High-Definition White-Light (HDWL) Colonoscopy and Higher Adenoma Detection Rate and the Potential for Paradoxical Over Surveillance

Background

Patients undergoing high-definition white-light colonoscopy by a high adenoma detector may have a lower risk of interval adenoma detection on follow-up colonoscopy and may require less frequent follow-up but may paradoxically be assigned to more frequent surveillance when more adenomas are detected.

Aims

To evaluate whether high-definition white-light colonoscopy (vs. standard-definition white-light colonoscopy) and endoscopist adenoma detection rate (ADR) at index colonoscopy are associated with increased likelihood of adenomas at follow-up.

Methods

Longitudinal follow-up of prior cross-section cohort study of patients who underwent colonoscopy at baseline with at least one detected adenoma was included. Associations of type of white-light at index colonoscopy and the ADR of the endoscopist at index colonoscopy (high vs. low adenoma detector) were evaluated with various adenoma and polyp detection endpoints. Eighteen endoscopists were classified as high and low adenoma detectors based on the median ADR of 0.255.

Results

There were no significant differences in subsequent interval adenoma or polyp detection endpoints with regard to whether baseline exam was performed with high-definition white-light or standard-definition white-light colonoscopy nor between high and low ADR after adjusting for multiple testing (P ≤ 0.0029 considered significant). Prior to multiple testing adjustment, there was a significantly lower detection rate of hyperplastic polyps in the left colon (24 vs. 35 %, OR: 0.56, P = 0.033) at follow-up colonoscopy when baseline exam was performed with high-definition white-light index colonoscopy.

Conclusions

The results of this study do not support adjusting colonoscopy surveillance guidelines based on type of colonoscopy performed or the endoscopist’s ADR.     

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.     

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres

Objective. The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). Material and methods. A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. Results. There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p<0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p<0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO₂ insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50–99 registered colonoscopies. Conclusions. In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.     

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.

     

Risk factors associated with the detection and missed diagnosis of colorectal flat adenoma: a Chinese multicenter observational study

Abstract

Objectives: Flat colorectal adenomas have a high risk of malignancy; however, their detection is often difficult due to their flat morphology. In this retrospective, large-scale study, we investigated the prevalence and characteristics of flat adenomas in a population in China.

Methods: We analyzed the data collected for 16951 consecutive patients who underwent colonoscopy at four participating hospitals between September 2013 and September 2015. All colonoscopies were performed without magnification.

Results: Among the 1,6951 patients, 2938 (17.3%) had adenoma and 796 (4.7%) had flat adenomas. The detection of flat adenoma showed a weak correlation with the detection of adenoma (r?=?0.666). Multivariable logistic regression analysis revealed the following independent factors influencing the detection of flat adenomas: patient-related factors of age, presence of warning symptoms, history of adenomas and bowel preparation as well as endoscopist-related factors of endoscopist’s level of proficiency, number of colonoscopy operators and withdrawal time.

Conclusions: The prevalence of flat adenomas in our study on Chinese patients was consistent with that reported from other countries. Factors conducive to the detection of flat adenomas were patient age of >?60 years, warning symptoms, history of adenoma, good bowel preparation, experienced endoscopist, single-operator colonoscopy and colonoscopy withdrawal time of >6?min.     

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.     

Diagnostic yield is not influenced by the timing of screening endoscopy: morning versus afternoon

Background: Previous studies have shown the colonoscopy quality affected by the endoscopist’s fatigue. This study was aimed to evaluate this potential factor in a colorectal cancer-screening cohort of Chinese patients.

Methods: The attendances at department of gastroenterology for colorectal cancer screening between 2013 and 2015 were retrospectively analyzed. The procedure time-of-day and hours elapse were recorded. The primary outcome was defined as adenoma detection rate (ADR).

Results: A total of 1342 screening colonoscopies were performed by 19 gastroenterologists in the study. Detection rates were 7.7% for all polyps and 20.0% for adenomas. Time-of-day was not significantly associated with ADR. With time elapsing, the first climax for ADR was presented at 09:00–10:00, and persistently rose again after the lunch break. Significant inclined trend in ADR was noted for each hour blocks of a full day (p?= .0021).

