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Jahn B, Bundo M, Arvandi M, Schaffner M, Todorovic J, Sroczynski G, Knudsen A, Fischer T, Schiller-Fruehwirth I, Öfner D, Renner F, Jonas M, Kuchin I, Kruse J, Santamaria J, Ferlitsch M, Siebert U. One in three adenomas could be missed by white-light colonoscopy - findings from a systematic review and meta-analysis. BMC Gastroenterol 2025; 25:170. [PMID: 40082770 PMCID: PMC11908064 DOI: 10.1186/s12876-025-03679-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2024] [Accepted: 02/11/2025] [Indexed: 03/16/2025] Open
Abstract
BACKGROUND White light (conventional) colonoscopy (WLC) is widely used for colorectal cancer screening, diagnosis and surveillance but endoscopists may fail to detect adenomas. Our goal was to assess and synthesize overall and subgroup-specific adenoma miss rates (AMR) of WLC in daily practice. METHODS We conducted a systematic review in MEDLINE, EMBASE, Cochrane Library, and grey literature on studies evaluating diagnostic WLC accuracy in tandem studies with novel-colonoscopic technologies (NCT) in subjects undergoing screening, diagnostic or surveillance colonoscopy. Information on study design, AMR overall and specific for adenoma size, histology, location, morphology and further outcomes were extracted and reported in standardized evidence tables. Study quality was assessed using the QUADAS-2 tool. Random-effects meta-analyses and meta-regression were performed to estimate pooled estimates for AMR with 95% confidence intervals (95% CI) and to explain heterogeneity. RESULTS Out of 5,963 identified studies, we included sixteen studies with 4,101 individuals in our meta-analysis. One in three adenomas (34%; 95% CI: 30-38%) was missed by WLC in daily practice individuals. Subgroup analyses showed significant AMR differences by size (36%, adenomas 1-5 mm; 27%, adenomas 6-9 mm; 12%, adenomas ≥ 10 mm), histology (non-advanced: 42%, advanced: 21%), morphology (flat: 50%, polypoid: 27%), but not by location (distal: 36%, proximal: 36%). CONCLUSIONS Based on our meta-analysis, one in three adenomas could be missed by WLC. This may significantly contribute to interval cancers. Our results should be considered in health technology assessment when interpreting sensitivity of fecal occult blood or other screening tests derived from studies using WLC as "gold standard".
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Affiliation(s)
- Beate Jahn
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Marvin Bundo
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland
| | - Marjan Arvandi
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Monika Schaffner
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Jovan Todorovic
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Gaby Sroczynski
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Amy Knudsen
- Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Timo Fischer
- Main Association of Austrian Social Security Institutions, Vienna, Austria
| | | | - Dietmar Öfner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Michael Jonas
- Medical Association of Vorarlberg, Dornbirn, Austria
| | - Igor Kuchin
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Julia Kruse
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Júlia Santamaria
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria
| | - Monika Ferlitsch
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT TIROL - University for Health Sciences and Technology, Hall in Tirol, Austria.
- Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Health Technology Assessment and Bioinformatics, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria.
- Center for Health Decision Science, Departments of Epidemiology and Health Policy & Management, Harvard T. H. Chan School of Public Health, Boston, USA.
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Rajivan R, Thayalasekaran S. Improving polyp detection at colonoscopy: Non-technological techniques. World J Gastrointest Endosc 2023; 15:354-367. [PMID: 37274557 PMCID: PMC10236979 DOI: 10.4253/wjge.v15.i5.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/03/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
Colonoscopy and polypectomy remain the gold standard investigation for the detection and prevention of colorectal cancer. Halting the progression of colonic adenoma through adequate detection of pre-cancerous lesions interrupts the progression to carcinoma. The adenoma detection rate is a key performance indicator. Increasing adenoma detection rates are associated with reducing rates of interval colorectal cancer. Endoscopists with high baseline adenoma detection rate have a meticulous technique during colonoscopy withdrawal that improves their adenoma detection. This minireview article summarizes the evidence on the following simple operator techniques and their effects on the adenoma detection rate; minimum withdrawal times, dynamic patient position change and proximal colon retroflexion.
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Affiliation(s)
- Ragul Rajivan
- Buckingham Medical School, Milton Keynes MK18 1EG, United Kingdom
| | - Sreedhari Thayalasekaran
- Department of Gastroenterology, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
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Weissman S, Mehta TI, Stein DJ, Tripathi K, Rosenwald N, Kolli S, Aziz M, Feuerstein JD. Comparative Efficacy of Endoscopic Assist Devices on Colonic Adenoma Detection: A Systematic Review With Network Meta-analysis. J Clin Gastroenterol 2022; 56:889-894. [PMID: 35324485 DOI: 10.1097/mcg.0000000000001643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/18/2021] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Numerous endoscopic assist devices exist, yet data surrounding their comparative efficacy is lacking. We conducted a systematic review with network meta-analysis to determine the comparative efficacy of endoscopic assist devices on colonic adenoma detection. METHODS A systematic search was performed using multiple electronic databases through July 2020, to identify all randomized controlled trials and dual-arm observational studies compared with either other endoscopic assist devices and/or standard colonoscopy. The primary outcome was adenoma detection rate (ADR). Secondary outcomes included polyp detection rate (PDR), serrated adenoma detection rate (SADR), right-sided adenoma detection rate (RADR), and proximal adenoma detection rate (PADR). RESULTS Fifty-seven studies (31,051 patients) met inclusion criteria and were analyzed. Network meta-analysis identified an enhanced ADR among (clear) cap [odds ratio (OR): 2.69, 95% confidence interval (CI): 1.45-4.99], endocuff, (OR: 4.95, 95% CI: 3.15-7.78), and endoring (OR: 3.68, 95% CI: 1.47-9.20)-with no significant difference amongst any particular device. Similar findings for PDR were also seen. Enhanced SADR was identified for endocuff (OR: 9.43) and endoring (OR: 4.06) compared with standard colonoscopy. Enhanced RADR (OR: 5.36) and PADR (OR: 3.78) were only identified for endocuff. Endocuff comparatively demonstrated the greatest ADR, PDR, and SADR, but this was not significant when compared with the other assist devices. Subgroup analysis of randomized controlled trials identified enhanced PDR and ADR for both cap and endocuff. CONCLUSIONS Endoscopic assist devices displayed increased ADR and PDR as compared with standard colonoscopy and thus should be widely adopted. A nonsignificant trend was seen toward higher efficacy for the endocuff device.
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Affiliation(s)
- Simcha Weissman
- Department of Medicine, Hackensack Meridian Health Palisades Medical Center, North Bergen, NJ
| | - Tej I Mehta
- Department of Medicine, Medical College of Wisconsin, Madison, WI
| | | | - Kartikeya Tripathi
- Department of Gastroenterology and Hepatology, University of Massachusetts Medical School-Baystate Campus, Springfield, MA
| | | | - Sindhura Kolli
- Department of Medicine, NYU Langone Medical Center, New York, NY
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, OH
| | - Joseph D Feuerstein
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
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Gubbiotti A, Spadaccini M, Badalamenti M, Hassan C, Repici A. Key factors for improving adenoma detection rate. Expert Rev Gastroenterol Hepatol 2022; 16:819-833. [PMID: 36151898 DOI: 10.1080/17474124.2022.2128761] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Colonoscopy is a fundamental tool in colorectal cancer (CRC) prevention. Nevertheless, one-fourth of colorectal neoplasms are still missed during colonoscopy, potentially being the main reason for post-colonoscopy colorectal cancer (PCCRC). Adenoma detection rate (ADR) is currently known as the best quality indicator correlating with PCCRC incidence. AREAS COVERED We performed a literature review in order to summarize evidences investigating key factors affecting ADR: endoscopists education and training, patient management, endoscopic techniques, improved navigation (exposition defect), and enhanced lesions recognition (vision defect) were considered. EXPERT OPINION 'Traditional' factors, such as split dose bowel preparation, adequate withdrawal time, and right colon second view, held a significant impact on ADR. Several devices and technologies have been developed to promote high-quality colonoscopy, however artificial intelligence may be considered the most promising tool for ADR improvement, provided that endoscopists education and recording are guaranteed.
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Affiliation(s)
- Alessandro Gubbiotti
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Marco Spadaccini
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Matteo Badalamenti
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Cesare Hassan
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Alessandro Repici
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
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Aziz M, Ahmed Z, Haghbin H, Pervez A, Goyal H, Kamal F, Kobeissy A, Nawras A, Adler DG. Does i-scan improve adenoma detection rate compared to high-definition colonoscopy? A systematic review and meta-analysis. Endosc Int Open 2022; 10:E824-E831. [PMID: 35692917 PMCID: PMC9187364 DOI: 10.1055/a-1794-0346] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 01/24/2022] [Indexed: 11/08/2022] Open
Abstract
Background and study aims Recent studies evaluated the impact of i-scan in improving the adenoma detection rate (ADR) compared to high-definition (HD) colonoscopy. We aimed to systematically review and analyze the impact of this technique. Methods A thorough search of the following databases was undertaken: PubMed/Medline, EMBASE, Cochrane and Web of Science. Full-text RCTs and cohort studies directly comparing i-scan and HD colonoscopy were deemed eligible for inclusion. Dichotomous outcomes were pooled and compared using random effects model and DerSimonian-Laird approach. For each outcome, relative risk (RR), 95 % confidence interval (CI), and P value was generated. P < 0.05 was considered statistically significant. Results A total of five studies with six arms were included in this analysis. A total of 2620 patients (mean age 58.6 ± 7.2 years and female proportion 44.8 %) completed the study and were included in our analysis. ADR was significantly higher with any i-scan (RR: 1.20, [CI: 1.06-1.34], P = 0.003) compared to HD colonoscopy. Subgroup analysis demonstrated that ADR was significantly higher using i-scan with surface and contrast enhancement only (RR: 1.25, [CI: 1.07-1.47], P = 0.004). Conclusions i-scan has the potential to increase ADR using the surface and contrast enhancement method. Future studies evaluating other outcomes of interest such as proximal adenomas and serrated lesions are warranted.
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Affiliation(s)
- Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, United States
| | - Zohaib Ahmed
- Department of Internal Medicine, University of Toledo, Toledo, Ohio, United States
| | - Hossein Haghbin
- Division of Gastroenterology, Ascension Providence Hospital, Southfield, Michigan, United States
| | - Asad Pervez
- Division of Gastroenterology and Hepatology, West Virginia University, Morgantown, West Virginia, United States
| | - Hemant Goyal
- Division of Gastroenterology and Hepatology, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, United States
| | - Faisal Kamal
- Division of Gastroenterology, University of California, San Francisco, California, United States
| | - Abdallah Kobeissy
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, United States
| | - Ali Nawras
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, United States
| | - Douglas G. Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Peak Gastroenterology, Denver, Colorado, United States
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Vemulapalli KC, Lahr RE, Rex DK. Most large colorectal polyps missed by gastroenterology fellows at colonoscopy are sessile serrated lesions. Endosc Int Open 2022; 10:E659-E663. [PMID: 35571477 PMCID: PMC9106434 DOI: 10.1055/a-1784-0959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/03/2021] [Indexed: 02/02/2023] Open
Abstract
Background and study aims Data on adenoma and sessile serrated lesion (SSL) miss rates for gastroenterology fellows during colonoscopy are limited. We aimed to describe the miss rate of fellows based on a second examination by a colonoscopist with a high rate of detection. Patients and methods Second- and third-year gastroenterology fellows at a single, tertiary center performed initial examinations. A single experienced attending doctor then performed a complete examination of the colon. We recorded the size and pathology of all lesions found at both examinations and calculated the adenoma and SSL miss rates for fellows. Results Ten trainees performed 100 examinations. Miss rates for conventional adenomas and SSLs were 30.5 % and 85.7 %, respectively. Among pre-cancerous polyps ≥ 10 mm, 10 of 14 lesions missed were SSLs. Conclusions While conventional adenoma detection skills of gastroenterology fellows are acceptable, SSL detection is poor.
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Affiliation(s)
- Krishna C. Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Rachel E. Lahr
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
| | - Douglas K. Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, United States
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Ikematsu H, Murano T, Shinmura K. Detection of colorectal lesions during colonoscopy. DEN OPEN 2022; 2:e68. [PMID: 35310752 PMCID: PMC8828173 DOI: 10.1002/deo2.68] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 12/11/2022]
Abstract
Owing to its high mortality rate, the prevention of colorectal cancer is of particular importance. The resection of colorectal polyps is reported to drastically reduce colorectal cancer mortality, and examination by endoscopists who had a high adenoma detection rate was found to lower the risk of colorectal cancer, highlighting the importance of identifying lesions. Various devices, imaging techniques, and diagnostic tools aimed at reducing the rate of missed lesions have therefore been developed to improve detection. The distal attachments and devices for improving the endoscopic view angle are intended to help avoid missing blind spots such as folds and flexures in the colon, whereas the imaging techniques represented by image‐enhanced endoscopy contribute to improving lesion visibility. Recent advances in artificial intelligence‐supported detection systems are expected to supplement an endoscopist's eye through the instant diagnosis of the lesions displayed on the monitor. In this review, we provide an outline of each tool and assess its impact on the reduction in the incidence of missed colorectal polyps by summarizing previous clinical research and meta‐analyses. Although useful, the many devices, image‐enhanced endoscopy, and artificial intelligence tools exhibited various limitations. Integrating these tools can improve their shortcomings. Combining artificial intelligence‐based diagnoses with wide‐angle image‐enhanced endoscopy may be particularly useful. Thus, we hope that such tools will be available in the near future.
