Sessile Serrated Adenoma Detection Rate Research Articles

A111 CLINICAL AND PATHOLOGICAL OUTCOMES BETWEEN WATER EXCHANGE AND AIR INSUFFLATION USING NON-SEDATED EXTENDED FLEXIBLE SIGMOIDOSCOPY FOR AVERAGE RISK COLORECTAL CANCER SCREENING: PRELIMINARY FINDINGS FROM A RANDOMIZED CONTROL TRIAL

Abstract Background Colorectal cancer (CRC) is Canada's third most common cancer type and represents approximately 11% of all cancer deaths. While sedated colonoscopy or flexible sigmoidoscopy (FS) continues to be considered for CRC screening, these modalities have limitations and risks. Another unevaluated screening modality, known as an extended FS (EFS), attempts to capitalize on the benefits of a FS while minimizing the risks involved with a sedated colonoscopy. EFS provides a scope-based examination up to the splenic flexure and then attempts to examine beyond, often to the point of the caecum. Providing the option for EFS may produce improvements in the patient experience and performance, which may improve the feasibility of using scope-based screening more broadly in screening programs. Purpose To determine the extent non-sedated EFS using the water exchange method (WE) is associated with a complete colon examination compared to the traditional air insufflation (AI) method using CO2 in an average-risk screening population. Method This randomized control trial included 90 non-sedated participants, screened by trained general surgery and gastroenterology clinicians at Kelowna General Hospital, British Columbia, Canada, using two different scope insufflation techniques, WE and AI. The primary outcome of interest was the cecal intubation rates (CIR), while secondary outcomes included the adenoma detection rate (ADR) and reported pain scores. Other metrics, such as patient satisfaction rates, sessile serrated adenoma detection rates (SSADR), and serrated lesion detection rates (SLDR) were also recorded. Result(s) The demographic characteristics between the WE and AI groups were statistically similar, with the mean age of participants being 58 and 57, respectively. During the study period, four endoscopists performed the EFS. There were higher initial satisfaction rates in the WE group vs the AI (95% vs 77%, satisfaction of ≥ 9/10 p = 0.028). CIR and ADR were similar between the WE and AI group (CIR = 93% vs 91%, p = 0.710), (ADR = 40% vs 34%, p = 0.660). The SSADR and SLDR were also similar between the WE and AI group (SSADR = 21% vs 14%, p = 0.408), (SLDR = 42% vs 36%, p = 0.528). Conclusion(s) EFS without sedation using either technique exceeds quality benchmarks recommended for sedated screening colonoscopy while maintaining adequate patient safety and comfort. The WE method optimizes a patient's overall experience making a strategy of average risk colorectal cancer screening with non-sedated WE EFS feasible. Please acknowledge all funding agencies by checking the applicable boxes below CAG, Other Please indicate your source of funding; Kelowna General Hospital, Interior Health Disclosure of Interest None Declared

Improving sessile serrated adenoma detection rates with high definition colonoscopy: A retrospective study

BACKGROUNDSessile serrated adenomas (SSAs) are important premalignant lesions that are difficult to detect during colonoscopy due to poor definition, concealment by mucous caps, and flat appearance. High definition (HD) colonoscopy may uniquely aid in the detection of these inconspicuous lesions compared to standard definition (SD) colonoscopes. In the absence of existing clinical guidelines to obligate the use of HD colonoscopy for colorectal cancer screening in average-risk patients, demonstrating the benefit of HD colonoscopy on SSA detection rate (SSADR) may help strengthen the evidence to recommend its use in all settings.AIMTo evaluate the benefit of HD colonoscopy compared to SD colonoscopy on SSADR in average-risk patients undergoing screening colonoscopy.METHODSData from screening colonoscopies for patients aged 50-76 years two years before and two years after the transition from SD colonoscopy to HD colonoscopy at our large, academic teaching center were collected. Patients with symptoms of colorectal disease, positive occult blood test, history of colon polyps, cancer, polyposis syndrome, inflammatory bowel disease or family history of colon cancer or polyps were excluded. Patients whose endoscopists did not perform colonoscopies both before and after scope definition change were also excluded. Differences in individual endoscopist SSADR, average SSADR, and overall SSADR with SD colonoscopy vs HD colonoscopy were also evaluated for significance.RESULTSA total of 3657 colonoscopies met eligibility criteria with 2012 colonoscopies from the SD colonoscopy period and 1645 colonoscopies from the HD colonoscopy period from a pool of 11 endoscopists. Statistically significant improvements of 2.30% in mean SSADR and 2.53% in overall SSADR were noted with HD colonoscopy (P = 0.00028 and P = 0.00849, respectively). On the individual level, three endoscopists experienced statistically significant benefit with HD colonoscopy (+5.74%, P = 0.0056; +4.50%, P = 0.0278; +4.84%, P = 0.03486).CONCLUSIONOur study suggests that HD colonoscopy statistically significantly improves sessile serrated adenoma detection rate in the screening of average risk patients during screening colonoscopy. By improving the detection and removal of these lesions, adoption of HD colonoscopy may reduce the significant premalignant burden of sessile serrated adenomas.

