Mean Adenoma Detection Rate Research Articles

Association between endoscopist adenoma detection rate and serrated polyp detection: Retrospective analysis of over 200,000 screening colonoscopies.

Background and study aims Serrated lesions have been identified as precursor lesions for 20% to 35% of colorectal cancers (CRCs) and may contribute to a significant proportion of interval-cancer. Sessile-serrated-lesions (SSLs), in particular, tend to be flat and located in the proximal colon, making their detection challenging and requiring expertise. It remains unclear whether the detection rate for serrated polyps should be considered as a quality indicator in addition to the adenoma detection rate (ADR). This study sought to assess whether the ADR has an effect on the detection rate for serrated polyps. atients and methods In this retrospective analysis, prospectively collected data from 212,668 screening colonoscopies performed between 2012 and September 2018 were included. Spearman correlation and Whitney-Mann U-test were used to assess the association of ADR and the detection rate of SSLs with (SDR) and without hyperplastic polyps (SPADRs), the sessile serrated detection rate (SSLDR) as well as the clinically relevant serrated detection rate (CRSDR), including all SSLs and traditional serrated adenoma, hyperplastic polyps (HPs) >10 mm anywhere in the colon or HPs > 5 mm proximal to the sigmoid. Results The overall mean ADR was 21.78% (standard deviation [SD] 9.27), SDR 21.08% (SD 11.44), SPADR 2.19% (SD 2.49), and CRSDR was 3.81% (3.40). Significant correlations were found between the ADR and the SDR, SPADR, SSLDR, and CRSDR (rho=0.73 vs. rho=0.51 vs. rho=0.51 vs. rho=0.63; all P <0.001). Endoscopists with a mean ADR ≥25% had significantly higher SDR, SPADR, and CRSDR than endoscopists with a mean ADR <25% (all P <0.001; Mann-Whitney U-Test). Conclusions This study shows that endoscopists with higher ADR detect significantly more serrated lesions than those with a lower ADR.

Quality in colonoscopy: time to ensure national standards are implemented?

BackgroundHigh-quality colonoscopy is crucial to ensure complete mucosal visualisation and to maximise detection of pathology. Previous audits showing variable quality have prompted national and international colonoscopy improvement programmes, including the...

Endoscopic surveillance after resection of sessile serrated lesions: so far, so good?

Polyp detection is on the rise! Since the establishment of the adenoma detection rate (ADR) as the primary quality parameter in colonoscopy [1], we have been focusing on improving our ability to detect colorectal adenomas, both through the refinement of our techniques and the growing availability and use of technological means that enhance detection capabilities. This increased awareness of the importance of meticulous mucosal inspection and the incorporation of quality assurance programs, including benchmarking, auditing, and retraining, have led to an increase in mean ADR across endoscopists and have played a decisive role in the global improvement of colonoscopy quality. However, we have also learned that not all that glitters is gold – ADR is not perfect! As a surrogate rather than direct measure of colonoscopy efficacy, it is suspectable to gaming (“one adenoma and done”) and may not reflect the colorectal cancer (CRC) risk for the individual patient or their need for surveillance colonoscopy. Indeed, up to 30 % of all CRCs appear to arise from the serrated neoplasia pathway rather than the conventional adenoma–carcinoma sequence. This raises doubts about the protective effects of a high ADR among this relatively large proportion of patients.

Feasibility of Continuous Monitoring of Endoscopy Performance and Adverse Events: A Single-Center Experience.

We integrated a standardized questionnaire focusing on adverse events and performance measures in gastrointestinal endoscopy as a mandatory component of the electronical medical record. This retrospective study was conducted using prospectively collected data on quality parameters and adverse events (AEPM) for all diagnostic and therapeutic endoscopic procedures at our center between 2018 and 2020. A total of 7532 consecutive endoscopic procedures were performed in 5035 patients. The proportion of high-risk examinations and high-risk patients was 20% and 23%, respectively. Severe adverse events (AEs, n = 21) occurred in 0.3% of procedures and significantly more often in patients with an ASA score > II (0.6%, p < 0.01). We observed no long-term morbidity after severe AEs. Mortality was 0.03% (n = 2). Following screening colonoscopy (n = 242), four endoscopists documented AEPM in more than 98% of the examinations. The cecal intubation rate was 97%, and the mean adenoma detection rate 60%. The quality of lavage was documented in 97% (rated as good in 70% and moderate in 24%). The risk of adverse events is significantly increased in patients with an ASA score > II, which should be considered when choosing treatment methods and precautionary measures. Continuous recording of AEPM can be effectively integrated into the clinical reporting process, enabling analysis of the data and feedback to be provided to endoscopists.

