European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Quality assurance in endoscopy in colorectal cancer screening and diagnosis

Endoscopic treatment of scarred polyps with a non-thermal device (Endorotor): A review of the literature‎

Endoscopic resection (ER) of colorectal polyps has become a daily practice in most endoscopic units providing a colorectal cancer screening program and requires the availability of local experts and high-end endoscopic devices. ER procedures have evolved over the past few years from endoscopic mucosal resection (EMR) to more advanced techniques, such as endoscopic submucosal dissection and endo-scopic full-thickness resection. Complete resection and disease eradication are the ultimate goals of ER-based techniques, and novel devices have been developed to achieve these goals. The EndoRotor® Endoscopic Powered Resection System (Interscope Medical, Inc., Northbridge, Massachusetts, United States) is one such device. The EndoRotor is a powered resection tool for the removal of alimentary tract mucosa, including post-EMR persistent lesions with scarring, and has both CE Mark and FDA clearance. This review covers available published evidence documenting the usefulness of EndoRotor for the management of recurrent colorectal polyps.

Multi-level Factors Influencing Decisions About Stopping Surveillance Colonoscopy in Older Adults: a Qualitative Study

BACKGROUND

Little is known about patient or provider experience and perceptions of stopping surveillance among older adults with a history of colon polyps. While guidelines recommend ceasing routine colorectal cancer screening in adults  > 75 years and those with limited life expectancy, guidance for ceasing surveillance colonoscopy in those with prior colon polyps suggests individualizing recommendations.

OBJECTIVE

Identify processes, experiences, and gaps around individualizing decisions to stop or continue surveillance colonoscopy for older adults and areas for improvement.

DESIGN

Phenomenological qualitative study design using recorded semi-structured interviews from May 2020 through March 2021.

PARTICIPANTS

15 patients aged  ≥ 65 in polyp surveillance, 12 primary care providers (PCPs), and 13 gastroenterologists (GIs).

APPROACH

Data were analyzed using a mixed deductive (directed content analysis) and inductive (grounded theory) approach to identify themes related to stopping or continuing surveillance colonoscopies.

KEY RESULTS

Analysis resulted in 24 themes and were clustered into three main categories: health and clinical considerations; communication and roles; and system-level processes or structures. Overall, the study found support for discussions around age 75-80 on stopping surveillance colonoscopy with considerations for health and life expectancy and that PCPs should take a primary role. However, systems and processes for scheduling surveillance colonoscopies largely bypass PCPs which reduces opportunities to both individualize recommendations and facilitate patients' decision-making.

CONCLUSIONS

This study identified gaps in processes to implement current guidelines for individualizing surveillance colonoscopy as adults grow older, including opportunities to discuss stopping. Increasing the role of PCPs in polyp surveillance as patients grow older provides more opportunities for individualized recommendations, so patients can consider their own preferences, ask questions, and make a more informed choice for themselves. Changing existing systems and processes and creating supportive tools for shared decision-making specific to older adults with polyps would improve how surveillance colonoscopy is individualized in this population.

Supply and quality of colonoscopy according to the characteristics of gastroenterologists in the French population-based colorectal-cancer screening program

BACKGROUND

Since its complete roll-out in 2009, the French colorectal cancer screening program (CRCSP) experienced 3 major constraints [use of a less efficient Guaiac-test (gFOBT), stopping the supply of Fecal-Immunochemical-Test kits (FIT), and suspension of the program due to the coronavirus disease 2019 (COVID-19)] affecting its effectiveness.

AIM

To describe the impact of the constraints in terms of changes in the quality of screening-colonoscopy (Quali-Colo).

METHODS

This retrospective cohort study included screening-colonoscopies performed by gastroenterologists between Jan-2010 and Dec-2020 in people aged 50-74 living in Ile-de-France (France). The changes in Quali-colo (Proportion of colonoscopies performed beyond 7 mo (Colo_7 mo), Frequency of serious adverse events (SAE) and Colonoscopy detection rate) were described in a cohort of Gastroenterologists who performed at least one colonoscopy over each of the four periods defined according to the chronology of the constraints [gFOBT: Normal progress of the CRCSP using gFOBT (2010-2014); FIT: Normal progress of the CRCSP using FIT (2015-2018); STOP-FIT: Year (2019) during which the CRCSP experienced the cessation of the supply of test kits; COVID: Program suspension due to the COVID-19 health crisis (2020)]. The link between each dependent variable (Colo_7 mo; SAE occurrence, neoplasm detection rate) and the predictive factors was analyzed in a two-level multivariate hierarchical model.

RESULTS

The 533 gastroenterologists (cohort) achieved 21509 screening colonoscopies over gFOBT period, 38352 over FIT, 7342 over STOP-FIT and 7995 over COVID period. The frequency of SAE did not change between periods (gFOBT: 0.3%; FIT: 0.3%; STOP-FIT: 0.3%; and COVID: 0.2%; P = 0.10). The risk of Colo_7 mo doubled between FIT [adjusted odds ratio (aOR): 1.2 (1.1; 1.2)] and STOP-FIT [aOR: 2.4 (2.1; 2.6)]; then, decreased by 40% between STOP-FIT and COVID [aOR: 2.0 (1.8; 2.2)]. Regardless of the period, this Colo_7 mo’s risk was twice as high for screening colonoscopy performed in a public hospital [aOR: 2.1 (1.3; 3.6)] compared to screening-colonoscopy performed in a private clinic. The neoplasm detection, which increased by 60% between gFOBT and FIT [aOR: 1.6 (1.5; 1.7)], decreased by 40% between FIT and COVID [aOR: 1.1 (1.0; 1.3)].

