Endocuff Vision Reduces Inspection Time Without Decreasing Lesion Detection: A Clinical Randomized Trial

Endocuff With or Without Artificial Intelligence-Assisted Colonoscopy in Detection of Colorectal Adenoma: A Randomized Colonoscopy Trial

INTRODUCTION

Both artificial intelligence (AI) and distal attachment devices have been shown to improve adenoma detection rate and reduce miss rate during colonoscopy. We studied the combined effect of Endocuff and AI on enhancing detection rates of various colonic lesions.

METHODS

This was a 3-arm prospective randomized colonoscopy study involving patients aged 40 years or older. Participants were randomly assigned in a 1:1:1 ratio to undergo Endocuff with AI, AI alone, or standard high-definition (HD) colonoscopy. The primary outcome was adenoma detection rate (ADR) between the Endocuff-AI and AI groups while secondary outcomes included detection rates of polyp (PDR), sessile serrated lesion (sessile detection rate [SDR]), and advanced adenoma (advanced adenoma detection rate) between the 2 groups.

RESULTS

A total of 682 patients were included (mean age 65.4 years, 52.3% male), with 53.7% undergoing diagnostic colonoscopy. The ADR for the Endocuff-AI, AI, and HD groups was 58.7%, 53.8%, and 46.3%, respectively, while the corresponding PDR was 77.0%, 74.0%, and 61.2%. A significant increase in ADR, PDR, and SDR was observed between the Endocuff-AI and AI groups (ADR difference: 4.9%, 95% CI: 1.4%-8.2%, P = 0.03; PDR difference: 3.0%, 95% CI: 0.4%-5.8%, P = 0.04; SDR difference: 6.4%, 95% CI: 3.4%-9.7%, P < 0.01). Both Endocuff-AI and AI groups had a higher ADR, PDR, SDR, and advanced adenoma detection rate than the HD group (all P < 0.01).

DISCUSSION

Endocuff in combination with AI further improves various colonic lesion detection rates when compared with AI alone.

Colonoscopy vs the Fecal Immunochemical Test: Which is Best?

Although there is no debate around the effectiveness of colorectal cancer screening in reducing disease burden, there remains a question regarding the most effective and cost-effective screening modality. Current United States guidelines present a panel of options that include the 2 most commonly used modalities, colonoscopy and stool testing with the fecal immunochemical test (FIT). Large-scale comparative effectiveness trials comparing colonoscopy and FIT for colorectal cancer outcomes are underway, but results are not yet available. This review will separately state the "best case" for FIT and colonoscopy as the screening tool of first choice. In addition, the review will examine these modalities from a health economics perspective to provide the reader further context about the relative advantages of these commonly used tests.

Comparison of adenoma miss rate and adenoma detection rate between conventional colonoscopy and colonoscopy with second-generation distal attachment cuff: a multicenter, randomized, back-to-back trial

BACKGROUND AND AIMS

Endocuff Vision (Olympus Europe, Hamburg, Germany) has been designed to enhance mucosal visualization, thereby improving detection of (pre-)malignant colorectal lesions. This multicenter, international, back-to-back, randomized colonoscopy trial compared the adenoma detection rate (ADR) and adenoma miss rate (AMR) between Endocuff Vision-assisted colonoscopy (EVC) and conventional colonoscopy (CC).

METHODS

Patients aged 40 to 75 years referred for non-immunochemical fecal occult blood test-based screening, surveillance, or diagnostic colonoscopy were included at 10 hospitals and randomized into 4 groups: group 1, 2 × CC; group 2, CC followed by EVC; group 3, EVC followed by CC; and group 4, 2 × EVC. Primary outcomes included ADR and AMR.

RESULTS

A total of 717 patients were randomized, of whom 661 patients (92.2%) had 1 and 646 (90.1%) patients had 2 completed back-to-back colonoscopies. EVC did not significantly improve ADR compared to CC (41.1%; [95% confidence interval (CI), 36.1-46.3] vs 35.5% [95% CI, 30.7-40.6], respectively; P = .125), but EVC did reduce AMR by 11.7% (29.6% [95% CI, 23.6-36.5] vs 17.9% [95% CI, 12.5-23.5], respectively; P = .049). AMR of 2 × CC compared to 2 × EVC was also not significantly different (25.9% [95% CI, 19.3-33.9] vs 18.8% [95% CI, 13.9-24.8], respectively; P = .172). Only 3.7% of the polyps missed during the first procedures had advanced pathologic features. Factors affecting risk of missing adenomas were age (P = .002), Boston Bowel Preparation Scale (P = .008), and region where colonoscopy was performed (P < .001).

CONCLUSIONS

Our trial shows that EVC reduces the risk of missing adenomas but does not lead to a significantly improved ADR. Remarkably, 25% of adenomas are still missed during conventional colonoscopies, which is not different from miss rates reported 25 years ago; reassuringly, advanced features were only found in 3.7% of these missed lesions. (Clinical trial registration number: NCT03418948.).

Texture and color enhancement imaging (TXI) plus endocuff vision versus TXI alone for colorectal adenoma detection: a randomized controlled trial

BACKGROUND AND AIMS

Increasing the adenoma detection rate (ADR) helps reduce the risk of post-colonoscopy colorectal cancer. Texture and Color Enhancement Imaging (TXI) improves ADR by enhancing the brightness and contrast of endoscopic images. Endocuff Vision (ECV) is a mucosal exposure device that helps flatten the colonic folds. The benefit of combining TXI with ECV has not been studied previously. Thus, we aimed to compare the ADR between using TXI combined with ECV and TXI alone.

METHODS

We conducted a prospective randomized controlled trial recruiting patients aged ≥ 40 years who underwent colonoscopy for colorectal cancer screening or gastrointestinal symptoms. The participants were randomized in a 1:1 ratio into the TXI with ECV (TXI + ECV) and the TXI groups. Experienced endoscopists with ≥ 40% ADR performed all colonoscopies. The primary outcome was ADR.