Outcomes Associated With Colorectal Cancer After Population-Based Colonoscopy Screening: Results From a European Pragmatic Randomized Trial

Bretthauer M, Løberg M, Wieszczy P, et al. Effect of colonoscopy screening on risks of colorectal cancer and related death. N Engl J Med 2022;387:1547–1556. Colorectal cancer (CRC) is an ideal target for both opportunistic and population-based screening. Currently recommended screening strategies rely primarily on stool-based modalities such as fecal immunochemical testing (FIT) and endoscopic modalities such as sigmoidoscopy and colonoscopy. Bretthauer et al performed the first randomized trial to assess the effects of population-based screening colonoscopy on CRC and CRC-associated death. Screening-naïve healthy participants aged 55 to 64 years from 4 European countries were identified from population registries and, in a 1:2 ratio, randomly invited to undergo screening colonoscopy or not invited for screening. Screening colonoscopies were performed from 2009 to 2014. Importantly, no participants received any competing CRC screening modalities outside of the trial during either the screening or follow-up periods. Follow-up data were available for 84,585 patients. Among the invited group, 42.0% of participants accepted their invitation and underwent colonoscopy. The mean adenoma detection rate (ADR) was 30.7%. In intention-to-treat analyses, the 10-year risk ratio (RR) of CRC was 0.82 (95% confidence interval [CI] 0.70–0.93) in the screening arm, although the risk of CRC-related death was not significantly different (RR 0.90, 95% CI 0.64–1.16). In per-protocol analyses, RRs of CRC and CRC-related death with screening were 0.69 (95% CI 0.55–0.83) and 0.50 (95% CI 0.27–0.77), respectively. These results have triggered a broad range of reactions. Given the acceptance rate of 42%, one widely repeated stance is that colonoscopy can be effective only if performed, and that the per-protocol analyses may be a better representation of colonoscopy’s benefits (Dominitz and Robertson, N Engl J Med 2022;387:1609–1611). While perhaps true at the patient level, the aims of this study were to assess the efficacy of colonoscopy as a population-based screening tool. Therefore, barriers to dissemination, acceptability, and uptake are all relevant. Put another way, one might ask whether offering screening colonoscopy as a primary population-based screening modality increases or decreases health equity. Furthermore, existing cohort studies, which likely overestimate colonoscopy’s effectiveness given healthy user bias and inability to adjust for poor uptake, have demonstrated similar results (Nishihara et al, N Engl J Med 2013;369:1095–1105). The issue of justifying the costs (and risks) of colonoscopy as a primary screening modality is therefore also paramount, especially in single-payer resource-limited health care systems, given the established benefits of FIT in reducing CRC incidence and mortality (Chiu et al, Cancer 2015;121:3221–3229). Another debatable point is that the mean ADR was potentially suboptimal at 30.7%. However, given (1) the study period (2009–2014), (2) the screening-naïve non-FIT population, and (3) the upper age limit of 64 years (with established increases in ADR with increasing age [Shaukat et al, Am J Gastroenterol 2021;116:1946–1949]), these results are likely generalizable. Furthermore, inter-endoscopist variations in ADR are well established, with outliers prevalent in most practice settings (Mazurek et al, Clin Gastroenterol Hepatol 2022;20:1931–1946; Bishay et al, Gastrointest Endosc 2020;92:1030–1040.e9). Although the benefits of screening colonoscopy are clear at the patient level, providers and policy makers should carefully consider its role in population-based average-risk screening. Similar studies with long(er) follow-up periods, studies comparing colonoscopy and FIT for population screening, and studies carried out in different populations are all needed. Regardless of the modalities employed, ongoing efforts should be made to provide widespread patient education on CRC screening to improve uptake and optimize health equity.

Adenoma Detection Rates in 45-49-Year-Old Persons Undergoing Screening Colonoscopy: Analysis From the GIQuIC Registry.