CONCLUSION

The constraints likely affected the time-to-colonoscopy as well as the colonoscopy detection rate without impacting the SAE’s occurrence, highlighting the need for a respectable reference time-to-colonoscopy in CRCSP.

Systematic review of shared decision-making in guidelines about colorectal cancer screening

INTRODUCTION

We aimed to systematically evaluate quality of shared decision-making (SDM) in colorectal cancer (CRC) screening clinical practice guidelines (CPGs) and consensus statements (CSs).

METHODS

Search for CRC screening guidances was from 2010 to November 2021 in EMBASE, Web of Science, MEDLINE, Scopus and CDSR, and the World Wide Web. Three independent reviewers and an arbitrator rated the quality of each guidance using a SDM quality assessment tool (maximum score: 31). Reviewer agreement was 0.88.

RESULTS

SDM appeared in 41/83 (49.4%) CPGs and 9/19 (47.4%) CSs. None met all the quality criteria, and 51.0% (52/102) failed to meet any quality items. Overall compliance was low (mean 1.63, IQR 0-2). Quality was better in guidances published after 2015 (mean 1, IQR 0-3 vs. mean 0.5, IQR 0-1.5; p = 0.048) and when the term SDM was specifically reported (mean 4.5, IQR 2.5-4.5 vs. mean 0.5, IQR 0-1.5; p < 0.001). CPGs underpinned by systematic reviews showed better SDM quality than consensus (mean 1, IQR 0-3 vs. mean 0, IQR 0-2, p = 0.040).

CONCLUSION

SDM quality was suboptimal and mentioned in less than half of the guidances, and recommendations were scarce. Guideline developers should incorporate evidence-based SDM recommendations in guidances to underpin the translation of evidence into practice.

Predictors That Identify Complications Such As Anastomotic Leak in Colorectal Surgery: A Systematic Review

Leakage of the anastomotic site is considered to be one of the most serious complications after colon and rectal surgery. It is associated with increased mortality, morbidity, and longer hospital stays. This systematic review examines the need for blood markers such as C-reactive protein (CRP), procalcitonin (PCT), albumin, and various other molecular markers that assist in their propensity to diagnose anastomotic leakage (AL) early after surgery.

Utilizing PubMed and Google Scholar as resources and including the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for the articles, and studies over the last five years were included. A total of 12 studies have been discussed, and most articles suggest CRP as an excellent indicator. CRP compared to Dutch leakage scores (DLS) and PCT studies suggest that the three combinations improve the predictable outcome of AL. In addition, CRP and PCT have been shown to diagnose AL early in the postoperative period. Other studies include the role of markers of oxidative stress markers, Interleukin-6, Interleukin-10, and other molecular markers in the peritoneal drain which are predictive for identifying AL after three days postoperatively (POD-3).

Overall, CRP has proven to be a reliable standard indicator of diagnosis. This is because the postoperative elevation of this protein indicates a problem of leakage with clinical symptoms. Other blood parameters are useful for diagnosis as well, but the limitations are the lack of appropriate studies and the number of randomized controlled trials in this area of ​​study.

Impact of COVID-19 pandemic on colonoscopy results – an overview

<b>Aim:</b> Colorectal cancers are common cancers. Colonoscopy procedure, which is applied in the early diagnosis and treatment of this disease, has a very important role. In this study, we aimed to examine the effect of the COVİD-19 pandemic period on our colonoscopic procedures. </br></br> <b> Material and methods:</b> In this observational study, the data of the patients who underwent colonoscopy in our General Surgery Endoscopy Unit, between March 11, 2019 and March 12, 2021 were scanned retrospectively. Patients under 18 years of age were excluded. The patients were divided into 2 groups. 1. Group patients between 11 March 2019–11 March 2020; patients in the pre-COVID-19 period, Group 2, on March 12, 2020–March 12, 2021; Grouped as the COVID-19 era. </br></br> <b>Results:</b> Data of 8285 patients were analyzed. A total of 4889 patients in Group 1 and 3396 patients in Group 2 were included in the study. The detection of precancerous polyps between the groups was found to be significantly higher in group 1 (p < 0.05) (4.3% vs 2.1). Similarly, the presence of precancerous polyps over the age of 65 was found to be significantly higher in the pre-covid group. In group 1, no significant difference was found in the evaluation of cancer patients according to gender (p > 0.05) (F/M: 1.2%/1.6%). In group 2, cancer patients were found to be significantly higher in males. </br></br> <b>Conclusions:</b> The COVİD-19 pandemic has had negative effects in many areas, as well as on our colonoscopic procedures. Experienced centers continue to work to minimize these negative effects.

Positive impact of a faecal-based screening programme on colorectal cancer mortality risk

INTRODUCTION

The effectiveness of colorectal cancer (CRC) screening programs is directly related to participation and the number of interval CRCs. The objective was to analyse specific-mortality in a cohort of individuals invited to a CRC screening program according to type of CRC diagnosis (screen-detected cancers, interval cancers, and cancers among the non-uptake group).

MATERIAL AND METHODS

Retrospective cohort that included invitees aged 50-69 years of a CRC screening program (target population of 85,000 people) in Catalonia (Spain) from 2000-2015 with mortality follow-up until 2020. A screen-detected CRC was a cancer diagnosed after a positive faecal occult blood test (guaiac or immunochemical); an interval cancer was a cancer diagnosed after a negative test result and before the next invitation to the program (≤24 months); a non-uptake cancer was a cancer in subjects who declined screening.