RESULTS

We had 189 and 192 patients in the TXI + ECV and TXI groups, respectively. The baseline characteristics of both groups were comparable. The ADR was significantly higher in the TXI + ECV group than in the TXI group (65.6% vs. 52.1%, P = 0.007). Adenoma per colonoscopy (APC) was significantly greater in the TXI + ECV group than in the TXI group (1.6 vs. 1.2, P = 0.021), prominently proximal (1.0 vs. 0.7, P = 0.031), non-pedunculated (1.4 vs. 1.1, P = 0.035), and diminutive (1.3 vs. 1, P = 0.045) adenomas. Serrated lesion detection rate, insertion time, and withdrawal time did not differ between the groups.

CONCLUSION

Adding ECV to TXI significantly improves ADR and APC compared to using TXI alone.

TRIAL REGISTRATION

Thai Clinical Trials Registry TCTR20220507004.

Performing High-Quality, Safe, Cost-Effective, and Efficient Basic Colonoscopy in 2023: Advice From Two Experts

Based on published evidence and our expert experience, we provide recommendations to maximize the efficacy, safety, efficiency, and cost-effectiveness of routine colonoscopy. High-quality colonoscopy begins with colon preparation using a split or same-day dose and preferably a low-volume regimen for optimal patient tolerance and compliance. Successful cecal intubation can be achieved by choosing the correct colonoscope and using techniques to facilitate navigation through challenges such as severe angulations and redundant colons. Safety is a primary goal, and complications such as perforation and splenic rupture can be prevented by avoiding pushing through fixed resistance and avoiding loops in proximal colon. Furthermore, barotrauma can be avoided by converting to water filling only (no gas insufflation) in every patient with a narrowed, angulated sigmoid. Optimal polyp detection relies primarily on compulsive attention to inspection as manifested by adequate inspection time, vigorous probing of the spaces between haustral folds, washing and removing residual debris, and achieving full distention. Achieving minimum recommended adenoma detection rate thresholds (30% in men and 20% in women) is mandatory, and colonoscopists should aspire to adenoma detection rate approaching 50% in screening patients. Distal attachments can improve mucosal exposure and increase detection while shortening withdrawal times. Complete resection of polyps complements polyp detection in preventing colorectal cancer. Cold resection is the preferred method for all polyps < 10 mm. For effective cold resection, an adequate rim of normal tissue should be captured in the snare. Finally, cost-effective high-quality colonoscopy requires the procedure not be overused, as demonstrated by following updated United States Multi Society Task Force on Colorectal Cancer postpolypectomy surveillance recommendations.

Recent advances in devices and technologies that might prove revolutionary for colonoscopy procedures

INTRODUCTION

Colorectal cancer (CRC) is the third most common malignancy and second leading cause of cancer-related mortality in the world. Adenoma detection rate (ADR), a quality indicator for colonoscopy, has gained prominence as it is inversely related to CRC incidence and mortality. As such, recent efforts have focused on developing novel colonoscopy devices and technologies to improve ADR.

AREAS COVERED

The main objective of this paper is to provide an overview of advancements in the fields of colonoscopy mechanical attachments, artificial intelligence-assisted colonoscopy, and colonoscopy optical enhancements with respect to ADR. We accomplished this by performing a comprehensive search of multiple electronic databases from inception to September 2023. This review is intended to be an introduction to colonoscopy devices and technologies.

EXPERT OPINION

Numerous mechanical attachments and optical enhancements have been developed that have the potential to improve ADR and AI has gone from being an inaccessible concept to a feasible means for improving ADR. While these advances are exciting and portend a change in what will be considered standard colonoscopy, they continue to require refinement. Future studies should focus on combining modalities to further improve ADR and exploring the use of these technologies in other facets of colonoscopy.

Computer-aided detection, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized controlled trial

BACKGROUND AND AIMS

Computer-aided detection (CADe) and a mucosal exposure device can improve adenoma detection rate (ADR). Potential benefits of combining the 2 modalities have never been studied. This study aimed to compare ADR differences among CADe alone, endocuff-assisted colonoscopy (EAC) alone, and the combination of CADe and EAC (CADe+EAC) with standard colonoscopy.

METHODS

This prospective randomized controlled study included 1245 participants who underwent screening colonoscopy. Participants were randomized to CADe, EAC, CADe+EAC, and standard colonoscopy as a control. The primary outcome was ADR. Secondary outcomes were proximal ADR (pADR), advanced ADR (AADR), and the number of adenomas per colonoscopy (APCs).

RESULTS

ADRs from the control, CADe, EAC, and CADe+EAC groups were 41.9%, 52.2%, 54.0%, and 58.8%, respectively; pADRs were 25.2%, 33.3%, 34.9%, and 37.0%, respectively; AADRs were 7.7%, 8.3%, 8.3%, and 13.6%, respectively; and APCs were .76, 1.11, 1.18, and 1.31, respectively. Significant increases in ADR and pADR were observed between the intervention and control groups (P < .05 in all comparisons). The AADR was significantly higher only in the CADe+EAC group than in the control group (P = .02). The adjusted incidence rate ratios of APCs were significantly higher in the intervention groups versus the control group (P < .01 in all comparisons).

CONCLUSIONS

CADe+EAC significantly improve ADR and AADR over standard colonoscopy. However, although CADe or EAC alone can substantially increase the detection of adenomas, they do not lead to increased detection of advanced adenomas unless used in combination. (Clinical trial registration number: TCTR20200929003.).

Impact of withdrawal time on adenoma detection rate: results from a prospective multicenter trial

BACKGROUND AND AIMS

Performing a high-quality colonoscopy is critical for optimizing the adenoma detection rate (ADR). Colonoscopy withdrawal time (a surrogate measure) of ≥6 minutes is recommended; however, a threshold of a high-quality withdrawal and its impact on ADR are not known.

