Endoscopic versus histological characterisation of polyps during screening colonoscopy.

BACKGROUND: As screening colonoscopy becomes more widespread, the costs for histopathological assessment of resected polyps are rising correspondingly. Reference centres have published highly accurate results for endoscopic polyp classification. Therefore, it has been proposed that, for smaller polyps, the differential diagnosis that guides follow-up recommendations could be based on endoscopy alone. OBJECTIVE: The aim was to prospectively assess whether the high accuracy for endoscopic polyp diagnosis as reported by reference centres can be reproduced in routine screening colonoscopy. DESIGN: Ten experienced private practice endoscopists had initial training in pit patterns. Then they assessed all polyps detected during 1069 screening colonoscopies. Patients (46% men; mean age 63 years) were randomly assigned to colonoscopy with conventional or latest generation HDTV instruments. The main outcome measure was diagnostic accuracy of in vivo polyp assessment (adenomatous vs hyperplastic). Secondary outcome measures were differences between endoscopes and reliability of image-based follow-up recommendations; a blinded post hoc analysis of polyp photographs was also performed. RESULTS: 675 polyps were assessed (461 adenomatous, 214 hyperplastic). Accuracy, sensitivity and specificity of in vivo diagnoses were 76.6%, 78.1% and 73.4%; size of adenomas and endoscope withdrawal time significantly influenced accuracy. Image-based recommendations for post-polypectomy surveillance were correct in only 69.5% of cases. Post hoc analysis of polyp photographs did not improve accuracy. CONCLUSIONS: In everyday practice, endoscopic classification of polyp type is not accurate enough to abandon histopathological assessment and use of latest generation colonoscopes does not improve this. Image-based surveillance recommendations after polypectomy would consequently not meet guideline requirements. TRIALREGNO: NCT01297712.

Factors determining the quality of screening colonoscopy: a prospective study on adenoma detection rates, from 12,134 examinations (Berlin colonoscopy project 3, BECOP-3).

BACKGROUND: Screening colonoscopy (SC) outcome quality is best determined by the adenoma detection rate (ADR). The substantial variability in the ADRs between endoscopists may reflect different skills, experience and/or equipment. OBJECTIVE: To analyse the potential factors that may influence ADR variance, including case volume. DESIGN: 12,134 consecutive SCs (mean age 64.5 years, 47% men) from 21 Berlin private-practice colonoscopists were prospectively studied during 18 months. The data were analysed using a two-level mixed linear model to adequately address the characteristics of patients and colonoscopists. The ADR was regressed after considering the following factors: sex, age, bowel cleanliness, NSAID intake, annual SC case volume, lifetime experience, instrument withdrawal times, instrument generations used, and the number of annual continuing medical education (CME) meetings attended by the physician. The case volume was also retrospectively analysed from the 2007 national SC registry data (312,903 colonoscopies and 1004 colonoscopists). RESULTS: The patient factors that correlated with the ADR were sex, age (p<0.001) and low quality of bowel preparation (p=0.005). The factors that were related to the colonoscopists were the number of CME meetings attended (p=0.012) and instrument generation (p=0.001); these factors accounted for approximately 40% of the interphysician variability. Within a narrow range (6-11 min), the withdrawal time was not correlated with the ADR. Annual screening case volume did not correlate with the ADR, and this finding was confirmed by the German registry data. CONCLUSIONS: The outcome quality of screening colonoscopies is mainly influenced by individual colonoscopist factors (ie, CME activities) and instrument quality. CLINICAL TRIAL REGISTRATION NUMBER: Clinical Trial Gov Registration number: NCT00860665.

Data quality of the German screening colonoscopy registry.

