A simple method to improve adenoma detection rate during colonoscopy: Altering patient position

BACKGROUND:

Colonoscopy is currently considered to be the gold standard method for detecting and removing adenomatous polyps. However, tandem colonoscopy studies reveal a pooled polyp miss rate of 22%.

OBJECTIVE:

A prospective randomized trial was conducted to assess whether alteration of patient position during colonoscopy withdrawal increases the adenoma detection rate (ADR).

METHOD:

The study group included 120 patients who presented for elective colonoscopic examination. After reaching the cecum, patients were randomly assigned in a 1:1 ratio to examination in either the left lateral position or other positions (left lateral position for the cecum, ascending colon and hepatic flexure; supine for transverse colon; and supine and right lateral position for splenic flexure, descending and sigmoid colon) first. Examination of the colon was performed segment by segment. The size, morphology and location of all polyps were recorded. Polyps were removed immediately after examination of a colon segment when all positions were completed. ADR and polyp detection rates (PDR) were calculated.

RESULTS:

A total of 102 patients completed the study. Examination in the left lateral position revealed 66 polyps in 31 patients (PDR 30.3%) and 42 adenomas in 24 patients (ADR 23.5%). PDR increased to 43.1% (81 polyps in 44 patients) and the ADR to 33.3% (53 adenomas in 34 patients) after the colon was examined in the additional positions (P<0.001 and P=0.002, respectively). The increase in the number of adenomas detected was statistically significant in the transverse and sigmoid colon. The addition of position changes led to a 9.8% increase in the ADR in the transverse colon, splenic flexure, and descending and sigmoid colon. The frequency of surveillance interval was shortened in nine (8.8%) patients after examination of the colon in dynamic positions.

CONCLUSION:

Alteration of patient position during colonoscopy withdrawal is a simple and effective method to improve ADR.     

Simple colonoscopy reporting system checking the detection rate of colon polyps

AIM: To present a simple colonoscopy reporting system that can be checked easily the detection rate of colon polyps.METHODS: A simple colonoscopy reporting system Kosin Gastroenterology (KG quality reporting system) was developed. The polyp detection rate (PDR), adenoma detection rate (ADR), serrated polyp detection rate (SDR), and advanced adenoma detection rate (AADR) are easily calculated to use this system.RESULTS: In our gastroenterology center, the PDR, ADR, SDR, and AADR test results from each gastroenterologist were updated, every month. Between June 2014, when the program was started, and December 2014, the overall PDR and ADR in our center were 62.5% and 41.4%, respectively. And the overall SDR and AADR were 7.5% and 12.1%, respectively.CONCLUSION: We envision that KG quality reporting system can be applied to develop a comprehensive system to check colon polyp detection rates in other gastroenterology centers.     

Efficacy of cap-assisted colonoscopy according to lesion location and endoscopist training level