Endocuff Vision improves adenoma detection rate in a large screening-related cohort.

Background and study aims Endocuff Vision (ECV) increases adenoma detection rate (ADR) in randomized clinical trials; however, observational effectiveness data are lacking. We evaluated the effectiveness, safety, and practical aspects of ECV use in a large screening-related real-world cohort. Patients and methods In this observational study, patients undergoing screening-related colonoscopy from November 2018 to April 2019 comprised the baseline period, and those undergoing it from June to November 2019 comprised the ECV period, where ECV use was discretionary. The primary outcome was ADR, compared: 1) between ECV use and standard colonoscopy across both periods; and 2) between time periods. Secondary outcomes included indication-specific ADR, sessile serrated ADR (SSADR), cecal intubation rate (CIR), procedure times, patient comfort scores, and sedation use. Multilevel logistic regression was performed, yielding adjusted odds ratios (AOR) with 95 % confidence intervals (CIs). Results In 15,814 colonoscopies across both time periods, ADR was 46.7 % with standard colonoscopy and 54.6 % when ECV was used ( P < 0.001). Endoscopists used ECV in 77.6 % of procedures in the ECV period, during which overall ADR rose to 53.2 % compared to 46.3 % in the baseline period ( P < 0.001). ECV use was significantly associated with higher ADR (AOR 1.24, 95 % CI 1.10 to 1.40) after adjusting for relevant covariates including time period. ECV use did not result in lower CIR, longer procedure time, increased sedation use, or poorer comfort scores. Conclusions ECV use is associated with improved ADR without negatively impacting other key procedure and patient-related factors. Future studies should evaluate the cost-effectiveness of incorporating ECV into routine screening-related practice.

S336 Significant Improvement in the Overall Sessile Serrated Adenoma Detection Rates With High Definition Colonoscopy Compared to Standard Definition Colonoscopy

S336 Significant Improvement in the Overall Sessile Serrated Adenoma Detection Rates With High Definition Colonoscopy Compared to Standard Definition Colonoscopy

Impact of feedback on adenoma detection rate: a systematic review and meta-analysis

BackgroundAdenoma detection rate (ADR) is one of the most important quality indicators of colonoscopy. Monitoring endoscopists and providing feedback has shown to improve ADR. We performed a systematic review of the literature and meta-analysis to determine the effect of any form of feedback on ADR.MethodsA literature search for comparative studies that employed any form of feedback to assess the impact on ADR before and after the feedback was done on MEDLINE, EMBASE, and Cochrane Database. The primary outcome of interest was ADR. Secondary outcomes included polyp detection rate, advanced adenoma detection rate, sessile serrated adenoma detection rate, withdrawal time, and cecal intubation rate. Cochrane Revman 5.3 software was used for statistical analysis.ResultsA total of 12 studies met the inclusion criteria for the analysis of primary outcomes. There were 78,355 subjects (45.42% male) with a mean age of 59.52 years. There was a significant improvement in ADR after any form of feedback compared to no feedback: 36.18% vs. 26.75%; pooled odds ratio 1.51, 95% confidence interval 1.37-1.66; P<0.001. There was a substantial heterogeneity (I2=82%). ADR improved in both active or passive feedback, irrespective of whether endoscopists knew about being monitored for their performance or not.ConclusionsMonitoring and providing feedback to endoscopists in any form leads to improvement in ADR. Feedback is an easy and effective way of improving the ADR of endoscopists, especially in those not achieving the recommended benchmarks.

Endocuff-assisted versus Cap-assisted Colonoscopy in Increasing Adenoma Detection Rate. A Meta-analysis.

Several add-on devices have been developed to increase rates of colon adenoma detection. We aimed to compare the endocuff-assisted colonoscopy with cap-assisted colonoscopy through a pairwise meta-analysis of randomized trials. We searched the PubMed/Medline and Embase database through March 2020 and identified 6 randomized controlled trials (comprising 2,027 patients). The primary outcome was adenoma detection rate; secondary outcomes included sessile serrated adenoma detection rate, mean adenoma per colonoscopy, cecal intubation rate and time to reach cecum. Safety data were also analyzed. We performed pairwise meta-analysis through a random effects model and expressed data as risk ratio and 95% confidence interval. Overall, pooled adenoma detection rate was 48.1% (39.3-56.8%) with endocuff and 40.5% (30.4- 50.6%; risk ratio 1.14, 0.96-1.35) with cap. Proximal adenoma detection rate was 45.7% (36.8-54.7%) and 24% (17-45.1%) with endocuff and cap, respectively (risk ratio 2.04, 0.93-4.49), whereas endocuff outperformed cap-assisted colonoscopy in detecting diminutive (≤ 5 mm) adenomas (risk ratio 2.74, 1.53-4.90) and in terms of mean adenoma per colonoscopy (mean difference 0.31, 0.05 -0.57; p=0.02). Sessile serrated adenoma detection rate (risk ratio 1.36, 0.72-2.59), cecal intubation rate (risk ratio 0.99, 0.98-1.00), and time to reach cecum (6.87 min versus 6.87 min) were similar between the two groups. No serious adverse event was observed. Endocuff-assisted colonoscopy seems to provide a higher adenoma detection rate as compared to cap-assisted colonoscopy, in particular concerning smaller diminutive polyps.

