Mean Withdrawal Time Research Articles

Quality of colonoscopy practice: a single-center experience in Egypt

Colonoscopy is a technically demanding procedure with the potential to cause harm if its performance is suboptimal. It is incumbent on endoscopists, therefore, to evaluate their practices and to make improvements wherever possible. Bolak Eldakror Hospital is a secondary-care governmental hospital in Egypt in which we set up an endoscopy quality-assurance program in 2003. The aim of this study was specifically to evaluate the quality of colonoscopy practice in our endoscopy unit and by publishing our experience to encourage others to develop a quality-improvement program. Predetermined international quality indicators for colonoscopy were employed to monitor the standard of endoscopic procedures between 2010 and 2014. Recorded information included all medical and technical details. A total of 286 colonoscopies were assessed. The main indication of colonoscopy was hematochezia (58.7%). Polyps were the main endoscopic findings (34.6%). Conscious sedation was used in 56.6%. Cecal intubation was achieved in 77.6%. The adjusted cecal intubation was 94%. Image documentation of cecal intubation was achieved in 92.3% examinations reaching the cecum. Mean cecal intubation time was 17.4±10 min. Mean withdrawal time was 6.6±4 min. The main reasons for unsuccessful cecal intubation were impassable mass or stricture in 23 (8%) colonoscopies and poor bowel preparation in 23 (8%). Colon preparation was rated adequate in 66.4%. Diagnostic colorectal biopsies for those with persistent diarrhea were obtained in 97%. Polyp detection rate was 36.1% and adenoma detection rate was 5.3%. Polypectomy was carried out in 89 (93.6%) patients with detected polyp/s. Retrieval of all excised polyps was successful in 84.3%. Postpolypectomy perforation occurred in one (0.4%) patient. A high standard of colonoscopy can be achieved by the rigorous application of quality-assurance measures.

OC-014 Extra Wide Angle View Colonoscope (EWAVE) has Superior Polyp Detection Rate When Compared to a Standard Colonoscope (SD): A Randomised Tandem Pre-Clinical Study: Abstract OC-014 Table 1

Introduction Colonoscopy screening with the removal of adenomas has been the preferred and most effective strategy to prevent colorectal cancer (CRC). However adenomas are often missed during colonoscopic examination, particularly on the proximal sides of folds and at the flexures. The prototype (EWAVE) Extra Wide Angle View colonoscope (Olympus, Tokyo, Japan) has a 147°–235° angle lateral/backward view lens and a standard 140° angle forward view lens. Views from both lenses are constructed and displayed as a single image. By improving visualisation behind the folds and flexures this new scope could increase the polyp detection rate (PDR). Objective is to compare the polyp detection rate between EWAVE and a standard colonoscope in a colonic model with simulated polyps. Methods Two colorectal (Koken, Japan) rubber colon models were prepared with 18 and 20 polyps of different size (520 mm) at various locations. Seventeen endoscopists, 14 gastroenterology trainees and 3 nurse endoscopists with varying levels of experience performed back to back examinations with the standard colonoscope and EWAVE scope. The order which they performed the procedure (i.e. EWAVE or SD first) was randomised using concealed envelopes. In order to minimise type 2 error, on the 2nd model the endoscopists performed the procedure in reverse order. Results There was no significant difference in mean insertion time (p = 0.8) or withdrawal time (p = 0.29) between EWAVE and standard colonoscope (Figure 1). Mean simulated PDR was significantly higher with EWAVE examination when compared to standard colonoscopic examination in both models (p = 0.026 and Conclusion Our non-clinical study showed significantly higher polyp detection rates with the novel extra wide angle colonoscope when colonoscopy was performed by moderately experienced colonoscopists. Further clinical trials appear warranted. Disclosure of Interest None Declared

OC-012 The Effect of Mental Workload Experienced During Colonoscopy on Endoscopists Performance

