Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

Effect of Endocuff use on colonoscopy outcomes: A systematic review and meta-analysis

BACKGROUND

Endocuff - a plastic device with flexible projections - mounted on the distal tip of the colonoscope, promises improved colonic mucosa inspection.

AIM

To elucidate the effect of Endocuff on adenoma detection rate (ADR), advanced ADR (AADR) and mean number of adenomas per colonoscopy (MAC).

METHODS

Literature searches identified randomized-controlled trials evaluating Endocuff-assisted colonoscopy (EAC) vs conventional colonoscopy (CC) in terms of ADR, AADR and MAC. The effect size on study outcomes was calculated using fixed or random effect model, as appropriate, and it is shown as relative risk (RR) [95% confidence interval (CI)] and mean difference (MD) (95%CI). The rate of device removal in EAC arms was also calculated.

RESULTS

We identified nine studies enrolling 6038 patients. All studies included mixed population (screening, surveillance and diagnostic examinations). Seven and two studies evaluated the first and the second-generation device, respectively. EAC was associated with increased ADR compared to CC [RR (95%CI): 1.18 (1.05-1.32); Ι 2 = 71%]; EAC benefits more endoscopists with ADR ≤ 35% compared to those with ADR > 35% [RR (95%CI): 1.37 (1.08-1.74); Ι 2 = 49% vs 1.10 (0.99-1.24); Ι 2 = 71%]. In terms of AADR and MAC, no difference was detected between EAC and CC [RR (95%CI): 1.03 (0.85-1.25); Ι 2 = 15% and MD (95%CI): 0.30 (-0.17-0.78); Ι 2 = 99%]. Subgroup analysis did not show any difference between the two device generations regarding all three endpoints. In EAC arms, the device had to be removed in 3% (95%CI: 2%-5%) of the cases mainly due to tortuous sigmoid or presence of diverticula along it.

CONCLUSION

EAC increases ADR compared to CC, especially for endoscopists with lower ADR. On the other hand, no significant effect on AADR and MAC was detected.

Diagnostic yield and miss rate of EndoRings in an organized colorectal cancer screening program: the SMART (Study Methodology for ADR-Related Technology) trial

BACKGROUND AND AIMS

The EndoRings add-on has been claimed to improve adenoma detection at colonoscopy, but available data are inconsistent. When testing a new technology, parallel and crossover methodologies measure different outcomes, leaving uncertainty about their correspondence. The aims of this study were to compare the diagnostic yield and miss rate of the EndoRings for colorectal neoplasia.

METHODS

Consecutive patients undergoing colonoscopy after a positive fecal immunochemical test (FIT) within an organized screening program in 7 Italian centers were randomized between a parallel (EndoRings or standard) or a crossover (EndoRings/standard or standard/EndoRings) methodology. Outcomes measures were the adenoma detection rate (ADR) and advanced adenoma detection rate (AADR) in the parallel arms and the miss rate of adenomas in the crossover arms.

RESULTS

Of 958 eligible patients, 927 (317 EndoRings; 317 standard; 142 EndoRings/standard; 151 standard/Endo-Rings) were included in the final analysis. In the parallel arms (mean ADR, 51.3%; mean AADR, 25.4%), no difference between standard and EndoRings was found for both ADR (relative risk [RR], 1.10; 95% confidence interval [CI], 0.95-1.28) and AADR (RR, 1.16; 95% CI, 0.88-1.51), as well as for the mean number of adenomas and advanced adenomas per patient (EndoRings, 1.9 ± 1.3 and 1.0 ± 1.2; standard, 2.1 ± 1.5 and 1.0 ± 1.2; P = not significant for both comparisons). In the crossover arms, no difference in the miss rate for adenomas between EndoRings and standard was found at per polyp (RR, 1.43; 95% CI, 0.97-2.10) or per-patient analysis (24% vs 26%; P = .76).

CONCLUSIONS

No statistically significant difference in diagnostic yield and miss rate between EndoRings and standard colonoscopy was detected in patients with a positive FIT result. A clinically relevant correspondence between miss and detection rates was shown, supporting a cause-effect relationship. (ISRCTN registry: ISRCTN10357435.).

Increasing adenoma detection rates in the right side of the colon comparing retroflexion with a second forward view: a systematic review

BACKGROUND AND AIMS

Right-sided lesions are often missed during standard colonoscopy (SC). A second forward-view examination or retroflexion in the right side of the colon have both been proposed as techniques to improve adenoma detection rate (ADR) in the right side of the colon. Comparative data on examining the right side of the colon with a second forward view or retroflexion is not known in a pooled analysis. We performed a systematic review of the literature to assess the yield of a second forward view compared with retroflexion examination for the detection of right-sided adenomas.

METHODS

A systematic literature search was performed using the following databases: PubMed, Embase, Web of Science, and Cochrane. Only full-length published articles that provided information on adenoma detection and miss rates during either a second forward view or retroflexed view of the right side of the colon after the initial standard forward withdrawal (SC) were included. The following outcomes were assessed: comparison of adenoma miss rate (AMR) for second forward view versus retroflexion after SC, AMR of SC compared with second forward view, AMR of SC compared with retroflexion, and right-sided adenoma detection with second forward view and retroflexion. Pooled rates were reported as risk difference or odds ratios (OR) with 95% confidence intervals (CI) with a P value <.05 indicating statistical significance. Statistical analysis was performed with Review Manager v5.3.

RESULTS

We identified 4 studies with 1882 patients who underwent a second forward view of the right side of the colon after an initial SC. The average age of the patients was 58.3 years. Data on right-sided ADR were available from all 4 studies for the second forward view; however, only 2 of the studies provided information on right-sided ADR with retroflexion. The pooled estimate of AMR of a single SC was 13.3% (95% CI, 6.6%-20%) compared with a second forward-view examination (n = 4), whereas it was 8.1% (3.7%-12.5%) compared with a retroflexion examination (n = 3). However, when the second forward view was compared with retroflexion in terms of AMR from an analysis of 3 eligible studies, there was no statistically significant difference (7.3% vs 6.3%; pooled OR, 1.2; 95% CI, 0.9-1.61; P = .21). Second forward view of the right side of the colon increased the right-sided ADR by 10% (n = 4; second forward view vs SC, 33.6% vs 26.7%) with a pooled risk difference of 0.09 (95% CI, 0.03-0.15; P < .01). Retroflexion increased the right-sided ADR by 6% (n = 3; retroflexion vs SC, 28.4% vs 22.7%) with a pooled risk difference of 0.06 (95% CI, 0.03-0.09; P < 01).

CONCLUSION

After SC withdrawal, a second forward view and retroflexed view of the right side of the colon are both associated with improvement in ADR. One of these techniques should be considered during SC to increase ADR and to improve the quality of colonoscopy.

