Quality in screening colonoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE)

Computer-aided quality assessment of endoscopist competence during colonoscopy: a systematic review

BACKGROUND AND AIMS

Endoscopists' competence can vary widely, as shown in the variation in the adenoma detection rate (ADR). Computer-aided quality assessment (CAQ) can automatically assess performance during individual procedures. In this review we identified and described different CAQ systems for colonoscopy.

METHODS

A systematic review of the literature was done using MEDLINE, EMBASE, and Scopus based on 3 blocks of terms according to the inclusion criteria: colonoscopy, competence assessment, and automatic evaluation. Articles were systematically reviewed by 2 reviewers, first by abstract and then in full text. The methodological quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

Of 12,575 identified studies, 6831 remained after removal of duplicates and 6806 did not pass the eligibility criteria and were excluded, leaving 25 studies, of which 13 studies were included in the final analysis. Five categories of CAQ systems were identified: withdrawal speedometer (7 studies), endoscope movement analysis (3 studies), effective withdrawal time (1 study), fold examination quality (1 study), and visual gaze pattern (1 study). The withdrawal speedometer was the only CAQ system that tested its feedback by examining changes in ADR. Three studies observed an improvement in ADR, and 2 studies did not. The methodological quality of the studies was high (mean MERSQI, 15.2 points; maximum, 18 points).

CONCLUSIONS

Thirteen studies developed or tested CAQ systems, most frequently by correlating it to the ADR. Only 5 studies tested feedback by implementing the CAQ system. A meta-analysis was impossible because of the heterogeneous study designs, and more studies are warranted.

Impact of inadequate bowel cleansing in sigmoidoscopy screening

BACKGROUND AND STUDY AIMS

Long-time follow-up of sigmoidoscopy screening trials has shown reduced incidence and mortality of colorectal cancer (CRC), but inadequate bowel cleansing may hamper efficacy. The aim of this study was to assess the impact of bowel cleansing quality in sigmoidoscopy screening.

PATIENTS AND METHODS

Individuals 50 to 74 years old who had a screening sigmoidoscopy in a population-based Norwegian, randomized trial between 2012 and 2019, were included in this cross-sectional study. The bowel cleansing quality was categorised as excellent, good, partly poor, or poor. The effect of bowel cleansing quality on adenoma detection rate (ADR) and referral to colonoscopy was evaluated by fitting multivariable logistic regression models.

RESULTS

35,710 individuals were included. The bowel cleansing at sigmoidoscopy was excellent in 20,934 (58.6%) individuals, good in 6580 (18.4%), partly poor in 7097 (19.9%) and poor in 1099 (3.1%). The corresponding ADRs were 17.0%, 16.6%, 14.5%, and 13.0%. Compared to participants with excellent bowel cleansing, those with poor bowel cleansing had an odds ratio for adenoma detection of 0.66 (95% confidence interval 0.55-0.79). We found substantial differences in the assessment of bowel cleansing quality among endoscopists.

CONCLUSIONS

Inadequate bowel cleansing reduces the efficacy of sigmoidoscopy screening, by lowering ADR. A validated rating scale and improved bowel preparation are needed to make sigmoidoscopy an appropriate screening method.

Trial registration Clinicaltrials.gov (NCT01538550).

Segmental colitis associated with diverticulosis (SCAD) in a colorectal cancer screening population: Prevalence, endoscopic features and oncological outcomes

BACKGROUND

Segmental colitis associated with diverticulosis (SCAD) is characterized by a chronic inflammatory response involving the inter-diverticular colonic mucosa, sparing the rectum and the right colon.

AIMS

to assess the prevalence of SCAD in a CRC screening program and to evaluate the differences in terms of oncological outcomes between SCAD and diverticulosis.

METHODS

retrospective analysis from a prospectively-maintained database including all subjects undergoing first screening colonoscopy.

RESULTS

1518 patients were included (51.8 % male, mean age 63.48 ± 6.39). Adenomas were detected in 638 patients (ADR 42 %), CRC was diagnosed in 5.7 %. Diverticulosis was described in 37.5 %, while SCAD in 4.5 %. Among them, 69.6 % presented crescentic-fold disease, 20.3 % mild-to-moderate UC-like pattern, 8.7 % CD-like pattern and 1.4 % severe UC-like pattern. When SCAD was compared to uncomplicated/asymptomatic diverticulosis (501 patients), we found no differences in terms of gender (p = 0.46) or age (p = 0.47). Interestingly, the use of anticoagulant/antiplatelet (p = 0.79), anti-hypertensive (p = 0.89) or anti-hyperglycaemic drugs (p = 0.52) had no effect on SCAD onset as compared to diverticulosis. SCAD patients had significant lower rate of adenomas (ADR 31.9% vs 47.3 %, p = 0.018, OR 0.52, 95 %CI 0.31-0.89), and lower-but not significant-rate of CRC (1.4% vs 6.2 %, p = 0.14, OR 0.22, 95 %CI 0.02-1.66).

CONCLUSIONS

SCAD can be diagnosed in about 5 % of population undergoing screening colonoscopy and in 12 % of those with diverticulosis. SCAD seems to be associated with a reduced rate of adenomas or CRC as compared with diverticulosis.

A Patient-Centered Approach to Communication during Endoscopic Procedures: The Importance of Providing Information to Patients

The study aimed to explore patients' experiences and perceptions throughout the various stages of endoscopic procedures and examine the association between patient-centered communication and the patient's experience. A total of 191 patients responded to pre- and post-procedure surveys that inquired about fear and pain, patients' satisfaction regarding the information provided to them, perceptions and experience. Pain was associated with post-procedure fear (r = 0.63, p < 0.01) and negatively associated with reported patient experience at the end of the visit (r = -0.17, p < 0.01). Significant positive associations were found between patient experience and satisfaction from the information provided before (r = 0.47, p < 0.01) and the information provided after the procedure (r = 0.51, p < 0.001). A predictive model found that perceptions toward the physicians, satisfaction from information provided before discharge, and feelings of trust are predictors of the patient experience (F = 44.9, R2 = 0.61, p < 0.001). Patients' satisfaction with information provided before and after the procedure can positively affect the patients' experience, leading to a decrease in fear and anxiety and increasing compliance with medical recommendations. Strategies for PCC with endoscopic patients should be developed and designed in a participatory manner, taking into account the various aspects associated with the patient experience.

The Effect of Informing Patients Who Will Undergo a Colonoscopy via Short Messaging Service on the Procedure Quality and Satisfaction: An Endoscopist-Blinded, Randomized Controlled Trial

PURPOSE

The present research was carried out to determine the impact of informing patients who would undergo a colonoscopy via short messaging service (SMS) on the procedure quality and satisfaction.

DESIGN

The study was designed as a randomized controlled experimental and single-blind.

METHODS

The study was completed with 170 patients (87 in the control group and 83 in the intervention group). Verbal and written information about bowel preparation was provided to all patients at the first appointment. Additionally, a total of nine informative SMS, including the time of colonoscopy, dietary restrictions to be followed, purgative drugs to be used, and the time of taking the drugs, were sent to the patients in the intervention group starting 2 days before the procedure. Data were collected using a patient questionnaire, Boston Bowel Preparation Scale (BBPS), and postcolonoscopy follow-up form.

FINDINGS

The mean score of each colon segment and the total BBPS mean score of the patients in the intervention group were higher compared to the control group, and the difference between them was statistically significant. The percentage of patients with adequate bowel preparation was significantly higher in the intervention group (84.3%) in comparison with the control group (71.3%). The intervention group had high compliance with a clear diet, enema application, and oral medication intake (P < .05). The cecum was reached in 85.5% of the intervention group. The majority of the patients (89.2%) in the intervention group reported that the information provided via SMS was adequate, and 91.6% were satisfied with the information provided by SMS.

CONCLUSIONS

The study shows that, in addition to written and verbal information provided before colonoscopy, SMS information positively impacts the quality of patients' bowel preparation, increases their compliance with the preparation instructions, the rate of reaching the cecum, and their satisfaction. Patient education with this practice can help ensure adequate bowel preparation quality and increase patient comfort in the colonoscopy procedure.

Longer Colonoscopy Withdrawal Time Is Associated With the Detection of Visible Dysplasia in Patients With Inflammatory Bowel Disease

Background

Colonoscopy withdrawal time (CWT) of at least 6-9 minutes is the minimum time needed for adequate adenoma detection in the general population. The ideal CWT in patients with inflammatory bowel disease (IBD) has not been determined. We aimed to identify the optimal CWT associated with the detection of visible dysplasia in patients with IBD.

Methods

This is a retrospective study from 1/1/2017 to 9/1/2022 of adult patients with IBD in endoscopic healing undergoing surveillance via high-definition white light colonoscopy. The primary outcome was the association of CWT with visible dysplasia detection.

Results

A total of 259 patients (mean age 56 ± 14.8 years; 51.3% female, 68% with ulcerative colitis; 8.9% with primary sclerosing cholangitis) underwent 330 colonoscopies. Patients with visible dysplasia were more likely to be older (P < .001) and have a personal history of visible dysplasia (P < .001) and invisible dysplasia (P = .023). The mean CWT was significantly longer in the visible dysplasia group at 26 minutes (interquartile range [IQR] 20-38.5) vs. 21 minutes (IQR 15-28) in procedures without visible dysplasia (P < .001). On multivariable analysis, increased age (P < .001), increased CWT (P = .001), and personal history of visible dysplasia (P = .013) were independently associated with the detection of visible dysplasia. A CWT of ≥15 minutes (odds ratio [OR] 2.71; 95% confidence interval [CI], 1.11-6.6; P = .02] and not ≥9 minutes (OR 2.57; 95% CI, 0.33-20.2; P = .35) is significantly associated with detection of visible dysplasia.

