Does Trainee Involvement in Colonoscopy Affect Cecal Intubation and Polyp Detection Rates?

Introduction Adenoma detection rate is important quality indicator in screening colonoscopy. The aim of this study was to measure the change in the colorectal polyp and adenoma detection rate before and after monitoring and feedback in first-year gastroenterology fellow. Method We prospectively analysed a total of 3312 screening colonoscopy data including successful cecal intubation rate, cecal intubation time, withdrawal time, polyp and adenoma detection at the Seoul National University Hospital between March 2013 and September 2014. 1959 colonoscopies performed by 7 first-year gastroenterology fellows without feedback (group A). And 1353 screening colonoscopies performed by another 6 first-year fellows who were informed the periodic monitoring and feedback (group B). We sent the results of polyp and adenoma detection rate to all fellows and professor in charge every month by E-mail. Then we compared before and after feedback group outcomes. Results The average age of patients was 59.4 years, and 55.8% were male. The successful cecal intubation rate was improved after 150 cases both group A (90.0%) and group B (91.3%). Before feedback, overall polyp detection rate was 0.51 ± 0.08, adenoma detection rate was 0.36 ± 0.05. After feedback, the overall polyp detection rate was 0.50 ± 0.05, adenoma detection rate was 0.36 ± 0.03. Compared with before and after feedback group, there was not a significant difference in overall polyp and adenoma detection rate (p = 0.901, p = 0.846). After 150 cases, polyp detection rate was 0.50 for group A, whereas 0.56 for group B (p = 0.041). And adenoma detection rate was significantly higher in group A than group B (0.37 vs. 0.42; p = 0.038). Conclusion The minimum threshold number of technical competence in colonoscopy is more than 150 colonoscopies for trainee who initially started learning colonoscopy. The monitoring and feedback program is associated with an increase in polyp and adenoma detection rate after 150 cases. The periodic monitoring and feedback can be effective for trainees who achieved technical competence. Disclosure of interest None Declared.

To evaluate the full-spectrum endoscopy (FUSE) colonoscopy system as the first report on the utility thereof in a Korean population. We explored the efficacy of the FUSE colonoscopy in a retrospective, single-center feasibility study performed between February 1 and July 20, 2015. A total of 262 subjects (age range: 22-80) underwent the FUSE colonoscopy for colorectal cancer screening, polyp surveillance, or diagnostic evaluation. The cecal intubation success rate, the polyp detection rate (PDR), the adenoma detection rate (ADR), and the diverticulum detection rate (DDR), were calculated. Also, the success rates of therapeutic interventions were evaluated with biopsy confirmation. All patients completed the study and the success rates of cecal and terminal ileal intubation were 100% with the FUSE colonoscope; we found 313 polyps in 142 patients and 173 adenomas in 95. The overall PDR, ADR and DDR were 54.2%, 36.3%, and 25.2%, respectively, and were higher in males, and increased with age. The endoscopists and nurses involved considered that the full-spectrum colonoscope improved navigation and orientation within the colon. No colonoscopy was aborted because of colonoscope malfunction. The FUSE colonoscopy yielded a higher PDR, ADR, DDR than did traditional colonoscopy, without therapeutic failure or complications, showing feasible, effective, and safe in this first Korean trial.

Background:In an effort to improve visualization during colonoscopy, a transparent plastic cap or hood may be placed on the end of the colonoscope. Cap-assisted colonoscopy (CAC) has been studied and is thought to improve polyp detection. Numerous studies have been conducted comparing pertinent clinical outcomes between CAC and standard colonoscopy (SC) with inconsistent results.Methods:Numerous databases were searched in November 2016. Only randomized controlled trials (RCTs) involving adult subjects that compared CAC to SC were included. Outcomes of total colonoscopy time, time to cecum, cecal intubation rate, terminal ileum intubation rate, polyp detection rate (PDR), and adenoma detection rate (ADR) were analyzed in terms of odds ratio (OR) or mean difference (MD) with fixed effect and random effects models.Results:Five hundred eighty-nine articles and abstracts were discovered. Of these, 23 RCTs (n=12,947) were included in the analysis. CAC showed statistically significant superiority in total colonoscopy time (MD -1.51 min; 95% confidence interval [CI] -2.67 to -0.34; P<0.01) and time to cecum (MD -0.82 min; 95%CI -1.20 to -0.44; P<0.01) compared to SC. CAC also showed better PDR (OR 1.17; 95%CI 1.06-1.29; P<0.01) but not ADR (OR 1.11; 95%CI 0.95-1.30; P=0.20). In contrast, on sensitivity analysis, ADR was better with CAC. Terminal ileum intubation and cecal intubation rates demonstrated no significant difference between the two groups (P=0.11 and P=0.73, respectively).Conclusions:The use of a transparent cap during colonoscopy improves PDR while reducing procedure times. ADR may improve in cap-assisted colonoscopy but further studies are required to confirm this.