BACKGROUND AND STUDY AIMS: The German screening colonoscopy program is accompanied by a central registry that records the main outcome quality indicators, namely colonoscopy completion rate, adenoma detection rate (ADR), and complication rate. The aim of the present study was to assess the quality of these registry data by comparing them with data from a prospective quality assurance study based on a self-reporting audit and patient feedback of screening colonoscopy. PATIENTS AND METHODS: The completeness of registry information was analyzed by comparing it with prospective data gathered by audit and patient feedback in a previous quality assurance study (ClinicalTrials.gov registration number: NCT00860665) between October 2006 and March 2008. The main outcome parameters were colonoscopy completion rate, ADR, and complication rate. Complications were recorded in three steps in the audit study using case report forms (immediate and subsequent documentation by physicians [CRF-1 and CRF-2], and patient follow-up [CRF-3]), but were documented in the registry without differentiation. RESULTS: A total of 12 134 individuals (mean age 64.5 years; 47 % men) who underwent screening colonoscopy at 19 private practices in Berlin over the 18-month period were included in the audit study. Patient feedback was obtained for 90.1 %. A total of 12 150 cases had been recorded in the registry by the same private practices during the same period. Colonoscopy completion rate and ADR data were comparable in the audit study and registry (completion rate 98.2 % vs. 97.7 %; ADR 21.0 % vs. 20.5 %). However, compared with the registry data, the complication rate was 3.1-fold higher in the audit (0.46 % vs. 0.15 %; P < 0.001), and double (0.33 % vs. 0.15 %; P < 0.05) when patient feedback was not included. CONCLUSIONS: Of the screening colonoscopy quality parameters, colonoscopy completion rate and ADR, but not complication rates, were reliably documented in the German national screening colonoscopy registry. Data on complications need to be appropriately standardized and audited in order to be used for credentialing and benchmarking purposes.

Latest generation, wide-angle, high-definition colonoscopes increase adenoma detection rate.

BACKGROUND & AIMS: Improvements to endoscopy imaging technologies might improve detection rates of colorectal cancer and patient outcomes. We compared the accuracy of the latest generation of endoscopes with older generation models in detection of colorectal adenomas. METHODS: We compared data from 2 prospective screening colonoscopy studies (the Berlin Colonoscopy Project 6); each study lasted approximately 6 months and included the same 6 colonoscopists, who worked in private practice. Participants in group 1 (n = 1256) were all examined by using the latest generation of wide-angle, high-definition colonoscopes that were manufactured by the same company. Individuals in group 2 (n = 1400) were examined by endoscopists who used routine equipment (a mixture of endoscopes from different companies; none of those used to examine group 1). The adenoma detection rate was calculated on the basis of the number of all adenomas/number of all patients. RESULTS: There were no differences in patient parameters or withdrawal time between groups (8.0 vs 8.2 minutes). The adenoma detection rate was significantly higher in group 1 (0.33) than in group 2 (0.27; P = .01); a greater number of patients with least 1 adenoma were identified in group 1 (22.1%) than in group 2 (18.2%; P = .01). A higher percentage of high-grade dysplastic adenomas were detected in group 1 (1.19%) than in group 2 (0.57%), but this difference was not statistically significant (P = .06). CONCLUSIONS: The latest generation of wide-angle, high-definition colonoscopes improves rates of adenoma detection by 22%, compared with mixed, older technology endoscopes used in routine private practice. These findings might affect definitions of quality control parameters for colonoscopy screening for colorectal cancer.

Narrow-band versus white-light high definition television endoscopic imaging for screening colonoscopy: a prospective randomized trial.

BACKGROUND & AIMS: Narrow-band imaging (NBI) has been implemented in gastrointestinal endoscopy to improve the contrast of endoluminal pathologic structures, one of the aims being to increase colonic adenoma detection. Previous studies from referral centers have yielded variable and conflicting results with regard to improvement in adenoma detection rates by using NBI. The present large randomized trial was designed to finally settle this issue. METHODS: In a prospective study performed exclusively in a multicenter private practice setting involving 6 examiners with substantial lifetime experience (>10,000 colonoscopies), 1256 patients (men:women, 47%:53%; mean age, 64.4 y) were randomized to HDTV screening colonoscopy with either NBI or white-light imaging on instrument withdrawal. The primary outcome measure was the adenoma detection rate (ie, number of adenomas/total number of patients). RESULTS: There was no difference between the 2 groups in terms of the general adenoma detection rate (0.32 vs 0.34), the total number of adenomas (200 vs 216), or in detection in subgroups of adenomas. This was despite a minimal, but significantly longer, withdrawal time in the NBI group (8.5 vs 7.9 min; P < .05). Only hyperplastic polyps were found more frequently in the NBI group (P = .03). CONCLUSIONS: This large randomized trial in a homogeneous private practice screening setting could not show any objective advantage of the NBI technique over white-light high definition television imaging in terms of improved adenoma detection rate. Contrast enhancement therefore likely will not contribute to a reduction in adenoma miss rates among experienced colonoscopists.

