Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate

Effectiveness and safety of a 1L polyethylene glycol and ascorbic acid preparation for colonoscopy in routine clinical practice in Spain

BACKGROUND AND AIMS

Large clinical trials and small real-world studies show that a 1L polyethylene glycol and ascorbic acid solution (1L PEG-ASC) is an effective and safe bowel preparation for colonoscopy. Here, the effectiveness and safety of 1L PEG-ASC was evaluated in a large cohort of patients in routine clinical practice in Spain.

METHODS

A sub-analysis was performed in an observational, multicenter, retrospective study assessing the effectiveness and safety of 1L PEG-ASC in adult patients undergoing a colonoscopy at 10 centers in Spain. Cleansing quality was assessed with the Boston Bowel Preparation Scale, scores ≥6 with all segmental scores ≥2 was considered adequate colon cleansing, high-quality was considered as cleansing ≥8 or =3 in the right colon. Polyp and adenoma detection rates, and adverse events were also assessed.

RESULTS

Data was collected from 7160 patients: 48.3% males; mean age 58.0, 33.6% ≥65 years old. Adequate overall bowel cleansing was achieved in 95.6% of patients (95% CI 95.1%-96.0%), high quality cleansing in 74.4% (95% CI 73.4%-75.4%) and high-quality right colon cleansing in 66.0% (95% CI 64.9-67.1). The adequate overall cleansing rate was 97.0% with a split-dose and 94.0% with same-day regimen (P<0.0001), and high-quality right colon cleansing was 69.0% and 62.5% (P<0.0001), respectively. Colonoscopy was completed in 97.2% of cases. A multivariate regression analysis revealed that an overnight split-dose regimen and age <65 years were independent predictors of adequate bowel cleansing of the overall colon, age <65 years and female gender were independent predictors of HQ cleansing of the overall colon, and the three covariates were independent predictors of HQ cleansing of the right colon. At least one adverse event was experienced by 3.3% of participants, with nausea (1.5%) and vomiting (1.2%) being the most frequent.

CONCLUSION

This sub-analysis confirmed 1L PEG-ASC to be an effective and safe bowel cleansing preparation in a real world setting in Spain.

Strategies to improve screening colonoscopy quality for the prevention of colorectal cancer

The incidence and mortality of colorectal cancer (CRC) have decreased through regular screening colonoscopy, surveillance, and endoscopic treatment. However, CRC can still be diagnosed after negative colonoscopy. Such CRC is called interval CRC and accounts for 1.8-9.0% of all CRC cases. Most cases of interval CRC originate from missed lesions and incompletely resected lesions. Interval CRC can be minimized by improving the quality of colonoscopy. This has led to a growing interest in and demand for high-quality colonoscopy. It is important to reduce the risk of CRC and its associated mortality by improving the quality of colonoscopy. In this review article, we provide an overview of colonoscopy quality indicators, including bowel preparation adequacy, the cecal intubation rate, the adenoma detection rate, the colonoscopy withdrawal time, appropriate polypectomy, and complication of the procedure. Because colonoscopy is a highly endoscopist-dependent procedure, colonoscopists should be well-acquainted with quality indicators and strive to apply them in daily clinical practice for the prevention of CRC.

Performance comparison between two computer-aided detection colonoscopy models by trainees using different false positive thresholds: a cross-sectional study in Thailand

BACKGROUND/AIMS

This study aims to compare polyp detection performance of "Deep-GI," a newly developed artificial intelligence (AI) model, to a previously validated AI model computer-aided polyp detection (CADe) using various false positive (FP) thresholds and determining the best threshold for each model.

METHODS

Colonoscopy videos were collected prospectively and reviewed by three expert endoscopists (gold standard), trainees, CADe (CAD EYE; Fujifilm Corp.), and Deep-GI. Polyp detection sensitivity (PDS), polyp miss rates (PMR), and false-positive alarm rates (FPR) were compared among the three groups using different FP thresholds for the duration of bounding boxes appearing on the screen.

RESULTS

In total, 170 colonoscopy videos were used in this study. Deep-GI showed the highest PDS (99.4% vs. 85.4% vs. 66.7%, p<0.01) and the lowest PMR (0.6% vs. 14.6% vs. 33.3%, p<0.01) when compared to CADe and trainees, respectively. Compared to CADe, Deep-GI demonstrated lower FPR at FP thresholds of ≥0.5 (12.1 vs. 22.4) and ≥1 second (4.4 vs. 6.8) (both p<0.05). However, when the threshold was raised to ≥1.5 seconds, the FPR became comparable (2 vs. 2.4, p=0.3), while the PMR increased from 2% to 10%.

CONCLUSION

Compared to CADe, Deep-GI demonstrated a higher PDS with significantly lower FPR at ≥0.5- and ≥1-second thresholds. At the ≥1.5-second threshold, both systems showed comparable FPR with increased PMR.

Clinical value of sigmoid colon water exchange colonoscopy: a prospective randomized clinical trial

This prospective randomized controlled trial investigated the clinical value of sigmoid colon water exchange (SWE) colonoscopy by comparing it with air insufflation (AI) colonoscopy in terms of the patient's pain score, insertion time, and screening quality. Consecutive patients who underwent colonoscopy without sedation were randomized into an AI group (n = 267) or an SWE group (n = 255). Patient characteristics, history of abdominal or pelvic surgery, maximum pain score, insertion time, cecal intubation rate, polyp detection rate, and the need for maneuvers were recorded. There was no significant between-group difference in insertion time, cecal intubation rate, assisted maneuvers (abdominal pressure, changing patients' position), or polyp detection rate (P > 0.05). The mean maximum pain score was significantly lower in the SWE group than in the AI group. (3.57 ± 2.01 vs. 4.69 ± 1.83, P < 0.001). For patients with a history of abdominal or pelvic surgery and those who were overweight (body mass index > 24), the maximum pain scores were lower in the SWE group than in the AI group (3.67 ± 1.95 vs. 4.88 ± 1.80, P < 0.001; 3.40 ± 1.96 vs. 4.79 ± 1.97, P < 0.001, respectively). SWE colonoscopy can significantly reduce abdominal pain with non-inferior screening quality and does not increase insertion time.Trial registration number: ChiCTR2200059057 (date April 23, 2022).

Quality indicators in colonoscopy: observational study in a supplementary health system

PURPOSE

Colorectal cancer is responsible for 9.4% of cancer deaths, and low polyp detection rate and cecal intubation rate increase the risks of interval colorectal cancer. Despite several population studies that address colonoscopy quality measures, there is still a shortage of these studies in Latin America. The aim of this study was to assess quality indicators in colonoscopy, enabling future strategies to improve colorectal cancer prevention.

METHODS

An observational retrospective study, in which all colonoscopies performed in 11 hospitals were evaluated through a review of medical records. Information such as procedure indication, colorectal polyp detection rate, cecal intubation rate, quality of colonic preparation, and immediate adverse events were collected and analyzed.

RESULTS

In 17,448 colonoscopies performed by 86 endoscopists, 57.9% were in patients aged 50 to 74 years old. Colon preparation was adequate in 94.4% procedures, with rates of cecal intubation and polyp detection of 94 and 36.6%, respectively. Acute adverse events occurred in 0.2%. In 53.9%, high-definition imaging equipment was used. The procedure location, colon preparation and high-definition equipment influenced polyp detection rates (p < 0.001).

CONCLUSIONS

The extraction and analysis of electronic medical records showed that there are opportunities for improvement in colonoscopy quality indicators in the participating hospitals.

Comparison of Quality Measures for Detection of Neoplasia at Screening Colonoscopy

BACKGROUND & AIMS

The proportion of colonoscopies with at least one adenoma (adenoma detection rate [ADR]) is inversely associated with colorectal cancer (CRC) risk and death. The aim of this study was to examine whether such associations exist for colonoscopy quality measures other than ADR.

METHODS

We used data from the Polish Colorectal Cancer Screening Program collected in 2000-2011. For all endoscopists who performed ≥100 colonoscopies we calculated detection rates of adenomas (ADR), polyps (PDR), and advanced adenomas (≥10 mm/villous component/high-grade dysplasia [AADR]); and number of adenomas per colonoscopy (APC) and per colonoscopy with ≥1 adenoma (APPC). We followed patients until CRC diagnosed before recommended surveillance, death, or December 31, 2019. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using Cox proportional-hazard models. We used Harrell's C statistic to compare the predictive power of the quality measures.

