Proximal Adenomas Research Articles

Abstract A56: Association between circulating 1,25(OH)2D concentration and recurrent colorectal adenoma

Abstract Cellular-level studies demonstrate that availability of the steroid hormone 1α,25-dihydroxyvitamin D (1,25(OH)2D) to colon cells induces anti-carcinogenic activities. Although epidemiological data are relatively sparse, suggestive inverse trends have been reported for circulating 1,25(OH)2D concentration and risk of colorectal neoplasia. Further, recent epidemiologic work has identified an inverse association between variation in circulating concentrations of 1,25(OH)2D and fibroblast growth factor 23 (FGF23), a hormone demonstrated to interfere with the anti-carcinogenic effects of 1,25(OH)2D, indicating that concentrations of 1,25(OH)2D may vary more widely than previously thought. We therefore conducted logistic regression analysis to evaluate the relationship between variation in serum 1,25(OH)2D concentrations and characteristics of baseline and recurrent colorectal adenomas among 1,151 participants from the Ursodeoxycholic Acid clinical trial. No relationship between 1,25(OH)2D and colorectal adenoma recurrence overall was observed. However, a statistically significant inverse association was observed between circulating 1,25(OH)2D concentration and odds of proximal colorectal adenoma recurrence, with an OR (95% CI) of 0.71 (0.52-0.98) for individuals in the highest tertile of circulating 1,25(OH)2D compared to those in the lowest (p-trend = 0.04). A significantly greater proportion of women were identified in the lowest 1,25(OH)2D tertile (p<0.01); however, gender did not modify the association between 1,25(OH)2D and proximal colorectal adenoma recurrence (LR-test p-value = 0.27). While there was no relationship overall between 1,25(OH)2D and recurrence of distal lesions, there was a significantly reduced odds for women in the highest tertile of 1,25(OH)2D compared to the lowest (OR=0.53; 95% CI 0.27-1.03; p-trend=0.05; p-interaction=0.08). No statistically significant associations were detected with any baseline colorectal adenoma characteristics or other classification of recurrent polyps. Associations with recurrent, as opposed to baseline lesions, may indicate that variation in circulating 1,25(OH)2D concentration influences progression of adenomas once the initiating event has occurred. The observed differences in associations with proximal and distal adenomas could indicate that delivery and activity of vitamin D metabolites in different anatomical sites in the colon may vary, particularly by gender. These results identify novel associations between 1,25(OH)2D and recurrent proximal and distal colorectal adenoma, which merit further epidemiologic studies. Citation Format: Elizabeth A. Hibler, Christine L. Sardo, Peter Lance, Peter Jurutka, Elizabeth T. Jacobs. Association between circulating 1,25(OH)2D concentration and recurrent colorectal adenoma. [abstract]. In: Proceedings of the Twelfth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2013 Oct 27-30; National Harbor, MD. Philadelphia (PA): AACR; Can Prev Res 2013;6(11 Suppl): Abstract nr A56.

The relationship between proximal and distal colonic adenomas

Because the relationship between distal and proximal colonic findings remains uncertain, controversy exists over whether proctosigmoidoscopy or colonoscopy is more suitable for colorectal cancer (CRC) screening. We aim to describe the distribution and characteristics of polyps removed in colonoscopy screening. A prospective registry of a colonoscopy-based CRC screening program was developed on asymptomatic individuals over 50 years. All polyps were removed and characterized. Polyp size and histology were noted. Adenomas were considered advanced if they measured greater than 10 mm or were tubulovillous, villous, or malignant. The prevalence of advanced proximal polyps was determined and patients were categorized according to their family history of CRC. A total of 696 individuals (418 women), aged 57.7 ± 10.3 years, were examined; 45.8% presented a colonic lesion, being adenomatous polyps in 32.7% individuals. Among these, 24.7% were advanced adenomas. Three patients (0.6%) presented invasive CRC. There were no significant differences with respect to sex and family history of CRC between patients with or without adenomas. Adenomas were more prevalent in individuals aged at least 65, irrespective of location (P<0.001). In 65.1% of individuals with adenomatous polyps in the right colon, there were no synchronous adenomas in the left colon (P<0.001). More adenomas were also present in the right colon of patients with no family history of CRC (P<0.001). Most patients with adenomatous polyps in the right colon showed no synchronic adenomas on the left side. Lesions on the right side would have gone undetected if the individuals undergoing CRC screening had been explored with proctosigmoidoscopy.