AIM: To evaluate the efficacy of cap-assisted colonoscopy(CAC) for detection of colorectal polyps and adenomas according to the lesion location and endoscopist training level.METHODS: Patients 20 years or older, who underwent their first screening colonoscopy in a single tertiary center from May 2011 to December 2012 were enrolled in this study. All patients underwent either CAC or standard colonoscopy(SC), and all of the procedures were performed by 11 endoscopists(8 trainees and 3 experts). All procedures were performed with highdefinition colonoscopes and narrow band imaging. The eight trainees had experiences of performing 150 to 500 colonoscopies, and the three experts had experiences of performing more than 3000 colonoscopies. A 4-mmlong transparent cap was attached to the end of a colonoscope in the CAC group. We retrospectively evaluated the number of polyps and adenomas, polyp detection rate(PDR), and the number of adenomas and adenoma detection rate(ADR) according to the lesion location and endoscopist training level between CAC and SC. We also evaluated the number of polyps and adenomas according to their size between CAC and SC.RESULTS: Overall, PDR and ADR using CAC were significantly higher than those using SC for both whole colon(48.5% vs 40.7%, P = 0.012; 35.7% vs 28.3%, P = 0.012) and right-side colon(35.3% vs 26.6%, P = 0.002; 27.0% vs 16.9%, P 0.001). The number of polyps and adenomas per patient using CAC was significantly higher than that using SC for both the whole colon(1.07 ± 1.59 vs 0.82 ± 1.31, P = 0.008; 0.72 ± 1.32 vs 0.50 ± 1.01, P = 0.003) and right-side colon(0.66 ± 1.18 vs 0.41 ± 0.83, P 0.001; 0.46 ± 0.97 vs 0.25 ± 0.67, P 0.001). In the trainee group, the PDR and ADR using CAC were significantly higher than those using SC for both the whole colon(46.7% vs 39.7%, P = 0.040; 33.9% vs 26.0%, P =0.012) and right-side colon(34.2% vs 26.5%, P = 0.015; 25.3% vs 15.9%, P = 0.001). In the expert group, the PDR and ADR using CAC were significantly higher than those using SC only for the right-side colon(42.1% vs 27.0%, P =0.035; 36.8% vs 21.0%, P = 0.020).CONCLUSION: CAC is more effective than SC for detection of colorectal polyps and adenomas, especially when performed by trainees and when the lesions are located in the right-side colon.     

Association of trainee participation with adenoma and polyp detection rates

AIM To investigate whether adenoma and polyp detection rates(ADR and PDR, respectively) in screening colonoscopies performed in the presence of fellows differ from those performed by attending physicians alone. METHODS We performed a retrospective review of all patients who underwent a screening colonoscopy at Grady Memorial Hospital between July 1, 2009 and June 30, 2015. Patients with a history of colon polyps or cancer and those with poor colon preparation or failed cecal intubation were excluded from the analysis. Associations of fellowship training level with the ADR and PDR relative to attendings alone were assessed using unconditional multivariable logistic regression. Models were adjusted for sex, age, race, and colon preparationquality. RESULTS A total of 7503 colonoscopies met the inclusion criteria and were included in the analysis. The mean age of the study patients was 58.2 years; 63.1% were women and 88.2% were African American. The ADR was higher in the fellow participation group overall compared to that in the attending group: 34.5% vs 30.7%(P = 0.001), and for third year fellows it was 35.4% vs 30.7%(a OR = 1.23, 95%CI: 1.09-1.39). The higher ADR in the fellow participation group was evident for both the right and left side of the colon. For the PDR the corresponding figures were 44.5% vs 40.1%(P = 0.0003) and 45.7% vs 40.1%(a OR = 1.25, 95%CI: 1.12-1.41). The ADR and PDR increased with increasing fellow training level(P for trend 0.05).CONCLUSION There is a stepwise increase in ADR and PDR across the years of gastroenterology training. Fellow participation is associated with higher adenoma and polyp detection.     

Feasibility of full-spectrum endoscopy:Korea’s first full-spectrum endoscopy colonoscopic trial

AIM: To evaluate the full-spectrum endoscopy(FUSE) colonoscopy system as the first report on the utility thereof in a Korean population.METHODS: We explored the efficacy of the FUSE colonoscopy in a retrospective, single-center feasibility study performed between February 1 and July 20, 2015. A total of 262 subjects(age range: 22-80) underwent the FUSE colonoscopy for colorectal cancer screening, polyp surveillance, or diagnostic evaluation. The cecal intubation success rate, the polyp detection rate(PDR), the adenoma detection rate(ADR), and the diverticulum detection rate(DDR), were calculated. Also, the success rates of therapeutic interventions were evaluated with biopsy confirmation.RESULTS: All patients completed the study and the success rates of cecal and terminal ileal intubation were 100% with the FUSE colonoscope; we found 313 polyps in 142 patients and 173 adenomas in 95. The overall PDR, ADR and DDR were 54.2%, 36.3%, and 25.2%, respectively, and were higher in males, and increased with age. The endoscopists and nurses involved considered that the full-spectrum colonoscope improved navigation and orientation within the colon.No colonoscopy was aborted because of colonoscope malfunction.CONCLUSION: The FUSE colonoscopy yielded a higher PDR, ADR, DDR than did traditional colonoscopy, without therapeutic failure or complications, showing feasible, effective, and safe in this first Korean trial.     