RESULTS

Data on 173,287 patients (median age, 56 years; 37.8% male) and 262 endoscopists were used. During a median follow-up of 10 years and 1,490,683 person-years, we identified 395 CRCs. All quality measures were significantly associated with CRC risk and death. The relative reductions in CRC risk were as follows: for ADR ≥24.9% (reference <12.1%; HR, 0.41; 95% CI, 0.25-0.66), PDR ≥42.7% (reference <19.9%; HR, 0.35; 95% CI, 0.24-0.51), AADR ≥9.1% (reference <4.1%; HR, 0.69; 95% CI, 0.49-0.96), APC ≥0.37 (reference <0.15; HR, 0.35; 95% CI, 0.21-0.58), and APPC ≥1.54 (reference <1.19; HR, 0.54; 95% CI, 0.35-0.83). AADR was the only quality measure with significantly lower predictive power than ADR (Harrell's C, 59.7 vs 63.4; P = .001). Similar relative reductions were observed for CRC death.

CONCLUSIONS

This large observational study confirmed the inverse association between ADR and CRC risk and death. The PDR and APC quality measures appear to be comparable with ADR.

Quality indicators for colonoscopy in Egypt: A prospective multicenter study

BACKGROUND AND STUDY AIMS

Despite its wide availability, we do not have sufficient data aboutthe quality of colonoscopy in Egypt. In this study, we proposed 13 indicators to assess the quality of colonoscopy procedures in the included study centers aiming to attain a representative image of the quality of CS in Egypt.

PATIENTS AND METHODS

A multicenter prospective study was conducted between July and December 2020, which included all patients who underwent colonoscopy in the participating centers. The following were the proposed quality indicators: indications for colonoscopy, preprocedure clinical assessment, obtaining written informed consent, adequate colon preparation, sedation, cecal intubation rate (CIR), withdrawal time, adenoma detection rate (ADR), complication rate, photographic documentation, automated sterilization, regular infection control check, and well-equipped postprocedure recovery room.

RESULT

A total of 1,006 colonoscopy procedures were performed during the study duration in the included centers. Our analysis showed the following four indicators that were fulfilled in all centers: appropriate indications for colonoscopy, preprocedure assessment, written informed consent, and automated sterilization. However, photographic documentation and postprocedure follow-up room were fulfilled only in 57 %. Furthermore, 71 % of the centers performed regular infection control checks. Adequate colon preparation was achieved in 61 % of the procedures, 81 % of the procedures were performed under sedation, 95.4 % CIR, 11-min mean withdrawal time, 15 % ADR, and 0.1 % overall complication rate. Statistically significant factors affecting CIR were age > 40 years, high-definition endoscope, previous colon intervention, and rectal bleeding, whereas those affecting ADR were age > 40 years, the use of image enhancement, previous colon intervention, rectal bleeding, the use of water pump, and a withdrawal time of > 9 min.

CONCLUSION

Our study revealed the bright aspects of colonoscopy practice in Egypt, including high CIRs and low complication rates; conversely, ADR, bowel cleansing quality, and infection control measures should be improved.

Anesthesia Assistance in Colonoscopy: Impact on Quality Indicators

Background

Adenoma detection rate (ADR) and polyp detection rate (PDR) are both indicators for colonoscopy quality. Improving ADR or PDR is critical for reducing the incidence and mortality of colorectal cancer (CRC). Although several studies have focused on identifying the factors that may influence ADR or PDR, the evidence remains limited and inconclusive. We conducted a retrospective study to evaluate the effect of anesthesia assistance (AA) on ADR or PDR in patients undergoing colonoscopy screening and identify risk factors affecting ADR or PDR.

Methods

We reviewed electronic medical records of patients who underwent colonoscopy screening between May 2019 and August 2020. Patients were divided into two groups according to whether they received AA: patients in Group A underwent colonoscopy screening with AA, whereas patients in Group O underwent colonoscopy screening without AA. Propensity score matching (PSM) was utilized to account for differences in baseline characteristics. After, ADR and PDR were compared between the two groups. Binary logistic regression was employed to identify risk factors that affected ADR or PDR.

Results

Of 9432 patients who underwent colonoscopy examination during the study period, 7170 were included in the final analyses (Group A = 5756 and Group O = 1414). After PSM, 736 patients remained in each group for analyses. There was no significant difference between groups A and O (P &gt; 0.05) in ADR or PDR. Binary logistic regression indicated that the endoscopic device version (Olympus HQ290), equipment image-based technique and number of images were independent risk factors that affected ADR, and the age (50–59 years and 60–69 years), gender (male), high-risk status, endoscopist seniority (senior endoscopist), equipment image-based technique and number of images were all independent risk factors that affected PDR.

Conclusions

We discovered that AA does not affect ADR or PDR. Despite improved patient satisfaction, using AA is unnecessary for improving colonoscopy quality. Endoscopists should consider all these factors as much as possible when performing colonoscopy screening.

Continuous ADR50 monitoring through automated linkage between endoscopy and pathology: a quality improvement initiative in a Brussels public hospital

Background and study aim: Adenoma detection rate in patients aged 50 years or older (ADR50) is considered by the European Society of Gastrointestinal Endoscopy (ESGE) a key performance measures for lower gastrointestinal endoscopy. Technical and human resources constrain implementation of recording quality monitoring. The aim was to deploy an infrastructure for continuous monitoring of endoscopy quality indicators. And to evaluate its potential benefit on quality performance. Methods: A company reporting system was adapted by adding a dedicated tab for quality monitoring, including: preparation, progression, number of resected polyps. Automated linkage with the pathology database resulted in continuous monitoring of inter alia: rate of adequate bowel preparation, cecal intubation rate and ADR50. Continuous monitoring was done for all nine endoscopists working at our center, with individual feedback after 4, 9 and 28 months. Results: A total of 1434 colonoscopies were performed during the first 9 months of monitoring, 682 during the first 4 months, 752 during the following 5 months. Five months after feedback a global increase in ADR50 of 4.6% (22.9% to 27.5%) (P<0.05) was observed, compared to the first 4 months. Thus meeting the benchmark (≥25%) recommended by ESGE. A durable effect of monitoring and feedback was observed after 28 months (ADR50: 29.4%). Conclusions: An easy to use infrastructure for registration of quality monitoring in daily endoscopy practice, automatically linking the pathology database, facilitates continuous monitoring of endoscopy quality indicators. A global and durable ADR50 increase was observed after feedback, considered a quality improvement in performance of lower gastrointestinal endoscopy at our center.

Correlation between Surrogate Quality Indicators for Adenoma Detection Rate and Adenoma Miss Rate in Qualified Colonoscopy, CORE Study: KASID Multicenter Study

Background/Aims

The adenoma detection rate (ADR) does not reflect the complete detection of every adenoma during colonoscopy; thus, many surrogate indicators have been suggested. This study investigated whether the ADR and surrogate quality indicators reflect the adenoma miss rate (AMR) when performing qualified colonoscopy.

Methods

We performed a prospective, multicenter, cross-sectional study of asymptomatic examinees aged 50 to 75 years who underwent back-to-back screening colonoscopies by eight endoscopists. The ADR and surrogate quality indicators, including polyp detection rate, total number of adenomas per colonoscopy, additional adenomas found after the first adenoma per colonoscopy (ADR-Plus), and total number of adenomas per positive participant, were calculated for the prediction of AMR.

Results

A total of 371 back-to-back colonoscopies were performed. There was a significant difference in ADRs (range, 44% to 75.4%; p=0.024), polyp detection rates (range, 56% to 86.9%; p=0.008) and adenomas per positive participants (range, 1.19 to 2.30; p=0.038), and a tendency of a difference in adenomas per colonoscopy (range, 0.62 to 1.31; p=0.051) and ADR-Plus (range, 0.13 to 0.70; p=0.054) among the endoscopists. The overall AMR was 20.1%, and AMRs were not different (range, 13.9 to 28.6; p>0.05) among the endoscopists. No quality indicators were significantly correlated with AMR. The number of adenomas found during the first colonoscopy was an independent factor for increased AMR (odds ratio, 1.79; p<0.001).

Conclusions

The colonoscopy quality indicators were significantly different among high-ADR endoscopists, and none of the quality indicators reflected the AMR of good quality colonoscopy performances. The only factor influencing AMR was the number of adenomas detected during colonoscopy.

Effect of Using Personal Protective Equipment during the COVID-19 Pandemic on the Quality Indicators of Screening Colonoscopies

Background

Coronavirus Disease 2019 (COVID-19) has affected many facets of the practice of medicine including screening colonoscopies.

Aims

Our study looks to observe if there has been an effect on the quality of colonoscopies, as indicated by quality measures such as the cecal intubation rate (CIR), cecal intubation time (CIT), scope withdrawal time (SWT), and adenoma detection rate (ADR) with the adoption of standard COVID-19 precautions.