Prevalence of Proximal Serrated Polyps and Conventional Adenomas in an Asymptomatic Average-Risk Screening Population

Background/AimsDetection of proximal serrated polyps (PSPs) is increasingly recognized as a new qualitative target for colonoscopy. The aims of this study were to assess the detected prevalence of PSPs and synchronous adenomas in an asymptomatic average-risk screening cohort and to evaluate potential factors associated with detection of PSPs.MethodsThe study included 1,375 asymptomatic average-risk Korean patients (aged 50 years or older) who underwent screening colonoscopy. In total, 1,710 polyps were evaluated pathologically.ResultsThe overall PSP detection rate (PSPDR) was low at 3.1%, despite high polyp (54.0%) and adenoma detection rates (ADRs, 43.5%). ADR did not correlate with PSPDR, but it was strongly correlated with PDR (r=0.810; p<0.001). Patients with PSPs were more likely to have longer withdrawal time and more proximal colon adenomas than patients without PSPs (adjusted odds ratio [OR], 1.19; 95% confidence interval [CI], 1.09 to 1.31; p<0.001) (adjusted OR, 2.03; 95% CI, 1.06 to 3.88; p=0.031, respectively).ConclusionsThe detected prevalence of PSPs was low (<5%) in an asymptomatic average-risk screening Korean population, despite the high prevalence of conventional adenomas. A longer mucosal inspection of the proximal colon may serve as a practical method to enhance detection of PSPs.

New Disposable Transanal Endoscopic Surgery Platform: Longer Channel, Longer Reach

Background: Transanal endoscopic surgical (TES) resection using rigid transanal platforms (TEM, TEO) is associated with improved outcomes compared to traditional transanal excision (TAE) of rectal lesions. An alternative technique using a disposable single incision surgery platform was developed in 2009, transanal minimally invasive surgery (TAMIS), resulting in a surge in interest and access to transanal access platforms to perform TES. However, compared to rigid transanal access platforms, the disposable platforms do not facilitate internal rectal retraction and have limited proximal reach. A new long channel disposable transanal access platform has been developed (15 cm in length, 4 cm in width) thereby facilitating endoluminal surgical access to the upper rectum and rectosigmoid colon. Methods: This is a retrospective case series report. Patient demographics and peri-operative outcome variables were recorded. The Gelpoint Path Long Channel was utilized in three patients with proximal rectal lesions that were not accessible using a standard disposable transanal access platform. Results: Three patients underwent TES excision of rectal adenomas using a long channel, disposable, transanal access platform. All patients were female, aged 51 – 53, BMI 23-32 kg/m2. The tumor size ranged from 2.4 – 8.5 cm, 15-100% circumference, and proximal location from the dentate line ranged from 9 – 11 cm. Final pathology revealed adenoma with negative margins in all three cases. The hospital length of stay ranged from 1 – 3 days and there were no peri-operative complications. None of the patients have developed a local recurrence during the follow up period ranging from 5 – 11 months. Conclusions: The new long channel, disposable, transanal access platform facilitates transanal endoluminal surgical removal of lesions in the mid to upper rectum that may be difficult to reach using the standard disposable transanal access devices. We have successfully achieved 100% margin negative rate using this new device in this small series of patients with proximal rectal adenomas. Keywords: TAMIS, TEM, TEO, Transanal Minimally Invasive Surgery, Transanal Endoscopic Surgery, Rectal Adenoma Endoscopy, Transanal Surgery. Read more →