METHODS

We examined withdrawal time (excluding polyp resection and bowel cleaning time) of subjects undergoing screening and/or surveillance colonoscopy in a prospective, multicenter, randomized controlled trial. We examined the relationship of withdrawal time in 1-minute increments on ADR and reported odds ratio (OR) with 95% confidence intervals. Linear regression analysis was performed to assess the maximal inspection time threshold that impacts the ADR.

RESULTS

A total of 1142 subjects (age, 62.3 ± 8.9 years; 80.5% men) underwent screening (45.9%) or surveillance (53.6%) colonoscopy. The screening group had a median withdrawal time of 9.0 minutes (interquartile range [IQR], 3.3) with an ADR of 49.6%, whereas the surveillance group had a median withdrawal time of 9.3 minutes (IQR, 4.3) with an ADR of 63.9%. ADR correspondingly increased for a withdrawal time of 6 minutes to 13 minutes, beyond which ADR did not increase (50.4% vs 76.6%, P < .01). For every 1-minute increase in withdrawal time, there was 6% higher odds of detecting an additional subject with an adenoma (OR, 1.06; 95% confidence interval, 1.02-1.10; P = .004).

CONCLUSIONS

Results from this multicenter, randomized controlled trial underscore the importance of a high-quality examination and efforts required to achieve this with an incremental yield in ADR based on withdrawal time. (Clinical trial registration number: NCT03952611.).

Variability in adenoma detection rate in control groups of randomized colonoscopy trials: a systematic review and meta-analysis

BACKGROUND AND AIMS

Adenoma detection rate (ADR) is still the main surrogate outcome parameter of screening colonoscopy, but most studies include mixed indications, and basic ADR is quite variable. We therefore looked at the control groups in randomized ADR trials using advanced imaging or mechanical methods to find out whether indications or other factors influence ADR levels.

METHODS

Patients in the control groups of randomized controlled trials (RCTs) on ADR increase using various methods were collected based on a systematic review; this control group had to use high-definition white-light endoscopy performed between 2008 and 2021. Random-effects meta-analysis was used to pool ADR in control groups and its 95% confidence interval (CI) according to clinical (indication and demographic), study setting (tandem/parallel, number of centers, sample size), and technical (type of intervention, withdrawal time) parameters. Interstudy heterogeneity was reported with the I² statistic. Multivariable mixed-effects meta-regression was performed for potentially relevant variables.

RESULTS

From 80 studies, 25,304 patients in the respective control groups were included. ADR in control arms varied between 8.2% and 68.1% with a high degree of heterogeneity (I² = 95.1%; random-effect pooled value, 37.5%; 95% CI, 34.6‒40.5). There was no difference in ADR levels between primary colonoscopy screening (12 RCTs, 15%) and mixed indications including screening/surveillance and diagnostic colonoscopy; however, fecal immunochemical testing as an indication for colonoscopy was an independent predictor of ADR (odds ratio [OR], 1.6; 95% CI, 1.1-2.4). Other well-known parameters were confirmed by our analysis such as age (OR, 1.038; 95% CI, 1.004-1.074), sex (male sex: OR, 1.02; 95% CI, 1.01-1.03), and withdrawal time (OR, 1.1; 95% CI, 1.0-1.1). The type of intervention (imaging vs mechanical) had no influence, but methodologic factors did: More recent year of publication and smaller sample size were associated with higher ADR.

CONCLUSIONS

A high level of variability was found in the level of ADR in the control groups of RCTs. With regards to indications, only fecal immunochemical test-based colonoscopy studies influenced basic ADR, and primary colonoscopy screening appeared to be similar to other indications. Standardization for variables related to clinical, methodologic, and technical parameters is required to achieve generalizability and reproducibility.

Endocuff-assisted versus standard colonoscopy for improving adenoma detection rate: meta-analysis of randomized controlled trials

BACKGROUND

The effect of Endocuff-assisted colonoscopy compared with standard colonoscopy is conflicting in terms of the adenoma detection rate. The aim of this meta-analysis was to compare the efficacy of Endocuff-assisted colonoscopy for adenoma detection.

METHODS

PubMed, Embase, Google Scholar and Cochrane Library were searched up to the end of June 8, 2021. All randomized controlled trials (RCTs) comparing Endocuff-assisted colonoscopy with standard colonoscopy were included. Dichotomous data were pooled to obtain the relative risk with a 95% CI, whereas continuous data were pooled using a mean difference with 95% CI.

RESULTS

A total of 23 RCTs involving 17,999 patients were included. Compared with standard colonoscopy, use of the Endocuff was associated with a significant improvement in the adenoma detection rate (RR = 1.16, 95% CI 1.08-1.24), polyp detection rate (RR = 1.17, 95% CI 1.09-1.25), sessile serrated lesion detection rate (RR = 1.23, 95% CI 1.05-1.43), left-side lesion detection rate (RR = 1.24, 95% CI 1.08-1.43), and mean number of adenomas per patient (MD = 0.17, 95% CI 0.08-0.26). There were no significant differences between the and groups in detection of advanced adenomas, mean number of polyps per patient, right-side lesion detection rate, cecal intubation rate, cecal intubation time and withdrawal time.

CONCLUSIONS

The pooled evidence suggests a significant improvement in the adenoma detection rate, and polyp detection rate using the Endocuff. On the other hand, no significant effect on the detection of advanced adenomas and mean number of polyps per patient was noted.

