Higher Adenoma Detection Rate Research Articles

Comparative effectiveness of water immersion and water exchange versus air insufflation for colonoscopy

Introduction: Water-aided colonoscopy can be categorized by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange), respectively. Objective: To assess the impact of water immersion and water exchange on insertion pain and adenoma detection rate, when compared with air insufflation colonoscopy. Setting: published randomized controlled trial (RcT) that compared water immersion or water exchange with air insufflation. Patients: patients undergoing colonoscopy. Interventions: Medline, pubMed, Google searches (January 2008 to December 2011) to identify appropriate RcTs. Main Outcome Measurements: pain during insertion phase and adenoma detection rate. Method: Review Manager Software (Version 5.1, cochrane collaboration, UK). Results: pain scores of both water-aided methods are lower than that of the air insufflation method. Subgroup analysis shows that compared with air insufflation, the water exchange group had a greater mean reduction of maximum pain during insertion -2.73 (-3.29, -2.18) than the water immersion group -1.31 (-1.64, -0.97). There is no significant difference in overall adenoma detection rate between water-aided methods and air insufflation. Subgroup analysis shows that compared with air insufflation, the water exchange group had higher adenoma detection rate, OR 1.52, (95%cI: 1.08-2.14) than the water immersion group, OR 0.92, (95%cI: 0.70-1.21). Limitation: Unblinded colonoscopists exposed observations to uncertain bias. Conclusion: compared with air insufflation, the data presentation in a meta-analysis format show that both water immersion and water exchange significantly reduce insertion pain. Water exchange may be superior to water immersion in minimizing insertion pain and in increasing adenoma detection rate.

A Blueprint for Quality

It is clear that enhancing the quality of endoscopic services improves patient outcomes. Benefits include shorter wait times, more appropriate screening and surveillance intervals, higher adenoma detection rates and fewer interval (or missed) cancers.

Experience with water-aided colonoscopy in a Canadian community population

Purpose: Water-aided colonoscopy, immersion (WI) or exchange (We), minimizes insertion pain and reduces sedation. We improves adenoma detection rates (ADR). In a performance improvement program, we assessed water-aided methods in a busy community GI practice in c anada. Methods: Over a 13 month period patients were offered water-aided colonoscopy with an option to complete the examination with on-demand sedation. WI was used in the first 1-2 months and replaced exclusively with W e thereafter. procedural outcomes were compared to a continuous retrospective cohort of standard sedated air insufflation (AI) colonoscopy. Results: 200 (106M/94F) water-aided colonoscopies were completed. cecal intubation without air insufflation was achieved in 93%. sedation was not required in 95% of patients accepting on-demand sedation. Average insertion time was 15 min with an average withdrawal time of 6 min. 145 (87M/58F) water-aided colonoscopies, completed for screening or surveillance were compared to a cohort of 145 (77M/68F) AI colonoscopies in the immediate prior period. The overall ADR of water-aided colonoscopy was 30% (43/145) with a proximal ADR of 21%. Using AI the overall ADR was 27.6% (40/145) with a proximal ADR of 14.5% (21/145). In males, the proximal colon ADR was 25% in water-aided colonoscopies and 14.3% using AI (p=0.0397). Conclusions: Water-aided colonoscopy is feasible in a busy community practice with respectable cecal intubation rates. A large percentage of patients consenting to on-demand sedation completed without sedation. ADR in male subjects is consistent with similar prior reports of a significantly higher ADR in the proximal colon using W e when compared to AI.