Mo1098 Results of Screening Colonoscopies in Uninsured Urban Minorities

BACKGROUND: Rates of colorectal cancer screening in general, and colonoscopy in particular, are known to be much lower in individuals who lack health insurance. In 2004, the New York City Council authorized funding for screening colonoscopies (SC) to averagerisk uninsured New Yorkers age 50 or older, and established a joint program with the New York City Department of Health and Mental Hygiene and the American Cancer Society to offer grants to interested institutions. We have been participating in this program for the past eight years. Little is known about the pathology findings when uninsured individuals undergo SC. AIM: To analyze colonoscopy findings from a group of average risk, mostly uninsured minority individuals, age 50 and older who received SC funded through this program. METHODS: Patients were referred from clinics at our institution and surrounding community health centers. A bilingual Spanish-speaking patient navigator facilitated colonoscopy completion. We analyzed findings from colonoscopy and pathology reports for patients who were referred between April 2004 and June 2011. Polyp pathology, location, size, rates of adenomas, and advanced adenomas were analyzed in relation to patient demographics. RESULTS: Of 493 referrals, 222 patients completed colonoscopies (271 did not for various reasons). Demographics of the 222 patients were as follows: Gender 55% Female, 45% Male; Ethnicity 16.6% African American, 63.5% Hispanic, 19.4% White, 0.5% others; Age 31.5% over 60 years old; Insurance status 94% had no insurance, 6% were underinsured. Bowel preparation was considered adequate in 92.3%. Polyps were identified in 21.2% of all patients; 14% had adenomas, 4.5% had advanced adenomas, and 1.8% had proximal advanced adenomas. The rates of adenomas, advanced adenomas, and proximal advanced adenomas were highest in African-Americans, then Hispanics, then Whites (Table 1). Differences in polyp type, location, and advanced adenomas did not reach statistical significance in terms of ethnicity or gender. Patients aged 60 and older were found to have a higher rate of advanced adenomas compared to younger patients (8.6% vs 2.6%, p=0.047). CONCLUSIONS: Among a mostly uninsured minority cohort undergoing SC, clinically significant pathology was detected. In this small cohort, ethnic minorities demonstrated higher rates of clinically significant pathology than theirWhite counterparts. These high rates of significant pathology are consistent with rates we have found among insured African-American and Hispanic average risk individuals undergoing SC. Since screening uninsured patients with colonoscopy identifies advanced premalignant lesions of the colon which therefore warrants earlier follow-up, our findings have implications for screening as well as surveillance colonoscopies in uninsured individuals. Table 1: Colonoscopy Findings

Su1038 Increased Prevalence of Proximal and Multiple Adenomas in Patients With Diabetes Mellitus

Su1038 Increased Prevalence of Proximal and Multiple Adenomas in Patients With Diabetes Mellitus

Factors Associated with the Risk of Adenoma Recurrence in Distal and Proximal Colon

Background/Aims: Colonoscopy may be less effective in preventing cancer in the proximal colon. We evaluated whether risk factors for adenoma recurrence exhibit differential effect on adenoma recurrence by colon subsite. Methods: We examined the association of age, sex, body mass index, smoking status and use of nonsteroidal anti-inflammatory drugs (NSAIDs) on proximal and distal adenoma recurrence among 1,864 participants in the Polyp Prevention Trial. We used multinomial logistic regression models to calculate the relative risk ratios (RRR) and 95% CI. Results: 733 (39.3%) participants had adenoma recurrence (228 distal only, 369 proximal only and 136 synchronous proximal and distal adenoma). When compared to participants without adenoma recurrence, no factor was associated with an increased risk of distal only adenoma recurrence. Age 65-69 years (RRR = 1.47, 95% CI 1.00-2.16), age ≥70 years (RRR = 2.24, 95% CI 1.57-3.20), and male sex (RRR = 1.73, 95% CI 1.32-2.27) were positively associated with proximal only adenoma recurrence. NSAIDs use was associated with a reduced risk of adenoma recurrence by similar magnitude in distal (RRR = 0.78, 95% CI 0.58-1.07) and proximal colon (RRR = 0.77, 95% CI 0.60-1.00). Conclusions: We did not find any modifiable risk factor that differentially increases proximal as compared to distal adenoma recurrence to be clinically useful for targeted intervention.

