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Background & Aims: Patients with serrated polyposis syndrome (SPS) are advised to undergo endoscopic surveillance for early detection of polyps and prevention of colorectal cancer (CRC). The optimal surveillance and treatment regimen is unknown. We performed a prospective study to evaluate a standardized endoscopic treatment protocol in a large cohort of patients with SPS. Methods: We followed a cohort of patients with SPS who received annual endoscopic surveillance at the Academic Medical Centre in Amsterdam, The Netherlands from January 2007 through December 2012. All patients underwent clearing colonoscopy with removal of all polyps ≥3 mm. After clearance, subsequent follow-up colonoscopies were scheduled annually. The primary outcomes measure was the incidence of CRC and polyps. Secondary outcomes were the incidence of complications and the rate of preventive surgery. Results: Successful endoscopic clearance of all polyps ≥3 mm was achieved in 41 of 50 (82%) patients. During subsequent annual surveillance, with a median follow-up time of 3.1 years (interquartile range, 1.5−4.3 years), CRC was not detected. The cumulative risks of detecting CRC, advanced adenomas, or large (≥10 mm) serrated polyps after 3 surveillance colonoscopies were 0%, 9%, 34%, respectively. Twelve patients (24%) were referred for preventive surgery; 9 at initial colonoscopy and 3 during surveillance. Perforations or severe bleeding did not occur. Conclusions: Annual surveillance with complete removal of all polyps ≥3 mm with timely referral of selected high-risk patients for prophylactic surgery prevents development of CRC in SPS patients without significant morbidity. Considering the substantial risk of polyp recurrence, close endoscopic surveillance in SPS seems warranted. www.trialregister.nl ID NTR2757. [Copyright &y& Elsevier]

Abstract: Serrated polyps represent a heterogeneous group of lesions, some of which have well-documented malignant potential. The histological classification of serrated polyps has evolved over the last two decades to recognize three major subtypes: hyperplastic polyp, sessile serrated adenoma/polyp and traditional serrated adenoma. Sessile serrated adenoma/polyp remains under-diagnosed while it represents up to 25% of all serrated polyps and is the precursor lesion to colorectal carcinoma evolving though the serrated neoplasia pathway with BRAF mutation and CpG island methylator phenotype. Pathologists need to be aware of the World Health Organisation criteria to correctly diagnose each entity as patient management guidelines are based upon the use of this classification. Serrated polyposis is an under-recognized syndrome with unknown genetic cause conferring an increased risk of colorectal carcinoma. Pathologists have a pivotal role in identifying these patients who should undergo yearly surveillance colonoscopy. [Copyright &y& Elsevier]