Automatic lumen detection and magnetic alignment control for magnetic-assisted capsule colonoscope system optimization.

We developed a magnetic-assisted capsule colonoscope system with integration of computer vision-based object detection and an alignment control scheme. Two convolutional neural network models A and B for lumen identification were trained on an endoscopic dataset of 9080 images. In the lumen alignment experiment, models C and D used a simulated dataset of 8414 images. The models were evaluated using validation indexes for recall (R), precision (P), mean average precision (mAP), and F1 score. Predictive performance was evaluated with the area under the P-R curve. Adjustments of pitch and yaw angles and alignment control time were analyzed in the alignment experiment. Model D had the best predictive performance. Its R, P, mAP, and F1 score were 0.964, 0.961, 0.961, and 0.963, respectively, when the area of overlap/area of union was at 0.3. In the lumen alignment experiment, the mean degrees of adjustment for yaw and pitch in 160 trials were 21.70° and 13.78°, respectively. Mean alignment control time was 0.902 s. Finally, we compared the cecal intubation time between semi-automated and manual navigation in 20 trials. The average cecal intubation time of manual navigation and semi-automated navigation were 9 min 28.41 s and 7 min 23.61 s, respectively. The automatic lumen detection model, which was trained using a deep learning algorithm, demonstrated high performance in each validation index.

Advanced endoscopy technologies to improve the detection and characterisation of colorrectal polyps. / Tecnologías de endoscopia avanzada para mejorar la detección y caracterización de los pólipos colorrectales.

Colorectal cancer is a major health problem. An improvement to its survival has been demonstrated by performing colonoscopy screenings and removing its precursor lesions: polyps. However, colonoscopy is not infallible and multiple strategies have been proposed aimed at improving the quality thereof. This report describes the endoscopic systems available to improve the detection and characterization of polyps, the different classifications for histological prediction and the current indications of advanced endoscopic diagnostic techniques.

Endocuff Vision-assisted colonoscopy: a randomized controlled trial.

BACKGROUND: Adenoma detection rate (ADR) has shown to be an independent predictor, to reduce the rate of interval colorectal cancer. Endocuff Vision is a relatively new device that has shown promise to improve the ADR. The primary objective was to conduct a randomized controlled trial to compare Endocuff Vision-assisted colonoscopy (EVAC) with standard colonoscopy (SC). The primary outcome of the study is ADR and the secondary outcomes are caecal intubation rate, terminal ileum intubation rate, scope withdrawal time, quality of bowel preparation and adverse events. METHODS: A randomized controlled trial was performed to compare EVAC versus SC. All patients who presented to the endoscopy suite at the Queen Elizabeth Hospital were assessed for eligibility. Patients were recruited from 15 June 2016 to 20 January 2017. A total of 360 patients were included; 40 were excluded. The patients were randomized using block randomization; 138 patients were recruited to SC and 182 to EVAC. RESULTS: A total of 231 polyps were retrieved during the study period. Polyp detection rate (PDR) was high in both groups: 53% in the EVAC group versus 41.1% in SC. This was statistically significant with a P-value of 0.035. ADR was similarly high in both groups: 36.81% in EVAC group versus 28.99% in SC group. ADR did not reach statistical significance. CONCLUSIONS: EVAC does improve the PDR. Though the ADR did not reach statistical significance, there is a trend towards improved adenoma detection and there is statistical significance in the overall PDR.

Effects of two instrument-generation changes on adenoma detection rate during screening colonoscopy: results from a prospective randomized comparative study.

BACKGROUND: Previous studies have shown that multiple colonoscope features have to be changed before an improvement in adenoma detection rate (ADR) becomes obvious, such as with changing from one instrument generation to the next but one. We wanted to evaluate whether such an effect can also be observed in a private-practice screening setting. METHODS: In a randomized study, we compared the latest generation colonoscopes from one company (Olympus Exera III, 190) with the next to last one (Olympus 165), including only patients presenting for screening colonoscopy. The primary outcome was ADR achieved with 190 colonoscopes (190-C) in comparison with 165 colonoscopes (165-C). RESULTS: 1221 patients (46.1 % men; mean age 62.2 years, standard deviation 6.6) were included (599 screened with the Olympus Exera III, 190). The ADR difference in favor of the 190-C instrument (32 % [95 % confidence interval (CI) 26 % to 39 %] vs. 28 % [95 %CI 22 % to 34 %] in the 165-C group) failed to reach statistical significance (P = 0.10); only the rate of small (< 5 mm) adenomas was significantly increased at 22.5 % (95 %CI 19 % to 26 %) vs. 15.6 % (95 %CI 13 % to 18 %; P = 0.002). Furthermore, significantly more adenomas were found in the 190-C group, with an adenoma rate (all adenomas/all patients) of 0.57 (95 %CI 0.53 to 0.61) vs. 0.47 (95 %CI 0.43 to 0.51; P < 0.001). CONCLUSIONS: This randomized comparative trial in a private-practice screening setting only partially confirmed the results of prior studies that, with multiple imaging improvements achieved over two instrument generations, an increase in overall adenoma number becomes measurable.