Impact of a quarterly report card on colonoscopy quality measures

Colonoscopy quality is operator-dependent. Studies assessing the effect of interventions to decrease variation in colonoscopy quality have shown inconsistent results. Since 2009, endoscopists at our university-affiliated, Veterans Affairs medical center have received a quarterly "report card" summarizing individual colonoscopy quality indicators as part of an ongoing quality assurance program. To determine the effect of the quality report card intervention on colonoscopy performance. Retrospective study. Tertiary-care, academic, university-affiliated, Veterans Affairs medical center in Indianapolis, Indiana. Data from 6 endoscopists practicing at the Roudebush Veterans Affairs Medical Center were included. Patients were average-risk, aged 50 years or older, undergoing their first screening colonoscopy. Quarterly report card. The study time frame was July 1, 2008 to December 31, 2008 (before-intervention) and April 1, 2009 to March 31, 2011 (intervention). The primary outcomes were cecal intubation and adenoma detection rates (ADR), adjusted for physician, patient age, and sex. Multivariable logistic regression was performed to determine factors associated with adenoma detection. A total of 928 patients (male 93%, white 78%) were included (before-intervention 336; intervention 592). There were no significant differences in patient age, sex, smoking status, body mass index, bowel preparation quality, colonoscope model, and proportion of colonoscopies performed with a trainee between the before-intervention and intervention phases. In the intervention phase, the adjusted adenoma detection and cecal intubation rates were significantly higher: 53.9% (95% confidence interval [CI], 49.7%-58.1%) vs 44.7% (95% CI, 39.1%-50.4%); P = .013 and 98.1% (95% CI, 96.7%-99.0%) vs 95.6% (95% CI, 92.5%-97.5%); P = .027, respectively. A higher ADR trend in the intervention phase was found for 5 of the 6 physicians. The increment in ADR was due mostly to increased detection of proximal adenomas. There were no significant changes in serrated polyp detection, advanced neoplasm detection, number of adenomas detected per colonoscopy, and mean size of adenomas after implementation of the intervention. The report card intervention remained significantly associated with higher ADRs after adjustment for patient age, sex, and physician (odds ratio 1.45; 95% CI, 1.08-1.94). Single center, small number of endoscopists. A quarterly report card was associated with improved colonoscopy quality indicators. This intervention is practical to generate and implement and may serve as a model for quality improvement programs in different patient and physician groups.

Nonpolypoid colorectal neoplasms: a challenge in endoscopic surveillance of patients with Lynch syndrome

Patients with Lynch syndrome may develop colorectal cancer (CRC), despite intensive colonoscopic surveillance. Nonpolypoid colorectal neoplasms might be a major contributor to the occurrence of these cancers. The aim of this case - control study was to compare the endoscopic appearance of colorectal neoplasms between patients with Lynch syndrome and control individuals at average risk for CRC. The endoscopists at the Maastricht University Medical Center were first given training to ensure familiarity with the appearance and classification of nonpolypoid lesions. Patients with Lynch syndrome and patients at average risk for CRC who underwent elective colonoscopy at the Center were prospectively included. Nonpolypoid lesions were defined as lesions with a height of less than half the diameter, and advanced histology was defined as the presence of high grade dysplasia or early cancer. A total of 59 patients with Lynch syndrome (mean age 48.7 years, 47.5 % men) and 590 matched controls (mean age 50.2 years, 47.5 % men) were included. In patients with Lynch syndrome, adenomas were significantly more likely to be nonpolypoid than they were in controls: 43.3 % vs. 16.9 % (OR 3.60, 95 %CI 1.90 - 6.83; P < 0.001). This was particularly true for proximal adenomas: 58.1 % vs. 16.3 % (OR 6.93, 95 %CI 2.92 - 16.40; P < 0.001). Adenomas containing advanced histology were more often nonpolypoid in patients with Lynch syndrome than in controls (4/5, 80.0 % vs. 5/17, 29.4 %; P = 0.19). Serrated polyps were also more often nonpolypoid in patients with Lynch syndrome than in controls: 49.2 % vs. 20.4 % (OR 3.57, 95 %CI 1.91 - 6.68; P < 0.001). In patients with Lynch syndrome, colorectal neoplasms are more likely to have a nonpolypoid shape than those from average risk patients, especially in the proximal colon. These findings suggest that proficiency in recognition and endoscopic resection of nonpolypoid colorectal lesions are needed to ensure colonoscopic prevention against CRC in this high risk population.

