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Tan CK, Suzuki S, Ang TL, Koh XH, Wang LM, Aniwan S, Chiu HM, Laohavichitra K, Chirapongsathorn S, Yamamura T, Kuo CY, Yoshida N, Takezawa T, Rerknimitr R, Ishikawa H, Gotoda T. Sessile serrated lesion prevalence and factors associated with their detection: a post-hoc analysis of a multinational randomized controlled trial from Asia. Endoscopy 2024. [PMID: 38857619 DOI: 10.1055/a-2324-6262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
BACKGROUND Sessile serrated lesions (SSLs) are associated with an increased risk of colorectal cancer. Data on the prevalence of SSLs in Asia are limited. We performed this study to estimate the prevalence of SSLs in Asia and to explore endoscopic factors that are associated with SSL detection. METHODS This is a post-hoc analysis of a multicenter randomized controlled trial from four Asian countries/regions that compared adenoma detection rates using linked-color imaging (LCI) and white-light imaging. Colonoscopies were performed in an average-risk population for screening, diagnostic examination, or polyp surveillance. Patients with SSLs were compared against those without SSLs to evaluate for possible predictors of SSL detection using Firth's logistic regression. RESULTS 2898 participants (mean age 64.5 years) were included in the analysis. The estimated prevalence of SSLs was 4.0% (95%CI 3.4%-4.8%), with no sex or age group differences. On multivariable analysis, use of LCI (adjusted odds ratio [aOR] 1.63, 95%CI 1.10-2.41), experienced endoscopists (aOR 1.94, 95%CI 1.25-3.00), use of transparent cap (aOR 1.75, 95%CI 1.09-2.81), and longer withdrawal time (aOR 1.06, 95%CI 1.03-1.10) were independently associated with SSL detection. Synchronous adenoma detection (aOR 1.89, 95%CI 1.20-2.99) was also predictive of SSL detection. CONCLUSION The prevalence of SSLs in Asia is 4.0%. Use of LCI or a transparent cap, greater endoscopist experience, and longer withdrawal time were all associated with increased SSL detection.
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Affiliation(s)
- Chin Kimg Tan
- Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
- Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Sho Suzuki
- Gastroenterology and Hepatology, International University of Health and Welfare School of Medicine, Narita, Japan
| | - Tiing Leong Ang
- Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
- Medicine Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Xuan Han Koh
- Health Services Research, Changi General Hospital, Singapore, Singapore
| | - Lai Mun Wang
- Laboratory Medicine, Changi General Hospital, Singapore, Singapore
- Pathology Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore, Singapore
| | - Satimai Aniwan
- Center of Excellence in Endoscopy for Gastrointestinal Oncology, Chulalongkorn University Department of Internal Medicine, Bangkok, Thailand
| | - Han-Mo Chiu
- Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Sakkarin Chirapongsathorn
- Gastroenterology and Hepatology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Takeshi Yamamura
- Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Chen Ya Kuo
- Gastroenterology, Fu Jen Catholic University Hospital, New Taipei City, Taiwan
| | - Naohisa Yoshida
- Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takahito Takezawa
- Medicine, Division of Gastroenterology, Jichi Medical University, Shimotsuke, Japan
| | - Rungsun Rerknimitr
- Center of Excellence in Endoscopy for Gastrointestinal Oncology, Chulalongkorn University Department of Internal Medicine, Bangkok, Thailand
| | - Hideki Ishikawa
- Molecular-Targeting Cancer Prevention, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takuji Gotoda
- Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
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Duan CW, Zhai HH, Xie H, Ma XZ, Yu DL, Yang L, Wang X, Tang YF, Zhang J, Su H, Sheng JQ, Xu JF, Jin P. Standard-definition White-light, High-definition White-light versus Narrow-band Imaging Endoscopy for Detecting Colorectal Adenomas: A Multicenter Randomized Controlled Trial. Curr Med Sci 2024:10.1007/s11596-024-2882-2. [PMID: 38842773 DOI: 10.1007/s11596-024-2882-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/03/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVE This study aimed to compare the performance of standard-definition white-light endoscopy (SD-WL), high-definition white-light endoscopy (HD-WL), and high-definition narrow-band imaging (HD-NBI) in detecting colorectal lesions in the Chinese population. METHODS This was a multicenter, single-blind, randomized, controlled trial with a non-inferiority design. Patients undergoing endoscopy for physical examination, screening, and surveillance were enrolled from July 2017 to December 2020. The primary outcome measure was the adenoma detection rate (ADR), defined as the proportion of patients with at least one adenoma detected. The associated factors for detecting adenomas were assessed using univariate and multivariate logistic regression. RESULTS Out of 653 eligible patients enrolled, data from 596 patients were analyzed. The ADRs were 34.5% in the SD-WL group, 33.5% in the HD-WL group, and 37.5% in the HD-NBI group (P=0.72). The advanced neoplasm detection rates (ANDRs) in the three arms were 17.1%, 15.5%, and 10.4% (P=0.17). No significant differences were found between the SD group and HD group regarding ADR or ANDR (ADR: 34.5% vs. 35.6%, P=0.79; ANDR: 17.1% vs. 13.0%, P=0.16, respectively). Similar results were observed between the HD-WL group and HD-NBI group (ADR: 33.5% vs. 37.7%, P=0.45; ANDR: 15.5% vs. 10.4%, P=0.18, respectively). In the univariate and multivariate logistic regression analyses, neither HD-WL nor HD-NBI led to a significant difference in overall adenoma detection compared to SD-WL (HD-WL: OR 0.91, P=0.69; HD-NBI: OR 1.15, P=0.80). CONCLUSION HD-NBI and HD-WL are comparable to SD-WL for overall adenoma detection among Chinese outpatients. It can be concluded that HD-NBI or HD-WL is not superior to SD-WL, but more effective instruction may be needed to guide the selection of different endoscopic methods in the future. Our study's conclusions may aid in the efficient allocation and utilization of limited colonoscopy resources, especially advanced imaging technologies.
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Affiliation(s)
- Chang-Wei Duan
- Chinese PLA General Hospital and Medical School, Beijing, 100853, China
| | - Hui-Hong Zhai
- Department of Gastroenterology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Hui Xie
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
| | - Xian-Zong Ma
- Chinese PLA General Hospital and Medical School, Beijing, 100853, China
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
| | - Dong-Liang Yu
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
| | - Lang Yang
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
- Senior Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Xin Wang
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
| | - Yu-Fen Tang
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
- Senior Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Jie Zhang
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
| | - Hui Su
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China
| | - Jian-Qiu Sheng
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China.
