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Adenoma detection rate (ADR) is a key measure of quality in colonoscopy. Low ADRs are associated with development of interval cancer after \"negative\" colonoscopy. Uncontrolled studies mandating longer withdrawal time, and other incentives, have not significantly improved ADR. We hypothesized that an endoscopist training program would increase ADRs. Our Endoscopic Quality Improvement Program (EQUIP) was an educational intervention for staff endoscopists. We measured ADRs for a baseline period, then randomly assigned half of the 15 endoscopists to undergo EQUIP training. We then examined baseline and post-training study ADRs for all endoscopists (trained and un-trained) to evaluate the impact of training. A total of 1,200 procedures were completed in each of the two study phases. Patient characteristics were similar between randomization groups and between study phases. The overall ADR in baseline phase was 36% for both groups of endoscopists. In the post-training phase, the group of endoscopists randomized to EQUIP training had an increase in ADR to 47%, whereas the ADR for the group of endoscopists who were not trained remained unchanged at 35%. The effect of training on the endoscopist-specific ADRs was estimated with an odds ratio of 1.73 (95% confidence interval 1.24-2.41, P=0.0013). Our results indicate that ADRs can be improved considerably through simple educational efforts. Ultimately, a trial involving a larger number of endoscopists is needed to validate the utility of our training methods and determine whether improvements in ADRs lead to reduced colorectal cancer.

ObjectiveAlthough a split regimen of bowel preparation has been associated with higher levels of bowel cleansing, it is still uncertain whether it has a favourable effect on the adenoma detection rate (ADR). The present study was aimed at evaluating whether a split regimen was superior to the traditional ‘full-dose, day-before’ regimen in terms of ADR.DesignIn a multicentre, randomised, endoscopist-blinded study, 50–69-year-old subjects undergoing first colonoscopy after positive-faecal immunochemical test within an organised colorectal cancer organised screening programmes were 1:1 randomised to receive low-volume 2-L polyethylene glycol (PEG)-ascorbate solution in a ‘split-dose’ (Split-Dose Group, SDG) or ‘day-before’ regimen (Day-Before Group, DBG). The primary endpoint was the proportion of subjects with at least one adenoma. Secondary endpoints were the detection rates of advanced adenomas and serrated lesions at per-patient analysis and the total number of lesions.Results690 subjects were included in the study. At per-patient analysis, the proportion of subjects with at least one adenoma was significantly higher in the SDG than in the DBG (183/345, 53.0% vs 141/345, 40.9%, relative risk (RR) 1.22, 95% CI 1.03 to 1.46); corresponding figures for advanced adenomas were 26.4% (91/345) versus 20.0% (69/345, RR 1.35, 95% CI 1.06 to 1.73). At per-polyp analysis, the total numbers of both adenomas and advanced adenomas per subject were significantly higher in the SDG (1.15 vs 0.8, p <0.001; 0.36 vs 0.22, p<0.001).ConclusionsIn an organised screening setting, the adoption of a split regimen resulted into a higher detection rate of clinically relevant neoplastic lesions, thus improving the effectiveness of colonoscopy. Based on such evidence, the adoption of a split regimen for colonoscopy should be strongly recommended.Clinical trial registration numberNCT02178033.