Association Between Early Stage Colon Neoplasms and False-negative Results From the Fecal Immunochemical Test

The fecal immunochemical test (FIT) can identify patients with advanced colorectal neoplasms, but it also has a high rate of false-negative results. It would be helpful to characterize colorectal neoplasms that are not detected by FIT to aid in development of new tests. We characterized colorectal neoplasms from patients who had negative results from the FIT. We analyzed data from 18,296 subjects who were screened for colorectal cancer by colonoscopy and the FIT at the Health Management Center of National Taiwan University Hospital from September 2005 through September 2010. We identified 4045 subjects with colorectal neoplasms (3385 with nonadvanced adenomas, 632 with advanced adenomas, and 28 with cancer). We analyzed the sensitivity of the FIT in identifying these patients, along with information on lesion size, location, and morphology. The FIT identified patients with nonadvanced adenomas, advanced adenomas, and cancer with sensitivity values of 10.6% (95% confidence interval [CI], 10.2%-12.3%), 28.0% (95% CI, 24.6%-31.7%), and 78.6% (95% CI, 58.5%-91.0%), respectively. The FIT detected proximal advanced adenomas and nonpolypoid lesions with lower levels of sensitivity than distal advanced adenomas; it had a high false-negative rate in detection of adenomas <15 mm (adjusted odds ratio, 2.85; 95% CI, 1.79-4.54) and nonpolypoid adenomas (adjusted odds ratio, 2.15; 95% CI, 1.22-3.80), after adjusting for demographic characteristics, colonoscopy findings, and potential confounders. The FIT produced a higher percentage of false-negative results in detection of carcinoma in situ and T1 cancer than in T2-T4 cancers (66.7% sensitivity vs 100%; P = .049). The FIT produces a high rate of false-negative results for patients with small or nonpolypoid adenomas. Early-stage cancers are associated with a high rate of false-negative results from the FIT.

Increase in proximal adenoma detection rate after transition from air to water method for screening colonoscopy in a community-based setting in the United States

Background: The water method of colonoscopy has been shown to increase adenoma detection rate in the United states veteran population, but this has not yet been demonstrated in a non-veteran community setting in the United states. Aims: Our aim is to perform a retrospective study to compare adenoma detection rate between the air and the water colonoscopy methods for screening colonoscopies at a non-veteran community site. Methods: We performed a retrospective review of 100 patients from before and after a single community endoscopist transitioned from air colonoscopy to water colonoscopy. The patients selected were the 50 most recent patients who presented for air colonoscopy and the first 50 patients who underwent water colonoscopy after the transition. patients who presented for indications other than colon cancer screening or surveillance were excluded. The primary end point was overall adenoma detection rate; secondary end points included cecal intubation time, procedure time, polyp detection rate, proximal colon adenoma detection rate, and sedation requirement. Results: There was no significant difference between the two methods in total adenoma detection rate, polyp detection rate, cecal intubation time, total procedure time, or sedation requirement. however, there was a significantly higher proximal adenoma detection rate (34%) with the water method compared to the air method (18%), p=0.015. Conclusion: In a non-veteran community setting, screening colonoscopy done with the water method resulted in a significantly higher proximal colon adenoma detection rate without significantly adding to total procedure time or sedation requirement.