Full spectrum endoscopy (FUSE) versus standard forward-viewing endoscope (SFV) in a high-risk population

Objectives: To investigate the diagnostic performance of Full Spectrum Endoscopy (FUSE) compared to a conventional standard forward-viewing endoscope (SFV). The primary outcome was adenoma detection rate (ADR) and mean adenoma detection. Secondary outcome was feasibility of FUSE opposed to SFV.

Materials and methods: Consecutive patients participating in the Danish colorectal cancer (CRC) screening programme were prospectively included in the study (n?=?205). Demographic and health-related characteristics were obtained. Following procedural parameters were recorded: completion rate, caecal intubation time, fentanyl and midazolam sedation, CRC detection, ADR, diverticulosis, bowel preparation, patient discomfort and endoscopist difficulty rating. Participants underwent FUSE colonoscopy on days when the FUSE system was available, while the remaining participants had SFV. All colonoscopies were performed by two trained endoscopists.

Results: A total of 109 patients were included in the FUSE group and 106 in the SFV group. Groups were comparable in baseline characteristics. Completion rate was 83.5% and 93.4% in the FUSE and SFV groups (p?=?.040). Caecal intubation time was 11.4?±?6.7?min versus 9.1?±?6.2?min in the FUSE and SFV groups (p?=?.040). ADR was 67.0% and 59.6% (p?=?.097), while the mean adenoma detection was 1.79 and 1.38 (p?=?.022) in the FUSE and SFV groups. Endoscopists reported increased difficulty rating with FUSE compared to SFV (p?>?.001).

Conclusion: FUSE colonoscopy provides a higher mean adenoma detection and there is tendency toward higher ADR compared to SFV in a high-risk population. Nonetheless, FUSE colonoscopy has a lower completion rate, longer caecal intubation time and a higher difficulty rating from an endoscopist point of view.     

Seeing better- Evidence based recommendations on optimizing colonoscopy adenoma detection rate

Colorectal cancer is one of the three most frequent causes of cancer deaths in men and women in Europe and North America. Diagnosis and resection of adenomas has convincingly demonstrated its utility in diminishing colorectal cancer incidence. Therefore, colonoscopy is now the gold standard for colorectal cancer screening. But it is also known that colonoscopy effectiveness varies among endoscopists. Among different quality indicators, the most used is the adenoma detection rate(ADR) which is the percentage of average-risk patients for colorectal cancer who are found to have at least one adenoma or adenocarcinoma during a screening colonoscopy. There is compelling evidence supporting an inverse correlation between ADR and interval colorectal cancer(cancer found after a screening colonoscopy). Many factors such as quality of precolonoscopy preparation, additional observers, manoeuvres with the endoscope(second view, retroflexion, water inflation rather than air), time spent during withdrawal, changes in patient position, foldflattener devices, new imaging or endoscopic modalities and use of intravenous or through the scope sprayed drugs, have been studied and developed with the aim of increasing the ADR. This reviews discusses these factors, and the current evidence, to "see better" in the colon and optimize ADR.     

Comparison of adenoma detection rate and adenoma per colonoscopy as a quality indicator of colonoscopy

Background: Although adenoma detection rate (ADR) has been proposed as a quality indicator of colonoscopies, adenomas per colonoscopy (APC) is a promising alternative to ADR, as it reflects inspection over the entire length of the colon. This study investigated the correlation between ADR and APC, and compared the efficacy of ADR and APC based on the correlation of each with the advanced adenoma detection rate (AADR).