Live image processing does not increase adenoma detection rate during colonoscopy: a randomized comparison between FICE and conventional imaging (Berlin Colonoscopy Project 5, BECOP-5).

OBJECTIVES: Fujinon intelligent chromoendoscopy (FICE) is a post-processing imaging technique for increasing contrast of mucosa and mucosal lesions that might lead to improvement in colonic adenoma detection during colonoscopy. Previous studies on similar contrast-enhancing techniques as well as on dye staining have yielded variable and conflicting results. This large randomized trial was undertaken to determine whether FICE technology enhances adenoma detection rate (ADR). METHODS: In a prospective study performed in a multicenter private practice and hospital setting, involving 8 examiners with substantial lifetime experience (>10,000 colonoscopies each), 1,318 patients (men 46.7%, women 53.3%; mean age 59.05 years) were randomly assigned to colonoscopy with either FICE or white light imaging on instrument withdrawal. Of the colonoscopies, 68% were screening and 32% were diagnostic examinations. The primary outcome measure was the ADR (i.e., number of adenomas/total number of patients). RESULTS: There was no difference between the two groups in terms of general ADR (0.28 in both groups), the total number of adenomas (184 vs. 183), or detection of subgroups of adenomas. The rate of identification of hyperplastic polyps was also the same in both groups (127 vs. 121; P=0.67). The results were the same for both the screening and the diagnostic colonoscopy subgroups. Withdrawal time was the same in both groups (8.4 vs. 8.3 min, P=0.55). CONCLUSIONS: This large randomized trial could not show any objective advantage of the FICE technique over conventional high-resolution endoscopy in terms of improved ADR.

Appropriateness of colonoscopy in the era of colorectal cancer screening: a prospective, multicenter study in a private-practice setting (Berlin Colonoscopy Project 1, BECOP 1).

PURPOSE: The introduction of reimbursement for screening colonoscopy in Germany more than one year ago raised concerns that the consequent workload might lead to underuse of diagnostic colonoscopy for symptomatic patients. Available appropriateness criteria for diagnostic colonoscopy have been rarely tested in a realistic outpatient setting. This study was designed to test current appropriateness criteria for diagnostic colonoscopy to better select patients and potentially provide more capacity for screening cases. Secondary goals were yield and quality control in both the diagnostic and screening cases. METHODS: A prospective study was initiated in 39 private-practice offices to collect data on consecutive colonoscopies conducted during a 6-day study period. A detailed questionnaire was developed to define indications and symptoms, and all findings at colonoscopy were recorded. Colonoscopies were further analyzed and stratified into a screening and a diagnostic group. In the diagnostic group, indications were assessed according to the current guidelines for appropriateness (American Society for Gastrointestinal Endoscopy, European Panel for the Appropriateness of Gastrointestinal Endoscopy), and the results were correlated with the percentage of relevant findings (tumors, inflammatory conditions). RESULTS: During the study period, 1,397 colonoscopies (57 percent screening, 43 percent diagnostic) were analyzed (male/female ratio = 39/61 percent; mean age, 61 years). Fourteen percent and 37 percent, respectively, of the 605 diagnostic colonoscopies were regarded as inappropriate relative to the criteria of the American Society for Gastrointestinal Endoscopy and the European Panel for the Appropriateness of Gastrointestinal Endoscopy. However, the percentage of relevant inflammatory and neoplastic findings (polyps, cancer, inflammatory bowel disease, benign strictures) was only 5 to 10 percent higher in the appropriate group than in the inappropriate group. On the basis of these data, a hypothetical model for selecting appropriate indications was developed: if patients older than aged 50 years with pain, bleeding, and diarrhea, but not constipation, are regarded as having an appropriate indication, such an approach would save 20 percent of colonoscopies in these main indication groups (bleeding, pain, diarrhea, constipation), with a hypothetical miss rate for relevant findings (as defined above) of 5 percent. CONCLUSIONS: Currently used appropriateness criteria for diagnostic colonoscopy increase the yield of relevant findings but lead to a miss rate for relevant findings in the range of 10 to 15 percent. Simple selection criteria based on age and symptoms could be more suitable and should be tested in a larger group of patients.