<h3>Introduction</h3> Studies have shown that there are a multitude of factors that affect the quality of colonoscopy. However, the effect of the endoscopist mental workload on their performance has been neglected. It is shown that health professionals exposed to excessive workloads and fatigue show degraded performance. The aim of this study was to measure the effect of mental workload as represented by the National Aeronautics and Space Administration-Task Load Index (NASA-TLX), on colonoscopic performance relative to the experience of the endoscopist and colonoscopy scheduling. <h3>Methods</h3> Procedures were observed prospectively in one institution for 3 groups; trainees, consultants and bowel cancer specialist programme (BCSP) endoscopists. On reaching the caecum the endoscopist marked on a validated pro-forma their corresponding workload on six subscales; mental demand, physical demand, temporal demand, effort, frustration and own performance, to generate a NASA-TLX score. Data on performance which included caecal intubation times (CIT), patient comfort and polyp detection rate (PDR) were noted. In addition, withdrawal times, time of day (am or pm) and queue order for procedures were recorded. <h3>Results</h3> A total of 202 procedures were undertaken between 6 endoscopists with a mean CIT of 9.2 minutes and PDR of 42%. Increasing mental workload was associated with increasing CIT (r = 0.61, p = 0.07) and inversely associated with withdrawal time (r = 0.72, p = 0.03). The mean mental workload during colonoscopy was lower in BCSP endoscopist v consultants v trainees (188 v 254 v 352 p &lt;0.01). On multivariate analysis, absence of polyp detection was associated with a procedure that was undertaken in pm with an above mean mental workload (OR 1.62, 95% CI 1.38–2.07) and withdrawal time of &lt;5 minutes (OR 1.53, 95% CI 1.32–1.91). Increased patient discomfort was associated with increased frustration on the subscale of the NASA-TLX score (OR 1.59, 95% 1.37–1.93) and being a trainee (OR 1.11, 95% 1.03–1.22). The use of ScopeGuide reduced the mental workload of consultants (227 v 282 p&lt;0.01), but not trainees or experts. Queue position had no impact on any of the markers of performance. <h3>Conclusion</h3> This study shows that high mental workload experienced during colonoscopy has a significant detrimental effect on the performance of endoscopists. Drop in PDR in pm procedures when only associated with high mental workload may explain some of the conflicting results of daily variations of PDR in other studies. Further studies are now required to look into measures that may reduce excessive mental workload. <h3>Disclosure of Interest</h3> None Declared

Non-anesthesiologist administration of propofol sedation for colonoscopy is safe in low risk patients: results of a noninferiority randomized controlled trial.

Propofol provides the best sedation in colonoscopy. The safety of non-anesthesiologist administration of propofol (NAAP) is still a matter of debate. The aim of the current study was to evaluate sedation safety, colonoscopy quality, and patient satisfaction with NAAP. The study was a single-blinded, noninferiority, randomized controlled trial comparing NAAP (Group A) with anesthesiologist-administered sedation (Group B) performed at a single academic institution. Patients (18 - 80 years) who underwent colonoscopy and were at low anesthetic risk (American Society of Anesthesiologists class I - II) were included. The primary end point was the incidence of adverse events. Secondary end points were propofol dose, patient satisfaction and pain, colonoscopy quality indicators, and procedure and recovery times. A total of 277 patients were included in the analysis. The incidence of adverse events was 39.3 % in Group A and 39.0 % in Group B (absolute difference - 0.3 %, 95 % confidence interval [CI] - 12.0 % to 11.4 %; P = 0.959). There were no sentinel adverse events. The following interventions (Group A vs. Group B) were necessary: atropine administration (0 % vs. 5.5 %; P = 0.004); airway repositioning (8.7 % vs. 4.7 %; P = 0.196); increased oxygen administration (6.7 % vs. 3.9 %; P = 0.317), and increased fluid rate (2.7 % vs. 0.8 %; P = 0.379). There were no differences in cecal intubation and adenoma detection rates. Recovery times were longer in Group B (58 ± 33 vs. 67 ± 29 minutes; P = 0.032). There were no differences in mean propofol dose, withdrawal time, painless colonoscopy, satisfaction, and amnesia. All but two patients (Group B) were willing to repeat the colonoscopy. NAAP is equivalent to anesthesiologist-administered sedation in the rate of adverse events in a low risk population. ClinicalTrials.gov (NCT02067065).

Feasibility study of minimal prepared hydroflush screening colonoscopy.