RESULTS

A total of 624 people were diagnosed with CRC (n = 265 screen-detected, n = 103 interval cancers, n = 256 non-uptake). In the multivariate analysis, we observed a 74% increase in mortality rate in the group with interval CRC compared to screen-detected CRC adjusted for age, sex, location and stage (HR: 1.74%, 95% CI:1.08-2.82, P = 0.02). These differences were found even when we restricted for advanced-cancers participants. In the stratified analysis for type of faecal occult blood test, a lower mortality rate was only observed among FIT screen-detected CRCs.

CONCLUSION

CRC screening with the FIT was associated with a significant reduction in CRC mortality.

A Comprehensive Overview of Colon Cancer- A Grim Reaper of the 21st Century

A few decades ago, the incidence of colorectal cancer (CRC) was low and is now the fourth in the list of deadly cancers producing nearly a million deaths annually. A population that is aging along with risk factors such as smoking, obesity, sedentary lifestyle with little or no physical activity, and non-healthy food habits of developed countries can increase the risk of colorectal cancer. The balance in gut microbiota and the metabolites produced during bacterial fermentation within the host plays a significant role in regulating intestinal diseases as well as colorectal cancer development. Recent progress in the understanding of illness resulted in multiple treatment options such as surgery, radiation, and chemotherapy, including targeted therapy and multitherapies. The treatment plan for CRC depends on the location, stage and grade of cancer as well as genomic biomarker tests. Despite all the advancements made in the genetic and molecular aspects of the disease, the knowledge seems inadequate as the drug action as well as the wide variation in drug response did not appear strongly correlated with the individual molecular and genetic characteristics, which suggests the requirement of comprehensive molecular understanding of this complex heterogeneous disease. Furthermore, multitherapies or a broad spectrum approach, which is an amalgamation of the various promising as well as effective therapeutic strategies that can tackle heterogeneity and act on several targets of the disease, need to be validated in clinical studies. The latest treatment options have significantly increased the survival of up to three years in the case of advanced disease. The fact that colorectal cancer is developed from a polypoid precursor, as well as the symptoms of the disease that occur at an advanced stage, underlines how screening programs can help early detection and decrease mortality as well as morbidity from CRC.

Insufflation of Carbon Dioxide versus Air During Colonoscopy Among Pediatric Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims:

Carbon dioxide is increasingly used in insufflation during colonoscopy in adult patients; however, air insufflation remains the primary practice among pediatric gastroenterologists. This systematic review and meta-analysis aims to evaluate insufflation using CO₂ versus air in colonoscopies in pediatric patients.

Methods:

Individualized search strategies were performed using MEDLINE, Cochrane Library, EMBASE, and LILACS databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane working methodology. Randomized control trials (RCTs) were selected for the present meta-analysis. Pooled proportions were calculated for outcomes including procedure time and abdominal pain immediately and 24 hours post-procedure.

Results:

The initial search yielded 644 records, of which five RCTs with a total of 358 patients (CO₂: n=178 versus air: n=180) were included in the final analysis. The procedure time was not different between the CO₂ and air insufflation groups (mean difference, 10.84; 95% confidence interval [CI], -2.55 to 24.22; p=0.11). Abdominal pain immediately post-procedure was significantly lower in the CO₂ group (risk difference [RD], -0.15; 95% CI; -0.26 to -0.03; p=0.01) while abdominal pain at 24 hours post-procedure was similar (RD, -0.05; 95% CI; -0.11 to 0.01; p=0.11).

Conclusions:

Based on this systematic review and meta-analysis of RCT data, CO₂ insufflation reduced abdominal pain immediately following the procedure, while pain was similar at 24 hours post-procedure. These results suggest that CO₂ is a preferred insufflation technique when performing colonoscopy in pediatric patients.

Electrochemical biosensors for measurement of colorectal cancer biomarkers

Colorectal cancer (CRC) is associated with one of the highest rates of mortality among cancers worldwide. The early detection and management of CRC is imperative. Biomarkers play an important role in CRC screening tests, CRC treatment, and prognosis and clinical management; thus rapid and sensitive detection of biomarkers is helpful for early detection of CRC. In recent years, electrochemical biosensors for detecting CRC biomarkers have been widely investigated. In this review, different electrochemical detection methods for CRC biomarkers including immunosensors, aptasensors, and genosensors are summarized. Further, representative examples are provided that demonstrate the advantages of electrochemical sensors modified by various nanomaterials. Finally, the limitations and prospects of biomarkers and electrochemical sensors in detection are also discussed. Graphical abstract.

Predictors of Metachronous Risk Polyps After Index Colonoscopy

INTRODUCTION

Guidelines for surveillance after polypectomy are lacking in strong evidence. Our aim was to identify some precursors of colorectal cancer lesions at 3 years after polypectomy to improve stratification and surveillance programs.

METHODS

We included patients with high-risk lesions (HRLs), defined as advanced adenoma (AA), large serrated polyps (SPs), and multiplicity (≥3 of any adenomas/SPs). Data on age, sex, cardiovascular risk factors, pharmacological treatment, and the histological characteristics in each individual, and mutations in genes involved in the most advanced index polyp, were collected. Parameters independently associated with a metachronous HRL diagnosis were evaluated through univariate and multivariate analyses. The results are reported as odds ratios and 95% confidence intervals along with P values.