The impact of lowering the colon cancer screening age from 50 to 45 years on the endoscopist adenoma detection rate (ADR) is not well studied. We used average-risk screening colonoscopies submitted to the GI Quality Improvement Consortium registry from 2014 to 2020 among individuals aged 45-75 years. We used the 1-way ANOVA test to determine differences between ADRs among 45-49-year-old, 50-54-year-old, and 50-75-year-old individuals. A total of 2,806,539 screening colonoscopies were performed by 814 endoscopists. The mean ADR in the 45-49-year-old group was 28.6% compared with 31.8% for the 50-54-year-old group (P < 0.001) and 36.3% for the 50-75-year-old group (P < 0.001). Endoscopists might see a small drop in their ADR once a higher proportion of 45-49-year-old patients start undergoing screening colonoscopy.

A Multicenter Randomized Controlled Trial Comparing Two Bowel Cleansing Regimens for Colonoscopy After Failed Bowel Preparation

Failed bowel preparation for colonoscopy occurs commonly, but the optimal regimen for the subsequent attempt is unknown. High-volume preparations often are used but are not well studied. The objective of this study was to compare the efficacy, tolerability, and safety of 2 regimens for use after failed bowel preparation. A multicenter, endoscopist-blinded randomized controlled trial was conducted in patients who previously failed bowel preparation despite adequate compliance. Patients were randomized to 1 of 2 split polyethylene glycol (PEG) regimens, preceded by 15 mg bisacodyl: PEG 2 L the evening before and 2 L the day of colonoscopy (PEG 2+2L+bisacodyl), or 4 L and 2 L (PEG 4+2L+bisacodyl). All patients followed a low-fiber diet on both the third and second day before the procedure, followed by a clear fluid diet the day before and the morning of the colonoscopy. The primary outcome was adequate bowel preparation, defined as a Boston Bowel Preparation Scale total score of 6 or higher, with all segment scores of 2 or higher. Secondary outcomes included adenoma detection rate, advanced adenoma detection rate, sessile serrated lesion detection, cecal intubation rate, tolerability, and adverse events. A total of 196 subjects were randomized at 4 academic centers in Canada (mean age, 60.7 y; SD, 11.4 y; 44.9% were women). There were no significant differences between the PEG 2+2L+bisacodyl and the PEG 4+2L+bisacodyl groups in achieving adequate bowel preparation (91.2% vs 87.6%; P= .44). There were no significant differences with regard to mean adenoma detection rate (37.4% vs 31.5%; P= .41), advanced adenoma detection rate (18.7% vs 11.2%; P= .16), sessile serrated lesion detection (8.8% vs 5.6%; P= .41), and cecal intubation rate (96.7% vs 92.1%; P= .19). The 2 regimens were similarly well tolerated, but PEG 2+2L+bisacodyl was associated with a higher willingness to repeat the bowel preparation (91.2% vs 66.2%; P < .001). Split-dose 4 L-PEG with 15 mg bisacodyl, along with dietary restrictions, has similar efficacy as a higher-volume preparation, and should be considered for patients who previously failed bowel preparation (ClinicalTrials.gov number, NCT02976805).

Quality Control in the Slovenian National Colorectal Cancer Screening Program

Objectives: The objective of the study was to assess the impact of an internal quality indicator (QI) audit on the quality level of colonoscopies in the National Colorectal Cancer Screening Program (NCCSP). Design: Sixty-eight colonoscopists from 29 endoscopic centres participated in the NCCSP from April 2009 to January 2015. Controlled QIs were the percentage of total colonoscopies, adenoma detection rate (ADR), mean adenoma per procedure (MAP), mean adenoma per positive procedure (MAP+), right-sided ADR, sessile serrated lesion (SSL) detection rate, and patient responses to post-procedural questionnaires. A group of 3 expert endoscopists from the NCCSP Council performed 91 inspections and provided education. Results: A total of 891.364 (58.2%) Slovenian citizens participated in the first 3 screening rounds of the NCCSP. Among 46.552 (6%) positive individuals, 42.866 (92.1%) underwent first colonoscopies. Total colonoscopies were performed in 98% of endoscopies (p = 0.459 between cycles), mean ADR was 51.8% (p = 0.872 between cycles), mean percentage of adenoma in the right colon was 37.5% (p = 0.227 between cycles), mean MAP was 1.1 (p = 0.981 between cycles), mean MAP+ was 2.0 (p = 0.824 between cycles), and mean SSL detection rate was 3% (p < 0.001). We observed great difference in QIs between endoscopists and a significant increase in MAP, ADR in the right colon, and SSL per endoscopist during the 6-year period. Due to quality underperformance, 3 endoscopic centres (10.3%) and 13 endoscopists (19.1%) were excluded from the program. Conclusions: The success of the NCCSP is related to the quality of colonoscopies performed. To ensure the proper quality level, regular audit and permanent education are needed.