Although screening colonoscopy is effective for early detection of colorectal cancer (CRC), screening rates remain low. Multiple factors are thought to be responsible for the low rates of screening colonoscopy, but bowel preparation appears to be a key deterrent. Tolerability issues with bowel preparations may lead to poor patient compliance, inadequate colon cleansing, and reduced detection of colonic polyps. The aim of this article is to evaluate the feasibility, safety, and outcomes of minimally prepared intra-procedural hydroflush technique as an alternative to traditional bowel preparation in screening colonoscopy. We conducted a prospective feasibility study of intraprocedural hydroflush technique aided by water-jet pumps and a mechanical suction novel device following minimal bowel preparation for CRC screening. Nine procedures were performed in nine healthy individuals scheduled for routine screening colonoscopy. Preparation included mild diet restriction, laxative tablets two to three days prior to the procedure and two Fleet enemas one to two hours before the colonoscopy. The cleanliness of the colon was assessed by using the Boston bowel preparation scale. Insertion and withdrawal times were recorded. Complete colonoscopy to the cecum was performed in all patients (100%). Mean time to the cecum was 5.78 ± 2.68 minutes, and mean withdrawal time was 15.33 ± 3.94 minutes. Endoscopic visualization of the entire mucosa was achieved in all cases with no colonoscopy repeated because of inadequate preparation. Four polyps have been detected and removed in three patients. Mild mucosal erosions were seen in some areas where the suction was used extensively, similar to those that can be seen during conventional colonoscopy. Mild stiffness of the shaft of the scope was noted. This was an uncontrolled feasibility study of selected patients. Minimally prepared colonoscopy with the intra-procedural hydroflush technique for colorectal screening is feasible. The water exchange technology compensates for the mild stiffness of the scope. This technique might increase patients' compliance for CRC screening.

Should Assessment of Quality Indicator of Colonoscopy Be Varied Depending on the Colonoscopic Technique Level?

The purpose of this research was to evaluate if withdrawal time is a useful index in spite of differences in gastroenterologists' ability and if there are other quality indicators of colonoscopy. A total of 665 consecutive, asymptomatic individuals of average risk between 50 and 75 years of age who underwent screening colonoscopies performed by 12 gastroenterologists were included in this study. The endoscopists were classified to either the experienced group (group A, N = 6) or the under-experienced group (group B, N = 6). The endoscopists were unaware that they were being studied during the two-month study period. In group A, adenoma detection rate was 0.56, while in group B it was 0.43 (P = 0.048). The mean withdrawal time ranged widely from 4.2 to 10.3 min per patient with a mean value of 6.83 for group A and 6.54 for group B. There was a significantly positive relationship between the number of adenomas detected and the withdrawal time for group B (r = 0.827, P = 0.005), but not for group A (r = -0.152, P = 0.584). In the case of group A, the ratio of cecal intubation time to withdrawal time (I/E ratio) less than 1 showed significantly correlated adenoma detection rate compared to I/E ratio greater than 1 (r = -0.308, P = 0.036). In the case of group B, mean I/E ratio was 1.7 and all endoscopists' I/E ratios were greater than 1. For experienced endoscopists, a useful supplementary quality indicator of colonoscopy is to keep intubation/withdrawal time ratio less than 1 and it is necessary for under-experienced endoscopists to try to keep enough withdrawal time.

Multicenter, randomized, tandem evaluation of EndoRings colonoscopy--results of the CLEVER study.

Adenoma miss rate during colonoscopy has become a widely acknowledged proxy measure for post-colonoscopy colorectal cancer. Among other reasons, this can happen because of inadequate visualization of the proximal aspects of colonic folds and flexures. EndoRings (EndoAid Ltd., Caesarea, Israel) is a silicone-rubber device that is fitted onto the distal end of the colonoscope. Its flexible circular rings engage and mechanically stretch colonic folds during withdrawal. The primary aim of this study was to compare adenoma miss rates between standard colonoscopy and colonoscopy using EndoRings. In this multicenter, randomized, tandem colonoscopy study, we performed same-day, back-to-back colonoscopies with EndoRings followed by standard colonoscopy, or vice versa. After exclusion of 10 patients for protocol violations, 116 patients (38.8% female; mean age 58.7) remained for analysis. The adenoma miss rate of EndoRings colonoscopy (7/67; 10.4%) was significantly lower (P<0.001) compared with standard colonoscopy (28/58; 48.3%). Similar results were found for polyp miss rates: EndoRings (9.1%) and standard colonoscopy (52.8%; P<0.001). Mean cecal intubation times (9.3 vs. 8.4 minutes; P=0.142) and withdrawal times (7.4 vs. 7.2 minutes; P=0.286), respectively, were not significantly different between EndoRings and standard colonoscopy. Mean total procedure time was longer with EndoRings than with standard colonoscopy (21.6 vs. 18.5 minutes, P=0.001) as more polyps were removed. This study demonstrates that colonoscopy with EndoRings has lower adenoma and polyp miss rates than standard colonoscopy, which may improve the efficacy particularly of screening and surveillance colonoscopies. ClinicalTrials.gov NCT01955122.