RESULTS

A total of 537 cases (median age: 60.7 years; 66% male) were included. Dyslipidemia and smoking correlated with metachronous HRLs. Multivariate logistic regression analysis showed that the presence of multiplicity with ≥3 polyps on the index colonoscopy was significantly associated with metachronous HRL, AA, proximal AA, and ≥3 polyps at 3 years. In addition, independent predictors of metachronous proximal AA were increasing age, female sex, and the loss of expression of the MLH1 protein.

DISCUSSION

Multiplicity was a strong predictor of HRLs at 3 years, although the inclusion of other clinical variables (age, sex, smoking status, and dyslipidemia) improves surveillance recommendations. Without these risk factors, the surveillance could be extended to 5 years; we propose examining the somatic expression of MHL1 in all patients.

Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations

BACKGROUND

Sedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to identify and synthesize existing recommendations on sedation practices for routine gastrointestinal endoscopy procedures.

METHODS

We systematically reviewed guidelines and position statements identified through a search of PubMed, guidelines databases, and websites of relevant professional associations from January 1, 2005 to May 10, 2019. We included English-language guidelines/position statements with recommendations relating to sedation for adults undergoing routine gastrointestinal endoscopy. Documents with guidance only for complex endoscopic procedures were excluded. We extracted and synthesized recommendations relating to: 1) choice of sedatives, 2) sedation administration, 3) personnel responsible for monitoring sedated patients, 4) skills and training of individuals involved in sedation, and 5) equipment required for monitoring sedated patients. We assessed the quality of included documents using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool.

RESULTS

We identified 19 guidelines and 7 position statements meeting inclusion criteria. Documents generally agreed that a single, trained registered nurse can administer moderate sedation, monitor the patient, and assist with brief, interruptible tasks. Documents also agreed on the routine use of pulse oximetry and blood pressure monitoring during endoscopy. However, recommendations relating to the drugs to be used for sedation, the healthcare personnel capable of administering propofol and monitoring patients sedated with propofol, and the need for capnography when monitoring sedated patients varied. Only 9 documents provided a grade or level of evidence in support of their recommendations.

CONCLUSIONS

Recommendations for sedation practices in routine gastrointestinal endoscopy differ across guidelines/position statements and often lack supporting evidence with potential implications for patient safety and procedural efficiency.

Novel biomarkers for the diagnosis and prognosis of colorectal cancer

Colorectal cancer (CRC) is among the most common malignancies and remains a major cause of cancer-related death worldwide. Despite recent advances in surgical and multimodal therapies, the overall survival of advanced CRC patients remains very low. Cancer progression, including invasion and metastasis, is a major cause of death among CRC patients. The underlying mechanisms of action resulting in cancer progression are beginning to unravel. The reported molecular and biochemical mechanisms that might contribute to the phenotypic changes in favor of carcinogenesis include apoptosis inhibition, enhanced tumor cell proliferation, increased invasiveness, cell adhesion perturbations, angiogenesis promotion, and immune surveillance inhibition. These events may contribute to the development and progression of cancer. A biomarker is a molecule that can be detected in tissue, blood, or stool samples to allow the identification of pathological conditions such as cancer. Thus, it would be beneficial to identify reliable and practical molecular biomarkers that aid in the diagnostic and therapeutic processes of CRC. Recent research has targeted the development of biomarkers that aid in the early diagnosis and prognostic stratification of CRC. Despite that, the identification of diagnostic, prognostic, and/or predictive biomarkers remains challenging, and previously identified biomarkers might be insufficient to be clinically applicable or offer high patient acceptability. Here, we discuss recent advances in the development of molecular biomarkers for their potential usefulness in early and less-invasive diagnosis, treatment, and follow-up of CRC.

Training in therapeutic endoscopy: meeting present and future challenges

Medical endoscopy trainees face numerous, often conflicting demands on their time. This can result in suboptimal endoscopy training and in difficulty achieving certification in basic endoscopy within the existing 5-year training programme. Endoscopic management of acute gastrointestinal bleeding and basic polypectomy are integral to basic service provision. Competence in these and other therapeutic procedures, including dealing with complications, is currently acquired opportunistically, or through experiential independent practice. This article proposes several potential solutions that may help with endotherapy training in the current UK training programmes. It also addresses issues relating to speciality training when reduced to 4 years in 2022. Advanced endotherapy training needs to be optimised by understanding how to select individuals with the appropriate skills and how to accelerate therapeutic training at the appropriate time. Training programmes will need to adapt and can learn from countries where the pathway is more developed and established. Future training will include a dedicated subspeciality training programme for advanced therapy with competitive entry. Advanced therapy training will be matched to service needs. Scoring systems for case complexity integrated with regional and supraregional networks, would allow referral of selected cases to the most appropriate specialised units.

Low detection rate of advanced neoplasia within 5 years after polypectomy of small serrated adenoma

AIM

Patients with small serrated adenomas (SAs) (<10 mm) often undergo surveillance colonoscopy before the routine recommended time. We aimed to determine the appropriate surveillance intervals following polypectomy of small SAs for symptomatic patients.

METHOD

We retrospectively reviewed the data of 638 patients, including 122 cases and 516 controls. Subjects in the case group had small SAs at baseline colonoscopy, including sessile SA/polyps and traditional SAs, while subjects in the control group had negative findings. All patients underwent at least one surveillance colonoscopy during the following 5 years.