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Affiliation(s)
- Hiroaki Ikematsu
- Division of Science and Technology for Endoscopy Exploratory Oncology Research & Clinical Trial Center National Cancer Center Chiba Japan.,Department of Gastroenterology and Endoscopy National Cancer Center Hospital East Chiba Japan
| | - Tatsuro Murano
- Department of Gastroenterology and Endoscopy National Cancer Center Hospital East Chiba Japan
| | - Kensuke Shinmura
- Department of Gastroenterology and Endoscopy National Cancer Center Hospital East Chiba Japan
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Cheng CL, Kuo YL, Hsieh YH, Tang JH, Leung FW. Comparison of Right Colon Adenoma Miss Rates Between Water Exchange and Carbon Dioxide Insufflation: A Prospective Randomized Controlled Trial. J Clin Gastroenterol 2021; 55:869-875. [PMID: 33074950 DOI: 10.1097/mcg.0000000000001454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/14/2020] [Indexed: 12/10/2022]
Abstract
GOALS To test the hypothesis that water exchange (WE), when compared with carbon dioxide (CO2) insufflation, significantly reduces the right colon adenoma miss rate (rAMR) in a blinded randomized controlled trial with cap-assisted colonoscopy. BACKGROUND The unblinded consecutive group observational data showed that WE significantly decreased rAMR. The unblinded data are limited by potential bias. STUDY Consecutive patients aged 45 years or more were randomized to undergo insertion with WE or CO2. Withdrawal and polypectomy were performed with CO2 in both groups to the hepatic flexure. The colonoscope was reinserted to the cecum. A second colonoscopist re-examined the right colon. The second colonoscopist was unaware, but made a guess, of the initial insertion method. The number of additional adenomas divided by the total number detected in both examinations equaled rAMR. RESULTS Among 262 patients (131/group), demographic variables were similar. The body mass index was significantly higher in the WE group. Compared with CO2, WE significantly decreased rAMR [18.0% (33/183) vs. 34.6% (62/179), P=0.0025] and right colon serrated polyp miss rate [17.4% (27/155) vs. 39.3% (33/84), P=0.002]. Multivariate logistic regression analysis showed that WE was an independent predictor of rAMR (odds ratio, 0.42; 95% confidence interval, 0.21-0.86), and so was ≥2 adenomas in the right colon (odds ratio, 2.35; 95% confidence interval, 1.17-4.76). Whether the second colonoscopist guessed the insertion method correctly or not, and demographic and procedure variables were not associated with rAMR. CONCLUSIONS The randomized controlled trial validated unblinded observational data showing that WE significantly decreased rAMR and right colon serrated polyp miss rate (clinical trial registration number: NCT03845933).
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Affiliation(s)
| | - Yen-Lin Kuo
- Department of Medicine, Evergreen General Hospital, Taoyuan
| | - Yu-Hsi Hsieh
- Division of Gastroenterology, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi
| | - Jui-Hsiang Tang
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Felix W Leung
- Department of Medicine, Division of Gastroenterology, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, North Hills and Los Angeles, CA
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Hasegawa I, Yamamura T, Suzuki H, Maeda K, Sawada T, Mizutani Y, Ishikawa E, Ishikawa T, Kakushima N, Furukawa K, Ohno E, Kawashima H, Nakamura M, Fujishiro M. Detection of Colorectal Neoplasms Using Linked Color Imaging: A Prospective, Randomized, Tandem Colonoscopy Trial. Clin Gastroenterol Hepatol 2021; 19:1708-1716.e4. [PMID: 33839277 DOI: 10.1016/j.cgh.2021.04.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 04/02/2021] [Accepted: 04/03/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS A higher adenoma detection rate (ADR) has been shown to be related to a lower incidence and mortality of colorectal cancer. We analyzed the efficacy of linked color imaging (LCI) by assessing the detection, miss, and visibility of various featured adenomas as compared with white light imaging (WLI). METHODS This was a prospective, randomized, tandem trial. The participants were randomly assigned to 2 groups: first observation by LCI, then second observation by WLI (LCI group); or both observations by WLI (WLI group). Suspected neoplastic lesions were resected after magnifying image-enhanced endoscopy. The primary outcome was to compare the ADR during the first observation. Secondary outcomes included evaluation of adenoma miss rate (AMR) and visibility score. RESULTS A total of 780 patients were randomized, 700 of whom were included in the final analysis. The ADR was 69.6% and 63.2% in the LCI and WLI groups, respectively, with no significant difference. However, LCI improved the average ADR in low-detectors compared with high-detectors (76.0% vs 55.1%; P < .001). Total AMR was 20.6% in the LCI group, which was significantly lower than that in the WLI group (31.1%) (P < .001). AMR in the LCI group was significantly lower, especially for diminutive adenomas (23.4% vs 35.1%; P < .001) and nonpolypoid lesions (25.6% vs 37.9%; P < .001) compared with the WLI group. CONCLUSION Although both methods provided a similar ADR, LCI had a lower AMR than WLI. LCI could benefit endoscopists with lower ADR, an observation that warrants additional study. (UMIN Clinical Trials Registry, Number: UMIN000026359).
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Affiliation(s)
- Issei Hasegawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Hiroto Suzuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keiko Maeda
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Tsunaki Sawada
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eri Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Zimmermann-Fraedrich K, Pohl H, Rösch T, Rex DK, Hassan C, Dekker E, Kaminski MF, Bretthauer M, de Heer J, Werner Y, Schachschal G, Groth S. Designs of colonoscopic adenoma detection trials: more positive results with tandem than with parallel studies - an analysis of studies on imaging techniques and mechanical devices. Gut 2021; 70:268-275. [PMID: 32409588 DOI: 10.1136/gutjnl-2020-320984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/15/2020] [Accepted: 04/19/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Adenoma detection rate (ADR) has been shown to correlate with interval cancers after screening colonoscopy and is commonly used as surrogate parameter for its outcome quality. ADR improvements by various techniques have been studied in randomised trials using either parallel or tandem methodololgy. METHODS A systematic literature search was done on randomised trials (full papers, English language) on tandem or parallel studies using either adenoma miss rates (AMR) or ADR as main outcome to test different novel technologies on imaging (new endoscope generation, narrow band imaging, iScan, Fujinon intelligent chromoendoscopy/blue laser imaging and wide angle scopes) and mechanical devices (transparent caps, endocuff, endorings and balloons). Available meta analyses were also screened for randomised studies. RESULTS Overall, 24 randomised tandem trials with AMR (variable definitions and methodology) and 42 parallel studies using ADR (homogeneous methodology) as primary outcome were included. Significant differences in favour of the new method were found in 66.7% of tandem studies (8222 patients) but in only 23.8% of parallel studies (28 059 patients), with higher rates of positive studies for mechanical devices than for imaging methods. In a random-effects model, small absolute risk differences were found, but these were double in magnitude for tandem as compared with parallel studies (imaging: tandem 0.04 (0.01, 0.07), parallel 0.02 (0.00, 0.04); mechanical devices: tandem 0.08 (0.00, 0.15), parallel 0.04 (0.01, 0.07)). Nevertheless, 94.2% of missed adenomas in the tandem studies were small (<1 cm) and/or non-advanced. CONCLUSIONS A tandem study is more likely to yield positive results than a simple parallel trial; this may be due to the use of different parameters, variable definitions and methodology, and perhaps also a higher likelihood of bias. Therefore, we suggest to accept positive results of tandem studies only if accompanied by positive results from parallel trials.
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Affiliation(s)
| | - Heiko Pohl
- Gastroenterology and Hepatology, VA White River Junction/Dartmout Hitchcock Medical Center, White River Junction, Vermont, USA
| | - Thomas Rösch
- Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, Indiana, USA
| | - Cesare Hassan
- Gastroenterology Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Michal Filip Kaminski
- Department of Gastroenterology, Hepatology and Oncology, Center for Postgraduate Medical Education, Warsaw, Poland
| | - Michael Bretthauer
- Clinical Effectiveness Research Group, Department of Health Management and Health Economics, University of Oslo, Oslo, Norway.,Section of Gastroenterology, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Jocelyn de Heer
- Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yuki Werner
- Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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11
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Lui TKL, Hui CKY, Tsui VWM, Cheung KS, Ko MKL, Foo DCC, Mak LY, Yeung CK, Lui TH, Wong SY, Leung WK. New insights on missed colonic lesions during colonoscopy through artificial intelligence-assisted real-time detection (with video). Gastrointest Endosc 2021; 93:193-200.e1. [PMID: 32376335 DOI: 10.1016/j.gie.2020.04.066] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Meta-analysis shows that up to 26% of adenomas could be missed during colonoscopy. We investigated whether the use of artificial intelligence (AI)-assisted real-time detection could provide new insights into mechanisms underlying missed lesions during colonoscopy. METHODS A validated real-time deep-learning AI model for the detection of colonic polyps was first tested in videos of tandem colonoscopy of the proximal colon for missed lesions. The real-time AI model was then prospectively validated in a total colonoscopy in which the endoscopist was blinded to real-time AI findings. Segmental unblinding of the AI findings were provided, and the colonic segment was then re-examined when missed lesions were detected by AI but not the endoscopist. All polyps were removed for histologic examination as the criterion standard. RESULTS Sixty-five videos of tandem examination of the proximal colon were reviewed by AI. AI detected 79.1% (19/24) of missed proximal adenomas in the video of the first-pass examination. In 52 prospective colonoscopies, real-time AI detection detected at least 1 missed adenoma in 14 patients (26.9%) and increased the total number of adenomas detected by 23.6%. Multivariable analysis showed that a missed adenoma(s) was more likely when there were multiple polyps (adjusted odds ratio, 1.05; 95% confidence interval, 1.02-1.09; P < .0001) or colonoscopy was performed by less-experienced endoscopists (adjusted odds ratio, 1.30; 95% confidence interval, 1.05-1.62; P = .02). CONCLUSIONS Our findings provide new insights on the prominent role of human factors, including inexperience and distraction, on missed colonic lesions. With the use of real-time AI assistance, up to 80% of missed adenomas could be prevented. (Clinical trial registration number: NCT04227795.).
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Affiliation(s)
- Thomas K L Lui
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Cynthia K Y Hui
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Vivien W M Tsui
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Ka Shing Cheung
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Michael K L Ko
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Dominic C C Foo
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Lung Yi Mak
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Chung Kwong Yeung
- Department of Surgery, Queen Mary Hospital, University of Hong Kong, Hong Kong; NISI (HK) Limited
| | | | - Siu Yin Wong
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - Wai K Leung
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
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12
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Silva LC, Arruda RM, Botelho PFR, Taveira LN, Giardina KM, de Oliveira MA, Dias J, Oliveira CZ, Fava G, Guimarães DP. Cap-assisted endoscopy increases ampulla of Vater visualization in high-risk patients. BMC Gastroenterol 2020; 20:214. [PMID: 32646369 PMCID: PMC7346639 DOI: 10.1186/s12876-020-01361-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 06/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background Periampullary adenocarcinoma is a major clinical problem in high-risk patients including FAP population. A recent modification for visualizing the ampulla of Vater (AV) involves attaching a cap to the tip of the forward-viewing endoscope. Our aim was to compare the rates of complete visualization of AV using this cap-assisted endoscopy (CAE) approach to standard forward-viewing endoscopy (FVE). We also determined: (i) the rates of complications and additional sedation; (ii) the mean time required for duodenal examination; and (iii) the reproducibility among endoscopists performing this procedure. Methods We performed esophagogastroduodenoscopy for AV visualization in 102 > 18 years old using FVE followed by CAE. Video recordings were blinded and randomly selected for independent expert endoscopic evaluation. Results The complete visualization rate for AV was higher in CAE (97.0%) compared to FVE (51.0%) (p < 0.001). The additional doses of fentanyl, midazolam, and propofol required for CAE were 0.05, 1.9 and 36.3 mg. in 0.9, 24.5, and 77.5% patients, respectively. The mean time of duodenal examination for AV visualization was lower on CAE compared to FVE (1.41 vs. 1.95 min, p < 0.001). Scopolamine was used in 34 FVE and 24 CAE, with no association to AV complete visualization rates (p = 0.30 and p = 0.14). Three more ampullary adenomas were detected using CAE compared to FVE. Cap displacement occurred in one patient, and there was no observed adverse effect of the additional sedatives used. Kappa values for agreement between endoscopists ranged from 0.60 to 0.85. Conclusions CAE is feasible, reproducible and safe, with a higher success rate for complete visualization compared to FVE. Trial registration: ClinicalTrials.gov, NCT02867826, 16 August 2016.
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Affiliation(s)
- Leonardo Correa Silva
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Rondinelle Martins Arruda
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Paula Fortuci Resende Botelho
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Leonardo Nogueira Taveira
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Kelly Menezio Giardina
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | | | - Julia Dias
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | | | - Gilberto Fava
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Denise Peixoto Guimarães
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil. .,Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil.
