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

Prevalence and predictive factors of colorectal sessile serrated lesions in younger individuals

BACKGROUND

Sessile serrated lesions (SSLs) are obscured lesions predominantly in the right-sided colon and associated with interval colorectal cancer; however, their prevalence and risk factors among younger individuals remain unclear.

METHODS

This retrospective study enrolled individuals who underwent index colonoscopy. The primary outcome was the SSL prevalence in the younger (<50 years) and older (≥50 years) age groups, while the secondary outcomes included clinically significant serrated polyps (CSSPs). Multivariable logistic regression was employed to identify predictors.

RESULTS

Of the 9854 eligible individuals, 4712 (47.8%) were categorized into the younger age group. Individuals in the younger age group exhibited lower prevalences of adenomas (22.6% vs. 46.2%; P<0.001) and right-sided adenomas (11.2% vs. 27.2%; P<0.001) compared with their older counterparts. However, both groups exhibited a similar prevalence of SSLs (7.2% vs. 6.5%; P=0.16) and CSSPs (10.3% vs. 10.3%;P=0.96). Multivariable analysis revealed that age 40-49 years (odds ratio [OR] 1.81, 95%CI 1.01-3.23), longer withdrawal time (OR 1.17, 95%CI 1.14-1.20, per minute increment), and endoscopist performance (OR 3.35, 95%CI 2.44-4.58) were independent predictors of SSL detection in the younger age group. No significant correlation was observed between adenoma and SSL detection rates among endoscopists.

CONCLUSION

SSLs are not uncommon among younger individuals. Moreover, diligent effort and expertise are of paramount importance in SSL detection. Future studies should explore the clinical significance of SSLs in individuals of younger age.

Sessile serrated lesion prevalence and factors associated with their detection: a post-hoc analysis of a multinational randomized controlled trial from Asia

BACKGROUND

Sessile serrated lesions (SSLs) are associated with an increased risk of colorectal cancer. Data on the prevalence of SSLs in Asia are limited. We performed this study to estimate the prevalence of SSLs in Asia and to explore endoscopic factors that are associated with SSL detection.

METHODS

This is a post-hoc analysis of a multicenter randomized controlled trial from four Asian countries/regions that compared adenoma detection rates using linked-color imaging (LCI) and white-light imaging. Colonoscopies were performed in an average-risk population for screening, diagnostic examination, or polyp surveillance. Patients with SSLs were compared against those without SSLs to evaluate for possible predictors of SSL detection using Firth's logistic regression.

RESULTS

2898 participants (mean age 64.5 years) were included in the analysis. The estimated prevalence of SSLs was 4.0% (95%CI 3.4%-4.8%), with no sex or age group differences. On multivariable analysis, use of LCI (adjusted odds ratio [aOR] 1.63, 95%CI 1.10-2.41), experienced endoscopists (aOR 1.94, 95%CI 1.25-3.00), use of transparent cap (aOR 1.75, 95%CI 1.09-2.81), and longer withdrawal time (aOR 1.06, 95%CI 1.03-1.10) were independently associated with SSL detection. Synchronous adenoma detection (aOR 1.89, 95%CI 1.20-2.99) was also predictive of SSL detection.

CONCLUSION

The prevalence of SSLs in Asia is 4.0%. Use of LCI or a transparent cap, greater endoscopist experience, and longer withdrawal time were all associated with increased SSL detection.

Efficacy of artificial intelligence in reducing miss rates of GI adenomas, polyps, and sessile serrated lesions: a meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

The aim of this study was to determine if utilization of artificial intelligence (AI) in the course of endoscopic procedures can significantly diminish both the adenoma miss rate (AMR) and the polyp miss rate (PMR) compared with standard endoscopy.

METHODS

We performed an extensive search of various databases, encompassing PubMed, Embase, Cochrane Library, Web of Science, and Scopus, until June 2023. The search terms used were artificial intelligence, machine learning, deep learning, transfer machine learning, computer-assisted diagnosis, convolutional neural networks, gastrointestinal (GI) endoscopy, endoscopic image analysis, polyp, adenoma, and neoplasms. The main study aim was to explore the impact of AI on the AMR, PMR, and sessile serrated lesion miss rate.