RESULTS

There was no significant difference in the incidence rate of advanced neoplasia between the two groups over a 5-year duration (3.6% vs 2.6%, p=0.455). Moreover, both groups also showed a low prevalence of SA formation over 1-5 years (3.6% vs 1.0%, p=0.145). Patients with baseline SA tended to undergo the first surveillance colonoscopy earlier than those without adenoma (≤1 year vs 1 to ≤3 years). Seventy-one (11.1%) of the total included subjects underwent inadequate initial colonoscopy, and 30 (42.3%) underwent early surveillance of adenoma formation within 1 year. Patients with a family history of colorectal cancer (OR 4.69, 95% CI 1.48 to 14.71, p=0.017) or inadequate baseline colonoscopy (OR 3.17, 95% CI 1.202 to 8.409, p=0.035) were at a higher risk of metachronous adenoma formation during the surveillance period.

CONCLUSION

Patients with small SAs at baseline gain little benefit from follow-up of colonoscopy within 5 years after complete polypectomy.

Quality indicators in colonoscopy. The colonoscopy procedure

The aim of the project this paper is part of was to propose quality and safety procedures and indicators to facilitate quality improvement in digestive endoscopy units. In this second issue, procedures and indicators are suggested regarding colonoscopy. First, a diagram charting the previous and subsequent steps of colonoscopy was designed. A group of experts in health care quality and/or endoscopy, under the auspices of the Sociedad Española de Patología Digestiva (SEPD), performed a qualitative review of the literature regarding colonoscopy-related quality indicators. Subsequently, using a paired-analysis method, the aforementioned literature was selected and analyzed. A total of 13 specific indicators were found aside of the common markers elsewhere described, ten of which are process-related (one pre-procedure, seven procedure, and two post-procedure markers) while the remaining three are outcome-related. Quality of evidence was assessed for each one of them using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) classification.

Performance measures for endoscopy services: A European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a list of key performance measures for endoscopy services. We recommend that these performance measures be adopted by all endoscopy services across Europe. The measures include those related to the leadership, organization, and delivery of the service, as well as those associated with the patient journey. Each measure includes a recommendation for a minimum and target standard for endoscopy services to achieve. We recommend that all stakeholders in endoscopy take note of these ESGE endoscopy services performance measures to accelerate their adoption and implementation. Stakeholders include patients and their advocacy groups; service leaders; staff, including endoscopists; professional societies; payers; and regulators.

Improving diagnosis, prognosis and prediction by using biomarkers in CRC patients (Review)

Colorectal cancer (CRC) is among the most common cancers. In fact, it is placed in the third place among the most diagnosed cancer in men, after lung and prostate cancer, and in the second one for the most diagnosed cancer in women, following breast cancer. Moreover, its high mortality rates classifies it among the leading causes of cancer‑related death worldwide. Thus, in order to help clinicians to optimize their practice, it is crucial to introduce more effective tools that will improve not only early diagnosis, but also prediction of the most likely progression of the disease and response to chemotherapy. In that way, they will be able to decrease both morbidity and mortality of their patients. In accordance with that, colon cancer research has described numerous biomarkers for diagnostic, prognostic and predictive purposes that either alone or as part of a panel would help improve patient's clinical management. This review aims to describe the most accepted biomarkers among those proposed for use in CRC divided based on the clinical specimen that is examined (tissue, faeces or blood) along with their restrictions. Lastly, new insight in CRC monitoring will be discussed presenting promising emerging biomarkers (telomerase activity, telomere length and micronuclei frequency).

Leaving colorectal polyps in place can be achieved with high accuracy using blue light imaging (BLI)

Objectives

A negative predictive value of more than 90% is proposed by the American Society of Gastrointestinal Endoscopy Preservation and Incorporation of Valuable Endoscopic Innovations (PIVI) statement for a new technology in order to leave distal diminutive colorectal polyps in place without resection. To our knowledge, no prior prospective study has yet evaluated the feasibility of the most recently introduced blue light imaging (BLI) system for real-time endoscopic prediction of polyp histology for the specific endpoint of leaving hyperplastic polyps in place.

Aims

Prospective assessment of real-time prediction of colorectal polyps by using BLI.

Material and methods

In total, 177 consecutive patients undergoing screening or surveillance colonoscopy were included. Colorectal polyps were evaluated in real-time by using high-definition endoscopy and the BLI technology without optical magnification. Before resection, the endoscopist described each polyp according to size, shape and surface characteristics (pit and vascular pattern, colour and depression), and histology was predicted with a level of confidence (high or low).

Results

Histology was predicted with high confidence in 92.5% of polyps. Sensitivity of BLI for prediction of adenomatous histology was 92.68%, with a specificity and accuracy of 94.87 and 93.75%, respectively. Following the recommendation of the PIVI statement, positive and negative predictive values were calculated with values of 95 and 92.5%, respectively. Prediction of surveillance based on both US and European guidelines was correctly predicted in 91% of patients.

Conclusion

The most recently introduced BLI technology is accurate enough to leave distal colorectal polyps in place without resection. BLI also allowed for assignment of postpolypectomy surveillance intervals. This approach therefore has the potential to reduce costs and risks associated with the redundant removal of diminutive colorectal polyps.