Longer Withdrawal Time Is Associated With a Reduced Incidence of Interval Cancer After Screening Colonoscopy

Withdrawal times and adenoma detection rates are widely used quality indicators for screening colonoscopy. More rapid withdrawal times have been associated with undetected adenomas, which can increase risk for interval colorectal cancer. We analyzed records of 76,810 screening colonoscopies performed between 2004 and 2009, by 51 gastroenterologists practicing in Minneapolis and St Paul, MN. Colonoscopy records were linked electronically to the state cancer registry (Minnesota Cancer Surveillance System) to identify incident interval cancers that were diagnosed within 5.5 years after the screening examination. The physicians' mean ± SD withdrawal time was 8.6 ± 1.7 minutes and adenoma detection rates were 25% ± 9%. Longer mean withdrawal times were associated with higher adenoma detection rates (3.6% per minute; 95% confidence interval: 2.4% to 4.8%; P < .0001). We identified 78 cancers during 410,687 person-years of follow-up, for an annual rate of 0.19/1000 person-years. Physicians' mean annual withdrawal times were inversely associated with cancer incidence (P < .0001). Compared with withdrawal times ≥6 minutes, the adjusted incidence rate ratio for withdrawal times of <6 minutes was 2.3 (95% confidence interval: 1.5-3.4; P < .0001). Shorter mean annual withdrawal times during screening colonoscopies were independently associated with lower adenoma detection rates and increased risk of interval colorectal cancer.

Quality Metrics in Surgery Resident Performance of Screening Colonoscopy

In an attempt to further standardize surgical training, the American Board of Surgery now requires that residents provide evidence that they are certified in flexible endoscopy. This prospective study was designed to determine whether, through a structured curriculum, junior level residents could learn to conduct competent and safe screening colonoscopy (SC). An Institutional Review Board-approved prospective analysis of SC performed by five postgraduate year-2 residents during the 2012-2013 academic year was completed. All SC were performed under direct supervision of one of the two surgical endoscopists after each resident passed a structured endoscopy simulation curriculum. The following metrics of the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology were recorded: bowel prep quality; cecal intubation; withdrawal time; number of visualized polyps; procedural duration; final pathology; adenoma detection rate (ADR); and, complications. Power analysis revealed that 108 procedures were required for an 80 per cent probability of data analysis accuracy. (American Society for Gastrointestinal Endoscopy ASGE/American College of Gastroenterology benchmark values in parentheses): 166 colonoscopies were performed, of which 149 met inclusion criteria. Bowel prep was considered "excellent" or "good" in 90 per cent of cases. The cecum was reached in 96 per cent of cases. Mean withdrawal time was 12 minutes (≥6 minute). Average procedure time was 30 minutes (≤ 30 minute). Polyp(s) were visualized and removed in 30 per cent of patients. The overall adenoma detection rate was 22.8 per cent (>20%). The ADR for males was 29.5 per cent (>25%). The ADR for females was 18.2 per cent (>15%). Average polyp size was 7.7 mm (range: 2-25 mm). No patients were readmitted for bleeding or perforation. Within a structured learning environment, trained surgical endoscopists can teach junior level surgery residents to perform safe and competent screening colonoscopy.

