Presentation on theme: "EQUIP Training session 1"— Presentation transcript:
1EQUIP Training session 1 Improving polyp/adenoma detection
2Background No prospective methods to increase ADR Detection of flat lesions not reported
3Hypothesis Intensive training (detection & classification) Increase in adenoma detectionWe will determine: ADR for EQuIP vs. non-EQuIP, per patient ADR, effect on total colonoscopy time, effect on total polypectomy rate and endoscopist acceptance
4Session I Objectives Importance Detection Methods Definition PrevalenceHistopathologyDetection MethodsSubtle clues to flat polypsColonoscopy Techniques
5Paris shape classification Paris class if probably the most recognized and used. It refers to the morphology of a lesion.At first glance this appears daunting. However the classification methods are actually quite simple.Type I lesions are raised. They are at least 2.5mm above the mucosal surface. I-p stands for pedunculated, I-s for sessile.For the purposes of today’s talk we’ll be focusing on the type II lesions.Again, they are very straight forward.There are flat polyps that are slightly elevated above lesions these are the II-aCompletely even with the mucosa are II-b and slightly depressed lesions are II-c.Ulcerated lesions are III, then there are mixed types.“Flat” polyps: Lesions with < 2.5mm elevation (width of snare catheter/bx cable)
6Definitions Flat Depressed Less than 2.5mm of elevation Base lower than normal mucosa heightWell demarcated; round or star shaped
7Flat and depressed lesions 1819 VA patients9.3% prevalence15% of all neoplasms54% of superficial carcinomas(OR 11.1; 95%CI, )1/3 of depressed lesions contained carcinomaFlat lesions have been well described in the Japanese populations, however this study in 2008 reports the U.S. prevalence.In this Veterens populations flat lesions accounted for 9.3% of all polyps but accounted for 15% of all neoplasms including 54% of superficial carinomas.1/3 of depressed lesions contained carcinoma.Soetikno et al; JAMA 2008
8Prevalence of Flat Polyps 27,400 colonoscopiesFlat adenoma 5.3%Among all adenomasPolypoid 74%Flat 26%More likely in right colon (OR 2.92)Risk of advanced histology similarUnless depressed (OR 10.56)What is the prevalance (quote other studies)Blanco et al. Endoscopy 2010;42:279
9Flat polyp pathology Flat (n = 289) Polypoid (n= 2463) 80 non-neoplastic195 tub. adenoma5 villous9 carcinomaDepressed, n = 1812 tubular adenomas6 carcinomasNO non-neoplasticPolypoid (n= 2463)1155 non-neoplastic1262 tub. adenoma33 villous adenoma13 carcinomaThis study by Soetikno et al. shows that although they were less frequent, flat and depressed polyps were more likely to contain neoplastia and advanced neoplasia. This was particularly true for depressed lesions where none contained “non-neoplastic” pathology.Reminder of miss rates of CRC XX/XX missed cancers were “flat” lesions.Soetikno et al; JAMA 2008
10Detection methods Subtle clues to detection Bowel preparation Colonoscopy techniquesWashing,working the foldsWithdrawalClear capsOptical enhancement ?We’ll now shift our focus to methods to detect flat and depressed neoplasias.We’ll review the subtle clues that indicate a flat or depressed lesion,The colonoscopy techniques necessary to detect these lesions, and briefly discuss the use of optical enhancement.
11Subtle clues Subtle color differences (red or pale) Spontaneous hemorrhage/friabilityDeformity of colon wallAbsence of vascular networkI borrowed this slide from the ASGE video on flat and depressed lesions.Some of the clues that should suggest the presence of a flat or depressed lesion.Include subtle difference in the color of the colon wall, usually described as a red patch but rarely may be pale,An area that is friable and bleeds spontaneously, a deformity in the colon wall and absence of the normal vascular network.We’ll look at video examples of each.From video (concepts + cases using chromo) 06:45 to 08:30Above from videoASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006
12Subtle clues: VideoTotal time = 01:44Case 1: redCase 2: friableCase 3: deformityCase 4: absence of vascular networkASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006
13Example from our practice. Small flat adenoma. Notice subtle red color difference and absence of vascularity.