- Senior Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.
| | - Jun-Feng Xu
- Senior Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.
| | - Peng Jin
- Department of Gastroenterology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, 100700, China.
- Senior Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China.
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McMillan C, Li DK, Mohamed G, Alsadoun DA, Almohsen LA, Gaidos JKJ, Proctor DD, Al-Bawardy B. Longer Colonoscopy Withdrawal Time Is Associated With the Detection of Visible Dysplasia in Patients With Inflammatory Bowel Disease. CROHN'S & COLITIS 360 2024; 6:otae020. [PMID: 38585555 PMCID: PMC10998460 DOI: 10.1093/crocol/otae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Indexed: 04/09/2024] Open
Abstract
Background Colonoscopy withdrawal time (CWT) of at least 6-9 minutes is the minimum time needed for adequate adenoma detection in the general population. The ideal CWT in patients with inflammatory bowel disease (IBD) has not been determined. We aimed to identify the optimal CWT associated with the detection of visible dysplasia in patients with IBD. Methods This is a retrospective study from 1/1/2017 to 9/1/2022 of adult patients with IBD in endoscopic healing undergoing surveillance via high-definition white light colonoscopy. The primary outcome was the association of CWT with visible dysplasia detection. Results A total of 259 patients (mean age 56 ± 14.8 years; 51.3% female, 68% with ulcerative colitis; 8.9% with primary sclerosing cholangitis) underwent 330 colonoscopies. Patients with visible dysplasia were more likely to be older (P < .001) and have a personal history of visible dysplasia (P < .001) and invisible dysplasia (P = .023). The mean CWT was significantly longer in the visible dysplasia group at 26 minutes (interquartile range [IQR] 20-38.5) vs. 21 minutes (IQR 15-28) in procedures without visible dysplasia (P < .001). On multivariable analysis, increased age (P < .001), increased CWT (P = .001), and personal history of visible dysplasia (P = .013) were independently associated with the detection of visible dysplasia. A CWT of ≥15 minutes (odds ratio [OR] 2.71; 95% confidence interval [CI], 1.11-6.6; P = .02] and not ≥9 minutes (OR 2.57; 95% CI, 0.33-20.2; P = .35) is significantly associated with detection of visible dysplasia. Conclusions For patients with IBD undergoing surveillance via high-definition white light colonoscopy, the mean CWT was independently associated with the detection of visible dysplasia.
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Affiliation(s)
| | - Darrick K Li
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Gamal Mohamed
- Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Danah A Alsadoun
- Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Leena A Almohsen
- Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
| | - Jill K J Gaidos
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Deborah D Proctor
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Badr Al-Bawardy
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, USA
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Majima K, Muraki Y. Does longer withdrawal time increase discomfort? Dig Endosc 2024; 36:496. [PMID: 38410087 DOI: 10.1111/den.14778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/28/2024]
Affiliation(s)
- Kenichiro Majima
- Department of Health Management, Kameda Medical Center, Chiba, Japan
| | - Yosuke Muraki
- Department of Health Management, Kameda Medical Center, Chiba, Japan
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Song J, Xu Y, Chen C, Qi X, Hu P, Ying X, Li H. The Effects of Combined Use of Linaclotide and Polyethylene Glycol Electrolyte Powder in Colonoscopy Preparation for Patients With Chronic Constipation. Surg Laparosc Endosc Percutan Tech 2024; 34:129-135. [PMID: 38444073 DOI: 10.1097/sle.0000000000001273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE The purpose of this study is to evaluate the safety and efficacy of linaclotide and polyethylene glycol (PEG) electrolyte powder in patients with chronic constipation undergoing colonoscopy preparation. PATIENTS AND METHODS We included 260 patients with chronic constipation who were scheduled to undergo a colonoscopy. They were equally divided into 4 groups using a random number table: 4L PEG, 3L PEG, 3L PEG+L, and 2L PEG+L. The 4 groups were compared based on their scores on the Boston Bowel Preparation Scale (BBPS) and Ottawa Bowel Preparation Quality Scale (OBPQS), adverse reactions during the bowel preparation procedure, colonoscope insertion time, colonoscope withdrawal time, detection rate of adenomas, and their willingness to repeat bowel preparation. RESULTS In terms of the score of the right half of the colon, the score of the transverse colon, the total score using BBPS, and the total score using OBPQS, the 3L PEG (polyethylene glycol)+L group was superior to groups 3L PEG and 2L PEG+L ( P <0.05), but comparable to the 4L PEG group ( P >0.05). The incidence rate of vomiting was higher in the 4L PEG group than in the 2L PEG+L group ( P <0.05). There was no statistically significant difference in the insertion time of the colonoscope between the 4 groups. The colonoscope withdrawal time in the 3L PEG+L group was shorter than in groups 4L PEG and 3L PEG ( P <0.05) and comparable to that in the 4L PEG group ( P >0.05). There was no statistically significant difference in the rate of adenoma detection among the 4 groups ( P >0.05). The 4L PEG group was the least willing of the 4 groups to undergo repeated bowel preparation ( P <0.05). CONCLUSION The 3L PEG+L is optimal among the 4 procedures. It can facilitate high-quality bowel preparation, reduce the incidence of nausea during the bowel preparation procedure, and encourage patients to undertake repeated bowel preparation.
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Affiliation(s)
- Jian Song
- Department of Gastroenterology, The Affiliated People's Hospital of Ningbo University, Ningbo, China
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Liang SY, Oscarson B, Kenkare P, Yan SX, Mudiganti S, Martinez MC, Huang ES. Trends in Detection of Adenoma and Sessile Serrated Lesions Over a Decade in a Community-Based Healthcare System. Clin Transl Gastroenterol 2024; 15:e00683. [PMID: 38270213 PMCID: PMC10962881 DOI: 10.14309/ctg.0000000000000683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/19/2024] [Indexed: 01/26/2024] Open
Abstract
INTRODUCTION Adenoma detection rate (ADR) is an accepted benchmark for screening colonoscopy. Factors driving ADR and its relationship with sessile serrated lesions detection rate (SSLDR) over time remain unclear. We aim to explore patient, physician, and procedural influences on ADR and SSLDR trends. METHODS Using a large healthcare system in northern California from January 2010 to December 2020, a total of 146,818 screening colonoscopies performed by 33 endoscopists were included. ADR and SSLDR were calculated over time using natural language processing. Logistic regression was used to calculate the odd ratios of patient demographics, physician attributes, and procedural details over time. RESULTS Between 2010 and 2020, ADR rose from 19.4% to 44.4%, whereas SSLDR increased from 1.6% to 11.6%. ADR increased by 2.7% per year (95% confidence interval 1.9%-3.4%), and SSLDR increased by 1.0% per year (95% confidence interval 0.8%-1.2%). Higher ADR was associated with older age, male sex, higher body mass index, current smoker, higher comorbidities, and high-risk colonoscopy. By contrast, SSLDR was associated with younger age, female sex, white race, and fewer comorbidities. Patient and procedure characteristics did not significantly change over time ( P -interaction >0.05). Longer years in practice and male physician were associated with lower ADR and SSLDR in 2010, but significantly attenuated over time ( P -interaction <0.05). DISCUSSION Both ADR and SSLDR have increased over time. Patient and procedure factors did not significantly change over time. Male endoscopist and longer years in practice had lower initial ADR and SSLDR, but significantly lessened over time.