Methods

We conducted a retrospective chart review to analyze the effects of the COVID-19 pandemic on screening colonoscopies. The study utilized data on CIR, CIT, SWT, and ADR from outpatient, nonemergent procedures conducted at 3 endoscopy suites of St. Luke's University Health Network. All inpatient and emergent procedures were excluded.

Results

Our study demonstrated that the total number of screening colonoscopies was decreased between 2019 and 2020 (318 in 2019 vs. 157 in 2020, p = 0.005). CIT (320 ± 105 seconds in 2019 vs. 392 ± 107 seconds in 2020, p = 0.001) and SWT (706 ± 232 seconds in 2019 vs. 830 ± 241 seconds in 2020, p = 0.001) were increased while CIR (98.2% in 2019 vs. 96.6% in 2020, p = 0.04) was decreased between 2019 and 2020 likely due to PPE introduction. ADR was similar between the two groups (38.23 (12.50-66.66) in 2019 vs. 38.18 (16.66-66.00) in 2020, p = 0.8).

Conclusion

Our study showed that quality indices for screening colonoscopies like CIR, CIT, and SWT were negatively impacted during the COVID-19 time period. ADR, however, was similar. Thus, the efficiency of the procedures was affected by the use of PPE but it did not affect the colonoscopy's clinical benefit.

[Position paper on endoscopic reporting in IBD]

The complete and reliable documentation of endoscopic findings make up the crucial foundation for the treatment of patients with inflammatory bowel diseases such as Crohn´s disease and ulcerative colitis. These findings are, on the one hand, a prerequisite for therapeutic decisions and, on the other hand, important as a tool for assessing the response to ongoing treatments. Endoscopic reports should, therefore, be recorded according to standardized criteria to ensure that the findings of different endoscopists can be adequately compared and that changes in the course of the disease can be traced back. In consideration of these necessities, fifteen members of the Imaging Working Group of the German Kompetenznetz Darmerkrankungen have created a position paper proposing a structure and specifications for the documentation of endoscopic exams. In addition to the formal report structure, the recommendations address a large number of attributes of acute and chronic inflammatory alterations as well as endoscopically detectable complications, which are explained in detail and illustrated using exemplary images. In addition, more frequently used endoscopic activity indices are presented and their use in everyday clinical practice is discussed.

The conversion factor for predicting adenoma detection rate from polyp detection rate varies according to colonoscopy indication and patient sex

The adenoma detection rate (ADR) is the primary quality indicator for colonoscopies. The polyp detection rate (PDR) is available from administrative data and does not depend on histology verification. The correlation between PDR and ADR and the ADR/PDR conversion factor in preventive colonoscopies were evaluated. In the prospective study, asymptomatic individuals aged 45-75 years with preventive colonoscopy in 2012-2016 were included. Spearman's correlation coefficient was used to assess PDR/ADR for each endoscopist. Conversion factor predicting ADR from PDR was obtained by linear regression and subsequently compared with adenoma to polyp detection rate quotient. One thousand six hundred fourteen preventive colonoscopies performed by 16 endoscopists in 8 screening colonoscopy centres in the Czech Republic were analysed. Correlation between PDR and ADR in all preventive colonoscopies was high and statistically significant (Rs 0.82; P < 0.001). There was a strong correlation between PDR and ADR in men (Rs 0.74; P = 0.002) and in screening colonoscopies (Rs 0.85; P < 0.001). The conversion factor to convert ADR from PDR was 0.72 in all preventive colonoscopies, 0.76 in FOBT+ colonoscopies and 0.67 in screening colonoscopies. ADR may be replaced by PDR in the assessment of colonoscopy quality. The value of the conversion factor varies according to colonoscopy indication and gender of examined individuals; in this Czech study, it was 0.72 in all preventive colonoscopies. The minimum requested ADR of 25 % corresponds to a PDR of 35 %, when converted with the appropriate conversion factor.

Assessment of quality benchmarks in adenoma detection in Mexico

Background and study aims  Several Latin American countries, including Mexico, have reported an increase in colorectal cancer (CRC) mortality. The effectiveness of a colonoscopy in preventing CRC depends on the quality of the procedure, for which the adenoma detection rate (ADR) is one of the most trusted indicators. Awareness of ADR can improve the quality of colonoscopies through proper feedback and training of the specialists. The goal of this study was to estimate the ADR among Mexican endoscopists with experience in CRC screening and to compare it with previously reported data from this country. Methods  We carried out a retrospective study to analyze ADR data in Mexico. The information was obtained from a group of certified endoscopists and compared with the former published data from Mexico. Results  We found a current ADR of 24.6 % (95 %CI, 22.4 %-26.8 %) from 1,478 colonoscopies performed by eight endoscopists in two third-level private hospitals. The average ADR reported in previous publications was 15.2 % (95 %CI, 13.3 %-17.1 %). Statistical analysis showed differences between our results and those from previous studies (24.6 % vs. 15.2 %, P  < 0.001). Conclusions  The actual ADR in Mexico is higher than previously reported. Previous low ADR values could be explained by poorly performed colonoscopies rather than by low adenoma and CRC incidence in our country.

Implementation of colonoscopy quality monitoring in a Belgian university hospital with integrated computer-based extraction of adenoma detection rate

Background and study aims  Quality in colonoscopy has been promoted in last decade with definition of different quality indicators (QI) as benchmarks. Currently, automatized monitoring systems are lacking, especially for merging pathologic and endoscopic data, which limits quality monitoring implementation in daily practice. We describe an adapted endoscopy reporting system that allows continuous QI recording, with automatic pathological data inclusion. Material and methods  We locally adapted a reporting system for colonoscopy by adding and structuring in a dedicated tab selected key QI. Endoscopic data from a reporting system and pathological results were extracted and merged in a separate database. During the initial period of use, performing physicians were encouraged to complete the dedicated tab on a voluntary basis. In a second stage, completing of the tab was made mandatory. The completeness of QI recording was evaluated across both periods. Performance measures for all endoscopists were compared to global results for the department and published targets. Results  During the second semester of 2017, a total of 1827 colonoscopies were performed with a QI tab completed in 100 % of cases. Among key QI, the cecal intubation rate was 93.8 %, the rate of colonoscopies with adequate preparation was 90.7 %, and the adenoma detection rate was 29.8 % considering all colonoscopies, irrespective of indication; 28.8 % considering screening procedures; and 36.6 % in colonoscopies performed in people older than age 50 years. Conclusion  This study shows that quality monitoring for colonoscopy can be easily implemented with limited human resources by adapting a reporting system and linking it to a pathology database.

Will purposely seeking detect more colorectal polyps than routine performing during colonoscopy?

BACKGROUND & GOALS

We observed that the number of colorectal polyps found intraoperatively was often higher than that encountered preoperatively during elective colonoscopic polypectomy. To evaluate whether more polyps can be detected when they are purposely sought than when they are routinely examined during colonoscopy.

MATERIALS AND METHODS

Patients undergoing colonoscopy were randomized into groups A and B. Before colonoscopy was performed, endoscopists were instructed to seek polyps for group A purposely but not for group B. Polypectomy was electively completed. In groups A and B, the cases of elective polypectomy were named groups AR and BR, including groups AR-1 and BR-1, during the first colonoscopy and groups AR-2 and BR-2 during the second colonoscopy for polypectomy, respectively. The following data were calculated: the number of polyps detected (NPD) and the polyp detection rate (PDR) in all cases and the number of polyps missed (NPM) and partial polyp miss rate (PPMR) in the cases of colorectal polyps.

RESULTS

A total of 419 cases were included in group A, 421 in group B, 43 in group AR, and 35 in group BR. No significant differences in PDR were found between groups A and B and in PPMR between groups AR-1 and BR-1 (P > .05), although PPMR in group AR-1 was higher than in group AR-2 (P < .05), similar results were found in PPMR between groups BR-1 and BR-2 (P < .05).

CONCLUSION

Purposely seeking for colorectal polyps did not result in more polyps detected compared with routine colonoscopy.