Study: Two prospectively collected databases, including the 1142 subjects who underwent screening colonoscopies by 28 colonoscopists, were retrospectively reviewed. AADR1 were definded as the proportion of participants having advanced neoplasms, and AADR2 were definded as the proportion of participants having advanced neoplasms or three or more adenomas. Pearson correlation and Steiger’s z-test was used to evaluate the relationship between ADR-APC, ADR-AADR and APC-AADR.

Results: The ADRs ranged from 16.67 to 66.67% (mean, 37.29%) and APCs ranged from 0.22 to 1.28 (mean, 0.65). The ADR and APC showed a significant correlation (R?=?0.82; p?R?=?0.60; p?=?0.001 and R?=?0.64; p?R?=?0.65; p?R?=?0.77; p?p?=?0.04).

Conclusions: Colonoscopists’ ADRs and APC were significantly correlated. Moreover, as the correlation coefficient for AADR was higher with APC than it was with ADR, APC might be a better quality indicator of colonoscopy than ADR.     

结直肠癌平均风险人群结肠镜检查的息肉与腺瘤检出率及其年龄分布情况

目的探讨我国结直肠癌平均风险人群结肠镜检查中的息肉检出率和腺瘤检出率及其年龄分布情况,为确定我国结直肠癌筛查起始年龄提供线索和数据支持。方法采用回顾性分析方法,调取2010年3月至2013年2月间进行“体检肠镜”检查的患者资料,按照不同性别、年龄组、肠道准备质量分别计算息肉检出率和腺瘤检出率。各组间率比较采用z。检验。结果共有1928例患者完成体检全结肠镜检查。总的息肉检出率为19．55％[95％CI（17．78％-21．32％）],男性为23．87％,女性为10．00％。40～70岁各年龄组息肉检出率男性均显著高于女性（P〈0．05）。总的腺瘤检出率为11．48％[95％CI（9．69％～13．28％）],男性为14．68％,女性为5．11％。40—70岁各年龄组腺瘤检出率男性均显著高于女性（P〈0．05）。肠道准备优良组息肉检出率显著优于较差组（P〈0．05）。结论息肉检出率和腺瘤检出率均随年龄增长而提高,男性较之女性有更大的息肉、腺瘤发生风险。肠道准备质量对息肉检出率有直接的影响。     

Endoscopy Nurse Participation May Increase the Polyp Detection Rate by Second-Year Fellows during Screening Colonoscopies

Background/Aims

The aim of this study was to assess the effects of endoscopy nurse participation on polyp detection rate (PDR) and adenoma detection rate (ADR) of second-year fellows during screening colonoscopies.

Methods

This was a single-center, prospective, randomized study comparing a fellow alone and a fellow plus an endoscopy nurse as an additional observer during afternoon outpatient screening colonoscopies. The primary end points were PDR and ADR.

Results

One hundred ninety-one colonoscopies performed by a fellow alone and 192 colonoscopies performed by a fellow plus an endoscopy nurse were analyzed. The PDR was significantly higher when the nurse was involved (53.1% vs. 41.3%, p<0.05); however, there was no significant difference in the ADR between the two groups (38.5% vs. 29.8%, p=0.073). There was no difference in the percentage of patients with ≥2 polyps, advanced adenomas, polyp size, polyp location, and polyp shapes between the two groups. There was no difference in the PDR according to the level of experience of the endoscopy nurse.

Conclusions

Endoscopy nurse participation as an additional observer during screening colonoscopy performed by second-year fellow increases the PDR; however, the level of experience of the nurse was not an important factor.     

