Colonoscopy procedural volume increases adenoma and polyp detection rates in gastroenterologytrainees

Overall Polyp Detection Rate as a Surrogate Measure for Screening Efficacy Independent of Histopathology: Evidence from National Endoscopy Database

Adenoma detection rate (ADR) is challenging to measure, given its dependency on pathology reporting. Polyp detection rate (PDR) (percentage of screening colonoscopies detecting a polyp) is a proposed alternative to overcome this issue. Overall PDR from all colonoscopies is a relatively novel concept, with no large-scale studies comparing overall PDR with screening-only PDR. The aim of the study was to compare PDR from screening, surveillance, and diagnostic indications with overall PDR and evaluate any correlation between individual endoscopist PDR by indication to determine if overall PDR can be a valuable surrogate for screening PDR. Our study analyzed a prospectively collected national endoscopy database maintained by the National Institute of Health from 2009 to 2014. Out of 354,505 colonoscopies performed between 2009-2014, 298,920 (n = 110,794 average-risk screening, n = 83,556 average-risk surveillance, n = 104,770 diagnostic) met inclusion criteria. The median screening PDR was 25.45 (IQR 13.15-39.60), comparable with the median overall PDR of 24.01 (IQR 11.46-35.86, p = 0.21). Median surveillance PDR was higher at 33.73 (IQR 16.92-47.01), and median diagnostic PDR was lower at 19.35 (IQR 9.66-29.17), compared with median overall PDR 24.01 (IQR 11.46-35.86; p < 0.01). The overall PDR showed excellent concordance with screening, surveillance, and diagnostic PDR (r > 0.85, p < 0.01, 2-tailed). The overall PDR is a reliable and pragmatic surrogate for screening PDR and can be measured in real time, irrespective of colonoscopy indication.

Sessile serrated lesion detection rates continue to increase: 2008-2020

Background and study aims  We assessed sessile serrated lesion detection rate (SSLDR) at a large academic medical center from 2008 to 2020 and modeled a local, aspirational target SSLDR. We also assessed SSLDRs among all gastroenterology fellows to better understand the relationship between SSLDRs and total colonoscopies performed. Patients and methods  SSL-positive pathology results were flagged from a dataset composed of all screening colonoscopies for average-risk patients from 2008 to 2020. Unadjusted SSLDRs were calculated for individual endoscopists by year. A mixed effects logistic regression was used to estimate the log odds of SSL detection, with one model estimating division-wide predictors of SSL detection and a second model focused exclusively on colonoscopies performed by fellows. Model-adjusted SSLDRs were estimated for all 13 years and across both categories of all endoscopists and fellows only. Results  Adjusted SSLDRs showed a consistent improvement in SSLDR from a low of 0.37 % (95 % confidence interval [CI]: 0.10-0.63) in 2008 to a high of 7.94 % (95 % CI: 6.34-9.54) in 2020. Among fellows only, the odds of SSL detection were significantly lower during their first year compared to their second year (OR: 0.80, 95 % CI: 0.66-0.98) but not significantly higher in their third year compared to their second year (OR: 1.09, 95 % CI: 0.85-1.4). Conclusions  SSLDR increased steadily and significantly throughout our study period but variance among endoscopists persists. The peak SSLDR from 2020 of 7.94 % should serve as the local aspirational target for this division's attendings and fellows but should be continuously reevaluated.

Adoption of Optimal Small (6-9 mm) Colorectal Polyp Resection Technique Over Time

BACKGROUND

Cold snare polypectomy (CSP) is the preferred resection technique for small (6-9 mm) polyps due to lower rate of incomplete resection compared to cold forceps polypectomy (CFP) and improved safety profile over hot snare polypectomy (HSP).

AIMS

To describe resection techniques for small (6-9 mm) polyps and determine factors associated with sub-optimal technique.

METHODS

This was retrospective cohort study of colonoscopies performed by gastroenterological and surgical endoscopists from 2012 to 2019 where at least one 6-9 mm polyp was removed. Patient, provider, and procedure characteristics were collected. Univariate and multivariate regression analyses were performed to determine factors associated with sub-optimal technique.