New endoscopy advances to refine adenoma detection rate for colorectal cancer screening: None is the winner

Colorectal cancer (CRC) is the third most common cancer in males and second in females, and globally the fourth cause for cancer death worldwide. Oncological screening of CRC has a major role in the management of the disease and it is mostly performed by colonoscopy. Anyway, effectiveness of endoscopic screening for CRC strictly depends on adequate detection and removal of potentially precancerous lesions, and accuracy of colonoscopy in detection of adenomas is still suboptimal. For this reason, several technological advances have been implemented in order to improve the diagnostic sensitivity of colonoscopy in adenoma detection. Among these: (1) Visual technologies such as chromoendoscopy and narrow band imaging; (2) optical innovation as high definition endoscopy, full-spectrum endoscopy or Third Eye Retroscope; and (3) mechanical advances as Cap assisted colonoscopy, Endocuff, Endoring and G-Eye endoscope. All these technologies advances have been tested over time by clinical studies with mixed results. Which of them is more likely to be successful in the next future?

The Diagnostic Yield of Colonoscopy Stratified by Indications

Introduction

Danish centers reserve longer time for screening colonoscopies and allocate the most experienced endoscopists to these cases. The objective of this study is to determine the diagnostic yield in colonoscopies for different indications to improve planning of colonoscopy activity and allocation of the highly skilled endoscopists.

Methods

Nine hundred and ninety-nine randomly collected patients from a prospectively maintained database were grouped in defined referral indication groups. Five groups were compared in respect of the detection rate of adenomas and cancers.

Results

Two hundred and eighty-nine of 1098 colonoscopies in 999 patients showed significant neoplastic findings, resulting in 591 adenoma resections. Eighty-five percent were treated with a snare resection, and 15% with endoscopic mucosa resection (EMR). Positive findings in the indication groups were (1) symptoms, 25%; (2) positive screening, 17%; (3) previous resection of adenomas, 45%; (4) previous resection of colorectal cancer, 15%; and (5) surveillance of patients with high-risk family history of cancer, 35%.

Conclusion

The majority of adenomas found during colonoscopy can be treated with simple techniques. If individualized time slots are considered, the adenoma follow-up colonoscopies are likely to be the most time-consuming group with more than twice the number of adenomas detected as compared to other indications.

Association Between Time to Colonoscopy After a Positive Fecal Test Result and Risk of Colorectal Cancer and Cancer Stage at Diagnosis

IMPORTANCE

The fecal immunochemical test (FIT) is commonly used for colorectal cancer screening and positive test results require follow-up colonoscopy. However, follow-up intervals vary, which may result in neoplastic progression.

OBJECTIVE

To evaluate time to colonoscopy after a positive FIT result and its association with risk of colorectal cancer and advanced-stage disease at diagnosis.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study (January 1, 2010-December 31, 2014) within Kaiser Permanente Northern and Southern California. Participants were 70 124 patients aged 50 through 70 years eligible for colorectal cancer screening with a positive FIT result who had a follow-up colonoscopy.

EXPOSURES

Time (days) to colonoscopy after a positive FIT result.

MAIN OUTCOMES AND MEASURES

Risk of any colorectal cancer and advanced-stage disease (defined as stage III and IV cancer). Odds ratios (ORs) and 95% CIs were adjusted for patient demographics and baseline risk factors.

RESULTS

Of the 70 124 patients with positive FIT results (median age, 61 years [IQR, 55-67 years]; men, 52.7%), there were 2191 cases of any colorectal cancer and 601 cases of advanced-stage disease diagnosed. Compared with colonoscopy follow-up within 8 to 30 days (n = 27 176), there were no significant differences between follow-up at 2 months (n = 24 644), 3 months (n = 8666), 4 to 6 months (n = 5251), or 7 to 9 months (n = 1335) for risk of any colorectal cancer (cases per 1000 patients: 8-30 days, 30; 2 months, 28; 3 months, 31; 4-6 months, 31; and 7-9 months, 43) or advanced-stage disease (cases per 1000 patients: 8-30 days, 8; 2 months, 7; 3 months, 7; 4-6 months, 9; and 7-9 months, 13). Risks were significantly higher for examinations at 10 to 12 months (n = 748) for any colorectal cancer (OR, 1.48 [95% CI, 1.05-2.08]; 49 cases per 1000 patients) and advanced-stage disease (OR, 1.97 [95% CI, 1.14-3.42]; 19 cases per 1000 patients) and more than 12 months (n = 747) for any colorectal cancer (OR, 2.25 [95% CI, 1.89-2.68]; 76 cases per 1000 patients) and advanced-stage disease (OR, 3.22 [95% CI, 2.44-4.25]; 31 cases per 1000 patients).

CONCLUSIONS AND RELEVANCE

Among patients with a positive fecal immunochemical test result, compared with follow-up colonoscopy at 8 to 30 days, follow-up after 10 months was associated with a higher risk of colorectal cancer and more advanced-stage disease at the time of diagnosis. Further research is needed to assess whether this relationship is causal.

Performance measures for lower gastrointestinal endoscopy: 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 lower gastrointestinal endoscopy. We recommend that endoscopy services across Europe adopt the following seven key performance measures for lower gastrointestinal endoscopy for measurement and evaluation in daily practice at a center and endoscopist level: 1 rate of adequate bowel preparation (minimum standard 90%); 2 cecal intubation rate (minimum standard 90%); 3 adenoma detection rate (minimum standard 25%); 4 appropriate polypectomy technique (minimum standard 80%); 5 complication rate (minimum standard not set); 6 patient experience (minimum standard not set); 7 appropriate post-polypectomy surveillance recommendations (minimum standard not set). Other identified performance measures have been listed as less relevant based on an assessment of their importance, scientific acceptability, feasibility, usability, and comparison to competing measures.

