1. EQUIP Training session 1
Improving polyp/adenoma detection

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

3. Hypothesis Intensive training (detection & classification)
Increase in adenoma detection
We will determine: ADR for EQuIP vs. non-EQuIP, per patient ADR, effect on total colonoscopy time, effect on total polypectomy rate and endoscopist acceptance

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

5. Paris 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-a
Completely 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)

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

7. Flat and depressed lesions
1819 VA patients
9.3% prevalence
15% of all neoplasms
54% of superficial carcinomas
(OR 11.1; 95%CI, )
1/3 of depressed lesions contained carcinoma
Flat 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

8. Prevalence of Flat Polyps
27,400 colonoscopies
Flat adenoma 5.3%
Among all adenomas
Polypoid 74%
Flat 26%
More likely in right colon (OR 2.92)
Risk of advanced histology similar
Unless depressed (OR 10.56)
What is the prevalance (quote other studies)
Blanco et al. Endoscopy 2010;42:279

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

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

11. Subtle clues Subtle color differences (red or pale)
Spontaneous hemorrhage/friability
Deformity of colon wall
Absence of vascular network
I 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 08:30
Above from video
ASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006

12. Subtle clues: Video
Total time = 01:44
Case 1: red
Case 2: friable
Case 3: deformity
Case 4: absence of vascular network
ASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006

13. Example from our practice. Small flat adenoma.
Notice subtle red color difference and absence of vascularity.

14. NBI of same small adenoma.

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

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

17. Colonoscopy technique
Criterion
High adenoma detector
Low adenoma detector
p Value
Looking on the proximal sides of folds, valves, etc.
31.5
19.6
< 0.001
Adequacy of cleaning
33.1
21.9
Adequacy of distention
33.5
24.0
Adequacy of time spent viewing
32.4
21.0
*Scores are the means for all colonoscopies and for all 4 judges. The highest score possible is 35. ‡Colonoscopist
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)
Rex D, GIE; 2000; Vol 51, No 1

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

19. Boston Bowel Preparation Score
Significant clinical outcomes
Polyp-detection rate
40% 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).

21. Washing 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%)
Public
Private
Significance
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
Rex et al; AJC, 2002, Vol 97 No. 7

22. Hidden flat lesions
Examples of flat lesions hidden by poor prep
1st lesion = T1N0
2nd lesion = adenoma
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
7 = advanced lesions
15 = non-rectal neoplasia (other 6 in rectum)
14 located on folds (10 back, 4 front)
1 located inner aspect of a flexure
Same 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)!

24. Withdrawal technique Total time: 01:27
ASGE video clip on withdrawal technique/working the folds
Exploring proximal side of each fold; tip deflection
Bowel prep; clearing mucus and chyme
Working the folds, sweeping right and left and pulling back to
Adequate distention

25. “Working” the folds From our practice.
Flat polyp on fold only found with careful prying of folds.

26. Clear 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 polyps
Cap
NBI
Procedure time
25m
21m
.04
Adenoma detection
31% 5%
<0.04
Interval increase in adenoma detection by size and shape
Cap
NBI
<5mm 24 5
5-10mm 9
Flat 7 2
Sessile 26 3
Initial colonoscopy randomized to repeat within 3 months NBI vs. (retractable) Cap WL
Cap during insertion at discretion of endoscopist, all had cap during withdrawal
During 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 NBI
Majority were in the ascending colon and rectum.
Studies have shown that using a hood increases adenoma detection
Lee, 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; 102:75-81
Matsushima 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

27. Clear caps

28. Clear caps
1st 30 seconds of video: Flat polyp found behind fold using cap.

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