Conclusions

For patients with IBD undergoing surveillance via high-definition white light colonoscopy, the mean CWT was independently associated with the detection of visible dysplasia.

The Effect of Intervention for Improving Colonoscopy Quality Is Associated with the Personality Traits of Endoscopists

Background/Aims

This study investigated whether the personality traits of endoscopists are associated with the effect of interventions for the improvement of colonoscopy quality.

Methods

This prospective, multicenter, single-blind study was performed with 13 endoscopists in three health screening centers over a 12-month period. Quality indicators (QIs), including adenoma detection rate (ADR), polyp detection rate (PDR), and withdrawal time, were measured every 3 months. Consecutive interventions for the improvement of colonoscopy quality were conducted every 3 months, which included the personal notification of QIs, the in-group notification of QIs, and finally a targeted "quality education" session. The personality traits of each endoscopist were evaluated for perfectionism, fear of negative evaluation, and cognitive flexibility after the last QI assessment.

Results

A total of 4,095 colonoscopies were evaluated to measure the QIs of the individual endoscopists for 12 months. The mean ADR, PDR, and withdrawal time of the 13 endoscopists were 32.3%, 47.7%, and 394 seconds at baseline and increased to 39.0%, 55.1%, and 430 seconds by the end of the study (p=0.003, p=0.006, and p=0.004, respectively). Among the three interventions, only quality education significantly improved QIs: ADR, 36.0% to 39.0% (odds ratio, 1.28; 95% confidence interval, 1.01 to 1.63). The improvement of ADR and PDR by education was significantly associated with perfectionism (r=0.617, p=0.033 and r=0.635, p=0.027, respectively) and fear of negative evaluation (r=0.704, p=0.011 and r=0.761, p=0.004, respectively).

Conclusions

Education can improve colonoscopy quality, and its effect size is associated with an endoscopist's personal traits such as perfectionism and fear of negative evaluation (Clinical-Trials.gov Registry NCT03796169).

Closing the Gap: A Critical Examination of Adherence, Inconsistency, and Improvements in Colonoscopy Reporting Practices

INTRODUCTION

Comprehensive and standardized colonoscopy reports are crucial in colorectal cancer prevention, monitoring, and research. This study investigates adherence to national and international guidelines by analyzing reporting practices among 21 endoscopists in 7 German centers, with a focus on polyp reporting.

METHODS

We identified and assessed German, European, American, and World Health Organization-provided statements to identify key elements in colonoscopy reporting. Board-certified gastroenterologists rated the relevance of each element and estimated their reporting frequency. Adherence to the identified report elements was evaluated for 874 polyps from 351 colonoscopy reports ranging from March 2021 to March 2022.

RESULTS

We identified numerous recommendations for colonoscopy reporting. We categorized the reasoning behind those recommendations into clinical relevance, justification, and quality control and research. Although all elements were considered relevant by the surveyed gastroenterologists, discrepancies were observed in the evaluated reports. Particularly diminutive polyps or attributes which are rarely abnormal (e.g., surface integrity) respectively rarely performed (e.g., injection) were sparsely documented. Furthermore, the white light morphology of polyps was inconsistently documented using either the Paris classification or free text. In summary, the analysis of 874 reported polyps revealed heterogeneous adherence to the recommendations, with reporting frequencies ranging from 3% to 89%.

CONCLUSION

The inhomogeneous report practices may result from implicit reporting practices and recommendations with varying clinical relevance. Future recommendations should clearly differentiate between clinical relevance and research and quality control or explanatory purposes. Additionally, the role of computer-assisted documentation should be further evaluated to increase report frequencies of non-pathological findings and diminutive polyps.

Restrictive diets are unnecessary for colonoscopy: Non-inferiority randomized trial

Background and study aims In colonoscopy, preparation is often regarded as the most burdensome part of the intervention. Traditionally, specific diets have been recommended, but the evidence to support this policy is insufficient. The aim of this study was to evaluate the impact of the decision not to follow a restrictive diet on bowel preparation and colonoscopy outcomes. Patients and methods This was a multicenter, controlled, non-inferiority randomized trial with FIT-positive screening colonoscopy. The subjects were assigned to follow the current standard (1-day low residue diet [LRD]) or a liberal diet. The allocation was balanced for the risk of inadequate cleansing using the Dik et al. score. All participants received the same instructions for morning colonoscopy preparation. The primary outcome was the rate of adequate preparations as defined by the Boston Bowel Preparation Scale. Secondary outcomes included tolerability and measures of colonoscopy performance and quality. Results A total of 582 subjects were randomized. Of these, 278 who received the liberal diet and 275 who received the 1-day LRD were included in the intent-to-treat analysis. Non-inferiority was demonstrated with adequate preparation rates of 97.8% in the 1-day LRD and 96.4% in the liberal diet group. Tolerability was higher with the liberal diet (94.7% vs. 83.2%). No differences were found with respect to cecal intubation time, aspirated volume, or length of the examination. Global and right colon average adenoma detection rates per colonoscopy were similar. Conclusions The liberal diet was non-inferior to the 1-day LRD, and increased tolerability. Colonoscopy performance and quality were not affected. (NCT05032794).

Excellent Bowel Preparation Quality Is Not Superior to Good Bowel Preparation Quality for Improving Adenoma/Polyp Detection Rate

Background

Adequate bowel preparation quality is essential for high-quality colonoscopy according to the current guidelines. However, the excellent effect of bowel preparation on adenoma/polyp detection rate (ADR/PDR) remained controversial.

Methods

During the period from December 2020 to August 2022, a total of 1566 consecutive patients underwent colonoscopy by an endoscopist. Their medical records were reviewed. According to the Boston bowel preparation scale, patients were divided into excellent, good, and poor bowel preparation quality groups. ADR/PDR, diminutive ADR/PDR, small ADR/PDR, intermediate ADR/PDR, large ADR/PDR, and number of adenomas/polyps were compared among them. Logistic regression analyses were performed to identify the factors that were significantly associated with ADR/PDR.

Results

Overall, 1232 patients were included, of whom 463, 636, and 133 were assigned to the excellent, good, and poor groups, respectively. The good group had a significantly higher ADR/PDR (63% vs 55%, P = .015) and a larger number of adenomas/polyps (2.5 ± 3.2 vs 2.0 ± 2.8, P = .030) than the poor group. Both ADR/PDR (63% vs 55%, P = .097) and number of adenomas/polyps (2.2 ± 2.8 vs 2.0 ± 2.8, P = .219) were not significantly different between excellent and poor groups. The excellent (9% vs 4%, P = .045) and good (9% vs 4%, P = .040) groups had a significantly higher intermediate ADR/PDR than the poor group. Logistic regression analyses showed that either good (odds ratio [OR] = 1.786, 95% CI = 1.046-3.047, P = .034) or excellent (OR = 2.179, 95% CI = 1.241-3.826, P = .007) bowel preparation quality was independently associated with a higher ADR/PDR compared with poor bowel preparation quality. Excellent (OR = 1.202, 95% CI = 0.848-1.704, P = .302) bowel preparation quality was not independently associated with a higher ADR/PDR compared with good bowel preparation quality.

Conclusions

The pursuit of excellence in bowel preparation does not show an association with increased ADR/PDR and number of adenomas/polyps compared with a good level. In addition, our study further contributes to the existing evidence that poor bowel preparation compromises ADR/PDR and number of adenomas/polyps.

Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

This ESGE Position Statement provides structured and evidence-based guidance on the essential requirements and processes involved in training in basic gastrointestinal (GI) endoscopic procedures. The document outlines definitions; competencies required, and means to their assessment and maintenance; the structure and requirements of training programs; patient safety and medicolegal issues. 1:  ESGE and ESGENA define basic endoscopic procedures as those procedures that are commonly indicated, generally accessible, and expected to be mastered (technically and cognitively) by the end of any core training program in gastrointestinal endoscopy. 2:  ESGE and ESGENA consider the following as basic endoscopic procedures: diagnostic upper and lower GI endoscopy, as well as a limited range of interventions such as: tissue acquisition via cold biopsy forceps, polypectomy for lesions ≤ 10 mm, hemostasis techniques, enteral feeding tube placement, foreign body retrieval, dilation of simple esophageal strictures, and India ink tattooing of lesion location. 3:  ESGE and ESGENA recommend that training in GI endoscopy should be subject to stringent formal requirements that ensure all ESGE key performance indicators (KPIs) are met. 4:  Training in basic endoscopic procedures is a complex process and includes the development and acquisition of cognitive, technical/motor, and integrative skills. Therefore, ESGE and ESGENA recommend the use of validated tools to track the development of skills and assess competence. 5:  ESGE and ESGENA recommend incorporating a multimodal approach to evaluating competence in basic GI endoscopic procedures, including procedural thresholds and the measurement and documentation of established ESGE KPIs. 7:  ESGE and ESGENA recommend the continuous monitoring of ESGE KPIs during GI endoscopy training to ensure the trainee's maintenance of competence. 9:  ESGE and ESGENA recommend that GI endoscopy training units fulfil the ESGE KPIs for endoscopy units and, furthermore, be capable of providing the dedicated personnel, infrastructure, and sufficient case volume required for successful training within a structured training program. 10:  ESGE and ESGENA recommend that trainers in basic GI endoscopic procedures should be endoscopists with formal educational training in the teaching of endoscopy, which allows them to successfully and safely teach trainees.