Efficacy and Patient Tolerability Profiles of Probiotic Solution with Bisacodyl Versus Conventional Cleansing Solution for Bowel Preparation: A Prospective, Randomized, Controlled Trial

Although adequate bowel preparation is essential in screening colonoscopy, patient intolerability to bowel cleansing agents is problematic. Recently, a probiotic mixture solution with bisacodyl emerged to improve patient tolerability. We investigated the efficacy, safety, and patient tolerability profiles of probiotics with bisacodyl versus conventional polyethylene glycol (PEG) solution for bowel preparation for screening colonoscopies in healthy patients in this prospective, randomized, case-control study. In total, 385 volunteers were randomly assigned to receive 2 L of water + 200 mL of probiotic solution (case group, n = 195) or 4 L of PEG solution (control group, n = 190). The efficacy of the bowel cleansing was evaluated using the Ottawa scale system, polyp detection rate, and adenoma detection rate, and the patient tolerability profiles were assessed using a questionnaire. The demographics were not significantly different between groups. When the Ottawa score for each bowel segment was stratified into an adequate vs. inadequate level (Ottawa score ≤ 3 vs. >3), there were no statistical differences between groups in each segment of the colon. There were no significant differences in the polyp and adenoma detection rates between groups (38.42% vs. 32.42, p = 0.30; 25.79% vs. 18.97%, p = 0.11). The case group showed significantly fewer events than the control group, especially nausea, vomiting, and abdominal bloating events. Regarding the overall satisfaction grade, the case group reported significantly more “average” scores (95% vs. 44%, p < 0.001) and were more willing to use the same agents again (90.26% vs. 61.85%, p < 0.001). As patient compliance with bowel preparation agents is associated with an adequate level of bowel cleansing, a probiotic solution with bisacodyl might be a new bowel preparation candidate, especially in patients who show a poor compliance with conventional bowel preparation agents.

Routine ileal intubation in colonoscopy does not increase the polyp detection rate: a retrospective study

Colonoscopy is effective in the prevention and screening of colorectal cancer. Whether terminal ileal (TI) intubation is required during conventional colonoscopy and whether it offers clinical benefits with respect to polyp detection rate (PDR) remain unclear. This retrospective study included patients who underwent colonoscopy at our hospital between July 1, 2018 and April 20, 2019. The positive findings and time for TI intubation were recorded. Univariate and multivariate analyses were performed to identify factors associated with PDR. There were 1675 patients with cecal intubation colonoscopy, including 994 (59 %) with TI intubation and 8 (1 %) with intestinal disease. The mean time for TI intubation was 40 seconds (3-338), and the mean time from cecal intubation to arrival at the deep part of TI mucosa was 24 seconds (2-118). The overall PDR was 27 %. On multivariable analysis, age > 50 years [95 % confidence interval (CI) 2.837-4.590], male sex (95 %CI, 0.406-0.649), presence of symptoms (abdominal symptoms vs. asymptomatic, 95 % CI, 1.146-2.468; stool changes vs. asymptomatic, 95 % CI, 1.070-1.834), and non-TI intubation (95 % CI, 1.040-1.648) were independent predictors of higher PDR. Trend analysis indicated decreasing trend of PDR among non-TI intubation group, 0-5 cm TI intubation group, and > 5 cm TI intubation group (30 % vs. 27 % vs. 24 %, respectively; p < 0.05). TI intubation is necessary to identify small bowel disease among a designated population, but it was not suggested to be routinely performed as part of colonoscopy, owing to limited positive intestinal findings, extra time requirement, and possible PDR worsening.

Effect of successive endoscopic procedures in polyp and adenoma detection rates: Too early is not always too good

BACKGROUND AND AIMS: There is conflicting evidence regarding the impact of hypothetical cumulative fatigue after performing too many endoscopic procedures on both polyp and adenoma detection rates (PDR, and ADR, respectively). The aim of this study is to evaluate the effect of successive endoscopic procedures on PDR and ADR.

METHODS

A retrospective cross-sectional study was undertaken among consecutive patients on whom colonoscopy and/or esophagogastroduodenoscopy were performed between January 2012 and August 2014. Data regarding polyp and adenoma detection, cecal intubation, and bowel cleansing quality as well as demographical data of subjects were extracted. Endoscopic procedures were classified according to the time slots of the procedures throughout the endoscopy session in three groups: from the 1st to 4th endoscopy study (round 1), from the 5th to the 8th study (round 2), above the 9th study (round 3). We compared PDR and ADR among rounds.

RESULTS

Overall, 3388 patients were enrolled. Median age was 50 years (range 18-95) and 52.39% were female. There was a significant difference in terms of PDR among rounds (36.83%, 41.24%, and 43.38%, respectively, p = 0.007) and a non-significant numerical difference when ADR was compared (23.2%, 25.71%, and 26.78%, p = 0.07). On multivariate analysis, ADR was significantly associated with age (odds ratio [OR] 1.02 [1.01-1.03]), and male sex (OR 1.64 [1.38-1.94]).

CONCLUSION

Theoretical endoscopist's fatigue due to cumulative performance of endoscopies does not diminish colonoscopy quality. Both PDR and ADR seem to improve after endoscopist's cumulative rounds of performed endoscopies. This could be due to a "warm-up" effect.

Relationship between the polyp detection rate and the post-colonoscopy colorectal cancer rate

AIM

the adenoma detection rate is the quality indicator of colonoscopy that is most closely related to the development of interval colorectal cancer or post-colonoscopy colorectal cancer. However, the recording of this indicator in different units of gastrointestinal endoscopy is obstructed due to the large consumption of resources required for its calculation. Several alternatives have been proposed, such as the polyp detection rate. The objective of this study was to evaluate the relationship between the polyp detection rate and its influence on post-colonoscopy colorectal cancer rate.

PATIENTS AND METHODS

in this study, 12,482 colonoscopies conducted by 14 endoscopists were analyzed. The polyp detection rate was calculated for each endoscopist. Endoscopists were grouped into quartiles (Q1, Q2, Q3, and Q4), from lowest to highest polyp detection rate, in order to evaluate whether there were any differences in the development of post-colonoscopy colorectal cancer.

RESULTS

the lowest polyp detection rate was 20.66% and the highest was 52.16%, with a median of 32.78 and a standard deviation of ± 8.54. A strong and positive association between polyp endoscopy diagnosis and adenoma histopathology result was observed and a linear regression was performed. A significantly higher post-colonoscopy colorectal cancer rate was observed in the group of endoscopists with a lower polyp detection rate (p < 0.02).

CONCLUSION

polyp detection rate is a valuable quality indicator of colonoscopy and its calculation is much simpler than that of the adenoma detection rate. In our study, the prevalence of post-colonoscopy colorectal cancer was inversely and significantly related to the endoscopists' polyp detection rate.

Polyp Detection Rate Correlates Strongly with Adenoma Detection Rate in Trainee Endoscopists

BACKGROUND

The adenoma detection rate (ADR) is a widely accepted quality benchmark for screening colonoscopy but can be burdensome to calculate. Previous studies have shown good correlation between polyp detection rate (PDR) and ADR, but this has not been validated in trainees. Additionally, the correlation between PDR and detection rates for sessile serrated polyps (SSPDR) and advanced neoplasia (ANDR) is not well studied.

AIMS

We investigated the relationship between PDR and ADR, SSPDR, and ANDR in trainees.

METHODS

We examined 1600 outpatient colonoscopies performed by 24 trainees at a VA hospital from 2014 to 2017. Variables collected included patient demographics, year of fellowship, colonoscopy indication, and endoscopic and histologic findings. We calculated the overall ratios of PDR to ADR, SSPDR, and ANDR to assess the correlation between measured and calculated ADR, SSPDR, and ANDR, which is equivalent to the correlation between PDR and measured ADR, SSPDR, and ANDR.

RESULTS

The overall PDR, ADR, SSPDR, and ANDR were 72%, 52%, 2%, and 14%. PDR (48%) was highest in the left colon, while ADR (32%) and ANDR (7%) were highest in the right colon (p < 0.001 for all). The overall ADR/PDR, SSPDR/PDR, and ANDR/PDR ratios were 0.73, 0.03, and 0.20. Correlation between PDR and ADR was highly positive overall (r = 0.87, p < 0.0001) and stronger in the right (r = 0.91) and transverse (r = 0.94) colon than the left colon (r = 0.80). Correlation between PDR and overall SSPDR and ANDR were not statistically significant.

CONCLUSIONS

PDR can serve as a surrogate measure of ADR to monitor colonoscopy quality in gastroenterology fellowship.

Implementing visual cues to improve the efficacy of screening colonoscopy: exploiting the Hawthorne effect

Background:

Colonoscopy is the gold standard for colon cancer screening. Adenoma detection rate and a withdrawal time of 6 min are quality metrics to measure the efficacy of colonoscopy in colon cancer screening. The aim of our study was to exploit the Hawthorne effect in an effort to ensure adherence to a minimum 6-min withdrawal time and subsequently increase adenoma detection rate.

Methods:

This was a retrospective single-center study where we reviewed the records of patients who underwent screening colonoscopy in 2015 and 2017. We divided our patient population into 2 groups. The first group of patients from 2015 underwent screening colonoscopy with no visual cues on the colonoscopy monitor. The second group of patients from 2017 had visual cues indicating withdrawal time on the colonoscopy monitor.