Increased Sessile Serrated Adenoma Detection Rate With Mechanical New Technology Devices: A Systematic Review and Meta-Analysis.

This meta-analysis aims to compare the sessile-serrated adenoma detection rate (SSADR) of currently available mechanical new technology devices (NTDs) to conventional colonoscopy (CC). NTDs including Endocuff, EndoRing, G-Eye, and AmplifEYE were developed with the aim of improving adenoma detection rate by enhancing colonic mucosal visualization. Increasing awareness of the risk of sessile-serrated adenoma progression to malignancy has ushered a need to increase the detection of these characteristically flat lesions. Embase and PubMed/Medline databases were searched from inception through January 2019 for published manuscripts or major conference abstracts reporting SSADR with Endocuff, EndoRing, G-Eye, AmplifEYE, and CC. Randomized controlled trials, high-quality case-control, cohort, and observational studies in adults with >10 subjects were included. The primary outcome was pooled SSADR odds ratio (ORs) with 95% confidence interval (95% CI) comparing CC with the NTDs. In addition, an analysis comparing each device to CC was performed. Of 207 citations identified, a total of 14 studies with 12,655 subjects were included in our analysis (5931 subjects with NTDs and 6724 with CC). There were 12 studies with Endocuff, 2 with EndoRing, 1 with G-EYE, and 1 with AmplifEYE. The mean age was 62.4 years and 57.5% were males. Pooled SSADR with NTDs was 12.3% as compared with 6.4% with CC, with an OR of 1.81 (95% CI: 1.6-2.0, I2: 77%). Analysis of Endocuff alone yielded an OR 1.81 (95% CI: 1.6-2.1, I2: 79%). Mechanical NTDs, notably Endocuff, are a safe and effective tool to increase the SSADR.

Enhanced Patient Education for Colonic Polyp and Adenoma Detection: Meta-Analysis of Randomized Controlled Trials.

Background To improve patients’ comprehension of bowel preparation instructions before colonoscopy, enhanced patient education (EPE) such as cartoon pictures or other visual aids, phone calls, mobile apps, multimedia education and social media apps have been proposed. However, it is uncertain whether EPE can increase the detection rate of colonic polyps and adenomas.ObjectiveThis meta-analysis aimed to evaluate the efficacy of EPE in detecting colonic polyps and adenomas.MethodsWe searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from their inception to June 2019 for the identification of trials comparing the EPE with standard patient education for outpatients undergoing colonoscopy. We used a random effects model to calculate summary estimates of the polyp detection rate (defined as the number of patients with at least one polyp divided by the total number of patients undergoing selective colonoscopy), adenoma detection rate (defined as the number of patients with at least one adenoma divided by the total number of patients undergoing selective colonoscopy), advanced adenoma detection rate (defined as the number of patients with at least one advanced adenoma divided by the total number of patients undergoing selective colonoscopy), sessile serrated adenoma detection rate (defined as the number of patients with at least one sessile serrated adenoma divided by the total number of patients undergoing selective colonoscopy), cancer detection rate (defined as the number of patients with at least one cancer divided by the total number of patients undergoing selective colonoscopy), or adenoma detection rate - plus (defined as the number of additional adenomas found after the first adenoma per colonoscopy). Moreover, we conducted trial sequential analysis (TSA) to determine the robustness of summary estimates of all primary outcomes.ResultsWe included 10 randomized controlled trials enrolling 4560 participants for analysis. The meta-analysis suggested that EPE was associated with an increased polyp detection rate (9 trials; 3781 participants; risk ratio [RR] 1.19, 95% CI 1.05-1.35; P<.05; I2=42%) and adenoma detection rate (5 trials; 2133 participants; RR 1.37, 95% CI 1.15-1.64; P<.001; I2=0%), which were established by TSA. Pooled result from the inverse-variance model illustrated an increase in the sessile serrated adenoma detection rate (3 trials; 1248 participants; odds ratio 1.76, 95% CI 1.22-2.53; P<.05; I2=0%). One trial suggested an increase in the adenoma detection rate - plus (RR 4.39, 95% CI 2.91-6.61; P<.001). Pooled estimates from 3 (1649 participants) and 2 trials (1375 participants) generated no evidence of statistical difference for the advanced adenoma detection rate and cancer detection rate, respectively.ConclusionsThe current evidence indicates that EPE should be recommended to instruct bowel preparation in patients undergoing colonoscopy because it can increase the polyp detection rate, adenoma detection rate, and sessile serrated adenoma detection rate. However, further trials are warranted to determine the efficacy of EPE for advanced adenoma detection rate, adenoma detection rate - plus, and cancer detection rate because of limited data.

Colonoscopy withdrawal time and polyp/adenoma detection rate: a single-site retrospective study in regional Queensland.

