Low Adenoma Detection Rate Research Articles

Tu1337 A Diagnostic Colonoscopy Is Associated With a Lower Adenoma Detection Rate Despite Longer Withdrawal Times Compared to a Screening or Surveillance Colonoscopy

Tu1337 A Diagnostic Colonoscopy Is Associated With a Lower Adenoma Detection Rate Despite Longer Withdrawal Times Compared to a Screening or Surveillance Colonoscopy

Sa1515 Should We Keep HIV Infected Patients in the Average-Risk Screening Category? a Sub-Analysis of the Comp (Colonoscopy Outcomes in Minority Population) Registry Data

Should We Keep HIV Infected Patients in the Average-Risk Screening Category? a Sub-Analysis of the Comp (Colonoscopy Outcomes in Minority Population) Registry Data Manhal Olaywi*, Shashideep Singhal, Kinesh Changela, Deepanshu Jain, Devin Lane, Mojdeh Momeni, Mahesh Krishnaiah, Sushil Duddempudi, Sury Anand Gastorenterology, The Brooklyn Hospital Center, Brooklyn, NY Introduction: Human Immunodeficiency Virus (HIV) infected patients have altered immune system and host defenses that affect their predisposition to cancers. There is limited literature to elucidate the effect of HIV on colorectal carcinogenesis and precancerous colonic adenomas. The analysis was targeted to determine the differences in development of colonic adenomas in HIV infected subjects in comparison to general population. Methods: The subjects with HIV were selected from the COMP registry at our institution using ICD 9 code. Subjects presenting for screening colonoscopy age 50 to 75 years were included, while colonoscopies done for evaluation of symptoms or surveillance of prior malignancy were excluded. The demographic, clinical, and pathological data of study subjects were analyzed using SPSS statistical software to compare HIV positive and control group. Results: A total of 1775 colonoscopies met the inclusion criteria with 115 subjects who were identified as HIV positive and 1660 in control group. Racial distribution was African Americans 58%, Hispanics 32% and 10% others. There was a predominance of males in the HIV group 60% in comparison to control group 40% (p 0.01). There were no other significant differences in demographics of HIV group in comparison to controls. A significantly higher proportion of HIV patients had poor bowel preparation 14.8% in comparison to control group 9.5% (p 0.05), hence were excluded from the analysis to exclude the confounding effect. The adenoma detection rate (ADR) for the HIV group 13% was lower 13% in comparison to the controls 23.6% (P 0.001). The advanced adenoma detection rate (AaDR) was also lower in the HIV group 7.8%, while it was 14% in the control group (P 0.03). On a multivariate analysis HIV positivity was independently associated with lower ADR and AaDR. Conclusion: In our study, the prevalence of pre-malignant colonic adenomas and advanced adenomas in HIV-infected patients was lower than the HIV negative patients. These data support the current practice of screening HIV-infected according to the average-risk screening guidelines.

An Endoscopic Quality Improvement Program Improves Detection of Colorectal Adenomas

Adenoma detection rate (ADR) is a key measure of quality in colonoscopy. Low ADRs are associated with development of interval cancer after "negative" colonoscopy. Uncontrolled studies mandating longer withdrawal time, and other incentives, have not significantly improved ADR. We hypothesized that an endoscopist training program would increase ADRs. Our Endoscopic Quality Improvement Program (EQUIP) was an educational intervention for staff endoscopists. We measured ADRs for a baseline period, then randomly assigned half of the 15 endoscopists to undergo EQUIP training. We then examined baseline and post-training study ADRs for all endoscopists (trained and un-trained) to evaluate the impact of training. A total of 1,200 procedures were completed in each of the two study phases. Patient characteristics were similar between randomization groups and between study phases. The overall ADR in baseline phase was 36% for both groups of endoscopists. In the post-training phase, the group of endoscopists randomized to EQUIP training had an increase in ADR to 47%, whereas the ADR for the group of endoscopists who were not trained remained unchanged at 35%. The effect of training on the endoscopist-specific ADRs was estimated with an odds ratio of 1.73 (95% confidence interval 1.24-2.41, P=0.0013). Our results indicate that ADRs can be improved considerably through simple educational efforts. Ultimately, a trial involving a larger number of endoscopists is needed to validate the utility of our training methods and determine whether improvements in ADRs lead to reduced colorectal cancer.