PTU-027 Is water assisted colonoscopy superior to carbon dioxide assisted standard colonoscopy: results of an observational study:

Introduction Water assisted colonoscopy [WAC] is known to reduce patient discomfort and improve the adenoma detection rate [ADR]. 1 In this retrospective observational study, we compared water assisted colonoscopy against standard colonoscopy[SC] using CO 2 in a bowel cancer screening positive population. Method This was a retrospective review of prospectively collected data. The population studied was undergoing colonoscopies following a positive faecal occult blood test as part of the bowel cancer screening programme [BCSP]. Endoscopist A preferred to intubate the caecum using the water exchange method and endoscopist B would insufflate the bowel using carbon dioxide. Sedation and analgesic use was at the discretion of the endoscopist. The primary outcome was the adenoma detection rate and the comfort scores in the two groups. Secondary outcomes included caecal intubation rate, mean withdrawal time, sedation use and polyp retrieval rate. Results Data from two hundred and seven colonoscopies performed from April 2014 to December 2014 [9 months] were analysed. 102 colonoscopies were performed using the water exchange method [group A] and 105 colonoscopies were performed using CO 2 [group B]. Primary outcomes: Adenoma detection rate [ADR] in group A was 53% compared to of 36% in group B. This was statistically significant [difference in rate = -0.1868 [95% CI 0.0052–0.3685 p = 0.0438]. The proportion of patients experiencing none [score 1] or minimal [score2] discomfort [based on modified Gloucester comfort score] were more in group A [n = 74] compared to group B [n = 62]. This was found to be statistically significant [Z = 2.046, p = 0.0408] Secondary outcomes: Conclusion Our finding of a significant improvement in ADR and better tolerability in the WAC group supports similar conclusions by Hsieh e t al. This may have potential implications for the bowel cancer screening programme since the perception of colonoscopy can influence public participation and improve uptake in the BCSP. Improved ADR may be due to combination of factors like improved bowel preparation, flattening of mucosal folds and floating effect of polyps with water irrigation. We hope our findings are validated in the future through randomised trials. Disclosure of interest None Declared. Reference Hsieh YH, Koo M, Leung FW. A patient blinded randomized, controlled trial comparing air insufflation, water immersion and water exchange during minimally sedated colonoscopy. Am J Gastroenterol. 2014;109(9):1390–400

PWE-365 Exploring adr performance in the nhs bowel scope programme

Introduction A new arm of the NHS Bowel Cancer Screening Programme began in 2013. One-off flexible sigmoidoscopy (FS) is to be offered to all 55 year olds. Six pilot sites were chosen to start this screening programme, with roll out to the rest of the country planned by 2016. A benchmark adenoma detection rate (ADR) for endoscopists within the programme is being discussed. Method The NHS Bowel Cancer Screening System database was interrogated for all FS performed at the pilot sites May ‘13-May 914. Data were extracted at procedural level. Participants aged 55 were included in analyses. Overall ADR was calculated. Data of endoscopists with ≥30 procedures were reviewed. Funnel plots were produced for ADR, and gender adjusted observed:expected adenoma detection ratio (GAADR). GAADR was calculated using the population risk of adenoma detection within the programme by gender, predicting how many adenomas each endoscopist should find based on case mix, and calculating the ratio of predicted:observed adenomas detected. Mean negative withdrawal time (time taken to withdraw scope when no adenoma/cancer detected) for each endoscopist was calculated and considered in 3 groups – those with GAADR Results 8582 subjects underwent FS, of which 8494 (99.0%) were aged 55. 4420 (52%) male, 4074 (48%) female. Adenomas were detected in 507 males (11.5%) vs 273 females (6.7%, p 44 endoscopists performed ≥30 FS. These endoscopists performed 8256 FS (range 32–476). Overall programme ADR was 780/8494 (9.2%). GAADR mean 0.99 (range 0.00–2.05). Funnel plots were produced; Figure 1(a)shows ADR and Figure 1(b)shows GAADR by endoscopist, with control lines at 95% and 99.8%. Increased mean negative withdrawal time (WT) is associated with higher GAADR (2.63min when GAADR Conclusion These data show that for 55 year olds within the BowelScope programme, overall ADR is 9.2%. ADR between endoscopists varies, and reasons for these variations should be investigated and acted upon. There is a significant difference between adenoma detection in men and women, and as such, a gender adjusted ratio could be used when analysing individual endoscopists’ performance should their ADR fall below a defined benchmark. The funnel plots demonstrate most endoscopists performing within an acceptable range, and highlights those that may need further investigation. A similiar approach could be taken with regards to withdrawal times, and depth of insertion to establish the effect of these on ADR. Disclosure of interest None Declared.