Endoscopic surveillance after colonic polyps and colorrectal cancer resection. 2018 update

There is limited scientific evidence available to stratify the risk of developing metachronous colorectal cancer after resection of colonic polyps and to determine surveillance intervals and is mostly based on observational studies. However, while awaiting further evidence, the criteria of endoscopic follow-up needs to be unified in our setting. Therefore, the Spanish Association of Gastroenterology, the Spanish Society of Family and Community Medicine, the Spanish Society of Digestive Endoscopy, and the Colorectal Cancer Screening Group of the Spanish Society of Epidemiology, have written this consensus document, which is included in chapter 10 of the "Clinical Practice Guideline for Diagnosis and Prevention of Colorectal Cancer. 2018 Update". Important developments will also be presented as regards the previous edition published in 2009. First of all, situations that require and do not require endoscopic surveillance are established, and the need of endoscopic surveillance of individuals who do not present a special risk of metachronous colon cancer is eliminated. Secondly, endoscopic surveillance recommendations are established in individuals with serrated polyps. Finally, unlike the previous edition, endoscopic surveillance recommendations are given in patients operated on for colorectal cancer. At the same time, it represents an advance on the European guideline for quality assurance in colorectal cancer screening, since it eliminates the division between intermediate risk group and high risk group, which means the elimination of a considerable proportion of colonoscopies of early surveillance. Finally, clear recommendations are given on the absence of need for follow-up in the low risk group, for which the European guidelines maintained some ambiguity.

Automated polyp detection in the colorectum: a prospective study (with videos)

BACKGROUND AND AIMS

Adenoma detection is a highly personalized task that differs markedly among endoscopists. Technical advances are therefore desirable for the improvement of the adenoma detection rate (ADR). An automated computer-driven technology would offer the chance to objectively assess the presence of colorectal polyps during colonoscopy. We present here the application of a real-time automated polyp detection software (APDS) under routine colonoscopy conditions.

METHODS

This was a prospective study at a university hospital in Germany. A prototype of a novel APDS ("KoloPol," Fraunhofer IIS, Erlangen, Germany) was used for automated image-based polyp detection. The software functions by highlighting structures of possible polyp lesions in a color-coded manner during real-time colonoscopy procedures. Testing the feasibility of APDS deployment under real-time conditions was the primary goal of the study. APDS polyp detection rates (PDRs) were defined as secondary endpoints provided that endoscopists' detection served as criterion standard.

RESULTS

The APDS was applied in 55 routine colonoscopies without the occurrence of any clinically relevant adverse events. Endoscopists' PDRs and ADRs were 56.4% and 30.9%, respectively. The PDRs and ADRs of the APDS were 50.9% and 29.1%, respectively. The APDS detected 55 of 73 polyps (75.3%). Smaller polyp size and flat polyp morphology were correlated with insufficient polyp detection by the APDS.

CONCLUSION

Computer-assisted automated low-delay polyp detection is feasible during real-time colonoscopy. Efforts should be undertaken to improve the APDS with respect to smaller and flat shaped polyps. (Clinical trial registration number: NCT02838888.).

Increasing rates of SSA/P detection in a large open-access Australian colonoscopy cohort

Background and study aims There are limited longitudinal data regarding detection rates for sessile serrated adenoma/polyps (SSADR) and right-sided hyperplastic polyps (RHPDR) that constitute the proximal serrated lesion detection rate (PSLDR). Recently, a minimum PSLDR of 4.5 % has been suggested. This study was designed to assess SSADR, PSLDR and adenoma detection rate (ADR) for a newly qualified gastroenterologist and compare them to published data and to assess the change in SSADR, PSLDR and ADR over time for potential improvement with experience.

Patients and methods All colonoscopies performed by a single colonoscopist (AM), at one Australian ambulatory direct-access endoscopy center over 4 years from 2011 to 2015 were retrospectively analyzed. Histology was reported by a single expert pathologist (SL). ADR, SSADR, RHPDR and PSLDR were recorded.

Results A total of 841 colonoscopies were performed on 637 patients. Of them, 454 (54 %) were males. Mean age was 59 years. Of the colonoscopies, 87 % were performed for patients with ASA scores of 1 – 2, 422 (50.2 %) were for screening or surveillance, 374 (44.5 %) for investigation of symptoms and 45 (5.4 %) had therapeutic indications. Conventional adenomas were detected in 346 colonoscopies (ADR = 41.1 %), SSA/P in 124 (SSADR = 14.7 %) and RHP in the absence of SSA/P in 35 (RHPDR = 4.2 %). PSLDR was 18.9 %. ADR was stable over time (range 33 %-50 %). SSADR and PSLDR increased over time [SSADR: 8.6 % (2011), 8.4 % (2012), 14.9 % (2013), 18.5 % (2014), 25.0 % (2015); PSLDR: 10.5 % (2011), 11.3 % (2012), 16.8 % (2013), 27.2 % (2014), 29.4 % (2015)]. There was a statistically significant improvement in SSADR (IRR 1.37) and PSLDR (IRR 1.36) over the study period (P < 0.001), whereas the ADR remained stable (IRR 1.04, P = 0.334).

Conclusions SSADR and PSLDR in this unselected direct-access cohort are high and exceed previously reported detection rates in the final 2 years. Detection rates improved with experience, likely representing a learning effect. The minimum expected PSLDR may need to be revised upwards and further studies are required, particularly in areas where screening colonoscopies are offered only for patients with increased colorectal cancer risk (family history or fecal immunochemical test-positive).

Adenoma detection rates in colonoscopies for positive fecal immunochemical tests versus direct screening colonoscopies

BACKGROUND AND AIMS

Recent guidelines propose higher adenoma detection rate (ADR) benchmarks for colonoscopies performed for positive results for fecal immunochemical tests (FIT), but this is based on low-quality evidence. We aimed to compare ADR, advanced ADR (AADR), and number of adenomas per colonoscopy (APC) in direct screening colonoscopy (DSC) versus FIT-positive colonoscopy (FITC) in a multicenter Asia-Pacific cohort to justify differential targets.

METHODS

Asymptomatic average-risk patients ≥50 years of age who underwent screening colonoscopy directly or as follow-up for positive OC-Sensor FIT results were identified from 8 sites across the Asia-Pacific region. Overall, sex-specific ADR, overall AADR, and overall APC were compared between the 2 screening methods. Multivariable logistic regression was performed to adjust for confounding by differences in patient characteristics. Linear regression was used to correlate ADR with APC and to propose APC benchmarks.

RESULTS

A total of 2901 (mean age, 60.1 years; 57% men) individuals had DSC, and 2485 (mean age, 62.8 years; 57% men) underwent FITC. Overall ADR (53.6% vs 37.5%; odds ratio [OR], 1.93; P < .001), male-specific ADR (61.6% vs 44.6%; OR, 2; P < .001), female-specific ADR (43.2% vs 28.2%; OR, 1.94; P < .001) and overall AADR (29.9% vs 4.9%; OR, 8.2; P < .001) in FITC were significantly higher than the corresponding values for DSC. Differences remained significant after adjustment for patient characteristics. ADR was strongly and positively correlated to APC, with an ADR of 45% and 35% correlating to an APC of ∼1 and ∼0.65.

CONCLUSIONS

Results from this international multicenter cohort study provide early evidence that newly proposed higher ADR targets are justified as quality indicators for FITC.