Sessile serrated adenomas in the proximal colon are likely to be flat, large and occur in smokers

To examine the epidemiology and the morphology of the proximal sessile serrated adenomas (SSAs). We conducted a retrospective study to identify patients with SSAs using a university-based hospital pathology database query from January 2007 to April 2011. Data collected included: age, gender, ethnicity, body mass index, diabetes, smoking, family history of colorectal cancer, aspirin, and statin use. We collected data on morphology of SSAs including site (proximal or distal), size, and endoscopic appearance (flat or protuberant). We also compared proximal SSAs to proximal tubular adenomas detected during same time period. One hundred and twenty patients with SSAs were identified: 61% were distal and 39% were proximal SSAs. Proximal SSAs were more likely to be flat than distal (100% vs 78% respectively; P = 0.0001). Proximal SSAs were more likely to occur in smokers (OR = 2.63; 95%CI: 1.17-5.90; P = 0.02) and in patients with family history of colorectal cancer (OR = 4.72; 95%CI: 1.43-15.55; P = 0.01) compared to distal. Proximal SSAs were statistically more likely to be ≥ 6 mm in size (OR = 2.94; P = 0.008), and also more likely to be large (≥ 1 cm) (OR = 4.55; P = 0.0005) compared to the distal lesions. Smokers were more likely to have proximal (P = 0.02), flat (P = 0.01) and large (P = 0.007) SSAs compared to non-smokers. Compared to proximal tubular adenomas, proximal SSAs were more likely to be large and occur in smokers. Proximal SSAs which accounted for two-fifths of all SSAs were more likely to present as flat lesions, larger SSAs, and were more likely to occur in smokers and in patients with family history of colorectal cancer. Our data has implications for colorectal cancer screening.

The Incidence and Clinical Characteristics of Proximal Colonic Polyps When the Polyps Are Noted on Rectosigmoid Colon by Colonoscopy

Colorectal cancer is the third most common type of cancer and second leading cause of cancer death overall. Recently, there has been an emphasis on primary screening for colorectal cancer with colonoscopy. In this study, we aimed to address clinical characteristics and incidence of colonic polyps according to location. From January 2009 to December 2010, 6,417 total colonoscopic examinations were performed at Boramae Hospital in Seoul, Korea. We reviewed these patients retrospectively. The distal colon was defined as the rectosigmoid junction. Overall, 1,972 patients (31.3%) had one of more colorectal polyps. Total of 4,445 patients were excluded from this study because of combined advanced colorectal cancer, inflammatory bowel disease, or familial adenomatous polyposis. Patients who had only proximal polyps were 633 (32.1%), 530 patients (26.9%) had both proximal and distal polyps, and 809 patients (41.0%) had polyps only in the rectosigmoid region. The prevalence of the proximal polyps in patients with rectosigmoid polyps was found to be significantly related to the male gender and elderly patients. However, the prevalence of the proximal colonic polyps was not related to the size and number of rectosigmoid polyps. In 530 patients with both rectosigmoid and proximal colonic polyps, the characteristics of proximal colonic polyps as size and number were similar to those of rectosigmoid polyps. Advanced proximal adenomas without distal polyps were found in 25 (29.4%) patients whom were associated with size and pathology. We recommend total colonoscopic examination in all patients regardless of the size and number, especially in elderly males.

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.

Ethnic Differences in Prevalence and Location of Colorectal Adenoma: Possible Link between Hispanic Advantage and Vitamin D Status

