Endoscopic management of large ileocecal valve lesions over an 18-year interval.

Background and study aims Ileocecal valve (ICV) lesions are challenging to remove endoscopically. Patients and methods This was a retrospective cohort study, performed at an academic tertiary US hospital. Sessile polyps or flat ICV lesions ≥ 20 mm in size referred for endoscopic mucosal resection (EMR) were included. Successful resection rates, complication rates and recurrence were compared to lesions ≥ 20 mm in size not located on the ICV. Results During an 18-year interval, there were 118 ICV lesions ≥ 20 mm with mean size 28.6 mm (44.9 % females; mean age 71.6 years), comprising 9.03 % of all referred polyps. Ninety ICV lesions (76.3 %) were resected endoscopically, compared to 91.3 % of non-ICV lesions ( P  < 0.001). However, in the most recent 8 years, successful EMR of ICV lesions increased to 93 %. Conventional adenomas comprised 92.2 % of ICV lesions and 7.8 % were serrated. Delayed hemorrhage and perforation occurred in 3.3 % and 0 % of ICV lesions, respectively, compared to 4.8 % and 0.5 % in the non-ICV group. At first follow-up, rates of residual polyp in the ICV and non-ICV groups were 16.5 % and 13.6 %, respectively ( P  = 0.485). At second follow-up residual rates in the ICV and non-ICV lesion groups were 18.6 % and 6.7 %, respectively ( P  = .005). Conclusions Large ICV polyps are a common source of tertiary referrals. Over an 18-year experience, risk of EMR for ICV polyps was numerically lower, and risk of recurrence was numerically higher at first follow and significantly higher at second follow-up compared to non-ICV polyps.

Disagreement between high confidence endoscopic adenoma prediction and histopathological diagnosis in colonic lesions ≤ 3 mm in size.

BACKGROUND: Diminutive colorectal polyps resected during colonoscopy are sometimes histologically interpreted as normal tissue. The aim of this observational study was to explore whether errors in specimen handling or processing account in part for polyps ≤ 3 mm in size being interpreted as normal tissue by pathology when they were considered high confidence adenomas by an experienced endoscopist at colonoscopy. METHODS: One endoscopist photographed 900 consecutive colorectal lesions that were ≤ 3 mm in size and considered endoscopically to be high confidence conventional adenomas. The photographs were reviewed blindly to eliminate poor quality images. The remaining 644 endoscopy images were reviewed by two external experts who predicted the histology while blinded to the pathology results. RESULTS: Of 644 consecutive lesions ≤ 3 mm in size considered high confidence conventional adenomas by a single experienced colonoscopist, 15.4 % were reported as normal mucosa by pathology. The prevalence of reports of normal mucosa in polyps removed by cold snare and cold forceps were 15.2 % and 16.0 %, respectively. When endoscopy photographs were reviewed by two blinded outside experts, the lesions found pathologically to be adenomas and normal mucosa were interpreted as high confidence adenomas by endoscopic appearance in 96.9 % and 93.9 %, respectively, by Expert 1 (P = 0.15), and in 99.6 % and 100 %, respectively, by Expert 2 (P = 0.51). CONCLUSION: Retrieval and/or processing of tissue specimens of tiny colorectal polyps resulted in some lesions being diagnosed as normal tissue by pathology despite being considered endoscopically to be high confidence adenomas. These findings suggest that pathology interpretation is not a gold standard for lesion management when this phenomenon is observed.

Risk of cancer in 10 - 19 mm endoscopically detected colorectal lesions.