Colonoscopy Key Performance Indicators in a Rural General Australian Hospital

We evaluated colonoscopic neoplastic yield (adenomas and cancers) in a rural endoscopic unit alongside several key performance indicators known to influence yield. A second aim was to compare neoplastic yield according to colonoscopic indication.Methods - We retrospectively audited 371 colonoscopies (163 male, 208 female) undertaken over six months (2007-2008) at the Mersey Hospital, Tasmania.ResultsCaecal intubation rate was 86.79% (males 90.8%, females 83.65%); bowel preparation judged as good (56.87%), fair (22.37%), poor (13.48%), not recorded (7.28%). Adenoma Detection Rate (ADR) was 11.86% (males 18.4%, females 6.7%). Inclusion of cancers - Significant Neoplastic Lesion Rate (SNL) was 15.9% (males 20.86%, females 12.02%). Mean withdrawal time to anus was 5.76 minutes with significantly higher ADR for 6-10, 11-15 and >15 minutes than 0-5 minutes (p<0.0001).SNL detection rates for major presenting indications were expressed as number needed to screen (NNS) with 95% confidence intervals (CI). Results: PR bleeding, NNS = 5, CI 3.45-7.69; Anaemia, NNS = 9.5, CI = 4-25; Abdominal Pain, NNS = 12.76, CI 5.26-33; Change in bowel habit, NNS = 6, CI 3.33-12.5; Family history colorectal cancer, NNS = 4.83, CI 3.03-8.33; Positive Faecal Occult Blood, NNS = 4.26, CI = 2.94-6.67, without significant sex differences amongst groups (p=0.5186)ConclusionsADR fell short of benchmark standards (25% males, 15% females); with slightly lower than recommended caecal intubation rate (e90%). Adequacy of bowel preparation was comparable to reference ranges. A statistically-significant trend between rapid withdrawal times and lower ADR was found, although caution should be exercised in interpretation.

Su1292 Lower Adenoma Detection Rates in Afternoon Colonoscopies May Be Due to Rushing and Not Fatigue

( 5, 5-10, 11-15, 16-20, 20 yrs), average endoscopic procedures/week (10-20, 21-30, 31-40, 40). Reasons for holding or continuing and time duration these agents weld held prior to and after procedures. Endoscopists experience of any complications secondary to holding or continuing different anti-platelet agents was also queried. Questions on holding or continuing specific anti-platelets agents in-combinations prior to low or high risk endoscopic procedures. Results: 400 study questionnaires were distributed and 136 responses received (response rate: 34%). The majority (82%) were community GIs, 68% in 4160 yrs age group, 76% 10 yrs of experience, 87% performed 30 procedures/week. GIs experiencing acute ischemic event when held: aspirin 11% (12/110); dipyridamole 6% (6/105) and clopidogrel 30% (34/114). GIs witnessed significant GI bleeding when continued: aspirin 38% (43/112); dipyridamole 23% (24/103) and clopidogrel 63% (71/112). GIs decision to continue/hold anti-platelet agents during endoscopy was based on patients factors (37%, 50/136), their own experience (15%, 21/136), and only 47% (64/136) followed ASGE guidelines for certain high risk procedures. 17% of all respondents would stop all anti-platelet agents for any endoscopic procedure; aspirin or NSAIDS held for 3-5 days (58%), dipyridamole or clopidogrel for 5-7 days (56%) and following endoscopy restarted within 3-5 days with polypectomy (73%), esophageal dilation (70%), ERCP with sphincterotomy (87%) and EUS with FNA (84%). Endoscopists who performed endoscopic procedures while patients were on single or multiple antiplatelet agents are shown in the Table. Conclusions: Results from this survey highlight the wide variation in practice patterns for managing various antiplatelet agents’ during endoscopic procedures among gastroenterologists despite the availability of guidelines on this topic. More than 15% of the respondents would hold all anti-platelet agents prior to any endoscopic procedures. This highlights the need for better educational tools to assist practicing gastroenterologists on this topic.