Impact of 2 generational improvements in colonoscopes on adenoma miss rates: results of a prospective randomized multicenter tandem study.

BACKGROUND AND AIMS: Numerous randomized studies have shown that changing certain features of colonoscopes, usually incorporated when switching from one endoscope generation to the next, mostly do not increase adenoma yield. There is, however, indirect evidence that it may be necessary to skip one instrument generation (ie, changing from one generation to the next but one) to achieve this effect. METHODS: We compared the latest-generation colonoscopes from one company (Olympus Exera III, 190-C) with the next to last one (Olympus 160/5-C) in a prospective multicenter study randomized for the order of colonoscopes in a tandem fashion, involving 2 different examiners. Patients with increased risk for colorectal neoplasia undergoing colonoscopy (positive fecal occult blood test, personal/familial history of colorectal cancer/adenoma, rectal bleeding, recent change in bowel movements) were included. The primary outcome was the adenoma miss rate with the 190 (190-C) colonoscope in comparison with the 160/5 colonoscope (160/5-C). RESULTS: A total of 856 patients (48.8% male; mean age, 58.3 years) with a personal (41%) or family (38%) history of colorectal neoplasia, rectal bleeding (19%), and other indications were included. Of the 429 patients in the 190-C first group, 16.6% (95% confidence interval [CI], 13.0%-20.1%) had at least one adenoma missed during the first procedure, compared with 30.2% (95% CI, 25.9%-34.6%) in the group with 160/5-C first (P < .001). Similarly, the adenoma detection rate during the first colonoscopy was 43.8% versus 36.5% (P = .030) for 190-C versus 160/5-C, respectively. CONCLUSIONS: This randomized tandem trial showed lower adenoma miss rates and higher adenoma detection rates for the newer 190 colonoscopes compared with the 160/5 series. These results suggest that it takes multiple improvements, such as those implemented over 2 instrument generations, before an effect on adenoma (miss) rate can be observed. (Study registration number: ISRCTN 2010-A01256-33.).

Double-Balloon Colonoscopy Has a Higher Cecal Intubation Rate Than Conventional Colonoscopy Using a Colon Simulator.

BACKGROUND/AIM: Cecal intubation using conventional colonoscopy (CC) requires substantial training. We hypothesized that double-balloon colonoscopy (DBC) facilitates cecal intubation by endoscopy naïve operators. The aim of this study is to evaluate the cecal intubation rate and learning curve of DBC compared with CC. METHODS: Eighteen endoscopy naïve medical students were allocated to two groups and attempted cecal intubation within 20 min using a colon simulator. In group A, CC was performed ten times and then DBC ten times. In group B, the reverse was carried out. We evaluated the cecal intubation rate and learning curve. RESULTS: The overall success rate for cecal intubation using DBC was significantly superior to CC [132/180 (73%) vs. 12/180 (7%), p < 0.001]. To evaluate the success rate overtime, we divided the ten repetitions of the procedure into three time periods: first (1-3), second (4-6), and third (7-10). The success rate using CC is <20%, even during the third time period, in both groups, and one perforation occurred. The success rate using DBC is over 30% in the first period and increased to nearly 80% in the third period in both groups. Finally, we evaluated the time needed for cecal intubation using DBC. The mean cecal intubation time in the first period is 14 min and decreased to 11 min in the third period. CONCLUSIONS: DBC has a higher cecal intubation rate than CC performed by endoscopy naïve medical students using a colon simulator in this randomized-controlled, cross-over study.

Meta-analysis of the performance of ultrathin vs. standard colonoscopes.