G-EYE colonoscopy is superior to standard colonoscopy for increasing adenoma detection rate: an international randomized controlled trial (with videos)

BACKGROUND AND AIMS

Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy still occur. An increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device includes a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics, and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing the ADR.

METHODS

In this randomized, controlled, international, multicenter study (11 centers), patients (aged ≥50 years) referred to colonoscopy for screening, surveillance, or changes in bowel habits were randomized to undergo either balloon-assisted colonoscopy by using an insufflated balloon during withdrawal or standard high-definition colonoscopy. The primary endpoint was the ADR.

RESULTS

One thousand patients were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (standard colonoscopy n = 396; balloon-assisted colonoscopy n = 407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the standard colonoscopy group (28% increase; P = .0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (P = .0033) flat adenomas (P < .0001) and sessile serrated adenomas/polyps (P = .0026).

CONCLUSION

Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat, and sessile serrated adenomas/polyps when compared with standard colonoscopy. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates and consequently reducing interval cancer incidence. (Clinical trial registration number: NCT01917513.).

Does Increased Adenoma Detection Reduce the Risk of Colorectal Cancer, and How Good Do We Need to Be?

PURPOSE OF REVIEW

Colorectal cancer (CRC) is largely preventable with colonoscopy and other screening modalities. However, the effectiveness of screening and surveillance depends on the quality of the colonoscopy exam. Adenoma detection rate (ADR) is the best-validated metric by which we measure individual physicians' performance.

RECENT FINDINGS

Recent evidence suggests that ADR benchmarks may be inappropriately low. There is proof that improving ADR leads to significant reductions in post-colonoscopy CRC (PCCRC). Two studies have demonstrated that when a colonoscopy is performed by physicians with higher ADRs, patients are less likely to have advanced adenomas on surveillance and less likely to develop or die from PCCRC. Finally, there is at least some evidence that higher ADRs do not lead to more cumulative surveillance exams. The ADR is a useful outcome measure that can provide individual endoscopists and their patients with information about the likelihood of developing PCCRC. To achieve the lowest possible PCCRC rate, we should be striving for higher ADRs. While strategies and innovations may help a bit in improving ADRs, our efforts should focus on ensuring a complete mucosal exam for each patient. Behavioral psychology theories may provide useful frameworks for studying motivating factors that drive a careful exam.

Quality indicators and patient satisfaction in colonoscopy

INTRODUCTION

Colonoscopy is the diagnostic/therapeutic confirmation test for colorectal cancer. The monitoring of the experience of people who have undergone the test is interesting to improve the quality of the colonoscopy. The aim of the project was to study factors affecting patients' experience and their relationship with the quality indicators of the Clinical Practice Guidelines.

PATIENTS AND METHODS

An observational cross-sectional study was conducted, including quality and experience indicators (adapted mGHAA-9 questionnaire and clinical history) in a sample of 432 participants aged between 40- and 75-years-old who had undergone a colonoscopy in 2015. Univariate and multivariate analysis with multiple logistic regression.

RESULTS

Satisfaction was associated in the multivariate analysis with evaluating the waiting time for the colonoscopy as short (OR=3.80) (1.76-10.90, 95% CI),>55-years-old (OR=2.60) (1.19-5.68, 95% CI), rating the experience with the preparation positively (OR=7.34) (3.15-17.09, 95% CI), not reporting pain or discomfort during the procedure (OR=3.71) (1.03-13.40, 95% CI) (P=.006) and being examined in a tertiary hospital (OR=2.81) (1.17-6.72; 95% CI) (P=.020).

DISCUSSION

The mGHAA-9 questionnaire adapted to Spanish is useful to evaluate patient experience factors. There are aspects to improve in terms of waiting time, colon cleansing, satisfaction with preparation and post-colonoscopy problems. Interventions should be implemented to enhance patient experience and colonoscopy quality.

Application of remifentanil combined with propofol in the diagnosis of colon cancer with awakening painless digestive endoscopy

Anesthetic effect of remifentanil combined with propofol in awakening painless endoscopy was analyzed. Retrospective analysis of 120 cases of colon cancer were treated in Dongying People's Hospital from June 2015 to December 2017. All of them were treated by awakening painless digestive endoscopy, divided into 60 cases in observation group (combined with remifentanil and propofol anesthesia), and 60 cases in control group (combined intravenous anesthesia of finanib and propofol). The data were respectively recorded at time-points of oxygen inhalation, intubation for 10 min, awakening time, waking time, and the time-points for each represented as the time-points of T1, T2, T3, T4, T5 and recorded the diastolic blood pressure (DBP), respiratory rate (RR) and heart rate (HR), and compared the awakening effect and the occurrence of adverse reaction. There was no significant difference in the DBP index between the two groups at time-point T1 (P>0.05). The time-points of T2, T3, T4 and T5 were significantly different from the observation group (P<0.05). There was no significant difference in RR index between the two groups and between the same groups (P>0.05). Compared with the control group, the awakening time and consciousness recovering of the observation group is lower (P<0.05). The incidence of adverse reactions after awakening operation between the two groups was statistically significant (P<0.05). The local pain rate in the observation group after the awakening operation was lower than the control group. The combined use of trace remifentanil and small dose propofol in the awakening painless digestive endoscopy can make the patients with colon cancer more stable when they are in the awakening state, so as to improve the safety of awakening painless digestive endoscopy. It is worth promoting in clinical practice.

Polyp detection with computer-aided diagnosis in white light colonoscopy: comparison of three different methods

Background and study aims  Detection of polyps during colonoscopy is essential for screening colorectal cancer and computer-aided-diagnosis (CAD) could be helpful for this objective. The goal of this study was to assess the efficacy of CAD in detection of polyps in video colonoscopy by using three methods we have proposed and applied for diagnosis of polyps in wireless capsule colonoscopy. Patients and methods  Forty-two patients were included in the study, each one bearing one polyp. A dataset was generated with a total of 1680 polyp instances and 1360 frames of normal mucosa. We used three methods, that are all binary classifiers, labelling a frame as either containing a polyp or not. Two of the methods (Methods 1 and 2) are threshold-based and address the problem of polyp detection (i. e. separation between normal mucosa frames and polyp frames) and the problem of polyp localization (i. e. the ability to locate the polyp in a frame). The third method (Method 3) belongs to the class of machine learning methods and only addresses the polyp detection problem. The mathematical techniques underlying these three methods rely on appropriate fusion of information about the shape, color and texture content of the objects presented in the medical images. Results  Regarding polyp localization, the best method is Method 1 with a sensitivity of 71.8 %. Comparing the performance of the three methods in the detection of polyps, independently of the precision in the location of the lesions, Method 3 stands out, achieving a sensitivity of 99.7 %, an accuracy of 91.1 %, and a specificity of 84.9 %. Conclusion  CAD, using the three studied methods, showed good accuracy in the detection of polyps with white light colonoscopy.