Adenoma Detection Rate is Not Influenced by the Timing of Colonoscopy

Purpose: Multiple factors have been proven to affect adenoma detection rates especially adequacy of bowel preparation, withdrawal time, and the endoscopist's experience. Recently afternoon colonoscopies have been reported to be associated with lower adenoma detection rate (ADR) we conducted a study to determine if the timing of colonoscopy (morning vs. afternoon) affects adenomas detection rates (ADR) and polyps detection rates (PDR). Methods: We performed a retrospective review of outpatient screening colonoscopies completed between 2007 and 2009 by 14 gastroenterologists in our practice. Patient demographics, indications, timing, and findings of colonoscopy were noted. Mean withdrawal time, time to reach cecum, quality of preparation (graded from 1 to 5 according to Aronchik stool preparation scale), fellow involvement, experience of the endoscopist, detection of polyps, and pathology reports for adenoma detection were reviewed. ADR and PDR were calculated as detection of at least one adenoma and/or one polyp per colonoscopy respectively. Morning colonoscopies were defined as those which were performed before 12 noon and afternoon colonoscopies were performed after 12 noon. Results: A total of 1526 colonoscopies were included, of which 1048 (68.68%) colonoscopies were performed in morning and 478 (31.32%) in the afternoon. There was no difference in basic demographics between both morning and afternoon groups including age, gender, and ethnicity. A total of 575 patients had at least one polyp removed giving a PDR of 37.7%, of these, 329 were adenomas (ADR = 21.56%). The afternoon PDR (27.3%) was significantly lower than morning PDR (39.9%, P value = 0.008). More adenomas were detected in the morning than in the afternoon but the ADR was not statistically significant (22.8% vs. 18.8%; p=0.08). Mean withdrawal time in morning vs. afternoon was 9.12 vs. 9.25 min respectively (p=0.69). The mean ADR was higher in the group with withdrawal time >8 min but it was not statistically significant (p=0.34). There was no association between fellow involvement and polyp detection. The association between years of provider's experience and ADR was statistically significant (p=0.016). Conclusion: Timing of colonoscopy seems to be a determinant of polyp detection rate (PDR) but not adenoma detection rate (ADR). Though the ADR decreased as day progressed the change was not significant. The reasons and implications of this finding should be studied further.

A Randomized Controlled Trial of an Endoscopic Quality Improvement Program (EQUIP) Results in Improved Detection of Colorectal Adenomas: ACG /Olympus Award

Purpose: Adenoma detection rate (ADR) has become a key measure of quality in colonoscopy with low ADR linked to interval cancer after “negative” colonoscopy. Previous studies mandating longer withdrawal time, and other incentives, have not been shown to improve ADR. We hypothesized that an intensive endoscopist training program would result in an increase in overall adenoma detection. Methods: The EQUIP study was a prospective randomized trial completed in two phases. In the first phase, baseline adenoma detection rates were measured. One half of endoscopists were then randomly assigned to EQUIP training and one half continued with routine practice in the second phase. Phase II data collection began once training was completed by those randomized to receive it. The training group also received personal monthly feedback on ADR, withdrawal time, and group averages. Each endoscopist was asked to describe all polyps according to shape, location, size and predicted pathology. The ADRs of the 8 trained endoscopists were compared to those of the 7 untrained endoscopists, adjusting for baseline levels and for patient age, sex, adequacy of bowel preparation (Boston Bowel Preparation Score), and indication (screening, surveillance or other). Results: 1200 procedures were completed in each phase of study by 15 endoscopists. Patient characteristics were similar between each study phase and between randomization groups. The overall ADR in phase I was 36% for both the “EQUIP trained” and “untrained” groups of endoscopists. In phase II, the group of endoscopists randomized to training had an overall increase in ADR to 47% whereas the ADR in the untrained endoscopists remained unchanged at 35%. The improvement in ADR with training at the endoscopist level was significant with an estimated odds ratio of 1.74 (95% CI 1.22 to 2.49, p=0.0022) (Figure 1). Conclusion: This is the first study to our knowledge to prospectively show that ADR can be significantly improved through an intensive structured endoscopist training program. We believe our efforts will provide a model for improvement efforts in colonoscopy. Our goal is to use this pilot data to develop a larger multi-center trial to evaluate these effects on a larger scale, and to validate long term clinical improvements in colorectal cancer prevention.