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13
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Rameshshanker R, Tsiamoulos Z, Wilson A, Rajendran A, Bassett P, Tekkis P, Saunders BP. Endoscopic cuff-assisted colonoscopy versus cap-assisted colonoscopy in adenoma detection: randomized tandem study-DEtection in Tandem Endocuff Cap Trial (DETECT). Gastrointest Endosc 2020; 91:894-904.e1. [PMID: 31836474 DOI: 10.1016/j.gie.2019.11.046] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/26/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Adenoma miss rate during colonoscopy is directly linked to risk of postcolonoscopy colorectal cancer. One of the reasons for missed adenomas is poor visualization of proximal folds during standard colonoscopy withdrawal. Disposable distal attachments such as the plastic cap and Endocuff (Arc Medical Design, Leeds, UK) that hold back folds appear to improve adenoma detection. The primary aim of this study was to compare adenoma detection rates between Endocuff-assisted colonoscopy (EAC) and cap-assisted colonoscopy (CAC). METHODS This is a randomized, single-center, tandem colonoscopy trial performed by the same endoscopists on the same day, first with Endocuff Vision (Arc Medical Design, Leeds, UK) followed by cap or vice versa. All procedures were performed by 3 experienced gastroenterology fellows. RESULTS One hundred fifty-four patients were recruited. Seventy-eight (50.6%) had CAC as their first procedure. Mean patient age was 61 years (male-to-female ratio, 1:1). Adenoma detection rate was significantly higher for EAC when compared to CAC (53% vs 26%, P = .001). Polyp miss rate was significantly lower in EAC (8.4%) compared with CAC (26.1%, P < .001) as was adenoma miss rate (EAC vs CAC, 6%, vs 19%; P = .002) and diminutive adenoma (<5 mm) miss rate in the EAC group (1.8% vs 19.6%, P < .001). However, there was no significant differences in the miss rates for small adenomas (5-9 mm) (3.7% vs 2.9%, P = .69) or adenomas 10 mm or larger (1.6% vs 2.6%, P = .98 ). The mean number of adenomas per procedure was significantly higher with EAC compared with CAC (1.5 vs .8, P < .001). Cecal intubation time was significantly shorter with EAC than CAC (median 6 vs 7 minutes, P = .01). Conversely, withdrawal time (median 10 vs 8 minutes, P = .01) was significantly longer in EAC. CONCLUSIONS This randomized, tandem study demonstrates that EAC has a significantly higher adenoma detection rate and lower adenoma miss rate than CAC. Although insertion times were shorter with EAC, procedures were slightly more uncomfortable, and the cuff had to be removed in a small number of cases. (Clinical trial registration number: NCT03254498.).
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Affiliation(s)
- Rajaratnam Rameshshanker
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Harrow, UK; Department of Surgery and Cancer, Imperial College, London, UK
| | - Zacharias Tsiamoulos
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Ana Wilson
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Harrow, UK
| | - Arun Rajendran
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Harrow, UK
| | | | - Paris Tekkis
- Department of Surgery and Cancer, Imperial College, London, UK
| | - Brian P Saunders
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Harrow, UK
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14
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Cap-Assisted Chromoendoscopy Using a Mounted Cap Versus Standard Colonoscopy for Adenoma Detection. Am J Gastroenterol 2020; 115:465-472. [PMID: 31972618 DOI: 10.14309/ajg.0000000000000510] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Some neoplastic lesions remain undetected on colonoscopy. To date, no studies have investigated whether combining cap-assisted colonoscopy with chromoendoscopy increases the adenoma detection rate (ADR). This study aimed to compare cap-assisted chromoendoscopy (CAP/CHROMO) with standard colonoscopy (SC) with respect to their efficacy in detecting adenomas. METHODS This prospective, multicenter, randomized controlled trial included asymptomatic subjects aged 45-75 years who underwent colonoscopy for the first time at 14 university hospitals. Subjects were randomized to either the CAP/CHROMO group (with 0.09% indigo carmine spraying using a cap-mounted catheter at the tip of the colonoscope) or the SC group. All polyps were resected, but only histologically confirmed neoplastic lesions were considered for analysis. The primary outcome was ADR, defined as the proportion of subjects with at least 1 adenoma. RESULTS A total of 1,905 subjects were randomized to the CAP/CHROMO (n = 948) or SC (n = 957) group at 14 centers. Subjects' demographic characteristics were similar between both groups. The CAP/CHROMO group had significantly higher ADR than the SC group (54.4% vs 44.9%, P < 0.001). Significantly, more subjects with at least 1 proximal colon adenoma were identified by CAP/CHROMO (38.6%) than by SC (31.2%) (P = 0.001). The proximal serrated polyp detection rate by CAP/CHROMO was significantly higher in the female subgroup vs SC. However, advanced ADR was not different between the CAP/CHROMO and SC groups (9.3% vs 7.6%, P = 0.180). DISCUSSION CAP/CHROMO markedly improved the ADR and enhanced the detection of proximal adenoma. CAP/CHROMO is feasible for routine application and will allow for a more effective surveillance program.
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15
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Marsano J, Johnson S, Yan S, Alli-Akintade L, Wilson M, Al-Juburi A, Stondell J, Tejaswi S. Comparison of colon adenoma detection rates using cap-assisted and Endocuff-assisted colonoscopy: a randomized controlled trial. Endosc Int Open 2019; 7:E1585-E1591. [PMID: 31788539 PMCID: PMC6877415 DOI: 10.1055/a-0996-7891] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Accepted: 04/10/2019] [Indexed: 12/13/2022] Open
Abstract
Objectives and study aim Colonoscopy prevents colorectal cancer by removing adenomatous polyps, but missed adenomas lead to interval cancers. Different devices have been used to increase adenoma detection rates (ADR). Two such devices of interest are the transparent cap (Olympus) and Endocuff (ARC Medical). Our study aimed to compare differences in ADR between Endocuff-assisted colonoscopy (EAC), cap-assisted colonoscopy (CAC) and standard colonoscopy (SC). Patients and methods A sample size of 126 subjects was calculated to determine an effect size of 30 %. Patients undergoing screening or surveillance colonoscopy between March 2016 and January 2017 were randomized to SC, CAC or EAC groups. Three experienced endoscopists performed all colonoscopies. Patient demographics, procedure indication, Boston Bowel Prep Score (BBPS), withdrawal time, polyp size, location, histopathology, were analyzed. Results There was no difference in ADR (52 %, 40 % and 54 %) in the SC, CAC and EAC groups respectively ( P = 0.4). Similar findings were also observed for proximal ADR (45 %, 35 %, and 50 %, P = 0.4) and SSA detection rate (16 %, 14 %, and 23 %, P = 0.5). EAC detected higher mean ADR per colonoscopy compared to CAC (1.70 vs 0.76, P = 0.01). However, there was no significant difference in mean ADR per positive colonoscopy (2.08, 1.63, and 2.59, P = 0.21). Conclusion In a randomized controlled trial comparing AC to CAC and SC, neither device conferred additional benefits in ADR among high detectors. When comparing each device, EAC may be better than CAC at detecting more total adenomas.
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Affiliation(s)
- Joseph Marsano
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Sheeva Johnson
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, United States
| | - Stephanie Yan
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, California, United States
| | - Latifat Alli-Akintade
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Machelle Wilson
- Department of Public Health Sciences, Division of Biostatistics, University of California Davis School of Medicine, Sacramento, California, United States
| | - Amar Al-Juburi
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Jesse Stondell
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, United States
| | - Sooraj Tejaswi
- Division of Gastroenterology and Hepatology, University of California Davis School of Medicine, Sacramento, California, United States,Corresponding author Sooraj Tejaswi, MD, MSPH University of California DavisDepartment of Internal MedicineDivision of Gastroenterology and Hepatology4150 V Street, Suite 3500Sacramento, California 95817USA+1- 916-734-7908
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16
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Zimmermann-Fraedrich K, Sehner S, Rex DK, Kaltenbach T, Soetikno R, Wallace M, Leung WK, Guo C, Gralnek IM, Brand EC, Groth S, Schachschal G, Ikematsu H, Siersema PD, Rösch T. Right-Sided Location Not Associated With Missed Colorectal Adenomas in an Individual-Level Reanalysis of Tandem Colonoscopy Studies. Gastroenterology 2019; 157:660-671.e2. [PMID: 31103625 DOI: 10.1053/j.gastro.2019.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/07/2019] [Accepted: 05/10/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Interval cancers occur more frequently in the right colon. One reason could be that right-sided adenomas are frequently missed in colonoscopy examinations. We reanalyzed data from tandem colonoscopies to assess adenoma miss rates in relation to location and other factors. METHODS We pooled data from 8 randomized tandem trials comprising 2218 patients who had diagnostic or screening colonoscopies (adenomas detected in 49.8% of patients). We performed a mixed-effects logistic regression with patients as cluster effects with different independent parameters. Factors analyzed included location (left vs right, splenic flexure as cutoff), adenoma size, form, and histologic features. Analyses were controlled for potential confounding factors such as patient sex and age, colonoscopy indication, and bowel cleanliness. RESULTS Right-side location was not an independent risk factor for missed adenomas (odds ratio [OR] compared with the left side, 0.94; 95% CI, 0.75-1.17). However, compared with adenomas ≤5 mm, the OR for missing adenomas of 6-9 mm was 0.62 (95% CI, 0.44-0.87), and the OR for missing adenomas of ≥10 mm was 0.51 (95% CI, 0.33-0.77). Compared with pedunculated adenomas, sessile (OR, 1.82; 95% CI, 1.16-2.85) and flat adenomas (OR, 2.47; 95% CI, 1.49-4.10) were more likely to be missed. Histologic features were not significant risk factors for missed adenomas (OR for adenomas with high-grade intraepithelial neoplasia, 0.68; 95% CI, 0.34-1.37 and OR for sessile serrated adenomas, 0.87; 95% CI, 0.47-1.64 compared with low-grade adenomas). Men had a higher number of adenomas per colonoscopy (1.27; 95% CI, 1.21-1.33) than women (0.86; 95% CI, 0.80-0.93). Men were less likely to have missed adenomas than women (OR for missed adenomas in men, 0.73; 95% CI, 0.57-0.94). CONCLUSIONS In an analysis of data from 8 randomized trials, we found that right-side location of an adenoma does not increase its odds for being missed during colonoscopy but that adenoma size and histologic features do increase risk. Further studies are needed to determine why adenomas are more frequently missed during colonoscopies in women than men.
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Affiliation(s)
| | - Susanne Sehner
- Department of Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Douglas K Rex
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Tonya Kaltenbach
- Veterans Administration San Francisco and University of California San Francisco, San Francisco, California
| | - Roy Soetikno
- Veterans Administration San Francisco and University of California San Francisco, San Francisco, California
| | - Michael Wallace
- Division of and Hepatology, Mayo Clinic Jacksonville, Jacksonville, Florida
| | - Wai K Leung
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Chuanguo Guo
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
| | - Eelco C Brand
- Department of Gastroenterology and Hepatology, University Medical Center, Utrecht, The Netherlands
| | - Stefan Groth
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Guido Schachschal
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Gastrointestinal Oncology, National Cancer Center Hospital East, Kashiwa, Chiba, Japan
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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17
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van Keulen KE, Soons E, Siersema PD. The Role of Behind Folds Visualizing Techniques and Technologies in Improving Adenoma Detection Rate. ACTA ACUST UNITED AC 2019; 17:394-407. [PMID: 31332633 DOI: 10.1007/s11938-019-00242-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Colorectal cancer is one of the most common malignancies in the Western world and is thought to develop from premalignant polyps. Over the past decade, several behind folds visualizing techniques (BFTs) have become available to improve polyp detection. This systematic review and meta-analysis aims to compare BFTs with conventional colonoscopy (CC). RECENT FINDINGS In the past five years, 14 randomized controlled trials (RCTs) including 8384 patients comparing different BFTs with CC were published. The overall relative risks for adenoma detection rate, polyp detection rate, and adenoma miss rate comparing BFTs with CC were 1.04 (95% confidence interval [CI] 0.98-1.10; P = 0.15), 1.03 (95% CI 0.98-1.09; P = 0.28), and 0.70 (95% CI 0.46-1.05; P = 0.08), respectively. Other quality metrics for colonoscopy were not significantly different between BFT-assisted colonoscopy and CC either. This meta-analysis of RCTs published in the past five years does not show a significant benefit of BFTs on any of the important quality metrics of colonoscopy. The lack of additional effect of BFTs might be due to improved awareness of colonoscopy quality metrics and colonoscopy skills among endoscopists combined with improvements of conventional colonoscope technology.
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Affiliation(s)
- K E van Keulen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - E Soons
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands.
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18
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Sano Y, Chiu H, Li X, Khomvilai S, Pisespongsa P, Co JT, Kawamura T, Kobayashi N, Tanaka S, Hewett DG, Takeuchi Y, Imai K, Utsumi T, Teramoto A, Hirata D, Iwatate M, Singh R, Ng SC, Ho S, Chiu P, Tajiri H. Standards of diagnostic colonoscopy for early-stage neoplasia: Recommendations by an Asian private group. Dig Endosc 2019; 31:227-244. [PMID: 30589103 PMCID: PMC6850515 DOI: 10.1111/den.13330] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/24/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM In recent years, the incidence of colorectal cancer has been increasing, and it is now becoming the major cause of cancer death in Asian countries. The aim of the present study was to develop Asian expert-based consensus to standardize the preparation, detection and characterization for the diagnosis of early-stage colorectal neoplasia. METHODS A professional group was formed by 36 experts of the Asian Novel Bio-Imaging and Intervention Group (ANBI2 G) members. Representatives from 12 Asia-Pacific countries participated in the meeting. The group organized three consensus meetings focusing on diagnostic endoscopy for gastrointestinal neoplasia. The Delphi method was used to develop the consensus statements. RESULTS Through the three consensus meetings with debating, reviewing the literature and regional data, a consensus was reached at third meeting in 2016. The consensus was reached on a total of 10 statements. Summary of statements is as follows: (i) Adequate bowel preparation for high-quality colonoscopy; (ii) Antispasmodic agents for lesion detection; (iii) Image-enhanced endoscopy (IEE) for polyp detection; (iv) Adenoma detection rate for quality indicators; (v) Good documentation of colonoscopy findings; (vi) Complication rates; (vii) Cecal intubation rate; (viii) Cap-assisted colonoscopy (CAC) for polyp detection; (ix) Macroscopic classification using indigocarmine spray for characterization of colorectal lesions; and (x) IEE and/or magnifying endoscopy for prediction of histology. CONCLUSION This consensus provides guidance for carrying out endoscopic diagnosis and characterization for early-stage colorectal neoplasia based on the evidence. This will enhance the quality of endoscopic diagnosis and improve detection of early-stage colorectal neoplasia.