RESULTS

A total of 7 randomized controlled trials were included in this meta-analysis. Pooled AMR was markedly lower in the AI group versus the non-AI group (pooled relative risk [RR], .46; 95% confidence interval [CI], .36-.59; P < .001). PMR was also reduced in the AI group in contrast with the non-AI control (pooled RR, .43; 95% CI, .27-.69; P < .001). The results showed that AI decreased the miss rate of sessile serrated lesions (pooled RR, .43; 95% CI, .20 to .92; P < .05) and diminutive adenomas (pooled RR, .49; 95% CI, .26-.93) during endoscopy, but no significant effect was observed for advanced adenomas (pooled RR, .48; 95% CI, .17-1.37; P = .17). The average number of polyps (Hedges' g = -.486; 95% CI, -.697 to -.274; P = .000) and adenomas (Hedges' g = -.312; 95% CI, -.551 to -.074; P = .01) detected during the second procedure also favored AI. However, AI implementation did not lead to a prolonged withdrawal time (P > .05).

CONCLUSIONS

This meta-analysis suggests that AI technology leads to significant reduction of miss rates for GI adenomas, polyps, and sessile serrated lesions during endoscopic surveillance. These results underscore the potential of AI to improve the accuracy and efficiency of GI endoscopic procedures.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

Thai Clinical Trials Registry TCTR20220507004.

Melanosis coli: a contrast effect or an oncogenic effect? A large-scale retrospective cohort study

BACKGROUND

Melanosis coli is characterized by brown mucosa with pigmentation. Studies have showed an increased adenoma detection rate in melanosis patients, whether it is caused by a contrast effect or an oncogenic effect is still controversial. The detection of serrated polys in melanosis patients remains unknown.

AIMS

The study aimed to clarify the correlation of adenoma detection rate with melanosis coli and discuss outcomes in less-experienced endoscopists. Serrated polyp detection rate was also been investigated.

METHODS

A total of 2150 patients and 39,630 controls were enrolled. A propensity score matching method was used to balance covariates between the two groups. The detection of polyps, adenomas, serrated polyps, and their features was analyzed.

RESULTS

The polyp detection rate (44.65% vs 41.01%, P = 0.005) and adenoma detection rate (30.34% vs 23.92%, P < 0.001) were significantly higher, and the serrated polyp detection rate (0.93% vs 1.58%, P = 0.033) was significantly lower in melanosis coli. The percentage of low-risk adenomas (44.60% vs 39.16%, P < 0.001) and polyps with 6 to 10 mm in size (20.16% vs 16.21%, P < 0.001) were higher in melanosis coli. The detection of large serrated polyps was lower (0.11% vs 0.41%, P = 0.026) in melanosis coli.

CONCLUSION

Melanosis coli correlates with an increased adenoma detection rate. The detection of large serrated polyps was lower in melanosis patients. Melanosis coli may not be considered a precancerous lesion.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

Clinical Trials NCT04651062.

Measuring and Improving Quality of Colonoscopy for Colorectal Cancer Screening

Colorectal cancer (CRC) is largely preventable, yet it remains a major public health issue as it is the third most common and deadly malignancy in the United States. While there are many ways to screen for CRC, colonoscopy remains the gold standard as it is the only test that is both cancer-detecting and cancer-preventing through removal of precancerous polyps. Through identifying and removing neoplastic lesions, colonoscopy reduces CRC incidence by 31%-91% and CRC mortality by 65%-88%. However, colonoscopy is not an infallible test-there is a chance for missed lesions during the exam and there is substantial variation in outcomes among endoscopists. To enhance the quality of colonoscopic exams, and ultimately to improve CRC outcomes, quality indicators have been developed for measuring endoscopists' performance. In this review, we describe the colonoscopic quality indicators and benchmarks recommended by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Task Force on Quality in Endoscopy for screening colonoscopies in average-risk individuals. Measuring and monitoring endoscopists' performance on these measures are critical first steps in striving toward conducting high quality exams. We also review the evidence for interventions that aim to improve critical measures including adenoma detection rate, withdrawal time, cecal intubation, and bowel preparation quality. Finally, we provide a preview of the forthcoming Advancing Care for Appropriate Colon Health Merit-Based Incentive Payment System Value Pathway by the Centers for Medicare & Medicaid Services and its potential impact on clinical practice.