Purpose: Ethnic differences in the incidence of colorectal cancer (CRC) and colorectal adenoma (CRA) are well documented. The majority of these studies have been focused on black-white disparities for CRC, however research on CRA prevalence among Hispanics is lacking. The objective of this study is to evaluate ethnic disparities in prevalence of CRA and its possible mechanism, particularly for Hispanics. Methods: In this retrospective case-control study in a suburban community of New York State, 1,656 patients who underwent complete colonoscopies from 2007 to 2011 were enrolled. 1,340 pathologically confirmed adenoma cases and 316 adenoma-free controls were analyzed for the association of CRA overall or by location with ethnicity, using multivariate logistic regression analyses after adjusting for other risk factors. A secondary analysis assessed a possible link between vitamin D status and observed ethnic differences using a subset of subjects with serum 25-hydroxyvitamin D level available.Table: [1957] Association between ethnicity and colorectal adenoma by locationResults: The study participants consisted of 45% Hispanics, 17% non-Hispanic whites, 32% non-Hispanic blacks and 6% others. Of 1656 patients, 316 (19%) were diagnosed with adenomas, 142 (8.6%) proximal adenomas, 93 (5.6%) distal adenomas, 37 (2.2%) rectal adenomas and 44 (2.7%) were found to have adenomas at multiple sites. The prevalence of CRA for Hispanics was lower than non-Hispanic whites and blacks (14.8% vs 22.5%; adjusted OR, 0.67; 95% CI, 0.47-0.96; P<0.01), while no differences were noted between whites and blacks. The reduced CRA prevalence among Hispanics vs. non-Hispanics was more pronounced for proximal adenoma (5.3% vs 11.2%; adjusted OR, 0.42; 95% CI, 0.26-0.70; P<0.001), but not significant for adenoma at other locations. In a subset of patients (n=128), we found higher serum 25-hydroxyvitamin D levels among Hispanics than non-Hispanics, as well as in controls than adenoma cases. Conclusion: Our data suggest a distinction between Hispanics and non-Hispanics in the risk of CRA. The lower adenoma rates, particularly proximal adenoma rates, for Hispanics might be partially attributed to better vitamin D status. These findings might be community-specific, thus additional multi-center studies are needed.

Prevalence of Adenomas during Screening Colonoscopy Using a Comprehensive Colonoscopy Screening Protocol

Purpose: Background and Aim: The adenoma detection rate is an independent predictor of the risk of interval colorectal cancer after screening colonoscopy. A number of techniques have been shown to maximize adenoma detection. We incorporated a comprehensive colonoscopy screening protocol that includes: 1. Ensuring a clean quality of colon preparation; 2. Cecal intubation in over 95%; 3. Colonoscope withdrawal time > 6 min; 4. Colonoscopy Screening Techniques for better adenoma detection (a. Use of a cap fitted endoscope to examine behind the folds; b. Patient position change to optimize distention of the colon; c. Eyes trained to detect flat lesions after looking at several flat lesions' images & videos). We have reported the effect of combining all these various techniques to maximize adenoma detection rate in 100 consecutive average risk patients (pts) undergoing screening colonoscopy previously. We report the adenoma detection rate in larger pool of 535 consecutive patients undergoing their first screening colonoscopy from 2009-2011. Methods: Endoscopist: Screening colonoscopy was performed by a single operator. Patients (pts): 535 consecutive patients undergoing screening colonoscopy from 2009-2011 were included in the study. Average risk pts: 495. Increased risk pts (Family history of colorectal cancer or polyps <60 years): 40. We used the comprehensive colonoscopy screening protocol to maximize adenoma detection in all patients during screening. Colonoscopy Report: The data was recorded in a structured colonoscopy report with well-defined fields to capture all the data. Main Outcome Measurements: We analyzed the adenoma detection rates. Results: Mean age: 58.3 ± 7.7; Sex: Men: Women: 220:315; BMI: 27.4 ± 5.4. Caucasians: 395(73.8%).The adenoma detection rate in screening population: 64.9%. The advanced adenoma detection rate (>1 cm adenoma or villous histology of any size or high grade dysplasia):14%.The multiple adenoma (≥ 3 adenomas) detection rate: 17%. The combined adenoma or proximal hyperplastic polyp detection rate: 69.7%. The proximal hyperplastic polyp detection rate: 15.3%. The serrated adenoma detection rate: 15%. The proximal hyperplastic polyp or serrated adenoma detection rate: 26.7%. See Table 1.Table: [1974] Prevalence of adenomas in 535 consecutive patients undergoing screening colonoscopies using a comprehensive colonoscopy screening protocolConclusion: Routine use of techniques to maximize adenoma detection result in persistent increase in adenoma detection rates, several fold higher than the adenoma detection rate set by the U.S Multi-Society Task Force on Colorectal Cancer (25% in men & 15% in women).