Background and study aims Colonoscopy should reliably intubate the cecum with minimal patient discomfort and without complications. Use of thinner endoscopes to overcome pain during the procedure has shown promise. However, the use of thinner scopes could lead to excess looping and difficulty with therapeutic procedures. The aim of this meta-analysis was to analyze the performance of ultrathin colonoscopes (UTC) and standard colonoscopes for routine colonoscopy. Patients and methods We searched several electronic databases for all randomized controlled trials and nonrandomized (prospective) studies that compared the efficacies of UTC (diameter ≤ 9.8 mm) and standard colonoscopes. We used fixed effect or random effects models to compare cecal intubation rate, cecal intubation time, pain score, and polyp and adenoma detection rates using standard mean differences (SMD) or odds ratios (OR) with 95 % confidence intervals (CI). Results Seven studies (2191 patients) met the inclusion criteria. There was no significant heterogeneity among studies except for pain scores. The cecal intubation rate was higher with UTC (OR 2.30; 95 %CI 1.31 to 4.03). There was no difference in the cecal intubation time between UTC and standard colonoscopes. Pain scores were significantly lower with UTC than with standard colonoscopes (SMD - 0.59, 95 %CI - 0.93 to - 0.25). Polyp and adenoma detection rates were similar for both types of colonoscope. Conclusion Use of UTC appears to improve the cecal intubation rate and reduce abdominal pain but does not affect polyp detection. Future trials are needed to evaluate the therapeutic performance of UTC vs. standard colonoscopes.

Impact of responsive insertion technology (RIT) on reducing discomfort during colonoscopy: randomized clinical trial.

BACKGROUND: In many countries, colonoscopies for colorectal cancer screening are performed without sedation due to the cost. Changes in the structure of the endoscopes are designed to facilitate the colonoscopic examination, reduce the duration of the procedure, and improve the imaging of the intestinal lumen. The variable stiffness of the endoscope and the recently introduced responsive insertion technology (RIT) are features aimed at easing colonoscope insertion and reducing the discomfort and pain during the examination. The aim of the study is to analyze whether the new RIT system can improve the practice of colonoscopy under no anesthesia with respect to the widely available variable stiffness colonoscopes. MATERIALS AND METHODS: This analysis included 647 patients who underwent complete colonoscopy in the screening program. All colonoscopies were performed without sedation. Olympus series 180 and 190 endoscopes equipped with a magnetic positioning system were used. Group I included patients who were examined using endoscopes equipped with responsive insertion technology (RIT), and group II included patients who were examined using conventional variable stiffness colonoscopies. The main objective was to evaluate the cecal intubation time, the number of loops, the requirement to apply manual pressure to different areas of the abdomen and the degree of discomfort and pain expressed on a visual analogue scale (VAS). ClinicalTrials.gov number, NCT01688557. RESULTS: Group I consisted of 329 patients, and group II included 318 patients. The mean age of the patients was 58.4 years (SD ± 4.21). Both groups were compared in terms of age, sex, and BMI. The mean cecal intubation time was 209 s in group I and 224 s in group II (p < 0.05). Increased loop formation was observed upon endoscope insertion in group II (1.7 vs. 1.35) (p < 0.05) and required more manual pressure to the abdomen (2.2 vs. 1.7) (p = 0.001). In group I, less discomfort and pain, as graded on a VAS (2.3 vs. 2.6), were noted. CONCLUSIONS: The implementation of RIT reduced of the cecal intubation time. The modified structure of the endoscope rendered the colonoscopic examination easier by reducing loop formation upon insertion with a subsequently reduced rate of auxiliary maneuvers.

Looping and Abdominal Pressure: A Visual Guide to a Successful Colonoscopy.

Looping is a common occurrence during colonoscopy. Once a loop has occurred and the endoscopist has reduced it, abdominal pressure given by the technician will help the loop from re-forming. In this article, we discuss some of the common loops that are formed, the methods the endoscopist must employ to reduce the loop, and the type of abdominal pressure used by the technician to help prevent the loop from re-forming and, thus, help attain cecal intubation. Hand placement for abdominal pressure is discussed and illustrated to provide a visual guide for the technician.

Forceps versus snare polypectomies in colorectal cancer screening: are we adhering to the guidelines?