The Colonoscopy Satisfaction and Safety Questionnaire (CSSQP) for Colorectal Cancer Screening: A Development and Validation Study

Colonoscopy services working in colorectal cancer screening programs must perform periodic controls to improve the quality based on patients' experiences. However, there are no validated instruments in this setting that include the two core dimensions for optimal care: satisfaction and safety. The aim of this study was to design and validate a specific questionnaire for patients undergoing screening colonoscopy after a positive fecal occult blood test, the Colonoscopy Satisfaction and Safety Questionnaire based on patients' experience (CSSQP). The design included a review of available evidence and used focus groups to identify the relevant dimensions to produce the instrument (content validity). Face validity was analyzed involving 15 patients. Reliability and construct and empirical validity were calculated. Validation involved patients from the colorectal cancer screening program at two referral hospitals in Spain. The CSSQP version 1 consisted of 15 items. The principal components analysis of the satisfaction items isolated three factors with saturation of elements above 0.52 and with high internal consistency and split-half readability: Information, Care, and Service and Facilities features. The analysis of the safety items isolated two factors with element saturations above 0.58: Information Gaps and Safety Incidents. The CSSQP is a new valid and reliable tool for measuring patient' experiences, including satisfaction and safety perception, after a colorectal cancer screening colonoscopy.

Adenoma and advanced neoplasia detection rates increase from 45 years of age

BACKGROUND

Colonoscopy is considered a valid primary screening tool for colorectal cancer (CRC). The decreasing risk of CRC observed in patients undergoing colonoscopy is correlated with the adenoma detection rate (ADR). Due to the fact that screening programs usually start from the age of 50, very few data are available on the risk of adenoma between 40 and 49 years. However, the incidence of CRC is increasing in young populations and it is not uncommon in routine practice to detect adenomas or even advanced neoplasia during colonoscopy in patients under 50 years.

AIM

To compare the ADR and advanced neoplasia detection rate (ANDR) according to age in a large series of patients during routine colonoscopy.

METHODS

All consecutive patients who were scheduled for colonoscopy were included. Exclusion criteria were as follows: patients scheduled for partial colonoscopy or interventional colonoscopy (for stent insertion or stenosis dilation). Colonoscopies were performed in our unit by a team of 30 gastroenterologists in 2016. We determined the ADR and ANDR in each age group in the whole population and in the population with an average risk of CRC (excluding patients with personal or family history of advanced adenoma or cancer).

RESULTS

6027 colonoscopies were performed in patients with a median age of 57 years (range, 15-96). The ADR and ANDR were 28.6% and 9.7%, respectively, in the whole population. When comparing patients aged 40-44 (n = 382) and 45-49 years (n = 515), a strong increase in all parameters from 45 years was observed, with the ADR rising from 9.7% in patients aged 40-44 to 21.2% between 45 and 49 (P < 0.001) and the ANDR increasing from 3.1% in patients aged 40-44 to 6.4% in those aged 45-49 years (P < 0.03). With regard to patients aged 50-54 (n = 849), a statistically significant increase in the ADR and ANDR was not observed between patients aged 45-49 and those aged 50-54 years. In the population with an average risk of CRC, the ADR and ANDR were still significantly higher in patients aged 45-49 compared with those aged 40-44 years.

CONCLUSION

This study shows a significant two-fold increase in the ADR and ANDR in patients aged 45 years and over.

Adverse events related to colonoscopy: Global trends and future challenges

Colonoscopy is a widely used method for diagnosing and treating colonic disease. The number of colonoscopies is increasing worldwide, and concerns about associated adverse events are growing. Large-scale studies using big data for post-colonoscopy complications have been reported. A colon perforation is a severe complication with a relatively high mortality rate. The perforation rate, as reported in large studies (≥ 50,000 colonoscopies) published since 2000, ranges from 0.005-0.085%. The trend in the overall perforation rate in the past 15 years has not changed significantly. Bleeding is a more common adverse event than perforation. Recent large studies (≥ 50,000 colonoscopies) have reported post-colonoscopy bleeding occurring in 0.001-0.687% of cases. Most studies about adverse events related to colonoscopy were performed in the West, and relatively few studies have been conducted in the East. The incidence of post-colonoscopy complications increases in elderly patients or patients with inflammatory bowel diseases. It is important to use a unified definition and refined data to overcome the limitations of previous studies. In addition, a structured training program for endoscopists and a systematic national management program are needed to reduce post-colonoscopy complications. In this review, we discuss the current trends in colonoscopy related to adverse events, as well as the challenges to be addressed through future research.

Quality assurance of colonoscopy within the Dutch national colorectal cancer screening program

Colorectal cancer (CRC) screening is capable of reducing CRC-related morbidity and mortality. Colonoscopy is the reference standard to detect CRC, also providing the opportunity to detect and resect its precursor lesions: colorectal polyps. Therefore, colonoscopy is either used as a primary screening tool or as a subsequent procedure after a positive triage test in screening programs based on non-invasive stool testing or sigmoidoscopy. However, in both settings, colonoscopy is not fully protective for the occurrence of post-colonoscopy CRCs (PCCRCs). Because most PCCRCs are the result of colonoscopy-related factors, a high-quality procedure is of paramount importance to assure optimal effectiveness of CRC screening programs. For this reason, at the start of the Dutch fecal immunochemical test (FIT)-based screening program, quality criteria for endoscopists performing colonoscopies in FIT-positive screenees, as well as for endoscopy centers, were defined. In conjunction, an accreditation and auditing system was designed and implemented. In this report, we describe the quality assurance process for endoscopists participating in the Dutch national CRC screening program, including a detailed description of the evidence-based quality criteria. We believe that our experience might serve as an example for colonoscopy quality assurance programs in other CRC screening programs.

Bowel preparation for colonoscopy: what is best and necessary for quality?

PURPOSE OF REVIEW

Colonoscopy is recognizably, the best colon cancer prevention test, provided the quality of the preparation is adequate for detection of precancerous polyps but also allowing for accurate identification of margins, thereby facilitating complete endoscopic resection. As there are many aspects effecting colon prep outcomes, it is timely to review new standards for optimizing outcomes, including product selection based on patient demographics.

RECENT FINDINGS

New national guidelines have set a minimum quality threshold for adequacy and also defined a split day delivery for oral options as the "standard of care". Several new prep options have been recently released and these data are discussed.

SUMMARY

Optimizing the quality of colon preps has major implications for clinical practice. Clinicians must recognize new targets for standard of care, providing the best approach for each individual patient, considering variable factors which may otherwise compromise success.

Colorectal Neuroendocrine Neoplasms: Areas of Unmet Need

The subject of colorectal neuroendocrine neoplasms (NENs), subdivided into well-differentiated NENs, termed neuroendocrine tumours (NETs; grade (G) 1 and 2), and poorly differentiated NENs, termed neuroendocrine carcinomas (NECs; G3) according to the 2010 World Health Organisation (WHO) classification, has arguably not had as much attention or study as NENs occurring in other sites. Colorectal NETs and NECs are however easier to study than many others since they are usually not difficult to remove and are increasingly detected because of intensified colorectal cancer screening and surveillance programmes. Colorectal NETs and NECs show site-specific heterogeneity with variable behaviour and different therapeutic options; these various aspects provide unique challenges. Because of bowel cancer screening programmes, colorectal NENs, like conventional adenocarcinomas, may be diagnosed at a stage that is associated with improved survival. In this article we intend to describe and define areas of unmet needs relating to the epidemiology, classification, pathology, diagnosis and therapy of colorectal NETs (including NETs G3), colorectal NECs, and finally, mixed adeno-neuroendocrine carcinomas (MANECs) by reviewing and discussing the relevant literature.