15Detection methods Colonoscopy technique Withdrawal time ? Washing Bowel prep score“Working” the foldsClear Caps
16Mandating longer WD time does NOT increase ADR Withdrawal TimeMandating longer WD time does NOT increase ADRADR after MandateCompliance w/ mandateSawhaney Gastro 2008;135;1892
17Colonoscopy technique CriterionHigh adenoma detectorLow adenoma detectorp ValueLooking on the proximal sides of folds, valves, etc.31.519.6< 0.001Adequacy of cleaning33.121.9Adequacy of distention33.524.0Adequacy of time spent viewing32.421.0*Scores are the means for all colonoscopies and for all 4 judges. The highest score possible is 35. ‡ColonoscopistHigh detector vs. low detectorPercentage of mucosa visualized (estimate)90.8% vs. 63.3%; p <0.001Mean withdrawal time8 min 55 sec vs. 6 min 41 sec; p = 0.02More retroflex exams (9 vs. 6)Re-examine prox. side rectal valves in all 9 (15 – 40 seconds)Rex D, GIE; 2000; Vol 51, No 1
18Prep Quality Missed CRC Flat and depressed neoplasms Retrospective data review; 5055 colonoscopies17/286 cancers missed by colonoscopy6/17 (3.5%) incomplete due to “poor prep”4/17 (2.4%) identified but not recognized as malignantFlat and depressed neoplasmsDetection lower with inadequate bowel prepSmall adenoma detectionRetrospective review; 93,000Adequate prep (76.9%) more likely detect“Suspected neoplasia”Lesions < 9mmNo difference in lesions >9 mm
19Boston Bowel Preparation Score Significant clinical outcomesPolyp-detection rate40% for BBPS >5 vs. 24% for BBPS <5 (P<.02)Repeat procedure recommendations (less for BBPS>5)2% for BBPS >5 vs. 73% for BBPS <5 (P,.001)Colonscope insertion and withdrawal times (Inverse correlation(insertion r = -0.16, P <.003; withdrawal r = -0.23, P < .001).
21Washing Study of 400 colonoscopies Public Private Significance Private hospital (200); “adequate” prep 86.5%PEG solution (92%)Public hospital (200); “Adequate” prep 73.5%Sodium phosphate (68%)PublicPrivateSignificanceEarly recall20%12.5%p = 0.04Aborted case6.5%1%p = 0.004Public hospital: Lower “adequate prep”, earlier recall and higher rate of aborted casesRex et al; AJC, 2002, Vol 97 No. 7
22Hidden flat lesionsExamples of flat lesions hidden by poor prep1st lesion = T1N02nd lesion = adenomaASGE 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 OC7 = advanced lesions15 = non-rectal neoplasia (other 6 in rectum)14 located on folds (10 back, 4 front)1 located inner aspect of a flexureSame day colonoscopy and virtual colonoscopy study of missed lesions.Colonoscopy missed 21 adenomas that were found by virtual colonoscopy.Key point = 14 of 21 were located on folds (10 back, 4 front)!
24Withdrawal technique Total time: 01:27 ASGE video clip on withdrawal technique/working the foldsExploring proximal side of each fold; tip deflectionBowel prep; clearing mucus and chymeWorking the folds, sweeping right and left and pulling back toAdequate distention
25“Working” the folds From our practice. Flat polyp on fold only found with careful prying of folds.
26Clear caps Cap NBI <5mm 24 5 5-10mm 9 Flat 7 2 Sessile 26 3 Cap NBI Retractable clear cap vs. NBI for 2nd colonoscopy in patients with known polypsCapNBIProcedure time25m21m.04Adenoma detection31%5%<0.04Interval increase in adenoma detection by size and shapeCapNBI<5mm2455-10mm9Flat72Sessile263Initial colonoscopy randomized to repeat within 3 months NBI vs. (retractable) Cap WLCap during insertion at discretion of endoscopist, all had cap during withdrawalDuring 1st colonoscopy polyps were recorded but not removed.During 2nd colonoscopy the endoscopist did not have prior knowledge of the polyps found, later compared polyps found during 2nd with those found during 1st to determine incremental change in detection.Significant incremental adenoma detection in those w clear cap vs. those with NBIMajority were in the ascending colon and rectum.Studies have shown that using a hood increases adenoma detectionLee, N=1000; intubation; 6 vs 7.2 p<0.001; total time 14.6 vs 16.7 P< ADR 30.5 vs 37.5 p<0.018; Lee et al, Endoscopy 2006;38:Kondo N=684, total time 11.5 vs p<0.01; ADR 49.3 vs 29.1 p<0.04; Kondo et al; Am J Gastro 2007; 102:75-81Matsushima M, et al, Endoscopy 1998; 30:Horiuchi A, Nakayama, Am J. Gastro 2008;103:Dafnis GM. Endoscopy 2000;32: (Technical considerations and patient confort…”Horiuchi et al. CGH 2010;8:379