Results:

Screening colonoscopy had a statistically significantly higher adenoma detection rate when performed with visual cues compared to without visual cues (25.3% vs. 19.45, P=0.04). Polyp detection rate was also higher in the group where visual cueing was used (52.9% vs. 22.9%, P<0.001). There were no statistically significant differences in actual withdrawal time or cecal intubation rates.

Conclusions:

Visual cues indicating withdrawal time are a useful intervention that results in an increased adenoma detection rate. Given its practicality and cost effectiveness, we recommend universally implementing visual cues to ensure adherence to a minimum 6-min withdrawal time.

Improved detection of adenomas and sessile serrated polyps is maintained with continuous audit of colonoscopy

BACKGROUND

The audit process may help improve performance indicators for colonoscopy quality but it is unclear whether this is sustained over several years.

METHODS

44138 procedures for 28 endoscopists from 2004 to 2019 were analysed for polyp detection rate and withdrawal time. From 2012, 14 endoscopists were analysed with additional data on polyp histology and number of polyps removed.

RESULTS

Polyp detection increased from 40.7% in 2004 to 62.2% in 2019; removal of polyps>1 cm remained constant (11%). Adenoma detection rate was 25.8% in 2012 and 28.3% in 2019. Sessile serrated polyp (SSP) detection rate increased from 4.5% to 14.7%; most of the increase was in the first 2 years of the histology part of the audit. There was a significant correlation of adenoma detection rate with mean number of adenomas (r=0.72, p=0.004) and a significant correlation of SSP detection with mean number of SSPs (r=0.85, p=0.0001).

CONCLUSION

The audit process appears to encourage a higher rate of polyp detection. This was due to increased detection of smaller polyps and increased detection of SSPs.

Dutch Gastrointestinal Endoscopy Audit: automated extraction of colonoscopy data for quality assessment and improvement

BACKGROUND AND AIMS

The importance of having quality assessment, assurance, and improvement tools in health care is increasingly recognized. However, the additional associated administration burden progressively interferes with the structural implementation and adoption of such tools, especially when it concerns high-volume procedures such as colonoscopies. The development of the Dutch Gastrointestinal Endoscopy Audit (DGEA), a registry with automated extraction of colonoscopy quality data, and its first results are described.

METHODS

In close cooperation with commercial endoscopy reporting systems and a national histopathology database, healthcare professionals performing colonoscopies initiated a quality registry that extracts data from its core hospital resource or histology database without manual interference of the healthcare providers. Data extracted consisted of patient age, gender, indication of the colonoscopy, American Society of Anesthesiologists score, Boston Bowel Preparation Score, and cecal intubation; for the colonoscopy after a positive fecal immunochemical test in the colorectal cancer screening program, other data were polyp detection rate, which was available for all 48 hospitals or endoscopy centers, and adenoma detection rate, which was available for 26 hospitals or endoscopy centers.

RESULTS

Between January 1, 2016 and March 31, 2019, 48 hospitals or endoscopy centers voluntarily participated in the DGEA, and 275,017 unique patients with 313,511 colonoscopies were registered. Overall missing values were limited to <1%.

CONCLUSIONS

The results of this study demonstrate that it is feasible to deploy a quality registry collecting uniform data without additional administration burden for healthcare professionals.

Detection rates for adenomas, serrated polyps and clinically relevant serrated polyps can be easily estimated by individually calculated detection rate ratios

Background and aims: Adenoma detection rate (ADR) is a key quality indicator for colonoscopy; however, it is cumbersome to obtain. We investigated if detection rates (DRs) for adenomas, serrated polyps (SPs) and clinically relevant SP (crSPDR) can be accurately estimated by individualized DR ratios (DRRs) in a multicenter primary colonoscopy screening cohort of average-risk individuals.Methods: DRRs were calculated by dividing DRs for a certain polyp entity by polyp detection rate (PDR) for each endoscopist individually on the basis of his/her first 50 (DRR₅₀) and 100 (DRR₁₀₀) consecutive colonoscopies. DRs were estimated for each endoscopist by multiplying his/her DRR for a certain polyp entity with his/her PDR of subsequent colonoscopies in groups of 50 (DRR₅₀) and 100 (DRR₁₀₀) consecutive colonoscopies. Estimated and actual DRs were compared.Results: Estimated DRs showed a strong correlation with actual DRs for adenomas (r = 0.86 and 0.87; each p < .001), SPs (r = 0.85 and 0.91; each p < .001) and crSPs (r = 0.82 and 0.86; each p < .001) using DRRs derived from first 50 and 100 consecutive colonoscopies. Corresponding root mean square error (RMSE) between individual estimated and actual DRs using DRR₅₀ and DRR₁₀₀ was 5.3(±4.6)% and 4.5(±4.8)% for adenomas, 5.2(±4.1)% and 3.9(±2.8)% for SP, 3.1(±3.1)% and 2.8(±2.5)% for crSP, respectively. RMSE was not significantly different between DRR₅₀ and DRR₁₀₀ for ADR (p = .445), SPDR (p = .178) and crSP (p = .544).Conclusions: DR for all relevant polyp entities can be accurately estimated by using individual DRRs. This approach may enable endoscopists to easily track their performance measures in daily routine.

Morning versus afternoon adenoma detection rate: a systematic review and meta-analysis

Adenoma detection rate (ADR) is a quality marker of colonoscopy and operator performance. Prior studies evaluating the effect of an extended workday on the ADR reported variable outcomes that remain controversial. Given the variable results of prior studies and the potential legal implications of reduced ADR in the afternoon, we aimed to further evaluate this parameter and its effect on ADR. We performed a systematic review of the PubMed, CINAHL and Scopus electronic databases. Studies were included if they reported ADR in patients undergoing colonoscopy in the morning session and the afternoon session. Afternoon sessions included both sessions following a morning shift and half-day block shifts. Subgroup analyses were performed for ADR comparing morning and afternoon colonoscopies in a continuous workday, advanced ADRs (AADRs) and polyp detection rates (PDRs) were also compared. Thirteen articles with 17 341 (61.2%) performed in the morning session and 10 994 (38.8%) performed in the afternoon session were included in this study. There was no statistical significance in the ADR or AADR between morning and afternoon sessions, respectively [relative risk (RR) 1.06, 95% confidence interval (CI) 0.99-1.14] and (RR 1.19, 95% CI 0.95-1.5). Afternoon procedures had a significantly higher PDR than morning procedures (RR 0.93, 95% CI 0.88-0.98). ADR was not significantly influenced in the afternoon session when operators continued to perform procedures throughout the day or on a half-day block schedule.

Actual and estimated adenoma detection rates: a 2-year monocentric colonoscopic screening outcome in Shenzhen, China

Background and Aim

While adenoma detection rate (ADR) is an important quality metric for screening colonoscopy, it remains difficult to be accessed due to the lack of integrated endoscopy and pathology databases. Hence, the use of an adenoma‐to‐polyp detection rate quotient and polyp detection rate (PDR) has been proposed to predict ADR. This study aimed to examine the usefulness of estimated ADR across different colonic segments in two age groups for Shenzhen people in China.

Methods

We retrospectively analyzed 7329 colonoscopy procedures performed by 12 endoscopists between January 2012 and February 2014. The PDR, actual ADR, and estimated ADR of the entire, proximal, and distal colon, and within each colonic segment, in two patient age groups: <50 and ≥50 years, were calculated for each endoscopist.

Results

The overall polyp and adenoma prevalence rates were 19.1 and 9.3%, respectively. The average age of adenoma‐positive patients was significantly higher than that of adenoma‐negative patients (54 ± 12.6 years vs 42.9 ± 13.2 years, respectively). A total of 1739 polyps were removed, among which 826 were adenomas. More adenomatous polyps were found in the proximal colon (60.4%, 341/565) than in the distal colon (40.9%, 472/1154). Overall, both actual and estimated ADR correlated strongly at the entire colon level and within most colonic segments, except for the cecum and rectum. In both age groups, these parameters correlated strongly within the traverse colon and descending colon.

Conclusion

Caution should be exercised when predicting ADR within the sigmoid colon and rectum.

Polyp Detection Rate as a Surrogate for Adenoma and Sessile Serrated Adenoma/Polyp Detection Rates

Introduction

Quality measures for colonoscopy such as adenoma detection rate (ADR) have been proposed to be surveilled for ensuring minimum standards. However, its direct measurement is time consuming and often neglected. Extrapolating ADR and other quality measures from polyp detection rate (PDR) can be a pragmatic alternative.