Can Colonoscopy Remain Cost-Effective for Colorectal Cancer Screening? The Impact of Practice Patterns and the Will Rogers Phenomenon on Costs

The adenoma detection rate (ADR) in screening colonoscopy is higher than original cost-effectiveness models estimated. Future colorectal cancer (CRC) risk is decreased once the ADR is 20%, but it is unclear how much additional protection is provided with higher ADRs. We modeled the impact of a high ADR on future CRC risk and surveillance colonoscopy burden. We created three hypothetical scenarios for 100,000 average-risk individuals undergoing screening colonoscopy at age 50: (i) 20% ADR with 30% future CRC risk reduction; (ii) 50% ADR with 30% future CRC risk reduction; and (iii) 50% ADR with 50% future CRC risk reduction. After colonoscopy, patients could have high-risk or low-risk adenomas, or no adenomas. When the ADR increases from 20% to 50% but no additional CRC cases are prevented, future CRC risk for each group is still reduced, because lower-risk patients migrate into apparently higher-risk groups (the Will Rogers phenomenon). Future risk is further reduced if a 50% ADR leads to greater protection from CRC. However, despite the reductions in group-specific and overall future CRC risk, 34,635 additional surveillance colonoscopies are performed before the cohort is 60 years old when the ADR is 50% compared with 20%. If current surveillance practices continue along with high ADRs, screening colonoscopy may not remain cost-effective.

Volume and accreditation, but not specialty, affect quality standards in colonoscopy

The Global Rating Scale, defined by the Joint Advisory Group for Gastrointestinal Endoscopy, requires monitoring of endoscopic performance indicators. There are known variations in colonoscopic performance, and investigation of factors causing this is needed. This study aimed to analyse the impact of endoscopist specialty and procedural volume on the quality of colonoscopy. Data collected prospectively from a UK hospital endoscopy service between June 2007 and January 2010 were analysed. The main endpoint was the adenoma detection rate (ADR). Secondary endpoints were polyp detection rate (PDR), reported caecal intubation rate (CIR) and reported complications. Multivariable binary regression models were built to adjust for confounding patient-level and endoscopist-level variation. A total of 10,026 colonoscopies were included, with an overall ADR of 19.2 per cent, a CIR of 90.2 per cent and a perforation rate of 0.06 per cent. In univariable analyses, surgeons had a higher ADR and higher PDR, but lower CIR, compared with physicians. Surgeons had a significantly different case mix in terms of age, sex and indication for colonoscopy. After adjusting for this case mix in multivariable analysis, specialty was no longer a significant predictor of ADR; however, surgeons retained their higher PDR and physicians their higher CIR. Endoscopists accredited for screening and those performing more than 100 colonoscopies per year had a higher ADR. Adjusting for case mix, physicians and surgeons performed equally well in terms of ADR. Accreditation and a higher annual number of colonoscopies were more important factors in achieving quality standards.

762 High Adenoma Detection Rate in First Degree Relatives of Patients With Serrated Polyposis Syndrome: A Prospective Study

762 High Adenoma Detection Rate in First Degree Relatives of Patients With Serrated Polyposis Syndrome: A Prospective Study

Tu1724 Effect of New Trainees on Colonosocpy Time and Adenoma Detection Rate

The success of screening and surveillance colonoscopies is largely based on detection and removal of adenomatous polyps. Previous studies have demonstrated that the overall higher adenoma detection rate (ADR) for colonoscopies involving fellows was largely driven by 3rd year fellows. There is limited data on performance characteristics of colonoscopy involving new trainees at the beginning of their training. Due to the structure of our program where the new fellows are involved in a high case load immediately, we believe our institution is in a unique position to report about the effect of new trainee on colonoscopy outcomes.

Su1444 High Adenoma Detection Rate and Adherence to Guidelines in Clinical Colonoscopy Practice

To minimize waits and delays for colonoscopy within Veterans Affair Medical Centers (VA), many VA centers utilize ‘fee-basis' contract work to local non-VA facilities. These fee-basis colonoscopies are performed at regional facilities with varying practice patterns and should therefore represent common clinical colonoscopy practice. Prior work suggests that endoscopists often recommend shorter follow up than endorsed by guidelines. Our aim was to compare the quality of referred fee-basis colonoscopies to colonoscopies performed at the VA medical center by examining adherence to surveillance guidelines and adenoma detection rate.