BACKGROUND AND STUDY AIMS: European guidelines for quality assurance in colorectal cancer screening recommend snare resection for polyps > 5 mm. The aim of this study was to investigate polypectomy technique according to lesion size and shape, and to assess adherence of endoscopists enrolled in the national quality assurance program to the European guidelines. PATIENTS AND METHODS: This cohort study included screening colonoscopies performed between 2007 and 2013 within a quality assurance program in Austria. Resection technique was analyzed according to lesion characteristics and endoscopy facility (private practices, hospitals, outpatient clinics) before publication of the EU guidelines (2007 - 2010) and adherence to the guidelines after publication (2011 - 2013). All surveillance colonoscopies and examinations with missing data were excluded. RESULTS: A total of 128 969 screening colonoscopies performed by 278 endoscopy units were included. The polyp detection rate was 39.6 % (n = 47 797) and 95.6 % of polyps were resected. Of polyps ≥ 5 mm, 46.0 % were resected using forceps and were therefore not treated in accordance with the guidelines. Forceps polypectomy of lesions 5 - 10 mm and > 10 mm decreased significantly in hospitals after implementation of the guidelines (both P < 0.0001). In private practices, there was no difference in forceps usage for polyps of 5 - 10 mm (P = 0.41) before and after the guidelines, and for polyps > 10 mm forceps usage even increased (P < 0.0001). Endoscopists' forceps removal rates for polyps ≥ 5 mm correlated significantly with respective adenoma detection rates (P = 0.0007, r p  - 0.187) and cecal intubation rates (P = 0.0001, r p  - 0.303). Among endoscopists in private practices, internists had slightly lower forceps removal rates for polyps ≥ 5 mm than surgeons, both before (47.2 % vs. 50.7 %; P = 0.014) and after publication of the guidelines (51.9 % vs. 53.5 %; P = 0.161). CONCLUSIONS: This study confirmed the importance of the European guidelines. The inclusion of adequate resection technique as a quality indicator in colorectal cancer screening programs is recommended.

Quality of colonoscopy and advances in detection of colorectal lesions: a current overview.

Colonoscopy is the gold standard for the detection of colorectal cancer and its precursors. Nevertheless multiple studies have demonstrated a significant miss-rate for polyps and, more importantly, demonstrated the occurrence of interval cancers in the years after colonoscopy. This imperfect protection against colorectal cancer can be explained by multiple factors related to both the endoscopist and the equipment. To ensure the quality of colonoscopy, several quality indicators have been described. These include bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate and complication rate. Measurement of these quality indicators, followed by awareness, benchmarking and additional training will hopefully optimize daily practice. If these basic quality parameters are well taken care of, advanced colonoscopic techniques will aim at further increasing the detection and differentiation of colonic lesions. In this review, the authors discuss the literature on quality indicators for colonoscopy and give a comprehensive overview of the advanced colonoscopic techniques currently available.

Differences in colonoscopy technique impact quality.

BACKGROUND: Colonoscopists differ in skill, technique, and attitude in relation to the examination. These differences have a potential impact on the quality of the examination and the risk of complications. This study aimed to document differences in technique between individual colonoscopists and to explore some possible consequences to the patient and the examination. METHODS: This prospective, comparative study analyzed 10 individual endoscopists practicing in outpatient endoscopy clinics at a major medical center. Consecutive patients presenting for elective outpatient colonoscopy were included in the study. Examinations were observed, and techniques used during scope insertion and withdrawal were recorded. The type and dose of medication, the pain score recorded by the endoscopy nurses (scale of 1-10), and the incidence of hypotension and hypoxia were noted. RESULTS: The study involved 245 patients (129 men and 116 women) with a mean age of 59.5 years. The number of colonoscopies per examiner ranged from 12 to 31, with nine tenths of the examiners performing more than 20 colonoscopies. Completion rates ranged from 82.6 to 100 %; the withdrawal time averages ranged from 3.5 to 21.7 min; and the average number of techniques used ranged from one per four exams to three per exam. The average pain score per endoscopist ranged from 2.1 to 4.3, and the percentage of patients with either hypoxia or hypotension ranged from 11.5 to 85.0 %. A sedation/analgesia product (SAP) was derived by multiplying the mean dose of versed by the mean dose of meperidine. Regression analysis showed significant relationships between the number of techniques used and the levels of pain (R (2) = 0.395) and hypoxia/hypotension (R (2) = 0.513). The findings showed that SAP was significantly associated with hypoxia/hypotension (R (2) = 0.826) but not pain (R (2) = 0.01). CONCLUSIONS: Use of ancillary techniques for colonoscope insertion minimizes pain, narcotic use, and hypoxia/hypotension. The product of benzodiazepine dose and narcotic dose is a good way of assessing sedative effect.

