Factors Associated With Adenoma Detection in Propofol-sedated Patients

Comparison of Right Colon Flat Polyp Detection Rate by Water Exchange Versus Water Immersion-pooled Results of Data File of 3 Published Reports

GOALS

We tested the hypothesis that water exchange (WE) achieved a significantly higher right colon flat polyp detection rate (rFPDR) than water immersion (WI).

BACKGROUND

Current endoscopy methods provide real-time morphology but not histopathology. Flat serrated polyps are difficult to find during colonoscopy. In 2022 2 studies reported that the serrated polyp detection rate (SPDR) significantly inversely predicted the development of interval cancers. In 2021 1 systemic review with meta-analysis showed that WE, but not WI increased SPDR. The relative contributions of WE and WI on rFPDR are unknown.

STUDY

Individual patient data from 3 reports comparing air insufflation, WI, and WE were pooled. Multiple logistic regression analysis was used to assess the factors associated with a higher rFPDR.

RESULTS

The pooled data showed that the rFPDR of air insufflation, WI, and WE were 15.4%, 14.1%, and 19.4% ( P =0.009), respectively. After adjusting for age and withdrawal time, multiple logistic regression analysis revealed that WE, when compared with WI, was significantly associated with a higher rFPDR (adjusted odds ratio[aOR]=1.53, P =0.002). Analysis of data on pathology and size were omitted to avoid duplicating our earlier publications.

CONCLUSIONS

Significantly higher rFPDR was achieved by WE. Water exchange rather than WI merits consideration for use to maximize rFPDR. Removal of flat polyps, and by inference serrated polyps, ensures their optimal management to minimize the occurrence of interval cancers. The potential benefit of WE in maximizing SPDR and minimizing interval cancers deserves evaluation in long-term randomized controlled studies focused on flat polyps detection.

Comparison of Procedural Sequences in Sedated Same-Day Bidirectional Endoscopy with Water-Exchange Colonoscopy: A Randomized Controlled Trial

Background: Previous studies have favored esophagogastroduodenoscopy (EGD) followed by colonoscopy as the optimal sequence in bidirectional endoscopy (BDE) with air insufflation. However, the optimal sequence in same-day BDE with WE colonoscopy is unclear. Methods: A total of 200 patients undergoing BDE with propofol sedation from May 2018 to January 2021 were randomized to either the EGD-first group (n = 100) or the colonoscopy-first group (n = 100). Results: The EGD-first group required a longer cecal-intubation time (median 16.0 min vs. 13.7 min, p < 0.001) and a lower Boston Bowel Preparation Scale score (8.5 vs. 9, p = 0.030) compared with the colonoscopy-first group. However, the EGD-first group needed a significantly lower dose of propofol (200 mg vs. 250 mg, p < 0.001) and a shorter recovery time (7 min vs. 13.5 min, p < 0.001), resulting in a shorter turnover time of the endoscopy room (39.5 min vs. 42.6 min, p = 0.004). There were no differences in the sedation-related adverse events, patients’ satisfaction scores, adenoma-detection rates, or the outcomes of EGD between the two groups. Conclusions: During propofol-sedated BDE, EGD followed by WE colonoscopy was more efficient with a shorter turnover time despite a longer cecal-intubation time (NCT03638713).

When should we perform colonoscopy to increase the adenoma detection rate?

The rate of adenoma detection is the most reliable quality indicator of colonoscopy. Studies have reported that colonoscopy performed in morning has a higher adenoma detection rate (ADR) than that performed in the afternoon. These studies have explained that several physician-related factors such as undergoing an emergency procedure the night before colonoscopy, accumulated workload, and increased fatigue level in the afternoon might have led to such finding. However, several opposing articles have indicated that the time of day and ADR is not quite related. Complex confounding factors can impact study results. Colonoscopy withdrawal time and bowel preparation quality are key factors. However, queue list numbers, participation of academic fellows, nurses' assistance, and the number of colonoscopies allocated per hour are also notable factors. Recently, an attempt has been made to homogenize the ADR in the morning and afternoon through artificial intelligence-assisted colonoscopy. This review article introduces the history of this long-debated topic, discusses points to consider in real-world practice, and suggests new ideas for planning future research. By understanding this issue, the rate of adenoma detection during colonoscopy is expected to be improved further.

Sessile serrated adenoma/polyp detection rate of water exchange, Endocuff, and cap colonoscopy: A network meta-analysis

BACKGROUND AND AIM

Sessile serrated adenoma/polyp (SSA/P) may contribute to interval cancer. In a recent meta-analysis, water exchange (WE) was shown to be superior to Endocuff and cap colonoscopy at adenoma and advanced adenoma detection. The strong positive correlation between adenoma detection rate (ADR), advanced adenoma detection rate (AADR), and sessile serrated adenoma/polyp detection rate (SSA/PDR) prompted us to hypothesize that WE could significantly improve SSA/PDR compared with Endocuff and cap colonoscopy.

METHODS

The literature was searched for all randomized controlled trials (RCTs) that reported SSA/PDR as an outcome and included the keywords colonoscopy, and water exchange, Endocuff, or cap. We performed traditional network meta-analyses with random effect models comparing SSA/PDR of each method using air insufflation as the control and reported the odds ratios (ORs) with 95% confidence interval (CI). Performances were ranked based on P-score.