Performance measures for endoscopic retrograde cholangiopancreatography and endoscopic ultrasound: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at centre and endoscopist level: 1 Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90%); 2 antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95%); 3 bile duct cannulation rate (key performance measure, at least 90%); 4 tissue sampling during EUS (key performance measure, at least 85%); 5 appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95%); 6 bile duct stone extraction (key performance measure, at least 90%); 7 post-ERCP pancreatitis (key performance measure, less than 10%); and 8 adequate documentation of EUS landmarks (minor performance measure, at least 90%). This present list of quality performance measures for ERCP and EUS recommended by the ESGE should not be considered to be exhaustive; it might be extended in future to address further clinical and scientific issues.

Complete polypectomy and early detection and management of residual disease to reduce the risk of interval colorectal cancers

Advances in colorectal polyp detection and resection methods aim to reduce interval cancer rates. Complete polypectomy is essential to reduce the risk of early recurrence and the development of interval cancers. To achieve this, polyps must first be correctly identified and then completely excised. This article reviews current adenoma detection methods in use and the management of residual disease.

Divergent Long-Term Detection Rates of Proximal and Distal Advanced Neoplasia in Fecal Immunochemical Test Screening Programs: A Retrospective Cohort Study

BACKGROUND

Short-term studies have reported that the fecal immunochemical test (FIT) is less accurate in detecting proximal than distal colorectal neoplasia.

OBJECTIVE

To assess the long-term detection rates for advanced adenoma and colorectal cancer (CRC), according to anatomical location.

DESIGN

Retrospective study.

SETTING

Population-based, organized screening program in the Veneto region of Italy.

PARTICIPANTS

Persons aged 50 to 69 years who completed 6 rounds of FIT screening.

MEASUREMENTS

At each screening round, the detection rates for advanced adenoma and cancer, as well as the proportional interval cancer rate (PICR), were calculated by anatomical location (proximal colon, distal colon, or rectum).

RESULTS

Between 2002 and 2014, a total of 123 347 participants had 441 647 FITs. The numbers of advanced adenomas and cancer cases detected, respectively, were 1704 and 200 in the proximal colon, 3703 and 324 in the distal colon, and 1220 and 209 in the rectum. Although the detection rate for proximal colon cancer declined only from the first to the second screening round (0.63 to 0.36 per 1000 screenees), the rate for both distal colon and rectal cancer steadily decreased across 6 rounds (distal colon, 1.65 in the first round to 0.17 in the sixth; rectum, 0.82 in the first round to 0.17 in the sixth). Similar trends were found for advanced adenoma (proximal colon, 5.32 in the first round to 4.22 in the sixth; distal colon, 15.2 in the first round to 5.02 in the sixth). Overall, 150 cases of interval cancer were diagnosed. The PICR was higher in the proximal colon (25.2% [95% CI, 19.9% to 31.5%]) than the distal colon (6.0% [CI, 3.9% to 8.9%]) or rectum (9.9% [CI, 6.9% to 13.7%]).

LIMITATIONS

Participants with irregular attendance were censored. Those who had a false-positive result on a previous FIT but negative colonoscopy results were included in subsequent rounds.

CONCLUSION

This FIT-based, multiple-round, long-term screening program had a negligible reduction in detection rates for neoplastic lesions in the proximal versus the distal colon after the first round. This was related to a higher PICR in the proximal colon and suboptimal efficacy in preventing the age-related proximal shifting of CRC.

PRIMARY FUNDING SOURCE

None.

Colonoscopy quality requisites for selecting surveillance intervals: A World Endoscopy Organization Delphi Recommendation

BACKGROUND AND AIMS

Different post-polypectomy guidelines underscore the need for high-quality baseline colonoscopy before appropriate surveillance recommendations can be made. Standards for colonoscopy practice have been advocated by gastrointestinal societies. Our aims were to define standards for the procedural practice of colonoscopy in this particular setting of surveillance and to generate a colonoscopy procedural quality checklist that could be implemented in clinical practice.

METHODS

This study was based on the Delphi process methodology. The baseline questionnaire included 12 domains and 56 individual statements. A total of three rounds were carried out between September 2015 and March 2016 until consensus or lack of consensus was reached.

RESULTS

In total, consensus was reached on 27 statements in nine domains. High levels of agreement and consensus were reached that: (i) colonoscopy should be considered complete only if the whole cecum has been inspected, including the ileocecal valve and the appendiceal orifice (agreement score 4.63; degree of consensus 82%); (ii) quality of the bowel preparation should always be reported (agreement score 4.9, degree of consensus 94%); and (iii) it is preferable to use a segmental validated scale (agreement score 4.36, degree of consensus 86%). Consensus was also reached regarding multiple statements related to documentation of polyps and their resection. Finally, a colonoscopy quality checklist was drafted.

CONCLUSION

Consensus on different statements regarding quality of colonoscopy has been reached. Based on this consensus, we propose a colonoscopy quality checklist that would be helpful for post-polypectomy surveillance recommendations.

Computerized feedback during colonoscopy training leads to improved performance: a randomized trial

BACKGROUND AND AIMS

Simulation-based training in colonoscopy is increasingly replacing the traditional apprenticeship method to avoid patient-related risk. Mentoring during simulation is necessary to provide feedback and to motivate, but expert supervisors are a scarce resource. We aimed to determine whether computerized feedback in simulated colonoscopy would improve performance, optimize time spent practicing, and optimize the pattern of training.

METHODS

Forty-four participants were recruited and randomized to either a feedback group (FG) or a control group (CG). Participants were allowed 2 hours of self-practice during which they could practice as they saw fit on 2 different cases: 1 easy and 1 difficult. The CG practiced without feedback, but the participants in the FG were given a score of progression every time they reached the cecum. All participants were tested on a different case after end of training. The primary outcome was the progression score in the final case, and secondary outcomes were time spent practicing and the training pattern.

RESULTS

Regression analysis adjusting for sex was done because of an uneven sex distribution between groups (P = .026) and significantly higher performance scores by men (37.6, standard deviation [SD] 25.9) compared with women (19.7, SD 18.7); P = .012. The FG outperformed the CG in the final case, FG scoring 14.4 points (95% confidence interval [CI], 1.2-27.6) more than the CG; P = .033, and they spent more time practicing, FG practicing 25.8 minutes (95% CI, 11.6-39.9) more than the CG; P = .001. The FG practiced more on the easy case and reached the cecum 3.2 times more (95% CI, 2-4.5) during practice (P < .001).

CONCLUSIONS

Our findings of this study revealed that an automatic, computerized score of progression during simulated colonoscopy motivates the novices to improve performance, optimizes time spent practicing, and optimizes their pattern of training. (Clinical trial registration number: NCT03248453.).

Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2: Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3: Bile duct cannulation rate (key performance measure, at least 90 %); 4: Tissue sampling during EUS (key performance measure, at least 85 %); 5: Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6: Bile duct stone extraction (key performance measure, at least 90 %); 7: Post-ERCP pancreatitis (key performance measure, less than 10 %). 8: Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.

Colonoscopy attachments for the detection of precancerous lesions during colonoscopy: A review of the literature

Although colonoscopy has been proven effective in reducing the incidence of colorectal cancer through the detection and removal of precancerous lesions, it remains an imperfect examination, as it can fail in detecting up to almost one fourth of existing adenomas. Among reasons accounting for such failures, is the inability to meticulously visualize the colonic mucosa located either proximal to haustral folds or anatomic curves, including the hepatic and splenic flexures. In order to overcome these limitations, various colonoscope attachments aiming to improve mucosal visualization have been developed. All of them - transparent cap, Endocuff, Endocuff Vision and Endorings - are simply mounted onto the distal tip of the scope. In this review article, we introduce the rationale of their development, present their mode of action and discuss in detail the effect of their implementation in the detection of lesions during colonoscopy.

Water exchange colonoscopy increases adenoma detection rate: a systematic review with network meta-analysis of randomized controlled studies

BACKGROUND AND AIMS

Water-aided colonoscopy techniques, such as water immersion (WI) and water exchange (WE), have shown different results regarding adenoma detection rate (ADR). We determined the impact of WI and WE on ADR and other procedural outcomes versus gas (air, AI; CO2) insufflation colonoscopy.

METHODS

A systematic search of multiple databases for randomized controlled trials comparing WI and/or WE with AI and/or CO2 and reporting ADR was conducted. A network meta-analysis with mixed comparisons was performed. Primary outcome was ADR (overall, in the right side of the colon and by colonoscopy indication).

RESULTS

Seventeen randomized controlled trials (10,350 patients) were included. WE showed a significantly higher overall ADR versus WI (odds ratio [OR], 1.31; 95% credible interval [CrI], 1.12-1.55) versus AI (OR, 1.40; CrI, 1.22-1.62) versus CO2 (OR, 1.48; 95% CrI, 1.15-1.86). WE achieved the highest ADR also in the right side of the colon and in colorectal cancer screening cases (both significant vs AI and WI) as well as in patients taking a split-dose preparation (significant vs all the other techniques). The Boston Bowel Preparation Scale cleanliness score (vs AI and WI) was significantly higher for WE. Both WI and WE showed increased proportion of unsedated examinations and decreased real-time insertion pain, with WE being the least-painful insertion technique. Withdrawal time was comparable across techniques, but WE showed the longest insertion time (3-5 additional minutes).

CONCLUSIONS

WE significantly increases overall ADR, ADR in screening cases, and in the right side of the colon; it also improves colon cleanliness but requires a longer insertion time.

Validation of same-day bowel preparation regimen using 4L polyethylene glycol: Comparison of morning and afternoon colonoscopy

A split-dose regimen is the recommended method of bowel preparation for colonoscopy. However, for colonoscopy performed in the afternoon, same-day preparation is recommended rather than a split-dose regimen. No study has compared the efficacy of same-day bowel-cleansing for morning colonoscopy (MC) and afternoon colonoscopy (AC). The aims of this study were to evaluate the bowel-cleansing efficacy, adverse events, and patient tolerability of same-day bowel preparation for colonoscopy using 4L polyethylene glycol (PEG).The medical records of consecutive patients who underwent colonoscopy at our healthcare center over 3 months were retrospectively reviewed. Colonoscopy was performed between 10:00 and 16:00. Study subjects were assigned to the MC or AC group according to their colonoscopy start time (MC group, before 12:00; AC group, after 12:00). Study subjects were instructed to drink 500-mL PEG every 15 minutes. In the MC group, bowel cleansing was started at 05:00 and finished at 07:00. For the AC group, 2L PEG was consumed from 07:00, and the remaining 2L PEG was started 3 hours before colonoscopy. The composite safety profile included vital signs, laboratory test results, and questionnaire findings. Laboratory testing of subjects and completion of the questionnaire were performed before colonoscopy. The questionnaire asked about adverse events and tolerability of the bowel cleansing regimen. Bowel-cleansing efficacy was assessed using the Boston bowel preparation scale (BBPS). Bowel-cleansing efficacy, tolerability, and safety profile were compared between the 2 groups.Two hundred and ninety-one subjects were included (MC group, 169; AC group, 122).The BBPS did not differ between the 2 groups (7.3 ± 0.8 vs. 7.3 ± 0.8, P = .68). There were no instances of electrolyte imbalance or hemodynamic instability in either group. The tolerability of the bowel-cleansing regimen did not differ between the 2 groups (P = .59).The bowel-cleansing efficacy, safety profile, and patient tolerability of MC and AC were comparable. A same-day dose of 4L PEG is a feasible bowel preparation method.

Efficacy and safety of a new low-volume PEG with citrate and simethicone bowel preparation for colonoscopy (Clensia): a multicenter randomized observer-blind clinical trial vs. a low-volume PEG with ascorbic acid (PEG-ASC)

BACKGROUND AND STUDY AIMS

Quality of inspection during colonoscopy is strictly related to the level of cleansing. High-volume (PEG-based) solutions are highly effective and safe, but their high volume affects tolerability and compliance. The aim of this study was to compare a new low-volume PEG with citrate and simethicone solution (PMF 104,Clensia) with a low-volume PEG with ascorbic acid solution (PEG-ASC; Moviprep).

PATIENTS AND METHODS

 This was a multicenter, randomized, observer-blind, parallel-group, phase 3 clinical trial, where patients were randomized between PMF 104 and PEG-ASC. In both groups, patients were instructed to take a full-dose regimen the evening before if colonoscopy was scheduled before 11 am to 12 pm, or to take a split regimen if colonoscopy was scheduled after 11 am to 12 pm. The primary end-point was an equivalence between PMF104 and PEG-ASC in the rate of adequate level of cleansing (Ottawa scale ≤ 6), with safety, mucosal visibility, tolerability, acceptance and compliance being also assessed.

RESULTS

Of the 403 enrolled, 367 patients (Mean age [SD]: 55.6 (14.4) years; male:166 [45.2 %]) were included in the per protocol (PP) analysis: 184 being randomized in the PMF 104 group and 183 in the PEG-ASC group. Successful bowel cleansing was 78.3 % and 74.3 % in PMF104 and in PEG-ASC, respectively ( P  = 0.37). Both preparations were equally safe (mild adverse events were observed in 9.2 % and 9.3 % of patients in the PMF104 and in the PEG-ASC group, respectively) and acceptable (no or mild distress during the intake in 81.4 % and 80.8 % in the PMF104 in the PEG-ASC, respectively [ P  = 0.74]).

CONCLUSION

The new low-volume product Clensia is equivalent to the reference low-volume PEG-ASC in terms of bowel cleansing, safety and acceptance.

