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EQUIP Training session 1 Improving polyp/adenoma detection.

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Presentation on theme: "EQUIP Training session 1 Improving polyp/adenoma detection."— Presentation transcript:

1 EQUIP Training session 1 Improving polyp/adenoma detection

2 Background No prospective methods to increase ADR No prospective methods to increase ADR Detection of flat lesions not reported Detection of flat lesions not reported

3 Hypothesis Intensive training (detection & classification) Increase in adenoma detection

4 Session I Objectives Importance Importance Definition Definition Prevalence Prevalence Histopathology Histopathology Detection Methods Detection Methods Subtle clues to flat polyps Subtle clues to flat polyps Colonoscopy Techniques Colonoscopy Techniques

5 Paris shape classification “Flat” polyps: Lesions with < 2.5mm elevation (width of snare catheter/bx cable)

6 Definitions Flat Flat Less than 2.5mm of elevation Less than 2.5mm of elevation Depressed Depressed Base lower than normal mucosa height Base lower than normal mucosa height Well demarcated; round or star shaped Well demarcated; round or star shaped

7 Soetikno et al; JAMA 2008 Flat and depressed lesions 1819 VA patients 1819 VA patients 9.3% prevalence 9.3% prevalence 15% of all neoplasms 15% of all neoplasms 54% of superficial carcinomas 54% of superficial carcinomas (OR 11.1; 95%CI, 4.98-24.8) (OR 11.1; 95%CI, 4.98-24.8) 1/3 of depressed lesions contained carcinoma 1/3 of depressed lesions contained carcinoma

8 Prevalence of Flat Polyps 27,400 colonoscopies 27,400 colonoscopies Flat adenoma5.3% Flat adenoma5.3% Among all adenomas Among all adenomas Polypoid74% Polypoid74% Flat26% Flat26% More likely in right colon (OR 2.92) More likely in right colon (OR 2.92) Risk of advanced histology similar Risk of advanced histology similar Unless depressed (OR 10.56) Unless depressed (OR 10.56) Blanco et al. Endoscopy 2010;42:279

9 Soetikno et al; JAMA 2008 Flat polyp pathology Flat polyp pathology Polypoid (n= 2463) Polypoid (n= 2463) 1155 non-neoplastic 1155 non-neoplastic 1262 tub. adenoma 1262 tub. adenoma 33 villous adenoma 33 villous adenoma 13 carcinoma 13 carcinoma Flat (n = 289) 80 non-neoplastic 195 tub. adenoma 5 villous 9 carcinoma Depressed, n = 18 12 tubular adenomas 6 carcinomas NO non-neoplastic

10 Detection methods Subtle clues to detection Subtle clues to detection Bowel preparation Bowel preparation Colonoscopy techniques Colonoscopy techniques Washing, Washing, working the folds working the folds Withdrawal Withdrawal Clear caps Clear caps Optical enhancement ? Optical enhancement ?

11 Subtle clues Subtle color differences (red or pale) Subtle color differences (red or pale) Spontaneous hemorrhage/friability Spontaneous hemorrhage/friability Deformity of colon wall Deformity of colon wall Absence of vascular network Absence of vascular network ASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006

12 Subtle clues: Video ASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006

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15 Detection methods Colonoscopy technique Colonoscopy technique Withdrawal time ? Withdrawal time ? Washing Washing Bowel prep score Bowel prep score “Working” the folds “Working” the folds Clear Caps Clear Caps

16 Withdrawal Time Mandating longer WD time does NOT increase ADR Compliance w/ mandate ADR after Mandate Sawhaney Gastro 2008;135;1892

17 Rex D, GIE; 2000; Vol 51, No 1 Colonoscopy technique CriterionHigh adenoma detectorLow adenoma detectorp Value Looking on the proximal sides of folds, valves, etc.31.519.6< 0.001 Adequacy of cleaning33.121.9< 0.001 Adequacy of distention33.524.0< 0.001 Adequacy of time spent viewing32.421.0< 0.001 *Scores are the means for all colonoscopies and for all 4 judges. The highest score possible is 35. ‡ Colonoscopist High detector vs. low detector High detector vs. low detector Percentage of mucosa visualized (estimate) 90.8% vs. 63.3%; p <0.001 Mean withdrawal time 8 min 55 sec vs. 6 min 41 sec; p = 0.02 More retroflex exams (9 vs. 6) Re-examine prox. side rectal valves in all 9 (15 – 40 seconds)

18 Prep Quality Missed CRC Missed CRC Retrospective data review; 5055 colonoscopies Retrospective data review; 5055 colonoscopies 17/286 cancers missed by colonoscopy 17/286 cancers missed by colonoscopy 6/17 (3.5%) incomplete due to “poor prep” 6/17 (3.5%) incomplete due to “poor prep” 4/17 (2.4%) identified but not recognized as malignant 4/17 (2.4%) identified but not recognized as malignant Flat and depressed neoplasms Flat and depressed neoplasms Detection lower with inadequate bowel prep Detection lower with inadequate bowel prep Small adenoma detection Small adenoma detection Retrospective review; 93,000 Retrospective review; 93,000 Adequate prep (76.9%) more likely detect Adequate prep (76.9%) more likely detect “Suspected neoplasia” “Suspected neoplasia” Lesions < 9mm Lesions < 9mm No difference in lesions >9 mm No difference in lesions >9 mm

19 Boston Bowel Preparation Score

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21 Rex et al; AJC, 2002, Vol 97 No. 7 Washing Study of 400 colonoscopies Study of 400 colonoscopies Private hospital (200); “adequate” prep 86.5% Private hospital (200); “adequate” prep 86.5% PEG solution (92%) PEG solution (92%) Public hospital (200); “Adequate” prep 73.5% Public hospital (200); “Adequate” prep 73.5% Sodium phosphate (68%) Sodium phosphate (68%) PublicPrivateSignificance Early recall 20%12.5% p = 0.04 Aborted case 6.5%1% p = 0.004 Public hospital: Lower “adequate prep”, earlier recall and higher rate of aborted cases

22 Hidden flat lesions ASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006

23 “Working” the folds Same day virtual and optical colonoscopy (1233 patients; 210 adenomas > 6mm) 21 adenomas > 6mm missed on OC 21 adenomas > 6mm missed on OC 7 = advanced lesions 7 = advanced lesions 15 = non-rectal neoplasia (other 6 in rectum) 15 = non-rectal neoplasia (other 6 in rectum) 14 located on folds (10 back, 4 front) 14 located on folds (10 back, 4 front) 1 located inner aspect of a flexure 1 located inner aspect of a flexure

24 Withdrawal technique

25 “Working” the folds

26 Clear caps CapNBI Procedure time 25m21m.04 Adenoma detection 31%5%<0.04 Horiuchi et al. CGH 2010;8:379CapNBI<5mm245 5-10mm90 Flat72 Sessile263 Retractable clear cap vs. NBI for 2 nd colonoscopy in patients with known polyps Interval increase in adenoma detection by size and shape

27 Clear caps

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29 Summary Flat polyps exist Flat polyps exist There are subtle clues to detect flat polyps There are subtle clues to detect flat polyps Color, friability, wall deformity, vessel changes Color, friability, wall deformity, vessel changes Good colonoscopy technique is needed Good colonoscopy technique is needed Washing Washing Clear caps Clear caps Working the folds Working the folds


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