EQUIPEQUIPTraining session 1Training session 1

Improving Improving polyp/adenoma polyp/adenoma

detectiondetection

BackgroundBackground

No prospective methods to increase No prospective methods to increase ADRADR

Detection of flat lesions not reportedDetection of flat lesions not reported

HypothesisHypothesis

Intensive training (detection & Intensive training (detection & classification)classification)

Increase in adenoma detection Increase in adenoma detection

Session I ObjectivesSession I Objectives

Importance Importance DefinitionDefinition PrevalencePrevalence HistopathologyHistopathology

Detection MethodsDetection Methods Subtle clues to flat polypsSubtle clues to flat polyps Colonoscopy TechniquesColonoscopy Techniques

Paris shape classificationParis shape classification

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

DefinitionsDefinitions FlatFlat

Less than 2.5mm of elevationLess than 2.5mm of elevation

DepressedDepressed Base lower than normal mucosa heightBase lower than normal mucosa height

Well demarcated; round or star shapedWell demarcated; round or star shaped

Soetikno et al; JAMA 2008Soetikno et al; JAMA 2008

Flat and depressed lesionsFlat and depressed lesions

1819 VA patients 1819 VA patients 9.3% prevalence9.3% prevalence 15% of all neoplasms15% 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 1/3 of depressed lesions contained

carcinomacarcinoma

Prevalence of Flat PolypsPrevalence of Flat Polyps 27,400 colonoscopies27,400 colonoscopies

Flat adenomaFlat adenoma 5.3%5.3% Among all adenomasAmong all adenomas

PolypoidPolypoid 74%74% FlatFlat 26%26%

More likely in right colon (OR 2.92)More likely in right colon (OR 2.92) Risk of advanced histology similarRisk of advanced histology similar

Unless depressed (OR 10.56)Unless depressed (OR 10.56)

•Blanco et al. Endoscopy 2010;42:279

Soetikno et al; JAMA 2008Soetikno et al; JAMA 2008

Flat polyp pathologyFlat polyp pathology

Polypoid (n= 2463)Polypoid (n= 2463) 1155 non-neoplastic1155 non-neoplastic 1262 tub. adenoma1262 tub. adenoma 33 villous adenoma33 villous adenoma 13 carcinoma13 carcinoma

Flat (n = 289) Flat (n = 289) 80 non-neoplastic80 non-neoplastic 195 tub. adenoma195 tub. adenoma 5 villous5 villous 9 carcinoma9 carcinoma

Depressed, n = 18Depressed, n = 18 12 tubular adenomas12 tubular adenomas 6 carcinomas6 carcinomas NO non-neoplasticNO non-neoplastic

Detection methodsDetection methods

Subtle clues to detectionSubtle clues to detection

Bowel preparationBowel preparation

Colonoscopy techniquesColonoscopy techniques Washing, Washing, working the foldsworking the folds WithdrawalWithdrawal Clear caps Clear caps Optical enhancement ?Optical enhancement ?

Subtle cluesSubtle clues

Subtle color differences (red or pale)Subtle color differences (red or pale)

Spontaneous hemorrhage/friabilitySpontaneous hemorrhage/friability

Deformity of colon wallDeformity of colon wall

Absence of vascular networkAbsence of vascular network

ASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006

Subtle clues: VideoSubtle clues: Video

ASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006

Detection methodsDetection methods

Colonoscopy techniqueColonoscopy technique Withdrawal time ?Withdrawal time ? WashingWashing

Bowel prep scoreBowel prep score ““Working” the foldsWorking” the folds Clear CapsClear Caps

Withdrawal TimeWithdrawal Time

Mandating longer WD time does Mandating longer WD time does NOT increase ADRNOT increase ADR

Compliance w/ mandate ADR after Mandate

Sawhaney Gastro 2008;135;1892

Rex D, GIE; 2000; Vol 51, No 1Rex D, GIE; 2000; Vol 51, No 1

Colonoscopy techniqueColonoscopy 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 < 0.001

Adequacy of distention 33.5 24.0 < 0.001

Adequacy of time spent viewing 32.4 21.0 < 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 detectorHigh detector vs. low detector Percentage of mucosa visualized (estimate)Percentage of mucosa visualized (estimate)

90.8% vs. 63.3%; p <0.00190.8% vs. 63.3%; p <0.001 Mean withdrawal timeMean withdrawal time

8 min 55 sec vs. 6 min 41 sec; p = 0.028 min 55 sec vs. 6 min 41 sec; p = 0.02 More retroflex exams (9 vs. 6)More retroflex exams (9 vs. 6) Re-examine prox. side rectal valves in all 9 (15 – 40 seconds)Re-examine prox. side rectal valves in all 9 (15 – 40 seconds)

Prep QualityPrep Quality Missed CRCMissed CRC

Retrospective data review; 5055 colonoscopiesRetrospective data review; 5055 colonoscopies 17/286 cancers missed by colonoscopy17/286 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 malignant4/17 (2.4%) identified but not recognized as malignant

Flat and depressed neoplasmsFlat and depressed neoplasms Detection lower with inadequate bowel prepDetection 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 detectAdequate prep (76.9%) more likely detect ““Suspected neoplasia”Suspected neoplasia” Lesions < 9mmLesions < 9mm No difference in lesions >9 mmNo difference in lesions >9 mm

Boston Bowel Preparation Boston Bowel Preparation ScoreScore

Hidden flat lesionsHidden flat lesions

ASGE Learning Library: Diagnosis of Flat and Depressed Colorectal Neoplasms; 2006

““Working” the foldsWorking” the folds

Same day virtual and optical Same day virtual and optical colonoscopycolonoscopy

(1233 patients; 210 adenomas > 6mm) (1233 patients; 210 adenomas > 6mm)

21 adenomas > 6mm missed on OC 21 adenomas > 6mm missed on OC 7 = advanced lesions7 = 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 flexure1 located inner aspect of a flexure

Withdrawal techniqueWithdrawal technique

““Working” the foldsWorking” the folds

Clear capsClear caps

CapCap NBINBI

Procedure timeProcedure time 25m25m 21m 21m .04.04

Adenoma Adenoma detectiondetection

31%31% 5%5% <0.04<0.04

Horiuchi et al. CGH 2010;8:379

CapCap NBINBI

<5mm<5mm 2424 55

5-10mm5-10mm 99 00

FlatFlat 77 22

SessileSessile 2626 33

Retractable clear cap vs. NBI for 2nd colonoscopy in patients with known polyps

Interval increase in adenoma detection by size and shape

Clear capsClear caps

SummarySummary

Flat polyps existFlat polyps exist There are subtle clues to detect flat There are subtle clues to detect flat

polypspolyps Color, friability, wall deformity, vessel Color, friability, wall deformity, vessel

changeschanges Good colonoscopy technique is neededGood colonoscopy technique is needed

WashingWashing Clear capsClear caps Working the foldsWorking the folds