Background and study aims The European Colonoscopy Quality Investigation (ECQI) Group comprises expert colonoscopists and investigators with the aim of raising colonoscopy standards. We assessed the levels of monitoring and achievement of European Society of Gastrointestinal Endoscopy (ESGE) performance measures (PMs) across Europe using responses to the ECQI questionnaires.Methods The questionnaire comprises three forms: institution and practitioner questionnaires are completed once; a procedure questionnaire is completed on multiple occasions for individual total colonoscopies. ESGE PMs were approximated as closely as possible from the data collected via the procedure questionnaire. Procedure data could provide rate of adequate bowel preparation, cecal intubation rate (CIR), withdrawal time, polyp detection rate (PDR), and tattooing resection sites.Results We evaluated ECQI questionnaire data collected between June 2016 and April 2018, comprising 91 practitioner and 52 institution questionnaires. A total of 6445 completed procedure forms were received.Institution and practitioner responses indicate that routine recording of PMs is not widespread: adenoma detection rate (ADR) is routinely recorded in 29 % of institutions and by 34 % of practitioners; PDR by 42 % and 47 %, CIR by 62 % and 64 %, bowel preparation quality by 56 % and 76 %, respectively.Procedure data showed a rate of adequate bowel preparation of 84.2 %, CIR 73.4 %, PDR 40.5 %, mean withdrawal time 7.8 minutes and 12.2 % of procedures with possible removal of a non-pedunculated lesion ≥ 20 mm reporting tattooing.Conclusions Our findings clearly show areas in need of quality improvement and the importance of promoting quality monitoring throughout the colonoscopy procedure.

Background and study aims Choice of sedation (propofol vs opioid/benzodiazepine) has been studied in the literature and has shown variable outcomes. The majority of recent studies have evaluated propofol sedation (PS) versus opioids, benzodiazepines, or a combination of both. We performed a systematic review and meta-analysis of studies comparing PS to other sedation methods to assess the impact on colonoscopy outcomes.Methods Multiple databases were searched and studies of interest were extracted. Primary outcome of the study was adenoma detection rate (ADR) and secondary outcomes included polyp detection rate (PDR), advanced adenoma detection rate (AADR), and cecal intubation rate (CIR).Results A total of 11 studies met the inclusion criteria with a total of 177,016 patients (148,753 and 28,263 in the opioids/benzodiazepine group and PS group, respectively). Overall, ADR (RR: 1.07, 95 % CI 0.99–1.15), PDR (RR: 1.01, 95 % CI 0.93–1.10), and AADR (RR: 1.17, 95 % CI 0.92–1.48) did not improve with the use of PS. The CIR was slightly higher for propofol sedation group (RR 1.02, 95 % CI 1.00–1.03).Conclusion Based on our analysis, PS and opioid/benzodiazepine sedation seem to have comparable ADR. Our results do not favor use of a particular sedation method and the choice of sedation should be individualized based on patient preference, risk factors and resource availability.

Su1018 Higher Polyp Detection Rate and Shorter Cecal Intubation Time With Cap-Assisted Colonoscopy (CAC): A Systematic Review and Meta-Analysis

Cap-Assisted Colonoscopy Increases Detection of Advanced Adenomas and Polyps

Background and AimColonoscopy can be performed with two‐operator (2OP) or one‐operator (1OP) methods. This study aimed to investigate the feasibility and colonoscopy quality outcomes for the two different colonoscopy insertion techniques.MethodsOne colonoscopist from Changhua Christian Hospital learned and changed the colonoscopy insertion technique from 2OP to 1OP during 2013. Real‐life results of screening colonoscopies performed by this colonoscopist between these two insertion techniques (year 2012: 2OP vs year 2014: 1OP) were retrospectively reviewed and compared.ResultsIn total, 219 screening colonoscopies were reviewed (2OP group, n = 103 vs 1OP group, n = 116). No differences were noted between both groups in terms of patient age, gender, weight, and height. The overall cecum intubation was 98.2%, adenoma detection rate (ADR) was 29.7%, and colonoscopy withdrawal time was 518.58 ± 972.04 s. On comparing colonoscopy quality outcomes between both methods, no differences were observed in cecal intubation rates (2OP vs 1OP: 100 vs 96.6%, P = 0.1626), ADR (28 vs 31%, P = 0.7401), and colonoscopy withdrawal time (454.88 ± 178.21 vs 576.92 ± 1325.01 s, P = 0.355). However, the 1OP group demonstrated significantly shorter colonoscopy insertion time (2OP vs 1OP: 298.28 ± 202.95 vs 216.21 ± 121.99 s, P = 0.003).ConclusionColonoscopy quality outcomes were not impaired when one endoscopist changed the colonoscopy practice pattern from 2OP to 1OP. However, 1OP significantly shortened the colonoscopy insertion time.