PWE-005 Outcomes from the first uk bowel cancer screening programme (bcsp) site: screening and surveillance experience since 2006

<h3>Introduction</h3> National BCSP screening for all 60–69 year olds commenced in 2006, and was extended to 60–74 year olds in 2010. The first site open was in Wolverhampton in July 2006. Previous trials had demonstrated the efficacy of population screening with the use of faecal occult blood test. We have previously shown that in the first two years of the BCSP downstaging of colorectal cancer in the screened group was demonstrated (45.3% Dukes A and 21.7% Dukes B).¹ <h3>Method</h3> Retrospective analysis of data from the first 7 years of the programme (August 2006 to December 2013) included demographics, screening outcomes (neoplasia and adenoma detection), pathological staging of cancers and colonoscopy quality indicators. Surveillance outcomes were reported on those patients eligible in the study period. <h3>Results</h3> During the study period (2006–13) 4506 colonoscopies were undertaken (63.4% Male; n = 2855). Mean caecal intubation rate was 97.1% and mean withdrawal time for normal procedures was 7.3 min. 355 cancers were detected (65.3% Male; n = 232). 62.5% of cancers were ‘early’ (23% Dukes A, 31.5% Dukes B) and 71.5% were left-sided (28% rectal, 37.4% sigmoid). 3699 adenomas were detected and the mean number of adenomas per procedure was 0.82. 37% (n = 1366) of these were 1 cm. The mean adenoma detection rate per colonoscopist was 43.25%. The high risk (n = 420) and intermediate risk (n = 768) adenomas were surveyed as per national guidance. In those high risk surveillance cases (n = 420) the detection of adenoma was seen in 31.4% (n = 132) of which 13.6% (n = 18) of them had adenomas greater than 1 cm. 0.47% (n = 3) of surveillance cases were found to have cancer suggestive of a potential post colonoscopy missed cancer. <h3>Conclusion</h3> These data confirm that a high quality screening colonoscopy service has been maintained since inception of the BCSP. Despite high quality indicators for endoscopic performance, surveillance has demonstrated missed adenoma and cancer still occur. Cancer staging data suggest a diminished benefit in the latter 5 years of the BCSP. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Ellul P, Fogden E, Simpson CL, <i>et al</i>. Downstaging of colorectal cancer by the national bowel cancer screening programme in England: first round data from the first centre. Colorectal Dis. 12:420–422

Proximal Serrated Polyp Detection Rate Correlates with Adenoma Detection Rate and is Impacted by Mean Withdrawal Time: A Retrospective Study

Background: Given the implicated role of proximal serrated polyps (PSP) in the development of interval colon cancer, it is important to investigate if proximal serrated polyp detection rate (PSPDR) correlates with adenoma detection rate (ADR) and the factors that are associated with higher detection rates. Methods: We performed a retrospective review of medical records of average-risk patients who underwent a screening colonoscopy at a tertiary care academic center. A total of 851 screening colonoscopies were analyzed. Results: Gastroenterologists (n=22) performed the 851 colonoscopies. In univariable logistic regression, endsocopists with a mean WT ≥11 minutes had a higher odds of detecting a PSP compared to endoscopists with a mean withdrawal time WT <11 minutes (p<0.001; OR 5.3; 95% CI 2.6-10.8). Odds of PSP detection were greater in males than females (p=0.01; OR 2.2; 95% CI 1.2-4.1). The multivariable regression analyses confirmed that PSPDR was higher for endoscopists with mean WT ≥11 minutes (p<0.001). In addition, there was a significant correlation between ADR and PSPDR among endoscopists who performed at least 50 colonoscopies during the study period (r=0.89, p=0.04). Conclusions: We concluded that there is a strong correlation between PSPDR and ADR and that a mean WT ≥11 minutes is an independent predictor of higher PSPDR.