BACKGROUND: Recent data indicate that the risk of cancer in colorectal lesions < 10 mm is lower than previously reported, possibly reflecting improved detection of flat, low-volume lesions with a low risk of cancer. Few studies have examined the prevalence of cancer in colorectal lesions 10 - 19 mm in size. METHODS: We reviewed a prospectively collected database of all colorectal lesions removed at a single endoscopy center in order to identify lesions of 10 - 19 mm in size and review their histology. Lesions ≥ 20 mm were evaluated as a control group. We reviewed photographs of cancerous lesions to determine the frequency of endoscopic features of cancer. RESULTS: A total of 5093 lesions ≥ 10 mm were removed from 4020 patients (mean age 63.2 years, 34.4 % female). Among 3068 lesions 10 - 19 mm in size, 28 (0.9 %) had adenocarcinoma, including 1.2 % of conventional adenomas and 0.3 % of serrated class lesions. These rates were lower than the 6.9 % and 2.0 % rates of cancer found in conventional adenomatous lesions and serrated lesions ≥ 20 mm, respectively. Cancer was suggested by endoscopic features in 52.0 % of malignancies 10 - 19 mm in size compared with 79.2 % of lesions ≥ 20 mm. CONCLUSIONS: The prevalence of cancer in 10 - 19 mm colorectal lesions was much lower than previously reported. The cancer risk was higher in conventional adenomas than in serrated lesions. Cancer was endoscopically evident prior to resection in slightly more than half of colorectal lesions 10 - 19 mm in size.

Diminutive Polyps With Advanced Histologic Features Do Not Increase Risk for Metachronous Advanced Colon Neoplasia.

BACKGROUND & AIMS: With advances in endoscopic imaging, it is possible to differentiate adenomatous from hyperplastic diminutive (1-5 mm) polyps during endoscopy. With the optical Resect-and-Discard strategy, these polyps are then removed and discarded without histopathology assessment. However, failure to recognize adenomas (vs hyperplastic polyps), or discarding a polyp with advanced histologic features, could result in a patient being considered at low risk for metachronous advanced neoplasia, resulting in an inappropriately long surveillance interval. We collected data from international cohorts of patients undergoing colonoscopy to determine what proportion of patients are high risk because of diminutive polyps advanced histologic features and their risk for metachronous advanced neoplasia. METHODS: We collected data from 12 cohorts (in the United States or Europe) of patients undergoing colonoscopy after a positive result from a fecal immunochemical test (FIT cohort, n = 34,221) or undergoing colonoscopies for screening, surveillance, or evaluation of symptoms (colonoscopy cohort, n = 30,123). Patients at high risk for metachronous advanced neoplasia were defined as patients with polyps that had advanced histologic features (cancer, high-grade dysplasia, ≥25% villous features), 3 or more diminutive or small (6-9 mm) nonadvanced adenomas, or an adenoma or sessile serrated lesion ≥10 mm. Using an inverse variance random effects model, we calculated the proportion of diminutive polyps with advanced histologic features; the proportion of patients classified as high risk because their diminutive polyps had advanced histologic features; and the risk of these patients for metachronous advanced neoplasia. RESULTS: In 51,510 diminutive polyps, advanced histologic features were observed in 7.1% of polyps from the FIT cohort and 1.5% polyps from the colonoscopy cohort (P = .044); however, this difference in prevalence did not produce a significant difference in the proportions of patients assigned to high-risk status (0.8% of patients in the FIT cohort and 0.4% of patients in the colonoscopy cohort) (P = .25). The proportions of high-risk patients because of diminutive polyps with advanced histologic features who were found to have metachronous advanced neoplasia (17.6%) did not differ significantly from the proportion of low-risk patients with metachronous advanced neoplasia (14.6%) (relative risk for high-risk categorization, 1.13; 95% confidence interval 0.79-1.61). CONCLUSION: In a pooled analysis of data from 12 international cohorts of patients undergoing colonoscopy for screening, surveillance, or evaluation of symptoms, we found that diminutive polyps with advanced histologic features do not increase risk for metachronous advanced neoplasia.

Faster colonoscope withdrawal time without impaired detection using EndoRings.