Impact of changing diagnostic criteria on the diagnosis of serrated polyposis syndrome

Background and study aims  The World Health Organization criteria for serrated polyposis syndrome (SPS) were established in 2010 and modified in 2019. Neither set of criteria have been validated against genetic markers or proven to be the optimal criteria for defining colorectal cancer risk in patients with serrated colorectal lesions. In this study, we sought to gain insight into how frequently the change in SPS criteria in 2019 impacted the diagnosis of SPS. Patients and methods  We reviewed 279 patients with SPS diagnosed between 2010 and 2019 using the 2010 criteria (n = 163) or since 2019 using the 2019 criteria (n = 116). We reviewed whether patients in each group met the diagnosis of SPS by the alternative criteria. Results  Of those diagnosed using 2010 criteria, 5.5 % did not meet 2019 criteria. Of those diagnosed by 2019 criteria, 10.3 % did not meet 2010 criteria. Conclusions  Most patients with SPS in our database met the diagnosis of SPS by both 2010 and 2019 criteria, with only 5 % to 10 % of patients in each cohort not meeting the alternative diagnostic criteria.

Second-generation distal attachment cuff for adenoma detection in screening colonoscopy: a randomized multicenter study

BACKGROUND AND AIMS

Randomized studies have demonstrated that a distal attachment cap with rubber side arms, the Endocuff Vision (ECV; Olympus America, Center Valley, Pa, USA), increased colonoscopic adenoma detection rate (ADR) in various mixed patient collectives. This is the first study to evaluate its use in a primary colonoscopic screening program.

METHODS

Patients over age 55 years undergoing screening colonoscopy in 9 German private offices in Berlin and Hamburg were randomized to either the study group using ECV or the control group using high-definition colonoscopies (standard of care). The main outcome parameter was ADR, whereas secondary outcomes were detection rates of all adenomas per colonoscopy (APCs), of adenoma subgroups, and of hyperplastic polyps.

RESULTS

Of 1416 patients (mean age, 61.1 years; 51.8% women), with a median of 41 examinations per examiner (n = 23; interquartile range, 12-81), 700 were examined with ECV and 716 without. Adjusting for the effects of the colonoscopies, ADR was 39.5% (95% confidence interval [CI], 32.6%-46.3%) in the ECV group versus 32.2% (95% CI, 25.9%-38.6%) in the control group, which resulted in an increase of 7.2% (95% CI, 2.3%-12.2%; P = .004). The increase in ADR was mainly because of small polyps, with adjusted ADRs for adenomas <10 mm of 33.3% (95% CI, 26.5%-40.2%) for study patients versus 24.0% (95% CI, 18.2%-29.8%) for control patients (P < .001). APC was also significantly increased (.57 ECV vs .51 control subjects, P = .045).

CONCLUSIONS

A distal attachment cap with side arms significantly increased the ADR in patients undergoing primary colonoscopic screening. Because of the correlation of ADR and interval cancer, its use should be encouraged, especially in this setting. (Clinical trial registration number: NCT03442738.).

The effect of the endoscopic device Endocuff™/Endocuff vision™ on quality standards in colonoscopy: A systematic review and meta-analysis of randomized trials

AIM

The adenoma detection rate (ADR) is an important quality measure, with a high ADR reflecting high-quality colonoscopy. This systematic review and meta-analysis aimed to assess the effects of Endocuff™/Endocuff Vision™-assisted colonoscopy (EAC) versus standard colonoscopy (SC) on ADR and other clinical, patient and resource-use outcomes.

METHOD

MEDLINE, EMBASE, Web of Science, Scopus and the Cochrane Central Register of Controlled Trials were searched for full papers reporting randomized studies comparing EAC with SC. The primary outcome was ADR. Secondary outcomes comprised key polyp/adenoma detection, procedure-related, patient-related and health economic measures. Random effects meta-analyses provided pooled estimates of outcomes [risk ratio (RR) or mean difference (MD), with 95% confidence intervals (CI)].

RESULTS

Twelve parallel-group randomized controlled trials (RCTs) and three crossover RCTs with data on 9140 patients were included. EAC significantly increased the ADR (RR 1.18, 95% CI 1.09-1.29), mean adenomas per procedure (MAP) (MD 0.19, 95% CI 0.06-0.33), polyp detection rate (PDR) (RR 1.20, 95% CI 1.10-1.30) and mean polyps per procedure (MPP) (MD 0.39, 95% CI 0.14-0.63) versus SC. EAC significantly increased segmental PDR versus SC in the sigmoid (RR 2.02, 95% CI 1.64-2.49), transverse (RR 1.63, 95% CI 1.09-2.42), ascending (RR 1.74, 95% CI 1.26-2.41) and caecal segments (RR 1.91, 95% CI 1.29-2.82). Procedure-related variables did not differ between arms. There were insufficient data for meta-analysis of health economic or patient-centred outcomes.

CONCLUSIONS

EAC increased ADR, MAP, PDR and MPP versus SC without detrimental effects on procedure measures. Cost-effectiveness and patient experience data are lacking and would be valuable to inform practice recommendations.

Comparative Efficacy of Endoscopic Assist Devices on Colonic Adenoma Detection: A Systematic Review With Network Meta-analysis

BACKGROUND AND AIMS

Numerous endoscopic assist devices exist, yet data surrounding their comparative efficacy is lacking. We conducted a systematic review with network meta-analysis to determine the comparative efficacy of endoscopic assist devices on colonic adenoma detection.

METHODS

A systematic search was performed using multiple electronic databases through July 2020, to identify all randomized controlled trials and dual-arm observational studies compared with either other endoscopic assist devices and/or standard colonoscopy. The primary outcome was adenoma detection rate (ADR). Secondary outcomes included polyp detection rate (PDR), serrated adenoma detection rate (SADR), right-sided adenoma detection rate (RADR), and proximal adenoma detection rate (PADR).

RESULTS

Fifty-seven studies (31,051 patients) met inclusion criteria and were analyzed. Network meta-analysis identified an enhanced ADR among (clear) cap [odds ratio (OR): 2.69, 95% confidence interval (CI): 1.45-4.99], endocuff, (OR: 4.95, 95% CI: 3.15-7.78), and endoring (OR: 3.68, 95% CI: 1.47-9.20)-with no significant difference amongst any particular device. Similar findings for PDR were also seen. Enhanced SADR was identified for endocuff (OR: 9.43) and endoring (OR: 4.06) compared with standard colonoscopy. Enhanced RADR (OR: 5.36) and PADR (OR: 3.78) were only identified for endocuff. Endocuff comparatively demonstrated the greatest ADR, PDR, and SADR, but this was not significant when compared with the other assist devices. Subgroup analysis of randomized controlled trials identified enhanced PDR and ADR for both cap and endocuff.