A randomized trial evaluating the utility of non-targeted biopsies for colorectal neoplasia detection in adults with inflammatory bowel disease: a pilot study protocol

BACKGROUND

Persons with inflammatory bowel diseases are at increased risk of developing colorectal cancer and require frequent colonoscopy surveillance. Guidelines recommend taking 30 to 40 non-targeted biopsies throughout the colorectum to detect "invisible" neoplasia in this setting, despite a lack of evidence supporting this practice. We sought to assess the utility of this practice through a randomized controlled trial. We first propose an internal pilot study to assess recruitment potential, protocol adherence and data capture to guide the full trial.

METHODS

We have designed a multi-centre, parallel-group, non-inferiority randomized controlled trial to test the utility of non-targeted biopsies as an adjunct to colonoscopy surveillance for neoplasia detection in persons with inflammatory bowel disease involving the colorectum in routine clinical practice. Participants are randomized 1:1, stratified by study site, to either standard of care high-definition white-light colonoscopy with 32 to 40 non-targeted biopsies of non-neoplastic-appearing mucosa along with a sampling of abnormal-appearing mucosa (control group) or modified colonoscopy with targeted sampling alone (intervention group). The primary outcome for the full trial will be the proportion of persons with ≥ 1 neoplastic focus detected during colonoscopy. For the pilot phase, we will assess the feasibility of recruiting a minimum of 15% of the estimated sample size within 1 year, under identical conditions as the full trial, while maintaining ≥ 90-95% rate of protocol adherence and data capture. These participants will contribute data to the full trial. The trial is being conducted at 12 centres across Canada, with a total sample size of 1952 persons.

DISCUSSIONS

The trial protocol has been approved by the ethics committees of all participating sites, and the pilot study has received funding through the Canadian Institutes of Health Research (PJT 159607). If feasibility metrics are met during the pilot phase, we will complete the full trial. The trial outcomes will contribute to update the practice guidelines in this area.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04067778.

Dysplasia detection rates under a surveillance program in a tertiary referral center for inflammatory bowel diseases: Real-world data

BACKGROUND AND AIMS

Surveillance colonoscopies are crucial for high-risk patients with inflammatory bowel diseases (IBD) to detect colorectal carcinoma (CRC). However, there is no established quality metric for dysplasia detection rate (DDR) in IBD surveillance. This study assessed the DDR in a dedicated surveillance program at a tertiary referral center for IBD.

METHODS

Consecutive patients with quiescent colitis were enrolled in a cross-sectional study evaluating DDR. High-definition colonoscopy with dye chromoendoscopy (DCE) was performed by a specialized operator. Advanced dysplasia (AD) was defined as low-grade dysplasia ≥ 10 mm, high-grade dysplasia, or colorectal cancer. Risk factors for dysplasia detection were analyzed.

RESULTS

In total, 119 patients underwent 151 procedures, identifying 206 lesions, of which 40 dysplastic with seven AD . Per-lesion and per-procedure DDR were 19.4 % and 20.5 %, respectively. The per-procedure AD detection rate (ADDR) was 4.6 %. A Kudo pit pattern of II-V had a sensitivity of 92.5 % for dysplasia detection but a false positive rate of 64.8 % (p < 0.001). Age at diagnosis and at index colonoscopy and past or indefinite dysplasia were associated with per-procedure dysplasia detection.

CONCLUSIONS

In a real-world setting, a dedicated surveillance program achieved a high DDR. We suggest that optimal DDR in high-risk IBD patients be defined and implemented as a standardized quality measure for surveillance programs.

Surveillance after colorectal polyp resection

Post-polypectomy surveillance has proven to reduce colorectal cancer (CRC) incidence in patients with high-risk polyps, but it implies a major burden on colonoscopy units. Therefore, it should be targeted to individuals with a higher risk. Different societies have published guidelines on surveillance after resection of polyps, with notable discrepancies among them, and many recommendations come from low-quality evidence based on surrogate measures, such as risk of advanced adenoma, and not CRC risk. In this review, we aimed to summarize the evidence supporting post-polypectomy surveillance, compare the recently updated major guidelines, and discuss the existing discrepancies on this topic. Briefly, patients with adenomas ≥10 mm or high-grade dysplasia and patients with serrated polyps ≥10 mm or dysplasia are generally considered to have an increased risk of metachronous CRC and require surveillance, whereas the indication of surveillance is not clearly established in patients without these high-risk features.

Measuring the observer (Hawthorne) effect on adenoma detection rates

Background and study aims An independent observer can improve procedural quality. We evaluated the impact of the observer (Hawthorne effect) on important quality metrics during colonoscopies. Patients and Methods In a single-center comparative study, consecutive patients undergoing routine screening or diagnostic colonoscopy were prospectively enrolled. In the index group, all procedural steps and quality metrics were observed and documented, and the procedure was video recorded by an independent research assistant. In the reference group, colonoscopies were performed without independent observation. Colonoscopy quality metrics such as polyp, adenoma, serrated lesions, and advanced adenoma detection rates (PDR, ADR, SLDR, AADR) were compared. The probabilities of increased quality metrics were evaluated through regression analyses weighted by the inversed probability of observation during the procedure. Results We included 327 index individuals and 360 referents in the final analyses. The index group had significantly higher PDRs (62.4% vs. 53.1%, P =0.02) and ADRs (39.4% vs. 28.3%, P =0.002) compared with the reference group. The SLDR and AADR were not significantly increased. After adjusting for potential confounders, the ADR and SLDR were 50% (relative risk [RR] 1.51; 95%, CI 1.05-2.17) and more than twofold (RR 2.17; 95%, CI 1.05-4.47) more likely to be higher in the index group than in the reference group. Conclusions The presence of an independent observer documenting colonoscopy quality metrics and video recording the colonoscopy resulted in a significant increase in ADR and other quality metrics. The Hawthorne effect should be considered an alternative strategy to advanced devices to improve colonoscopy quality in practice.

Prospective study of computer-aided detection of colorectal adenomas in hospitalized patients

BACKGROUND

Adenoma detection with polypectomy during total colonoscopy reduces the incidence of colorectal cancer (CRC) and colorectal cancer-associated mortality. The adenoma detection rate (ADR) is an established quality indicator, which is associated with a decreased risk for interval cancer. An increase in ADR could be demonstrated for several artificially intelligent, real-time computer-aided detection (CADe) systems in selected patients. Most studies concentrated on outpatient colonoscopies. This sector often lacks funds for applying costly innovations like CADe. Hospitals are more likely to implement CADe and information about the impact of CADe in the distinct patient cohort of hospitalized patients is scarce.

METHODS

In this prospective, randomized-controlled study, we compared colonoscopies performed with or without computer-aided detection (CADe) system (GI Genius, Medtronic) performed at University Medical Center Schleswig-Holstein, Campus Luebeck. The primary endpoint was ADR.

RESULTS

Overall, 232 patients were randomized with n = 122 patients in the CADe arm and n = 110 patients in the control arm. Median age was 66 years (interquartile range 51-77). Indication for colonoscopy was most often workup for gastrointestinal symptoms (88.4%) followed by screening, post-polypectomy and post-CRC surveillance (each 3.9%). Withdrawal time was significantly prolonged (11 vs. 10 min, p = 0.039), without clinical relevance. Complication rate was not different between the arms (0.8% vs. 4.5%; p = 0.072). The ADR was significantly increased in the CADe arm compared to the control (33.6% vs. 18.1%, p = 0.008). ADR increase was particularly strong for the detection in elderly patients aged ≥50 years (OR 6.3, 95% CI 1.7 - 23.1, p = 0.006).

CONCLUSION

The use of CADe is safe and increases ADR in hospitalized patients.

CT colonography: can we achieve an adequate bowel preparation without diet restriction?

OBJECTIVE

To evaluate if an adequate bowel preparation for CT colonography, can be achieved without diet restriction, using a reduced amount of cathartic agent and fecal tagging. To investigate the influence of patients' characteristics on bowel preparation and the impact on patients' compliance.

METHODS

In total, 1446 outpatients scheduled for elective CT colonography were prospectively enrolled. All patients had the same bowel preparation based on a reduced amount of cathartic agent (120 g of macrogol in 1.5 l of water) the day before the exam and a fecal tagging agent (60 ml of hyperosmolar oral iodinated agent) the day of the exam. No dietary restrictions were imposed before the exam. The bowel preparation was evaluated using a qualitative and quantitative score. Patients were grouped by age, gender, and presence of diverticula in both scores. Patients' compliance has been evaluated with a questionnaire after the end of the exam and with a phone-calling interview the day after the exam.

RESULTS

According to the qualitative score, adequate bowel preparation was achieved in 1349 patients (93.29%) and no statistical differences were observed among the subgroups of patients. Quantitative scores demonstrated that colon distension was significantly better in younger patients and without diverticula. A good patients' compliance was observed and most patients (96.5%) were willing to repeat it.

CONCLUSIONS

The lack of diet restriction does not affect the quality of CTC preparation and good patient's compliance could potentially increase the participation rate in CRC screening programs.

KEY POINTS

• An adequate quality bowel preparation for CT colonography can be achieved without diet restriction, using a reduced amount of cathartic agent (120 g of macrogol in 1.5 l of water) and fecal tagging (60 ml of hyperosmolar oral iodinated agent). • A bowel preparation based on the combination of a reduced amount of cathartic agent and fecal tagging, without diet restriction, allows obtaining good quality in more than 90% of patients. • The bowel preparation scheme proposed reduces the distress and discomfort experienced by the patients improving adherence to CTC.