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Affiliation(s)
- Su-Ying Liang
- Center for Health Systems Research, Palo Alto, California, USA
| | | | - Pragati Kenkare
- Center for Health Systems Research, Palo Alto, California, USA
| | - Sherry X. Yan
- Center for Health Systems Research, Walnut Creek, California, USA
| | - Satish Mudiganti
- Center for Health Systems Research, Walnut Creek, California, USA
| | | | - Edward S. Huang
- Department of Gastroenterology, Palo Alto Medical Foundation, Sutter Health, San Jose, California, USA
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Lui TKL, Ko MKL, Liu JJ, Xiao X, Leung WK. Artificial intelligence-assisted real-time monitoring of effective withdrawal time during colonoscopy: a novel quality marker of colonoscopy. Gastrointest Endosc 2024; 99:419-427.e6. [PMID: 37858761 DOI: 10.1016/j.gie.2023.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND AND AIMS The importance of withdrawal time during colonoscopy cannot be overstated in mitigating the risk of missed lesions and postcolonoscopy colorectal cancer. We evaluated a novel colonoscopy quality metric called the effective withdrawal time (EWT), which is an artificial intelligence (AI)-derived quantitative measure of quality withdrawal time, and its association with various colonic lesion detection rates as compared with standard withdrawal time (SWT). METHODS Three hundred fifty video recordings of colonoscopy withdrawal (from the cecum to the anus) were assessed by the new AI model. The primary outcome was adenoma detection rate (ADR) according to different quintiles of EWT. Multivariate logistic regression, adjusting for baseline covariates, was used to determine the adjusted odd ratios (ORs) for EWT on lesion detection rates, with the lowest quintile as reference. The area under the receiver-operating characteristic curve of EWT was compared with SWT. RESULTS The crude ADR in different quintiles of EWT, from lowest to highest, was 10.0%, 31.4%, 33.3%, 53.5%, and 85.7%. The ORs of detecting adenomas and polyps were significantly higher in all top 4 quintiles when compared with the lowest quintile. Each minute increase in EWT was associated with a 49% increase in ADR (aOR, 1.49; 95% confidence interval [CI], 1.36-1.65). The area under the receiver-operating characteristic curve of EWT was also significantly higher than SWT on adenoma detection (.80 [95% CI, .75-.84] vs .70 [95% CI, .64-.74], P < .01). CONCLUSIONS AI-derived monitoring of EWT is a promising novel quality indicator for colonoscopy, which is more associated with ADR than SWT.
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Affiliation(s)
- Thomas K L Lui
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Michael K L Ko
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | | | | | - Wai K Leung
- Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
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Hsu WF, Chiu HM. Optimization of colonoscopy quality: Comprehensive review of the literature and future perspectives. Dig Endosc 2023; 35:822-834. [PMID: 37381701 DOI: 10.1111/den.14627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 06/27/2023] [Indexed: 06/30/2023]
Abstract
Colonoscopy is crucial in preventing colorectal cancer (CRC) and reducing associated mortality. This comprehensive review examines the importance of high-quality colonoscopy and associated quality indicators, including bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate (ADR), complete resection, specimen retrieval, complication rates, and patient satisfaction, while also discussing other ADR-related metrics. Additionally, the review draws attention to often overlooked quality aspects, such as nonpolypoid lesion detection, as well as insertion and withdrawal skills. Moreover, it explores the potential of artificial intelligence in enhancing colonoscopy quality and highlights specific considerations for organized screening programs. The review also emphasizes the implications of organized screening programs and the need for continuous quality improvement. A high-quality colonoscopy is crucial for preventing postcolonoscopy CRC- and CRC-related deaths. Health-care professionals must develop a thorough understanding of colonoscopy quality components, including technical quality, patient safety, and patient experience. By prioritizing ongoing evaluation and refinement of these quality indicators, health-care providers can contribute to improved patient outcomes and develop more effective CRC screening programs.
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Affiliation(s)
- Wen-Feng Hsu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Han-Mo Chiu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Aziz M, Haghbin H, Gangwani MK, Nawras M, Nawras Y, Dahiya DS, Sohail AH, Lee-Smith W, Kamal F, Shaukat A. 9-Minute Withdrawal Time Improves Adenoma Detection Rate Compared With 6-Minute Withdrawal Time During Colonoscopy: A Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol 2023; 57:863-870. [PMID: 37389958 DOI: 10.1097/mcg.0000000000001878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
INTRODUCTION Adenoma detection rate (ADR) is a quality metric that has been emphasized by multiple societies as improved ADR leads to reduced interval colorectal cancer (CRC). It is postulated that increased withdrawal time (WT) can lead to higher ADR. Multiple randomized controlled trials (RCTs) were undertaken to evaluate this. We performed a systematic review and meta-analysis of RCTs to analyze the impact of higher WT on ADR during colonoscopy. METHODS The following databases were comprehensively searched through November 8, 2022: Embase, MEDLINE, Cochrane, Web of Science, and Google Scholar. Only RCTs were eligible for inclusion. We applied the random effects model using the DerSimonian Laird approach and calculated risk ratio (RR) for binary outcomes and mean difference (MD) for continuous outcomes. 95% CI and P values were generated. RESULTS A total of 3 RCTs with 2159 patients were included of which 1136 patients were included in the 9-minute withdrawal group (9WT) and 1023 patients in the 6-minute withdrawal group (6WT). The mean age range was 53.6 to 56.8 years and the male gender was 50.7%. The overall ADR was significantly higher for 9WT (RR=1.23; 95% CI, 1.09-1.40; P <0.001). The overall adenoma per colonoscopy (APC) was also higher for the 9WT group (MD: 0.14; 95% CI, 0.04-0.25; P =0.008). CONCLUSION The 9-minute withdrawal time improved ADR and APC compared with the 6-minute withdrawal. Given the high-quality evidence, we recommend that clinicians at least perform a 9-minute withdrawal to achieve higher quality metrics including ADR to reduce interval CRC.