Comparative Efficacy of Colonoscope Distal Attachment Devices in Increasing Rates of Adenoma Detection: A Network Meta-analysis

BACKGROUND & AIMS

Several add-on devices have been developed to increase rates of colon adenoma detection (ADR). We assessed their overall and comparative efficacy, and estimated absolute magnitude of benefit through a network meta-analysis.

METHODS

We searched the PubMed/Medline and Embase database through March 2017 and identified 25 randomized controlled trials (comprising 16,103 patients) that compared the efficacy of add-on devices (cap; Endocuff; Arc Medical Design Ltd, Leeds, UK, and Endorings; Us Endoscopy, Mentor, OH) with each other or with standard colonoscopy. The primary outcome was ADR; secondary outcomes included rate of polyp detection, and rate of and time to cecal intubation. We performed pairwise and network meta-analyses, and appraised quality of evidence using Grading of Recommendations Assessment, Development and Evaluation. We estimated the magnitude of increase in ADR by low-performing endoscopists (baseline ADR, 10%) and high-performing endoscopists (baseline ADR, 40%) with use of these devices.

RESULTS

Overall, distal attachment devices increased ADR compared with standard colonoscopy (relative risk [RR], 1.13; 95% CI, 1.03-1.23; low-quality evidence), with potential absolute increases in ADR to 11.3% for low-performing endoscopists and to 45.2% for high-performing endoscopists. In a comparative evaluation, we found low-quality evidence that Endocuff increases ADR compared with standard colonoscopy (RR, 1.21; 95% CI, 1.03-1.41), with anticipated increases in ADR to 12% for low-performing endoscopists and to 48% for high-performing endoscopists. We found very low quality evidence to support the use of Endorings (RR, 1.70; 95% CI, 0.86-3.36) or caps (RR, 1.07; 95% CI, 0.96-1.19) vs standard colonoscopy for increasing ADR. The benefit of one distal attachment device over another was uncertain due to very low quality evidence.

CONCLUSIONS

Based on network meta-analysis, we anticipate only modest improvement in ADRs with use of distal attachment devices, especially in low-performing endoscopists.

Is water exchange superior to water immersion in detecting adenomas during colonoscopies? Results from a Bayesian network meta-analysis

AIM

Water-assisted colonoscopy (water exchange [WE] and water immersion [WI]) has been shown to improve the adenoma detection rate. However, few studies have compared these two methods head-to-head. Thus, we conducted a network meta-analysis to integrate both direct and indirect evidence comparing the effectiveness of these two procedures.

METHOD

We searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for original papers and abstracts published up to March 2018. Randomized controlled trials (RCTs) reporting data in accordance with the eligibility criteria were included in this study. We performed a Bayesian random effects network meta-analysis with mixed comparisons.

RESULTS

Twenty-nine studies (n = 11464 patients) including 6 direct and 23 indirect comparisons were included in this network meta-analysis. There was a statistically significant difference in the efficacy of adenoma detection when WE was compared with WI (risk ratio [RR]: 1.2, 95% credible interval [CrI]: 1.1-1.3), air insufflation (AI; RR: 1.3, 95% CrI: 1.1-1.4), and carbon dioxide (CO2) insufflation (RR: 1.2, 95% CrI: 1.1-1.5). The different methods were ranked in order from the most to least effective in adenoma detection as follows: WE, WI, AI, and CO2. Moreover, although there were no significant differences in pain scores, willingness to repeat, caecal intubation rate, or total procedure time between WI and WE colonoscopy, WE required a longer caecal intubation time than WI.

CONCLUSION

This network meta-analysis supposes that WE may be superior to WI in detecting adenomas during colonoscopies without affecting other technical features or patient acceptance.

What defines quality in small bowel capsule endoscopy

Small bowel capsule endoscopy is considered a first-line diagnostic tool for the investigation of small bowel diseases. Gastroenterological and endoscopic societies have proposed and established measures known as quality indicators, quality measures or performance measures for the majority of endoscopic procedures, in order to ensure competence, healthcare quality and define areas requiring improvement. However, there is a paucity of publications describing small bowel capsule endoscopy quality indicators. Hereby, we attempt to identify and describe a number of pre-procedure, intra-procedure and post-procedure quality indicators, regarding process measures in small bowel capsule endoscopy, after a comprehensive review of the literature.

Revision of Quality Indicators for the Endoscopy Quality Improvement Program of the National Cancer Screening Program in Korea

Gastroscopy and colonoscopy are widely used for the early diagnosis of stomach and colorectal cancer. The present revision integrates recent data regarding previous quality indicators and novel indicators suggested for gastroscopy and colonoscopy procedures for the National Cancer Screening Program in Korea. The new indicators, developed by the Quality Improvement Committee of the Korean Society for Gastrointestinal Endoscopy, vary in the level of supporting evidence, and most are based solely on expert opinion. Updated indicators validated by clinical research were prioritized, but were chosen by expert consensus when such studies were absent. The resultant quality indicators were graded according to the levels of consensus and recommendations. The updated indicators will provide a relevant guideline for high-quality endoscopy. The future direction of quality indicator development should include relevant outcome measures and an evidence-based approach to support proposed performance targets.

Characteristics of right-sided colonic neoplasia and colonoscopy barriers limiting their early detection and prognosis: a review of the literature

Colonoscopy provides less protection from colorectal cancer in the right colon than the left. Areas covered: This review examines patient outcomes and colonoscopy success rates to identify factors that limit the protective effect of colonoscopy in the right colon. The MEDLINE and Embase databases were searched for literature from 2000 onwards, on the long-term outcomes and differences in screening practice between the right and left colon. In total, 12 systematic reviews (including nine meta-analyses) and 44 primary data records were included. Differences in patient outcomes and colonoscopy practice were identified between the right and left colon, suggesting that several factors, many of which disproportionally affect the right colon, impact lesion detection rates. Shorter withdrawal times reduce detection rates, while longer times significantly increase detection; mostly of adenomas in the right colon. Colonoscope attachments often only show a significant improvement in detection rates in the right colon, suggesting detection is more challenging due to visibility of the right colonic mucosa. Higher bowel cleansing grades significantly improve detection rates in the right colon compared to the left. Expert commentary: These findings confirm the need for continued improvement of colonoscopy effectiveness, and obligatory quality assessment, overall and especially in the right colon.

[Revision of Quality Indicators for the Endoscopy Quality Improvement Program of the National Cancer Screening Program in Korea]

Gastroscopy and colonoscopy are widely used for the early diagnosis of stomach and colorectal cancer. The present revision integrates recent data regarding previous quality indicators and novel indicators suggested for gastroscopy and colonoscopy procedures for the National Cancer Screening Program in Korea. The new indicators, developed by the Quality Improvement Committee of the Korean Society for Gastrointestinal Endoscopy, vary in the level of supporting evidence, and most are based solely on expert opinion. Updated indicators validated by clinical research were prioritized, but were chosen by expert consensus when such studies were absent. The resultant quality indicators were graded according to the levels of consensus and recommendations. The updated indicators will provide a relevant guideline for high-quality endoscopy. The future direction of quality indicator development should include relevant outcome measures and an evidence-based approach to support proposed performance targets.