Objective

To determine quotients for estimating ADR and sessile serrated adenoma/polyp detection rate (SSA/P-DR) from PDR in an Australian cohort.

Methods

Consecutive adult patient colonoscopies during a 1-year period were retrospectively assessed in a single Australian tertiary endoscopy center. Adenoma detection quotient (ADQ) and SSA/P detection quotient (SSA/P-DQ) were defined as the division of ADR and SSA/P-DR by PDR, respectively. The primary outcome was the number of procedures to achieve a stable cumulative ADQ and SSA/P-DQ. Secondary outcomes included evaluation of ADQ and SSA/P-DQ in different subsets.

Results

In total, 2,657 colonoscopies were performed by 15 endoscopists in 2016. The ADR, SSA/P-DR, and PDR found were 32.2, 6.7, and 47.3%, respectively. The ADQ and SSA/P-DQ values found were 0.68 and 0.14, respectively. After approximately 500 procedures, both ADQ and SSA/P-DQ became stable. Interclass correlation coefficient (ICC) for the prediction of ADR from ADQ was excellent for all endoscopists that performed >177 procedures in that year (ICC 0.84).

Conclusions

ADQ and SSA/P-DQ values were consistent when over 500 procedures were analyzed. ADQ had an excellent correlation with ADR when >177 procedures per endoscopist were evaluated.

Correlation between adenoma detection rate and polyp detection rate at endoscopy in a non-screening population

It is understood that colorectal adenomas progress to colonic adenocarcinoma. Adenoma detection rate (ADR) at endoscopy has been used as a key performance indicator at endoscopy and is inversely associated with diagnosis of interval colorectal cancer. As most endoscopy reporting systems do not routinely incorporate histological assessment, ADR reporting is a cumbersome task. Polyp Detection Rate (PDR) has therefore been adopted as a surrogate marker for ADR. A prospectively maintained database of colonoscopies performed between July 2015 and July 2017 was analysed. This was cross referenced with a histological database. Statistical analysis was performed using IBM SPSS, version 24. Inferential procedures employed included the Pearson’s correlation coefficient (r) and Binomial logistic regression. Of 2964 procedures performed by 8 endoscopists, overall PDR was 27% and ADR was 19%. The PDR, ADR, adenoma to polyp detection rate quotient (APDRQ) and estimated ADR (PDR x APDRQ group average = 0.72) was calculated for each individual. There was a strong positive linear correlation between PDR and ADR,r(8) = 0.734, p = 0.038 and between PDR and estimated ADR, r(8) = 0.998, p < 0.001. Adenoma detection rate strongly correlated with estimated ADR, r(8) = 0.720, p = 0.044. With the exclusion of a moderate outlier, these correlations increased in both strength and significance. There was a stronger correlation between PDR and ADR,r(7) = 0.921, p = 0.003 and between ADR and estimated ADR, r(7) = 0.928, p = 0.003.

Validation of an automated adenoma detection rate calculating system for quality improvement of colonoscopy

Purpose

This study aimed to validate an automated calculating system developed for determining the adenoma detection rate (ADR).

Methods

To calculate the automated ADR, the data linking processes were as follows: (1) matching the selected colonoscopy results with the pathological results, (2) matching the polyp number from colonoscopy with that from pathology and confirming the histopathological results of each colonic polyp, and (3) confirming the histopathological results, especially the adenoma status of each colonic polyp. To verify the accuracy of the automated ADR calculating system, we manually calculated the ADR for 3 months through medical record review. Accuracy was calculated by measuring the error rate for each value. The cause of error was analyzed by additional order and chart review.

Results

After excluding 318 cases, 2,543 patients (1,351 men and 1,192 women; median age, 57.9 years) who underwent colonoscopy were included in this study. When the automated calculating system was used, polyps were found in 1,336 cases (52.6%) and adenomas were found in 1,003 cases (39.4%). When the manual calculating system was used, polyps were found in 1,327 cases (52.2%) and adenomas were found in 1,003 cases (39.4%). The accuracies of the polyp detection rate and ADR according to the automated calculating system were 99.3% and 100%, respectively.

Conclusion

We developed a system to automatically calculate the ADR by extracting hospital electronic medical record results and verified that it provided satisfactory results. It may help to improve colonoscopy quality.

Screening colonoscopy and flexible sigmoidoscopy for reduction of colorectal cancer incidence: A case-control study

BACKGROUND

Flexible sigmoidoscopy and colonoscopy are both recommended colorectal cancer screening options, but their relative effectiveness needs clarification. The aim of this study was to compare the effectiveness of colonoscopy and flexible sigmoidoscopy for reduction of colorectal cancer incidence.

METHODS

We conducted a case-control study within the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Cases were subjects age 70-85 years in the SEER-Medicare database diagnosed with CRC during 2004-2013. Up to 3 controls were matched to each case by birth year, sex, race, and SEER region. Receipt of screening colonoscopy or flexible sigmoidoscopy was ascertained from Medicare claims. Conditional logistic regression models were developed to estimate the odds ratios (ORs) and 95% confidence intervals (CI) for a history of screening in cases vs. controls. We conducted secondary analyses by sex, race, endoscopist characteristics, and with varying timing and duration of the look-back period.

RESULTS

Receipt of screening colonoscopy and sigmoidoscopy was associated with a 59% (OR 0.41, 95%CI 0.39, 0.43) and 22% reduction (OR 0.78, 95%CI 0.67, 0.92) in colorectal cancer incidence, respectively. Colonoscopy was associated with greater reduction in the distal colorectal cancer incidence (OR 0.22, 95%CI 0.20, 0.24) than proximal colorectal cancer incidence (OR 0.62, 95%CI 0.59, 0.66). Sigmoidoscopy was associated with a 52% reduction in distal colorectal cancer incidence (OR 0.48, 95%CI 0.37, 0.63), but with no reduction in proximal colorectal cancer incidence. These associations were stronger in men than in women. No differences by race or endoscopist characteristics were observed.

CONCLUSION

Both screening colonoscopy and sigmoidoscopy were associated with reductions in overall colorectal cancer incidence, with a greater magnitude of reduction observed with colonoscopy.

Screening flexible sigmoidoscopy versus colonoscopy for reduction of colorectal cancer mortality

PURPOSE

Colonoscopy and flexible sigmoidoscopy are both recommended colorectal cancer (CRC) screening strategies, but their relative effectiveness is unclear. We sought to evaluate the ability of each of these two modalities to reduce CRC mortality.

METHODS

We conducted a case-control study using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Cases were persons aged 70-85 years who died of CRC and were matched to up to three non-CRC controls. Receipt of endoscopy was ascertained from Medicare claims and endoscopy indication assigned using a validated algorithm. Conditional logistic regression models were developed to estimate the association between screening colonoscopy or sigmoidoscopy and CRC mortality. We conducted secondary analyses by race, sex, and endoscopist characteristics, and with varying duration of the look-back period.

RESULTS

In the initial analysis using all available look-back years, screening flexible sigmoidoscopy was associated with a 35% reduction in CRC mortality (OR 0.65, 95% CI 0.48, 0.89), while screening colonoscopy was associated with a 74% reduction (OR 0.26, 95% CI 0.23, 0.30). Sigmoidoscopy was not associated with any reduction in proximal CRC mortality. The association between colonoscopy and reduced CRC mortality was stronger in the distal than the proximal colon. Results were similar in analyses using a 5-year look-back period.

CONCLUSIONS

Screening colonoscopy was associated with greater reductions in CRC mortality than screening sigmoidoscopy, and with a greater reduction in the distal than the proximal colon. These results provide additional information on the relative benefits of screening for CRC with sigmoidoscopy and colonoscopy.

Factors associated with polyp detection during colonoscopy: A retrospective observational study

The polyp detection rate (PDR) is an important quality indicator for colonoscopy. Several factors have been shown to be associated with PDR. However, whether the moderate sedation is a factor for polyp detection remains controversial. This study aims to assess factors associated with polyp detection including the moderate sedation factor during colonoscopy. Patients who underwent colonoscopy from June 1, 2014 to May 31, 2015 were enrolled into this retrospective study. Patients with poor colon preparation and failure to reach the cecum were excluded. The clinical factors, including patient's sex, age, midazolam/fentanyl sedation, indications, endoscopist colonoscopy volume, and use of antispasmodic agent were evaluated by multivariate analysis. A total of 3373 patients were included in this study. The mean age was 55.8 years, and 1980 patients (58.7%) were male. Among the 3373 patients, 2513 (74.5%) underwent midazolam/fentanyl-based sedated colonoscopy. The multivariate analysis showed that male sex, age over 50 years old, midazolam/fentanyl sedation and indications of screening and surveillance were significantly associated with polyp detection. Moreover, when stratified by sex and age, the midazolam/fentanyl sedation was associated with polyp detection in male patients and patients over 50 years old. This study has highlighted the role of midazolam/fentanyl sedation administered by colonoscopists as a modifiable factor that may increase polyp detection during colonoscopy.