BACKGROUND AND STUDY AIMS: Mucosal exposure devices on the colonoscope tip have improved detection. We evaluated detection and procedure times in colonoscopies performed with EndoRings. PATIENTS AND METHODS: We had 14 endoscopists in a university practice trial EndoRings. We compared detection and procedure times to age- and indication-matched procedures by the same endoscopists. RESULTS: There were 137 procedures with EndoRings. The adenoma detection rate was 44 % with EndoRings vs. 39 % without ( P  = 0.39). Mean adenomas per colonoscopy (standard deviation) was 1.2 (2.3) with EndoRings vs. 0.9 (1.6) without ( P  = 0.055). Mean insertion time with EndoRings was 6.2 (3.2) minutes vs. 6.6 (6.7) minutes without ( P  = 0.81). Mean withdrawal time with EndoRings in all patients with or without polypectomy was 12.2 (5.3) minutes and 16.1 (10.3) minutes without ( P  = 0.0005). CONCLUSION: EndoRings may allow faster withdrawal during colonoscopy without any reduction in detection. Prospective trials with mucosal exposure devices targeting procedure times as primary endpoints are warranted.

High-definition colonoscopy versus Endocuff versus EndoRings versus full-spectrum endoscopy for adenoma detection at colonoscopy: a multicenter randomized trial.

BACKGROUND AND AIMS: Devices used to improve polyp detection during colonoscopy have seldom been compared with each other. METHODS: We performed a 3-center prospective randomized trial comparing high-definition (HD) forward-viewing colonoscopy alone to HD with Endocuff to HD with EndoRings to the full spectrum endoscopy (FUSE) system. Patients were age ≥50 years and had routine indications and intact colons. The study colonoscopists were all proven high-level detectors. The primary endpoint was adenomas per colonoscopy (APC). RESULTS: Among 1188 patients who completed the study, APC with Endocuff (APC mean ± standard deviation: 1.82 ± 2.58), EndoRings (1.55 ± 2.42), and standard HD colonoscopy (1.53 ± 2.33) were all higher than FUSE (1.30 ± 1.96; P < .001 for APC). The APC for Endocuff was higher than standard HD colonoscopy (P = .014). Mean cecal insertion times with FUSE (468 ± 311 seconds) and EndoRings (403 ± 263 seconds) were both longer than with Endocuff (354 ± 216 seconds; P = .006 and .018, respectively). CONCLUSIONS: For high-level detectors at colonoscopy, forward-viewing HD instruments dominate the FUSE system, indicating that for these examiners image resolution trumps angle of view. Further, Endocuff is a dominant strategy over EndoRings and no mucosal exposure device on a forward-viewing HD colonoscope. (Clinical trial registration number: NCT02345889.).

Neoplasia at 10-year follow-up screening colonoscopy in a private U.S. practice: comparison of yield to first-time examinations.

BACKGROUND AND AIMS: Prior studies assessing the yield of a second screening colonoscopy performed 10 years after an initial screening colonoscopy with negative results did not include a control group of persons undergoing a first screening colonoscopy during the same time interval. Our aim was to describe the incidence of neoplasia at a second screening colonoscopy (performed at least 8 years after the first colonoscopy) in average-risk individuals and compare it with the yield of first screening examinations performed during the same time interval. METHODS: Review of a database of outpatient screening colonoscopies performed between January 2010 and December 2015 in an Atlanta private practice. RESULTS: A total of 2105 average-risk individuals underwent screening colonoscopy, including 470 individuals (53.6% female; mean age ± standard deviation [SD] 64.0 ± 3.9 years) who underwent a second screening examination. In those undergoing second screening, the mean (± SD) interval between examinations was 10.4 years (± 1.1 years, range 8-15 years). At second screening, the polyp detection rate, adenoma detection rate, and advanced neoplasm rate were 44.7%, 26.6%, and 7.4%, respectively. Of 40 advanced neoplasms in 35 individuals, 33 (82.5%) were proximal to the sigmoid colon, and there were no cancers. During the same interval, 1635 individuals (49.4% female; mean age [± SD] 52.6 ± 3.4 years) underwent a first screening colonoscopy. The polyp detection rate, adenoma detection rate, and advanced neoplasm detection rate were 53.5%, 32.2%, and 11.7%, respectively. Of 243 advanced neoplasms in 192 individuals, 152 (62.6%) were proximal to the sigmoid colon, and there were no cancers. After adjustment for age, sex, body mass index, and endoscopist, polyp detection rate, adenoma detection rate, and advanced neoplasm detection rate were all lower at the second screening colonoscopies than at first-time colonoscopies (all P < .001). CONCLUSIONS: Despite being 10 years older, persons with a screening colonoscopy with negative results 10 years earlier had lower rates of adenoma and advanced neoplasm at the second screening examination compared with patients in the same practice undergoing a first screening colonoscopy, and they had no cancers. The fraction of advanced neoplasms that were proximal to the sigmoid colon was high in both first and second screenings. These results support the safety of the recommended 10-year interval between colonoscopies in average-risk persons with an initial examination with negative results.