Prospective study of the factors associated with poor tolerance to ambulatory colonoscopy under conscious sedation

BACKGROUND

conscious sedation with benzodiazepines and opiates for colonoscopy is a widespread clinical practice.

OBJECTIVE

to determine the patient's tolerance to colonoscopy and identify the factors associated with lower tolerance.

METHODS

a prospective, single-center, descriptive study of patients undergoing ambulatory colonoscopy under conscious sedation. The pain was assessed using a visual analogue scale with a score of 0 to 100 and also qualitatively.

RESULTS

three hundred patients with a median age of 54 years completed the study (p25-75: 45-64); 138 were men (46%). Tolerance was good in 273 cases (91%). The median value of tolerance was 13 (p25-p75: 4-33). Pain was considered as mild in 215 (71.7%), moderate in 57 (19%) and intense in 28 (9.3%). In the univariate study, greater pain was associated with females, anxiety, the indication for the procedure, the length of time and difficulty of the examination, and the doses of sedatives. In the multivariate study, both the indication (OR 2.92, 95% CI = 1.03-8.2, p < 0.05) and the difficulty of the examination (OR 4.68, 95% CI = 1.6-13.6, p < 0.01) were significant. Complications were found in 16 patients (5.3%), although all of them were insignificant.

CONCLUSIONS

tolerance of patients undergoing ambulatory colonoscopy under conscious sedation is good in most cases and complications are infrequent and minor. A worse tolerance to the test is associated with women patients, individuals with anxiety prior to colonoscopy, indication, difficult and longer exploration and lower doses of sedatives.

Methods for certification in colonoscopy - a systematic review

INTRODUCTION

Reliable, valid, and feasible assessment tools are essential to ensure competence in colonoscopy. This study aims to provide an overview of the existing assessment methods and the validity evidence that supports them.

METHODS

A systematic search was conducted in October 2016. Pubmed, EMBASE, and PsycINFO were searched for studies evaluating assessment methods to ensure competency in colonoscopy. Outcome variables were described and evidence of validity was explored using a contemporary framework.

RESULTS

Twenty-five observational studies were included in the systematic review. Most studies were based on small sample sizes. The studies were categorized after outcome measures into five groups: Clinical process related outcome metrics (n = 2), direct observational colonoscopy assessment (n = 8), simulator based metrics (n = 11), automatic computerized metrics (n = 2), and self-assessment (n = 1). Validity score varied among the studies and only five studies presented sufficient evidence to recommend the tool for clinical assessment.

CONCLUSIONS

The objectives vary throughout the presented tools. Some tools are global tools where others focus on procedural technical skill assessment or even part-task skills. There is a tendency in the most recent studies towards more specific assessment of technical skills. The majority of assessment methods lack sufficient validity evidence.

Limitations of teaching endoscopy

BACKGROUND AND AIM

Endoscopic procedures of the gastrointestinal tract represent a category of diagnostic tests that considerably rely on skills and dexterity of a human tester. The present analysis aimed to delineate factors that affect the success of teaching endoscopy and potentially limit the acquisition of new skills and knowledge.

METHODS

The performance of the endoscopist is described in terms of sensitivity and specificity. The outcomes of sequential testing and acquisition of new knowledge are calculated using matrix algebra. Teaching is modeled as an iterative process with an incremental improvement in a fellow's performance matrix.

RESULTS

As a diagnostician, an endoscopist cannot measure beyond his/her own level of competence. The cognition and endoscopic skills of both the fellow and the attending physician determine how fast the fellow's endoscopic performance improves over time. The better the fellow's and the attending's abilities are to recognize and amend residual deficiencies, the faster the fellow's endoscopic performance improves. Severe or even complete diagnostic incompetence by either party can draw out the training process or even result in a complete standstill, respectively.

CONCLUSION

The description of endoscopic performance in terms of test characteristics provides valuable insights into the influence of endoscopic performance characteristics on the outcome of endoscopy and on the constraints of teaching endoscopic skills.

Ultrasonography in Gastroenterology: The Need for Training

The use of ultrasonography (US) as an imaging modality in medicine has spread across almost every clinical specialty. This diffusion is based on the simplicity, accessibility, portability and affordability of the technique producing real-time high-resolution images using non-ionising radiation. On the other hand, this trend also extended the technique to settings other than healthcare, such as public facilities, private houses or remote sites. This tendency can be observed worldwide, from developing countries to prestigious medical schools and tertiary referral hospitals. Furthermore, point-of-care US (POCUS), i.e., US executed at the patient's bedside to obtain real-time objective information with diagnostic and clinical monitoring purposes or to guide invasive procedures, has been incorporated in many specialties. In gastroenterology, despite the essential role of endoscopy, clinical practice is highly dependent on non-endoscopic imaging techniques. However, as in other specialties, the indications of US in gastroenterology have been increasing steadily, covering a broad range of conditions. In response to the generalised employment of US by non-radiologists, institutions such as the European Federation of Societies for Ultrasound in Medicine and Biology and the Royal College of Radiologists issued recommendations to ensure high-quality practice. These theoretical and practical requisites include performing a certain number of examinations and mandatory skills in order to achieve certification to execute unsupervised US. Therefore, there is a need for modern gastroenterology to include US as a basic skill in its clinical practice. To ensure the provision of high-quality US, adequate instruction of future specialists should be guaranteed by the gastroenterology departments and required in the residency training programme.

High Efficacy of Repeating Colonoscopy by an Advanced Endoscopist after an Incomplete Colonoscopy

Background and Aims

This study aims to evaluate the role of an advanced endoscopist to study the entire colon after an incomplete colonoscopy.

Methods

All patients with an elective incomplete colonoscopy performed under deep sedation in our department between January 2010 and October 2016 were included. Patients with a colonic stenosis, an inadequate bowel preparation, or a colonoscopy performed without deep sedation were excluded. Included patients were followed up to evaluate if and what type of subsequent examinations (colonoscopy by an advanced endoscopist, single-balloon enteroscopy [SBE], and/or CT colonography) was performed to complete the study of the entire colon. Lesions found during these subsequent examinations were also recorded.

Results

Ninety-three patients had an incomplete colonoscopy, with no diagnosis of colorectal cancer (CRC) and a high-risk polyp rate of 5.4% (n = 5). Seventy-seven patients with incomplete colonoscopies underwent subsequent examinations, namely CT colonography in 45.5% (n = 35), colonoscopy by an advanced endoscopist in 53.2% (n = 41), and SBE in 13% (n = 10). In the 49 patients who performed either colonoscopy (n = 39) or SBE (n = 10) by an advanced endoscopist, the cecal intubation rate was 100%, and high-risk polyps were found in 26.5% (n = 13) and CRC in 4.1%. CT colonography revealed findings consistent with polyps and CRC in 22.9% (n = 8) and 2.9% (n = 1) of the cases, respectively. Colonoscopy was further repeated in 6 patients with suspected polyps in CT colonography, confirming the initial diagnosis in 5 patients.

Conclusions

Colonoscopy by an advanced endoscopist achieved cecal intubation in all patients, representing a good choice after an incomplete colonoscopy.