The impact of video recording colonoscopy on adenoma detection rates

The adenoma detection rate (ADR) is a quality benchmark for colonoscopy, influenced by several factors including bowel preparation, withdrawal time, and withdrawal technique. To assess the impact of video recording of all colonoscopies on the ADR. Comparison of two cohorts of patients undergoing colonoscopy before and after implementation of video recording. Academic outpatient endoscopy facility. This study involved asymptomatic, average-risk adults undergoing screening colonoscopy. Video recording of all colonoscopy procedures. Polyp findings and withdrawal times were recorded for 208 consecutive screening colonoscopies. A policy of video recording all colonoscopies was implemented and announced to the staff. Data on another 213 screening colonoscopies were subsequently collected. Adenoma detection rate, withdrawal time, advanced polyp detection rate, hyperplastic polyp detection rate. At least one adenoma was found in 38.5% of patients after video recording versus 33.7% before video recording (P = .31). There was a significant increase in the hyperplastic polyp detection rate (44.1% vs 34.6%; P = .046). Most endoscopists had a numerical increase in their ADRs, but only one was significant (57.7% vs 22.6%; P < .01). There were trends toward higher detection of adenomas of <5 mm (59.1% vs 52%; P = .23) and right-sided adenomas (40.2% vs 30.4%; P = .11) in the video recorded group. No randomization, confounding of intervention effects, and sample size limitations. Video recording of colonoscopies is associated with a nonsignificant increase in the ADR and a significant increase in the hyperplastic polyp detection rate. There may be a benefit of video recording for endoscopists with low ADRs.

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.

Adenoma Detection Rate Is Not Influenced by the Timing of Colonoscopy When Performed in Half-Day Blocks

Afternoon colonoscopies have recently been reported to be associated with lower adenoma detection rate (ADR), which was attributed to physician fatigue resulting from the same endoscopist performing procedures throughout the day. The aim of our study was to assess ADR in morning compared with afternoon colonoscopy performed in half-day blocks with different physicians. We evaluated the primary hypothesis that morning and afternoon ADRs would not differ significantly when performed in half-day blocks by different endoscopists. Data on all colonoscopies performed between January 2009 and December 2009 were obtained from our endoscopy database. All patients who underwent colonoscopies in 2009 for screening, surveillance, and family history of colon cancer/polyps were included in the study. Morning colonoscopies were defined as those that were performed from 0800 to 1200 hours. Afternoon colonoscopies were defined as those that were performed from 1300 to 1700 hours. Colonoscopies in each block were performed either by different endoscopists working in half-day (morning or afternoon) block schedules or by the same endoscopist working a full-day schedule. A total of 4,665 patients were included in the study. For endoscopists working the full-day, the afternoon ADR was significantly lower than the morning ADR (21 vs. 26.1%; odds ratio (OR)=0.75; 95% confidence interval (CI) 0.59, 0.96; P=0.02). Conversely, in the half-day group, there was no significant difference in ADR between afternoon and morning (27.6 vs. 26.6%; OR=1.05; 95% CI 0.88, 1.26; P=0.56). Performing colonoscopies in half-day blocks by different endoscopists increases the detection of adenomas in afternoon procedures, probably by reducing physician fatigue.

Measuring the quality of screening colonoscopy: moving on from adenoma detection rate

Introduction Adenoma detection rate (ADR) is the most widely used metric to assess quality of colonoscopy. Studies have shown ADR to correlate with other measures of colonoscopic performance such as withdrawal time, caecal intubation rate and longer term outcomes such as interval cancer rate. ADR is calculated by dividing the number of procedures in which one or more adenomas are detected by the total number of procedures. It has an inherent limitation in that it does not measure the total number of adenomas detected. The ethos of screening colonoscopy, in addition to detecting cancer, is to detect and remove all adenomas. This abstract examines other measures of adenoma detection in the context of the NHS Bowel Cancer Screening Programme (BCSP). Methods Data from all screening colonoscopies in the BCSP performed between August 2006 and August 2009 were analysed. The following measures of adenoma detection were calculated for each colonoscopist who had performed ≤50 procedures: ADR, MAP (mean adenomas per patient−total number of adenomas detected/ number of procedures), MAP+ (mean adenomas per positive procedure−total number of adenomas detected/ number of procedures in which one or more adenoma were detected). Correlation was assessed using Pearson9s correlation coefficient. This abstract examines other measures of adenoma detection in the context of the NHS BCSP. Results 31 088 procedures performed by 148 colonoscopists (mean 210 procedures per colonoscopist) were analysed. The mean, range, SD and correlation with ADR of each of the measures of adenoma detection are shown in table 1. 46.5% of patients have one or more adenomas, of these 53% have only one adenoma. For this reason, MAP and ADR correlate closely. However, MAP displays much greater variation than ADR. MAP+ demonstrated less variation and correlates less well with ADR. Conclusion MAP reflects the aim of screening colonoscopy to detect and remove all adenomas. MAP may be a more sensitive measure of colonoscopic performance but prospective studies are required to confirm this. MAP+ is a less useful measure of adenoma detection in isolation. It is largely dependent on the ADR but may still be high despite a low ADR. It may be useful as an adjunct to ADR or MAP in colonoscopists with evidence of high colonoscopic performance (ADR greater than the mean of the population). In this group, MAP+ identifies a group of colonoscopists attaining very high adenoma detection.