RESULTS

In total, 773 colonoscopies where 1,360 6-9 mm polyps removed by 21 endoscopists were included. CSP was used for 1,122 (82.5%), CFP for 61 (4.5%), and HSP for 177 (13.0%). Surgeon specialty was associated with CFP use (aOR 7.81; 95% CI 3.02-20.16). Polyp location in left colon (aOR 1.65; 95% CI 1.17-2.33) and pedunculated morphology (aOR 12.76; 95% CI 7.24-22.50) were associated with HSP. There was a significant increase in overall CSP use from 30.4% in 2012 to 96.8% in 2019.

CONCLUSIONS

82.5% of all 6-9 mm polyps removed from 2012 to 2019 were removed using a cold snare with significant increase in CSP from 2012 to 2019. Differences in how optimal technique was adopted over time based on specialty highlight the need for standardized practice guidelines and quality monitoring.

Impact of looping on premalignant polyp detection during colonoscopy

BACKGROUND

The presence of premalignant polyps on colonoscopy is an indicator of metachronous colorectal cancer. Looping during colonoscopy is associated with old age, female sex, and colonoscopy insertion time. However, the clinical significance of looping is not fully understood. We aimed to clarify the effect of looping on colorectal premalignant polyp detection.

AIM

To assess the effects of looping on premalignant polyp detection using logistic regression analyses.

METHODS

We retrospectively investigated patients who underwent colonoscopy at Toyoshima Endoscopy Clinic between May, 2017 and October, 2020. From the clinic’s endoscopy database, we extracted data on patient age, sex, endoscopist-assessed looping, colonoscopy duration, endoscopist experience, detection rate, and number of premalignant polyps.

RESULTS

We assessed 12259 patients (mean age, 53.6 years; men, 50.7%). Looping occurred in 54.3% of the patients. Mild and severe looping were noted in 4399 and 2253 patients, respectively. The detection rates of adenomas, advanced adenomas, high-risk adenomas, clinically significant serrated polyps (CSSPs), and sessile serrated lesions (SSLs) were 44.7%, 2.0%, 9.9%, 8.9% and 3.5%, respectively. The mean numbers of adenomas and SSLs were 0.82 and 0.04, respectively. The detection rates of adenomas, high-risk adenomas, and CSSPs increased with looping severity (all P < 0.001). The number of adenomas increased with looping severity (P < 0.001). Multivariate analyses found that detection of adenomas, high-risk adenomas, and CSSPs was associated with severe looping (P < 0.001, P < 0.001, and P = 0.007, respectively) regardless of age, sex, time required for colonoscope insertion and withdrawal, and endoscopist experience.

CONCLUSION

Looping severity was independently associated with high detection rates of premalignant polyps. Therefore, looping may predict the risk of metachronous colorectal cancer. Endoscopists should carefully examine the colorectum of patients with looping.

Post-polypectomy follow-up recommendations by practicing academic gastroenterologists-does number of years in practice matter?

AIM

Colorectal cancer (CRC) is the third most deadly and fourth most common cancer worldwide. Early detection, resection, and appropriate surveillance of precursor polyps result in better outcomes. Colonoscopy is a safe, accurate, and effective tool for surveillance and follow-up of premalignant polyps. Recommended surveillance intervals are based on polyp, procedural, and patient-related factors. The United States Multi-Society Task Force (MSTF) on CRC publishes guidelines with periodic updates on surveillance. We sought to evaluate adherence to post-polypectomy surveillance guidelines by academic gastroenterologists at a high-volume center.

METHODS

One-year retrospective study evaluating compliance with post-polypectomy recommendations after average risk adult screening colonoscopies. Data was collected on number and size of polyps, quality of bowel prep, initial follow-up recommendations, polyp pathology, and follow-up recommendations. Correlation with the 2012 MSTF guidelines was also evaluated. Endoscopist experience was categorized as greater or less than 10 years of practice experience. Binomial regression was used to model the association between the providers' years of experience (<10 vs. >10) and the likelihood of agreement between initial assessment and post-pathology assessment.

RESULTS

There was a greater than 85% adherence to post-polypectomy surveillance guidelines, independent of endoscopist experience.

CONCLUSION

There is a high level of adherence to post-polypectomy guidelines by practicing academic gastroenterologists independent of post-fellowship clinical experience.