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Affiliation(s)
- Yasushi Sano
- Gastrointestinal Center and Institute of Minimally invasive Endoscopic Care (iMEC)Sano HospitalHyogo
| | - Han‐Mo Chiu
- Department of Internal MedicineCollege of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Xiao‐bo Li
- Division of Gastroenterology and HepatologyKey Laboratory of Gastroenterology and HepatologyMinistry of HealthRenji HospitalSchool of MedicineShanghai Institute of Digestive DiseaseShanghai Jiao Tong UniversityShanghaiChina
| | - Supakij Khomvilai
- Surgical EndoscopyColorectal SurgeryDepartment of SurgeryChulalongkorn UniversityBangkokThailand
| | - Pises Pisespongsa
- Digestive Disease CenterBumrungrad International HospitalBangkokThailand
| | - Jonard Tan Co
- St. Luke's Medical Centre ‐ Global CityTaguig City, Metro ManilaPhilippines
| | - Takuji Kawamura
- Department of GastroenterologyKyoto Second Red Cross HospitalKyotoJapan
| | | | - Shinji Tanaka
- Department of EndoscopyHiroshima University HospitalHiroshimaJapan
| | - David G. Hewett
- Faculty of MedicineUniversity of QueenslandBrisbaneAustralia
| | - Yoji Takeuchi
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Kenichiro Imai
- Division of EndoscopyShizuoka Cancer CenterShizuokaJapan
| | - Takahiro Utsumi
- Department of Gastroenterology and HepatologyKyoto University Graduate School of MedicineKyotoJapan
| | - Akira Teramoto
- Gastrointestinal Center and Institute of Minimally invasive Endoscopic Care (iMEC)Sano HospitalHyogo
| | - Daizen Hirata
- Gastrointestinal Center and Institute of Minimally invasive Endoscopic Care (iMEC)Sano HospitalHyogo
| | - Mineo Iwatate
- Gastrointestinal Center and Institute of Minimally invasive Endoscopic Care (iMEC)Sano HospitalHyogo
| | - Rajvinder Singh
- Gastroenterology UnitDivision of MedicineLyell McEwin HospitalSchool of MedicineThe University of AdelaideAdelaideAustralia
| | - Siew C. Ng
- Departments of Medicine and TherapeuticsInstitute of Digestive DiseaseState Key Laboratory of Digestive DiseasesLKS Institute of Health ScienceThe Chinese University of Hong KongHong KongChina
| | - Shiaw‐Hooi Ho
- Department of MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Philip Chiu
- SurgeryInstitute of Digestive DiseaseState Key Laboratory of Digestive DiseasesLKS Institute of Health ScienceThe Chinese University of Hong KongHong KongChina
| | - Hisao Tajiri
- Department of Innovative Interventional Endoscopy ResearchThe Jikei University School of MedicineTokyoJapan
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19
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Anderson JC, Kahi CJ, Rex DK. Response. Gastrointest Endosc 2019; 89:1071-1073. [PMID: 31005130 DOI: 10.1016/j.gie.2019.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 01/09/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Joseph C Anderson
- Department of Veterans Affairs Medical Center, White River Junction, Vermont, USA; The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Charles J Kahi
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA; Richard L. Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Douglas K Rex
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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20
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Comparing adenoma and polyp miss rates for total underwater colonoscopy versus standard CO 2: a randomized controlled trial using a tandem colonoscopy approach. Gastrointest Endosc 2019; 89:591-598. [PMID: 30367879 DOI: 10.1016/j.gie.2018.09.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although water exchange may improve adenoma detection compared with CO2, it is unclear whether water is a better medium to fill the lumen during withdrawal and visualize the mucosa. Total underwater colonoscopy (TUC) involves the use of water exchange with the air valve off during insertion followed by the inspection of the mucosa under water. Our goal was to compare miss rates for TUC with standard CO2 for polyps and adenomas using a tandem colonoscopy design. METHODS We randomized participants to undergo tandem colonoscopies using TUC or CO2 first. In TUC, water exchange was performed during insertion, and withdrawal was performed under water. For the CO2 colonoscopy, both insertion and withdrawal were performed with CO2. The main outcomes were miss rates for polyps and adenomas for the first examination calculated as the number of additional polyps/adenomas detected during the second examination divided by the total number of polyps/adenomas detected for both examinations. Inspection times were calculated by subtracting the time for polypectomy, and care was taken to keep the times equal for both examinations. RESULTS A total of 121 participants were randomized with 61 having CO2 first. The overall miss rate for polyps was higher for the TUC-first group (81/237; 34%) compared with the CO2-first cohort (57/264; 22%) (P = .002). In addition, the overall miss rate for all adenomas was higher for the TUC-first group (52/146; 36%) compared with the CO2 group (37/159; 23%) (P = .025). However, 1 of the 3 endoscopists had higher polyp/adenoma miss rates for CO2, but these were not statistically significant differences. The insertion time was longer for TUC than for CO2. After adjusting for times, participant characteristics, and bowel preparation, the miss rate for polyps was higher for TUC than for CO2. CONCLUSIONS We found that TUC had an overall higher polyp and adenoma miss rate than colonoscopy performed with CO2, and TUC took longer to perform. However, TUC may benefit some endoscopists, an issue that requires further study. (Clinical trial registration number: NCT03231917.).
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Thayalasekaran S, Alkandari A, Varytimiadis L, Subramaniam S, Coda S, Longcroft-Wheaton G, Bhandari P. To cap/cuff or ring: do distal attachment devices improve the adenoma detection? Expert Rev Gastroenterol Hepatol 2019; 13:119-127. [PMID: 30791785 DOI: 10.1080/17474124.2019.1551131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Colonoscopy reduces the risk of colorectal cancer, by interrupting the adenoma-carcinoma sequence enabling the detection and removal of adenomas before they turn into colorectal cancer. Colonoscopy has its limitations as adenoma miss rates as high as 25% have been reported. The reasons for missed pathology are complicated and multi-factorial. The recent drive to improve adenoma detection rates has led to a plethora of new technologies. Areas covered: An increasing number of advanced endoscopes and distal attachment devices have appeared in the market. Advanced endoscopes aim to improve mucosal visualization by widening the field of view. Distal attachment devices aim to increase adenoma detection behind folds by flattening folds on withdrawal. In this review article, we discuss the three following distal attachment devices: the transparent cap, the Endocuff, and the Endoring. Expert commentary: The authors believe that the distal attachment devices will have a greater benefit for endoscopists with low baseline adenoma detection rates.
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Affiliation(s)
| | - Asma Alkandari
- a Gastroenterology Queen Alexandra Hospital , Portsmouth , United Kingdom
| | | | | | - Sergio Coda
- a Gastroenterology Queen Alexandra Hospital , Portsmouth , United Kingdom.,b InHealth Endoscopy Limited , London , United Kingdom
| | | | - Pradeep Bhandari
- a Gastroenterology Queen Alexandra Hospital , Portsmouth , United Kingdom.,c Pharmacy and Biomedical Sciences , University of Portsmouth , Portsmouth , United Kingdom
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22
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Gkolfakis P, Tziatzios G, Facciorusso A, Muscatiello N, Triantafyllou K. Meta-analysis indicates that add-on devices and new endoscopes reduce colonoscopy adenoma miss rate. Eur J Gastroenterol Hepatol 2018; 30:1482-1490. [PMID: 30188409 DOI: 10.1097/meg.0000000000001245] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION A variety of add-on devices and new-generation endoscopes have the potential to detect lesions 'hidden' behind colonic folds. We measured the effect of these new modalities on colonoscopy's lesions miss rates by a meta-analysis of data from individual studies. MATERIALS AND METHODS We performed literature searches in Medline and Cochrane Library for back-to-back randomized-controlled trials evaluating colonoscope add-on devices and new endoscopes in terms of lesions miss rates. The effect size on study outcomes is shown as relative risk (95% confidence interval). RESULTS We identified nine tandem studies with 1594 patients: seven evaluating add-on devices (one with cap, two with Endocuff, one with Endorings, one with Third-Eye Retroscope, two with G-EYE endoscope) and two evaluating the full-spectrum endoscopy system (FUSE) in comparison with conventional colonoscopy (CC). Overall, adenoma miss rate (AMR) was significantly lower with add-on devices/FUSE [0.33 (0.22-0.50), P<0.00001] compared with CC, the effect being similar among the add-on devices [0.35 (0.22-0.57), P<0.0001] and the FUSE [0.26 (0.15-0.46), P<0.00001] studies, respectively. Advanced AMR and polyp miss rate (PMR) were also significantly lower using add-on devices/FUSE [0.30 (0.21-0.44), P<0.0001 and 0.31 (0.13-0.79), P=0.01, respectively]. Use of add-on devices/FUSE scope was associated with significantly lower AMR and PMR in the proximal colon and it was associated with shortening of the colonoscopy surveillance interval. CONCLUSION Our meta-analysis provides evidence that AMR, advanced AMR, and PMR are significantly lower using add-on to colonoscope devices and the full-spectrum endoscopy systems compared with CC. Heterogeneity among the included studies and the small number of detected advanced adenomas call for cautious interpretation of the results.
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Affiliation(s)
- Paraskevas Gkolfakis
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Nicola Muscatiello
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine-Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
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Kudo T, Saito Y, Ikematsu H, Hotta K, Takeuchi Y, Shimatani M, Kawakami K, Tamai N, Mori Y, Maeda Y, Yamada M, Sakamoto T, Matsuda T, Imai K, Ito S, Hamada K, Fukata N, Inoue T, Tajiri H, Yoshimura K, Ishikawa H, Kudo SE. New-generation full-spectrum endoscopy versus standard forward-viewing colonoscopy: a multicenter, randomized, tandem colonoscopy trial (J-FUSE Study). Gastrointest Endosc 2018; 88:854-864. [PMID: 29908178 DOI: 10.1016/j.gie.2018.06.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 06/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Although colonoscopy is the criterion standard for detection of colorectal adenomas, some adenomas are missed. Full-spectrum endoscopy (FUSE) allows for observation with a 330-degree angle of view, which is expected to decrease the miss rate. However, no consensus has been reached regarding the superiority of FUSE over standard forward-viewing colonoscopy (SFVC) for detection of adenomas; we therefore compared new-generation FUSE and SFVC regarding colorectal adenoma miss rate (AMR) in this, the first reported randomized control trial using new-generation FUSE. METHODS We enrolled individuals aged 40 to 75 years who had been referred for screening, surveillance, fecal occult blood test positivity, or symptoms in a prospective randomized trial of tandem colonoscopy in 8 institutions. Patients were randomly assigned (1:1) via computer-generated stratified randomization. Neither the endoscopists nor patients were blinded to the allocation. The primary endpoint was AMR per patient (AMR-PP). RESULTS We enrolled 345 patients and included 319 in the per-protocol analyses. AMR-PP was significantly lower with FUSE (11.7%; 95% confidence interval [CI], 8.0%-15.4%) than with SFVC (22.9%; 95% CI, 17.5%-28.3%; P < .001). AMR-PP for lesions ≤5 mm in size was significantly lower with FUSE (10.4%; 95% CI, 6.5%-14.3%) than with SFVC (20.0%; 95% CI, 14.4%-25.6%; P = .0057). Furthermore, AMR-PP in the ascending colon was significantly lower with FUSE (4.3%; 95% CI, 1.4%-7.2%) than with SFVC (10.6%; 95% CI, 6.1%-15.1%; P = .0212). CONCLUSIONS FUSE is superior to SFVC regarding both AMR-PP and AMR; additionally, AMR-PP is both significantly lower with FUSE than SFVC for lesions ≤5 mm in size and in the ascending colon. (Clinical trial registration number: UMIN000020448.).