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Affiliation(s)
| | - Hossein Haghbin
- Division of Gastroenterology, Ascension Providence Southfield, Southfield
| | | | | | | | - Dushyant Singh Dahiya
- Department of Internal Medicine, Central Michigan University College of Medicine, Saginaw, MI
| | | | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo, Toledo, OH
| | - Faisal Kamal
- Division of Gastroenterology and Hepatology, Thomas Jefferson University, Philadelphia, PA
| | - Aasma Shaukat
- Division of Gastroenterology, NYU Langone Health, New York, NY
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Sui X, Zhang S, Zhao Y, Li Z, Zhao S, Bai Y. Impact of withdrawal time on adenoma detection rate: some issues to be addressed. Gastrointest Endosc 2023; 98:676-677. [PMID: 37734820 DOI: 10.1016/j.gie.2023.04.2064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/11/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Xiangyu Sui
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Song Zhang
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Youdong Zhao
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shengbing Zhao
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Bai
- Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
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Yang MM, Usiskin K, Ahmad HA, Ather S, Sreih A, Canavan JB, Farraye FA, Ma C. Considerations for Colorectal Neoplasia Detection in Inflammatory Bowel Disease Clinical Trials. Dig Dis 2023; 42:12-24. [PMID: 37757769 PMCID: PMC10836758 DOI: 10.1159/000533395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 07/25/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND High-quality colonoscopic surveillance can lead to earlier and increased detection of colorectal neoplasia in patients with inflammatory bowel disease (IBD). In IBD clinical trials, endoscopy is used to assess mucosal disease activity before and after treatment but also provides an opportunity to surveil for colorectal neoplasia during follow-up. SUMMARY Best practices for colorectal cancer identification in IBD clinical trials require engagement and collaboration between the clinical trial sponsor, site endoscopist and/or principal investigator, and central read team. Each team member has unique responsibilities for maximizing dysplasia detection in IBD trials. KEY MESSAGES Sponsors should work in accordance with scientific guidelines to standardize imaging procedures, design the protocol to ensure the trial population is safeguarded, and oversee trial conduct. The site endoscopist should remain updated on best practices to tailor sponsor protocol-required procedures to patient needs, examine the mucosa for disease activity and potential dysplasia during all procedures, and provide optimal procedure videos for central read analysis. Central readers may detect dysplasia or colorectal cancer and a framework to report these findings to trial sponsors is essential. Synergistic relationships between all team members in IBD clinical trials provide an important opportunity for extended endoscopic evaluation and colorectal neoplasia identification.
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Affiliation(s)
- Mira M Yang
- Division of Immunology and Fibrosis Development, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Keith Usiskin
- Division of Immunology and Fibrosis Development, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Harris A Ahmad
- Division of Immunology and Fibrosis Development, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Shabana Ather
- Division of Immunology and Fibrosis Development, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Antoine Sreih
- Division of Immunology and Fibrosis Development, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - James B Canavan
- Division of Immunology and Fibrosis Development, Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Francis A Farraye
- Division of Gastroenterology and Hepatology, Inflammatory Bowel Disease Center, Mayo Clinic, Jacksonville, Florida, USA
| | - Christopher Ma
- Division of Gastroenterology and Hepatology, Department of Medicine, and Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Medical Research and Development, Alimentiv Inc (formerly Robarts Clinical Trials, Inc.), London, Ontario, Canada
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Rajivan R, Thayalasekaran S. Improving polyp detection at colonoscopy: Non-technological techniques. World J Gastrointest Endosc 2023; 15:354-367. [PMID: 37274557 PMCID: PMC10236979 DOI: 10.4253/wjge.v15.i5.354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/03/2023] [Accepted: 04/12/2023] [Indexed: 05/16/2023] Open
Abstract
Colonoscopy and polypectomy remain the gold standard investigation for the detection and prevention of colorectal cancer. Halting the progression of colonic adenoma through adequate detection of pre-cancerous lesions interrupts the progression to carcinoma. The adenoma detection rate is a key performance indicator. Increasing adenoma detection rates are associated with reducing rates of interval colorectal cancer. Endoscopists with high baseline adenoma detection rate have a meticulous technique during colonoscopy withdrawal that improves their adenoma detection. This minireview article summarizes the evidence on the following simple operator techniques and their effects on the adenoma detection rate; minimum withdrawal times, dynamic patient position change and proximal colon retroflexion.
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Affiliation(s)
- Ragul Rajivan
- Buckingham Medical School, Milton Keynes MK18 1EG, United Kingdom
| | - Sreedhari Thayalasekaran
- Department of Gastroenterology, University Hospitals of Leicester, Leicester LE1 5WW, United Kingdom
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13
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Samnani S, Khan R, Heitman SJ, Hilsden RJ, Byrne MF, Grover SC, Forbes N. Optimizing adenoma detection in screening-related colonoscopy. Expert Rev Gastroenterol Hepatol 2023:1-14. [PMID: 37158052 DOI: 10.1080/17474124.2023.2212159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Screening-related colonoscopy is a vital component of screening initiatives to both diagnose and prevent colorectal cancer (CRC), with prevention being reliant upon early and accurate detection of pre-malignant lesions. Several strategies, techniques, and interventions exist to optimize endoscopists' adenoma detection rates (ADR). AREAS COVERED This narrative review provides an overview of the importance of ADR and other colonoscopy quality indicators. It then summarizes the available evidence regarding the effectiveness of the following domains in terms of improving ADR: endoscopist factors, pre-procedural parameters, peri-procedural parameters, intra-procedural strategies and techniques, antispasmodics, distal attachment devices, enhanced colonoscopy technologies, enhanced optics, and artificial intelligence. These summaries are based on an electronic search of the databases Embase, Pubmed, and Cochrane performed on December 12, 2022. EXPERT OPINION Given the prevalence and associated morbidity and mortality of CRC, the quality of screening-related colonoscopy quality is appropriately prioritized by patients, endoscopists, units, and payers alike. Endoscopists performing colonoscopy should be up to date regarding available strategies, techniques, and interventions to optimize their performance.