Variation of Adenoma Prevalence by Age, Sex, Race, and Colon Location in a Large Population: Implications for Screening and Quality Programs

Reliable community-based colorectal adenoma prevalence estimates are needed to inform colonoscopy quality standards and to estimate patient colorectal cancer risks; however, minimal data exist from populations with large numbers of diverse patients and examiners. We evaluated the prevalence of adenomas detected by sex, age, race/ethnicity, and colon location among 20,792 Kaiser Permanente Northern California members ≥50 years of age who received a screening colonoscopy examination (102 gastroenterologists, 2006-2008). Prevalence of detected adenomas increased more rapidly with age in the proximal colon (adjusted odds ratio [OR], 2.39; 95% confidence interval [CI], 2.05-2.80; 70-74 vs 50-54 years) than in the distal colon (OR, 1.89; 95% CI, 1.63-2.19). Prevalence was higher among men vs women at all ages (OR, 1.77; 95% CI, 1.66-1.89), increasing in men from 25% to 39% at ≥70 years and in women from 15% at 50-54 years to 26% (P < .001). Proximal adenoma prevalence was higher among blacks than whites (OR, 1.26; 95% CI, 1.04-1.54), although total prevalence was similar, including persons <60 years old (OR, 1.17; 95% CI, 0.91-1.50). Prevalence of detected adenomas increases substantially with age and is much higher in men; proximal adenomas are more common among blacks than whites, although the total prevalence and the prevalence for ages <60 years were similar by race. These demographic differences are such that current adenoma detection guidelines may not be valid, without adjustment, for comparing providers serving different populations. The variation in prevalence and location may also have implications for the effectiveness of screening methods in different demographic groups.

APC Gene Testing for Familial Adenomatosis Polyposis

APC Gene Testing for Familial Adenomatosis Polyposis

Helicobacter Pylori Infection Increases the Risk of Colorectal Adenomas: Cross-Sectional Study and Meta-Analysis

The studies concerning the association between Helicobacter pylori status and colorectal adenoma, premalignant lesions of colorectal cancers, are not consistent. This cross-sectional study investigated the association of colorectal adenoma with H. pylori infection in a consecutive series of 2,195 asymptomatic average-risk subjects who underwent screening colonoscopy and H. pylori testing. Multivariate analyses were adjusted for potential relevant confounders, including age, sex, smoking, alcohol consumption, family history of colorectal cancer, and regular use of aspirin. Furthermore, we performed a systematic literature review and meta-analysis of available studies, including the current study, to clarify whether H. pylori infection is associated with an increased risk of colorectal adenoma. Among 2,195 eligible subjects, 1,253 subjects were H. pylori seropositive and 942 subjects were seronegative. In the H. pylori (+) group, the prevalence of colorectal adenoma and advanced adenoma was significantly higher than in the H. pylori (-) group (25.3 vs. 20.1 %, p = 0.004 and 6.1 vs. 2.9 %, p < 0.001, respectively). In our multivariate analysis, H. pylori seropositivity was an independent risk factor for overall colorectal adenoma (OR = 1.36, 95 % CI = 1.10-1.68) and advanced adenoma (OR = 2.21, 95 % CI = 1.41-3.48). The positive association was confined in cases with any proximal adenoma. In the meta-analysis, which included ten studies and 15,863 patients, the pooled OR for colorectal adenoma related to H. pylori infection was 1.58 (95 % CI = 1.32-1.88). Our results from this cross-sectional study and current studies included in our meta-analysis indicated that H. pylori infection was associated with a modest increase in the risk for colorectal adenoma.