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

The number of colonoscopies required to reach satisfactory adenoma detection rate (ADR) is not well established. The aim of this study was to identify the appropriate number of procedures required to attain satisfactory ADR for those well-trained endoscopists who have a cecal intubation rate (CIR)≥90% and start to perform colonoscopy independently. All endoscopists with compelete independent colonoscopy data during career in our database were enrolled. The number of procedures required to achieve ADR≥20% was identified by cumulative summation (Cusum), learning curve Cusum (LC-Cusum), and moving average method. Mixed effect logistic regression model was developed to determine the relationship between endoscopist as well as patient-related factors and adenoma detection. A total of 24943 procedures and 14 endoscopists were enrolled. By Cusum analysis, the interest point was at 207 procedures. By LC-Cusum analysis, 71% (10/14) and 86% (12/14) of endoscopists had attained satisfactory ADR after 200 and 300 procedures, respectively. By moving average method, endoscopists reached a mean ADR of 20% at 216 and 261 procedures over blocks of 50 and 100 procedures, respectively. The total number of procedures, number of daily procedures, patient age and gender, bowel preparation, sedation, and diverticulosis were significantly associated with adenoma detection. This is the first study to investigate the learning curve of ADR for those well-trained endoscopists who have a CIR≥90% and start to perform colonoscopy independently. Two hundred procedures might be an optimal number required to reach an ADR≥20%.

Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients.

Background and study aims The demand for screening colonoscopy has continued to rise over the past two decades. As a result, the current workforce of gastroenterologists is unable to meet the needs for colorectal cancer (CRC) screening. Therefore, solutions are needed to improve this disparity, with non-physician endoscopists being a potential option. However, current literature on the performance of non-physicians in endoscopy is limited. The aim of this study was to assess the quality of colonoscopy performed by three gastrointestinal fellowship-trained nurse practitioners (NPs). Methods This was a retrospective study performed at a single tertiary academic medical center. Colonoscopies performed by three gastrointestinal-specialized NPs after having completed training of at least 140 supervised colonoscopies were reviewed for analysis. Inclusion criteria were patients undergoing colonoscopy for colorectal cancer screening purposes. Outcomes included colonoscopy quality indicators as defined by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology Taskforce (ASGE/ACG) Taskforce. Results The study included 1,012 subjects (mean age 56.2 years, female 51.5 %, African American 73.9 %) who underwent screening colonoscopies by three NPs. Cecal intubation was successful in 997 subjects (98.5 %). Mean adenoma detection rate was 35.6 %. Mean withdrawal time was 18.9 minutes. There were no adverse events including colonic perforations or delayed post-polypectomy bleeding. Conclusions Three fellowship-trained NPs in colonoscopy in the United States satisfied the quality indicators proposed by the ASGE/ACG Task force, demonstrating that adequately trained NPs can perform colonoscopy safely and effectively. With the demand for colonoscopy exceeding the supply, non-physicians could be part of the solution to meet the demands for CRC screening.

Sa2051 IMPACT OF LINKED COLOR IMAGING ON THE ADENOMA DETECTION RATE IN NAIVE GASTROENTEROLOGY TRAINEES: A RANDOMIZED CONTROLLED TRIAL