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Affiliation(s)
- Sunil Samnani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Rishad Khan
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Steven J Heitman
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Robert J Hilsden
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michael F Byrne
- Division of Gastroenterology, University of British Columbia, Vancouver, BC, Canada
| | - Samir C Grover
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, University of Toronto, Toronto, ON, Canada
| | - Nauzer Forbes
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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14
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Li J, Chen K, Wei Y, Zhang D, Wang Y, Hou X, Wu R, Peng K, Li L, Huang C, Wang Y, Xun L, Liu F. Colorectal sessile serrated lesion detection using linked-color imaging versus narrow-band imaging: a parallel randomized controlled trial. Endoscopy 2023; 55:546-554. [PMID: 36482165 DOI: 10.1055/a-1995-2685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Previous studies have reported the effectiveness of narrow-band imaging (NBI) and linked-color imaging (LCI) in improving the detection of colorectal neoplasms. There has however been no direct comparison between LCI and NBI in the detection of colorectal sessile serrated lesions (SSLs). The present study aimed to compare the effectiveness of LCI and NBI in detecting colorectal SSLs. METHODS A prospective, parallel, randomized controlled trial was conducted. The participants were randomly assigned to the LCI or NBI arms. The primary end point was the SSL detection rate (SDR). RESULTS 406 patients were involved; 204 in the LCI arm and 202 in the NBI arm. The total polyp detection rate, adenoma detection rate, and SDR were 54.2 %, 38.7 %, and 10.8%, respectively. The SDR was not significantly different between the LCI and NBI arms (12.3 % vs. 9.4 %; P = 0.36). The differences in the detection rate and the per-patient number of polyps, adenomas, diminutive lesions, and flat lesions between LCI and NBI also were not statistically significant. Multivariate analysis showed that LCI and NBI were not independent factors associated with SDR, whereas Boston Bowel Preparation Scale score (odds ratio [OR] 1.35, 95 %CI 1.03-1.76; P = 0.03), withdrawal time (OR 1.13, 95 %CI 1.00-1.26; P = 0.04), and operator experience (OR 3.73, 95 %CI 1.67-8.32; P = 0.001) were independent factors associated with SDR. CONCLUSIONS LCI and NBI are comparable for SSL detection, as well as for the detection of polyps and adenomas.
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Affiliation(s)
- Jun Li
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Gastroenterology, Shanghai Tenth People's Hospital Chongming Branch, Shanghai, China
| | - Kan Chen
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunlei Wei
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Di Zhang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuxin Wang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaojia Hou
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ruijin Wu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Kangsheng Peng
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Li
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chao Huang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yilong Wang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Linjuan Xun
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Feng Liu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Gastroenterology, Shanghai Tenth People's Hospital Chongming Branch, Shanghai, China
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Li J, Zhang D, Wei Y, Chen K, Wu R, Peng K, Hou X, Li L, Huang C, Wang Y, Xun L, Xu H, Wang J, Chen Z, Shen M, Liu F. Colorectal Sessile Serrated Lesion Detection Using Linked Color Imaging: A Multicenter, Parallel Randomized Controlled Trial. Clin Gastroenterol Hepatol 2023; 21:328-336.e2. [PMID: 35390509 DOI: 10.1016/j.cgh.2022.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/10/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Linked color imaging (LCI) is a novel technology that improves the color differences between colorectal lesions and the surrounding mucosa. The present study aims to compare the detection of colorectal sessile serrated lesions (SSL) using LCI with white light imaging (WLI). METHOD A large-scale, multicenter, parallel prospective randomized controlled trial was conducted in 4 hospitals in China. The participants were randomly assigned to the LCI group and WLI group. The primary endpoint was the SSL detection rate (SDR). RESULTS A total of 884 patients were involved in the intention-to-treat analysis, with 441 patients in the LCI group and 443 patients in the WLI group. The total polyp detection rate, adenoma detection rate, and SDR were 51.8%, 35.7%, and 8.6%, respectively. The SDR was significantly higher in the LCI group than in the WLI group (11.3% vs 5.9%, P = .004). Furthermore, LCI significantly increased the number of polyps and adenomas detected per patient, when compared with WLI (P < .05). In addition, there was higher detection rate of diminutive and flat lesions in the LCI group (P < .05). Multivariate analysis revealed that LCI is an independent factor associated with SDR (hazard ratio, 1.990; 95% confidence interval, 1.203-3.293; P = .007), along with withdrawal time (hazard ratio, 1.157; 95% confidence interval, 1.060-1.263; P = .001) and operator experience (hazard ratio, 1.850; 95% confidence interval, 1.045-3.273; P = .035). CONCLUSIONS LCI is significantly superior to WLI for SSL detection, and may improve polyp and adenoma detection. LCI can be recommended as an appropriate method for routine inspection during colonoscopy (http://www.chictr.org.cn number, ChiCTR2000035705).
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Affiliation(s)
- Jun Li
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Di Zhang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunlei Wei
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Kan Chen
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ruijin Wu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Kangsheng Peng
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaojia Hou
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Li
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chao Huang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuxin Wang
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Linjuan Xun
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hongwei Xu
- Department of Gastroenterology, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Yangzhou University, Kunshan, China
| | - Jianhua Wang
- Department of Gastroenterology, The First People's Hospital of Kunshan, Kunshan, China
| | - Zhirong Chen
- Department of Gastroenterology, Suzhou Municipal Hospital (Eastern), Suzhou Hospital Affiliated to Nanjing Medical University, Suzhou, China
| | - Ming Shen
- Department of Gastroenterology, Jiangyin Hospital of Traditional Chinese Medicine, Jiangyin Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Feng Liu
- Digestive Endoscopy Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
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16
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Reduced Adenoma Miss Rate With 9-Minute vs 6-Minute Withdrawal Times for Screening Colonoscopy: A Multicenter Randomized Tandem Trial. Am J Gastroenterol 2022; 118:802-811. [PMID: 36219172 PMCID: PMC10144327 DOI: 10.14309/ajg.0000000000002055] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 09/02/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Although the 9-minute mean withdrawal time (m-WT) is often reported to be associated with the optimal adenoma detection rate (ADR), no randomized trials of screening colonoscopy have confirmed the impact of a 9-minute m-WT on adenoma miss rate (AMR) and ADR. METHODS A multicenter tandem trial was conducted in 11 centers. Seven hundred thirty-three asymptomatic participants were randomized to receive segmental tandem screening colonoscopy with a 9-minute withdrawal, followed by a 6-minute withdrawal (9-minute-first group, 9MF, n = 366) or vice versa (6-minute-first group, 6MF, n = 367). The primary outcome was the lesion-level AMR. RESULTS The intention-to-treat analysis revealed that 9MF significantly reduced the lesion-level (14.5% vs 36.6%, P < 0.001) and participant-level AMR (10.9% vs 25.9%, P < 0.001), advanced adenoma miss rate (AAMR, 5.3% vs 46.9%, P = 0.002), multiple adenomas miss rate (20.7% vs 56.5%, P = 0.01), and high-risk adenomas miss rate (14.6% vs 39.5%, P = 0.01) of 6MF without compromising detection efficiency ( P = 0.79). In addition, a lower false-negative rate for adenomas ( P = 0.002) and high-risk adenomas ( P < 0.05), and a lower rate of shortening surveillance schedule ( P < 0.001) were also found in 9MF, accompanying with an improved ADR in the 9-minute vs 6-minute m-WT (42.3% vs 33.5%, P = 0.02). The independent inverse association between m-WT and AMR remained significant even after adjusting ADR, and meanwhile, 9-minute m-WT was identified as an independent protector for AMR and AAMR. DISCUSSION In addition to increasing ADR, 9-minute m-WT also significantly reduces the AMR and AAMR of screening colonoscopy without compromising detection efficiency.