Bowel cancer is the second most common non-cutaneous cancer diagnosed in Australia among both genders. Colonoscopy withdrawal time of at least 6 min has been accepted as the standard to achieve the target polyp detection rate (PDR) and adenoma detection rate (ADR). A retrospective review was conducted in Bundaberg Hospital to evaluate the relationship between colonoscopy withdrawal time against polyp, adenoma and cancer detection rates. A retrospective study was carried out in Bundaberg Hospital on patients who had colonoscopies performed between 1 October 2016 and 30 September 2017 by the general surgical team. Data collection was conducted by reviewing patient charts, general practitioner referral letters and endoscopy reports. Statistical analysis was performed with chi-squared test using Prism 8.2.1. A total of 1579 colonoscopies were analysed. The median age of patients undergoing a colonoscopy was 64 years (95% confidence interval (CI) 60.55-61.93). Median total duration of colonoscopy was 19 min (95% CI 20.9-22.0), with median withdrawal time of 9 min (95% CI 10.06-10.95). PDR, ADR and sessile serrated adenoma (SSA) detection rates were 43.3%, 33.1% and 5.4%, respectively. Cancer detection rate was 2.8%. Longer withdrawal times were associated with higher PDR, ADR and SSA detection rates (P < 0.0001) and higher mean number of polyp/adenoma/SSA detected. Colonoscopies with withdrawal times of less than 6 min did not achieve the target detection rates. It is clear that achieving the advocated withdrawal time for screening colonoscopy improves detection rates.

A Theory-based Educational Pamphlet With Low-residue Diet Improves Colonoscopy Attendance and Bowel Preparation Quality.

Patients who "no-show" for colonoscopy or present with poor bowel preparation waste endoscopic resources and do not receive adequate examinations for colorectal cancer (CRC) screening. Using the Health Belief Model, we modified an existing patient education pamphlet and evaluated its effect on nonattendance rates and bowel preparation quality. We implemented a color patient education pamphlet to target individual perceptions about CRC and changed bowel preparation instructions to include a low-residue diet instead of the previous clear liquid diet. We compared the nonattendance rate over a 2-month period before and after the introduction of the pamphlet, allowing for a washout period during which pamphlet use was inconsistent. We compared the Boston Bowel Preparation Scale (BBPS) in 100 consecutive patients who underwent colonoscopy during each of the 2 periods. Baseline characteristics between the 2 groups were similar, although patients who received the pamphlet were younger (P=0.03). The nonattendance rate was significantly lower in patients who received the pamphlet (13% vs. 21%, P=0.01). The percentage of patients with adequate bowel preparation increased from 82% to 86% after introduction of the pamphlet, although this was not statistically significant (P=0.44). The proportion of patients with a BBPS score of 9 was significantly higher in the pamphlet group (41% vs. 27%, P=0.03). There was no difference in adenoma and sessile serrated adenoma detection rates before and after pamphlet implementation. After implementing a theory-based patient education intervention with a low-residue diet, our absolute rate for colonoscopy nonattendance decreased by 8% and the proportion of patients with a BBPS score of 9 increased by 14%. The Health Belief Model appears to be a useful construct for CRC screening interventions.

Multidirectional Colonoscopy Quality Improvement Increases Adenoma Detection Rate: Results of the Seoul National University Hospital Healthcare System Gangnam Center Colonoscopy Quality Upgrade Project (Gangnam-CUP).

To prevent colorectal cancer, high-quality colonoscopy is advocated, undertaken by endoscopists with high adenoma detection rates (ADRs). Despite reports that various factors may impact ADRs, the significance of such factors is still unclear. The analysis was aimed at quality-oriented interventions for boosting ADRs. Study enrollees were adults subjected to screening colonoscopy between September 2013 and August 2016 at the Gangnam Center of Seoul National University Hospital Healthcare System. The investigation entailed six periods (P1-6) of 6months each, during which serial multidirectional quality improvement efforts were instituted. In particular, we sought to further educate endoscopists, provide feedback on individual ADRs, and introduce a split-dose regimen, gauging results via the Boston Bowel Preparation Score. Changes in polyp detection rates (PDRs) and ADRs were then analyzed. A total of 13,430 colonoscopies were undertaken by 15 experienced endoscopists. Overall, the ADR increased from 45.6% (P1) to 48.2% (P6, p < 0.001). The PDR, ADR, and advanced adenoma detection rate (AdvADR) showed the greatest increases between P3 and P4 [PDR 67.8% → 71.2% (p < 0.001); ADR 44.1% → 47.7% (p = 0.001); AdvADR 2.3% → 3.3% (p = 0.028)] in keeping with the introduction of a split-dose regimen. The sessile serrated adenoma detection rate (SSADR) increased substantially from 2.1% (P1) to 7.9% (P6, p < 0.001), with the largest gain between P1 and P2, just after education (p = 0.023). Successful quality improvement in colonoscopy was achieved through comprehensive multidirectional efforts in education, feedback, and enhanced bowel preparation. Achieving high-level bowel preparation was paramount in ADR improvement. The SSADR was improved through education.

