterogeneity without materially changing pooled estimates, supporting the robustness of findings.
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Summary content
7 Key Takeaways
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The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.