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Affiliation(s)
- Toyoki Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Kinichi Hotta
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masaaki Shimatani
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Ken Kawakami
- Second Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Naoto Tamai
- Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan
| | - Yuichi Mori
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Yasuharu Maeda
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Masayoshi Yamada
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Taku Sakamoto
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahisa Matsuda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Kenichiro Imai
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Sayo Ito
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kenta Hamada
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Norimasa Fukata
- Third Department of Internal Medicine, Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
| | - Takuya Inoue
- Second Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Hisao Tajiri
- Department of Innovative Interventional Endoscopy Research, Jikei University School of Medicine, Tokyo, Japan
| | - Kenichi Yoshimura
- Innovative Clinical Research Center, Kanazawa University Hospital, Kanazawa, Japan
| | - Hideki Ishikawa
- Department of Molecular-Targeting Cancer Prevention, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shin-Ei Kudo
- Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
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León Moreno JF. ADR evaluation of screening colonoscopies during 2016 - 2017 in a private health clinic in Peru. Endosc Int Open 2018; 6:E1304-E1309. [PMID: 30410949 PMCID: PMC6221814 DOI: 10.1055/a-0672-1045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/14/2018] [Indexed: 11/03/2022] Open
Abstract
Background and study aims High-quality colonoscopy is fundamental for preventing colorectal cancer (CRC). The adenoma detection rate (ADR) is a key colonoscopy quality measure. The aim of this study was to establish the screening colonoscopy ADR of a tertiary referral center in Peru, identify the relationship between the ADR and patient age, sex and the colonoscopist, and determine the endoscopic and histopathological characteristics of the lesions found. Patients and methods A retrospective observational longitudinal study was undertaken between January 2016 and June 2017. Results Eight colonoscopists performed screening colonoscopies on 620 patients scoring ≥ 6 points on the Boston Bowel Preparation Scale (BBPS); cecal intubation was complete in 595 patients (cecal intubation rate [CIR] 95.9 %). The overall ADR was 29.7 % (females 25.4 %, males 33.1 %, P = 0.040, 95 %Cl). The ADR colonoscopist range was 25.0 % to 34.4 %. The highest ADR (41.2 %, P = 0.013, 95 %Cl) was for patients aged 65 to 75 years. Adenoma colon locations were: left 49 %, transverse 21.6 % and right 29.4 %. Adenoma dysplasia grades: low 98 %, high 2 %. Sixty-three percent of the lesions were 5 mm to 10 mm. Resections performed: 78.5 % cold biopsy forceps (CBF), 3.4 % cold snare polypectomy (CSP) and 18.1 % endoscopic mucosal resection (EMR). Conclusions The ADR established was in line with the joint American College of Gastroenterology (ACG)/American Society for Gastrointestinal Endoscopy (ASGE) recommendations and related to patient age and gender but not to the colonoscopist. Colonoscopists should ensure rigorous application of the colonoscopy quality actions. ADR should be evaluated frequently.
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Affiliation(s)
- Julio F. León Moreno
- Instituto de Enfermedades Digestivas, Department of Gastroenterology, Clínica Internacional, Lima, Perú
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Gkolfakis P, Tziatzios G, Spartalis E, Papanikolaou IS, Triantafyllou K. Colonoscopy attachments for the detection of precancerous lesions during colonoscopy: A review of the literature. World J Gastroenterol 2018; 24:4243-4253. [PMID: 30310257 PMCID: PMC6175757 DOI: 10.3748/wjg.v24.i37.4243] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 08/06/2018] [Accepted: 08/24/2018] [Indexed: 02/06/2023] Open
Abstract
Although colonoscopy has been proven effective in reducing the incidence of colorectal cancer through the detection and removal of precancerous lesions, it remains an imperfect examination, as it can fail in detecting up to almost one fourth of existing adenomas. Among reasons accounting for such failures, is the inability to meticulously visualize the colonic mucosa located either proximal to haustral folds or anatomic curves, including the hepatic and splenic flexures. In order to overcome these limitations, various colonoscope attachments aiming to improve mucosal visualization have been developed. All of them - transparent cap, Endocuff, Endocuff Vision and Endorings - are simply mounted onto the distal tip of the scope. In this review article, we introduce the rationale of their development, present their mode of action and discuss in detail the effect of their implementation in the detection of lesions during colonoscopy.
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Affiliation(s)
- Paraskevas Gkolfakis
- Hepato-gastroenterology Unit, Second Department of Internal Medicine -Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, ‘‘Attikon” University General Hospital, Athens 12462, Greece
| | - Georgios Tziatzios
- Hepato-gastroenterology Unit, Second Department of Internal Medicine -Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, ‘‘Attikon” University General Hospital, Athens 12462, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, National and Kapodistrian University of Athens, Athens 12462, Greece
| | - Ioannis S Papanikolaou
- Hepato-gastroenterology Unit, Second Department of Internal Medicine -Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, ‘‘Attikon” University General Hospital, Athens 12462, Greece
| | - Konstantinos Triantafyllou
- Hepato-gastroenterology Unit, Second Department of Internal Medicine -Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, ‘‘Attikon” University General Hospital, Athens 12462, Greece
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26
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Nutalapati V, Kanakadandi V, Desai M, Olyaee M, Rastogi A. Cap-assisted colonoscopy: a meta-analysis of high-quality randomized controlled trials. Endosc Int Open 2018; 6:E1214-E1223. [PMID: 30302379 PMCID: PMC6175690 DOI: 10.1055/a-0650-4258] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 05/09/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Standard colonoscopy (SC) is the preferred modality for screening for colon cancer; however, it carries a significant polyp/adenoma miss rate. Cap-assisted colonoscopy (CC) has been shown to improve polyp/adenoma detection rate, decrease cecal intubation time and increase cecal intubation rate when compared to standard colonoscopy (SC). However, data on adenoma detection rate (ADR) are conflicting. The aim of this meta-analysis was to compare the performance of CC with SC for ADR among high-quality randomized controlled trials. Patients and methods We performed an extensive literature search using MEDLINE, EMBASE, Scopus, Cochrane and Web of Science databases and abstracts published at national meetings. Only comparative studies between CC and SC were included if they reported ADR, adenoma per person (APP), cecal intubation rate, and cecal intubation time. The exclusion criterion for comparing ADR was studies with Jadad score ≤ 2. The odds ratio (OR) was calculated using Mantel-Haenszel method. I 2 test was used to measure heterogeneity among studies. Results Analysis of high-quality studies (Jadad score ≥ 3, total of 7 studies) showed that use of cap improved the ADR with the results being statistically significant (OR 1.18, 95 % CI 1.03 - 1.33) and detection of 0.16 (0.02 - 0.30) additional APP. The cecal intubation rate in the CC group was 96.3 % compared to 94.5 % with SC (total of 17 studies). Use of cap improved cecal intubation (OR 1.61, 95 % CI 1.33 - 1.95) when compared to SC ( P value < 0.001). Use of cap decreased cecal intubation time by an average of 0.88 minutes (95 % CI 0.37 - 1.39) or 53 seconds. Conclusions Meta-analysis of high-quality studies showed that CC improved the ADR compared to SC.
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Affiliation(s)
- Venkat Nutalapati
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Vijay Kanakadandi
- Department of Gastroenterology, The University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Madhav Desai
- Department of Gastroenterology, The University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Mojtaba Olyaee
- Department of Gastroenterology, The University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Amit Rastogi
- Department of Gastroenterology, The University of Kansas Medical Center, Kansas City, Kansas, United States,Corresponding author Amit Rastogi, MD Department of Gastroenterology & HepatologyUniversity of Kansas Medical Center3901 Rainbow BlvdKansas City, KS 66160USA
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Abstract
So, is there enough evidence to incorporate CC in clinical practice? If we interpret the literature and the meta-analysis by Nutalapati et al., the answer for the clinically-focused endoscopist, with regard to adenoma detection rate (ADR), at present, may be "no". Significant differences do not necessarily imply clinical benefits and translation into clinical practice. The answer for the improvement of cecal intubation frequency and intubation time by the cap depends on the focus of training commitment, because these effects of the cap may be beneficial, especially for unexperienced endoscopists. It is obvious that further studies are needed. In this line, it is interesting to know, that in a recent meta-analysis of prospective studies, the length of the transparent cap had opposite effects on investigation time and polyp detection rate. Whereas, the anal to cecal time was significantly shortened by a cap length of > 7 mm and a polyp detection rate was significantly improved by a cap length of < 4 mm.
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Affiliation(s)
- Thomas Frieling
- Department of Gastroenterology, Hepatology, Infectiology, Neurogastroenterology, Hematology, Oncology, and Palliative Medicine, HELIOS-Clinic Krefeld, Krefeld, Germany
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Wang CL, Huang ZP, Chen K, Yan FH, Zhu LL, Shan YQ, Gao YJY, Li BR, Wang H, Yu ED, Zhao ZY. Adenoma miss rate determined by very shortly repeated colonoscopy: Retrospective analysis of data from a single tertiary medical center in China. Medicine (Baltimore) 2018; 97:e12297. [PMID: 30235675 PMCID: PMC6160154 DOI: 10.1097/md.0000000000012297] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Adenoma miss rate (AMR) has been calculated in several tandem colonoscopy studies, but it costs overmuch to carry out a clinical trial.We aimed to put forward AMR by taking advantage of retrospective data, and to judge the comparability between AMRs from prospective and retrospective data.Data of the patients accepting repeated colonoscopies during January to September 2016 was retrospectively collected and analyzed. Information was recorded, including bowel preparation quality of the first colonoscopy, size, location, histology and whether missed within the first colonoscopy of each single adenoma. AMR was compared by different risk factors through χ test and multivariable logistic regression.Around 267 adenomas were detected during 309 pairs of repeated colonoscopies, of which 66 were missed during the first colonoscopies. AMRs of the lesions small in size, nonadvanced in histology, in poor bowel preparation context and located in the proximal colon, were significantly higher than the opposite ones, and old age and male were related to adenoma missing (P < .05). In multivariable logistic regression analysis, adenoma-related factors (diminutive in size, poor bowel preparation and located in ascending colon, transverse colon or sigmoid colon), and patient-related factors (older than 60 years, male and poor bowel preparation) were found to be independently associated with missing adenomas (P < .05).AMR of retrospective data is comparable to that of tandem studies. Several risk factors influence AMR dramatically, which should be paid attention to.
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Affiliation(s)
- Cheng-Long Wang
- Department of Colorectal Surgery and GI Endoscopy Center, Changhai Hospital
| | - Zhi-Ping Huang
- Department of General Surgery, Guangzhou General Hospital of PLA, Guangzhou
| | - Kai Chen
- Department of General Surgery, Guangzhou General Hospital of PLA, Guangzhou
| | - Fei-Hu Yan
- Department of Colorectal Surgery and GI Endoscopy Center, Changhai Hospital
| | - Liang-Liang Zhu
- Department of Colorectal Surgery and GI Endoscopy Center, Changhai Hospital
| | - Yong-Qi Shan
- Department of General Surgery, Shenyang General Hospital of PLA, Shenyang
| | - Yong-Jun-Yi Gao
- Department of Emergency Medicine, The 309th Hospital of PLA, Beijing
| | - Bai-Rong Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hao Wang
- Department of Colorectal Surgery and GI Endoscopy Center, Changhai Hospital
| | - En-Da Yu
- Department of Colorectal Surgery and GI Endoscopy Center, Changhai Hospital
| | - Zi-Ye Zhao
- Department of Colorectal Surgery and GI Endoscopy Center, Changhai Hospital
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Faster colonoscope withdrawal time without impaired detection using EndoRings. Endosc Int Open 2018; 6:E957-E960. [PMID: 30083584 PMCID: PMC6070371 DOI: 10.1055/a-0614-2052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/22/2018] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Mucosal exposure devices on the colonoscope tip have improved detection. We evaluated detection and procedure times in colonoscopies performed with EndoRings. PATIENTS AND METHODS We had 14 endoscopists in a university practice trial EndoRings. We compared detection and procedure times to age- and indication-matched procedures by the same endoscopists. RESULTS There were 137 procedures with EndoRings. The adenoma detection rate was 44 % with EndoRings vs. 39 % without ( P = 0.39). Mean adenomas per colonoscopy (standard deviation) was 1.2 (2.3) with EndoRings vs. 0.9 (1.6) without ( P = 0.055). Mean insertion time with EndoRings was 6.2 (3.2) minutes vs. 6.6 (6.7) minutes without ( P = 0.81). Mean withdrawal time with EndoRings in all patients with or without polypectomy was 12.2 (5.3) minutes and 16.1 (10.3) minutes without ( P = 0.0005). CONCLUSION EndoRings may allow faster withdrawal during colonoscopy without any reduction in detection. Prospective trials with mucosal exposure devices targeting procedure times as primary endpoints are warranted.