251 Detection Rates by Anatomic Location in Caucasians, Hispanics, and Asians

INTRODUCTION: Ethnic and racial disparities in colorectal cancer (CRC) incidence and mortality rate have been well studied in the literature. However, no study to date has compared surrogates of precancerous polyp prevalence: adenoma detection rate (ADR), polyp detection rate (PDR), sessile serrated adenoma detection rate (SDR) amongst ethnic groups with respect to polyp location. This study serves to compare ethnicities with respect to ADR, PDR, and SDR in 3 ethnic groups as a function of anatomic location. METHODS: This retrospective nonrandomized nonblinded cohort study utilized prospectively collected data at our single tertiary referral center from the UCICQDRes database. A total of 19 attendings and 55 fellows performed 8,894 colonoscopies from June 2012 to October 2018. Three study subgroups (Asian n = 1505, Hispanic n = 951, and Caucasian n = 6438) were compared for age, gender, BMI, total procedure time (TT), bowel prep score (BPS), cecal intubation rate (CIR), ADR, PDR, and SDR stratified by anatomic location. RESULTS: Asians had the highest BPS and age, while Hispanics had the lowest TT. There were differences in PDR and ADR across the ethnicities in all areas of the colon. For instance, in the cecum, Caucasians had the highest PDR (0.18, P = 0.0007), ADR (0.11, P = 0.0142), and SDR (0.027, P = 0.0034). In the left colon, SDR was not significantly different between the ethnicities. With the exception of transverse colon ADR, Hispanics had the lowest PDR and ADR for all anatomic locations. CONCLUSION: Except for ADR in transverse colon and SDR in the descending colon, Hispanics had significantly lower ADR, PDR, and SDR compared to other ethnicities. That Hispanic patients, in general, had lower detection rates in all anatomic locations may be at least partially attributed to the lower BPS and higher BMI and TT in this group. Further analysis is required to ascertain the effect of these variables. In the cecum and ascending colon, differences in ADR, PDR and SDR were significant between all groups. This study suggests that variations in detection rates based on anatomic location may contribute to variations in CRC incidence rates across ethnicities. Additional studies may be of interest to confirm and further explore these differences, as they may have the potential to warrant ethnicity-dependent CRC screening guidelines.

Sa1040 PREDICTIVE CALCULATION FOR THE SESSILE SERRATED ADENOMA DETECTION RATE

Introduction: The potential inclusion of the sessile serrated adenoma detection rate (SSADR) in the key performance indicators of quality colonoscopy has been rapidly gaining understandable interest, given the associated pathway may contribute to 30% of colorectal cancers, particularly in the proximal colon. However, obtaining and calculating colonoscopy performance indicators is generally time‐consuming and laborious, as it involves manually reviewing and matching colonoscopy results with pathology results. It has been proposed that a formula based on polyp detection rate of the unit and the individual could perform as a proxy for adenoma detection rate (ADR) (Francis 2011), which was modified to account for high polyp detectors, but no such predictive proxy for SSADR exists. Although the SSADR is highly correlated with the ADR, the two rates are not directly predicative of one another. Aim: Our aim was to determine whether polyp detection rate (PDR) predicts SSADR. Methods: Colonoscopy records from July 2014 to September 2017 were retrospectively examined at two regional hospital endoscopy units in Australia. Patients with inflammatory bowel disease, polyposis syndromes, preoperative indications, failed examination due to inadequate bowel preparation, anastomosis, obstructing mass and failed intubation were excluded. In our previously proposed modification to the Francis calculation, the ADR target of 25% was replaced with the Proximal PDR (Prox‐PDR) and the adenoma to polyp detection rate quotient (APDRQ) then calculated from this (APDRQ = Prox‐PDR ÷ PDR). The group average weighted APDRQ was then calculated (0.6349) and the individual's PDR was multiplied by the weighted APDRQ. For the SSADR calculation, the SS‐APRDQ was determined by (PDR ÷ Prox‐PDR) + (group weighted average PDR ÷ group weight average Prox‐PDR), which was then multiplied by the individual PDR to determine the calculated SSADR. These calculations were then compared with the confirmed SSADR. Results: A total of 10 571 colonoscopies were included. The mean number of completed colonoscopies per endoscopist was 352. The average age of patients was 58 years and 45% were male. Including all endoscopists, the average PDR for all indications was 60.6% (SD, 14.1%), the average ADR was 39% (SD, 10.8%), and the average SSADR was 12.6% (SD, 7.4%). Table 1 presents the PDR, Prox‐PDR, actual SSADR, and calculated SSADR. The calculated SSADR had a strong positive calculation with the actual SSADR (r = 0.8646, P < 0.00001) and only differed from the actual SSADR by a mean of −0.003%. This correlation increased as the required minimum scope number was increased to at least 50 in the study period (n = 10 414, r = 0.8873, P < 0.00001). Conclusion: It is possible to accurately estimate SSADR for an individual endoscopist by using a proposed calculation incorporating the Prox‐PDR. In this study, this result is highly correlated to their actual SSADR. This may be invaluable in estimating SSADR before obtaining histology confirmation or for estimating SSADR for large centers.