Cold snare versus cold forceps polypectomy for endoscopic resection of diminutive polyps: meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

The practices for resection of diminutive colon polyps vary among endoscopists, and U.S. Multi-Society Task force guidelines recommend use of cold snare polypectomy (CSP) for this purpose. In this meta-analysis, we compared CSP and cold forceps polypectomy (CFP) for resection of diminutive polyps.

METHODS

Several databases were reviewed to identify randomized controlled trials that compared CSP and CFP for resection of diminutive polyps. The study outcomes of interest were complete resection of all diminutive polyps, complete resection of polyps ≤3 mm in size, failure of tissue retrieval, and polypectomy time. For categorical variables, pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated; for continuous variables, mean differences (MDs) with 95% CIs were calculated. Data were analyzed by using a random-effects model, and heterogeneity was assessed by using the I2 statistic.

RESULTS

We included 9 studies with 1037 patients. Rate of complete resection of all diminutive polyps was significantly higher in the CSP group (OR, 1.68; 95% CI, 1.09-2.58). Subgroup analysis, including jumbo or large-capacity forceps, found no significant difference in complete resection between groups (OR, 1.43; 95% CI, .80-2.56). We found no significant between-groups in the rates of complete resection of polyps ≤3 mm in size (OR, .83; 95% CI, .30-2.31). Rate of failure of tissue retrieval was significantly higher in the CSP group (OR, 10.13; 95% CI, 2.29-44.74). No significant between-group difference was noted in polypectomy time.

CONCLUSIONS

CFP using large-capacity or jumbo biopsy forceps is noninferior to CSP for complete resection of diminutive polyps.

Unlocking quality in endoscopic mucosal resection

A review of the development of the key performance metrics of endoscopic mucosal resection (EMR), learning from the experience of the establishment of widespread colonoscopy quality measurements. Potential future performance markers for both colonoscopy and EMR are also evaluated to ensure continued high quality performance is maintained with a focus service framework and predictors of patient outcome.

Increasing the accuracy of colorectal cancer screening

INTRODUCTION

Colorectal cancer (CRC) is a major health issue, being responsible for nearly 10% of all cancer-related deaths. Since CRC is often an asymptomatic or paucisymptomatic disease until it reaches advanced stages, screening is crucial for the diagnosis of preneoplastic lesions or early CRC.

AREAS COVERED

The aim of this review is to summarize the literature evidence on currently available CRC screening tools, with their pros and cons, focusing on the level of accuracy reached by each test over time. We also provide an overview of novel technologies and scientific advances that are currently being investigated and that in the future may represent real game-changers in the field of CRC screening.

EXPERT OPINION

We suggest that best screening modalities are annual or biennial FIT and colonoscopy every 10 years. We believe that the introduction of artificial intelligence (AI)-tools in the CRC screening field could lead to a significant improvement of the screening efficacy in reducing CRC incidence and mortality in the future. More resources should be put into implementing CRC programmes and support research project to further increase accuracy of CRC screening tests and strategies.

The connection between diverticulosis and colonic superficial neoplastic lesions in patients who underwent screening colonoscopy

PURPOSE

If could be a potential pathophysiological connection between colonic diverticula and colonic superficial neoplastic lesions, beyond the shared risk factors, has been a subject of debate in the last years. This study tries to evaluate the association between diverticulosis and colonic neoplastic lesions.

METHODS

This is a cross-sectional study including asymptomatic patients who underwent a screening colonoscopy (patients with a positive fecal occult blood test under the regional program of colorectal cancer (CRC) screening), surveillance after polypectomy resection, or familiarity (first-degree relatives) between 2020 and 2021 to evaluate the association between diverticula and colonic polyps. A multivariate analysis with multiple logistic regression and odds ratio (OR) to study the independent association between adenomas and adenocarcinomas was performed.

RESULTS

One thousand five hundred one patients were included. A statistically significant association between adenomas or CRC alone and colonic diverticula was found (p = 0.045). On a multivariate analysis of demographic (age, gender) and clinical parameters (familiarity for diverticula and adenoma/CRC), only age was significantly associated with the development of colorectal adenomas or cancer (OR 1.05, 95% CI 1.03-1.07, p < 0.0001).

CONCLUSIONS

This study showed a statistically significant association between diverticula and colonic adenomas. However, it is impossible to establish a cause-effect relationship due to the intrinsic characteristics of this study design. A study with a prospective design including both patients with diverticulosis and without colonic diverticula aimed at establishing the incidence of adenoma and CRC could help to answer this relevant clinical question, since a potential association could indicate the need for closer endoscopic surveillance.

Incidence of colonoscopy-related perforation and risk factors for poor outcomes: 3-year results from a prospective, multicenter registry (with videos)

BACKGROUND AND AIMS

Perforation is a life-threatening adverse event of colonoscopy that often requires hospitalization and surgery. We aimed to prospectively assess the incidence of colonoscopy-related perforation in a multicenter registry and to analyze the clinical factors associated with poor clinical outcomes.

METHODS

This prospective observational study was conducted at six tertiary referral hospitals between 2017 and 2020, and included patients with colonic perforation after colonoscopy. Poor clinical outcomes were defined as mortality, surgery, and prolonged hospitalization (> 13 days). Logistic regression was used to identify factors associated with poor clinical outcomes.

RESULTS

Among 84,673 patients undergoing colonoscopy, 56 had colon perforation (0.66/1000, 95% confidence interval [CI] 0.51-0.86). Perforation occurred in 12 of 63,602 diagnostic colonoscopies (0.19/1000, 95% CI 0.11-0.33) and 44 of 21,071 therapeutic colonoscopies (2.09/1000, 95% CI 1.55-2.81). Of these, 15 (26.8%) patients underwent surgery, and 25 (44.6%) patients had a prolonged hospital stay. One patient (1.8%) died after perforation from a diagnostic colonoscopy. In the multivariate analysis, diagnostic colonoscopy (adjusted odds ratio [aOR] 196.43, p = 0.025) and abdominal rebound tenderness (aOR 17.82, p = 0.012) were independent risk factors for surgical treatment. The location of the sigmoid colon (aOR 18.57, p = 0.048), delayed recognition (aOR 187.71, p = 0.008), and abdominal tenderness (aOR 63.20, p = 0.017) were independent risk factors for prolonged hospitalization.

CONCLUSIONS

This prospective study demonstrated that the incidence of colonoscopy-related perforation was 0.66/1000. The incidence rate was higher in therapeutic colonoscopy, whereas the risk for undergoing surgery was higher in patients undergoing diagnostic colonoscopy. Colonoscopy indication (diagnostic vs. therapeutic), physical signs, the location of the sigmoid perforation, and delayed recognition were independent risk factors for poor clinical outcomes in colonoscopy-related perforation.

Quality of rural colonoscopy outperforms key performance indicators in a multi-centre prospective clinical study

BACKGROUND

High-quality colonoscopy is vital for the detection and removal of adenomatous polyps and early diagnosis of colorectal cancer. The aim of this study was to prospectively assess the quality and safety of colonoscopies performed in the non-metropolitan setting. Key performance indicators measured include completion, polypectomy and adenoma/serrated polyp detection rates, rate of adequate bowel preparation, withdrawal time and complications.

METHODS

Prospective data collection for all colonoscopies performed over a one-year period in seven non-metropolitan South Australian hospitals. Two general surgeons and twelve registrars working in rural South Australian hospitals (Mount Gambier, Millicent, Naracoorte, Port Lincoln, Port Augusta, Whyalla and Berri) contributed to this study.

RESULTS

In total 3497 colonoscopies were analysed. Complete colonoscopy was achieved in 96.1%. The adenoma detection and serrated polyp detection rates were 25.6% and 5.4% respectively. Cancer was detected in 71 patients (2%). Colonic perforation occurred in five patients (0.1%). There was no procedure-related mortality.

CONCLUSIONS

Colonoscopy performed in the non-metropolitan Australian setting outperforms key performance indicators set by national institutions. This is the first Australian prospective multi-centre study investigating the quality and safety of endoscopic procedures.

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.

SPLIT-DOSE BOWEL PREPARATION IS SUPERIOR TO STRAIGHT-DOSE IN HOSPITALIZED PATIENTS UNDERGOING INPATIENT COLONOSCOPY

BACKGROUND

There is a two-fold higher rate of failed colonoscopy secondary to inadequate bowel preparation among hospitalized versus ambulatory patients. Split-dose bowel preparation is widely used in the outpatient setting but has not been generally adapted for use among the inpatient population.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of split versus single dose polyethylene glycol bowel (PEG) preparation for inpatient colonoscopies and determine additional procedural and patient characteristics that drive inpatient colonoscopy quality.

METHODS

A retrospective cohort study was performed on 189 patients who underwent inpatient colonoscopy and received 4 liters PEG as either split- or straight-dose during a 6-month period in 2017 at an academic medical center. Bowel preparation quality was assessed using Boston Bowel Preparation Score (BBPS), Aronchick Score, and reported adequacy of preparation.

RESULTS

Bowel preparation was reported as adequate in 89% of the split-dose group versus 66% in the straight-dose group (P=0.0003). Inadequate bowel preparations were documented in 34.2% of the single-dose group and 10.7% of the split-dose group (P<0.001). Only 40% of patients received split-dose PEG. Mean BBPS was significantly lower in the straight-dose group (Total: 6.32 vs 7.73, P<0.001).