Assessing endoscopic disease severity in ulcerative colitis (UC) is a key element in determining therapeutic response, but its use in clinical practice is limited by the requirement for experienced human reviewers. To determine whether deep learning models can grade the endoscopic severity of UC as well as experienced human reviewers. In this diagnostic study, retrospective grading of endoscopic images using the 4-level Mayo subscore was performed by 2 independent reviewers with score discrepancies adjudicated by a third reviewer. Using 16 514 images from 3082 patients with UC who underwent colonoscopy at a single tertiary care referral center in the United States between January 1, 2007, and December 31, 2017, a 159-layer convolutional neural network (CNN) was constructed as a deep learning model to train and categorize images into 2 clinically relevant groups: remission (Mayo subscore 0 or 1) and moderate to severe disease (Mayo subscore, 2 or 3). Ninety percent of the cohort was used to build the model and 10% was used to test it; the process was repeated 10 times. A set of 30 full-motion colonoscopy videos, unseen by the model, was then used for external validation to mimic real-world application. Model performance was assessed using area under the receiver operating curve (AUROC), sensitivity and specificity, positive predictive value (PPV), and negative predictive value (NPV). Kappa statistics (κ) were used to measure agreement of the CNN relative to adjudicated human reference cores. The authors included 16 514 images from 3082 unique patients (median [IQR] age, 41.3 [26.1-61.8] years, 1678 [54.4%] female), with 3980 images (24.1%) classified as moderate-to-severe disease by the adjudicated reference score. The CNN was excellent for distinguishing endoscopic remission from moderate-to-severe disease with an AUROC of 0.966 (95% CI, 0.967-0.972); a PPV of 0.87 (95% CI, 0.85-0.88) with a sensitivity of 83.0% (95% CI, 80.8%-85.4%) and specificty of 96.0% (95% CI, 95.1%-97.1%); and NPV of 0.94 (95% CI, 0.93-0.95). Weighted κ agreement between the CNN and the adjudicated reference score was also good for identifying exact Mayo subscores (κ = 0.84; 95% CI, 0.83-0.86) and was similar to the agreement between experienced reviewers (κ = 0.86; 95% CI, 0.85-0.87). Applying the CNN to entire colonoscopy videos had similar accuracy for identifying moderate to severe disease (AUROC, 0.97; 95% CI, 0.963-0.969). This study found that deep learning model performance was similar to experienced human reviewers in grading endoscopic severity of UC. Given its scalability, this approach could improve the use of colonoscopy for UC in both research and routine practice.

BACKGROUND:Endoscopists have low adherence to guideline-recommended colonoscopy surveillance intervals. We performed a cluster-randomized single-blind pilot trial in Winnipeg, Canada, to assess the effectiveness of a newly developed digital application tool that computes guideline-recommended follow-up intervals.METHODS:Participant endoscopists were randomized to either receive access to the digital application (intervention group) or not receive access (control group). Pathology reports and final recommendations for colonoscopies performed in the 1-4 months before randomization and 3-7 months postrandomization were extracted. Generalized estimating equation models were used to determine whether the access to the digital application predicted guideline congruence.RESULTS:We included 15 endoscopists in the intervention group and 14 in the control group (of 42 eligible endoscopists in the city), with 343 patients undergoing colonoscopy before randomization and 311 postrandomization. Endoscopists who received the application made guideline-congruent recommendations 67.6% of the time before randomization and 76.1% of the time after randomization. Endoscopists in the control group made guideline-congruent recommendations 72.4% and 72.9% of the time before and after randomization, respectively. Endoscopists in the intervention group trended to have an increase in guideline adherence comparing postintervention with preintervention (odds ratio [OR]: 1.50, 95% confidence interval [CI] 0.82-2.74). By contrast, the control group had no change in guideline adherence (OR: 1.07, 95% CI 0.50-2.29). Endoscopists in the intervention group with less than median guideline congruence prerandomization had a significant increase in guideline-congruent recommendations postrandomization.DISCUSSION:An application that provides colonoscopy surveillance intervals may help endoscopists with guideline congruence, especially those with a lower preintervention congruence with guideline recommendations (ClincialTrials.gov number, NCT04889352).

Objective Conventional colonoscopy (CC) is considered the reference standard for detection of colorectal neoplasia, but it can still miss a substantial number of adenomas. The use of a transparent plastic cap may improve colonic visualisation. Cap-assisted colonoscopy (CAC) was compared with CC for adenoma detection. Secondary outcomes were caecal intubation time, caecal intubation rate and the degree of discomfort of colonoscopy. Design This is a parallel, randomised, controlled trial at two centres. Asymptomatic participants (aged 50–75 years) in a primary colonoscopy screening programme were consecutively invited. Consenting subjects were 1:1 randomised to either CAC or CC. All colonoscopies were performed by experienced endoscopists (≥1000 colonoscopies) who were trained in CAC. Colonoscopy quality indicators were prospectively recorded. Results A total of 1380 participants were randomly allocated to CC (N=694) or CAC (N=686). Caecal intubation rate was comparable in the two groups (98% vs 99%; p=0.29). Caecal intubation time was significantly lower in the CAC group: 7.7±5.0 min with CAC vs 8.9±6.2 min with CC (p<0.001) (values mean±SD). Adenoma detection rates of all endoscopists were ≥20%. The proportion of subjects with at least one adenoma was similar in the two groups (28% vs 28%; RR 0.98; 95% CI 0.82 to 1.16), as well as the mean number of adenomas per subject (0.49±1.05 vs 0.50±1.03; p=0.91). Detection of small size, flat and proximally located adenomas was comparable. CAC participants had lower Gloucester Comfort Scores during colonoscopy (2.2±1.0 vs 2.0±1.0; p=0.03). Conclusion CAC does not improve adenoma detection, but does reduce caecal intubation time by more than 1 min and does lessen the degree of discomfort during colonoscopy.