Artificial intelligence and colonoscopy experience: lessons from two randomised trials

BACKGROUND AND AIMS

Artificial intelligence has been shown to increase adenoma detection rate (ADR) as the main surrogate outcome parameter of colonoscopy quality. To which extent this effect may be related to physician experience is not known. We performed a randomised trial with colonoscopists in their qualification period (AID-2) and compared these data with a previously published randomised trial in expert endoscopists (AID-1).

METHODS

In this prospective, randomised controlled non-inferiority trial (AID-2), 10 non-expert endoscopists (<2000 colonoscopies) performed screening/surveillance/diagnostic colonoscopies in consecutive 40-80 year-old subjects using high-definition colonoscopy with or without a real-time deep-learning computer-aided detection (CADe) (GI Genius, Medtronic). The primary outcome was ADR in both groups with histology of resected lesions as reference. In a post-hoc analysis, data from this randomised controlled trial (RCT) were compared with data from the previous AID-1 RCT involving six experienced endoscopists in an otherwise similar setting.

RESULTS

In 660 patients (62.3±10 years; men/women: 330/330) with equal distribution of study parameters, overall ADR was higher in the CADe than in the control group (53.3% vs 44.5%; relative risk (RR): 1.22; 95% CI: 1.04 to 1.40; p<0.01 for non-inferiority and p=0.02 for superiority). Similar increases were seen in adenoma numbers per colonoscopy and in small and distal lesions. No differences were observed with regards to detection of non-neoplastic lesions. When pooling these data with those from the AID-1 study, use of CADe (RR 1.29; 95% CI: 1.16 to 1.42) and colonoscopy indication, but not the level of examiner experience (RR 1.02; 95% CI: 0.89 to 1.16) were associated with ADR differences in a multivariate analysis.

CONCLUSIONS

In less experienced examiners, CADe assistance during colonoscopy increased ADR and a number of related polyp parameters as compared with the control group. Experience appears to play a minor role as determining factor for ADR.

TRIAL REGISTRATION NUMBER

NCT:04260321.

Impact of COVID-19 on gastroenterology fellowship training: a multicenter analysis of endoscopy volumes

Background and study aims  The COVID-19 pandemic has had a profound impact on gastroenterology training programs. We aimed to objectively evaluate procedural training volume and impact of COVID-19 on gastroenterology fellowship programs in the United States. Methods  This was a retrospective, multicenter study. Procedure volume data on upper and lower endoscopies performed by gastroenterology fellows was abstracted directly from the electronic medical record. The study period was stratified into 2 time periods: Study Period 1, SP1 (03/15/2020 to 06/30/2020) and Study Period 2, SP2 (07/01/2020 to 12/15/2020). Procedure volumes during SP1 and SP2 were compared to Historic Period 1 (HP1) (03/15/2019 to 06/30/2019) and Historic Period 2 (HP2) (07/01/2019 to 12/15/2019) as historical reference. Results  Data from 23 gastroenterology fellowship programs (total procedures = 127,958) with a median of 284 fellows (range 273-289; representing 17.8 % of all trainees in the United States) were collected. Compared to HP1, fellows performed 53.6 % less procedures in SP1 (total volume: 28,808 vs 13,378; mean 105.52 ± 71.94 vs 47.61 ± 41.43 per fellow; P  < 0.0001). This reduction was significant across all three training years and for both lower and upper endoscopies ( P  < 0.0001). However, the reduction in volume was more pronounced for lower endoscopy compared to upper endoscopy [59.03 % (95 % CI: 58.2-59.86) vs 48.75 % (95 % CI: 47.96-49.54); P  < 0.0001]. The procedure volume in SP2 returned to near baseline of HP2 (total volume: 42,497 vs 43,275; mean 147.05 ± 96.36 vs 150.78 ± 99.67; P  = 0.65). Conclusions  Although there was a significant reduction in fellows' endoscopy volume in the initial stages of the pandemic, adaptive mechanisms have resulted in a return of procedure volume to near baseline without ongoing impact on endoscopy training.

Comprehensive evaluation of the learning curve to achieve satisfactory adenoma detection rate

BACKGROUND AND AIM

The number of colonoscopies required to reach satisfactory adenoma detection rate (ADR) is not well established. The aim of this study was to identify the appropriate number of procedures required to attain satisfactory ADR for those well-trained endoscopists who have a cecal intubation rate (CIR) ≥ 90% and start to perform colonoscopy independently.