Old habits die hard: a case study on how new ways of teaching colonoscopy affect the habitus of experienced clinicians

OBJECTIVES

The purpose of this study is to explore the habitual constraints and opportunities that affect how experienced clinicians learn new skills and, in particular, how new ways of teaching can influence these.

METHODS

  We conducted a case study based on a specialized training program for colonoscopy services in Denmark. Data was obtained from a short-term ethnographic fieldwork and in-depth interviews during this program. Participants were 12 experienced colonoscopists and three expert colonoscopy trainers from Denmark and UK. The analysis of data involved categorization, inductive coding, and theoretical reading inspired by sociological theory.

RESULTS

The experienced clinicians' responsiveness to training was shaped by an underlying logic of colonoscopy practice that was characterized by tacit skills, routine work, lower status, skepticism and self-protectiveness. In order to overcome these habitual constraints, the trainers applied a pedagogical approach based on four methods: 1) intellectualization: 'academization' of skills and competencies, 2) sensing and scaffolding: hands-on experiences and learning by doing, 3) asymmetry: accentuating the authority and respect of the trainer, and 4) relation-building: building relationship and engagement between trainer and clinician. This multi-dimensional approach to teaching enabled the trainers to affect the clinicians' logic of practice and to create buy-in (so-called illusio).

CONCLUSIONS

Clinical skills include socially constructed behaviors and unconscious competences which affect experienced clinicians' responsiveness to continuing medical education. This study suggests four educational strategies that may help trainers to establish new logics of practice in experienced clinicians and to improve the clinicians' conscious competence.

Should Assessment of Quality Indicator of Colonoscopy Be Varied Depending on the Colonoscopic Technique Level?

BACKGROUND/AIM

The purpose of this research was to evaluate if withdrawal time is a useful index in spite of differences in gastroenterologists' ability and if there are other quality indicators of colonoscopy.

METHODS

A total of 665 consecutive, asymptomatic individuals of average risk between 50 and 75 years of age who underwent screening colonoscopies performed by 12 gastroenterologists were included in this study. The endoscopists were classified to either the experienced group (group A, N = 6) or the under-experienced group (group B, N = 6). The endoscopists were unaware that they were being studied during the two-month study period.

RESULTS

In group A, adenoma detection rate was 0.56, while in group B it was 0.43 (P = 0.048). The mean withdrawal time ranged widely from 4.2 to 10.3 min per patient with a mean value of 6.83 for group A and 6.54 for group B. There was a significantly positive relationship between the number of adenomas detected and the withdrawal time for group B (r = 0.827, P = 0.005), but not for group A (r = -0.152, P = 0.584). In the case of group A, the ratio of cecal intubation time to withdrawal time (I/E ratio) less than 1 showed significantly correlated adenoma detection rate compared to I/E ratio greater than 1 (r = -0.308, P = 0.036). In the case of group B, mean I/E ratio was 1.7 and all endoscopists' I/E ratios were greater than 1.

CONCLUSIONS

For experienced endoscopists, a useful supplementary quality indicator of colonoscopy is to keep intubation/withdrawal time ratio less than 1 and it is necessary for under-experienced endoscopists to try to keep enough withdrawal time.

Quality Assurance in Endoscopy: Which Parameters?

BACKGROUND

The verbalisation of quality standards and parameters by medical societies are relevant for qualitative improvement but may also be an instrument to demand more resources for health care or be a unique characteristic. Within the health care system 3 different quality levels can be defined: structure, process and result quality.

METHODS

The current S2k guideline of the German Society for Gastroenterology (quality requirements for gastrointestinal endoscopy) AWMF registry no. 021-022 provides recommendations based on the available evidence for the structure quality (requirements for equipment, human resources) as well as for the process quality (patient preparation, conduct, documentation) and result quality (follow-up of specific endoscopic procedures).

RESULTS

Based on these recommendations, measurable quality indicators/parameters for the endoscopy have been selected and formulated. General quality parameters for endoscopic examinations are given as well as quality parameters for specific procedures for the preparation, conduct, and follow-up of specific endoscopic interventions.

CONCLUSION

Only the regular review of processes and courses by means of defined measurement parameters builds up the basis for corrections based on facts. In addition, the implementation of recommended standards may be an instrument in demanding more resources from the health care system and, therefore, should be embedded as routine.

Carbon dioxide insufflation or warm-water infusion for unsedated colonoscopy: A randomized controlled trial in patients with chronic constipation in China

AIMS

The effect of carbon dioxide (CO2) insufflation and warm-water infusion during colonoscopy on patients with chronic constipation remains unknown. We evaluated CO 2 insufflation and warm-water irrigation versus air insufflation in unsedated patients with chronic constipation in China.

PATIENTS AND METHODS

This randomized, single-center, controlled trial enrolled 287 consecutive patients, from January 2014 to January 2015, who underwent colonoscopy for chronic constipation. Patients were randomized to CO2 insufflation, warm-water irrigation and air insufflation colonoscopy insertion phase groups. Pain scores were assessed by the visual analog scale (VAS). The primary outcome was real-time maximum insertion pain, recorded by an unblinded nurse assistant. At discharge, the recalled maximum insertion pain was recorded. Meanwhile, patients were requested to select the VAS at 0, 10, 30, and 60 min after the procedure. In addition, cecal intubation and withdrawal time, total procedure time, and adjunct measures were recorded.