Transparent cap colonoscopy versus standard colonoscopy: a systematic review and meta-analysis.

Due to the increasing demand for colonoscopy, devices to advance examination techniques are highly sought after. Several studies have examined the use of a transparent cap attached to the tip of the colonoscope, but the data are inconsistent. The aim of our study was to establish whether transparent cap colonoscopy is beneficial in the improvement of caecal intubation rate, time and polyp detection. We undertook a systematic review and meta-analysis in the form of a Cochrane review to evaluate these outcomes. We included fourteen randomised controlled trials that have been published to date. Transparent cap colonoscopy demonstrates a significant reduction in caecal intubation time, by an average of 48 s, when compared to standard colonoscopy. There was no significant difference in caecal intubation rate or polyp detection between the two groups. Despite a significant difference in caecal intubation time, the clinical significance of the transparent cap remains to be seen. We believe further research is needed to investigate this adjunct.

Benefits and limitations of cap-fitted colonoscopy in screening colonoscopy.

BACKGROUND: Colonoscopy is widely used to detect colorectal cancer and to remove precancerous lesions to reduce the risk of colonic cancer. AIMS: To examine the benefits and limitations of cap-fitted colonoscopy compared to conventional colonoscopy in terms of technical performance and colorectal adenoma detection rate. METHODS: Screening colonoscopies performed from 2009 to 2010 with or without a transparent cap were retrospectively examined to compare the rate of successful intubation, cecal intubation time, and number, size, shape, and location of adenomas detected. An inclusion criterion was visualization of >95 % of the right colon. RESULTS: Data from 2,301 colonoscopies (1,165 with cap-fitted colonoscopy, 1,136 without the transparent cap) were retrospectively analyzed. Procedures were performed by four experienced endoscopists. The subjects' demographic characteristics and technical performances were similar between the two methods. The only significant difference in the technical performance between the two techniques was a shorter cecal intubation time with cap-fitted colonoscopy (5.3 vs. 6.6 min; p = 0.045) by one endoscopist. The total number of adenomas detected was significantly higher with cap-fitted colonoscopy than without the cap (586 vs. 484, respectively; p < 0.0001). Adenoma detection with cap-fitted endoscopy was significantly higher in the right colon than in the left colon (19 vs. 12 %, respectively; p = 0.0001). CONCLUSION: Cap-fitted colonoscopy did not improve the technical aspects of colonoscopy but significantly increased adenoma detection, especially in the right colon. It did not increase the detection rate of flat or depressed adenomas.

Transparent cap colonoscopy versus standard colonoscopy to improve caecal intubation.

BACKGROUND: Colonoscopy is considered the gold-standard investigation for screening and diagnosis of colorectal cancer. It is also becoming increasingly desirable for assessment, management, diagnosis and follow-up of other colorectal diseases, such as inflammatory bowel diseases and acute diverticulitis. Hence, due to the increasing demand for colonoscopy, devices to advance examination techniques are highly sought-after and the colonoscope with the transparent cap could be one of these. OBJECTIVES: To identify and review all relevant data in order to determine whether colonoscopy with a transparent cap is a more effective diagnostic tool than colonoscopy. SEARCH METHODS: We searched the MEDLINE, EMBASE and CINAHL databases, and the Cochrane Central Register of Controlled Trials for all randomised controlled trials (RCTs) comparing the use of colonoscopy with a transparent cap with standard colonoscopy. SELECTION CRITERIA: Studies were included if they were randomised controlled trials which compared the use of colonoscopy with a transparent cap with standard colonoscopy. DATA COLLECTION AND ANALYSIS: Data on study methods, participants, interventions used and outcomes measured was extracted from each study. Data was entered into the Cochrane Review Manager software (RevMan 5.0, 2008) and analysed using Cochrane MetaView. MAIN RESULTS: In the present meta-analysis, we considered 14 randomised controlled trials so far published. The findings of our work indicate that colonoscopy with transparent cap has a faster caecal intubation time when compared with standard colonoscopy. Reviewing studies individually would also seem to favour colonoscopy with transparent cap for polyp detection rate and pain during procedure but due to lack of comparable data meta-analysis was not feasible. AUTHORS' CONCLUSIONS: This review suggests that a transparent cap on the end of the colonoscope may give a marginally faster caecal intubation time compared with standard colonoscopy. It also suggests that there is a better polyp detection rate and less pain with the cap. However, the authors feel that further randomised controlled trials in this area would provide more clinically significant information on this adjunct to colonoscopy.