Tu1043 – Gastroenterology Fellows Have Similar Polyp, Adenoma and Sessile Serrated Adenoma Detection Rates with Underwater Colonoscopy Vs Air-Insufflation Colonoscopy Each Quarter of Fellowship

Tu1043 – Gastroenterology Fellows Have Similar Polyp, Adenoma and Sessile Serrated Adenoma Detection Rates with Underwater Colonoscopy Vs Air-Insufflation Colonoscopy Each Quarter of Fellowship

Screening Colonoscopy Polyp, Adenoma and Sessile Serrated Adenoma Detection Rate Differences in Hispanics and Whites in Age-Matched Cohorts

Introduction: Colorectal cancer is the third leading cause of cancer death in Hispanics. Hispanics are a rapidly growing population within the United States. Although Whites appear to have higher rates of colorectal cancer compared to Hispanics, data may be flawed by differences in access to care. Our objective was to compare polyp, adenoma and sessile serrated adenoma prevalence among age-matched Hispanic and White cohorts. Methods: Colonoscopy quality data was collected prospectively at our single tertiary referral center from June 2012 to June 2018 using Qualoscopy (Docbot, Inc.). Among screening colonoscopies we compared Hispanics to Whites in age-matched cohorts for polyp (PDR), adenoma (ADR) and sessile serrated adenoma detection rates (SSADR). Subgroup analysis was performed on left vs. right colon polyps. Significance was determined by a two-tailed Fischer’s exact test. Results: 3097 colonoscopies met our inclusion criteria, of which 463 were performed in Hispanics and 2634 in Whites. Baseline characteristics are shown in Table 1. No significant difference in PDR, ADR and SSADR was seen before age 40 or after age 60. However, Hispanics aged 40-49 had a statistically significant lower PDR compared to Whites within the entire colon, 0.44 vs. 0.67 and within the left colon, 0.26 vs. 0.48, respectively. Hispanics aged 50-59 had statistically lower PDR, ADR and SSADR compared to Whites, 0.50 vs. 0.69, 0.34 vs. 0.44 and 0.05 vs. 0.11, respectively. Hispanics aged 50-59 had significantly lower PDR in the left colon 0.33 vs. 0.47, significantly lower PDR in the right colon 0.36 vs. 0.48 and significantly lower ADR in the right colon 0.25 vs. 0.32, respectively. Interestingly, PDR, ADR and SSADR was only marginally higher between Hispanics aged 40-49 vs. Hispanics aged 50-59 and Whites aged 40-49 vs. Whites aged 50-59. Conclusion: Our data demonstrate Hispanics have statistically significant lower PDR in ages 40-49 and 50-59 and lower ADR and SSADR in ages 50-59 compared to Whites. We also know that sessile serrated adenomas are thought to play a role in the development of interval colorectal cancer. Lower PDR, ADR and especially SSADR in Hispanics aged 50-59 may play a pivotal role in the lower rates of colorectal cancer seen in Hispanics.115_A Figure 1. Baseline Characteristics115_B Figure 2. Screening Colonoscopy Polyp, Adenoma and Sessile Serrated Adenoma Detection Rates in Hispanics and Whites115_C Figure 3. Screening Colonoscopy Polyp, Adenoma and Sessile Serrated Adenoma Detection Rates in Hispanics and Whites Based on Colon Location in Ages 40-49 and 50-59

Sessile serrated adenoma detection rate is correlated with adenoma detection rate

AIMTo investigated the association between adenoma detection rate (ADR) and sessile serrated ADR (SSADR) and significant predictors for sessile serrated adenomas (SSA) detection.METHODSThis study is a retrospective, single-center analysis. Total colonoscopies performed by the gastroenterologists at the University of Tokyo Hospital between January and December 2014 were retrospectively identified. Polyps were classified as low-grade or high-grade adenoma, cancer, SSA, or SSA with cytological dysplasia, and the prevalence of each type of polyp was investigated. Predictors of adenoma and SSA detection were examined using logistic generalized estimating equation models. The association between ADR and SSADR for each gastroenterologist was investigated by calculating a correlation coefficient weighted by the number of each gastroenterologist’s examination.RESULTSA total of 3691 colonoscopies performed by 35 gastroenterologists were assessed. Overall, 978 (26.5%) low- and 84 (2.2%) high-grade adenomas, 81 (2.2%) cancers, 66 (1.8%) SSAs, and 2 (0.1%) SSAs with cytological dysplasia were detected. Overall ADR was 29.5% (men 33.2%, women 23.8%) and overall SSADR was 1.8% (men 1.7%, women 2.1%). In addition, 672 low-grade adenomas (68.8% of all the detected low-grade adenomas), 58 (69.9%) high-grade adenomas, 29 (34.5%) cancers, 52 (78.8%) SSAs, and 2 (100%) SSAs with cytological dysplasia were found in the proximal colon. Adenoma detection was the only significant predictor of SSA detection (adjusted OR: 2.53, 95%CI: 1.53-4.20; P < 0.001). The correlation coefficient between ADR and SSADR weighted by the number of each gastroenterologist’s examinations was 0.606 (P < 0.001).CONCLUSIONOur results demonstrated that ADR is correlated to SSADR. In addition, patients with adenomas had a higher prevalence of SSAs than those without adenomas.