Conclusions: The procedure time-of-day, morning versus afternoon, did not affect the diagnostic efficacy of screening endoscopy in Chinese patients.     

Association of Adenoma Detection Rate and Adenoma Characteristics With Colorectal Cancer Mortality After Screening Colonoscopy

Background & AimsThe adenoma detection rate (ADR) and characteristics of previously resected adenomas are associated with colorectal cancer (CRC) incidence and mortality. However, the combined effect of both factors on CRC mortality is unknown.Patients and methodsUsing data of the Austrian quality assurance program for screening colonoscopy, we evaluated the combined effect of ADR and lesion characteristics on subsequent risk for CRC mortality. We analyzed mortality rates for individuals with low-risk adenomas (1–2 adenomas <10 mm), individuals with high-risk adenomas (advanced adenomas or ≥3 adenomas), and after negative colonoscopy (negative colonoscopy or small hyperplastic polyps) performed by endoscopists with an ADR <25% compared with ≥25%. Cox regression was used to determine the association of combined risk groups with CRC mortality, adjusted for age and sex.ResultsWe evaluated 259,885 colonoscopies performed by 361 endoscopists. A total of 165 CRC-related deaths occurred during the follow-up period, up to 12.2 years. In all risk groups, CRC mortality was higher when colonoscopy was performed by an endoscopist with an ADR <25%. Compared with negative colonoscopy with an ADR ≥25%, CRC mortality was similar for individuals with low-risk adenomas irrespective of ADR (for ADR ≥25%: adjusted hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.59–2.49; for ADR <25%: adjusted HR, 1.25; 95% CI, 0.64–2.43) and after negative colonoscopy with ADR <25% (adjusted HR, 1.27; 95% CI, 0.81–2.00). Individuals with high-risk adenomas were at significantly higher risk for CRC death if colonoscopy was performed by an endoscopist with an ADR <25% (adjusted HR, 2.25; 95% CI, 1.18–4.31) but not if performed by an endoscopist with an ADR ≥25% (adjusted HR, 1.35; 95% CI, 0.61–3.02).ConclusionsOur study adds important evidence for mandatory assessment and monitoring of performance quality in screening colonoscopy. High-quality colonoscopy was associated with a lower risk for CRC death, and the impact of ADR was strongest for individuals with high-risk adenomas.     

The performance indicator of colonic intubation (PICI) in a FIT-based colorectal cancer screening program

Abstract

Objective: Cecal intubation rate (CIR) is known to be inversely associated with interval colorectal cancer (CRC) risk. Cecal intubation may be achieved by the use of force and sedation jeopardizing patient safety. The Performance Indicator of Colonic Intubation (PICI) is defined as the proportion of colonoscopies achieving cecal intubation with use of ≤2?mg midazolam and no-mild patient-experienced discomfort. We aimed (i) to measure the variation of PICI between colonoscopists and colonoscopy units; (ii) to assess the correlation between the individual components of PICI; and (iii) to evaluate the association between PICI and commonly used performance indicators.

Materials and methods: For the period 1 July 2015 through 30 June 2017 of the prevalent round of the Danish FIT-based CRC screening program, we included colonoscopies performed at four units in the Central Denmark Region within 60?days after a positive FIT-test. The PICI variation was evaluated using rates and ranges. Correlations between individual PICI components were assessed using Pearson correlation coefficients. Polyp detection rate (PDR), Adenoma detection rate (ADR), Polyp retrieval rate (PRR) and Withdrawal time (WT) were assessed within PICI quartiles.

Results: The overall PICI was 78.7% with substantial variation between colonoscopists (40.0–91.9%) and units (72.6–82.0%). CIR was significantly correlated with patient-experienced comfort (r?=?0.49, n?=?73, p?0001) and we observed that colonoscopists with a PICI between 79.9% and 84.3%) had the highest ADR.

Conclusion: We found a substantial variation in PICI between colonoscopists and between colonoscopy units, which may reflect potential for quality improvements.     