CONCLUSIONS

Endoscopic assist devices displayed increased ADR and PDR as compared with standard colonoscopy and thus should be widely adopted. A nonsignificant trend was seen toward higher efficacy for the endocuff device.

Endocuff Vision to Improve Adenoma Vision: A Brief Overview

Colorectal cancer (CRC)-related mortality can be reduced through screening and early detection. The aim of any CRC screening program is to detect as many adenomas/polyps in the early stage as possible and hence, adenoma detection rate (ADR) is a key quality indicator of colonoscopy. Various methods and techniques have been studied and developed over the years to improve the quality of colonoscopy and thereby increase ADR. This ranges from use of various regimens to improve bowel preparation, defining an optimum colonoscope withdrawal time for the operator, distal attachment caps, use of different wavelength of light, colonoscope with increased degree of view to the use of modern-day artificial intelligence to improve ADR. Of all the various measures, use of distal attachment device seems an easy, cheap and readily usable technique to increase real-time ADR. A variety of such devices have been evaluated over time starting from simple transparent caps, EndoRings, Endocuff to Endocuff Vision for their effectiveness. In this review, we have provided a brief description of the various available distal attachment devices and a detailed technical overview of Endocuff and its modification the Endocuff Vision.

High-Definition Colonoscopy Compared With Cuff- and Cap-Assisted Colonoscopy: Results From a Multicenter, Prospective, Randomized Controlled Trial

BACKGROUND AND AIMS

Mucosal exposure devices including distal attachments such as the cuff and cap have shown variable results in improving adenoma detection rate (ADR) compared with high-definition white light colonoscopy (HDWLE).

METHODS

We performed a prospective, multicenter randomized controlled trial in patients undergoing screening or surveillance colonoscopy comparing HDWLE to 2 different types of distal attachments: cuff (CF) (Endocuff Vision) or cap (CP) (Reveal). The primary outcome was ADR. Secondary outcomes included adenomas per colonoscopy, advanced adenoma and sessile serrated lesion detection rate, right-sided ADR, withdrawal time, and adverse events. Continuous variables were compared using Student's t test and categorical variables were compared using chi-square or Fisher's exact test using statistical software Stata version16. A P value <.05 was considered significant.

RESULTS

A total of 1203 subjects were randomized to either HDWLE (n = 384; mean 62 years of age; 81.3% males), CF (n = 379; mean 62.7 years of age; 79.9% males) or CP (n = 379; mean age 62.1 years of age; 80.5% males). No significant differences were found among 3 groups for ADR (57.3%, 59.1%, and 55.7%; P = .6), adenomas per colonoscopy (1.4 ± 1.9, 1.6 ± 2.4, and 1.4 ± 2; P = .3), advanced adenoma (7.6%, 9.2%, and 8.2%; P = .7), sessile serrated lesion (6.8%, 6.3%, and 5.5%; P = .8), or right ADR (48.2%, 49.3%, and 46.2%; P = .7). The number of polyps per colonoscopy were significantly higher in the CF group compared with HDWLE and CP group (2.7 ± 3.4, 2.3 ± 2.5, and 2.2 ± 2.3; P = .013). In a multivariable model, after adjusting for age, sex, body mass index, withdrawal time, and Boston Bowel Preparation Scale score, there was no impact of device type on the primary outcome of ADR (P = .77). In screening patients, CF resulted in more neoplasms per colonoscopy (CF: 1.7 ± 2.6, HDWLE: 1.3 ± 1.7, and CP: 1.2 ± 1.8; P = .047) with a shorter withdrawal time.

CONCLUSIONS

Results from this multicenter randomized controlled trial do not show any significant benefit of using either distal attachment devices (CF or CP) over HDWLE, at least in high-detector endoscopists. The Endocuff may have an advantage in the screening population. (ClinicalTrials.gov, Number: NCT03952611).

Quality Indicators for the Detection and Removal of Colorectal Polyps and Interventions to Improve Them

Modifiable risk factors for postcolonoscopy colorectal cancer include suboptimal lesion detection (missed neoplasms) and inadequate lesion removal (incomplete polypectomy) during colonoscopy. Competent detection and removal of colorectal polyps are thus fundamental to ensuring adequate colonoscopy quality. Several well-researched quality metrics for polyp detection have been implemented into clinical practice, chief among these the adenoma detection rate. Less data are available on quality indicators for polyp removal, which currently include complete resection rates and skills assessment tools. This review summarizes the available literature on quality indicators for the detection and removal of colorectal polyps, as well as interventions to improve them.

Adenoma and serrated lesion detection with distal attachment in screening colonoscopy: a randomized controlled trial

BACKGROUND

Adenoma detection rate (ADR) is the single most important measure of quality in colonoscopy, but little is known about the detection rate of serrated lesions (SLDR). To improve ADR, Endocuff Vision (EV) can be used. Studies have shown differing results as to the effect on ADR; an effect on SLDR has not been shown. To investigate the effect of Endocuff Vision on ADR in a screening population, this randomized controlled open label trial with concealed allocation was performed. Randomization to trial group was carried out by the endoscopist using prepared numbered envelopes.

METHODS

Patients referred as part of the national bowel screening program at Regional Hospital Herning, Denmark were recruited and allocated to one of two groups: Endocuff Vision colonoscopy (EVC) and standard colonoscopy (SC). Outcomes were ADR, mean number, site, and size of lesions per procedure. SLDR as outcome was added after inclusion had begun.