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Facciorusso A, Del Prete V, Buccino RV, Della Valle N, Nacchiero MC, Monica F, Cannizzaro R, Muscatiello N. Comparative Efficacy of Colonoscope Distal Attachment Devices in Increasing Rates of Adenoma Detection: A Network Meta-analysis. Clin Gastroenterol Hepatol 2018; 16:1209-1219.e9. [PMID: 29133257 DOI: 10.1016/j.cgh.2017.11.007] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/01/2017] [Accepted: 11/04/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Several add-on devices have been developed to increase rates of colon adenoma detection (ADR). We assessed their overall and comparative efficacy, and estimated absolute magnitude of benefit through a network meta-analysis. METHODS We searched the PubMed/Medline and Embase database through March 2017 and identified 25 randomized controlled trials (comprising 16,103 patients) that compared the efficacy of add-on devices (cap; Endocuff; Arc Medical Design Ltd, Leeds, UK, and Endorings; Us Endoscopy, Mentor, OH) with each other or with standard colonoscopy. The primary outcome was ADR; secondary outcomes included rate of polyp detection, and rate of and time to cecal intubation. We performed pairwise and network meta-analyses, and appraised quality of evidence using Grading of Recommendations Assessment, Development and Evaluation. We estimated the magnitude of increase in ADR by low-performing endoscopists (baseline ADR, 10%) and high-performing endoscopists (baseline ADR, 40%) with use of these devices. RESULTS Overall, distal attachment devices increased ADR compared with standard colonoscopy (relative risk [RR], 1.13; 95% CI, 1.03-1.23; low-quality evidence), with potential absolute increases in ADR to 11.3% for low-performing endoscopists and to 45.2% for high-performing endoscopists. In a comparative evaluation, we found low-quality evidence that Endocuff increases ADR compared with standard colonoscopy (RR, 1.21; 95% CI, 1.03-1.41), with anticipated increases in ADR to 12% for low-performing endoscopists and to 48% for high-performing endoscopists. We found very low quality evidence to support the use of Endorings (RR, 1.70; 95% CI, 0.86-3.36) or caps (RR, 1.07; 95% CI, 0.96-1.19) vs standard colonoscopy for increasing ADR. The benefit of one distal attachment device over another was uncertain due to very low quality evidence. CONCLUSIONS Based on network meta-analysis, we anticipate only modest improvement in ADRs with use of distal attachment devices, especially in low-performing endoscopists.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy.
| | - Valentina Del Prete
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | | | - Nicola Della Valle
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | | | - Fabio Monica
- Division of Gastroenterology and Digestive Endoscopy, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Renato Cannizzaro
- Gastroenterology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Centro di Riferimento Oncologico, Aviano, Italy
| | - Nicola Muscatiello
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
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Ngu WS, Rees C. Can technology increase adenoma detection rate? Therap Adv Gastroenterol 2018; 11:1756283X17746311. [PMID: 29383029 PMCID: PMC5784538 DOI: 10.1177/1756283x17746311] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/16/2017] [Indexed: 02/04/2023] Open
Abstract
Colorectal cancer is the third most common cancer worldwide and the second most common cause of cancer-related death in Europe and North America. Colonoscopy is the gold standard investigation for the colon but is not perfect, and small or flat adenomas can be missed which increases the risk of patients subsequently developing colorectal cancer. Adenoma detection rate is the most widely used marker of quality, and low rates are associated with increased rates of post-colonoscopy colorectal cancer. Standards of colonoscopy and adenoma detection vary widely between different endoscopists. Interventions to improve adenoma detection rate are therefore required. Many devices have been purported to increase adenoma detection rate. This review looks at current available evidence for device technology to improve adenoma detection rate during colonoscopy.
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Affiliation(s)
- Wee Sing Ngu
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, UK
| | - Colin Rees
- Department of Gastroenterology, South Tyneside District Hospital, South Shields, NE34 0PL, UK
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Tseng CW, Koo M, Hsieh YH. Cecal intubation time between cap-assisted water exchange and water exchange colonoscopy: a randomized-controlled trial. Eur J Gastroenterol Hepatol 2017; 29:1296-1302. [PMID: 28857895 DOI: 10.1097/meg.0000000000000954] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM The water exchange (WE) method can decrease the discomfort of the patients undergoing colonoscopy. It also provides salvage cleansing and improves adenoma detection, but a longer intubation time is required. Cap-assisted colonoscopy leads to a significant reduction in cecal intubation time compared with traditional colonoscopy with air insufflation. The aim of this study was to investigate whether combined cap-assisted colonoscopy and water exchange (CWE) could decrease the cecal intubation time compared with WE. PATIENTS AND METHODS A total of 120 patients undergoing fully sedated colonoscopy at a regional hospital in southern Taiwan were randomized to colonoscopy with either CWE (n=59) or WE (n=61). The primary endpoint was cecal intubation time. RESULTS The mean cecal intubation time was significantly shorter in CWE (12.0 min) compared with WE (14.8 min) (P=0.004). The volume of infused water during insertion was lower in CWE (840 ml) compared with WE (1044 ml) (P=0.003). The adenoma detection rate was 50.8 and 47.5% for CWE and WE, respectively (P=0.472). The Boston Bowel Preparation Scale scores were comparable in the two groups. Results from the multiple linear regression analysis indicated that WE with a cap, a higher degree of endoscopist's experience, a higher Boston Bowel Preparation Scale score, and a lower volume of water infused during insertion, without abdominal compression, without change of position, and without chronic laxative use, were significantly associated with a shorter cecal intubation time. CONCLUSION In comparison with WE, CWE could shorten the cecal intubation time and required lower volume of water infusion during insertion without compromising the cleansing effect of WE.
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Affiliation(s)
- Chih-Wei Tseng
- Departments of aInternal Medicine, Division of Gastroenterology bMedical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi cSchool of Medicine, Tzu Chi University, Hualien City, Taiwan dDalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Min M, Deng P, Zhang W, Sun X, Liu Y, Nong B. Comparison of linked color imaging and white-light colonoscopy for detection of colorectal polyps: a multicenter, randomized, crossover trial. Gastrointest Endosc 2017; 86:724-730. [PMID: 28286095 DOI: 10.1016/j.gie.2017.02.035] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 02/23/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Linked color imaging (LCI), a recently developed technology, uses a laser endoscopic system to enhance the color separation of red color to depict red and white colors more vividly. The benefits of LCI in the detection of colorectal polyps remain unknown. The aim of this study was to assess the ability of LCI to improve the detection of colorectal polyps compared with white-light (WL) endoscopy. METHODS We performed a multicenter, crossover, prospective, randomized controlled trial in 3 hospitals in China. All patients underwent crossover colonoscopies with LCI and WL endoscopy in a randomized order. All lesions were removed during the second endoscopic procedure. The primary outcome measure was the difference in sensitivity between LCI and WL endoscopy for the detection of colorectal polyps. The secondary outcome measures were the adenoma detection rate per patient in the 2 groups and the factors associated with polyp miss rates. RESULTS A total of 152 patients were randomized, and 141 were included in the analysis. The overall polyp detection rate increased significantly by 24% for LCI colonoscopy, corresponding to a higher sensitivity with LCI than with WL endoscopy (91% vs 73%, P < .0001). Furthermore, LCI identified significantly more patients (32%) with polyps. The per-patient adenoma detection rate was significantly higher for LCI than for WL endoscopy (37% vs 28%; 95% confidence interval, 2.39%-19.41%). CONCLUSIONS LCI improves the detection of colorectal polyps and adenomas during colonoscopy. (Clinical trial registration number: NCT02724397.).
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Affiliation(s)
- Min Min
- Department of Gastroenterology and Hepatology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, China
| | - Pei Deng
- Department of Gastroenterology and Hepatology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, China
| | - Wenhua Zhang
- Department of Gastroenterology and Hepatology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nan Ning, Guangxi, China
| | - Xiaomin Sun
- Department of Gastroenterology and Hepatology, Shanghai Tenth People's Hospital, Shanghai, 200000, China
| | - Yan Liu
- Department of Gastroenterology and Hepatology, Affiliated Hospital of Academy of Military Medical Sciences, Beijing, China
| | - Bing Nong
- Department of Gastroenterology and Hepatology, The People's Hospital of Guangxi Zhuang Autonomous Region, Nan Ning, Guangxi, China
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Desai M, Sanchez-Yague A, Choudhary A, Pervez A, Gupta N, Vennalaganti P, Vennelaganti S, Fugazza A, Repici A, Hassan C, Sharma P. Impact of cap-assisted colonoscopy on detection of proximal colon adenomas: systematic review and meta-analysis. Gastrointest Endosc 2017; 86:274-281.e3. [PMID: 28365356 DOI: 10.1016/j.gie.2017.03.1524] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/17/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Proximal colon adenomas can be missed during routine colonoscopy. Use of a cap or hood on the tip of the colonoscope has been shown to improve overall adenoma detection with variable rates. However, it has not been systematically evaluated for detection of proximal colon or right-sided adenomas where the cap may have maximum impact on adenoma detection rate (ADR). Our aim was to perform a systematic review and meta-analysis to evaluate the impact of cap-assisted colonoscopy (CC) on right-sided ADRs (r-ADRs) compared with standard colonoscopy (SC). METHODS PubMed, EMBASE, SCOPUS, and Cochrane databases as well as secondary sources (bibliographic review of selected articles and major GI proceedings) were searched through October 1, 2016. Primary outcome was the pooled rate of r-ADR. Detection of flat adenoma, sessile serrated adenoma/polyp (SSA/P), and number of right-sided adenomas per patient were also assessed. Pooled odds ratio (OR) and 95% confidence intervals (CIs) were calculated using random-effect models. RESULTS We screened 686 records and analyzed data from 4 studies (CC group, 2546 patients; SC group, 2547 patients) that met criteria for determination of r-ADRs, whereas 6 studies (CC group, 3159 patients; SC group, 3137 patients) were analyzed to estimate right-sided adenomas per patient. r-ADR was significantly higher with CC compared with SC (23% vs 17%; OR, 1.49; 95% CI, 1.08-2.05; I2 = 79%; P = .01). CC also improved detection rates of flat adenoma (OR, 2.08; 95% CI, 1.35-3.20; P < .01) and SSA/P (OR, 1.33; 95% CI, 1.01-1.74; P = .04). The total number of right-sided adenomas (CC: 1428 [60%] vs SC: 1127 [58%]) and number of right-sided adenomas per patient (CC, .71 ± .5, vs SC, .65 ± .62 [mean ± standard deviation]) were numerically higher for CC but were not statistically significant (P = .43). Approximately 17 CCs would be required to detect an additional patient with right-sided adenoma. CONCLUSIONS Use of CC significantly improves the proximal colon ADR. In addition, flat adenoma and serrated colonic lesion detection rates are also significantly higher as compared with SC.
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Affiliation(s)
- Madhav Desai
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | | | - Abhishek Choudhary
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Asad Pervez
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Neil Gupta
- Department of Gastroenterology and Hepatology, Loyola University Medical Center, Chicago, Illinois, USA
| | - Prashanth Vennalaganti
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA
| | - Sreekar Vennelaganti
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Alessandro Fugazza
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - Alessandro Repici
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - Cesare Hassan
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - Prateek Sharma
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Missouri, USA; Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
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Polyp detection at colonoscopy: Endoscopist and technical factors. Best Pract Res Clin Gastroenterol 2017; 31:425-433. [PMID: 28842052 DOI: 10.1016/j.bpg.2017.05.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 05/31/2017] [Indexed: 01/31/2023]
Abstract
The adenoma detection rate (ADR) has emerged as the most important quality measure in colonoscopy, as it predicts the risk of interval cancer after colonoscopy. Measuring and improving ADR is the central focus of the current quality movement in colonoscopy. High ADRs can be achieved by a colonoscopist with a thorough understanding of the wide range of endoscopic appearances of precancerous lesions in the colorectum, effective bowel preparation, and meticulous technique using high definition colonoscopes. The knowledgeable and effective examiner needs no adjunctive devices or techniques to achieve master level ADRs. However, measurement reveals that many colonoscopists have ADRs that are below recommended minimum thresholds or below master levels. These colonoscopists, and even master level performers, can choose from a variety of adjunctive tools to improve ADR. This review describes these tools according to whether they are non-device methods (e.g. double right colon examination, patient position change, water exchange), mucosal exposure devices (wide angle colonoscopy, fold flattening devices), and lesion highlighting techniques (e.g. chromoendoscopy, electronic chromoendoscopy).
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Mir FA, Boumitri C, Ashraf I, Matteson-Kome ML, Nguyen DL, Puli SR, Bechtold ML. Cap-assisted colonoscopy versus standard colonoscopy: is the cap beneficial? A meta-analysis of randomized controlled trials. Ann Gastroenterol 2017; 30:640-648. [PMID: 29118558 PMCID: PMC5670283 DOI: 10.20524/aog.2017.0180] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 06/21/2017] [Indexed: 12/14/2022] Open
Abstract
Background: In an effort to improve visualization during colonoscopy, a transparent plastic cap or hood may be placed on the end of the colonoscope. Cap-assisted colonoscopy (CAC) has been studied and is thought to improve polyp detection. Numerous studies have been conducted comparing pertinent clinical outcomes between CAC and standard colonoscopy (SC) with inconsistent results. Methods: Numerous databases were searched in November 2016. Only randomized controlled trials (RCTs) involving adult subjects that compared CAC to SC were included. Outcomes of total colonoscopy time, time to cecum, cecal intubation rate, terminal ileum intubation rate, polyp detection rate (PDR), and adenoma detection rate (ADR) were analyzed in terms of odds ratio (OR) or mean difference (MD) with fixed effect and random effects models. Results: Five hundred eighty-nine articles and abstracts were discovered. Of these, 23 RCTs (n=12,947) were included in the analysis. CAC showed statistically significant superiority in total colonoscopy time (MD -1.51 min; 95% confidence interval [CI] -2.67 to -0.34; P<0.01) and time to cecum (MD -0.82 min; 95%CI -1.20 to -0.44; P<0.01) compared to SC. CAC also showed better PDR (OR 1.17; 95%CI 1.06-1.29; P<0.01) but not ADR (OR 1.11; 95%CI 0.95-1.30; P=0.20). In contrast, on sensitivity analysis, ADR was better with CAC. Terminal ileum intubation and cecal intubation rates demonstrated no significant difference between the two groups (P=0.11 and P=0.73, respectively). Conclusions: The use of a transparent cap during colonoscopy improves PDR while reducing procedure times. ADR may improve in cap-assisted colonoscopy but further studies are required to confirm this.