Improvement in caecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: A randomized trial of patients referred for colonoscopy

Objective. Use of magnetic endoscope imaging (MEI) during colonoscopy has the potential to ease caecal intubation and patient discomfort and to reduce dependence on sedation and/or analgesics (SAs). However, pain reduction by using MEI has not been demonstrated so far, probably because of the liberal use of SAs. The aim of the present study was to evaluate the effect of MEI on caecal intubation and patient pain during unsedated colonoscopy performed by experienced and inexperienced colonoscopists. Material and methods. A consecutive series of outpatients referred for colonoscopy were randomly allocated to examination with (imager group) or without (standard group) the use of MEI. Patients agreeing to SAs being given only on demand were included in the study. End-points were caecal intubation and pain, the latter to be graded by category on a form to be completed on the day after the examination. Results. The proportion of colonoscopies performed without SAs was similar when comparing imager and standard groups and experienced with inexperienced colonoscopists; altogether 367(88%) out of 419 colonoscopies. The caecal intubation rate was higher in the imager group (190/212 (90%)) than in the standard group (153/207(74%)) (p<0.001), both collectively and separately for experienced and inexperienced colonoscopists. A pain-reducing effect of MEI was shown only when performed by experienced colonoscopists, with severe pain in 10/137 patients (7.3%) in the imager group and 21/132 patients (16%) in the standard group (p=0.03). Conclusions. In colonoscopy without the routine use of SAs, MEI significantly improves the caecum intubation rate and reduces pain during the procedure.     

Hyoscine N-butylbromide for adenoma detection during colonoscopy: A randomized,double-blind,placebo-controlled study

BackgroundHyoscine N-butylbromide (HBB), commonly used during colonoscopy to facilitate cecal intubation, has been proposed to increase the adenoma detection rate (ADR).AimsTo evaluate whether HBB administration increases the adenoma detection rate and influences patients’ tolerance.MethodsConsecutive colonoscopy outpatients were randomized after cecal intubation to receive either 20 mg HBB or placebo i.v. The number, size, histology and location of polyps were recorded. The air retained in the abdomen was either indirectly estimated by ΔAC (difference in the abdominal circumference measured before and after colonoscopy) or directly evaluated by patients’ perception (visual analogic scale, range 0–100).Results402 patients (44% male; mean age 57.7 ± 12.5 years) received either HBB or placebo. No differences in ADR (31.7% vs. 28%, p = 0.48), advanced-ADR (7.4% vs. 10.5%, p = 0.35) were observed between HBB and placebo group, respectively. A significantly lower detection rate of flat/depressed lesions was observed in the HBB group (0.5% vs. 5.5%, p = 0.003). The ΔAC and the bloating perception were comparable between the two groups (p = 0.22 and p = 0.48, respectively).ConclusionsHBB administered before colonoscope withdrawal does not increase adenoma detection rate and seems to hamper the visualization of flat/depressed lesions. This finding raises concerns on the indiscriminate use of HBB during colonoscopy.     

Retrograde inspection vs standard forward view for the detection of colorectal adenomas during colonoscopy: A back-to-back randomized clinical trial

BACKGROUND The adenoma detection rate(ADR) is inversely associated with the incidence of interval colorectal cancer and serves as a benchmark quality criterion during screening colonoscopy. However, adenoma miss rates reach up to 26% and studies have shown that a second inspection of the right colon in retroflected view(RFV) can increase ADR.AIM To assess whether inspection of the whole colon in RFV compared to standard forward view(SFV) can increase ADR.METHODS Patients presenting for screening or surveillance colonoscopy were invited to participate in this randomized controlled trial and randomized into two arms. In RFV arm colonoscopy was initially performed with SFV, followed by a second inspection of the whole colon in RFV. In the SFV arm first withdrawal was performed with SFV, followed by a second inspection of the whole colon again with SFV. Number, size and morphology of polyps found during first and second inspection in each colonic segment were recorded and all polyps were removed and sent for histopathology in separate containers.RESULTS Two hundred and five patients were randomly assigned to the RFV(n = 101) and SFV(n = 104) arm. In the RFV arm, both polyp detection rate(PDR) and ADR were increased under second inspection in RFV(PDR 1~(st) SFV: 39.8%, PDR 2~(nd)RFV: 46.6%; ADR 1~(st) SFV: 35.2%, ADR 2~(nd) RFV: 42%). Likewise, in the SFV arm,PDR and ADR were increased under second inspection(PDR 1~(st) SFV: 37.5%, PDR 2~(nd) SFV: 46.6%; ADR 1~(st) SFV: 34.1%, ADR 2~(nd)SFV: 44.3%) with no significant differences in ADR and PDR between the SFV and RFV arm. Mean number of adenomas per patient(APP) was increased in the RFV and SFV(APP RFV arm: 1~(st) SFV: 1.71; 2~(nd) RFV: 2.38; APP SFV arm: 1~(st) SFV: 1.83, 2~(nd)SFV:2.2). The majority of adenomas additionally found during second inspection in RFV or in SFV were located in the transverse and left-sided colon and were 5 mm in size.CONCLUSION Second inspection of the whole colon leads to increased adenoma detection with no differences between SFV and RFV. Hence, increased detection is most likely a feature of the second inspection itself but not of the inspection mode.     