RESULTS

A total of 1178 participants were included, with 1166 (EVC 583 and SC 583) available for analysis. There was no clinical relevant difference in ADR (59.2% [CI 55.1; 63.1] v 60.5% [CI 56.5; 64.4]) or SLDR (13.0% [CI 10.5; 16.0] v 10.3% [CI 8.0; 13.0]) between groups. More serrated lesions were found per procedure (MSP) (0.2 v 0.1, IRR 57% [CI 17; 109]. Removal rate of EV was similar in the two study groups.

CONCLUSION

We found no significant effects of the use of Endocuff Vision on ADR, when compared to standard colonoscopy, but more serrated lesions were detected in the Endocuff group.

TRIAL REGISTRATION

Clinical Trials NCT04651062.

Yield of a second right colon examination during colonoscopy after a first examination using a mucosal exposure device

BACKGROUND AND AIMS

Double right colon examination during colonoscopy has been advocated to reduce the risk of interval cancer in the right colon. Whether 2 examinations are necessary when the first examination is performed with a mucosal exposure device is uncertain. We documented the rates of missed adenomas, sessile serrated lesions, and hyperplastic polyps after an initial right colon examination by a high-level detector using a mucosal exposure device.

METHODS

At a single tertiary hospital outpatient practice, we prospectively collected data on the yield of a second examination of the right colon after an initial examination by a single high-detecting colonoscopist using a mucosal exposure device.

RESULTS

During the study period, 1331 eligible consecutive patients underwent colonoscopy. Right colon adenoma, sessile serrated lesion, and hyperplastic polyp miss rates were 15.8%, 14.1%, and 16.7%, respectively. Four percent of patients had adenomas detected in the right colon only with a second examination.

CONCLUSIONS

A second examination of the right colon is warranted, even when using a distal mucosal exposure device to perform colonoscopy.

Sessile serrated adenoma/polyp detection rate of water exchange, Endocuff, and cap colonoscopy: A network meta-analysis

BACKGROUND AND AIM

Sessile serrated adenoma/polyp (SSA/P) may contribute to interval cancer. In a recent meta-analysis, water exchange (WE) was shown to be superior to Endocuff and cap colonoscopy at adenoma and advanced adenoma detection. The strong positive correlation between adenoma detection rate (ADR), advanced adenoma detection rate (AADR), and sessile serrated adenoma/polyp detection rate (SSA/PDR) prompted us to hypothesize that WE could significantly improve SSA/PDR compared with Endocuff and cap colonoscopy.

METHODS

The literature was searched for all randomized controlled trials (RCTs) that reported SSA/PDR as an outcome and included the keywords colonoscopy, and water exchange, Endocuff, or cap. We performed traditional network meta-analyses with random effect models comparing SSA/PDR of each method using air insufflation as the control and reported the odds ratios (ORs) with 95% confidence interval (CI). Performances were ranked based on P-score.

RESULTS

A total of 531 articles resulted from initial keywords search. Eleven RCTs were included in the analysis. A total of 7856 patients underwent air insufflation, WE, Endocuff, or cap colonoscopy. WE significantly increased SSA/PDR (OR 2.04; 95% CI 1.33-3.13). Endocuff (OR 1.15; 95% CI 0.94-1.41) and cap (OR 1.08; 95% CI 0.42-2.74) did not significantly impact SSA/P detection. P-scores for WE (0.96), Endocuff (0.49), cap (0.37), and air insufflation (0.17) suggested that WE had the highest SSA/PDR. The results did not change after adjusting for mean withdrawal time and indication for colonoscopy.

CONCLUSION

Water exchange significantly increases SSA/PDR and is superior to Endocuff and cap colonoscopy at detecting SSA/P.

Endocuff Vision improves adenoma detection rate in a large screening-related cohort

Background and study aims  Endocuff Vision (ECV) increases adenoma detection rate (ADR) in randomized clinical trials; however, observational effectiveness data are lacking. We evaluated the effectiveness, safety, and practical aspects of ECV use in a large screening-related real-world cohort. Patients and methods  In this observational study, patients undergoing screening-related colonoscopy from November 2018 to April 2019 comprised the baseline period, and those undergoing it from June to November 2019 comprised the ECV period, where ECV use was discretionary. The primary outcome was ADR, compared: 1) between ECV use and standard colonoscopy across both periods; and 2) between time periods. Secondary outcomes included indication-specific ADR, sessile serrated ADR (SSADR), cecal intubation rate (CIR), procedure times, patient comfort scores, and sedation use. Multilevel logistic regression was performed, yielding adjusted odds ratios (AOR) with 95 % confidence intervals (CIs). Results  In 15,814 colonoscopies across both time periods, ADR was 46.7 % with standard colonoscopy and 54.6 % when ECV was used ( P  < 0.001). Endoscopists used ECV in 77.6 % of procedures in the ECV period, during which overall ADR rose to 53.2 % compared to 46.3 % in the baseline period ( P  < 0.001). ECV use was significantly associated with higher ADR (AOR 1.24, 95 % CI 1.10 to 1.40) after adjusting for relevant covariates including time period. ECV use did not result in lower CIR, longer procedure time, increased sedation use, or poorer comfort scores. Conclusions  ECV use is associated with improved ADR without negatively impacting other key procedure and patient-related factors. Future studies should evaluate the cost-effectiveness of incorporating ECV into routine screening-related practice.

Computer-aided detection versus advanced imaging for detection of colorectal neoplasia: a systematic review and network meta-analysis

BACKGROUND

Computer-aided detection (CADe) techniques based on artificial intelligence algorithms can assist endoscopists in detecting colorectal neoplasia. CADe has been associated with an increased adenoma detection rate, a key quality indicator, but the utility of CADe compared with existing advanced imaging techniques and distal attachment devices is unclear.