Calculating the adenoma detection rate in screening colonoscopies only: Is it necessary? Can it be gamed?

Background Current recommendations are to calculate the adenoma detection rate (ADR) in screening colonoscopies only. The need to confine the measure to screening has not been established. Methods We retrospectively assessed our quality database for whether calculating ADR from screening, surveillance, and diagnostic colonoscopies (overall ADR) would alter conclusions about the performance of colonoscopists, compared to using an ADR based only on screening colonoscopies. We also prospectively tested the extent to which one physician could corrupt the screening-only ADR by changing the procedure indication after reviewing the examination findings. Results For 15 physicians, screening ADRs differed from the overall ADR by a mean of 2.6 percentage points (range 0 - 6.9 percentage points). Using the overall ADR rather than screening ADR changed the ADR from just below to just above the recommended screening threshold for one physician. In the prospective assessment, a single expert colonoscopist utilized indication gaming in patients with both screening and diagnostic indications and was able to increase his apparent screening-only ADR from 48.4 % to 55.1 %. Conclusions Use of an overall ADR rather than screening-only ADR could simplify ADR measurement, increase the number of examinations available to measure ADR, seldom affect whether a doctor meets recommended ADR thresholds, and eliminate the potential for gaming the ADR by changing the colonoscopy indication.

High yield of synchronous lesions in referred patients with large lateral spreading colorectal tumors.

BACKGROUND AND AIMS: There are few data on the prevalence of synchronous colorectal lesions in patients who have large lateral spreading tumors (LLSTs). We sought to describe the rate of synchronous lesions found in patients who underwent endoscopic resection of large sessile adenomas and serrated lesions. METHODS: This is a retrospective assessment of a prospectively created database of 728 consecutive patients with resected LLSTs who underwent complete clearing of the colon during 2 colonoscopies by a single expert endoscopist. RESULTS: The 728 patients with resected LLSTs and complete clearing had 4578 synchronous lesions, including 584 patients (80.2%) with at least 1 synchronous conventional adenoma, 132 (18.1%) with at least 1 synchronous conventional adenoma ≥ 20 mm in size, 294 (40.4%) with at least 1 synchronous advanced conventional adenoma, and 6 patients with a synchronous lesion with cancer. Patients with an index large sessile conventional adenoma compared with those with an index large serrated lesion had on average more synchronous conventional adenomas (4.8 vs 2.9, P = .001) and fewer synchronous serrated lesions (1.4 vs 4.5, P < .001). Of the 97 patients with a serrated class index lesion, 28 (28.9%) met criteria for serrated polyposis. CONCLUSIONS: There is a very high prevalence of synchronous lesions, including other large and advanced synchronous lesions, in patients with flat or sessile conventional adenomas and serrated colorectal polyps. Patients with LLSTs in the colon need detailed clearing of the rest of the colon. Patients referred for endoscopic resection of serrated lesions ≥ 20 mm have a very high prevalence of serrated polyposis. This study has potential implications for further stratification of high-risk patient groups in postpolypectomy surveillance guidelines.

The "valley sign" in small and diminutive adenomas: prevalence, interobserver agreement, and validation as an adenoma marker.