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17
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Komanduri S, Dominitz JA, Rabeneck L, Kahi C, Ladabaum U, Imperiale TF, Byrne MF, Lee JK, Lieberman D, Wang AY, Sultan S, Shaukat A, Pohl H, Muthusamy VR. AGA White Paper: Challenges and Gaps in Innovation for the Performance of Colonoscopy for Screening and Surveillance of Colorectal Cancer. Clin Gastroenterol Hepatol 2022; 20:2198-2209.e3. [PMID: 35688352 DOI: 10.1016/j.cgh.2022.03.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 02/23/2022] [Accepted: 03/17/2022] [Indexed: 02/07/2023]
Abstract
In 2018, the American Gastroenterological Association's Center for GI Innovation and Technology convened a consensus conference, entitled "Colorectal Cancer Screening and Surveillance: Role of Emerging Technology and Innovation to Improve Outcomes." The conference participants, which included more than 60 experts in colorectal cancer, considered recent improvements in colorectal cancer screening rates and polyp detection, persistent barriers to colonoscopy uptake, and opportunities for performance improvement and innovation. This white paper originates from that conference. It aims to summarize current patient- and physician-centered gaps and challenges in colonoscopy, diagnostic and therapeutic challenges affecting colonoscopy uptake, and the potential use of emerging technologies and quality metrics to improve patient outcomes.
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Affiliation(s)
- Srinadh Komanduri
- Department of Department of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System and the Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Linda Rabeneck
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Charles Kahi
- Indiana University School of Medicine, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California
| | - Thomas F Imperiale
- Department of Medicine, Indiana University School of Medicine, the Regenstrief Institute, the Simon Cancer Center, and the Center for Innovation at Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana
| | - Michael F Byrne
- Division of Gastroenterology, Vancouver General Hospital/University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey K Lee
- Collaborative Health Outcomes Research in Digestive Diseases (CHORD) Group, Kaiser Permanente Division of Research, Kaiser Permanente San Francisco, San Francisco, California
| | - David Lieberman
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology and Nutrition, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Aasma Shaukat
- Division of Gastroenterology, Minneapolis Veterans Affairs Health Care System and Department of Medicine, School of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Heiko Pohl
- Veterans Affairs Medical Center White River Junction, Vermont; Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, Department of Medicine, University of California Los Angeles, Los Angeles, California.
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18
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Gubbiotti A, Spadaccini M, Badalamenti M, Hassan C, Repici A. Key factors for improving adenoma detection rate. Expert Rev Gastroenterol Hepatol 2022; 16:819-833. [PMID: 36151898 DOI: 10.1080/17474124.2022.2128761] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Colonoscopy is a fundamental tool in colorectal cancer (CRC) prevention. Nevertheless, one-fourth of colorectal neoplasms are still missed during colonoscopy, potentially being the main reason for post-colonoscopy colorectal cancer (PCCRC). Adenoma detection rate (ADR) is currently known as the best quality indicator correlating with PCCRC incidence. AREAS COVERED We performed a literature review in order to summarize evidences investigating key factors affecting ADR: endoscopists education and training, patient management, endoscopic techniques, improved navigation (exposition defect), and enhanced lesions recognition (vision defect) were considered. EXPERT OPINION 'Traditional' factors, such as split dose bowel preparation, adequate withdrawal time, and right colon second view, held a significant impact on ADR. Several devices and technologies have been developed to promote high-quality colonoscopy, however artificial intelligence may be considered the most promising tool for ADR improvement, provided that endoscopists education and recording are guaranteed.
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Affiliation(s)
- Alessandro Gubbiotti
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Marco Spadaccini
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Matteo Badalamenti
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Cesare Hassan
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Alessandro Repici
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
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Shaukat A, Tuskey A, Rao VL, Dominitz JA, Murad MH, Keswani RN, Bazerbachi F, Day LW. Interventions to improve adenoma detection rates for colonoscopy. Gastrointest Endosc 2022; 96:171-183. [PMID: 35680469 DOI: 10.1016/j.gie.2022.03.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/25/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Aasma Shaukat
- Division of Gastroenterology, Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Anne Tuskey
- Division of Gastroenterology, Department of Medicine, University of Virginia, Arlington, Virginia, USA
| | - Vijaya L Rao
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Jason A Dominitz
- Division of Gastroenterology, Department of Medicine, Puget Sound Veterans Affairs Medical Center and University of Washington, Seattle, Washington, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rajesh N Keswani
- Division of Gastroenterology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Fateh Bazerbachi
- Division of Gastroenterology, CentraCare, Interventional Endoscopy Program, St Cloud, Minnesota, USA
| | - Lukejohn W Day
- Division of Gastroenterology, Department of Medicine, Zuckerberg San Francisco General Hospital and University of San Francisco, San Francisco, California, USA
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Díaz-Tasende J. Colonoscopy - When quality matters. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:314-316. [PMID: 35638771 DOI: 10.17235/reed.2022.8942/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Colonoscopy technical quality is a primary determinant of clinical outcome. Unfortunately, there is enough evidence available for significant variability in endoscopists' performance. An assessment of the factors determining these differences will be crucial for designing measures to ensure effectiveness and safety in these procedures.