METHODS

For this systematic review and network meta-analysis, we did a comprehensive search of PubMed/Medline, Embase, and Scopus databases from inception to Nov 30, 2020, for randomised controlled trials investigating the effectiveness of the following endoscopic techniques in detecting colorectal neoplasia: CADe, high definition (HD) white-light endoscopy, chromoendoscopy, or add-on devices (ie, systems that increase mucosal visualisation, such as full spectrum endoscopy [FUSE] or G-EYE balloon endoscopy). We collected data on adenoma detection rates, sessile serrated lesion detection rates, the proportion of large adenomas detected per colonoscopy, and withdrawal times. A frequentist framework, random-effects network meta-analysis was done to compare artificial intelligence with chromoendoscopy, increased mucosal visualisation systems, and HD white-light endoscopy (the control group). We estimated odds ratios (ORs) for the adenoma detection rate, sessile serrated lesion detection rate, and proportion of large adenomas detected per colonoscopy, and calculated mean differences for withdrawal time, with 95% CIs. Risk of bias and certainty of evidence were assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

FINDINGS

50 randomised controlled trials, comprising 34 445 participants, were included in our main analysis (six trials of CADe, 18 of chromoendoscopy, and 26 of increased mucosal visualisation systems). HD white-light endoscopy was the control technique in all 50 studies. Compared with the control technique, the adenoma detection rate was 7·4% higher with CADe (OR 1·78 [95% CI 1·44-2·18]), 4·4% higher with chromoendoscopy (1·22 [1·08-1·39]), and 4·1% higher with increased mucosal visualisation systems (1·16 [1·04-1·28]). CADe ranked as the superior technique for adenoma detection (with moderate confidence in hierarchical ranking); cross-comparisons of CADe with other imaging techniques showed a significant increase in the adenoma detection rate with CADe versus increased mucosal visualisation systems (OR 1·54 [95% CI 1·22-1·94]; low certainty of evidence) and with CADe versus chromoendoscopy (1·45 [1·14-1·85]; moderate certainty of evidence). When focusing on large adenomas (≥10 mm) there was a significant increase in the detection of large adenomas only with CADe (OR 1·69 [95% CI 1·10-2·60], moderate certainty of evidence) when compared to HD white-light endoscopy; CADe ranked as the superior strategy for detection of large adenomas. CADe also seemed to be the superior strategy for detection of sessile serrated lesions (with moderate confidence in hierarchical ranking), although no significant increase in the sessile serrated lesion detection rate was shown (OR 1·37 [95% CI 0·65-2·88]). No significant difference in withdrawal time was reported for CADe compared with the other techniques.

INTERPRETATION

Based on the published literature, detection rates of colorectal neoplasia are higher with CADe than with other techniques such as chromoendoscopy or tools that increase mucosal visualisation, supporting wider incorporation of CADe strategies into community endoscopy services.

FUNDING

None.

AGA Clinical Practice Update on Strategies to Improve Quality of Screening and Surveillance Colonoscopy: Expert Review

The purpose of this American Gastroenterological Association Institute Clinical Practice Update was to review the available evidence and provide best practice advice regarding strategies to improve the quality of screening and surveillance colonoscopy. This review is framed around 15 best practice advice statements regarding colonoscopy quality that were agreed upon by the authors, based on a review of the available evidence and published guidelines. This is not a formal systematic review and thus no formal rating of the quality of evidence or strength of recommendation has been carried out.

Increased Sessile Serrated Adenoma Detection Rate With Mechanical New Technology Devices: A Systematic Review and Meta-Analysis

GOAL

This meta-analysis aims to compare the sessile-serrated adenoma detection rate (SSADR) of currently available mechanical new technology devices (NTDs) to conventional colonoscopy (CC).

BACKGROUND

NTDs including Endocuff, EndoRing, G-Eye, and AmplifEYE were developed with the aim of improving adenoma detection rate by enhancing colonic mucosal visualization. Increasing awareness of the risk of sessile-serrated adenoma progression to malignancy has ushered a need to increase the detection of these characteristically flat lesions.

STUDY

Embase and PubMed/Medline databases were searched from inception through January 2019 for published manuscripts or major conference abstracts reporting SSADR with Endocuff, EndoRing, G-Eye, AmplifEYE, and CC. Randomized controlled trials, high-quality case-control, cohort, and observational studies in adults with >10 subjects were included. The primary outcome was pooled SSADR odds ratio (ORs) with 95% confidence interval (95% CI) comparing CC with the NTDs. In addition, an analysis comparing each device to CC was performed.

RESULTS

Of 207 citations identified, a total of 14 studies with 12,655 subjects were included in our analysis (5931 subjects with NTDs and 6724 with CC). There were 12 studies with Endocuff, 2 with EndoRing, 1 with G-EYE, and 1 with AmplifEYE. The mean age was 62.4 years and 57.5% were males. Pooled SSADR with NTDs was 12.3% as compared with 6.4% with CC, with an OR of 1.81 (95% CI: 1.6-2.0, I2: 77%). Analysis of Endocuff alone yielded an OR 1.81 (95% CI: 1.6-2.1, I2: 79%).

CONCLUSION

Mechanical NTDs, notably Endocuff, are a safe and effective tool to increase the SSADR.

Second-generation distal attachment cuff improves adenoma detection rate: meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Multiple randomized controlled trials (RCTs) using the second-generation distal attachment cuff device (Endocuff Vision; Olympus America, Center Valley, Pa, USA) have reported conflicting results in improving adenoma detection rate (ADR) compared with standard high-definition colonoscopy without the distal attachment. We conducted a systematic review and meta-analysis of RCTs to compare outcomes between second-generation cuff colonoscopy (CC) versus colonoscopy without the distal attachment (standard colonoscopy [SC]).

METHODS

An electronic literature search was performed using PubMed, Google Scholar, Embase, and Cochrane Library through May 2020. The primary outcome was reporting of ADR, and secondary outcomes were polyp detection rate (PDR), mean withdrawal time, mean adenomas per colonoscopy (APC), sessile serrated lesion detection rate, and adverse events. Pooled rates and risk ratios (RRs) with 95% confidence intervals were reported.