BACKGROUND AND AIMS: Classification schemes for differentiation of conventional colorectal adenomas from serrated lesions rely on patterns of blood vessels and pits. Morphologic features have not been validated as predictors of histology. The aim of this study was to describe the prevalence of the "valley sign" and validate it as a marker of conventional adenomas. METHODS: Three experts judged the prevalence of the valley sign in 301 consecutive small adenomas. Medical students were taught to recognize the valley and were tested on their recognition of the valley sign. Consecutive diminutive polyps were video-recorded and used to validate the association of the valley sign with conventional adenomas. RESULTS: The prevalence of the valley sign in 301 consecutive adenomas <10 mm in size, determined by 3 experts, ranged from 35% to 50%. Kappa values for agreement among the 3 experts were 0.557, 0.679, and 0.642. Ten medical students were taught to interpret the valley sign and recognized it with accuracy of 96% or higher in 50 selected photographs of diminutive polyps. Four medical students evaluated video-recordings of 170 consecutive diminutive polyps for the presence of the valley sign. Kappa values for the interpretation of the valley sign ranged from 0.52 to 0.68 among the students. The sensitivity of the valley sign for adenoma ranged from 40.2% to 54.9%, and specificity ranged from 90.2% to 91.7%. The valley sign was strongly associated with adenomas (P < .0001). CONCLUSIONS: The valley sign is insensitive but highly specific for conventional adenoma in diminutive polyps. It may enhance classification schemes for differentiation of adenomas from serrated lesions based on vessels and pits.

Prevalence of sessile serrated adenoma/polyp in hyperplastic-appearing diminutive rectosigmoid polyps.

BACKGROUND AND AIMS: The American Society for Gastrointestinal Endoscopy recommends that distal colon hyperplastic lesions can be left in place without resection if adenomatous histology can be excluded with >90% negative predictive value. However, some lesions could be sessile serrated adenomas/polyps (SSA/Ps), which is also precancerous. The aim of this study was to describe the prevalence of SSA/Ps in hyperplastic-appearing diminutive rectosigmoid polyps. METHODS: We prospectively placed 513 consecutive diminutive rectosigmoid polyps that appeared hyperplastic to an expert endoscopist in individual bottles for pathologic. Each polyp was examined by 3 expert GI pathologists. RESULTS: The prevalence of SSA/P in the study polyps ranged from .6% to 2.1%. The lowest negative predictive value found by the endoscopist for the combination of adenomas plus SSA/Ps was 96.7%. CONCLUSIONS: The prevalence of SSA/Ps in diminutive rectosigmoid hyperplastic-appearing polyps is very low. These results support the safety and feasibility of a "do not resect" policy for diminutive hyperplastic-appearing rectosigmoid polyps.

Yield of a second screening colonoscopy 10 years after an initial negative examination in average-risk individuals.

BACKGROUND AND AIMS: Current guidelines recommend screening colonoscopy at 10-year intervals in average-risk individuals who had baseline screening colonoscopy (no polyps or only hyperplastic polyps ≤5 mm in the recto-sigmoid colon), but the yield of repeat screening at 10 years is unknown. Our aim was to describe the yield of second screening colonoscopy in average-risk individuals performed at least 8 years after a first screening colonoscopy had shown no polyps or only distal hyperplastic polyps ≤5 mm in size. METHODS: This was a review of a database for colonoscopies performed at Indiana University Hospital between January 1999 and November 2015. RESULTS: A total of 4463 individuals underwent screening colonoscopy between January 1999 and July 2007, of which 1566 individuals had no polyps, and 334 individuals had only distal hyperplastic polyps ≤5 mm; 378 individuals (58.4% female) had follow-up screening at least 8 years after the baseline screening examination, with a mean (± standard deviation [SD]) interval of 9.74 years (± 1.2 years; range 8-15 years). Mean (± SD) age at baseline screening examination was 56.7 years (± 5.5 years) and at follow-up screening examination was 66.4 years (± 5.6 years). At the second screening, there were 224 patients (59.3%) with at least 1 polyp, including 144 (38.1%) with at least 1 conventional adenoma. The adenoma detection rate at the second screening examination was 36.1% and 56.8% in the groups with no polyp at baseline and with only distal hyperplastic polyps, respectively. There were 15 advanced neoplasms in 13 individuals (3.4%), of which 12 lesions were proximal to the sigmoid colon. There were no cancers at follow-up. CONCLUSIONS: Among individuals aged ≥50 years, with normal baseline screening colonoscopy results, the incidence of advanced lesions at a second screening colonoscopy at least 8 years later was comparable to that in baseline screening studies. Our findings support current recommendations for screening at 10-year intervals in average-risk individuals.