We recently completed a randomized controlled trial of an endoscopic quality improvement program (EQUIP) that demonstrated an improved adenoma detection rate (ADR) through simple educational interventions. The aim of this study (phase III) is to examine whether the improvement in ADR in the trained endoscopists remained stable with further follow-up. We prospectively followed up 15 staff endoscopists who had previously been randomized to a quality improvement intervention. In the current study, we examined an additional 1,200 colonoscopy procedures conducted over a 5-month time period following the original study, referred to as phase III. During this time, all physicians received quarterly ADR and other quality metric feedback, and the previous control group was offered the educational intervention voluntarily. ADRs and adenoma per patient (APP) rates were estimated in the endoscopists who were and were not randomized to EQUIP training and compared with those obtained in phases I and II of the original study. The study was conducted in a tertiary care Academic Medical Center. The study sample comprised 1200 patients undergoing routine colonoscopy. The main outcome measurement was adenoma detection rate. The previously observed increase in ADR in the trained group from 36% in phase I to 47% in phase II was maintained into phase III (46%). The ADR of the untrained group remained unchanged from phase I (36%) to phase II (35%); it was increased only marginally in phase III to 39%, which was still lower than the 46% ADR in the trained group. The trained group had an increase in APP, from 0.72 in Phase I to 0.87 in Phase II and 0.98 in Phase III. For the previously untrained group, there was no change in APP from phase I (0.68) to phase II (0.68), but there was possibly a small increase (to 0.74) in Phase III. This study provides evidence that improvements in ADR obtained through the endoscopic quality-training program can persist for at least 5 months after completion of the program. It further suggests that a focus on ADR does not lead to a \"one and done\" phenomenon. The limitations of this study were as follows: single-center setting, and lack of sessile polyp information/standardization.

To determine whether a second observer during colonoscopy increases adenoma detection. Consecutive patients undergoing screening colonoscopy were prospectively randomized to routine colonoscopy or physician and nurse observation during withdrawal. Of 502 patients, 249 were randomized to routine colonoscopy, and 253 to physician plus nurse observation during withdrawal. A total of 592 polyps were detected, 40 identified by the endoscopy nurse only. With nurse observation, 1.32 polyps and 0.82 adenomas were found per colonoscopy, vs. 1.03 polyps and 0.64 adenomas in the routine group, demonstrating a 1.29-fold and a 1.28-fold increase in the average number of polyps and of adenomas detected, respectively. The overall adenoma detection rate (ADR) was 44.1%, with trends toward increased ADR and all-polyp detection rate with nurse observation. Nurse observation during colonoscopy resulted in an increase in the number of polyps and adenomas found per colonoscopy, along with a trend toward improved overall ADR and all-polyp detection rate.