CONCLUSION

Split-dose bowel preparation is superior to straight-dose preparation across reportable quality metrics for non-screening colonoscopies and was readily performed in the inpatient setting. Interventions should be targeted at shifting the culture of gastroenterologist prescribing practices towards use of split-dose bowel preparation for inpatient colonoscopy.

An Italian prospective multicenter study on colonoscopy practice and quality: What has changed in the last 10 years

BACKGROUND

A relevant number of adenomas can be missed during colonoscopy.

AIMS

Assess the current status of colonoscopy procedures in Italian centers.

METHODS

A prospective observational study involving 17 hospitals (34 endoscopists) included consecutive patients undergoing standard colonoscopy. In the first phase, endoscopists performed consecutive colonoscopies. In the second phase, retraining via an online learning platform was planned, while in the third phase data were collected analogously to phase 1.

RESULTS

A total of 3,504 patients were enrolled. Overall, a BBPS score ≥6 was obtained in 95.6% of cases (94.8% and 96.9% in the pre- and post-training phases, respectively). 88.4% of colonoscopies had a withdrawal time ≥6 min (88.2% and 88.7% in the pre- and post-training phases). Median adenoma detection rate (ADR) was 39.1%, with no significant differences between the pre- and post-training phases (40.1% vs 36.9%; P = 0.83). In total, 81% of endoscopists had a ADR performance above the 25% threshold.

CONCLUSION

High colonoscopy quality standards are achieved by the Italian hospitals involved. Quality improvement initiatives and repeated module-based colonoscopy-training have been promoted in Italy during the last decade, which appear to have had a significant impact on quality colonoscopy metrics together with the activation of colorectal cancer screening programs.

High Adenoma Detection Rates in Fecal Immunochemical Test-Based Colorectal Cancer Screening: Interim Results of the National Bowel Cancer Screening Program in Qatar

INTRODUCTION

Colorectal cancer is one of the most common cancers globally. Recent reductions in mortality rates have been primarily attributed to screening programs. The State of Qatar established a national bowel cancer screening program in 2016.

METHODOLOGY

Fecal immunochemical testing (FIT) was used for average-risk individuals aged 50 to 74 years. Fecal immunochemical testing -positive participants were referred for total colonoscopy to detect polyps and cancers.

RESULTS

Among 32,751 FIT invitees, 11,130 took the test, and 758 (6%) of those were FIT positive. Of these, 375 (56.13%) participants underwent a colonoscopy, and polyps were detected in 198 (52.8%) and cancers in 19 (5.1%) participants. The adenoma detection rate exceeded 40%.

DISCUSSION AND CONCLUSION

The high yield of polyps and cancers in the screening program justifies an active, resource-intensive, and organized bowel cancer screening effort. The high adenoma detection rate in a FIT-based program warrants recalibration of target adenoma detection rates in screening programs.

Missed colorectal cancers in a fecal immunochemical test-based screening program: Molecular profiling of interval carcinomas

BACKGROUND

For optimizing fecal immunochemical test (FIT)-based screening programs, reducing the rate of missed colorectal cancers (CRCs) by FIT (FIT-interval CRCs) is an important aspect. Knowledge of the molecular make-up of these missed lesions could facilitate more accurate detection of all (precursor) lesions.

AIM

To compare the molecular make-up of FIT-interval CRCs to lesions that are detected by FIT [screen-detected CRCs (SD-CRCs)].

METHODS

FIT-interval CRCs observed in a Dutch pilot-program of FIT-based screening were compared to a control group of SD-CRCs in a 1:2 ratio, resulting in 27 FIT-interval CRC and 54 SD-CRCs. Molecular analyses included microsatellite instability (MSI), CpG island methylator phenotype (CIMP), DNA sequence mutations and copy number alterations (CNAs).

RESULTS

Although no significant differences were reached, FIT-interval CRCs were more often CIMP positive and MSI positive (33% CIMP in FIT-interval CRCs vs 21% in SD-CRCs (P = 0.274); 19% MSI in FIT-interval CRCs vs 12% in SD-CRCs (P = 0.469)), and showed more often serrated pathway associated features such as BRAF (30% vs 12%, P = 0.090) and PTEN (15% vs 2.4%, P = 0.063) mutations. APC mutations, a classic feature of the adenoma-carcinoma-sequence, were more abundant in SD-CRCs (68% vs 40% in FIT-interval CRCs P = 0.035). Regarding CNAs differences between the two groups; FIT-interval CRCs less often showed gains at the regions 8p11.22-q24.3 (P = 0.009), and more often gains at 20p13-p12.1 (P = 0.039).

CONCLUSION

Serrated pathway associated molecular features seem to be more common in FIT-interval CRCs, while classic adenoma carcinoma pathway associated molecular features seem to be more common in SD-CRCs. This indicates that proximal serrated lesions may be overrepresented among FIT-interval CRCs.

Current practice of colonoscopy surveillance in patients with lynch syndrome: A multicenter retrospective cohort study in Japan

Objectives

Colonoscopy surveillance reduces the incidence of colorectal cancer through the detection and endoscopic removal of adenomas. Current guidelines recommend that patients with Lynch syndrome should have colonoscopy surveillance every 1–2 years starting at the age of 20–25. However, insufficient data are available to evaluate the quality and safety of colonoscopy surveillance for patients with Lynch syndrome nationwide in Japan.

Methods

Patients with Lynch syndrome (n = 309) from 13 institutions who underwent one or more colonoscopy procedures were enrolled in this retrospective analysis. Colonoscopy completion rate, colonoscopy‐related complication rate, proportion with an adequate colonoscopy interval, and adenoma detection rate were reviewed.

Results

The colonoscopy completion rate was 98.8% and a history of previous colorectal cancer surgery was significantly associated with a higher completion rate. All complications were associated with endoscopic treatment and the rate of bleeding needing hemostasis and perforation needing surgical repair were both 0.16% after colonoscopy with polypectomy. The adenoma detection rate at the first colonoscopy was 25%. Although there was no difference in the completion and complication rates based on differences in the colonoscopy experience of the endoscopist, the detection rate of adenomas and intramucosal cancers was significantly higher with more experienced endoscopists. The proportion of patients developing cancer was significantly higher with a >24 months than a ≤24 months interval.

Conclusion

High‐volume experienced endoscopists and appropriate surveillance intervals may minimize the risk of developing colorectal cancers in patients with Lynch syndrome.

Systematic review of shared decision-making in guidelines about colorectal cancer screening

INTRODUCTION

We aimed to systematically evaluate quality of shared decision-making (SDM) in colorectal cancer (CRC) screening clinical practice guidelines (CPGs) and consensus statements (CSs).

METHODS

Search for CRC screening guidances was from 2010 to November 2021 in EMBASE, Web of Science, MEDLINE, Scopus and CDSR, and the World Wide Web. Three independent reviewers and an arbitrator rated the quality of each guidance using a SDM quality assessment tool (maximum score: 31). Reviewer agreement was 0.88.

RESULTS

SDM appeared in 41/83 (49.4%) CPGs and 9/19 (47.4%) CSs. None met all the quality criteria, and 51.0% (52/102) failed to meet any quality items. Overall compliance was low (mean 1.63, IQR 0-2). Quality was better in guidances published after 2015 (mean 1, IQR 0-3 vs. mean 0.5, IQR 0-1.5; p = 0.048) and when the term SDM was specifically reported (mean 4.5, IQR 2.5-4.5 vs. mean 0.5, IQR 0-1.5; p < 0.001). CPGs underpinned by systematic reviews showed better SDM quality than consensus (mean 1, IQR 0-3 vs. mean 0, IQR 0-2, p = 0.040).

CONCLUSION

SDM quality was suboptimal and mentioned in less than half of the guidances, and recommendations were scarce. Guideline developers should incorporate evidence-based SDM recommendations in guidances to underpin the translation of evidence into practice.

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.

Feasibility of Rescue Colonoscopy Using a Short-type Enteroscope (SIF-H290S) without Overtube after Incomplete Colonoscopy: A Single-center Retrospective Pilot Study

Objectives:

Recently, a newly designed short-type single-balloon enteroscope (SBE), SIF-H290S, has been developed with a smaller outer diameter and a longer working length than conventional colonoscopes. It has passive bending and high-force transmission, making insertion easier. However, it is difficult to perform rescue colonoscopy with an SBE after incomplete colonoscopy in the same session. Therefore, this study evaluated the feasibility of consecutive rescue colonoscopy using SIF-H290S without overtube after incomplete colonoscopy.

Methods:

This was a single-center retrospective study. We included 19 rescue colonoscopies (19 patients) with SIF-H290S without overtube performed by 11 endoscopists in the SIF group and 38 rescue colonoscopies (38 patients) using a small-caliber colonoscope (PCF-PQ260L) were randomly selected for the control group from procedures performed by the same 11 endoscopists. We compared the cecal intubation rate and other outcomes, such as insertion time, between the two groups.

Results:

The median age of the patients was 72 and 69 years, with 8 and 26 males in the SIF and control groups, respectively. The median body mass index was 21.6 and 22.7 kg/m² in the SIF and control groups, respectively. There were no significant differences in the patient backgrounds between the groups, except for the reason for incomplete colonoscopy (p = 0.048). The cecal intubation rate was 78.9% (15/19 procedures) and 92.1% (35/38 procedures) in the SIF and control groups, respectively.

Conclusions:

This study revealed the real-world experience and feasibility of rescue colonoscopy using SIF-H290S, which could be a potential rescue device option after incomplete colonoscopy.