Correlation between adenoma detection rate and novel quality indicators for screening colonoscopy. A proposal for quality measures tool kit

Background and aims: Adenoma detection rate (ADR) is the most validated quality indicator for colonoscopy. Calculating ADR may not yield information in regards to advanced adenoma detection rate (advanced ADR). In addition, calculating ADR for individual endoscopists cannot distinguish between those who find only one versus more than one adenoma per colonoscopy. Several novel quality indictors were recently proposed to ensure adequate assessment of quality during colonoscopy. Our study aims to determine the correlation between ADR and novel quality indicators.

Methods: A retrospective cohort study of patients undergoing screening colonoscopy in a university hospital setting. Patient characteristics and colonoscopy findings were combined and analyzed to calculate the correlation of ADR with novel quality indicators using Spearman’s rank-order correlation were used.

Results: A total of 1433 patients out of 2116 patients met the inclusion criteria. There was a significant positive correlation between ADR correlated with [advanced-ADR-2, nonadvanced-ADR, adenoma per colonoscopy, Multiplicity detection rate and ADR-Plus] r?=?(0.82, 0.99, 0.99, 0.07 and 0.85), respectively. However, ADR did not correlate with advanced-ADR and adenomas per positive participant.

Conclusion: Adding advanced-ADR and adenomas per positive participant to ADR may create a more comprehensive quality indicators tool kit, which is sensitive and difficult to game. Future studies are needed to investigate the impact of the tool kit on the interval cancers and adenoma missing rate.     

Intraprocedural bowel cleansing with the Jet Prep cleansing system improves adenoma detection

AIM: To investigate the impact of Jet Prep cleansing on adenoma detection rates.METHODS: In this prospective,randomized,crossover trial,patients were blindly randomized to an intervention arm or a control arm.In accordance with the risk profile for the development of colorectal carcinoma,the study participants were divided into high-risk and low-risk groups.Individuals with just one criterion(age 70 years,adenoma in medical history,and first-degree relative with colorectal cancer) were regarded as high-risk patients.Bowel preparation was performed in a standardized manner one day before the procedure.Participants in the intervention arm underwent an initial colonoscopy with standard bowel cleansing using a 250-m L syringe followed by a second colonoscopy that included irrigation by the use of the Jet Prep cleansing system.The reverse sequence was used in the control arm.The study participants were divided into a high-risk group and a low-risk group according to their respective risk profiles for the development of colorectal carcinoma.RESULTS: A total of 64 patients(34 men and 30 women) were included in the study; 22 were included in the high-risk group.After randomization,30 patients were assigned to the control group(group A) and 34 to the intervention group(group B).The average Boston Bowel Preparation Scale score was 5.15 ± 2.04.The withdrawal time needed for the first step was significantly longer in group A using the Jet Prep system(9.41 ± 3.34 min) compared to group B(7.5 ± 1.92 min).A total of 163 polyps were discovered in 64 study participants who underwent both investigation steps.In group A,49.4% of the polyps were detected during the step of standard bowel cleansing while the miss rate constituted 50.7%.Group B underwent cleansing with the Jet Prep system during the first examination step,and as many as 73.9% of polyps were identified during this step.Thus,the miss rate in group B was a mere 26.1%(P 0.001).When considering only the right side of the colon,the miss rate in group A during the first examination was 60.6%,in contrast to a miss rate of 26.4% in group B(P 0.001).CONCLUSION: Jet Prep is recommended for use during colonoscopy because a better prepared bowel enables a better adenoma detection,particularly in the proximal colon.     