ObjectiveTo assess the safety and quality of baseline screening colonoscopy in a randomised controlled trial (RCT).MethodsA population-based RCT with an explanatory design is ongoing to evaluate the efficacy of colonoscopy screening in 9751 men and women aged 40–74 years at average risk of colorectal cancer (CRC) in Japan. Screening colonoscopies for the intervention group were performed from June 2009 to June 2017.ResultsOf the 4861 participants in the intervention group, 4495 (92.5%) underwent screening colonoscopy. The quality of bowel preparation was excellent (34.8%) or good (45.6%) in 80.4% of cases. The caecal intubation rate was 99.7% (4483/4495), and the mean (±SD) withdrawal time was 9.7 (±5.3) min. The adenoma detection rate (ADR) was 39.4% (1770/4495). A total of 27 participants (0.6%) were diagnosed with CRC, and 266 (5.9%) were diagnosed with advanced neoplasia (AN). In women, adenomas were more frequently detected in the proximal colon than in the distal colon (proximal: 18.9% vs distal: 16.4%, p=0.024), and a similar trend was observed for AN (proximal: 2.4% vs distal: 1.5%, p=0.045). No serious adverse events related to screening colonoscopy were reported, and minor adverse events were observed in two participants (0.04%).ConclusionsAdequate performance in compliance, ADR, and safety was confirmed in the intervention arm of the RCT evaluating the efficacy of screening colonoscopy. The high quality of screening colonoscopy observed in the trial suggests its feasibility as a population-based screening approach.Trial registration numberUMIN000001980.

BackgroundOpen access colonoscopy (OAC) has gained widespread acceptance and has the potential to increase colorectal cancer (CRC) screening. However, there is little data evaluating its appropriateness for CRC prevention.AimsThe aim of this study is to evaluate the appropriateness of OAC in CRC screening and polyp surveillance by comparing to procedures ordered by gastroenterologists (NOAC). As secondary outcomes, we compared the quality of bowel preparation and adenoma detection rate (ADR) between OAC and NOAC.MethodsIt is retrospective single-center study. Inclusion criteria included patients > 50 years of age undergoing a colonoscopy for CRC screening and surveillance. Appropriateness was defined as those colonoscopies performed within 12 months of the recommended 2012 consensus guidelines. Secondary outcomes included the quality of bowel preparation and ADR.Results5211 colonoscopies met inclusion criteria, and 64.9% were OAC. Screening OAC was appropriately 91.6% and NOAC 92.9% of the time (p = 0.179). Surveillance NOAC were inappropriate in 26.4% of cases, and surveillance OAC was 32.6% (p = 0.008). Multivariate analysis demonstrated that OAC did not influence ADR (OR for NOAC 0.97; 95% CI 0.86–1.1; p = 0.644) or an adequate bowel preparation (OR for NOAC 1.11; 95% CI 0.91–1.36; p = 0.306).ConclusionOAC performed similarly to NOAC for screening indications, quality of bowel preparation, and ADR. However, more surveillance procedures were inappropriate in the OAC group although both groups had a high number of inappropriate indications. Although OAC can be efficiently performed for screening indications, measures to decrease inappropriate surveillance colonoscopies are needed.

Background Quality performance measures for screening colonoscopy vary among endoscopists. The impact of practice setting is unknown. Aims We aimed to (1) compare screening colonoscopy performance measures among three different US practice settings; (2) evaluate factors associated with adenoma detection; and (3) assess a scorecard intervention on performance metrics. Methods This multi-center prospective study compared patient, endoscopist, and colonoscopy characteristics performed at a tertiary care hospital (TCH), community-based hospital (CBH), and private practice group (PPG). Withdrawal times (WT), cecal intubation, and adenoma detection rates (ADR) were compared by site at baseline and 12 weeks following scorecard distribution. Generalized linear mixed models identified factors associated with adenoma detection. Results Twenty-eight endoscopists performed colonoscopies on 1987 asymptomatic, average-risk individuals ≥50 years. Endoscopist and patient characteristics were similar across sites. The PPG screened more men (TCH: 42.8%, CBH: 45.0%, PPG: 54.2%; p  < 0.0001). Preparation quality varied with good/excellent results in 70.6, 88.3, and 92% of TCH, CBH, and PPG cases, respectively ( p  < 0.0001). Male ADRs, cecal intubation, and WT exceeded recommended benchmarks despite variable results at each site; female ADRs were <15% at the PPG which screened the fewest females. Performance remained unchanged following scorecard distribution. Adenoma detection was associated with increasing patient age, male gender, WT, adequate preparation, but not practice setting. Conclusions Each practice performed high-quality screening colonoscopy. Scorecards did not improve performance metrics. Preparation quality varies among practice settings and can be modified to improve adenoma detection.