Gastroenterologists Have Higher Polyp Detection Rates During Screening Colonoscopy Than Non-gastroenterologists

Introduction: It has been reported that gastroenterologists are better at polyp detection and polyp removal as compared to Non-gastroenterologists. After a negative colonoscopy, those who have had their procedures performed by a gastroenterologist are less likely to develop interval CRC. However specific information about polypectomy rate (PR), adenoma detection rate (ADR), serrated polyp detection rate (SPDR) and sessile serrated adenoma detection rate (SSADR) and their variation by gender and colonic segment between gastroenterologist and non-gastroenterologists is not clearly defined. Methods: A retrospective review of all screening colonoscopies in patients ≥50 years of age performed at our institution between 2012 and 2014 was done. Patients with complete colonoscopy with excellent, good and adequate bowel preparation were included. Non-gastroenterologists included general surgeons, colorectal surgeons and primary care physicians. Serrated polyps included hyperplastic polyps and sessile serrated adenomas. Overall, gender and colon segment specific PR, ADR, SPDR and SSADR were calculated and compared using t-tests. Data are presented as mean ± standard deviation. All analyses were done using SAS (version 9.4, The SAS Institute, Cary, NC) and a P<0.05 was considered statistically significant.Table: Table. Characteristics of Endoscopists and PatientsTable: Table. Polyp Detection Rates by Specialty of the EndoscopistResults: A total of 4151 patients were included in the analysis. Average patient age was 60.0±7.7 years and 53.2% were females. Colonoscopies were performed by 54 gastroenterologists (63.5%) and 31 (36.5%) non-gastroenterologists (General Surgeons=9; Colorectal Surgeons=21; Primary care physician=1). Overall PR (49.3±14.9 vs. 37.5±14.9; P<0.05) and overall ADR (28.8±10.5 vs. 22.1±10.8; P=0.007) was significantly higher for gastroenterologists compared to non-gastroenterologists in both males and females; Overall SSADR and proximal SSADR was significantly higher for gastroenterologists compared to non-gastroenterologists. Overall SPDR is significantly higher for gastroenterologists; however proximal and distal SPDR did not vary significantly by the specialty of endoscopist or gender of the patient. Conclusion: Gastroenterologists have higher PR, ADR, SPDR, SSADR and proximal SSADR compared to non-gastroenterologists. These findings suggest a need for developing targeted programs to improve colonoscopy quality for non-gastroenterologists performing colonoscopy.

Higher Rates of Proximal Sessile Serrated Adenomas Among Whites Compared to Asians, Hispanics and Blacks

Introduction: Surveillance, Epidemiology, End Results (SEER) data in the United States reveal that Whites rank third behind Blacks and American Indian/Alaska Natives for incidence and mortality from colorectal cancer. Sessile Serrated Adenomas (SSAs) have been proposed to play a role in the development of interval colorectal cancer; however, limited studies have assessed the prevalence of SSAs among Whites, Asians, Hispanics and Blacks. Our objective was to compare the prevalence of SSAs between Whites, Asians, Hispanics and Blacks using sessile serrated adenoma detection rate (SSADR) as a surrogate of prevalence. Methods: Colonoscopy quality data was collected prospectively at our single tertiary referral center from June 2012 to May 2017 using Qualoscopy (Docbot, Inc.). We included all diagnostic, screening and surveillance colonoscopies in Whites, Asians, Hispanics and Blacks over 40 years of age. Whites were compared to Asians, Hispanics and Blacks for detection of polyps (PDR), adenomas (ADR) and sessile serrated adenoma (SSADR) (Table 2). Subgroup analysis included colon location. Baseline characteristics included gender, age, BMI, bowel prep scores, bowel prep liters, total procedure time and cecal intubation rates (Table 1). Significance was determined by a two-tailed Fischer's exact test and T-test.Table: Table. Average Polyp Detection RatesTable: Table. Baseline CharacteristicsResults: 6085 colonoscopies met our inclusion criteria, of which 4448 were performed in Whites, 989 in Asians, 481 in Hispanics and 167 in Blacks. Overall, Whites had statistically higher rates of proximal sessile serrated adenomas (9.10%) compared to Asians (7.10%), Hispanics (3.70%) and Blacks (4.20%). Compared to Hispanics, Whites had significantly higher PDRs, ADRs, SSADRs within the entire colon and right colon and higher PDRs and ADRs within the left colon. Compared to Asians, Whites had significantly higher SSADRs within the entire colon but significantly lower ADRs within the left colon. Conclusion: Our data demonstrate significant racial differences in detections rates of polyps, adenomas and sessile serrated adenomas. Whites have higher proximal SSADRs compared to Asians, Hispanics and Blacks. Although Blacks have a higher incidence and mortality from colorectal cancer compared to Whites, we were unable to demonstrate increased prevalence of precancerous polyps in this group, perhaps due to the small sample size of our Black cohort. Larger studies are needed to verify our findings, which have significance relative to optimal screening and surveillance strategies.