The impact of colonoscopy indication on polyp detection rate

Background

Adenoma/polyp detection rates are considered to be among the most important quality indicators of colonoscopy and are key measures of a quality procedure. However, they are designed for use in the screening setting and are not amenable to other colonoscopy indications. Little is known about their significance in other colonoscopy indications. We aimed to evaluate the impact of the various indications on polyp detection rate (PDR).

Methods

This was a retrospective, single-center study. Electronic reports of index colonoscopy procedures with adequate bowel preparation over a 10-year period were reviewed. Patients were divided into 7 groups based on the study indication. PDR was determined for each group and was compared to that of a control group, the screening indication group. Adjustment was made for potential confounders such as age, sex, and procedural setting.

Results

A total of 13,054 patients were considered suitable for the study. PDR was greatest in the positive fecal occult blood test group, with a value of 33.1% (P<0.01). Overall, the remaining groups showed similar PDRs compared with screening (22.1% vs. 20.4%; P=0.15). This trend persisted in a multivariate analysis, which showed the odds ratio in the positive fecal occult blood test group to be significantly higher, with a value of 1.955 (1.759-2.172, P<0.001) compared with the screening group.

Conclusion

PDR was highest for the positive fecal occult blood test indication, but was not affected significantly by most indications. Further randomized studies are warranted to confirm these findings and help calculate recommended thresholds for "overall" PDR.

Polyp detection rate: does length matter?

INTRODUCTION

Polyp detection rate is a surrogate marker for adenoma detection rate and therefore a surrogate marker of quality colonoscopy. To our knowledge, this is the first study that compares distance from the monitor to the endoscopist on polyp detection rate.

METHODS

This was a retrospective study comparing polyp detection rate across two different endoscopy room set-ups. All colonoscopies performed between December 2013 and November 2014 were retrieved. The difference in the room set-up was the distance from the endoscopist to the endoscopy monitor. Room A had a distance of 219 cm and Room B had 147 cm. We used two identical rooms, C and D, as a control arm with a distance of 190 cm between the endoscopist and the monitor.

RESULTS

There were significant differences in polyp detection rates between Room A and Room B in the bowel cancer screening lists. For these lists, the room with the closest distance from the endoscopist to the monitor (147 cm) had a statistically significant higher polyp detection rate than the room that had a further monitor to endoscopist distance of 219 cm (p<0.0006) and a trend towards a higher polyp detection rate compared with the room where the distance between the monitor and the endoscopist was 190 cm (p=0.08). This effect was not noticed across the service lists.

CONCLUSIONS

This study has suggested that the distance from the endoscopist to the monitor can affect polyp detection rate. It appears that for bowel cancer screening lists, the further the endoscopist from the monitor the lower their polyp detection rate.

Data quality and colonoscopy performance indicators in the prevalent round of a FIT-based colorectal cancer screening program

Objective: From the prevalent round of the Danish FIT-based colorectal cancer (CRC) screening program, we aimed (i) to evaluate the quality of recorded data and (ii) to characterize the colonoscopies by measuring variation in performance indicators between colonoscopists and assessing the ratio between adenoma detection rate (ADR) and polyp detection rate (PDR). Materials and methods: This study included screening colonoscopies performed in Central Denmark Region within 60 days of a positive FIT-result from 1 July 2015 through 30 June 2017. The participants were the colonoscopists, performing these procedures. The quality indicators cecal intubation rate (CIR), PDR, polyp retrieval rate (PRR), ADR and withdrawal time (WT) were evaluated. ADR/PDR ratios were calculated. Results: The concordance between the recorded data and the colonoscopy reports showed Kappa values in the range of 0.47-0.97. The overall CIR was 90.6% (range 73.7%-100%), PDR: 51.9% (range 18.4%-70.2%), PRR: 94.6% (range 69.6%-100%), ADR (conventional adenomas): 50.6% (range 18.4%-70.2%), ADRx (conventional adenomas, traditional serrated adenomas and sessile serrated lesions with dysplasia): 50.9% (range 18.4%-70.2%) and the mean WT was 11.3 min (range 4.5-24.9 min). The ADR/PDR ratio was 92.8% (95% CI: 92.0%-93.6%) and the ADRx/PDR ratio was 93.2% (95% CI: 92.4%-93.9%). Conclusion: Data quality was generally high. We found considerable variation in performance indicators between colonoscopists reflecting the potential for improvement. Further, our findings revealed that the PDR might be a good proxy for ADR in the context of the prevalent round of FIT-based CRC screening programs.

Quality measures improving endoscopic screening of colorectal cancer: a review of the literature

INTRODUCTION

Colorectal cancer (CRC) is a major health-care problem all over the world and CRC screening is effective in reducing mortality and increasing the 5-year survival. Colonoscopy has a central role in CRC screening. It can be performed as a primary test, as a recall policy after a positive result of another screening test, and for surveillance. Since effectiveness of endoscopic screening depends on adequate detection and removal of colonic polyps, consistent quality measures, which are useful in enhancing the diagnostic yield of examination, are essential. Areas covered: The aim of this review is to analyze current evidence from literature supporting quality measures able to refine endoscopic screening of colorectal cancer. Expert commentary: Quality measures namely a) time slot allotted to colonoscopy, b) assessment of indication, c) bowel preparation, d) Cecal intubation, e) withdrawal time, f) adenoma detection rate, g) proper management of lesions (polypectomy technique, polyps retrieval rate and tattooing of resection sites), and h) adequate follow-up intervals play a key role in identifying malignant and at-risk lesions and improving the outcome of screening. Adherence to these quality measures is critical to maximize the effectiveness of CRC screening, as well as, a proper technique of colonoscopy and a quality report of the procedure. Among all recommended measures, adenoma detection rate is the most important and must be kept above the recommended quality threshold by all physicians practicing in the setting of screening.

No Interval Cancers in Endoscopic Practice

Colonoscopy is long time the most preferred method for CRC screening along with diagnosis and treatment for a range of colon diseases. Based on its difficulty in visualizing precursor CRC lesions, mostly those located on the right colon, this method can be subject of improvement. The colonoscopy quality can be influenced by many factors such as colon preparation, retraction time, the colonoscopists medical training and knowledges as well as the performance of endoscopy equipment. The bad quality of colonoscopy will result in the emergence of interval cancers defined, based on the author, as cancers that appear at 3-5 years up to 10 years from the colonoscopy procedure. Interval cancers have predominantly incriminated both the colonoscopy quality and the clinician competences and less the tumor biology. Subsequently there were set quality indicators of colonoscopy in order to raise the quality of the exploration. Among the important indicators, proving their utility in studies, the ADR (adenoma detection rate) is most commonly used along with PDR (polyp detection rate) and APC (adenoma per colonoscopy). Following the purpose of obtaining a higher colonoscopy quality the medical units should keep in check all indicators. Furthermore, there should be an active involvement in an additional training of non-conforming medical personnel or even restrain of practice, given the medical legal actions that have interval cancers as a main cause.

Melanosis Coli: A Helpful Contrast Effect or a Harmful Pigmentation?

Background

Melanosis coli, a brown discoloration of colonic mucosa, is considered as a benign condition mainly observed in patients under chronic anthranoid laxatives. Recent data link this condition with an increased adenoma detection rate. Moreover, its tumorigenic potential and possible association with the development of colorectal cancer remains uncertain. We conducted this study to compare the polyp detection rate and colorectal cancer diagnosis in patients with melanosis against matched control group without melanosis.

Patients and methods

A retrospective single-center study. Patients diagnosed with melanosis coli on colonoscopy over a 15-year period were included. Each melanosis coli patient was matched with three controls by age, gender, setting (inpatient/outpatient), and procedure's indication. Polyp detection rate and diagnosis of colorectal cancer were recorded and compared between the groups before and after adjustment for bowel preparation.

Results

A cohort of 718 patients with melanosis and 2154 controls were included. The polyp detection rates were 33.4% and 21.8% of melanosis and control groups, respectively (P < .001). Melanosis coli, however, was associated with less diagnosis of colorectal cancer than controls (0.3% vs 3.9%; P < .001). In multivariate analysis, melanosis diagnosis on endoscopy was significantly associated with higher polyp detection rate (odds ratio [OR] = 1.986, 95% confidence interval [CI]: 1.626-2.425; P value < .01).