Association Between Visual Gaze Patterns and Adenoma Detection Rate During Colonoscopy: A Preliminary Investigation

Eye gaze tracking (EGT) technology follows a person's gaze and records the resulting visual gaze pattern (VGP). Adenoma detection rate (ADR) is a validated measure of colonoscopy quality. Higher ADRs are associated with prolonged withdrawal times and other endoscopic maneuvers that allow a better visualization of the mucosa; however, the influence of VGP has yet to be explored. We aim to quantify the VGP for endoscopists observing colonoscopy videos and describe the association between VGP and ADR. Furthermore, we will evaluate the relationship between VGP and the endoscopists' years of experience. Eleven endoscopists watched three videos while their VGP was recorded. The videos corresponded to 3 min of three different colonoscopy withdrawals. We divided the screen into a 3 × 3 grid of nine segments: eight peripheral and one central. We compared percent of gaze time (GT) in the central vs. peripheral segments using a paired t-test. VGP with ADR and years of practice were evaluated using Pearson's test. Subjects spent more GT in the screen's central segment (65 vs. 33%, P<0.001). ADR was significantly associated with increased percentage of central GT (r = 0.67, P = 0.024) and increased mean GT in the central segment (r = 0.70, P = 0.017). There was negative correlation between endoscopists' years of practice and the percentage of central GT (r = -0.67, P = 0.025), but no correlation between years of practice and percentage of peripheral GT (r = 0.24, P = 0.47). This reveals an association between a centrally focused VGP and ADR. Future steps include confirming in a larger sample and exploring if VGP can retrain low ADR endoscopists to perform higher quality colonoscopies.

Sedation Practices in Canada:A propos dePropofol

Sedation Practices in Canada:<i>A propos de</i>Propofol

Morning-Only One-Gallon Polyethylene Glycol Improves Bowel Cleansing for Afternoon Colonoscopies: A Randomized Endoscopist-Blinded Prospective Study

Inadequate bowel preparation is a known factor associated with increased failure rates of afternoon colonoscopy and lower adenoma detection rates. The aim of our study was to compare the efficacy of bowel cleansing achieved by administering 1-gallon (4 l) polyethylene glycol (PEG) preparation to patients in the morning of an afternoon colonoscopy with that of the traditional evening regimen. A prospective endoscopist-blinded study was conducted, in which patients undergoing afternoon colonoscopy were randomized to receive either 1 gallon of PEG the evening before the procedure or the morning of the colonoscopy. Bowel cleansing efficacy was scored by a blinded endoscopist using the Ottawa scale and each participant filled out a satisfaction survey. Mean scores for each bowel segment, composite mean scores, and rates of "good prep" interpreted from the Ottawa scale were compared between the two groups. A total of 136 patients (mean age 51.8 years, 52.2% men) evenly distributed between the two groups formed the study sample. Patients in the morning group had significantly lower Ottawa scale scores and were more likely to have a good preparation for each bowel segment and overall when compared with the evening group (P<0.01). Moreover, patients in the morning group were over 50% less likely to lose sleep or have bloating compared with the evening group (P<0.05). There was no difference in the study groups on overall polyp detection rate, adenomatous polyps, or number of patients with adenomas. This study shows that the bowel cleansing efficacy of morning-only 1-gallon PEG is superior and better tolerated compared with consumption of 1-gallon PEG in the evening before the day of an afternoon colonoscopy. Thus, administering 1-gallon PEG solution in the morning of an afternoon colonoscopy is a feasible option that can improve the quality of an afternoon colonoscopy.