Quality measures in colonoscopy are at the forefront in the field of gastroenterology, particularly in light of the current emphasis on ‘‘accountable’’ care. Colonoscopy quality measures include cecal intubation rate, complication rate, adenoma detection rate (ADR), and appropriate screening and surveillance intervals. For screening and surveillance colonoscopy, ADR is emerging as perhaps the most important quality indicator, since identification and removal of adenomas is the primary goal. Factors that improve ADR include adequacy of bowel preparation, cecal withdrawal time, time of day that colonoscopy is performed, type of sedation regimen used, and use of techniques such as cap-assisted colonoscopy and retroflexion in the right colon [1, 2]. Whether fellow involvement in colonoscopy affects ADR, the subject of the paper by Oh et al. [3] in this issue of Digestive Diseases and Sciences, has been less well studied. Most endoscopists who train fellows to perform colonoscopy probably have an opinion, based on personal experience, about whether fellow involvement increases or decreases ADR. Oh et al. looked at the issue more objectively by performing a meta-analysis of relevant studies to determine if a difference in polyp detection rate (PDR) or ADR occurs when a fellow is involved in colonoscopy. On the one hand, it might seem intuitive that PDRs and ADRs would be higher with a fellow and attending both observing the same procedure, as dual observers increase ADR [4]. Additionally, since fellows tend to take longer to complete a colonoscopy, one might infer that increased cecal withdrawal time by a fellow is associated with an increased ADR, similar to the data showing increased ADR with increased cecal withdrawal time amongst attending endoscopists. On the other hand, one might predict a lower ADR with fellows due to other factors, such as rapid withdrawal through colon segments when the fellow is having difficulty managing the colonoscope, a less thorough examination of the back surfaces of colonic folds, and inability to retroflex the colonoscope in the right colon. The impact, if any, of fellow participation on the PDR and ADR is important information for clinicians who regularly train fellows, particularly if ADR is recorded and/ or reported as a quality indicator. Although PDR is not relevant for determining screening and surveillance intervals, calculating PDR is much simpler since polyp histology is not required. If PDR correlates with ADR, some programs may choose to monitor PDR as a useful metric as fellows progress through training, allowing an objective assessment of fellow proficiency. Additionally, there may be patients who receive care at training institutions who want to know whether having a trainee involved affects the quality of their medical care. To determine if fellow involvement in colonoscopy affects ADR, Oh et al. [3] performed a comprehensive literature search, identifying articles in which the ADR, as well as the percent of colonoscopies, involving fellows was reported. From this information, they applied a modified Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool to the data to determine the impact of fellow participation in colonoscopy on ADR. A total of 14 studies met inclusion criteria, accounting for 21,504 colonoscopies. Based on the combined data, the RR (95 % CI) for detecting polyps when a fellow was present was 1.04 (0.94, 1.15), and for detecting adenomas was 1.03 (0.93, 1.14) suggesting that fellow involvement has no impact on D. S. Early (&) Department of Medicine, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8124, St. Louis, MO 63110, USA e-mail: dearly@dom.wustl.edu

The adenoma detection rate (ADR) of conventional colonoscopy can still be improved. We conducted a prospective multicenter cohort study to assess the feasibility, safety, and diagnostic yield of the Extra Wide Angle View (EWAVE) colonoscope, which offers a 235° view obtained from a forward-viewing and two lateral backward-viewing lenses incorporated into one image. The study was performed between November 2015 and June 2016. EWAVE colonoscopy was performed in patients with an increased risk of colorectal cancer by experienced and EWAVE-trained endoscopists (≥ 500 colonoscopies, ≥ 10 with the EWAVE system). A total of 193 patients underwent EWAVE colonoscopy. The cecal intubation rate was 97.4 %. EWAVE colonoscopy had a polyp detection rate (PDR) of 61.1 % (118 /193), ADR of 39.9 % (77 /193), and advanced ADR of 13.5 % (26 /193). No adverse events occurred. EWAVE colonoscopy is feasible and safe. The ADR appears comparable to those achieved with conventional colonoscopes in similar patient populations. To further elucidate the additional benefits of wide-angle-view colonoscopes, randomized trials would be required.