[Quality Assurance of Screening Colonoscopy in Austria and Europe]

Die Vorsorgekoloskopie als effizientes Tool zur Reduktion von Kolorektalkarzinominzidenz und -mortalität ist nur dann effektiv, wenn sie unter hohen Qualitätsstandards durchgeführt wurde. Die European Society for Gastrointestinal Endoscopy gibt hierbei Key Performance Measures, wie die Adenomentdeckungsrate, die Zökumerreichsrate und die Rate an adäquater Vorbereitungsqualität, vor, auf die beim Screening geachtet werden sollten. Das „Qualitätszertifikat Darmkrebsvorsorge“, das als Qualitätssicherungsprogramm auf freiwilliger Basis von der Österreichischen Gesellschaft für Gastroenterologie und Hepatologie gemeinsam mit dem Dachverband der österreichischen Sozialversicherungsträger und der Österreichischen Krebshilfe für Endoskopiker:innen in ganz Österreich ins Leben gerufen wurde, überprüft diese Qualitätsparameter. Es wird ein Darmkrebsscreening auf höchsten Standards angestrebt, um somit die besten Outcomes für Patient:innen zu erzielen. Auch europaweit ist das Interesse an einer qualitätsgesicherten Vorsorgekoloskopie groß: Viele Länder, wie z. B. die Niederlande, Norwegen und das Vereinigte Königreich haben Programme, um die Qualität des Screenings zu überwachen und zu verbessern.

Improved adenoma detection by a novel distal attachment device-assisted colonoscopy: a prospective randomized controlled trial

BACKGROUND AND AIMS

WingCap (A&A Medical Supply LLC, Seongnam, South Korea) is a novel distal attachment device for colonoscopy that combines a cap and an existing mucosal exposure device, such as Endocuff Vision (Arc Medical Design Ltd, Leeds, UK) and AmplifEYE (Medivators Inc, Minneapolis, Minn, USA). We aimed to investigate whether WingCap-assisted colonoscopy can improve the adenoma detection rate (ADR) and adenoma per colonoscopy (APC) and simultaneously shorten cecal intubation time compared with standard colonoscopy.

METHODS

We conducted a single-center, prospective, randomized controlled trial for outpatients aged ≥18 years undergoing colonoscopy. The primary outcome was ADR differences with the assistance of WingCap. Secondary outcomes were APC and other colonoscopy quality indicators, such as cecal intubation and withdrawal times.

RESULTS

In total, 537 patients were randomized for WingCap-assisted or standard colonoscopy. Their mean age was 59.3 years, and 48.5% were men. ADR was significantly higher in the WingCap group than in the control group (37.2% vs 26.6%, P = .012). APC was greater with WingCap than with standard colonoscopy (.72 ± 1.34 vs .45 ± 0.97, P = .008), prominently for nonpedunculated (.65 ± 1.25 vs .42 ± .95, P = .015) and diminutive (.42 ± .94 vs .20 ± .64, P = .002) adenomas. With WingCap, ADR and APC significantly increased for beginner endoscopists, whereas a modest increase was seen for experienced endoscopists. There were no differences in cecal intubation and withdrawal times between the 2 arms. No serious adverse event was associated with the use of WingCap.

CONCLUSIONS

WingCap-assisted colonoscopy was tolerable and efficacious for improving ADR and APC compared with standard colonoscopy, especially for nonpedunculated and diminutive adenomas and for beginner endoscopists. (Clinical trial registration number: KCT0005214.).

Prospective evaluation of the motorized spiral enteroscope for previous incomplete colonoscopy

Background and study aims  A significant percentage of colonoscopies remain incomplete because of failure to intubate the cecum. The motorized spiral enteroscope (MSE) technique, originally developed for deep small bowel enteroscopy, may be an effective alternative technique in cases of incomplete examination of abnormally long colons (dolichocolon). We prospectively evaluated the success rate of cecal intubation, safety and the therapeutic consequences of using MSE after incomplete conventional colonoscopy. Patients and methods  A total of 36 consecutive patients with an indication for diagnostic and/or therapeutic colonoscopy were prospectively enrolled in this multicenter trial. All patients had undergone at least one incomplete colonoscopy attributed to abnormally long colons. Patients with incomplete colonoscopy due to stenosis were excluded. Results  Twenty-two men and 14 women (median age 66 years, range 35-82) were enrolled. Median procedure time was 30 minutes (range 16-50). Cecal intubation rate was 100 % and median cecal intubation time was 10 minutes (range 4-30). Abnormalities, mostly neoplastic lesions, were detected in 23 of 36 patients, corresponding to a diagnostic yield of 64 %. All these findings were in the right side of the colon and had not been described by the antecedent incomplete coloscopy. No adverse events occurred. Conclusions  In case of a difficult and long colon, MSE is safe and effective for diagnostic and therapeutic colonoscopy. It may provide an attractive solution to accomplish completeness of previous incomplete colonoscopies in these patients.

Prevalence of adenomatous polyposis in a fecal immunochemical test-based colorectal cancer screening program and risk of advanced neoplasia during follow-up

BACKGROUND : Current guidelines recommend genetic counseling and intensive colonoscopy surveillance for patients with ≥ 10 colorectal adenomas based on scarce data. We investigated the prevalence of this condition in a fecal immunochemical test (FIT)-based colorectal (CRC) screening program, and the incidence of metachronous lesions during follow-up.

METHODS

We retrospectively included all FIT-positive participants with ≥ 10 adenomas at index colonoscopy between 2010 and 2018. Surveillance colonoscopies were collected until 2019. Patients with inherited syndromes, serrated polyposis syndrome, total colectomy, or lacking surveillance data were excluded. The cumulative incidence of CRC and advanced neoplasia were analyzed by Kaplan-Meier analysis. Risk factors for metachronous advanced neoplasia were investigated by multivariable logistic regression analysis.

RESULTS

215 of 9582 participants (2.2 %) had ≥ 10 adenomas. Germline genetic testing was performed in 92 % of patients with ≥ 20 adenomas, identifying two inherited syndromes (3.3 %). The 3-year cumulative incidence of CRC and advanced neoplasia were 1 % and 16 %, respectively. In 39 patients (24.2 %), no polyps were found on first surveillance colonoscopy. The presence of an advanced adenoma was independently associated with a higher risk of advanced neoplasia at first surveillance colonoscopy (odds ratio 3.91, 95 %CI 1.12-13.62; P = 0.03). Beyond the first surveillance colonoscopy, the risk of metachronous advanced neoplasia was lower.

CONCLUSIONS

The prevalence of ≥ 10 adenomas in a FIT-based CRC screening program was 2.2 %; a small proportion of inherited syndromes were detected, even amongst those with ≥ 20 adenomas. A low rate of post-colonoscopy CRC was observed and the risk of advanced neoplasia beyond the first surveillance colonoscopy tended to progressively decrease throughout successive follow-ups.

Colonoscopy Quality Assurance and Maintenance of Competency Among Pediatric Gastroenterology Staff Members: A Canadian Center Experience

Introduction

Colonoscopy quality indicators and maintenance of competency skills are relatively well established in the adult literature as compared to the pediatric gastroenterology. One of the suggested quality assurance measures is cecal intubation rate, which is suggested to be >90% in all colonoscopies as per American Society of Gastrointestinal Endoscopy (ASGE) guidelines. Terminal ileum (TI) intubations are essentially required for diagnostic reasons in pediatric colonoscopies as compared to the screening reasons in adults. Maintenance of competency in pediatric colonoscopies has been described in the literature but in smaller studies contrary to the adult ones. The aims of this study are to compare our center’s individual and group cecal intubation rates and compare it with the published literature, assess the group’s terminal ileal intubation rates in comparison with the published literature, assess the most common reasons for failure to intubate the cecum and/or terminal ileum, and to assess whether the presence of a trainee affects the intubation rates and the duration of the procedure.

Methods

A retrospective chart review was performed on all pediatric patients (0-18 years). Colonoscopies performed over a two-year period at our single center were included in the study. Patients scheduled for sigmoidoscopy and with altered anatomy of their colon were excluded from the study. The endoscopy and pathology reports were reviewed to ascertain whether the cecum and TI were reached. Quality of bowel preparation and any other stated reasons for incompletion were obtained. Clinical charts were reviewed to obtain indication for colonoscopy. Skin-to-skin time, which is the time from starting to the finishing of the procedure, was recorded for each procedure.

Results

A total of 391 colonoscopies were performed during the two-year study period by six gastroenterologists. The number of colonoscopies per staff ranged from 57 to 89 procedures. The overall cecal intubation rate was observed to be 98.5% (range: 95.9%-98.9%). TI intubation rate was lower at a rate of 83.1% (range: 63.3%-92.1%). The main stated reason for the inability to attain cecum/TI was technical difficulty and poor bowel prep. Daytime colonoscopies were shorter (39.5 minutes vs 50.3 minutes) compared to after-hours ones and had a higher TI intubation rate (84.5% vs 62.5%). No complications were encountered in the procedures.

Conclusion

Despite relatively low volumes, cecal intubation rates are very high, exceeding suggested standards. TI intubation rates were low, and there was noted to be a high degree of variability. However, multicentric collaborative evaluations are required over a longer period of time to establish relevant parameters for quality assurance and competency in pediatric endoscopy.

Colonoscope retraction technique and predicting adenoma detection rate: a multicenter study

BACKGROUND AND AIMS

The success of preventing colorectal cancer relies on the expertise of the colonoscopists. Studies suggest that the retraction technique is a powerful indicator of expertise in distinguishing endoscopists with various adenoma detection rates (ADRs). We aimed to develop a retraction technique score and explore the correlation between endoscopists' retraction technique and their ADRs.