A pilot study to assess feasibility of the water method to aid colonoscope insertion in community settings in the United States

BACKGROUND: The water method decreases patient discomfort and sedation requirement. Applicability in non-veteran community settings in the United States (U.S.) has not been reported. AIMS: Our aim is to perform a pilot study to establish feasibility of use the water method at 2 community sites. We tested the hypothesis that compared with air insufflation patients examined with the water method would require less sedation without adverse impact on outcomes. METHODS: Two performance improvement projects were carried out. Consecutive patients who consented to respond to a questionnaire after colonoscopy were enrolled. Project 1: The design was single-blinded (patient only); quasi-randomized - odd days (water), even days (air). Colonoscopy was performed by a staff attending. Project 2: A supervised trainee performed the reported procedures. In both, patient demographics (age, gender and body mass index), amount of sedation required during colonoscopy and procedure-related variables were recorded. The patients completed a questionnaire that enquired about discomfort during colonoscopy and willingness to repeat the procedure within 24 hours after the procedure. RESULTS: Project 1: Significantly lower doses of fentanyl and midazolam were used and a higher adenoma detection rate (ADR) was demonstrated in the water group. Project 2: 100% cecal intubation rate was achieved by the supervised trainee. CONCLUSION: This is the first pilot report in the U.S. documenting feasibility of the water method as the principal modality to aid colonoscope insertion in both male and female community patients. In a head-to-head comparison, significant reduction of sedation requirement is confirmed as hypothesized. No adverse impact on outcomes was noted.

Trainees’ adenoma detection rate is higher if ≥10 minutes is spent on withdrawal during colonoscopy

It has been demonstrated that prolonged colonoscopic withdrawal times (WT; >6 min) are beneficial for the adenoma detection rate (ADR) for experienced endoscopists. There are little data, however, to guide the appropriate colonoscopic withdrawal times for trainees. The purpose of this study was to determine whether there is a relationship between WTs and ADR for first-year fellows training in colonoscopy. This is a prospective study of first-year gastroenterology fellows at a single academic teaching hospital who documented each colonoscopy with a self-report form over the course of an academic year (March 2010 to February 2011). The internal policy for the trainees was to have at least a 6-min withdrawal time for each colonoscopy. Four first-year fellows in gastroenterology at an academic medical center completed self-reports for 1,210 colonoscopies. Mean WT was 10.2 ± 3.4 min. The aggregate polyp detection rate was 33.2% and the aggregate ADR was 22.3%. For colonoscopies with WT < 10 min, ADR was 9.5%, and for colonoscopies with WT ≥ 10 min, ADR was 32.3% (p < 0.001). When the quality indicator of 25% goal ADR for males and 15% goal ADR for females is applied, this aggregate rate is achieved for both sexes for screening colonoscopies (n = 676) with WT ≥ 10 min. First-year trainees had a significantly higher ADR if their colonoscopic WT is ≥ 10 min.

Bowel cancer screening is safe, detects earlier stage cancer and adenomas in 50% of cases: experience of the prevalent round of screening from two first wave centres in the North East of England

ObjectiveThe NHS Bowel Cancer Screening Programme (BCSP) began roll-out in 2006 aiming to reduce cancer mortality through detection at an earlier stage. We report results from the prevalent round of...

Higher adenoma detection rates with cap-assisted colonoscopy: a randomised controlled trial

ObjectiveCap-assisted colonoscopy (CAC) uses a small plastic transparent cap attached to the tip of the colonoscope that can depress and flatten colonic folds and thus improve visualisation of their proximal...

Proficiency in the Diagnosis of Nonpolypoid Colorectal Neoplasm Yields High Adenoma Detection Rates