Adenoma detection rate (ADR) is the most widely used marker of quality, and low rates are associated with increased rates of post-colonoscopy colorectal cancer (CRC). As a newly developed image-enhanced endoscopy technique, linked-color imaging (LCI) provides very bright images with enhanced red-color tones and has been purported to increase ADR. Some studies suggest that LCI by experienced endoscopists may be more effective at detecting adenomas than white-light imaging (WLI). However, the usefulness of screening colonoscopy with LCI by novice trainees remains unknown. We undertook a randomized trial to evaluate the detection rates of colorectal polyps and adenomas with LCI in comparison to WLI during fellowship training. All colonoscopies for CRC screening were eligible for the study. Exclusion criteria included patient age <18 or >75 years, prior colon resection, or Boston bowel preparation scale (BBPS) less than 5. Patients were randomized to either LCI or WLI in a 1:1 fashion. The primary outcome was ADR. Secondary outcomes were polyp detection rate (PDR), adenoma per colonoscopy (APC), polyp per colonoscopy (PPC), and withdrawal time of each trainee throughout the first year of colonoscopy training. Further, these study outcomes were compared among the first 6-month and the last 6-month period of training. During November 2018 and October 2019, 6 trainees involved CRC screening in 804 patients with a mean age of 61.7±10.9 years, and 38% were male. Three hundred fifty-two patients and 452 patients underwent colonoscopic withdrawal using LCI and WLI, respectively. Patient characteristics were comparable between both groups concerning comorbidities, antiplatelet/anticoagulant usage, indication for the colonoscopy, and BBPS (Table1). Overall independent cecal intubation rate by trainees was 86.2%, and the performance of each trainee was similar between groups. However, the withdrawal time was shorter in the LCI group (14.6±8.3 min vs. 16.7±8.0 min, p<0.01). The mean ADR was 40.1% and 43.6% in LCI and WLI, respectively (p=0.32). The PDR, APC and PPC were not significantly different between both two groups. To evaluate learning curves for the quality of screening colonoscopy, the primary and secondary outcomes were compared among the first and second 6-month periods. The analysis showed that the ADR during both periods was not significantly different between the LCI and WLI groups (Table 2). The PDR, APC, and PPC between both groups were also similar between both periods. Overall, ADR by gastroenterology trainees reached the standard ADR recommended by international guidelines. Although withdrawal times with LCI were shorter than those of WLI, colonoscopy with LCI did not facilitate ADR and had no impact on the learning curve of CRC screening by novice trainees.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Tu1132 ASSOCIATION BETWEEN THE ADENOMA DETECTION RATE AND A COMPOSITE QUALITY INDICATOR OF CAECAL INTUBATION, PATIENT COMFORT AND SEDATION IN FIT-POSITIVE COLONOSCOPIES

The Performance Indicator of Colonic Intubation (PICI) has been introduced as a new measure of high-quality colonic intubation, taking three key parameters into account. An adequate PICI was defined as caecal intubation without significant discomfort and use of less than the median midazolam dose in the UK. In an UK national audit, adequate PICI was achieved in 54.1% of colonoscopies. It was associated with higher polyp detection rates, but an association with the adenoma detection rate (ADR) was not assessed. In this study, we determined the association between PICI, using the UK and Dutch median sedation dose, and detection rates of (advanced) adenomas in colonoscopies for the Dutch FIT-based colorectal cancer (CRC) screening program. Furthermore, we assessed the feasibility of PICI as quality indicator in this population. This study was conducted within the Dutch FIT-based screening program. Colonoscopy and pathology data is prospectively collected in a national database, providing data on ADR. Data between 01-01-2016 and 01-01-2018 were analyzed. Achieving an adequate PICI was defined as a procedure with caecal intubation, a Gloucester Comfort Scale (GCS) between 1 and 3 (no to mild discomfort) and use of a maximum dose of 2.5 mg midazolam. Besides, we studied the PICI when using the median dose of midazolam given in this Dutch population. During the study period, 107.328 colonoscopies were performed in FIT-positive participants. The mean ADR was 64.2%. No to mild discomfort (GCS: 1-3) was recorded in 95.6% of the colonoscopies and the median midazolam dose was 5 mg (IQR: 2.5-5 mg). Adequate PICI, using the cut-off of 2.5 mg midazolam was achieved in 49.500 (46.1%) colonoscopies. In 87.8% of the colonoscopies in which PICI was inadequate, this was solely due to a higher dose of midazolam or use of propofol. Adequate PICI was associated with higher ADR (OR: 1.05; 95%CI: 1.03-1.08), but not with advanced adenoma detection rates (OR: 1.01; 95%CI: 0.99-1.04). When using the cut-off of 5 mg, the median midazolam dose in this Dutch population, adequate PICI was achieved in 95.410 colonoscopies (88.9%) and it was associated with both higher ADR (OR: 1.52; 95%CI: 1.46-1.58) and advanced adenoma detection rates (OR: 1.19; 95%CI: 1.14-1.24). Adequate PICI, using the UK and Dutch median sedation dose, was associated with higher ADRs. However, in this FIT-positive population, the UK-defined PICI was inadequate in more than half of all colonoscopies. This was mainly due to sedation practice in the Netherlands with a higher median midazolam dose of 5 mg. PICI appears to be an indicator that is heavily dependent on sedation practice, which is not the same across countries. Therefore, the PICI should be considered in the light of regional sedation practices and related to outcome parameters, like ADR.