Transparent Cap Colonoscopy versus Standard Colonoscopy for Investigation of Gastrointestinal Tract Conditions.

BACKGROUND: Colonoscopy is considered the gold-standard investigation for screening and diagnosis of colorectal cancer. It is also becoming increasingly desirable for assessment, management, diagnosis and follow-up of other colorectal diseases, such as inflammatory bowel diseases and acute diverticulitis. Hence, due to the increasing demand for colonoscopy, devices to advance examination techniques are highly sought-after and the colonoscope with the transparent cap could be one of these. OBJECTIVES: To identify and review all relevant data in order to determine whether colonoscopy with a transparent cap is a more effective diagnostic tool than colonoscopy. SEARCH STRATEGY: We searched the MEDLINE, EMBASE and CINAHL databases, and the Cochrane Central Register of Controlled Trials for all randomised controlled trials (RCTs) comparing the use of colonoscopy with a transparent cap with standard colonoscopy. SELECTION CRITERIA: Studies were included if they were randomised controlled trials which compared the use of colonoscopy with a transparent cap with standard colonoscopy. DATA COLLECTION AND ANALYSIS: Data on study methods, participants, interventions used and outcomes measured was extracted from each study. Data was entered into the Cochrane Review Manager software (RevMan 5.0, 2008) and analysed using Cochrane MetaView. MAIN RESULTS: In the present meta-analysis, we considered for the first time all five randomised controlled trials so far performed. The findings of our work indicate that colonoscopy with transparent cap has a faster caecal intubation time when compared with standard colonoscopy. Reviewing studies individually would also seem to favour colonoscopy with transparent cap for polyp detection rate and pain during procedure but due to lack of comparable data meta-analysis was not feasible. AUTHORS' CONCLUSIONS: This review suggests that a transparent cap on the end of the colonoscope may give a marginally faster caecal intubation time compared with standard colonoscopy. It also suggests that there is a better polyp detection rate and less pain with the cap. However, the authors feel that further randomised controlled trials in this area would provide more clinically significant information on this adjunct to colonoscopy.

Evaluation of colonoscopy technical skill levels by use of an objective kinematic-based system.

BACKGROUND: Colonoscopy requires training and experience to ensure accuracy and safety. Currently, no objective, validated process exists to determine when an endoscopist has attained technical competence. Kinematics data describing movements of laparoscopic instruments have been used in surgical skill assessment to define expert surgical technique. We have developed a novel system to record kinematics data during colonoscopy and quantitatively assess colonoscopist performance. OBJECTIVE: To use kinematic analysis of colonoscopy to quantitatively assess endoscopic technical performance. DESIGN: Prospective cohort study. SETTING: Tertiary-care academic medical center. POPULATION: This study involved physicians who perform colonoscopy. INTERVENTION: Application of a kinematics data collection system to colonoscopy evaluation. MAIN OUTCOME MEASUREMENTS: Kinematics data, validated task load assessment instrument, and technical difficulty visual analog scale. RESULTS: All 13 participants completed the colonoscopy to the terminal ileum on the standard colon model. Attending physicians reached the terminal ileum quicker than fellows (median time, 150.19 seconds vs 299.86 seconds; p<.01) with reduced path lengths for all 4 sensors, decreased flex (1.75 m vs 3.14 m; P=.03), smaller tip angulation, reduced absolute roll, and lower curvature of the endoscope. With performance of attending physicians serving as the expert reference standard, the mean kinematic score increased by 19.89 for each decrease in postgraduate year (P<.01). Overall, fellows experienced greater mental, physical, and temporal demand than did attending physicians. LIMITATION: Small cohort size. CONCLUSION: Kinematic data and score calculation appear useful in the evaluation of colonoscopy technical skill levels. The kinematic score appears to consistently vary by year of training. Because this assessment is nonsubjective, it may be an improvement over current methods for determination of competence. Ongoing studies are establishing benchmarks and characteristic profiles of skill groups based on kinematics data.