Experience of a Nurse Practitioner Performing Colonoscopy at a Tertiary Center in the United States

Background: The majority of the literature that involves non-physician endoscopists pertains to the performance of flexible sigmoidoscopy, with only limited reports of their performance of colonoscopy. Recent ASGE guidelines stated that there is insufficient data to support non-physician endoscopists to perform colonoscopy. Objective: To assess the performance of a fellowship-trained nurse practitioner (NP) in colonoscopy. Methods: The NP's performance was evaluated using quality indicators for colonoscopy as defined by the ASGE/ACG Taskforce, including appropriate indication, informed consent, appropriate surveillance interval, documentation of bowel preparation quality, photo documentation of cecal landmarks, cecal intubation rate, adenoma detection rate (ADR), withdrawal time, and incidence of procedure-related complications. Results: The study included 300 consecutive subjects (mean age 55.4 years, female 48.3%, African American 84.6%) who underwent average risk screening colonoscopies. A total of 385 polyps were detected for a mean polyp detection rate of 1.28 per colonoscopy. The overall adenoma detection rate was 35.0%, with 41.3% detection in men and 28.3% detection in females. Cecal intubation was successful in 297 (99.0%) subjects. The mean withdrawal time was 19.3 minutes (range 6.7-66.7 minutes). There were no adverse events including colonic perforations or post-polypectomy bleeding. Conclusion: We describe the technical and cognitive performance of a non-physician in colonoscopy in the United States. The NP adequately satisfied all of the quality indicators proposed by the ASG/ACG Taskforce. With the demand for screening colonoscopies exceeding the supply of qualified providers, non-physicians could be a potential solution to increasing the capacity of endoscopists needed to perform CRC screening. However, non-physicians, similar to physicians, should be subjected to a quality monitoring program.

Difference in adenoma detection rates according to colonoscopic withdrawal times and the level of expertise.

Adequate screening colonoscopy in the general population decreases the mortality associated with colorectal cancer through detection and removal of adenomatous polyps. Prolonged colonoscopic withdrawal times (>6 min) are reportedly beneficial for adenoma detection rates (ADRs). However, the quality of the endoscopist compared with colonoscopic withdrawal times is not known. The aims of this study were to investigate the difference in ADRs between trainees and experienced examiners. A total of 967 consecutive patients who underwent screening colonoscopy in a single University hospital from June 2010 to November 2011 were enrolled in this prospective observational study. Colonoscopy was performed by four experienced staff and seven gastroenterology fellows. Seven gastroenterology fellows performed 633 colonoscopies and four experienced staff performed 334 colonoscopies. The overall detection rates of colorectal adenoma were 31.5% with ADRs of fellows and staff of 29.4% and 35.6%, respectively (p=0.047). Fellows also showed lower advanced ADRs (5.7% vs. 9.9%, p=0.016), and fellows had longer mean withdrawal times than staff (12.4±B1;4.9 min vs. 8.2±B1;4.1 min, p<0.001). Multivariate analysis showed significantly increased ADRs and advanced ADRs for staff compared with fellows (adjusted OR 2.41, 95% CI 1.70-3.43; adjusted OR 2.55, 95% CI 1.47-4.45, respectively). ADRs were significantly lower when colonoscopy was performed by trainees, although withdrawal times were longer than those of staff. Our results demonstrated that the quality of colonoscopy, as measured by ADRs, may be improved by experienced examiners.

Comparing Quality, Safety, and Costs of Colonoscopies Performed by Nurse vs Physician Trainees

We evaluated the quality and safety of colonoscopies performed by nurse and physician endoscopy trainees as well as the cost differences. We performed a study of 7 nurse and 8 physician (gastroenterology fellows) endoscopy trainees at 2 medical centers in the Netherlands from September 2008 through April 2012. At the beginning of the study, the subjects had no experience in endoscopy; they were trained in gastrointestinal endoscopy according to the regulations of the Dutch Society of Gastroenterology, performing a minimum of 100 colonoscopies. Each trainee then performed 135 consecutive colonoscopies (866 total by nurse trainees and 1080 by physician trainees) under supervision of a gastroenterologist; the colonoscopies were evaluated for quality and safety. We performed statistical analyses of data, assessing multilevel and cost minimization. The mean age of the patients was 57 years, and about half were women in each group. The endoscopic quality and safety were comparable between nurse and physician trainees. Overall rates of cecal intubation were 95% for nurses and 93% for physicians (P = .38), including procedures that required assistance from a supervisor; mean withdrawal times were 10.4 and 9.8 minutes, respectively (P = .44). Each group detected 27% of adenomas and had a 0.5% rate of complication. In both groups, the rates of unassisted cecal intubation gradually increased with the number of colonoscopies performed, from 70% for nurses and 74% for physicians at the beginning to 89% and 86%, respectively, at the end of the assessment period. Using a strategy in which 1 gastroenterologist supervises 3 nurses, the personnel costs decreased from $64.65 to $54.58. In a supervised setting, nurse endoscopists perform colonoscopies according to quality and safety standards that are comparable with those of physician endoscopist and can substantially reduce costs.