Impact of Endoscopists' Personality Traits on Adenoma and Polyp Detection Rates in Colonoscopy: A KASID Multicenter Study.

The personality traits of endoscopists have been suggested to affect the adenoma detection rate (ADR). We thus evaluated the relationship between endoscopists' personality traits and the ADR during colonoscopy using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). In total, 1230 patients (asymptomatic and aged 50-80years) who underwent screening or surveillance (≥ 5years) colonoscopy were recruited from 13 university hospitals by 20 endoscopists between September 2015 and December 2017. We retrospectively measured the ADR, polyp detection rate (PDR), and number of adenomas per colonoscopy (APC). All 20 endoscopists completed all 567 true/false MMPI-2 items. The overall mean colonoscopy withdrawal time, PDR, ADR, and APC were 7.3 ± 2.8min, 55%, 45.3%, and 0.97 ± 1.58, respectively. No significant difference was observed in the MMPI-2 clinical scales (e.g., hypochondriasis and psychasthenia), content scales (e.g., obsessiveness and type A character), or supplementary scales (e.g., dominance and social responsibility) between the high ADR group (ADR ≥45%, n = 10) and the low ADR group (ADR < 45%, n = 10). In multivariate logistic regression analysis, the ADR was associated significantly with patient age and sex. The ADR was related significantly to endoscopists' colonoscopy experience and the per-minute increase in the colonoscopy withdrawal time (OR 1.21, 95% CI 1.06-1.38, p = 0.005). In a logistic regression analysis adjusted for patient factors, the ADR was associated significantly with ego strength (OR 1.04, 95% CI 1.00-1.09, p = 0.044), as measured by the MMPI-2. With the exception of ego strength, the endoscopists' personality traits were not associated with adenoma or polyp detection.

Does the withdrawal time affect adenoma detection in non-screening colonoscopies?

AimsThere are no studies looking at the relationship between colonoscopy withdrawal time (CWT) and adenoma detection rate (ADR) in non-screening patients. Our aim is to explore the relationship between CWT...

Impact of adenoma detection rate on detection of advanced adenomas and endoscopic adverse events in a study of over 200,000 screening colonoscopies

Adenoma detection rate (ADR) is the best established quality parameter for screening colonoscopy. Guidelines recommend a target ADR >25% because previous studies have shown that patients of endoscopists with higher ADRs have a lower risk of postcolonoscopy interval cancers. However, studies have shown that improvement in ADR mainly results in increased detection of clinically irrelevant nonadvanced adenomas (NAAs). The impactof ADR on the detection of advanced adenomas (AAs) as well as adverse event rates has yet to be determined. A total of 218,193 screening colonoscopies performed between 2007 and 2010 by 262 endoscopists within the Austrian quality assurance program were analyzed. We divided endoscopists into quintiles based on ADRs and calculated mean advanced ADRs (AADRs), NAA detection rates (NAADRs), and adverse event rates for each quintile. Spearman rank-order was used to calculate overall correlations between ADRs and AADRs as well as adverse event rates. Endoscopists with an ADR<25% were compared with those with an ADR >25%. Fifty-one percent of patients were women. Mean ADR was 23.03% (95% confidence interval [CI], 21.93-24.13), AADRs 7.72% (95% CI, 7.19-8.25), and NAADRs 15.31% (95% CI, 14.36-16.27). Overall, there was a significant correlation between ADR and AADR (rho= .51; P< .001). When ADR was divided into quintiles, mean AADR increased with increasing ADR. Even in the highest ADR group (ADR, 31.36%-52.27%) there was a further increase in AADR with a mean of 10.75% (95% CI, 9.31-12.19). Importantly, NAADRs increased continuously with improvement in ADRs but never dissociated from a simultaneous improvement in AADRs. However, there was also a significant correlation of ADRs and endoscopic adverse events (rho= .26, P< .001), even if the perforation rate of .028% (95% CI, .004-.052) in the highest ADR group still remained within the accepted limits based on guidelines. Increasing ADR is associated with improved detection of AAs and therefore is likely to prevent more cases of colorectal cancer. However, higher ADR was also associated with a higher rate of adverse events, although the adverse event rate was low.

Significant Variation in the Detection Rates of Proximal Serrated Polyps Among Academic Gastroenterologists, Community Gastroenterologists, and Colorectal Surgeons in a Single Tertiary Care Center.