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Schrader C, Wallstabe I, Schiefke I. Künstliche Intelligenz in der Vorsorgekoloskopie. COLOPROCTOLOGY 2022. [DOI: 10.1007/s00053-022-00593-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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22
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Spada C, Koulaouzidis A, Hassan C, Amaro P, Agrawal A, Brink L, Fischbach W, Hünger M, Jover R, Kinnunen U, Ono A, Patai Á, Pecere S, Petruzziello L, Riemann JF, Staines H, Stringer AL, Toth E, Antonelli G, Fuccio L. Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group. Diagnostics (Basel) 2022; 12:diagnostics12020503. [PMID: 35204593 PMCID: PMC8871420 DOI: 10.3390/diagnostics12020503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/02/2022] [Accepted: 02/03/2022] [Indexed: 11/30/2022] Open
Abstract
The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy. Conclusions: On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.
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Affiliation(s)
- Cristiano Spada
- Digestive Endoscopy Unit and Gastroenterology, Fondazione Poliambulanza, 25124 Brescia, Italy
- Digestive Endoscopy Unit, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence:
| | - Anastasios Koulaouzidis
- Department of Medicine, OUH Svendborg Sygehus, 5700 Svendborg, Denmark;
- Department of Clinical Research, University of Southern Denmark (SDU), 5000 Odense, Denmark
- Surgical Research Unit, OUH, 5000 Odense, Denmark
- Department of Social Medicine and Public Health, Pomeranian Medical University, 70-204 Szczecin, Poland
| | - Cesare Hassan
- Endoscopy Unit, IRCCS Humanitas Clinical and Research Center, 20089 Milan, Italy;
| | - Pedro Amaro
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, 3000-075 Coimbra, Portugal;
| | - Anurag Agrawal
- Gastroenterology, Doncaster Royal Infirmary, Doncaster DN2 5LT, UK;
| | - Lene Brink
- Gastro Unit, Division of Endoscopy, Herlev and Gentofte Hospital, Copenhagen University, 2730 Herlev, Denmark;
| | | | - Matthias Hünger
- Independent Researcher for Internal Medicine, 97070 Würzburg, Germany;
| | - Rodrigo Jover
- Instituto de Investigación Sanitaria ISABIAL—Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, 03010 Alicante, Spain;
| | - Urpo Kinnunen
- Department of Gastroenterology, Tampere University Hospital, 33521 Tampere, Finland;
| | - Akiko Ono
- Department of Gastroenterology, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, 30120 Murcia, Spain;
| | - Árpád Patai
- Department of Gastroenterology and Medicine, Markusovszky University Teaching Hospital, 9700 Szombathely, Hungary;
| | - Silvia Pecere
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.P.); (L.P.)
| | - Lucio Petruzziello
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy; (S.P.); (L.P.)
| | - Jürgen F. Riemann
- Department of Medicine C, Klinikum Ludwigshafen, 67063 Ludwigshafen, Germany;
- LebensBlicke Foundation, 67063 Ludwigshafen, Germany
| | - Harry Staines
- Sigma Statistical Services Ltd., Saint Andrews KY16 0BD, UK;
| | | | - Ervin Toth
- Department of Gastroenterology, Skåne University Hospital, Lund University, 205 02 Malmö, Sweden;
| | - Giulio Antonelli
- Department of Anatomical, Histological, Forensic Medicine and Orthopedics Sciences, “Sapienza” University of Rome, 00185 Rome, Italy;
- Gastroenterology and Digestive Endoscopy Unit, Ospedale dei Castelli, Ariccia, 00040 Rome, Italy
| | - Lorenzo Fuccio
- Gastroenterology Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, 40138 Bologna, Italy;
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Butterly LF. Withdrawal Time: Is Nine the New Six? Clin Gastroenterol Hepatol 2022; 20:e22-e24. [PMID: 33493694 DOI: 10.1016/j.cgh.2021.01.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Lynn F Butterly
- Section of Gastroenterology, Department of Medicine, Dartmouth-Hitchcock Medical Center and Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; New Hampshire Colonoscopy Registry, Lebanon, New Hampshire
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Bhurwal A, Rattan P, Sarkar A, Patel A, Haroon S, Gjeorgjievski M, Bansal V, Mutneja H. A comparison of 9-min colonoscopy withdrawal time and 6-min colonoscopy withdrawal time: A systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:3260-3267. [PMID: 34617312 DOI: 10.1111/jgh.15701] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/16/2021] [Accepted: 09/28/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION The optimal colonoscopy withdrawal time is still a controversial topic. While several studies demonstrate that longer withdrawal time improves adenoma detection rate, others have contradicted these findings. METHODS Three independent reviewers performed a comprehensive review of all original articles published from inception to January 2021 and included studies reporting comparison of the two cohorts-(i) ≥ 6 but less than 9 min of colonoscopy withdrawal time (CWT) and (ii) ≥ 9 min of CWT. The outcome measures were the following: (i) adenoma detection rate (ADR), (ii) advanced ADR, and (iii) sessile serrated adenoma detection rate (SDR). The meta-analysis was performed, and the statistics were two-tailed. RESULTS A total of seven studies met the inclusion criteria after a thorough search of the literature was completed. The analysis revealed that ≥ 9 min of CWT had significantly higher odds of adenoma detection as compared with 6-9 min of CWT (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.30-1.82; I2 = 93.7). Additionally, a significantly higher odds of sessile serrated adenoma detection (OR 1.68, 95% CI 1.28-2.22; I2 = 0) and a trend towards higher odds of advanced adenoma detection (OR 1.38, 95% CI 0.98-1.95, I2 = 90) were seen with CWT of at least 9 min when compared with 6-9 min of CWT. CONCLUSION This systematic review and meta-analysis analysis provides further evidence that at least 9 min of CWT cohort had significantly higher ADR and SDR as compared with the at least 6 min but less than 9 min of cohort.