Assessment of the multiple components of the variability in the adenoma detection rate in sigmoidoscopy screening, and lessons for training

The determinants of the observed variability of adenoma detection rate (ADR) in endoscopy screening have not yet been fully explained. Between November 1999 and November 2006 13 764 people (7094 men, 6670 women; age range 55-64) underwent screening flexible sigmoidoscopy at five hospital endoscopy units in Turin. To study the determinants of the ADR for distal adenomas, accounting for patient, examiner, and hospital characteristics, we applied a multivariate multilevel regression model. Average ADRs for all adenomas and for advanced adenomas (size > or = 10 mm, villous component > 20 %, high grade dysplasia) were 13.5 % (range 5.2 %-25.0 %) and 6.4 % (3.1 %-10.7 %) for men, and 8.0 % (2.5 %-14.0 %) and 3.7 % (0.2 % - 7.4 %) for women. In multivariate analysis, increased ADR of advanced adenomas was associated with male gender (odds ratio [OR] 1.78, 95 %CI 1.49 - 2.11), self-report of one first-degree relative with colorectal cancer (CRC) (1.44, 1.11-1.86), or of recent-onset rectal bleeding (1.73, 1.24-2.40). Adjusting for these variables, a significantly lower ADR was found for endoscopists with either a lower rate of incomplete sigmoidoscopy (< 9 %; OR 0.59, 95 %CI 0.41-0.87) or a higher rate (> 12 %; 0.64, 0.45-0.91), or with low activity volume (< 85 sigmoidoscopies/year; 0.66, 0.50-0.86). Residual variability explained by the endoscopy center effect was about 1 % and statistically significant. Endoscopist performance in flexible sigmoidoscopy CRC screening is highly variable. Low volume of screening activity independently predicts lower ADR, suggesting that operators devoting more time to screening sigmoidoscopy may perform better. Variability among pathologists in adenoma classification might explain part of the residual variability across endoscopy units.

OC-056 The utility of measuring adenoma detection rate as a key performance indicator at diagnostic colonoscopy: Abstract OC-056

<h3>Introduction</h3> Adenoma detection rate (ADR) is a key performance indicator for colonoscopy. Evidence suggests that various factors influence ADR. The BSG quality and safety indicators for endoscopy and the Global Rating Scale recommend ADR&gt;10%. <h3>Methods</h3> To assess how case mix affects ADR in a tertiary centre. We analysed 25 consecutive colonoscopies from each of the 15 non-trainee endoscopists at our institution. A further 50 cases each from six of the 15 endoscopists with low ADR, were assessed. Indications were divided into high (polyp follow-up, surveillance, familial cancer syndromes, rectal bleeding, anaemia) and low risk (IBD, diarrhoea, constipation, pain). <h3>Results</h3> Six endoscopists had a median ADR of 8% (0–16%). The other nine had a median ADR of 28% (24–40%) with significantly more high-risk indications (p&lt;0.0001). A further 50 cases from each of the six endoscopists with lower ADR were analysed. Median ADR was 12% (8–22%). <h3>Conclusion</h3> In the 50 cases analysed for each of the six colonoscopists with low ADR, there were significantly more low risk cases (p&lt;0.0001). The ADR was significantly lower for the low risk cases (2.6% vs 22.6%, p&lt;0.0001). ADR should be measured as a key performance indicator in the context of indication for colonoscopy.

High Definition versus Standard Colonoscopy: Adenoma Detection in an Average Risk Screening Population in Clinical Practice

Purpose: High definition (HD) colonoscopy has the potential to identify more polyps, especially flat lesions which could be missed during a standard (SD) colonoscopy. This advantage may be important in screening in high risk patients. Its utility in average risk screening colonoscopy in clinical practice is unclear. Methods: 378 consecutive patients undergoing average risk screening colonoscopy with two experienced gastroenterologists over a six month period in one endoscopy center were included. 207 patients were examined with a standard scope in the initial 3 months, and 177 patients with high definition scope in the later 3 months. Patients with personal history of polyps, family history of colorectal neoplasia, inflammatory bowel disease, and those referred for reasons other than screening were excluded. Results: Both groups were well matched, mean age (56 vs 56.6 yrs)and sex (female 66% vs 68%). A total of 77 (37%) patients had at least one polyp detected during standard colonoscopy vs 74 (43%) of patients with high definition colonoscopy. The adenoma detection rate was 18% with standard colonoscopy vs 24% with high definition colonoscopy. These differences were not statistically significant (polyp detection p = 0.11, adenoma detection p = 0.18). The adenoma detection rates varied between the two endoscopists (SD 30% vs 11%, HD 30% vs 19%). The endoscopist with the lower adenoma detection rate had a younger and more female (77% vs 48%) population. Conclusion: High definition colonoscopy did not significantly improve adenoma detection rates in our average risk screening colonoscopy population. The adenoma detection rate is likely to be influenced more by the population studied and operator technique, than by the use of high definition colonoscopy during screening.Table: Polyp detection by HD and SD colonoscopyTable: Distribution of Polyps