Recent studies have demonstrated that the protective effect of colonoscopy against colorectal cancer is lower in the proximal colon. Proximal serrated polyps, including sessile serrated adenomas and proximal hyperplastic polyps, can be frequently missed and pose a risk of interval cancers. To investigate the overall adenoma detection rate (ADR) and the proximal serrated polyp detection rate (PSPDR) among academic gastroenterologists, community gastroenterologists, and colorectal surgeons from a single institution, all of whom have received formal training in colonoscopy during their fellowship. All complete screening colonoscopies for patients aged 50 or older with a good to excellent bowel preparation performed by different endoscopists at Medstar Washington Hospital Center (Washington, DC) from July 2015 to December 2017 were reviewed. Pathology reports of the resected polyps were manually reviewed. A total of 2850 screening colonoscopies meeting the inclusion criteria were performed by 18 endoscopists (6 academic, 7 community, and 5 colorectal surgeons). There was no significant difference in the mean ADR among the three groups of endoscopists: academic gastroenterologists, community gastroenterologists, and colorectal surgeons (40.3% vs 36.0% vs 39.6%, respectively). However, academic gastroenterologists had a significantly higher PSPDR compared to community gastroenterologists or colorectal surgeons (12.3% vs 5.4% vs 4.5%, respectively, ANOVA p = 0.006). Our novel data show that academic gastroenterologists had a significantly higher PSPDR compared to community gastroenterologists or colorectal surgeons despite a comparable overall ADR among the three groups. PSPDR may be considered as an important quality indicator for colonoscopy, apart from ADR.

Detection of proximal serrated polyps: a single-center retrospective analysis

Objective To investigate the prevalence and endoscopic detection rate of proximal serrated polyps and to screen the risk factors. Methods The data of 9 010 colonoscopies performed by 22 endoscopists between September 2016 and September 2017 were reviewed. The adenoma detection rate (ADR) and proximal serrated polyp detection rate (PSDR) were calculated, and the correlation between ADR and PSDR was estimated by Pearson correlation coefficients. Multivariate logistic regression was used to analyze PSDR among endoscopists. Results For all subjects, the mean ADR was 30.07% (ranged from 20.00% to 40.78%) and mean PSDR was 4.70% (ranged from 1.52% to 9.28%). PSDR of males was 1.38 times of that of females (OR=1.38, 95%CI: 1.13-1.69, P<0.01). For 3 560 cases (39.51%) of 50 years and older subjects, the mean ADR was 45.01% (28.99%-57.78%) and mean PSDR was 6.08% (2.07%-10.56%). PSDR was moderately correlated with ADR (r=0.48, P=0.02). PSDR of males was 1.36 times of that of females (OR=1.36, 95%CI: 1.04-1.80, P=0.03). Endoscopist was a significant risk factor for detection of proximal serrated polyps (P<0.01). Compared with endoscopist with the highest PSDR, odds ratio of other endoscopists ranged from 0.16 (95%CI: 0.06-0.40, P<0.01) to 0.83 (95%CI: 0.53-1.32, P=0.44). Conclusion Proximal serrated polyps are more common in males, who are over 50 years old. The PSDR is highly variable and dependent on endoscopists. It is possible that a certain proportion of proximal serrated polyps are missed during colonoscopy. Key words: Colonoscopy; Adenoma; Serrated polyps, proximal; Detection rate

Defining and Applying Locally Relevant Benchmarks for the Adenoma Detection Rate.

The adenoma detection rate (ADR) is the best validated colonoscopy performance quality indicator. The ASGE/ACG Task Force on Colonoscopy Quality set an ADR benchmark of ≥25% in a mixed male/female population. We propose a novel means for defining locally relevant ADR benchmarks using data from the population of interest and for applying ADR benchmarks using 95% confidence intervals (CIs) of an endoscopist's ADR. We further propose that ADR benchmarks should be raised to reflect what can be achieved by high-performing endoscopists. We used endoscopists' performance in a baseline year to develop and apply benchmarks in an assessment year. We defined assessment year benchmarks (Minimally Acceptable, Standard of Care, and Aspirational) based on the average ADR of performance groups defined by baseline year ADR quartiles. We demonstrated the use of these benchmarks in endoscopists performing screening colonoscopies by determining if the upper bound of the 95% CI of the endoscopist's ADR included the ADR benchmark. The study included 8,492 colonoscopies (mean ADR 29%) in 2014 and 5,193 colonoscopies (mean ADR 32%) in 2015, completed at a regional screening center in Calgary, Canada. The Minimally Acceptable, Standard of Care, and Aspirational benchmarks for 2015 were 25%, 30%, and 39%, respectively. The 95% CI of the ADR of 1 (3%), 3 (10%), and 12 (39%) endoscopists did not include the benchmark. We have proposed methods for defining and applying benchmarks for ADR in average-risk patients that go beyond the "minimally acceptable" threshold currently recommended.