Técnicas colonoscópicas para la detección de pólipos: un estudio egipcio

Introduction and aimsThe polyp detection rate (PDR) is defined as the percentage of colonoscopies in which one or more polyps are detected, and has been shown to be highly correlated with the adenoma detection rate. The aim of the present study was to evaluate the PDR at the Endoscopy Unit of the Kasr Al-Ainy Hospital, Cairo University, Egypt, through the i-SCAN, Endocuff, and underwater colonoscopy techniques.Materials and methodsThe study was conducted on 100 Egyptian subjects over 50 years of age. Their polyp detection rate was measured through 4 different colonoscopic techniques. An equal number of patients were divided into 4 groups: i-SCAN, Endocuff, underwater colonoscopy, and controls. The control group was examined using standard white light colonoscopy. The colonoscopy evaluation included the type of agent utilized for bowel preparation, preparation grade, and colonoscopy withdrawal time.ResultsThe general PDR was 48%. The i-SCAN technique had the highest rate (56%), followed by the underwater (52%) and the Endocuff (48%) techniques.ConclusionThe i-SCAN and underwater colonoscopy techniques produced higher PDR than the Endocuff-assisted and standard techniques, but with no statistical significance.     

Quality indicators for colonoscopy in Egypt: A prospective multicenter study

Background and Study AimsDespite its wide availability, we do not have sufficient data about the quality of colonoscopy in Egypt. In this study, we proposed 13 indicators to assess the quality of colonoscopy procedures in the included study centers aiming to attain a representative image of the quality of CS in Egypt.Patients and MethodsA multicenter prospective study was conducted between July and December 2020, which included all patients who underwent colonoscopy in the participating centers. The following were the proposed quality indicators: indications for colonoscopy, preprocedure clinical assessment, obtaining written informed consent, adequate colon preparation, sedation, cecal intubation rate (CIR), withdrawal time, adenoma detection rate (ADR), complication rate, photographic documentation, automated sterilization, regular infection control check, and well-equipped postprocedure recovery room.ResultA total of 1,006 colonoscopy procedures were performed during the study duration in the included centers. Our analysis showed the following four indicators that were fulfilled in all centers: appropriate indications for colonoscopy, preprocedure assessment, written informed consent, and automated sterilization. However, photographic documentation and postprocedure follow-up room were fulfilled only in 57 %. Furthermore, 71 % of the centers performed regular infection control checks. Adequate colon preparation was achieved in 61 % of the procedures, 81 % of the procedures were performed under sedation, 95.4 % CIR, 11-min mean withdrawal time, 15 % ADR, and 0.1 % overall complication rate. Statistically significant factors affecting CIR were age > 40 years, high-definition endoscope, previous colon intervention, and rectal bleeding, whereas those affecting ADR were age > 40 years, the use of image enhancement, previous colon intervention, rectal bleeding, the use of water pump, and a withdrawal time of > 9 min.ConclusionOur study revealed the bright aspects of colonoscopy practice in Egypt, including high CIRs and low complication rates; conversely, ADR, bowel cleansing quality, and infection control measures should be improved.     

Latest Generation High-Definition Colonoscopy Increases Adenoma Detection Rate by Trainee Endoscopists

Background

Adenoma detection rate (ADR) is an important quality indicator of colonoscopy. High-definition (HD) colonoscopy has been reported to increase ADR compared to standard-definition (SD) colonoscopy. Although there are few reports comparing the latest generation and the previous generation of HD colonoscopy equipment, there are reports that the latest generation colonoscopy equipment improves ADR. However, there are no reports on the impact of the latest generation HD colonoscopy on the ADR of trainee endoscopists.

Aims

The aim of this study was to investigate whether the latest generation HD colonoscopy increases the ADR of trainee endoscopists compared with the previous generation HD colonoscopy.

Method

We conducted a retrospective review of medical records of patients aged 40–79 years old, who underwent screening or surveillance colonoscopy performed by nine gastroenterology fellows at Dong-A University Hospital from March 2019 to February 2020. We calculated the overall ratios of the ADR: the ADRs of the group using the older generation HD colonoscopy equipment and the group using the latest HD colonoscopy equipment. Polyp detection rate (PDR), sessile serrated polyp detection rate (SSPDR), and advanced neoplasia detection rate (ANDR) were calculated for each group. Factors related to adenoma detection were identified using logistic regression analysis.