Quality indicators in pediatric colonoscopy: an Australian tertiary center experience

Objectives: Quality indicators for colonoscopy in adults are largely driven by colorectal cancer screening, and include cecal intubation rates, with rates of >90% recommended. In contrast, colorectal cancer is rare in childhood, with paucity of data on relevant quality indicators for pediatric colonoscopy. It is also unclear whether high rates of cecal intubation are achievable in small children. Our aim was to audit all colonoscopies performed in a tertiary pediatric center to examine clinical indications for procedure, completeness of examination with cecal and ileal intubation, significant findings, and complications.

Methods: Retrospective review of colonoscopies performed between November 2011 and October 2015 was undertaken.

Results: Total colonoscopy was performed in 652 patients, 53% male, with median age 13.0 (range 0.4–18.2) years. The most common indications for colonoscopy were assessment of inflammatory bowel disease (IBD) 57.9% (378/652), rectal bleeding 10% (68/652) and abdominal pain 10% (68/652). Trainees performed 69.8% (452/652) of procedures. Quality of bowel preparation was mentioned in 63% (410/652), of which 22% (90/410) were considered inadequate. Cecal intubation rate was 96.3% (628/652) and ileal intubation rate was 92.4% (603/652). Extent of procedure was confirmed in 99.2% of patients with photographs and/or ileal biopsy. Poor quality of bowel preparation (p?=?.001) and age <5years (p?=?.007) were inversely related to successful ileal intubation.

Conclusions: High rates of cecal and ileal intubation are achievable in pediatric colonoscopy. Ileal intubation should be considered a quality indicator since the main indicator for pediatric colonoscopy is to investigate IBD.     

Sodium phosphate is superior to polyethylene glycol in bowel cleansing and shortens the time it takes to visualize colon mucosa

Background: Both sodium phosphate (NaP) and polyethylene glycol‐electrolyte (PEG‐EL) have been used to cleanse the bowel prior to colonoscopy, and recent reviews suggest that the former is the more effective and convenient cleansing regimen. The aim of this study was to compare the bowel cleansing effect of NaP solution with that of PEG‐EL solution and to evaluate whether the cleansing effect correlates with the time needed to perform colonoscopy. Methods: 111 patients admitted for colonoscopy were randomized to receive either 90?mL oral NaP or 4?litres of PEG‐EL solution. Cleansing was scored blindly by one colonoscopist and the following times were recorded: caecal intubation, withdrawal and total colonoscopy. Results: Of all the patients included in the study, 99 were evaluable. The mean and standard error of the mean (±s_x ) cleansing score was 3.64?±?0.16 in the NaP group and 2.69?±?0.9 in the PEG‐EL group (P?=?0.005). The mean (±s_x ) caecal intubation times were 6.39?±?0.50?min and 5.39?±?0.41?min (P?=?0.13), the withdrawal times 4.26?±?0.20?min and 5.78?±?0.34?min (P?=?0.0001) and the total colonoscopy times 10.65?±?0.52?min and 11.17?±?0.56?min (P?=?0.50) in the NaP and PEG‐EL groups, respectively. The subgroup of patients with a cleansing score of 3 or more was associated with shortened colonoscopy withdrawal time compared to the group scoring below 3. Conclusions: Better cleansing of the large bowel shortens colonoscopy withdrawal time. Sodium phosphate is a more effective bowel‐cleansing regimen than polyethylene glycol, and the better cleansing result is associated with shortened colonoscopy withdrawal time.     