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Affiliation(s)
- Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey, USA
| | - Puru Rattan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Avik Sarkar
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey, USA
| | - Anish Patel
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey, USA
| | - Shahid Haroon
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey, USA
| | - Mihajlo Gjeorgjievski
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson School of Medicine, New Brunswick, New Jersey, USA
| | - Vikas Bansal
- Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, Minnesota, USA
| | - Hemant Mutneja
- Division of Gastroenterology and Hepatology, John H. Stroger Cook County Hospital, Chicago, Illinois, USA
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Zhu XJ, Yang L. Progress in understanding of factors related to colonoscopic adenoma detection rate. Shijie Huaren Xiaohua Zazhi 2021; 29:1304-1310. [DOI: 10.11569/wcjd.v29.i22.1304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Adenoma detection rate (ADR) is the proportion of average-risk patients undergoing screening colonoscopy in whom an adenoma is found, and it is an important quality indicator of colonoscopy. ADR is closely related to the risk of interval colorectal cancer. A deeply study of ADR is essential for endoscopists. In this paper, we review the progress in the understanding of factors related to ADR before, during, and after colonoscopy, as well as several issues worthy of attention.
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Affiliation(s)
- Xiao-Jia Zhu
- Department of Gastroenterology, Third People's Hospital of Jingdezhen, Jingdezhen 333000, Jiangxi Province, China
| | - Li Yang
- Department of Gastroenterology, Third People's Hospital of Jingdezhen, Jingdezhen 333000, Jiangxi Province, China
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26
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Zhao SB, Yang W, Wang SL, Pan P, Wang RD, Chang X, Sun ZQ, Fu XH, Shang H, Wu JR, Chen LZ, Chang J, Song P, Miao YL, He SX, Miao L, Jiang HQ, Wang W, Yang X, Dong YH, Lin H, Chen Y, Gao J, Meng QQ, Jin ZD, Li ZS, Bai Y. Establishment and validation of a computer-assisted colonic polyp localization system based on deep learning. World J Gastroenterol 2021; 27:5232-5246. [PMID: 34497447 PMCID: PMC8384745 DOI: 10.3748/wjg.v27.i31.5232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/10/2021] [Accepted: 07/20/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Artificial intelligence in colonoscopy is an emerging field, and its application may help colonoscopists improve inspection quality and reduce the rate of missed polyps and adenomas. Several deep learning-based computer-assisted detection (CADe) techniques were established from small single-center datasets, and unrepresentative learning materials might confine their application and generalization in wide practice. Although CADes have been reported to identify polyps in colonoscopic images and videos in real time, their diagnostic performance deserves to be further validated in clinical practice.
AIM To train and test a CADe based on multicenter high-quality images of polyps and preliminarily validate it in clinical colonoscopies.
METHODS With high-quality screening and labeling from 55 qualified colonoscopists, a dataset consisting of over 71000 images from 20 centers was used to train and test a deep learning-based CADe. In addition, the real-time diagnostic performance of CADe was tested frame by frame in 47 unaltered full-ranged videos that contained 86 histologically confirmed polyps. Finally, we conducted a self-controlled observational study to validate the diagnostic performance of CADe in real-world colonoscopy with the main outcome measure of polyps per colonoscopy in Changhai Hospital.
RESULTS The CADe was able to identify polyps in the test dataset with 95.0% sensitivity and 99.1% specificity. For colonoscopy videos, all 86 polyps were detected with 92.2% sensitivity and 93.6% specificity in frame-by-frame analysis. In the prospective validation, the sensitivity of CAD in identifying polyps was 98.4% (185/188). Folds, reflections of light and fecal fluid were the main causes of false positives in both the test dataset and clinical colonoscopies. Colonoscopists can detect more polyps (0.90 vs 0.82, P < 0.001) and adenomas (0.32 vs 0.30, P = 0.045) with the aid of CADe, particularly polyps < 5 mm and flat polyps (0.65 vs 0.57, P < 0.001; 0.74 vs 0.67, P = 0.001, respectively). However, high efficacy is not realized in colonoscopies with inadequate bowel preparation and withdrawal time (P = 0.32; P = 0.16, respectively).
CONCLUSION CADe is feasible in the clinical setting and might help endoscopists detect more polyps and adenomas, and further confirmation is warranted.
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Affiliation(s)
- Sheng-Bing Zhao
- Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Wei Yang
- Tencent AI Lab, National Open Innovation Platform for Next Generation Artificial Intelligence on Medical Imaging, Shenzhen 518063, Guangdong Province, China
| | - Shu-Ling Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Peng Pan
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Run-Dong Wang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Xin Chang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Zhong-Qian Sun
- Tencent AI Lab, National Open Innovation Platform for Next Generation Artificial Intelligence on Medical Imaging, Shenzhen 518063, Guangdong Province, China
| | - Xing-Hui Fu
- Tencent AI Lab, National Open Innovation Platform for Next Generation Artificial Intelligence on Medical Imaging, Shenzhen 518063, Guangdong Province, China
| | - Hong Shang
- Tencent AI Lab, National Open Innovation Platform for Next Generation Artificial Intelligence on Medical Imaging, Shenzhen 518063, Guangdong Province, China
| | - Jian-Rong Wu
- Tencent Healthcare (Shenzhen) Co. LTD., Shenzhen 518063, Guangdong Province, China
| | - Li-Zhu Chen
- Tencent Healthcare (Shenzhen) Co. LTD., Shenzhen 518063, Guangdong Province, China
| | - Jia Chang
- Tencent Healthcare (Shenzhen) Co. LTD., Shenzhen 518063, Guangdong Province, China
| | - Pu Song
- Tencent Healthcare (Shenzhen) Co. LTD., Shenzhen 518063, Guangdong Province, China
| | - Ying-Lei Miao
- Department of Gastroenterology, The First Affiliated Hospital of Kunming Medical University, Kunming 650000, Yunnan Province, China
| | - Shui-Xiang He
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an 710061, Shaanxi Province, China
| | - Lin Miao
- Institute of Digestive Endoscopy and Medical Center for Digestive Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing 210011, Jiangsu Province, China
| | - Hui-Qing Jiang
- Department of Gastroenterology, The Second Hospital of Hebei Medical University, Hebei Key Laboratory of Gastroenterology, Hebei Institute of Gastroenterology, Shijiazhuang 050000, Hebei Province, China
| | - Wen Wang
- Department of Gastroenterology, 900th Hospital of Joint Logistics Support Force, Fuzhou 350025, Fujian Province, China
| | - Xia Yang
- Department of Gastroenterology, No. 905 Hospital of The Chinese People's Liberation Army, Shanghai 200050, China
| | - Yuan-Hang Dong
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Han Lin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Yan Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Jie Gao
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Qian-Qian Meng
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Zhen-Dong Jin
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
| | - Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University/Naval Medical University, Shanghai 200433, China
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