Results

Altogether, 2189 patients were included in the study (the older HD colonoscopy group comprising 1183 and the latest HD colonoscopy group comprising 1006). We found that PDR (45.98 vs. 51.69%, p?=?0.008) and ADR (35.67 vs. 40.85%, p?=?0.013) were significantly higher in the latest generation HD colonoscopy group. The generational differences were not statistically significant for SSPDR (1.94 vs. 2.78%, p?=?0.195) or ANDR (4.65 vs. 4.97%, p?=?0.726). In the multivariate regression analysis, age, male sex, the latest generation HD colonoscopy, and long withdrawal time were the most significant factors affecting adenoma detection.

Conclusions

The latest generation HD colonoscopy improved PDR and ADR by trainee endoscopists. These findings suggest that latest generation, higher-resolution colonoscopy equipment can improve the quality of colonoscopy for less experienced endoscopists.

     

Artificial intelligence technologies for the detection of colorectal lesions: The future is now

Several studies have shown a significant adenoma miss rate up to 35% during screening colonoscopy, especially in patients with diminutive adenomas. The use of artificial intelligence(AI) in colonoscopy has been gaining popularity by helping endoscopists in polyp detection, with the aim to increase their adenoma detection rate(ADR) and polyp detection rate(PDR) in order to reduce the incidence of interval cancers. The efficacy of deep convolutional neural network(DCNN)-based AI system for polyp detection has been trained and tested in ex vivo settings such as colonoscopy still images or videos. Recent trials have evaluated the real-time efficacy of DCNN-based systems showing promising results in term of improved ADR and PDR. In this review we reported data from the preliminary ex vivo experiences and summarized the results of the initial randomized controlled trials.     

Patient age and duration of colonoscopy are predictors for adenoma detection in both proximal and distal colon

AIM: To investigate the relation of patient characteristics and procedural parameters to the endoscopic detection rate of colonic adenomas. Further to study,which factors may be capable to predict the localization of adenomatous lesions.METHODS: We used the data base of a prospective randomized colonoscopy study(The Colo Cap trial) to identify patients being diagnosed with colon adenoma. Logistic regression analysis was conducted to reveal predictors for adenoma detection in the entire colon and also with respect to the proximal and distal part. Covariates including age, gender, duration of colonoscopy and comorbidities were defined to determine association between predictors and adenoma detection.RESULTS: Equal numbers of adenomas were detected in the proximal and distal side of the splenic flexure [126(57%) vs 94(43%), P = 0.104]. Simultaneous occurrence of adenomas in both sides of the colon was rare. The appearance of both proximal and distal adenoma was associated with increasing age(P = 0.008 and P = 0.024) and increasing duration of colonoscopy(P < 0.001 and P = 0.001). Male gender was a predictor for adenoma detection in the proximal colon(P = 0.008) but statistical significance was slightly missed with respect to the distal colon(P = 0.089). Alcohol abuse was found to be a predictor for the detection of distal adenoma(P = 0.041). CONCLUSION: Increasing age and longer duration of colonoscopy are factors with a strong impact on adenoma detection both in the proximal and distal colon. Since proximal adenomas occurred in absence of distal adenomas, complete colonoscopy should be performed for screening.     

Lack of Impact on Polyp Detection by Fellow Involvement During Colonoscopy: A Meta-Analysis

Background

Conflicting data regarding the impact of fellow involvement during colonoscopy on the adenoma detection rate (ADR) and polyp detection rate (PDR) have been reported in the literature.

Aims

Our aim was to perform a meta-analysis to determine the impact of fellow participation during colonoscopy on the ADR and PDR.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, pertinent articles that reported ADR and/or PDR between attending physicians alone compared to gastroenterology fellows with attending physicians were obtained through database searches. Data was abstracted and pooled using a random effects model. The quality of each included study was ascertained using a modified version of the Quality Assessment of Diagnostic Accuracy Studies tool, and potential publication bias was assessed.