Current efforts to prevent colorectal cancer focus on the detection and removal of neoplasms. Nonpolypoid colorectal neoplasms (NP-CRN) have a subtle appearance that can be difficult to recognize during colonoscopy. Endoscopists must first be familiar with the patterns of NP-CRN in order to detect and diagnose them. We studied the adenoma detection rates of endoscopists who had trained to detect NP-CRN, versus endoscopists who had not. Retrospective Nested Case Control Study. Outpatient Screening Colonoscopy. Adult Veterans. Proficiency in the features and diagnosis of NP-CRN. Adenoma detection. In total, 462 patients had screening colonoscopies-267 by colonoscopists who had trained in the features and diagnosis of NP-CRN. Patient characteristics were similar between groups-the majority were men with a mean age of 62 ± 6 years. Neoplasia was more prevalent (45.7 vs. 34.9%; p = 0.02) in patients evaluated by the trained compared to the conventionally trained group. Trained colonoscopists had a higher adenoma detection rate (0.76 vs. 0.54 adenomas per patient, p < 0.001); removed a higher proportion of neoplasia (77 vs. 35%, p < 0.001); and more frequently diagnosed NP-CRN lesions (OR 2.98, 95% CI: 1.46-6.08) compared to colonoscopists without supplemental training. Endoscopists who are proficient in the detection of NP-CRN had significantly higher adenoma detection rates-of both polypoid and flat adenomas-compared to endoscopists without training, and were more specific in resection of adenomatous over hyperplastic lesions.

Removal of Infused Water Predominantly During Insertion (Water Exchange) is Consistently Associated with a Higher Adenoma Detection Rate - Review of Data in Randomized Controlled Trials of Water Method Colonoscopy

Purpose: Variations in the differences in adenoma detection rate in randomized controlled trials comparing usual air or carbon dioxide (CO2) insufflation and different modifications of water infusion in lieu of air insufflation (e.g., water immersion, water infusion, water method) have been described, raising concerns regarding the consistency and utility of the approach. The aim of the current report is to review the impact of the timing of removal of the infused water on these variations in reported randomized controlled trials. Methods: Appropriate randomized controlled trials (published or presented at the 2011 Digestive Disease Week) with data on adenoma detection rate were reviewed. Results: Five randomized controlled trials (n=1347) were identified (Tables 1 and 2).Table 1: Randomized controlled trialsTable 2: Data on adenoma detection rateConclusion: While water immersion, water infusion and the water method have been repeatedly demonstrated and acknowledged to significantly minimize colonoscopy discomfort in randomized controlled trails, the standard practice of sedation in the U.S. nullifies the importance of this attribute of the approach. The current comparative data from these trials, however, reveal that removal of the infused water predominantly during insertion (water exchange) is consistently associated with a higher adenoma detection rate, at times reaching significance, notably in the proximal colon in screening cases. Further evaluation of the implications of rigorous adherence to water exchange during insertion using the water method in screening colonoscopy is warranted.

Colonoscopy Quality Indicators Differ in the Proximal and Distal Colon

Purpose: Colonoscopy with polypectomy is associated with a reduction in colorectal cancer of the distal colon, but appears to be less protective for lesions of the proximal colon. The adenoma detection rate (ADR) is a validated measure of quality in colonoscopy. Polypectomy detection rate (PDR) has been proposed as a surrogate marker for ADR, demonstrating correlation with ADR in retrospective studies. The aim of this study was to evaluate PDR and ADR separately in the proximal and distal colon. Methods: We reviewed a colonoscopy database for outpatient procedures performed over a 6-month period by 20 gastroenterologists of a single academic medical center. Quality measures including ADR, PDR, mean adenomas per patient (MAP), mean polyps per patient (MPP) and advanced neoplasia detection rate (ANDR) were calculated. Procedures identifying 3 or more adenomas per patient (≥3DR) were also noted. The ratio of adenomas detected to polyps removed (adenoma/polyp ratio) was calculated. ADR and PDR were compared for lesions of the proximal versus distal colon (splenic flexure and below). Data were compared using the Chi-square test. Results: A total of 1921 colonoscopies were performed during the study period. ADR was 31% (13%-42%). ADR was significantly higher in men (36%) compared to women (26%), and in surveillance (47%) compared to screening studies (29%) (p < 0.001). PDR was 49% (16%-64%). PDR was significantly higher in men (63%) than in women (35%) (p < 0.001). The adenoma/polyp ratio was 0.49 (0.29-0.81). MAP was 0.58 (0.27-0.96) and MPP was 1.19 (0.27-1.71). Each measure was lower in the subset of screening colonoscopies (0.50 vs.0.58, p= 0.011 and 1.04 vs. 1.19, p< 0.001). ≥ 3DR was 5.4%, and ANDR was 6.7%. Colorectal cancer was detected in 10 patients (0.52%). In terms of distribution, 1038 polyps (corresponding to 753 adenomas) were removed from the proximal colon, and 1248 polyps (corresponding to 372 adenomas) were removed from the distal colon. Proximal PDR was significantly lower than distal PDR (26% vs. 32%, p= 0.05). Conversely, proximal ADR exceeded distal ADR overall (23% vs. 14%, p< 0.001) and in screening studies (19% vs. 14%; p = 0.016). Conclusion: Quality measures such as ADR and MAP varied amongst endoscopists. Higher ADR did not correlate with endoscopist's volume, patient gender, % surveillance, or withdrawal time. Adenoma/polyp ratio also varied, and PDR was not a consistent correlate of ADR in this study. The majority of adenomas were located in the proximal colon. Proximal polyps were more likely to be adenomas, compared with distal polyps. Proximal PDR may be a better surrogate marker compared with overall PDR for the detection of precancerous lesions of the colon.Table: Proximal and distal ADR and PDRTable: Table. Adenoma vs. polyp detection and other quality measures