Time Trends in Detection of Sessile Serrated Adenomas: The Impact of the 2010 WHO Guidelines and Adenoma Detection Rates

Introduction: Screening colonoscopy has reduced the rates of colorectal cancer (CRC) and mortality, but it remains the second leading cause of death amongst men and women. The benefit of screening colonoscopy is less robust in the proximal colon. As such, a topic of interest is the sessile serrated adenoma (SSA), which is more commonly detected in the proximal colon. Adenoma detection rate (ADR) is one surrogate marker of colonoscopic quality, and is associated with reduced CRC incidence and mortality. Measures to increase ADR have likely helped increase SSA detection, which may have been misclassified as hyperplastic polyps. The WHO outlined diagnostic criteria in 2010 to help reduce under diagnosis of SSAs. A retrospective chart review of all screening colonoscopies was conducted at our institution to determine the impact of trends in ADR and WHO classification on SSA detection. Methods: Using ICD- 9 code V76.51, screening colonoscopies performed between 1/1/06 to 03/01/16 were identified. Our pathology database review identified patients with all polyp types. Procedure notes and pathology reports were reviewed to identify polyp characteristics, location, and to identify a subset with sessile serrated adenomas. Results: A total of 61,591 colonoscopies occurred between 2006 and 2016. The average age was 59 years, and 55% were female. SSA was detected in 1.97% (n=1211) while 26% (n=15,999) had at least one tubular adenoma. Majority of SSAs were detected in the proximal colon, with ascending colon being the predominant location (Figure 1). In patients with SSA, 45% (n=545) had tubular adenoma, 1.6% (n=20) had tubulovillous adenoma, and 1.8% (n=22) had villous adenoma. Up to 2011, the SSA detection rate was <1% but increased in subsequent years and correlated with a progressive increase in the ADR (Table 1) (Figure 2).Figure: Distribution of sessile serrated adenomas in the colon.Figure: Trends in tubular adenoma and sessile serrated adenoma detection rates from 2006-2016.Table: Table. Tubular Adenoma, Sessile Serrated Adenoma, Hyperplastic, Tubulovillous and Villous Adenoma Detection Rates from 2006-2016Conclusion: A large majority of SSAs occurred in the proximal colon with a dramatic increase in SSA diagnosis every year post 2011, which strongly corresponds to progressive increase in ADR and changes in histologic classification by the WHO in 2010. In fact, in multivariate logistic regression analysis looking at risk factors for SSA, later year of procedure had the highest risk [OR 1.65(1.6-1.70)]. These findings strongly support sustained efforts aimed at increasing the quality of screening colonoscopies. Future studies that evaluate cancer registries may reveal the effect of increased SSA detection on CRC incidence and mortality, specifically proximal CRC and interval CRC.

A Theory-Based Educational Booklet Improves Colonoscopy Attendance and Bowel Preparation Quality

Introduction: Patients who “no-show” for colonoscopy or present with poor bowel preparation waste endoscopic resources and do not receive adequate examination for colorectal cancer (CRC) screening. At our VA hospital, which does not use open access endoscopy, the colonoscopy no-show rate is high and inadequate bowel preparation is a common occurrence. To address these issues, we designed a patient education booklet using health behavior theory and evaluated its effect on no-show rates and bowel preparation quality. Methods: We adapted the Health Belief Model for screening/surveillance colonoscopy and identified major targets for intervention. We then designed a 12-page color patient education booklet to target individual perceptions about CRC using simple facts, provide cues to action using graphics to explain the bowel preparation process, and increase likelihood of action by adopting a more palatable low residue diet (Fig 1). We compared the no-show rate over a two month period before and after introduction of the booklet, allowing for a wash-out period during which booklet use was inconsistent. We compared the Boston Bowel Prep Scale (BPPS) in 100 consecutive patients who underwent colonoscopy during each of the two periods.Figure: Select Sections of Patient Education Pamphlet.Results: Baseline characteristics between the two groups were similar, although patients who received the booklet were younger (Table). The no-show rate was significantly lower in patients who received the booklet than those who did not (13% vs. 21%, P=.01). The percentage of patients with adequate bowel prep—defined as BBPS>1 in all segments—increased from 82% to 86% after introduction of the booklet and surpassed the 85% metric recommended US Multi-Society Task Force, although the difference was not statistically significant (P=.44). The proportion of patients with BBPS=9 was significantly higher in the booklet group (Fig 2; 41% vs. 27%, P=.03). There was no difference in adenoma and sessile serrated adenoma detection rates before and after the booklet.Figure: Boston Bowel Preparation Scale Outcomes Before and After Patient Education Booklet.Table: Table. Patient Characteristics and OutcomesConclusion: Using a theory-based patient education intervention, we decreased our colonoscopy noshow rate by 38% and increased our adequate bowel preparation rate above the guideline-recommended 85%. Our adaptation of the Health Belief Model for screening/surveillance colonoscopy may be a useful construct for future health behavioral interventions.