Results

A total of 14 articles that included 21,504 colonoscopies met the inclusion criteria. The overall PDR and ADR were 44.4 and 30.8 %, respectively. No significant differences were found between participant characteristics and colonoscopies performed with or without fellow participation. No significant differences were found in the relative rate of ADR (1.04, 95 % CI 0.94–1.15) or PDR (1.03, 95 % CI 0.93–1.14) with or without a fellow. An important limitation is that none of the included studies randomized fellow involvement.

Conclusions

Involvement of a fellow during colonoscopy did not affect adenoma and polyp detection rates.     

Technical interventions to increase adenoma detection rate in colonoscopy

Introduction: Adenoma detection rate (ADR) is the most robust colonoscopy quality metric and clinical studies have adopted it as the ideal method to assess the impact of technical interventions.

Areas covered: We reviewed papers focusing on the impact of colonoscopy technical issues on ADR, including withdrawal time and technique, second evaluation of the right colon, patient positional changes, gastrointestinal assistant participation during colonoscopy, water-aided technique, optimization of bowel preparation and antispasmodic administration.

Expert commentary: Overall, technical interventions are inexpensive, available worldwide and easy to implement. Some of them, such as the adoption of split dose regimen and slow scope withdrawal to allow a careful inspection, have been demonstrated to significantly improve ADR. Emerging data support the use of water-exchange colonoscopy. According to published studies, other technical interventions seem to provide only marginal benefit to ADR. Unfortunately, the available evidence has methodological limitations, such as small sample sizes, the inclusion of expert endoscopists only and the evaluation of single technical interventions. Additionally, larger studies are needed to clarify whether these interventions might have a higher benefit on low adenoma detectors and whether the implementation of a bundle of them, instead of a single technical maneuver, might have a greater impact on ADR.     

Prevalence and Characteristics of Colonic Polyps and Adenomas in 2654 Colonoscopies in Saudi Arabia

Background/Aims:

Colorectal cancer (CRC) is the second most common malignancy in the Saudi population, with an increasing incidence over the past 20 years. We aim to determine the baseline polyp as well as adenoma prevalence in a large cohort of patients and to find the possible age in which, if deemed appropriate, a CRC screening program should be initiated.

Patients and Methods:

A retrospective cohort study was conducted using an endoscopic reporting database of individuals seen at a major tertiary care university hospital (King Khalid University Hospital) in Riyadh, Saudi Arabia. Consecutive Saudi patients who underwent a colonoscopy between August 2007 and April 2012 were included. Patients were excluded if the indication for the colonoscopy was colon cancer, colonic resection, active colitis, active diverticulitis, inflammatory bowel disease, or if the patient was referred for polypectomy.

Results:

2654 colonoscopies were included in the study. The mean age of the study population was 50.5 years [standard deviation (SD) 15.9] and females represented 57.7%. The polyp detection rate in completed colonoscopies was 20.8% (95% CI: 19.2-22.5). Adenomas were found in 8.1% (95% CI: 7.1-9.1), while advanced adenomas were found in only 0.5% (95% CI: 0.2-0.7). Adenomas were found in the left side of the colon in 33.9%, followed by the rectum in 14.6%, ascending colon and cecum in 14.2%, transverse colon in 8.7%, and in multiple locations in 28.7%. Those with a prior history of polyps or CRC were more likely to have an adenoma at colonoscopy than those who did not (14.3% vs. 6.6%; P < 0.01). The adenoma prevalence varied between age groups and ranged from 6.2% to 13.6% with a higher proportion in older individuals; this trend was seen both in males (6.0-14.5%) and females (6.4-14.6%) as well as in those who had screening colonoscopies (6.3-18.4%). No age could be found at which a CRC screening program would be appropriate to initiate.

Conclusion:

The prevalence of polyps and adenomas in this cohort is less than that reported in the Western populations. But as this cohort included younger and symptomatic patients with only a small proportion undergoing screening, further studies in an asymptomatic population are needed.