Can the Adenoma Detection Rate Reliably Identify Low-Performing Endoscopists? Results of a Modeling Study

Background

Experts have stated that adenoma detection rates (ADR) of individual endoscopists should be measured to assess colonoscopy quality.

Aim

The purpose of this study was to quantify the reliability of the ADR as a quality marker.

Methods

We simulated a population of endoscopists and patients using published data on adenoma prevalence and adenoma miss rates. For each endoscopist, the ADR was calculated. The proportion of ADR variance attributable to endoscopist and the area under the ROC (AUROC) curve for low-performing endoscopists (lowest quartile or decile) were also calculated.

Results

In the base-case analysis (200 patients per endoscopist, miss rate 22 %, adenoma prevalence 24 %), only 13 % of ADR variance was attributable to endoscopist performance (AUROC up to 0.73). An ADR cutoff of <16.5 % identified approximately half of endoscopists in the lowest performance decile (test sensitivity = 53 %), but most (79 %) of the endoscopists identified by this cutoff were NOT low performers (i.e., false positives). In sensitivity analysis, increasing the number of patients per endoscopist, reducing the variance of adenoma prevalence between endoscopists (i.e., performing case-mix adjustment), and increasing the variance in performance between endoscopists all improved ADR test characteristics (AUROC up to 0.88). However, regardless of assumptions, a substantial proportion of endoscopists would be misclassified if a simple ADR cutoff were utilized.

Conclusions

The ADR has limited reliability as a quality marker under real-world assumptions. Simple cutoffs are likely to either be insufficiently sensitive or have high false positive rates. Future studies should identify alternative means for assessing endoscopist performance.     

Benefits and Limitations of Cap-Fitted Colonoscopy in Screening Colonoscopy

Background

Colonoscopy is widely used to detect colorectal cancer and to remove precancerous lesions to reduce the risk of colonic cancer.

Aims

To examine the benefits and limitations of cap-fitted colonoscopy compared to conventional colonoscopy in terms of technical performance and colorectal adenoma detection rate.

Methods

Screening colonoscopies performed from 2009 to 2010 with or without a transparent cap were retrospectively examined to compare the rate of successful intubation, cecal intubation time, and number, size, shape, and location of adenomas detected. An inclusion criterion was visualization of >95 % of the right colon.

Results

Data from 2,301 colonoscopies (1,165 with cap-fitted colonoscopy, 1,136 without the transparent cap) were retrospectively analyzed. Procedures were performed by four experienced endoscopists. The subjects’ demographic characteristics and technical performances were similar between the two methods. The only significant difference in the technical performance between the two techniques was a shorter cecal intubation time with cap-fitted colonoscopy (5.3 vs. 6.6 min; p = 0.045) by one endoscopist. The total number of adenomas detected was significantly higher with cap-fitted colonoscopy than without the cap (586 vs. 484, respectively; p < 0.0001). Adenoma detection with cap-fitted endoscopy was significantly higher in the right colon than in the left colon (19 vs. 12 %, respectively; p = 0.0001).

Conclusion

Cap-fitted colonoscopy did not improve the technical aspects of colonoscopy but significantly increased adenoma detection, especially in the right colon. It did not increase the detection rate of flat or depressed adenomas.     

Fecal immunochemical test in cancer screening – colonoscopy outcome in FIT positives and negatives

Objectives: Fecal immunochemical test (FIT) is used in colorectal cancer (CRC) screening, but evaluations of multiple sample strategies in colonoscopy screening cohorts are rare. The aim of this study was to assess accuracy of FIT for advanced neoplasia (AN) with two fecal samples in a colonoscopy screening cohort.

Materials and methods: The study comprised 1155 participants of the colonoscopy arm in SCREESCO (Screening of Swedish Colons, NCT02078804), a randomized controlled study on CRC screening of 60-year-olds from the Swedish average-risk population. Participants provided two FIT samples prior to colonoscopy. First sample, mean of two, and any of the two samples above cut off level were assessed. Colonoscopy findings (CRC, advanced adenoma (AA), AN (CRC?+?AA) and adenoma characteristics) were evaluated in uni- and multivariable analysis in relation to FIT positivity (at ≥10?µg hemoglobin (Hb)/g).