Clip retention rates and rates of residual polyp at the base of retained clips on colorectal EMR sites.

BACKGROUND AND AIMS: Prophylactic endoscopic clipping may be effective in preventing delayed post-polypectomy hemorrhage after EMR of large colorectal lesions. The rate of retention of hemoclips on EMR sites has not been fully described. The aim of this study was to evaluate the adherence rates of hemoclips placed after EMR of large colorectal lesions. METHODS: This was a retrospective review of a prospectively maintained database of large colorectal polyps (≥20 mm) referred to Indiana University Hospital between June 2006 and August 2015. Sites were closed with a mean of 4 clips. Patients were followed up for 3 to 6 months after EMR with a second follow-up 1 year later. Biopsy specimens of EMR scars were examined at follow-up, including the tissue at the base of retained clips. RESULTS: There were 479 EMR sites in 424 patients that had first follow-up at our center with high-quality photographs of the EMR sites taken immediately after clip placement and at follow-up. Of 1407 Boston Scientific Resolution clips placed, 59 (4.2%) were retained at follow-up. Of 532 Cook Instinct clips placed, 46 (8.6%) were retained at first follow-up (P = .0001). There was no difference in the follow-up interval for the 2 clips. No patient had residual polyp by biopsy at the base of a retained clip. CONCLUSIONS: Clip retention at first follow-up at 3 to 6 months after EMR was twice as high for the Cook Instinct clip compared with Boston Resolution clip but retention rates were low for both clips. Residual polyp at the base of retained clips was not a significant clinical problem.

Risk of cancer in small and diminutive colorectal polyps.

The prevalence of cancer in small and diminutive polyps is relevant to "resect and discard" and CT colonography reporting recommendations. We evaluated a prospectively collected colonoscopy polyp database to identify polyps <10mm and those with cancer or advanced histology (high-grade dysplasia or villous elements). Of 32,790 colonoscopies, 15,558 colonoscopies detected 42,630 polyps <10mm in size. A total of 4790 lesions were excluded as they were not conventional adenomas or serrated class lesions. There were 23,524 conventional adenomas <10mm of which 22,952 were tubular adenomas. There were 14,316 serrated class lesions of which 13,589 were hyperplastic polyps and the remainder were sessile serrated polyps. Of all conventional adenomas, 96 had high-grade dysplasia including 0.3% of adenomas ≤5mm in size and 0.8% of adenomas 6-9mm in size. Of all conventional adenomas, 2.1% of those ≤5mm in size and 5.6% of those 6-9mm in size were advanced. Among 36,107 polyps ≤5mm in size and 6523 polyps 6-9mm in size, there were no cancers. These results support the safety of resect and discard as well as current CT colonography reporting recommendations for small and diminutive polyps.

Cold snare polypectomy effectively reduces polyp burden in familial adenomatous polyposis.

BACKGROUND AND STUDY AIMS: Familial adenomatous polyposis (FAP) is generally managed by colectomy, but in some cases surgery is delayed and polyp burdens are managed endoscopically. We aimed to describe the use of cold snare polypectomy to control the polyp burden in selected patients with FAP. PATIENTS AND METHODS: This was a retrospective cohort study. Polyps were counted and the range of polyp size recorded at each examination. Patients with a reduction in polyp number and mean size were considered to have successful endoscopic reduction of their polyp burdens. RESULTS: Of 79 patients with FAP, 21 had an attempt at delaying surgery by cold snaring of at least 30 adenomas, and had at least one follow-up at our institution. Ten patients had intact colons, 6 had intact rectums, and 5 had heavy polyp burdens in an ileo-anal pouch. Among the 21 patients, the mean number of polyps resected at the first examination was 85, range 30 - 342. Nineteen of 21 patients had fewer polyps at the second examination, and of those, only one had any persistence of adenomas ≥ 1 cm in size. During follow-up, two patients underwent surgical resection and the remainder had reductions in their polyp burdens at follow-up endoscopy. CONCLUSIONS: Cold snare polypectomy effectively reduces polyp burden in selected FAP patients.