Conclusions

Melanosis coli is not associated with increased diagnosis of colorectal cancer. It is associated, however, with enhanced polyp detection likely due to chromo-endoscopy-like effect.

Carbon Dioxide Insufflation Increases Colonoscopic Adenoma Detection Rate Compared With Air Insufflation

GOALS

To determine the effect of carbon dioxide insufflation on the most important outcome measure of colonoscopic quality: adenoma detection rate (ADR).

BACKGROUND

Bowel cancer is the second most common cause of cancer deaths in males and females in Australia. Carbon dioxide has in recent times become the insufflation methodology of choice for screening colonoscopy for bowel cancer, as this has been shown to have significant advantages when compared with traditional air insufflation.

STUDY

Endoscopies performed over a period of 9 months immediately before and after the implementation of carbon dioxide insufflation at endoscopy centers were eligible for inclusion.

RESULTS

The difference in ADR between the carbon dioxide and air insufflation methods was statistically significant, with an increased ADR in the carbon dioxide group. The superiority of carbon dioxide insufflation was sustained with a logistic regression model, which showed ADR was significantly impacted by insufflation method.

CONCLUSIONS

Carbon dioxide insufflation is known to reduce abdominal pain, postprocedural duration of abdominal pain, abdominal distension, and analgesic requirements. This study represents for the first time the beneficial effect of carbon dioxide insufflation upon the key quality colonoscopy indicator of ADR.

Impact of Changeover to Newer Endoscopic Systems on Quality and Efficiency of Screening and Surveillance Colonoscopy: Equipment or Endoscopist

GOALS

The goal of this study is to assess whether changeover to newer endoscopic systems impacts quality or efficiency, and quantify the relation between increased withdrawal time and detection rates of sessile serrated polyps (SSPDR) and adenomas (ADR) in real-world practice.

STUDY

Beginning 2 months after new endoscopic systems were implemented at 2 endoscopy units, we included all outpatients undergoing screening/surveillance colonoscopy for 4 months. Outpatients during the same 4-month period 1 year earlier comprised the control group. Quality endpoints included ADR, advanced ADR, SSPDR, polyp detection rate (PDR), and withdrawal time. The efficiency endpoint was procedure time. Statistical adjustment for potential confounding factors was performed with multivariable analysis.

RESULTS

Significant increases occurred in postchangeover (N=1122) versus prechangeover (N=1131) procedure time (difference=2.6 minutes; 1.6 to 3.6) and withdrawal time (difference=1.6 minutes; 0.8 to 2.5). Significant increases also occurred in ADR [435 (39%) vs. 380 (34%)], advanced ADR [82 (7%) vs. 50 (4%)], and PDR [664 (59%) vs. 611 (54%)], but these differences lost significance when withdrawal time was added to the multivariable model. For every minute increase in withdrawal time a significant increase was seen in ADR (OR=1.09; 1.08 to 1.11), advanced ADR (OR=1.10; 1.08 to 1.13), SSPDR (OR=1.07; 1.06 to 1.09), and PDR (OR=1.16; 1.14 to 1.18).

CONCLUSIONS

After changeover to newer endoscopy systems withdrawal times lengthened, resulting in increased procedure time, ADR, and advanced ADR. Regardless of endoscopic system, lengthening withdrawal time increased SSPDR, ADR, and advanced ADR: odds of detection increased 7% to 10% with every additional minute of withdrawal time. Greater attention to withdrawal time and endoscopist examination may be more productive than upgrading endoscopic systems.

Number of polyps detected is a useful indicator of quality of clinical colonoscopy

BACKGROUND AND STUDY AIMS

 Adenoma detection rate (ADR) is a well-known quality indicator (QI) for colonoscopy. It is, however, difficult to evaluate ADR during practice. The aim of this study was to investigate the number of endoscopically detected polyps as a QI for colonoscopy.

PATIENTS AND METHODS

 This was a retrospective single-center cohort study of 5,190 consecutive patients who underwent colonoscopy from January 2015 to May 2016. Among these patients, we ultimately enrolled 1,937 patients for initial colonoscopy. We evaluated QIs including bowel preparation, cecum intubation time, withdrawal time, number of endoscopically detected polyps, ADR and advanced neoplasia detection rate (ANDR).

RESULTS

The mean number of endoscopically detected polyps, ADR and ANDR were 1.5 ± 2.3 (95 % confidence interval (CI)1.4 - 1.6), 38.6 % (95 % CI 36.5-40.8), and 18.3 % (95 % CI 16.6 - 20.1), respectively. ADR and ANDR increased with the number of endoscopically detected polyps, but the correlation reached a plateau at five or more polyps. We divided the patients into three groups based on the number of polyps (1 to 2, 3 to 4, and 5 or more). Logistic regression analysis adjusted by age and sex revealed that presence of a large number of polyps was a strong predictor of advanced neoplasia (odds ratio: 3.1 [95 % CI 2.2 - 4.3] for 3 to 4 polyps and 7.9 [95 % CI 5.4 - 11.8] for 5 or more polyps when using the presence of 1 or 2 polyps as a reference).

CONCLUSION

The number of endoscopically detected polyps can predict risk of advanced neoplasia and may thus be a new QI for colonoscopy.

Polyp detection rate may predict adenoma detection rate: a meta-analysis

BACKGROUND

Adenoma detection rate (ADR) is defined as the number of colonoscopies with at least one adenoma, expressed as the ratio of the total number of colonoscopies performed. Recently, an application of a conversion factor to estimate the ADR from the polyp detection rate (PDR) was described.

AIM

In this meta-analysis, we examined the correlation between ADR and PDR in the published studies and assessed the relative ratio of these ratios for a better and more accurate estimation.

METHODS

English Medical literature searches were performed for 'PDR' AND 'ADR'. A meta-analysis was carried out for papers that fulfilled the inclusion criteria using comprehensive meta-analysis software.

RESULTS

Twenty-five studies and 42 sets of data, including 31 623 patients, from nine countries published till 31 August 2017, were found. Funnel plot did not indicate a significant publication bias. relative ratio for ADR calculated from PDR was 0.688, 95% confidence intervals: 0.680-0.695, P value of less than 0.0001 in the meta-analysis fixed model. Heterogeneity (the proportion of inconsistency in individual studies) between studies was significant, with Q=492.753, d.f. (Q) 41, P<0.0001, and I 91.679.

CONCLUSION

We found the ratio of 0.688 can be used to calculate ADR from PDR for the individual endoscopist or for a group of endoscopists before receiving the formal results from the pathology department.

Can technology increase adenoma detection rate?

Colorectal cancer is the third most common cancer worldwide and the second most common cause of cancer-related death in Europe and North America. Colonoscopy is the gold standard investigation for the colon but is not perfect, and small or flat adenomas can be missed which increases the risk of patients subsequently developing colorectal cancer. Adenoma detection rate is the most widely used marker of quality, and low rates are associated with increased rates of post-colonoscopy colorectal cancer. Standards of colonoscopy and adenoma detection vary widely between different endoscopists. Interventions to improve adenoma detection rate are therefore required. Many devices have been purported to increase adenoma detection rate. This review looks at current available evidence for device technology to improve adenoma detection rate during colonoscopy.

Can polyp detection rate be used prospectively as a marker of adenoma detection rate?

BACKGROUND

Adenoma detection rate (ADR) is a quality indicator for screening colonoscopy, but its calculation is time-consuming. Polyp detection rate (PDR) has been found to correlate with ADR; however, its use as a quality indicator has been criticized out of concern for endoscopists artificially inflating the PDR. We aim to evaluate whether active monitoring affects PDR.

METHODS

In March 2015, 14 endoscopists were made aware that their personal PDRs would be tracked monthly as a quality improvement project. Endoscopists received a report of their individual monthly and cumulative PDR, departmental averages, and a benchmark PDR. Following the intervention, data were collected for consecutive patients undergoing average risk screening colonoscopy for six months. PDR, ADR, and adenoma to polyp detection ratio quotient (APDRQ) were compared to a six-month pre-intervention period.

RESULTS

2203 patients were included in the study. There was no statistically significant difference in PDR when comparing pre- and post-intervention (44 vs. 45%, OR 1.04; 95% CI 0.77-1.36). No statistically significant difference in ADR was observed when comparing pre- and post-intervention (29 vs. 30%, OR 1.03; 95% CI 0.64-1.52). There was no statistically significant difference in APDRQ when comparing pre- and post-intervention (0.67 vs. 0.66, OR 0.99; 95% CI 0.69-1.33).

CONCLUSIONS

Monthly report cards did not result in a change in PDR or APDRQ. In some environments, PDR can be used as a surrogate marker of ADR, despite endoscopist awareness that PDR is being measured.