METHODS

All endoscopists with compelete independent colonoscopy data during career in our database were enrolled. The number of procedures required to achieve ADR ≥ 20% was identified by cumulative summation (Cusum), learning curve Cusum (LC-Cusum), and moving average method. Mixed effect logistic regression model was developed to determine the relationship between endoscopist as well as patient-related factors and adenoma detection.

RESULTS

A total of 24 943 procedures and 14 endoscopists were enrolled. By Cusum analysis, the interest point was at 207 procedures. By LC-Cusum analysis, 71% (10/14) and 86% (12/14) of endoscopists had attained satisfactory ADR after 200 and 300 procedures, respectively. By moving average method, endoscopists reached a mean ADR of 20% at 216 and 261 procedures over blocks of 50 and 100 procedures, respectively. The total number of procedures, number of daily procedures, patient age and gender, bowel preparation, sedation, and diverticulosis were significantly associated with adenoma detection.

CONCLUSIONS

This is the first study to investigate the learning curve of ADR for those well-trained endoscopists who have a CIR ≥ 90% and start to perform colonoscopy independently. Two hundred procedures might be an optimal number required to reach an ADR ≥ 20%.

Disparities in Utilization of Medical Specialists for Colonoscopy

Purpose: Colonoscopy is the preferred screening modality for colorectal cancer (CRC) prevention. The quality of the procedure varies although medical specialists such as gastroenterologists and colorectal surgeons tend to have better outcomes. We aimed to determine whether there are demographic and clinical differences between those who received a colonoscopy from a specialist versus those who received a colonoscopy from a nonspecialist.

Methods: Using the population-based South Carolina Outpatient Ambulatory Surgery Database, we looked retrospectively to obtain patient-level endoscopy records from 2010 to 2014. We used multilevel logistic regression to model whether patients saw a specialist for their colonoscopy. The primary variables were patient race and insurance type, and an interaction by rurality was tested.

Results: Of the 392,285 patients included in the analysis, 81% saw a specialist for their colonoscopy. County of residence explained 30% of the variability in the outcome. Non-Hispanic black (OR=0.65; confidence interval [95% CI]: 0.64–0.67) and Hispanic patients (OR=0.75; 95% CI: 0.67–0.84) were significantly less likely than non-Hispanic white patients to see a specialist. Compared with commercial/HMO insurance, all other types were less likely to see a specialist, and even more so for rural patients. The interaction of race by rurality was not significant.

Conclusions: Specialists play a key role in CRC screening and can affect later downstream outcomes. This study has shown that ethnic minorities and adults with public or other insurance, particularly in rural areas, are most likely not to see a specialist. These results are consistent with disparities in CRC incidence, mortality, and survival.

Efficacy and safety of cold forceps polypectomy utilizing the jumbo cup: a prospective study

Background/Aims

There are few prospective studies on cold forceps polypectomy (CFP) using jumbo cup forceps. Therefore, we examined patients with diminutive polyps (5 mm or smaller) treated with CFP using jumbo cup forceps to achieve an adenoma-free colon and also assessed the safety of the procedure and the recurrence rate of missed or residual polyp after CFP by performing follow-up colonoscopy 1 year later.

Methods

We included patients with up to 5 adenomas removed at initial colonoscopy and analyzed data from a total of 361 patients with 573 adenomas. One-year follow-up colonoscopy was performed in 165 patients, at which 251 lesions were confirmed.

Results

The one-bite resection rate with CFP was highest for lesions 3 mm or smaller and decreased significantly with increasing lesion size. Post-procedural hemorrhage was observed in 1 of 573 lesions (0.17%). No perforation was noted. The definite recurrence rate was 0.8% (2/251 lesions). The probable recurrence rate, which was defined as recurrence in the same colorectal segment, was 17%. Adenoma-free colon was achieved in 55% of patients at initial resection. Multivariate analysis revealed that achievement of an adenoma-free colon was significantly associated with number of adenomas and years of endoscopic experience.

Conclusions

CFP using jumbo biopsy forceps was safe and showed a high one-bite resection rate for diminutive lesions of 3 mm or smaller. The low definite recurrence rate confirms the reliability of CFP using jumbo biopsy forceps. Number of adenomas and years of endoscopic experience were key factors in achieving an adenoma-free colon.