The “Mozart Effect” and Adenoma Detection

Purpose: To determine whether or not the endoscopist listening to Mozart while performing a colonoscopy has an impact on adenoma detection rate. Shaw et al., demonstrated that listening to Mozart would increase students' scores on the spatial IQ subtest of the Stanford-Binet Intelligence Scale. Results indicated significant short-term enhancement of spatial-temporal reasoning, later called the “Mozart effect”. Adenoma detection rate is emerging as an important quality measure. The U.S. Multi-Society Task Force and a joint ACG and ASGE task force confirmed that in patients (age 50 or greater) who undergo first-time colonoscopy, one or more adenomas will be present in at least 25% of men and 15% of women. Methods: Utilizing the procedure software, baseline adenoma detection rates were calculated for a one year period of time for two endoscopists. 161 colonoscopies were examined, and the pathology was reviewed for all polyps removed during these screening colonoscopies. In this unblinded/blinded randomized controlled trial, the same two endoscopists with an experience level of a minimum of 1000 colonoscopies performed screening colonoscopies randomly assigned to music or no music. In the cases where music was assigned, a selection of Mozart was played. Each endoscopist was unblinded to music exposure. Endoscopist #1 was blinded to outcome and the data that was collected for the study while endoscopist #2 was unblinded. For consistency, each colonoscopy was performed using Monitored Anesthesia Care. Adenoma detection rates from this study were then calculated and compared to the baseline rates. Results: Between October 2010 and April 2011, 120 screening colonoscopies were scheduled with two incomplete procedures resulting in 118 procedures. A split dose bowel preparation was used in all cases. The indications for procedures were screening, personal history of colon polyps/cancer, or family history of colon polyps/cancer. Cecum and withdrawal times were consistent for both endoscopists with music and without. The baseline adenoma detection rates were 21.25% (endoscopist #1) and 27.16% (endoscopist #2). The adenoma detection rates for both endoscopists increased from baseline values with music and without during this study. Endoscopist #1 who was blinded to outcome had an adenoma detection rate of 66.7% with music and 30.4% without music. Endoscopist #2 who was unblinded to outcome had an adenoma detection rate of 36.7% with music and 40.5% without music. Conclusion: The endoscopist blinded to the study outcome had a higher adenoma detection rate while listening to Mozart as compared to without Mozart.

Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme

ObjectivesColonoscopy is central to colorectal cancer (CRC) screening. Success of CRC screening is dependent on colonoscopy quality. The NHS Bowel Cancer Screening Programme (BCSP) offers biennial faecal occult blood (FOB)...

A head-to-head comparison of the water vs. air method in patients undergoing screening colonoscopy.