METHODS

In a prospective, multicenter study, 8 colonoscopist nurses and physicians with various ADRs were included. Data from patients admitted for a colonoscopy, as part of the Danish nationwide screening program, were gathered directly from the Olympus ScopeGuide system (UPD-3; Olympus Optical, Tokyo, Japan) providing XYZ-coordinates from the coils along the length of the colonoscope. Motor skill measures were developed based on tip retraction, retraction efficiency, and retraction distance. The principal component analysis was used to study the association among the 3 measures and the historical ADR to create a combined score, the colonoscopy retraction score (CoRS).

RESULTS

Three hundred thirty-three recordings were analyzed. We demonstrated a significant and strong correlation between CoRS and ADR (.90, P < .01). Conversely, withdrawal time did not correlate significantly with ADR (.33, P = .42). In procedures without polypectomies or biopsy sampling, a significant and strong correlation was found between CoRS and ADR (.88, P < .01) and between withdrawal time and ADR (.75, P = .03).

CONCLUSIONS

This study presents a novel, real-time computerized and unbiased assessment tool for colonoscopy withdrawal. CoRS strongly correlated with ADR with and without therapeutic interventions during withdrawal and could be used to ensure quality instead of minimal withdrawal time. (Clinical trial registration number: NCT03587935.).

CC-CLEAR (Colon Capsule Cleansing Assessment and Report): the novel scale to evaluate the clinical impact of bowel preparation in capsule colonoscopy - a multicentric validation study

BACKGROUND

Colon Capsule Cleansing Assessment and Report (CC-CLEAR) is a novel quantitative bowel preparation scale for colon capsule.

AIM

The aim of this study is to validate the association between CC-CLEAR's classification and major CC outcomes: lesion detection rate, surveillance recommendations and post-CC endoscopic treatment.

METHODS

Multicentric cohort of consecutive CCs. An expert's panel decided post-CC recommendations. Data included CC-CLEAR and Leighton-REX scales. Major CC outcomes were associated with the different cleansing grades.

RESULTS

From 168 CC's included, findings were reported in 123 (73.2%), 67 (54.4%) of those being colorectal polyps. CC-CLEAR influenced CC's lesion detection (OR 1.25 95% IC [1.07-1.46], p-value .004) and polyp detection rate (OR 1.22 95% IC [1.04-1.43], p-value.014). Thirty-two (19%) post-CC colonoscopies were recommended, including 22 (68.75%) with at least one polypectomy. CC-CLEAR was associated with post-CC colonoscopy treatment (OR 1.40 95% IC [1.07-1.84], p-value .015). Regarding surveillance, CC-CLEAR influenced the decision for immediate CC repetition (OR 0.21 95% IC [0.12-0.36], p-value < .001) and the recommendation for CC in 3-5 years' time (OR 1.47 95% IC [1.50-1.86], p-value < .002). The Leighton-Rex scale was not correlated with major CC outcomes.

CONCLUSION

CC-CLEAR impacts major CC outcomes: lesion detection, surveillance recommendations and post-CC endoscopic treatment.

Factors Associated with Polyp Detection Rate in European Colonoscopy Practice: Findings of The European Colonoscopy Quality Investigation (ECQI) Group

Background: The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analysed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the polyp detection rate (PDR) target. We also investigated factors associated with PDR, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at PDR according to European Society of Gastrointestinal Endoscopy (ESGE) definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In our sample there were 3365 screening and diagnostic procedures performed in those over 50 years. The PDR was 40.5%, which is comparable with the ESGE minimum standard of 40%. The variables found to be associated with PDR were in descending order: use of high-definition equipment, body mass index (BMI), patient gender, age group, and the reason for the procedure. Use of HD equipment was associated with a significant increase in the reporting of flat lesions (14.3% vs. 5.7%, p < 0.0001) and protruded lesions (34.7% vs. 25.4%, p < 0.0001). Conclusions: On average, the sample of European practice captured by the ECQI survey meets the minimum PDR standard set by the ESGE. Our findings support the ESGE recommendation for routine use of HD colonoscopy.

Pediatric Endoscopy Quality Improvement Network Quality Standards and Indicators for Pediatric Endoscopic Procedures: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality pediatric gastrointestinal procedures are performed when clinically indicated and defined by their successful performance by skilled providers in a safe, comfortable, child-oriented, and expeditious manner. The process of pediatric endoscopy begins when a plan to perform the procedure is first made and ends when all appropriate patient follow-up has occurred. Procedure-related standards and indicators developed to date for endoscopy in adults emphasize cancer screening and are thus unsuitable for pediatric medicine.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used the methodological strategy of the Appraisal of Guidelines for REsearch and Evaluation (AGREE) II instrument to develop standards and indicators relevant for assessing the quality of endoscopic procedures. Consensus was sought via an iterative online Delphi process and finalized at an in-person conference. The quality of evidence and strength of recommendations were rated according to the GRADE (Grading of Recommendation Assessment, Development, and Evaluation) approach.

RESULTS

The PEnQuIN working group achieved consensus on 14 standards for pediatric endoscopic procedures, as well as 30 indicators that can be used to identify high-quality procedures. These were subcategorized into three subdomains: Preprocedural (3 standards, 7 indicators), Intraprocedural (8 standards, 18 indicators), and Postprocedural (3 standards, 5 indicators). A minimum target for the key indicator, "rate of adequate bowel preparation," was set at ≥80%.

DISCUSSION

It is recommended that all facilities and individual providers performing pediatric endoscopy worldwide initiate and engage with the procedure-related standards and indicators developed by PEnQuIN to identify gaps in quality and drive improvement.

Colonoscopy-Related Adverse Events in Patients With Abnormal Stool-Based Tests: A Systematic Review of Literature and Meta-analysis of Outcomes

INTRODUCTION

Colorectal cancer (CRC) screening programs based on the fecal immunochemical test (FIT) and guaiac-based fecal occult blood (gFOBT) are associated with a substantial reduction in CRC incidence and mortality. We conducted a systematic review and comprehensive meta-analysis to evaluate colonoscopy-related adverse events in individuals with a positive FIT or gFOBT.

METHODS

A systematic and detailed search was run in January 2021, with the assistance of a medical librarian for studies reporting on colonoscopy-related adverse events as part of organized CRC screening programs. Meta-analysis was performed using the random-effects model, and the results were expressed for pooled proportions along with relevant 95% confidence intervals (CIs).

RESULTS

A total of 771,730 colonoscopies were performed in patients undergoing CRC screening using either gFOBT or FIT across 31 studies. The overall pooled incidence of severe adverse events in the entire patient cohort was 0.42% (CI 0.20-0.64); I2 = 38.76%. In patients with abnormal gFOBT, the incidence was 0.2% (CI 0.1-0.3); I2 = 24.6%, and in patients with a positive FIT, it was 0.4% (CI 0.2-0.7); I2 = 48.89%. The overall pooled incidence of perforation, bleeding, and death was 0.13% (CI 0.09-0.21); I2 = 22.84%, 0.3% (CI 0.2-0.4); I2 = 35.58%, and 0.01% (CI 0.00-0.01); I2 = 33.21%, respectively.

DISCUSSION

Our analysis shows that in colonoscopies performed after abnormal stool-based testing, the overall risk of severe adverse events, perforation, bleeding, and death is minimal.

Pediatric Endoscopy Quality Improvement Network Pediatric Endoscopy Reporting Elements: A Joint NASPGHAN/ESPGHAN Guideline

INTRODUCTION

High-quality procedure reports are a cornerstone of high-quality pediatric endoscopy as they ensure the clear communication of procedural events and outcomes, guide patient care and facilitate continuous quality improvement. The aim of this document is to outline standardized reporting elements that achieved international consensus as requirements for high-quality pediatric endoscopy procedure reports.

METHODS

With support from the North American and European Societies of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN and ESPGHAN), an international working group of the Pediatric Endoscopy Quality Improvement Network (PEnQuIN) used Delphi methodology to identify key elements that should be found in all pediatric endoscopy reports. Item reduction was attained through iterative rounds of anonymized online voting using a 6-point scale. Responses were analyzed after each round and items were excluded from subsequent rounds if ≤50% of panelists rated them as 5 ("agree moderately") or 6 ("agree strongly"). Reporting elements that ≥70% of panelists rated as "agree moderately" or "agree strongly" were considered to have achieved consensus.

RESULTS

Twenty-six PEnQuIN group members from 25 centers internationally rated 63 potential reporting elements that were generated from a systematic literature review and the Delphi panelists. The response rates were 100% for all three survey rounds. Thirty reporting elements reached consensus as essential for inclusion within a pediatric endoscopy report.

DISCUSSION

It is recommended that the PEnQuIN Reporting Elements for pediatric endoscopy be universally employed across all endoscopists, procedures and facilities as a foundational means of ensuring high-quality endoscopy services, while facilitating quality improvement activities in pediatric endoscopy.

Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group

The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy. Conclusions: On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.

Impact of 9-Minute Withdrawal Time on the Adenoma Detection Rate: A Multicenter Randomized Controlled Trial

BACKGROUND & AIMS

Although current quality indicators of colonoscopy recommend 6 minutes as the minimum standard for withdrawal time (WT), the impact of a WT longer than 6 minutes on neoplasia detection is unclear.

METHODS

A multicenter randomized controlled trial involving 1027 patients was conducted from January 2018 to July 2019. Participants were randomly divided into a 9-minute (n = 514) and 6-minute (n = 513) WT group, and a timer was used to adjust the withdrawal speed. The primary outcome was the adenoma detection rate (ADR).

