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

Use of a Novel Artificial Intelligence System Leads to the Detection of Significantly Higher Number of Adenomas During Screening and Surveillance Colonoscopy: Results From a Large, Prospective, US Multicenter, Randomized Clinical Trial

INTRODUCTION

Adenoma per colonoscopy (APC) has recently been proposed as a quality measure for colonoscopy. We evaluated the impact of a novel artificial intelligence (AI) system, compared with standard high-definition colonoscopy, for APC measurement.

METHODS

This was a US-based, multicenter, prospective randomized trial examining a novel AI detection system (EW10-EC02) that enables a real-time colorectal polyp detection enabled with the colonoscope (CAD-EYE). Eligible average-risk subjects (45 years or older) undergoing screening or surveillance colonoscopy were randomized to undergo either CAD-EYE-assisted colonoscopy (CAC) or conventional colonoscopy (CC). Modified intention-to-treat analysis was performed for all patients who completed colonoscopy with the primary outcome of APC. Secondary outcomes included positive predictive value (total number of adenomas divided by total polyps removed) and adenoma detection rate.

RESULTS

In modified intention-to-treat analysis, of 1,031 subjects (age: 59.1 ± 9.8 years; 49.9% male), 510 underwent CAC vs 523 underwent CC with no significant differences in age, gender, ethnicity, or colonoscopy indication between the 2 groups. CAC led to a significantly higher APC compared with CC: 0.99 ± 1.6 vs 0.85 ± 1.5, P = 0.02, incidence rate ratio 1.17 (1.03-1.33, P = 0.02) with no significant difference in the withdrawal time: 11.28 ± 4.59 minutes vs 10.8 ± 4.81 minutes; P = 0.11 between the 2 groups. Difference in positive predictive value of a polyp being an adenoma among CAC and CC was less than 10% threshold established: 48.6% vs 54%, 95% CI -9.56% to -1.48%. There were no significant differences in adenoma detection rate (46.9% vs 42.8%), advanced adenoma (6.5% vs 6.3%), sessile serrated lesion detection rate (12.9% vs 10.1%), and polyp detection rate (63.9% vs 59.3%) between the 2 groups. There was a higher polyp per colonoscopy with CAC compared with CC: 1.68 ± 2.1 vs 1.33 ± 1.8 (incidence rate ratio 1.27; 1.15-1.4; P < 0.01).

DISCUSSION

Use of a novel AI detection system showed to a significantly higher number of adenomas per colonoscopy compared with conventional high-definition colonoscopy without any increase in colonoscopy withdrawal time, thus supporting the use of AI-assisted colonoscopy to improve colonoscopy quality ( ClinicalTrials.gov NCT04979962).

What are the priority quality indicators for colonoscopy in real-world clinical practice?

Colonoscopy is widely used as a colorectal cancer (CRC) screening tool. The effectiveness of a screening colonoscopy is associated with a decreased risk of CRC. However, colonoscopy is an operator-dependent procedure, and endoscopists' quality performance varies widely. This article reviewed the priority metrics and practices that contribute to high-quality screening colonoscopy in real-world clinical practice. With growing evidence, quality indicators have been subject to intense research and associated with reducing postcolonoscopy CRC incidence and mortality. Some quality metrics can reflect an endoscopy unit-based practice (i.e. quality of bowel preparation and withdrawal time). Other quality indicators primarily reflect individuals' skill and knowledge (i.e. cecal intubation rate, adenoma detection rate, and appropriately assigned follow-up colonoscopy interval). Measurement and improvement of priority quality indicators for colonoscopy should be made at both the endoscopist and unit levels. Substantial evidence supports the impact of high-quality colonoscopy in reducing the incidence of postcolonoscopy CRC.

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.

Adenoma detection rate in colonoscopy: how can it be improved?

INTRODUCTION

The introduction of widespread colonoscopy screening programs has helped in decreasing the incidence of Colorectal Cancer (CRC). However, 'back-to-back' colonoscopies revealed relevant percentage of missed adenomas. Quality indicators were created to further homogenize detection performances and decrease the incidence of post-colonoscopy CRC. Among them, the Adenoma Detection Rate (ADR), defined as the percentage obtained by dividing the number of endoscopic procedures in which at least one adenoma was resected, by the total number of procedures, was found to be inversely associated with the risks of interval colorectal cancer, advanced-stage interval cancer, and fatal interval cancer.

AREAS COVERED

In this paper, we performed a comprehensive review of the literature focusing on promising new devices and technologies, which are meant to positively affect the endoscopist performance in detecting adenomas, therefore increasing ADR.

EXPERT OPINION

Considering the current knowledge, although several devices and technologies have been proposed with this intent, the recent implementation of AI ranked over all of the other strategies and it is likely to become the new standard within few years. However, the combination of different device/technologies need to be investigated in the future aiming at even further increasing of endoscopist detection performances.

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.).

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.).