BACKGROUND: The water method facilitates colonoscope insertion in unsedated patients. OBJECTIVE: To compare quality indicators in sedated veterans. DESIGN: Performance improvement. SETTING: VA endoscopy unit. PATIENTS: 368 consecutive screening patients. INTERVENTION: Air or water method assignment (high definition colonoscope) was based on the last digit of social security number. MEASUREMENTS: Adenoma detection rate (ADR), cecal intubation rate; intubation and withdrawal times; sedation requirements and external pressure used. RESULTS: ADR was higher with the water method (57.1% vs. 46.1%, p=0.04). After controlling for age, body mass index, smoking, alcohol, withdrawal time and quality of bowel preparation, the odds of detecting an adenoma was 81% higher with the water method (OR 1.81; 95% cI: 1.12-2.90). In the proximal colon ADR was higher with the water method (45.8% vs. 34.6%, p=0.03), including adenomas <10 mm in size (41.8% vs. 31.4%, p=0.04). The water method showed significantly longer cecal intubation time (6.9±0.3 vs. 5.3±0.3 min, p=0.0001); less external pressure used (11.9% vs. 28.3%, p=0.0001); lower need for additional sedation (17.5% vs. 27.2%, p<0.03). LIMITATIONS: Predominance of males, single unblinded endoscopist with high ADR. CONCLUSIONS: The water method is an independent factor associated with significantly higher ADR. Replication by blinded colonoscopist(s) is indicated.

Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos)

Studies suggest that endoscopist-related factors such as colonoscopy withdrawal time are important in determining the adenoma detection rate (ADR). To determine the importance of withdrawal technique in differentiating among endoscopists with varying ADRs. Prospective, multicenter study. Five academic tertiary-care medical centers. This study involved 11 gastroenterology faculty endoscopists. A retrospective review of screening colonoscopies was performed to categorize endoscopists into low, moderate, and high ADR groups. Video recordings were randomly obtained for each endoscopist on 20 (10 real, 10 sham) withdrawals during colonoscopies performed for average-risk colorectal cancer screening. Three blinded reviewers assigned withdrawal technique scores (total of 75 points) on 110 video recordings. A separate reviewer recorded withdrawal times. Withdrawal technique scores and withdrawal times. Mean (± standard deviation [SD]) withdrawal technique scores were higher in the moderate (62 ± 2.5) and high (59.5 ± 3) ADR groups compared with the low (40.8±3) ADR group (P = .002). Mean (± SD) withdrawal times were 6.3 ± 1.8 minutes (low ADR), 10.2 ± 1.5 minutes (moderate ADR), and 8.2 ± 1.8 minutes (high ADR) (P = .29). A comparison of the withdrawal times and technique scores of the two individual endoscopists with the lowest and highest ADRs did not find a significant difference in withdrawal times (6.6 ± 1.7 vs 7.4 ± 1.7 minutes) (P = .36) but did find a nearly 2-fold difference in technique scores (36.2 ± 9 vs 62.8 ± 9.9) (P = .0001). Not adequately powered to detect small differences in withdrawal times. Withdrawal technique is an important indicator that differentiates between endoscopists with varying ADRs. It is possible that withdrawal technique is equal to, if not more important than, withdrawal time in determining ADRs.

605 Removing Polyps During Both Insertion and Withdrawal Phases Is Associated With Higher Adenoma Detection Rates At Colonoscopy

Mean age, y 62.5 63.5 NS Male sex (%) 76 (44%) 9 (55%) NS Adequate bowel preparation, (%) 168 (99%) 170 (100) NS Total insertion time, min (SE) 8.42 (0.42) 5.10 (0.24) 0.001 Inspection time on insertion, min (SE) 3.11 (0.04) 0 0.001 Total inspection time, m (SE) 9.63 9.44 NS Total procedure time, min (SE) 24.2 (1.04) 27.4 (1.35) 0.07 Adenoma prevalence, n (%) 89 (52%) 98 (59%) NS Mean adenoma per patient, n (SE) 1.38 (0.16) 1.86 (0.21) NS