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.

Longer mean colonoscopy withdrawal time is associated with increased adenoma detection: evidence from the Bowel Cancer Screening Programme in England

Increasing colonoscopy withdrawal time (CWT) is thought to be associated with increasing adenoma detection rate (ADR). Current English guidelines recommend a minimum CWT of 6 minutes. It is known that in the Bowel Cancer Screening Programme (BCSP) in England there is wide variation in CWT. The aim of this observational study was to examine the relationship between CWT and ADR. The study examined data from 31 088 colonoscopies by 147 screening program colonoscopists. Colonoscopists were grouped in four levels of mean CWT ( < 7, 7 - 8.9, 9 - 10.9, and ≥ 11 minutes). Univariable and multivariable analysis (binary logistic and negative binomial regression) were used to explore the relationship between CWT, ADR, mean number of adenomas and number of right-sided and advanced adenomas. In colonoscopists with a mean CWT < 7 minutes, the mean ADR was 42.5 % compared with 47.1 % in the ≥ 11-minute group (P < 0.001). The mean number of adenomas detected per procedure increased from 0.77 to 0.94, respectively (P < 0.001). The increase in adenoma detection was mainly of subcentimeter or proximal adenomas; there was no increase in the detection of advanced adenomas. Regression models showed an increase in ADR from 43 % to 46.5 % for mean CWT times ranging from 6 to 10 minutes. This study demonstrates that longer mean withdrawal times are associated with increasing adenoma detection, mainly of small or right-sided adenomas. However, beyond 10 minutes the increase in ADR is minimal. Mean withdrawal times longer than 6 minutes are not associated with increased detection of advanced adenomas. Withdrawal time remains an important quality metric of colonoscopy.

Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies

Adenoma detection rate (ADR) has become the most important quality indicator for colonoscopy. The aim of this study was to investigate which modifiable factors, directly related to the endoscopic procedure, influenced the ADR in screening colonoscopies. Observational, nested study. Multicenter, randomized, controlled trials. Asymptomatic people aged 50 to 69 years were eligible for a multicenter, randomized, controlled trial designed to compare colonoscopy and fecal immunochemical testing in colorectal cancer screening. A total of 4539 individuals undergoing a direct screening colonoscopy were included in this study. Colonoscopy. Bowel cleansing, sedation, withdrawal time in normal colonoscopies, and cecal intubation were analyzed as possible predictors of adenoma detection by using logistic regression analysis, adjusted for age and sex. In multivariate analysis, after adjustment for age and sex, factors independently related to the ADR were a mean withdrawal time longer than 8 minutes (odds ratio [OR] 1.51; 95% CI, 1.17-1.96) in normal colonoscopies and split preparation (OR 1.26; 95% CI, 1.01-1.57). For advanced adenomas, only withdrawal time maintained statistical significance in the multivariate analysis. For proximal adenomas, withdrawal time and cecal intubation maintained independent statistical significance, whereas only withdrawal time longer than 8 minutes and a <10-hour period between the end of preparation and colonoscopy showed independent associations for distal adenomas. Only endoscopic variables have been analyzed. Withdrawal time was the only modifiable factor related to the ADR in colorectal cancer screening colonoscopies associated with an increased detection rate of overall, advanced, proximal, and distal adenomas.

Abstract FO02-01: Community-based interventions to reduce for colon cancer disparites in African Americans in South Carolina.

Abstract FO02-01: Community-based interventions to reduce for colon cancer disparites in African Americans in South Carolina.