Results: Of 1155 invited, 806 (416 women, 390 men) participated. CRC, AA and non-AA were found in one (0.1%), 80 (9.9%) and 145 (18%), respectively. Sensitivity and specificity for AN were 20%/93%, 25%/92% and 26%/89% for first, mean of two and any of the two samples respectively at cut off level 10?µg/g, corresponding to 60 (74%)–65 (80%) participants with missed AN. The difference in sensitivity between screening strategies was non-significant. The specificity for first sample was significantly higher than for any of the two samples at cut off 10?µg/g (p?=?.02) and 20?µg/g (p?=?.04). FIT positivity in participants with adenoma was associated with pedunculated shape (p?=?.007) and high-risk dysplasia (p?=?.009).

Conclusions: In an average-risk colonoscopy screening cohort of 60-year-olds, sensitivity for AN was modest and did not increase when using two samples instead of one. FIT predominantly detected adenomas with pedunculated shape and high-risk dysplasia, and participants with flat or broad based adenomas may thus be missed in screening.     

Intermediate-length colonoscope needs more training duration than long-length colonoscope

Abstract

Objective. Few data are available on the influence of a colonoscope length for trainees, which could affect both the duration of training and colonoscopy quality. We conducted this study to validate which scope needs more duration for training to reach technical competence and to shows better quality indicators during diagnostic colonoscopy. Materials and methods. We conducted a prospective randomly assigned study from April 2010 to February 2011 at Asan Medical Center. Among the 1329 patients enrolled, 1200 colonoscopies were analyzed. We compared cecal intubation rate, adenoma detection rate, cecal intubation time (<20 min), and withdrawal time between the trainees using the intermediate-length colonoscope and those using long-length colonoscope. Results. Trainees who used the long-length colonoscope showed a higher overall cecal intubation rate (88.2% vs. 81.0%, p = 0.001) and adenoma detection rate (49.7% vs. 34.2%, p < 0.001) than those using the intermediate-length colonoscope. The successful cecal intubation rate improved significantly and reached the requisite standard of competence (>90%) after 90 procedures in the long-length colonoscope group. However, the trainees using the intermediate-length colonoscope reached the requisite standard of competence after 150 procedures. Logistic regression analysis revealed that prolonged cecal intubation was associated with the use of the intermediate-length colonoscope, poor colon preparation, a small number of esophagastroduodenoscopy or sigmoidoscopy procedures conducted, and pain during procedures. Conclusions. During the same training period, use of the long-length colonoscope in trainee was better in terms of reaching competency and quality indicators, and was less painful for the patients during colonoscopic procedures.     

Comparison of Colonoscopy Quality Measures Across Various Practice Settings and the Impact of Performance Scorecards

Background

Quality performance measures for screening colonoscopy vary among endoscopists. The impact of practice setting is unknown.

Aims

We aimed to (1) compare screening colonoscopy performance measures among three different US practice settings; (2) evaluate factors associated with adenoma detection; and (3) assess a scorecard intervention on performance metrics.

Methods

This multi-center prospective study compared patient, endoscopist, and colonoscopy characteristics performed at a tertiary care hospital (TCH), community-based hospital (CBH), and private practice group (PPG). Withdrawal times (WT), cecal intubation, and adenoma detection rates (ADR) were compared by site at baseline and 12 weeks following scorecard distribution. Generalized linear mixed models identified factors associated with adenoma detection.

Results

Twenty-eight endoscopists performed colonoscopies on 1987 asymptomatic, average-risk individuals ≥50 years. Endoscopist and patient characteristics were similar across sites. The PPG screened more men (TCH: 42.8%, CBH: 45.0%, PPG: 54.2%; p < 0.0001). Preparation quality varied with good/excellent results in 70.6, 88.3, and 92% of TCH, CBH, and PPG cases, respectively (p < 0.0001). Male ADRs, cecal intubation, and WT exceeded recommended benchmarks despite variable results at each site; female ADRs were <15% at the PPG which screened the fewest females. Performance remained unchanged following scorecard distribution. Adenoma detection was associated with increasing patient age, male gender, WT, adequate preparation, but not practice setting.

Conclusions

Each practice performed high-quality screening colonoscopy. Scorecards did not improve performance metrics. Preparation quality varies among practice settings and can be modified to improve adenoma detection.