RESULTS

A total of 287 patients were randomized. The correlation between real-time and recalled maximum insertion pain ((Pearson coefficient r = 0.929; P < 0.0001) confirmed internal validation of the primary outcome. The mean real-time maximum pain scores during insertion 2.9 ± 2.1 for CO2, 2.7 ± 1.9 for water achieved a significantly lower pain score compared with air (5.7 ± 2.5) group (air vs CO2 P < 0.001; air vs water P < 0.001). However, no significant pain score differences were found between the patients in the CO2 and water groups (CO2 vs water, P = 0.0535). P values in painless colonoscopy and only discomfort colonoscopy (pain 1-2) were, respectively, 6 (6.4%) and 8 (8.5%) for air; 17 (17.7%) and 29 (30.2%) for CO2; 16 (16.5%) and 31 (31.9%) for water. At 0, 10, 30, and 60 min postprocedure, pain scores showed in the CO2 and water groups had significantly reduced than in air group. Insertion time was significantly different between air (10.6 ± 2.5) and CO2 ( 7.2 ± 1.4) (air vs CO2 P < 0.001), air and water (6.9 ± 1.3) (air vs water P < 0.001). However, CO2 and was not significantly different in cecum-intubated time (CO2 vs water, P = 0.404). CO2 and water group in extubation time were significantly different, respectively, CO2 (7.9 ± 1.1) and water (8.0 ± 1.1) (CO2 vs water, P = 0.707). CO2 or water group required less implementation of adjunct measures and more willingness to repeat the procedure.

CONCLUSIONS

Compared with air, the CO2 or water-aided method reduced real-time maximum pain and cecum-intubated time for chronic constipated patients in unsedated colonoscopy. The CO2 insufflation or warm-water irrigation may be a simple and inexpensive way to reduce discomfort in unsedated patients with constipation. This study demonstrated an advantage of using CO2 insufflation and warm-water irrigation during colonoscopy in unsedated constipated patients in China.

Colorectal cancer

Colorectal cancer had a low incidence several decades ago. However, it has become a predominant cancer and now accounts for approximately 10% of cancer-related mortality in western countries. The 'rise' of colorectal cancer in developed countries can be attributed to the increasingly ageing population, unfavourable modern dietary habits and an increase in risk factors, such as smoking, low physical exercise and obesity. New treatments for primary and metastatic colorectal cancer have emerged, providing additional options for patients; these treatments include laparoscopic surgery for primary disease, more-aggressive resection of metastatic disease (such as liver and pulmonary metastases), radiotherapy for rectal cancer, and neoadjuvant and palliative chemotherapies. However, these new treatment options have had limited impact on cure rates and long-term survival. For these reasons, and the recognition that colorectal cancer is long preceded by a polypoid precursor, screening programmes have gained momentum. This Primer provides an overview of the current state of the art of knowledge on the epidemiology and mechanisms of colorectal cancer, as well as on diagnosis and treatment.

MAPRE1 as a plasma biomarker for early-stage colorectal cancer and adenomas

Blood-based biomarkers for early detection of colorectal cancer could complement current approaches to colorectal cancer screening. We previously identified the APC-binding protein MAPRE1 as a potential colorectal cancer biomarker. Here, we undertook a case-control validation study to determine the performance of MAPRE1 in detecting early colorectal cancer and colon adenoma and to assess the potential relevance of additional biomarker candidates. We analyzed plasma samples from 60 patients with adenomas, 30 with early colorectal cancer, 30 with advanced colorectal cancer, and 60 healthy controls. MAPRE1 and a set of 21 proteins with potential biomarker utility were assayed using high-density antibody arrays, and carcinoembryonic antigen (CEA) was assayed using ELISA. The biologic significance of the candidate biomarkers was also assessed in colorectal cancer mouse models. Plasma MAPRE1 levels were significantly elevated in both patients with adenomas and patients with colorectal cancer compared with controls (P < 0.0001). MAPRE1 and CEA together yielded an area under the curve of 0.793 and a sensitivity of 0.400 at 95% specificity for differentiating early colorectal cancer from controls. Three other biomarkers (AK1, CLIC1, and SOD1) were significantly increased in both adenoma and early colorectal cancer patient plasma samples and in plasma from colorectal cancer mouse models at preclinical stages compared with controls. The combination of MAPRE1, CEA, and AK1 yielded sensitivities of 0.483 and 0.533 at 90% specificity and sensitivities of 0.350 and 0.467 at 95% specificity for differentiating adenoma and early colorectal cancer, respectively, from healthy controls. These findings suggest that MAPRE1 can contribute to the detection of early-stage colorectal cancer and adenomas together with other biomarkers.

Colorectal cancer screening--optimizing current strategies and new directions

The first evidence that screening for colorectal cancer (CRC) could effectively reduce mortality dates back 20 years. However, actual population screening has, in many countries, halted at the level of individual testing and discussions on differences between screening tests. With a wealth of new evidence from various community-based studies looking at test uptake, screening-programme organization and the importance of quality assurance, population screening for CRC is now moving into a new realm, promising better results in terms of reducing CRC-specific morbidity and mortality. Such a shift in the paradigm requires a change from opportunistic, individual testing towards organized population screening with comprehensive monitoring and full-programme quality assurance. To achieve this, a combination of factors--including test characteristics, uptake, screenee autonomy, costs and capacity--must be considered. Thus, evidence from randomized trials comparing different tests must be supplemented by studies of acceptance and uptake to obtain the full picture of the effectiveness (in terms of morbidity, mortality and cost) the different strategies have. In this Review, we discuss a range of screening modalities and describe the factors to be considered to achieve a truly effective population CRC screening programme.