Polyethylene glycol (PEG) is the standard agent for bowel preparation in colonoscopy. However, its combination with linaclotide may enhance bowel cleansing. This systematic review and meta-analysis compared the efficacy and safety of linaclotide combined with PEG versus PEG alone in patients undergoing colonoscopy. We searched PubMed, Embase, and Cochrane Library databases. We calculated pooled risk ratios (RRs) for dichotomous and mean differences (MDs) for continuous outcomes, with 95% confidence intervals (CIs). We included 8 RCTs (3591 patients). Linaclotide improved preparation quality (MD 0.31; 95% CI [0.08, 0.54]), willingness to repeat the preparation (RR 1.16; 95% CI [1.09, 1.23]), and reduced adverse events (AEs). Adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate, and withdrawal time were similar between the groups. Subgroup analyses showed consistent results, except for: (1) patients with constipation - linaclotide improved PDR and reduced withdrawal time; (2) studies using a lower volume of PEG in the intervention group - preparation quality was similar between groups; and (3) studies using the same volume of PEG in both groups- linaclotide improved PDR and ADR, but with similar willingness to repeat the preparation and risk of AEs. Linaclotide with PEG improved preparation quality, willingness to repeat the preparation, and reduced AEs compared to PEG alone. Subgroup analyses findings are particularly relevant for patients with a history of inadequate bowel preparation, especially those with low tolerance to high-volume PEG or difficulty achieving effective colonic cleansing. Future studies should further explore the cost-effectiveness and the applicability across diverse regimens and patient characteristics.

Introduction: The detection and removal of pre-cancerous polyps via colonoscopy is widely recognized gold standard for the prevention of colon cancer. The Endocuff® (Arc medical Design Ltd) is a recently developed device comprised of a cap with several soft plastic projections designed to flatten out the colonic folds on withdrawal to optimize polyp detection. Several studies have evaluated the role of Endocuff -assisted colonoscopies compared to conventional colonoscopies with variable results. The goal of this meta-analysis is define the extent to which the use of Endocuff may affect polyp detection compared to standard colonoscopies. Methods: A comprehensive search of multiple databases was performed. All studies of adult patients who underwent colonoscopy examination using Endocuff® were included. Meta-analysis was performed using the DerSimonian and Laird (random effects) model with odds ratio (OR) to assess for polyp detection rate, cecal intubation rate, and procedural complications. Results: Of the 72 studies found, 6 studies met the inclusion criteria and were included in the final metaanalysis. In a pooled analysis of 6 studies (N=3,006), there was a significantly higher rate of adenoma detection of 47.4% in the Endocuff group compared to 40.1% in the control group (OR 1.62, 95% CI 1.23, 2.12, p< 0.001). Three of the included studies (N=1,052) demonstrated nearly 2-fold higher rate of rightsided polyp in the Endocuff group compared to the control group (OR 1.98, 95% CI 1.50 2.62). Four of the studies evaluated the cecal intubation rate, which were similar between the Endocuff group compared to the control group (OR 1.23, 95% 0.68, 2.23). The complication rate was higher in the Endocuff group compared to the control group (6.11% vs 0.91%, p < 0.001), with the most common complication being mucosal abrasions in the Endocuff group. Conclusion: Pooling 6 studies of over 3,000 patients, there was nearly a 2-fold higher rate for adenoma detection and right-sided polyp detection rates in the Endocuff group compared to standard colonoscopy examination. Though there was a slightly higher rate of mucosal abrasions in the Endocuff group, important factors such as cecal intubation rate and frequencies of colonic perforation were similar between the two groups. Therefore, the routine use of Endocuff may optimize polyp detection, particularly flat, right-sided polyps.

BackgroundModifying patient position during colonoscopy has been proposed as a simple and inexpensive technique to increase luminal distention and improve navigation through the large bowel. The left lateral (LL) decubitus starting position is commonly used during colonoscopy. However, reports indicate that other starting positions may offer additional benefit. We aimed to determine if the right lateral (RL) starting position compared to the standard LL starting position could improve outcomes in colonoscopy.MethodsWe searched PubMed, Medline, and EMBASE through June 2020 to identify studies comparing RL and LL starting positions during colonoscopy. The primary outcomes included mean cecal insertion time and cecal intubation rate, and adverse events were assessed by pooling data using a random-effects model expressed in terms of odds ratio (OR), mean difference, and 95% confidence interval (CI).ResultsWe identified 5 randomized controlled trials, including 809 participants, that compared LL vs. RL colonoscopy. The pooled OR for cecal intubation rate was 1.3 (95%CI 0.8-2.3; P=0.3). The mean difference in mean cecal insertion time was 0.08 (95%CI -0.09 to 0.26; P=0.4). Heterogeneity between studies was low (I2=0%). No complications were reported in either arm of the study. Pain scores assessed using a visual analog scale were comparable among both arms of the study.ConclusionThe RL starting position for colonoscopy was comparable to the LL and offered no additional benefit in terms of cecal intubation time, intubation rate, or patient discomfort.

Analysis of Various Colonoscopy Preparation Methods and Its Advantages and Complications – An Observational, Cross-Sectional, Multicenter Study

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.