RESULTS

Eight RCTs with 5695 patients were included in the final analysis, with 2862 patients (mean age, 62.8 years; 52.9% men) in the CC group and 2833 patients (mean age, 62.6 years; 54.2% men) in the SC group. Compared with SC, use of CC was associated with a significant improvement in ADR (49.8% vs 45.6%, respectively; RR, 1.12; P = .02), PDR (58.1% vs 53%, respectively; RR, 1.12; P = .009), and APC (P < .01). Furthermore, use of CC had a .93-minute lower mean withdrawal time (P < .01) when compared with SC. The difference in ADR was larger in the screening/surveillance population (6.5%, P = .02) and when used by endoscopists with ADRs <30% (9.4%, P = .03).

CONCLUSIONS

The results of this meta-analysis of randomized trials show a significant improvement in ADR and APC with shorter withdrawal times using the second-generation cuff device compared with SC.

ACG Clinical Guidelines: Colorectal Cancer Screening 2021

Colorectal cancer (CRC) is the third most common cancer in men and women in the United States. CRC screening efforts are directed toward removal of adenomas and sessile serrated lesions and detection of early-stage CRC. The purpose of this article is to update the 2009 American College of Gastroenterology CRC screening guidelines. The guideline is framed around several key questions. We conducted a comprehensive literature search to include studies through October 2020. The inclusion criteria were studies of any design with men and women age 40 years and older. Detailed recommendations for CRC screening in average-risk individuals and those with a family history of CRC are discussed. We also provide recommendations on the role of aspirin for chemoprevention, quality indicators for colonoscopy, approaches to organized CRC screening and improving adherence to CRC screening. CRC screening must be optimized to allow effective and sustained reduction of CRC incidence and mortality. This can be accomplished by achieving high rates of adherence, quality monitoring and improvement, following evidence-based guidelines, and removing barriers through the spectrum of care from noninvasive screening tests to screening and diagnostic colonoscopy. The development of cost-effective, highly accurate, noninvasive modalities associated with improved overall adherence to the screening process is also a desirable goal.

Efficacy of Endocuff Vision compared to first-generation Endocuff in adenoma detection rate and polyp detection rate in high-definition colonoscopy: a systematic review and network meta-analysis

Background and study aims  Recently, the newer Endocuff Vision (ECV) has been evaluated for improving colonoscopy outcome metrics such as adenoma detection rate (ADR) and polyp detection rate (PDR). Due to lack of direct comparative studies between ECV and original Endocuff (ECU), we performed a systematic review and network meta-analysis to evaluate these outcomes. Methods  The following databases were searched: PubMed, Embase, Cochrane, and Web of Sciences to include randomized controlled trials (RCTs) comparing ECV or ECU colonoscopy to high-definition (HD) colonoscopy. Direct as well as network meta-analyses comparing ADR and PDR were performed using a random effects model. Relative-risk (RR) with 95 % confidence interval (CI) was calculated. Results  A total of 12 RCTs with 8638 patients were included in the final analysis. On direct meta-analysis, ECV did not demonstrate statistically improved ADR compared to HD colonoscopy (RR: 1.12, 95 % CI 0.99-1.27). A clinically and statistically improved PDR was noted for ECV compared to HD (RR: 1.15, 95 % CI 1.03-1.28) and ECU compared to HD (RR: 1.26, 95 % CI 1.09-1.46) as well as improved ADR (RR: 1.22, 95 % CI 1.05-1.43) was observed for ECU colonoscopy when compared to HD colonoscopy. These results were also consistent on network meta-analysis. Lower overall complication rates (RR: 0.14, 95 % CI 0.02-0.84) and particularly lacerations/erosions (RR: 0.11, 95 % CI 0.02-0.70) were noted with ECV compared to ECU colonoscopy. Conclusions  Although safe, the newer ECV did not significantly improve ADR compared to ECU and HD colonoscopy. Further device modification is needed to increase the overall ADR and PDR.

GIE Editorial Board top 10 topics: advances in GI endoscopy in 2019

The American Society for Gastrointestinal Endoscopy's GIE Editorial Board reviewed original endoscopy-related articles published during 2019 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of disinfection, artificial intelligence, bariatric endoscopy, adenoma detection, polypectomy, novel imaging, Barrett's esophagus, third space endoscopy, interventional EUS, and training. This document summarizes these "top 10" endoscopic advances of 2019.

Proximal retroflexion versus second forward view of the right colon during screening colonoscopy: A multicentre randomized controlled trial

BACKGROUND

Colonoscopy is the gold standard investigation for the detection of colorectal cancer, but the right colon is more difficult to examine than the left colon. A second examination of the proximal colon has the potential to reduce rates of missed pathology.

OBJECTIVE

To determine whether proximal retroflexion improves the adenoma detection rate or other outcomes in the right colon compared with the forward view.

METHODS

We performed a multicentre randomized controlled trial of patients from the colorectal cancer screening programme with a positive faecal immunochemical test. Patients were randomized to a second right colon examination using proximal retroflexion or forward view.

RESULTS

A total of 692 patients were included. A second examination of the right colon, with an average additional procedure time of 1.62 min, increased the adenoma detection rate by 11%, regardless of the method used (9% proximal retroflexion vs. 12% second forward view, p = 0.21). The adenoma miss rate was 19% (17% proximal retroflexion vs. 20% forward view, p = 0.28) The success rate of retroflexion was 83%, without secondary complications. In the 15.6% of patients in whom lesions were detected during the second pass, endoscopic follow-up was modified by reducing the time of the next colonoscopy.

CONCLUSIONS

A second examination of the right colon, either from retroflexion or second forward view, can increase adenoma detection rate and shorten surveillance intervals in patients undergoing screening colonoscopy. This should be emphasized during colonoscopy training and integrated into diagnostic colonoscopy practice.