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Affiliation(s)
- Fazia A Mir
- Department of Medicine, University of Missouri, Columbia (Fazia A. Mir, Christine Boumitri, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Christine Boumitri
- Department of Medicine, University of Missouri, Columbia (Fazia A. Mir, Christine Boumitri, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Imran Ashraf
- Department of Medicine, University of Missouri, Columbia (Fazia A. Mir, Christine Boumitri, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Michelle L Matteson-Kome
- Department of Medicine, University of Missouri, Columbia (Fazia A. Mir, Christine Boumitri, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
| | - Douglas L Nguyen
- Department of Medicine, University of California, Irvine (Douglas L. Nguyen), USA
| | - Srinivas R Puli
- Department of Medicine, University of Illinois, Peoria (Srinivas R. Puli), USA
| | - Matthew L Bechtold
- Department of Medicine, University of Missouri, Columbia (Fazia A. Mir, Christine Boumitri, Imran Ashraf, Michelle L. Matteson-Kome, Matthew L. Bechtold), USA
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Ishaq S, Siau K, Harrison E, Tontini GE, Hoffman A, Gross S, Kiesslich R, Neumann H. Technological advances for improving adenoma detection rates: The changing face of colonoscopy. Dig Liver Dis 2017; 49:721-727. [PMID: 28454854 DOI: 10.1016/j.dld.2017.03.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/06/2017] [Accepted: 03/27/2017] [Indexed: 12/11/2022]
Abstract
Worldwide, colorectal cancer is the third commonest cancer. Over 90% follow an adenoma-to-cancer sequence over many years. Colonoscopy is the gold standard method for cancer screening and early adenoma detection. However, considerable variation exists between endoscopists' detection rates. This review considers the effects of different endoscopic techniques on adenoma detection. Two areas of technological interest were considered: (1) optical technologies and (2) mechanical technologies. Optical solutions, including FICE, NBI, i-SCAN and high definition colonoscopy showed mixed results. In contrast, mechanical advances, such as cap-assisted colonoscopy, FUSE, EndoCuff and G-EYE™, showed promise, with reported detections rates of up to 69%. However, before definitive recommendations can be made for their incorporation into daily practice, further studies and comparison trials are required.
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Affiliation(s)
- Sauid Ishaq
- Gastroenterology Department, Dudley Group Hospitals, Dudley, United Kingdom; Birmingham City University, Birmingham, United Kingdom; St. George's University, Grenada, West Indies.
| | - Keith Siau
- Gastroenterology Department, Dudley Group Hospitals, Dudley, United Kingdom
| | - Elizabeth Harrison
- Gastroenterology Department, Dudley Group Hospitals, Dudley, United Kingdom
| | - Gian Eugenio Tontini
- Gastroenterology and Digestive Endoscopy Unit, IRCCS Policlinico San Donato, San Donato, Italy
| | - Arthur Hoffman
- Department of Internal Medicine and Gastroenterology, St. Marienkrankenhaus Frankfurt, Frankfurt, Germany
| | - Seth Gross
- Division of Gastroenterology, NYU Langone Medical Center, New York, NY, USA
| | - Ralf Kiesslich
- Department of Internal Medicine and Gastroenterology, St. Marienkrankenhaus Frankfurt, Frankfurt, Germany
| | - Helmut Neumann
- Interventional Endoscopy Center, University Hospital Mainz, Germany
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Cap Assisted Upper Endoscopy for Examination of the Major Duodenal Papilla: A Randomized, Blinded, Controlled Crossover Study (CAPPA Study). Am J Gastroenterol 2017; 112:725-733. [PMID: 28291239 DOI: 10.1038/ajg.2017.47] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 01/29/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Examination of major duodenal papilla (MDP) by standard forward-viewing esophagogastroduodenoscopy (S-EGD) is limited. Cap assisted esophagogastroduodenoscopy (CA-EGD) utilizes a cap fitted to the tip of the endoscope that can depress the mucosal folds and thus might improve visualization of MDP. The aim of this study was to compare CA-EGD to S-EGD for complete examination of the MDP. METHODS Prospective, randomized, blinded, controlled crossover study. Subjects scheduled for elective EGD were randomized to undergo S-EGD (group A) or CA-EGD (group B) before undergoing a second examination by the alternate method. Images of the MDP were evaluated by three blinded multicenter-experts. Our primary outcome measure was complete examination of the papilla. Secondary outcome measures were duration and overall diagnostic yield. RESULTS A total of 101 patients were randomized and completed the study. Complete examination of MDP was achieved in 98 patients using CA-EGD compared to 24 patients using S-EGD (97 vs. 24%, P<0.001). Median duration from intubation of the esophagus until localization of the MDP was shorter with CA-EGD (46. vs. 96 s., P<0.001). In group A, 11 extra lesions and 12 additional incidental findings were detected by secondary CA-EGD, whereas neither were detected by secondary S-EGD in group B (22 vs. 0% and 24 vs. 0%, P<0.001 and P<0.001). CONCLUSION CA-EGD enabled complete examination of MDP in almost all cases compared to a low success rate of S-EGD. CA-EGD detected a significant amount of lesions and incidental findings when added to S-EGD. CA-EGD is a safe and effective method for examination of MDP.
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Othman MO, Zhang D, Elhanafi S, Eloliby M, Davis B, Guererro R, Alvarado L, Sanchez L, Dwivedi A, Zuckerman MJ. Cap-Assisted Colonoscopy Increases Detection of Advanced Adenomas and Polyps. Am J Med Sci 2017; 353:367-373. [PMID: 28317624 DOI: 10.1016/j.amjms.2017.01.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 01/29/2017] [Accepted: 01/30/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cap-assisted colonoscopy (CAC) has been reported to increase the adenoma detection rate (ADR) in Asian population. However, CAC trials in non-Asian population have had conflicting results. Studies in North America have shown an improvement in ADRs with the use of CAC, but it mainly included white and African American patients. Given the lack of prospective studies of CAC in Hispanics, we conducted this randomized controlled trial. MATERIALS AND METHODS This is a randomized controlled trial comparing CAC with standard colonoscopy (SC) in patients undergoing screening or surveillance colonoscopy. Our primary outcome was the ADR. Secondary outcomes were polyp detection rate, mean polyp and ADR, advanced ADR (AADR) and detection rates based on polyp morphology and location. RESULTS A total of 440 patients were included in the study (88.5% Hispanic). Cecal and terminal ileum intubation rates were similar in both groups (CAC: 97% and 86% versus SC: 99% and 81%, respectively). CAC did not improve ADR in comparison with SC (0.65 versus 0.52; P = 0.079); however, CAC had a higher AADR in comparison with SC (9.9% versus 4.6%; P = 0.049). CAC detected significantly more pedunculated polyps as compared with flat and sessile polyps (P = 0.011). Complication rates were similar in the CAC and SC groups (0.9% versus 0%). CONCLUSIONS In a predominantly Hispanic population, no difference was seen in the mean ADR with the use of CAC. However, CAC, when compared with SC, resulted in an increased AADR and mean polyp detection rate.
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Affiliation(s)
- Mohamed O Othman
- Department of Medicine, Baylor College of Medicine, Houston, Texas.
| | - Daniel Zhang
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Sherif Elhanafi
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Mohamed Eloliby
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Brian Davis
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Richard Guererro
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Luis Alvarado
- Department of Biomedical Sciences, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Linda Sanchez
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Alok Dwivedi
- Department of Biomedical Sciences, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Marc J Zuckerman
- Department of Internal Medicine, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas
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Hill A, Horswill MS, Plooy AM, Watson MO, Rowlands LN, Wallis GM, Riek S, Burgess-Limerick R, Hewett DG. Assessment of colorectal polyp recognition skill: development and validation of an objective test. Surg Endosc 2016; 31:2426-2436. [PMID: 27651355 DOI: 10.1007/s00464-016-5243-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/07/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The quality of colonoscopy is known to vary. The extent to which colonoscopists can recognize the presence of subtle colorectal lesions by visually distinguishing them from the surrounding mucosa (i.e., polyp recognition skill) may be one of several attributes that influence polyp detection rates. The aim of the present study was to develop and validate the first objective test of polyp recognition skill. METHODS Validation study. Twenty-eight experienced colonoscopists and eighty novices took a preliminary 280-item computer-based polyp recognition test. Items were genuine endoscopic images which participants assessed for the presence of "likely polyps." Half included clinically identified polyps. Participants clicked on a suspected lesion or a button marked "no likely polyp", and the main outcome measures were accuracy and response latency. The best items were selected for the final 50-item test. RESULTS In the preliminary test, experienced colonoscopists correctly identified more polyps than novices (P < .0001) and better discriminated between clinically identified polyps and non-polyp features (as measured by d', P < .0001). For polyp items, the experienced group also responded faster (P < .01). Effect sizes were large for accuracy (Cohen's d = 3.22) and d' (Cohen's d = 3.22). The 50 final test items produced comparable results for accuracy, d', and response latency. For both versions of the test, score scale reliability was high for both polyp and non-polyp items (α = .82 to .97). CONCLUSIONS The observed experienced-novice differences support the construct validity of the performance measures derived from the tests, indicating that polyp recognition skill can be quantified objectively. The final test may potentially be used to assess trainees, but test sensitivity may be insufficient to make fine-grained distinctions between different skill levels among experienced colonoscopists. More sensitive future tests may provide a valuable supplement to clinical detection rates, allowing objective comparisons between skilled colonoscopists.
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Affiliation(s)
- Andrew Hill
- Clinical Skills Development Service, Metro North Hospital and Health Service, Brisbane, Australia. .,School of Psychology, The University of Queensland, Brisbane, Australia.
| | - Mark S Horswill
- School of Psychology, The University of Queensland, Brisbane, Australia
| | - Annaliese M Plooy
- School of Human Movement Studies, The University of Queensland, Brisbane, Australia
| | - Marcus O Watson
- Clinical Skills Development Service, Metro North Hospital and Health Service, Brisbane, Australia.,School of Psychology, The University of Queensland, Brisbane, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
| | | | - Guy M Wallis
- School of Human Movement Studies, The University of Queensland, Brisbane, Australia
| | - Stephan Riek
- School of Human Movement Studies, The University of Queensland, Brisbane, Australia
| | | | - David G Hewett
- Clinical Skills Development Service, Metro North Hospital and Health Service, Brisbane, Australia.,School of Medicine, The University of Queensland, Brisbane, Australia
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41
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Abstract
Colonoscopy is a frequently performed diagnostic and therapeutic test and the primary screening tool in several nationalized bowel cancer screening programs. There has been a considerable focus on maximizing the utility of colonoscopy. This has occurred in four key areas: Optimizing patient selection to reduce unnecessary or low yield colonoscopy has offered cost-benefit improvements in population screening. Improving quality assurance, through the development of widely accepted quality metrics for use in individual practice and the research setting, has offered measurable improvements in colonoscopic yield. Significant improvements have been demonstrated in colonoscopic technique, from the administration of preparation to the techniques employed during withdrawal of the colonoscope. Improved techniques to avoid post-procedural complications have also been developed-further maximizing the utility of colonoscopy. The aim of this review is to summarize the recent evidence-based advances in colonoscopic practice that contribute to the optimal practice of colonoscopy.
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Affiliation(s)
- Crispin J Corte
- Department of Gastroenterology, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Rupert W Leong
- Department of Gastroenterology, Concord Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
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Schmidt-Tänzer W, Eickhoff A. What Influences the Quality of Prevention Colonoscopy? VISZERALMEDIZIN 2015; 30:26-31. [PMID: 26288579 PMCID: PMC4513811 DOI: 10.1159/000358747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Colorectal cancer still has a high incidence and mortality. Although colonoscopy is considered as gold standard of colorectal cancer screening, there still exists an unsatisfactory level of adenomas missed in screening and surveillance colonoscopy. Furthermore, patients bear the burden of potentially unpleasant and painful examination and preparation procedures. Method A search of the literature using PubMed was carried out, supplemented by a review of the programs of the Digestive Disease Week (DDW) and the United European Gastroenterology Week (UEGW) 2011-2013. Results Several new approaches to colonoscopy were described: water, CO2 and cap colonoscopy, and application of spasmolytics such as hyoscine butylbromide and glucagon. The use of these methods does not necessitate the purchase of new endoscopes. They are feasible and safe, facilitate achieving the aim of more comfort and less pain, and perhaps allow lower doses of sedatives to be used. However, a clear effect on procedure time is lacking. Furthermore, the published data do not consistently answer the question of whether these techniques have a positive impact on the most important goal, the better detection of carcinoma precursors. Conclusion More efforts to optimize bowel preparation have to be made to improve visualization of the mucosal surface. The most reliable criteria for the quality of screening and surveillance colonoscopy remain a minimum cecal intubation rate of >90%, a withdrawal time of at least 6 or better 9 min, and an adenoma detection rate of >20%. These results should be achieved with a complication rate lower than 1%, including polypectomy.
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Affiliation(s)
- Wolfgang Schmidt-Tänzer
- Medizinische Klinik II, Klinik für Gastroenterologie, Diabetologie und Infektiologie, Klinikum Hanau GmbH, Hanau, Germany
| | - Axel Eickhoff
- Medizinische Klinik II, Klinik für Gastroenterologie, Diabetologie und Infektiologie, Klinikum Hanau GmbH, Hanau, Germany
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43
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Kim DJ, Kim HW, Park SB, Kang DH, Choi CW, Hong JB, Ji BH, Lee CS. Efficacy of cap-assisted colonoscopy according to lesion location and endoscopist training level. World J Gastroenterol 2015; 21:6261-6270. [PMID: 26034361 PMCID: PMC4445103 DOI: 10.3748/wjg.v21.i20.6261] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/27/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the efficacy of cap-assisted colonoscopy (CAC) for detection of colorectal polyps and adenomas according to the lesion location and endoscopist training level.