Efficacy of Cap-Assisted Colonoscopy in Comparison With Regular Colonoscopy: A Randomized Controlled Trial

Colonoscopy cannot be completed in up to 10% of cases. We postulate that cap-assisted colonoscopy (CAC), by fitting a mucosectomy cap to the tip of a colonoscope, could improve the outcome. We conducted a prospective randomized controlled trial in two regional endoscopy centers. All colonoscopies were performed by experienced colonoscopists. Patients 18 years or older undergoing their first colonoscopy were recruited. Patients were randomized to the CAC group or to the regular colonoscopy (RC) group. The first successful cecal intubation rate, rescue cecal intubation rate, cecal intubation and total colonoscopy times, and polyp detection rate were compared. One thousand patients were enrolled (mean age 52.6 years, 46% men). There was no statistically significant difference in the first successful cecal intubation rate between CAC and RC groups (96.2% vs. 94.6%, P=0.23). The cecal intubation and total colonoscopy times were shorter in the CAC group than in the RC group (6.0+/-4.0 min vs. 7.2+/-4.8 min, P<0.001; 14.7+/-8.6 min vs. 16.7+/-10.3 min, P=0.001). The adenoma detection rate was significantly lower in the CAC group than in the RC group (30.5% vs. 37.5%, P=0.018), but there was no significant difference in the detection of advanced lesions. In case of failing cecal intubation, use of CAC as a rescue method could achieve a higher success rate than RC (66.7% vs. 21.1%, P=0.003). Among experienced colonoscopists, CAC did not improve the initial cecal intubation rate and had a lower adenoma detection rate. However, it shortened the cecal intubation time and performed better as a rescue method. Its utilization should be reserved for selected cases, especially when initial cecal intubation fails.

Quality of Performance at Screening Flexible Sigmoidoscopy Correlates with Adenoma Detection Rates

Background: Adenoma detection rates (ADR) at screening flexible sigmoidoscopy (FS) are known to be variable. We have previously described an objective performance score for screening FS based on video footage. Aims: To determine whether quality of exam performance correlates with ADR. Methods: Video footage from 260 FS cases was selected from 40000 cases from the UK Flexible Sigmoidoscopy Screening Trial. The endoscopic view of the extubation phase of 20 cases from each of the 13 endoscopists were edited together in batches of 5, (4 batches per endoscopist) and then randomised. Each batch of 5 was from the same endoscopist. Cases in each batch had the same grade of bowel preparation, Excellent, Good, Adequate or a mixture of these grades. Each endoscopist had cases with all grades of prep. An experienced scorer, blinded to the endoscopists' identity, gave a single ‘quality of performance’ score for each batch of 5 cases; scores given were from 5-1 where 5/4=Excellent/Good, 2/1=Not Good Enough/ Unacceptable. Results: Total scores for endoscopist performance ranged from 9-17 (maximum possible 20) and the mean batch score for each endoscopist ranged from 2.25-4.25. The endoscopists fell into two groups. 6 of the 13 with a mean batch score > 3 had a higher ADR of 12.6-15.9%. 7 of the 13 with a mean batch score ≤3 had a lower ADR of 8.6-11.8%; 5 of these had a score of <3, defined as being ‘Not Good Enough’ or ‘Unacceptable’. ADR was strongly correlated with the total performance score: Pearson correlation coefficient 0.79 p=0.001. Conclusions: An endoscopist's performance at screening flexible sigmoidoscopy can be judged using video footage. Good performance correlates with higher adenoma detection rates. This tool could be used to improve technique and ensure quality in screening flexible sigmoidoscopy.