RESULTS

Intention-to-treat analysis showed a significantly higher ADR in the 9-minute versus 6-minute WT group (36.6% vs. 27.1%, P = .001). Prolonging WT from 6 to 9 minutes significantly increased ADR of the proximal colon (21.4% vs. 11.9%, P < .001) as well as of the less experienced colonoscopists (36.8% vs. 23.5%, P = .001). Improvements were also observed in the polyp detection rate (58.0% vs. 47.8%, P < .001), and mean number of polyps and adenomas detected per colonoscopy (1.1 vs. 0.9, P = .002; 0.5 vs. 0.4, P = .008, respectively). The higher ADRs in 9-minute WT were also confirmed by the per-protocol (PP) analysis and subgroup analyses, with an increased rate of sessile serrated lesion detection in the 9-minute WT by PP analysis (4.0% vs. 1.3%, P = .04). Multivariate logistic regression demonstrated that the 9-minute WT was independently associated with increased ADR (P = .005).

CONCLUSIONS

Prolonging WT from 6 to 9 minutes significantly improved ADR, especially in the proximal colon and for less experienced colonoscopists. A 9-minute WT benchmark should be considered as one of the quality indicators of colonoscopy. ClinicalTrials.gov (identifier, NCT03399045).

A colonoscopy quality improvement intervention in an endoscopy unit

Many studies identified colonoscopy quality indicators in order to improve performance and safety. We conducted a colonoscopy improvement study. Our study was designed according to a Plan-Do-Study-Act cycle: first recording of our quality indicators and identification of shortcomings, second identification of improvement targets and implementation of new procedures, third second recording of quality indicators, fourth validation of procedures and identification of new goals. Quality indicators derived from European and French guidelines were recorded before and after our improvement actions. We were mainly interested in the quality indicators of the colonic preparation, the description of the diagnosed lesions and on the examination reports. The data of 134 patients prospectively included in January-February 2017 were compared to 133 patients included in May-June 2019, after implementation of improvement procedures, in the digestive endoscopy unit of the university hospital of Dijon, France. Our intervention, and in particular the implementation of new standardized forms, improved preparation quality: Boston Bowel Preparation Scale scores increased significantly from 7.8 to 8.2. Cecal intubation rate increased by 6%, and more adenomas were diagnosed and removed (+3.3%). Adenoma detection rate increased significantly from 26 to 42%. The completion of withdrawal time measure improved from 6.7 to 100%. Our study led to the rapid implementation of corrective actions and improved quality in our unit and in our personal practice. This quality improvement strategy could be easily implemented in every digestive endoscopy unit.

Disparate age and sex distribution of sessile serrated lesions and conventional adenomas in an outpatient colonoscopy population-implications for colorectal cancer screening?

PURPOSE

Colorectal cancer (CRC) is increasingly diagnosed in individuals aged < 50 years, resulting in advocacy of screening from age 45 years. Despite existing knowledge associating CRC with conventional adenomas, the significance of sessile serrated lesions (SSLs) on the burden of CRC is less detailed. We aimed to provide contemporary estimates for SSL prevalence and examine patient and procedure factors associated with SSL detection.

METHODS

Retrospective observational study examining associations between SSL and conventional adenoma detection, polyp histopathology, patient, and procedure characteristics in an outpatient colonoscopy unit over 12 months.

RESULTS

From 2097 colonoscopies, SSL detection was 13.8% overall and 12.5% in patients < 50 years. SSLs were mostly proximal in location (64%), and SSL detection was significantly higher in females compared with males (16.2% vs. 11.7%, p = 0.003), particularly in those < 50 years (16.8% vs. 8.6%, p < 0.001). In multivariable analysis, SSL detection was associated with female sex (adjusted odds ratio [aOR] 1.48, 95% confidence interval [CI] 1.15-1.91), synchronous conventional adenoma detection (aOR 1.36, 95% CI 1.04-1.78) and BMI ≥ 25 kg/m² (aOR 1.34, 95% CI 1.02-1.77). Conventional adenoma detection was 33.6% and associated with age ≥ 50 years (aOR 3.57, 95% CI 2.84-4.47) and synchronous SSL detection (aOR 1.36, 95% CI 1.03-1.79).

CONCLUSIONS

We observed age and sex disparities in polyp types and prevalence in this outpatient colonoscopy population. SSLs were most prevalent in females aged < 50 years, suggesting a potential increased susceptibility of young females to SSLs and CRC. Our findings may have implications for the design of CRC screening programs.

Low-volume regimen without additional liquids or adjunctive agents versus standard bowel preparation in non-constipated patients: a propensity score matching analysis

AIMS

Split-dose, 4-L polyethylene glycol (PEG, HSD) is currently the first-line choice for unselected or difficult colon preparations. Almost all low-volume bowel preparations (BPs) include a large volume of additional liquid and adjunctive agents to improve cleansing efficiency. However, neither HSD nor additional liquids or adjunctive agents of low-volume regimens may be necessary for low-risk patients. The aim of this study was to compare the cleansing efficiency between split-dose, low-volume (2-L) PEG without additional liquids or adjunctive agents (LSD) and HSD in non-constipated patients.

METHODS

A retrospective study was performed from January 2013 to December 2015. Consecutive non-constipated patients who received LSD or HSD BPs were enrolled into LSD and HSD groups. Propensity score matching (PSM) was used to reduce selection bias and potential confounders. The primary outcome was bowel cleansing quality, as evaluated by the Boston Bowel Preparation Scale (BBPS). The adenoma detection rate (ADR), the most important secondary outcome, was also recorded. Follow-up was conducted in 2016.

RESULTS

After excluding those participants who meet exclusion criteria or lost follow-up, 1656 non-constipated patients underwent LSD (n = 999) or HSD (n = 657) BP. Most patients had a BBPS score ≥6 (LSD vs. HSD, 93.6 vs. 92.9%, p = .166). The segmental BBPS scores were ≥2 in 92 and 91.9% in the LSD and HSD groups, respectively. The overall ADR was 16.7% in the LSD group and 17.5% in the HSD group (p = .334).

CONCLUSION

For non-constipated patients, LSD is not inferior to HSD in cleansing efficiency, while more willing to repeat the same BP.

A comparison of 9-min colonoscopy withdrawal time and 6-min colonoscopy withdrawal time: A systematic review and meta-analysis

INTRODUCTION

The optimal colonoscopy withdrawal time is still a controversial topic. While several studies demonstrate that longer withdrawal time improves adenoma detection rate, others have contradicted these findings.

METHODS

Three independent reviewers performed a comprehensive review of all original articles published from inception to January 2021 and included studies reporting comparison of the two cohorts-(i) ≥ 6 but less than 9 min of colonoscopy withdrawal time (CWT) and (ii) ≥ 9 min of CWT. The outcome measures were the following: (i) adenoma detection rate (ADR), (ii) advanced ADR, and (iii) sessile serrated adenoma detection rate (SDR). The meta-analysis was performed, and the statistics were two-tailed.

RESULTS

A total of seven studies met the inclusion criteria after a thorough search of the literature was completed. The analysis revealed that ≥ 9 min of CWT had significantly higher odds of adenoma detection as compared with 6-9 min of CWT (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.30-1.82; I²  = 93.7). Additionally, a significantly higher odds of sessile serrated adenoma detection (OR 1.68, 95% CI 1.28-2.22; I²  = 0) and a trend towards higher odds of advanced adenoma detection (OR 1.38, 95% CI 0.98-1.95, I²  = 90) were seen with CWT of at least 9 min when compared with 6-9 min of CWT.

CONCLUSION

This systematic review and meta-analysis analysis provides further evidence that at least 9 min of CWT cohort had significantly higher ADR and SDR as compared with the at least 6 min but less than 9 min of cohort.

Sodium picosulfate/magnesium citrate versus 4L split-dose polyethylene glycol for bowel cleansing prior to colonoscopy in high fibre diet African patients

Introduction

an adequate bowel preparation is essential for good mucosal inspection during colonoscopy. This study aims to compare the efficacy of two validated oral lavage solutions for colonoscopy preparation in African patients.

Methods

a prospective observational study of patients undergoing colonoscopy in a referral endoscopy facility in Port Harcourt, Nigeria, using sodium picosulfate magnesium citrate (SPMC) and 4L split-dose polyethylene glycol (PEG). Variables collated were sociodemographic, primary indication, comorbidities, Aronchick bowel preparation scale, polyp/adenoma detection, caecal intubation and outcome. Statistical analysis was performed using IBM SPSS version 20.

Results

one hundred and twenty-four patients received PEG prior to colonoscopy and SPMC in 175 patients. The age range was from 22 to 92 years; mean age of 53.8 ± 14.2 years for PEG group and 55.3 ± 13.2 years for SPMC group (p=0.361). There were 215 males and 84 females. An excellent/good bowel preparation scale was recorded in 77 (62%) PEG group and 130 (74.3%) for SPMC group (p=0.592). PEG was predominantly used in the early years of endoscopists practice with the odds ratio (OR) of no polyp detection in the PEG vs SPMC groups as 1.64 (confidence interval CI 1.06-2.55) versus 0.76 (CI 0.62-0.92), respectively (p=0.016). For no adenoma detection, OR was 4.18 (CI 1.12-15.60) versus OR 0.63 (CI 0.52-0.75), respectively (p=0.012).

Conclusion

there is similar efficacy profile using either split volume PEG or SPMC prior to colonoscopy in these African patients. Polyp and adenoma detection rates are highly dependent on the expertise of the endoscopist.