Effect of time of day and specialty on polyp detection rates in Australia.

Adenoma detection rate (ADR) is an important quality metric in colonoscopy. However, there is conflicting evidence around factors that influence ADR. This study aims to investigate the effect of time of day and endoscopist background on ADR and sessile serrated adenoma/polyp detection rate (SSA/P-DR) for screening colonoscopies. Consecutive patients undergoing colonoscopy in 2016 were retrospectively evaluated. Primary outcome was the effect of time of day and endoscopist specialty on screening ADR. Secondary outcomes included evaluation of the same factors on SSA/P-DR and other metrics and collinearity of ADR and SSA/P-DR. Linear regression models were used for association between ADR, time of day, and endoscopist background. Bowel preparation, endoscopist, session, patient age, and gender were adjusted for. Linear regression model was also used for comparing ADR and SSA/P-DR. Chi-square was used for difference of proportions. Two thousand six hundred fifty-seven colonoscopies, of which 558 were screening colonoscopies, were performed. The adjusted mean ADR (screening) was 36.8% in the morning compared with 30.5% in the afternoon (P<0.0001) and was 36.8% for gastroenterologists compared with 30.4% for surgeons (P<0.0001). For every 1-h delay in commencing the procedure, there was a reduction in mean ADR by 3.4%. Using a linear regression model, a statistically significant positive association was found between ADR and SSA/P-DR (P<0.0001). Morning and afternoon sessions and gastroenterologists and surgeons achieved the minimum standards recommended for ADR. Afternoon lists and surgeons were associated with a lower ADR compared with morning and gastroenterologists, respectively. Additionally, SSA/P-DR showed collinearity with ADR.

Peppermint Oil to Improve Visualization in Screening Colonoscopy: A Randomized Controlled Clinical Trial

BackgroundScreening colonoscopy has been associated with reduced mortality from colorectal cancer by means of early detection and timely treatment. However, visualization during colonoscopy is often impaired since the colon is naturally prone to peristalsis and spasm. There is evidence to suggest benefit of topical peppermint oil in causing smooth muscle relaxation, thereby decreasing peristalsis. The aim of our study was to determine if peppermint oil helps reduce colonic spasticity so as to allow for better visualization during screening colonoscopy.MethodsWe performed a randomized controlled, double-blinded, clinical trial where patients undergoing screening colonoscopy were assigned to receive either peppermint oil or placebo. Once cecum was reached, 50 mL of either solution was directly injected via the working channel of the colonoscope. Colonic peristalsis, spasticity and bowel visibility were documented. Bowel preparation quality, withdrawal time and adenoma detection rate (ADR) were also assessed. Continuous variables were analyzed using t-test or Wilcoxon rank-sum test while categorical variables were compared using the two-way Chi-square test.ResultsForty-eight patients were included, of whom 24 patients received peppermint oil and 24 received placebo. Mean Boston bowel preparation score (BBPS) was excellent for both groups (8 points vs. 7.9 points; P = 0.98). Both mean total colonoscopy time (17.8 min vs. 21.9 min; P = 0.07) and mean cecal intubation time (7.2 min vs. 10.3 min; P = 0.04) were shorter with peppermint oil as compared to placebo. Complete absence of bowel spasticity was observed among 58.3% patients in the peppermint oil group as compared to 45.8% patients in the placebo group (P = 0.05). More than 75% of bowel was visualized in 83% of patients in both groups (P = 0.56). Mean ADR was higher in the peppermint group as compared to the placebo group (45.8% vs. 37.5%; P = 0.56).ConclusionOur study suggests that topical peppermint oil reduces bowel wall spasticity, which could lead to better visualization of the bowel during screening colonoscopy. Although use of peppermint oil was associated with better ADRs, these results did not achieve statistical significance. Larger sample size and use of alternative methods of peppermint oil administration allowing for more absorption time may establish stronger results.