METHODS: Patients 20 years or older, who underwent their first screening colonoscopy in a single tertiary center from May 2011 to December 2012 were enrolled in this study. All patients underwent either CAC or standard colonoscopy (SC), and all of the procedures were performed by 11 endoscopists (8 trainees and 3 experts). All procedures were performed with high-definition colonoscopes and narrow band imaging. The eight trainees had experiences of performing 150 to 500 colonoscopies, and the three experts had experiences of performing more than 3000 colonoscopies. A 4-mm-long transparent cap was attached to the end of a colonoscope in the CAC group. We retrospectively evaluated the number of polyps and adenomas, polyp detection rate (PDR), and the number of adenomas and adenoma detection rate (ADR) according to the lesion location and endoscopist training level between CAC and SC. We also evaluated the number of polyps and adenomas according to their size between CAC and SC.
RESULTS: Overall, PDR and ADR using CAC were significantly higher than those using SC for both whole colon (48.5% vs 40.7%, P = 0.012; 35.7% vs 28.3%, P = 0.012) and right-side colon (35.3% vs 26.6%, P = 0.002; 27.0% vs 16.9%, P < 0.001). The number of polyps and adenomas per patient using CAC was significantly higher than that using SC for both the whole colon (1.07 ± 1.59 vs 0.82 ± 1.31, P = 0.008; 0.72 ± 1.32 vs 0.50 ± 1.01, P = 0.003) and right-side colon (0.66 ± 1.18 vs 0.41 ± 0.83, P < 0.001; 0.46 ± 0.97 vs 0.25 ± 0.67, P < 0.001). In the trainee group, the PDR and ADR using CAC were significantly higher than those using SC for both the whole colon (46.7% vs 39.7%, P = 0.040; 33.9% vs 26.0%, P =0.012) and right-side colon (34.2% vs 26.5%, P = 0.015; 25.3% vs 15.9%, P = 0.001). In the expert group, the PDR and ADR using CAC were significantly higher than those using SC only for the right-side colon (42.1% vs 27.0%, P =0.035; 36.8% vs 21.0%, P = 0.020).
CONCLUSION: CAC is more effective than SC for detection of colorectal polyps and adenomas, especially when performed by trainees and when the lesions are located in the right-side colon.
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44
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Atia MA, Ramirez FC, Gurudu SR. Quality monitoring in colonoscopy: Time to act. World J Gastrointest Endosc 2015; 7:328-335. [PMID: 25901211 PMCID: PMC4400621 DOI: 10.4253/wjge.v7.i4.328] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 01/03/2015] [Accepted: 01/20/2015] [Indexed: 02/05/2023] Open
Abstract
Colonoscopy is the gold standard test for colorectal cancer screening. The primary advantage of colonoscopy as opposed to other screening modalities is the ability to provide therapy by removal of precancerous lesions at the time of detection. However, colonoscopy may miss clinically important neoplastic polyps. The value of colonoscopy in reducing incidence of colorectal cancer is dependent on many factors including, the patient, provider, and facility level. A high quality examination includes adequate bowel preparation, optimal colonoscopy technique, meticulous inspection during withdrawal, identification of subtle flat lesions, and complete polypectomy. Considerable variation among institutions and endoscopists has been reported in the literature. In attempt to diminish this disparity, various approaches have been advocated to improve the quality of colonoscopy. The overall impact of these interventions is not yet well defined. Implementing optimal education and training and subsequently analyzing the impact of these endeavors in improvement of quality will be essential to augment the utility of colonoscopy for the prevention of colorectal cancer.
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45
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Abstract
Colonoscopy for average-risk colorectal cancer screening has transformed the practice of gastrointestinal medicine in the United States. However, although the dominant screening strategy, its use is not supported by randomized controlled trials. Observational data do support a protective effect of colonoscopy and polypectomy on colorectal cancer incidence and mortality, but the level of protection in the proximal colon is variable and operator-dependent. Colonoscopy by high-level detectors remains highly effective, and ongoing quality improvement initiatives should consider regulatory factors that motivate changes in physician behavior.
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Affiliation(s)
- David G Hewett
- School of Medicine, The University of Queensland, Brisbane, QLD 4006, Australia; Department of Gastroenterology, Queen Elizabeth II Jubilee Hospital, Brisbane, QLD 4108, Australia.
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, 550 North University Boulevard, Indiana University Hospital #4100, Indianapolis, IN 46202, USA
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46
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Asai S, Fujimoto N, Tanoue K, Akamine E, Nakao E, Hashimoto K, Ichinona T, Nambara M, Sassa S, Yanagi H, Hirooka N, Mori T, Ogawa M, Ogawa A. Water immersion colonoscopy facilitates straight passage of the colonoscope through the sigmoid colon without loop formation: randomized controlled trial. Dig Endosc 2015; 27:345-53. [PMID: 25413483 DOI: 10.1111/den.12406] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/17/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM One of the major causes of pain during colonoscopy is looping of the instrument during insertion through the sigmoid colon, which causes discomfort by stretching the mesentery. There are many studies in colonoscope techniques, but they have not been assessed objectively with respect to colonoscope passage through the sigmoid colon without loop formation. The aim of the present study was to determine whether cap-fitted colonoscopy and water immersion increase the success rate of insertion through the sigmoid without loop formation. METHODS A total of 1005 patients were randomized to standard colonoscopy, cap-fitted colonoscopy or water immersion technique. All examinations were carried out under a magnetic endoscope imaging device. Main outcome was the success rate of insertion without loop formation. RESULTS Success rate of insertion without loop formation was 37.5%, 40.0%, and 53.8% in the standard, cap, and water groups, respectively (standard vs water P = 0.00014, cap vs water P = 0.00186). There were no significant differences among the groups regarding cecal intubation rate, cecal intubation time and number of polyps ≥5 mm per patient. CONCLUSIONS Water immersion increases the success rate of insertion through the sigmoid colon without loop formation. This practical technique, requiring only preparation of a cap and water, is useful without compromising cecal intubation rate, cecal intubation time, or polyp detection rate.
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Affiliation(s)
- Satoshi Asai
- Department of Gastroenterology, Tane General Hospital, Osaka, Japan
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Crockett SD, Snover DC, Ahnen DJ, Baron JA. Sessile serrated adenomas: an evidence-based guide to management. Clin Gastroenterol Hepatol 2015; 13:11-26.e1. [PMID: 24216467 DOI: 10.1016/j.cgh.2013.10.035] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 10/29/2013] [Accepted: 10/31/2013] [Indexed: 02/07/2023]
Abstract
The concept of serrated colorectal neoplasia and a serrated pathway to colorectal cancer (CRC) is relatively new and continuing to evolve, but it has become highly relevant to gastroenterologists, pathologist, and oncologists alike. Sessile serrated adenomas (SSA) are now thought to be the major precursor lesion of serrated pathway cancers, which represent up to one-third of all sporadic CRC cases. However, despite their increasingly recognized importance, relatively little is known about the epidemiology and natural history of SSAs, and the molecular and epigenetic aspects are incompletely understood. Endoscopists must be aware of the unique features of SSAs so that the practice of colonoscopic screening for CRC can include optimized detection, removal, and appropriate surveillance of SSAs and other serrated precursor lesions. In this review, we discuss the history, epidemiology, and pathologic aspects of SSAs, as well as a recommended management approach and a discussion of uncertainties and opportunities for future research.
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Affiliation(s)
- Seth D Crockett
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Dale C Snover
- Department of Pathology, Fairview Southdale Hospital, Edina, Minnesota
| | - Dennis J Ahnen
- Division of Gastroenterology, Department of Veterans Affairs Eastern Colorado Health Care System and University of Colorado School of Medicine, Denver, Colorado
| | - John A Baron
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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48
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Abstract
Since the implementation of screening programmes, both the incidence and mortality of colorectal cancer have been decreasing. The choice of the preferred screening tool, however, is divergent and the adherence to screening programmes in most countries is still low. Cancer detection tests such as the guaiac faecal occult blood test (gFOBT) and the immunohistochemical FOBT (iFOBT) achieve higher acceptance than endoscopy. The sensitivity and specificity of iFOBT are higher than those of gFOBT, but gFOBT is cheaper and easier to perform. Endoscopic screening, which represents cancer prevention tests, has higher sensitivity for premalignant lesions than gFOBT and iFOBT and enables diagnosis and therapy in one single procedure. Since screening colonoscopy and sigmoidoscopy are invasive procedures with potentially severe adverse events, the highest possible quality must be provided. High-tech equipment, experience, training, quality control programmes, excellent bowel preparation and low adverse event rates are pivotal. Alternative screening tools such as CT colonography, barium enema CT and multitarget stool DNA tests have not been established as routine screening tools to date.
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Affiliation(s)
- Elisabeth Waldmann
- Division of Gastroenterology and Hepatology, Internal Medicine III, Medical University of Vienna, Vienna, Austria
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49
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Omata F, Ohde S, Deshpande GA, Kobayashi D, Masuda K, Fukui T. Image-enhanced, chromo, and cap-assisted colonoscopy for improving adenoma/neoplasia detection rate: a systematic review and meta-analysis. Scand J Gastroenterol 2014; 49:222-37. [PMID: 24328858 DOI: 10.3109/00365521.2013.863964] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The effectiveness of narrow band imaging (NBI), chromoendoscopy (CE), and cap-assisted colonoscopy (CAC) on adenoma detection rate (ADR) has been investigated in previous meta-analyses; however, there have been no meta-analyses of autofluorescence imaging (AFI) or flexible spectral imaging color enhancement (FICE) or i-scan. The aim of this study was to determine whether AFI and FICE/i-scan was more effective than standard/high-definition white light endoscopy to improve ADR and to update previous meta-analyses of NBI, CE, and CAC. DESIGN A systematic review and meta-analysis was conducted. Four investigators selected appropriate randomized controlled trials (RCT) using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. All RCTs in which colonoscopy were performed with AFI, FICE, i-scan, NBI, CE, and CAC were included. The risk ratios (RRs) calculated from adenoma/neoplasia detection rate were used as the main outcome measurement. RESULTS A total of 42 studies were included in the analysis. Pooled estimates of RR (95%confidence interval [CI]) using AFI, FICE/i-scan, NBI, CE, and CAC were 1.04 (95% CI: 0.87-1.24) (I² = 0%) (fixed effects model [FEM]); 1.09 (95% CI: 0.97-1.23) (I² = 5%) (FEM); 1.03 (95% CI: 0.96-1.11) (I² = 0%) (FEM); 1.36 (95% CI: 1.23-1.51) (I² = 16%) (FEM); and 1.03 (95% CI: 0.93-1.14) (I² = 48%) (random effects model [REM]), respectively. The pooled estimate of RR (95%CI) using indigo carmine in non-ulcerative colitis (UC) patients and methylene blue in UC patients was 1.33 (95% CI: 1.20-1.48) (I² = 14%) (FEM) and 2.39 (95% CI: 1.18-4.84) (I² = 0%) (FEM), respectively. CONCLUSION In contrast to AFI, FICE/i-scan, NBI, and CAC, only CE improves ADR. CE with methylene blue, though not NBI, is effective for surveillance of neoplasia in chronic UC patients.
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Affiliation(s)
- Fumio Omata
- Department of Internal Medicine, St. Luke's International Hospital , Chuo-Ku , Japan
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50
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Sharma P, Gupta N, Kuipers EJ, Repici A, Wallace M. Advanced imaging in colonoscopy and its impact on quality. Gastrointest Endosc 2014; 79:28-36. [PMID: 24119713 DOI: 10.1016/j.gie.2013.08.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/15/2013] [Indexed: 02/08/2023]
Abstract
Detecting and resecting colonic polyps during endoscopy has been shown to reduce CRC. At the same time, endoscopy has faced substantial technical improvements and continues to undergo major changes. Detection of colorectal neoplasias is facilitated by using high-definition endoscopy, and characterization of lesions is more accurate by using virtual CE. High-definition endoscopy has found widespread use, whereas virtual CE is still more often used in tertiary centers and for high-risk patient groups. Endomicroscopy has opened the door for in vivo histology and functional as well as molecular imaging. Thorough training of the endoscopists is necessary, and redefined reimbursement codes may help make these techniques available in the clinical arena for high-risk patients who are most probable to benefit from the more advanced diagnostic endoscopy techniques. Over recent years, there has also been an increasing push by healthcare payors and providers to improve the quality of healthcare services. The ultimate goal of monitoring quality measures is to improve the overall health of the population and, for colon cancer screening, to reduce the incidence and mortality of colon cancer. However, the development of an appropriate quality measure and ensuring the accuracy of the data on which we base our efforts are among the first challenges that we must meet (Table 1). The continued technologic advancements in colonoscopy and endoscopic imaging may result in improvements in the quality of colonoscopy and should lead to a decrease in the incidence and mortality from colon cancer.
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Affiliation(s)
- Prateek Sharma
- Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri, USA; Department of Gastroenterology and Hepatology, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Neil Gupta
- Department of Gastroenterology, Loyola University Health System, Maywood, Illinois, USA
| | - Ernst J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Alessandro Repici
- Department of Gastroenterology, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Michael Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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