RESULTS

A total of 531 articles resulted from initial keywords search. Eleven RCTs were included in the analysis. A total of 7856 patients underwent air insufflation, WE, Endocuff, or cap colonoscopy. WE significantly increased SSA/PDR (OR 2.04; 95% CI 1.33-3.13). Endocuff (OR 1.15; 95% CI 0.94-1.41) and cap (OR 1.08; 95% CI 0.42-2.74) did not significantly impact SSA/P detection. P-scores for WE (0.96), Endocuff (0.49), cap (0.37), and air insufflation (0.17) suggested that WE had the highest SSA/PDR. The results did not change after adjusting for mean withdrawal time and indication for colonoscopy.

CONCLUSION

Water exchange significantly increases SSA/PDR and is superior to Endocuff and cap colonoscopy at detecting SSA/P.

Variation Over Time and Factors Associated With Detection Rates of Sessile Serrated Lesion Across the United States: Results Form a National Sample Using the GIQuIC Registry

INTRODUCTION

Sessile serrated lesions (SSLs) are important precursor lesions for the CpG island-methylated pathway to colorectal cancer. The reported detection rates of SSL are highly variable, and national or population-based estimates are not available. Patient-, provider-, and procedure-level factors associated with the detection rates of SSL have not been well described. The aim of our study was to study the detection rates of SSL, variability of rates over time, and factors associated with detection rates of SSL in a national sample of patients undergoing colonoscopy using the GIQuIC registry.

METHODS

We used colonoscopies submitted to the GIQuIC registry from 2014 to 2017 on adults, aged 18-89 years. Only the first colonoscopy record per patient was included. Indications for colonoscopy were categorized as screening, diagnostic, and surveillance. We used the hierarchical logistic models to study the factors associated with the detection rates of SSL. The Cochrane-Armitage test was used to study the significance of trend over time.

RESULTS

There were a total of 5,173,211 colonoscopies performed by 3,934 endoscopists during the study period. Among the 2,101,082 screening colonoscopies over the study period in adults older than or equal to 50 years that were complete to the cecum, the average detection rate per endoscopist for SSL was 6.43% (SD 5.18) and 6.25% standardized for the 2010 US population. There was a significant increase in the detection rates of SSLs from screening colonoscopies over the study period from 4.99% in 2014 to 7.09% in 2017 (P trend <0.001). Clinically significant factors associated with higher detection rates of SSL were longer withdrawal times (>11 minutes vs ≤6 minutes) (odds ratio [OR] 9.61; 9.03-10.24), adequate preparation (OR 1.25; 1.22-1.28), female sex (OR 1.17; 1.16-1.18), and use of a specialized gastrointestinal pathology group (OR 1.12; 95% confidence interval 1.04, 1.19).

DISCUSSION

Population-based estimates of the detection rates of SSL are 6% and have increased over time.

Impact of new techniques on adenoma detection rate based on meta-analysis data

The high incidence of colorectal cancer and the occurrence of interval cancers after screening colonoscopy support the need to develop methods to increase adenoma detection rate (ADR). This review focuses on the importance of ADR and the impact of new techniques on ADR based on meta-analysis data. The low-cost interventions (such as water-aided colonoscopy, second observation, and dynamic position change) were effective in increasing ADR. So were enhanced imaging techniques and add-on devices. Increase with higher cost interventions such as newer scopes is uncertain. Water exchange (WE) has the highest ADR compared with water immersion, air insufflation, and carbon dioxide insufflation. Second observation with forward or retroflexed views improved the right colon ADR. Add-on devices result in only modest improvement in ADR, of particular help in low performing endoscopists. The second-generation narrow-band imaging (NBI) provided a two-fold brighter image than the previous system. The improvement in ADR with NBI required the "best" quality bowel preparation. New endoscopic techniques incur various additional costs, nil for WE, small for tip attachments but large for the newer scopes. In conclusion, one or more of the above methods to improve ADR may be applicable in Taiwan. A comparison of these approaches to determine which is the most cost-effective is warranted.

An overview of deep learning algorithms and water exchange in colonoscopy in improving adenoma detection

Introduction: Among the Gastrointestinal (GI) Endoscopy Editorial Board top 10 topics in advances in endoscopy in 2018, water exchange colonoscopy and artificial intelligence were both considered important advances. Artificial intelligence holds the potential to increase and water exchange significantly increases adenoma detection.Areas covered: The authors searched MEDLINE (1998-2019) using the following medical subject terms: water-aided, water-assisted and water exchange colonoscopy, adenoma, artificial intelligence, deep learning, computer-assisted detection, and neural networks. Additional related studies were manually searched from the reference lists of publications. Only fully published journal articles in English were reviewed. The latest date of the search was Aug10, 2019. Artificial intelligence, machine learning, and deep learning contribute to the promise of real-time computer-aided detection diagnosis. By emphasizing near-complete suction of infused water during insertion, water exchange provides salvage cleaning and decreases cleaning-related multi-tasking distractions during withdrawal, increasing adenoma detection. The review will address how artificial intelligence and water exchange can complement each other in improving adenoma detection during colonoscopy.Expert opinion: In 5 years, research on artificial intelligence will likely achieve real-time application and evaluation of factors contributing to quality colonoscopy. Better understanding and more widespread use of water exchange will be possible.