Differences in proximal serrated polyp detection among endoscopists are associated with variability in withdrawal time

doi:10.1016/j.gie.2012.10.018

Gastrointestinal Endoscopy

Volume 77, Issue 4, April 2013, Pages 617-623

https://doi.org/10.1016/j.gie.2012.10.018 Get rights and content

Background

Insufficient detection of proximal serrated polyps (PSP) might explain the occurrence of a proportion of interval carcinomas in colonoscopy surveillance programs.

Objective

To compare PSP detection among endoscopists and to identify patient-related and endoscopist-related factors associated with PSP detection.

Design

Prospective study in unselected patients.

Setting

Colonoscopy screening program for colorectal cancer at two academic medical centers.

Patients

Asymptomatic consecutive screening participants (aged 50-75 years).

Intervention

Colonoscopies were performed by 5 experienced endoscopists. All detected polyps were removed. Multiple colonoscopy quality indicators were prospectively recorded.

Main Outcome Measurements

We compared PSP detection among endoscopists by calculating odds ratios (OR) with logistic regression analysis. Logistic regression also was used to identify patient features and colonoscopy factors associated with PSP detection.

Results

A total of 1354 patients underwent a complete screening colonoscopy: 1635 polyps were detected, of which 707 (43%) were adenomas and 685 (42%) were serrated polyps, including 215 PSPs. In 167 patients (12%) 1 or more PSPs were detected. The PSP detection rate differed significantly among endoscopists, ranging from 6% to 22% (P < .001). Longer withdrawal time (OR 1.12; 95% confidence interval, 1.10-1.16) was significantly associated with better PSP detection, whereas patient age, sex, and quality of bowel preparation were not.

Limitations

Limited number of highly experienced endoscopists.

Conclusion

The PSP detection rate differs among endoscopists. Longer withdrawal times are associated with better PSP detection, but patient features are not. (Clinical trial registration number: NTR1888.)

Section snippets

Study population

Data were collected in the randomized, multicenter Colonoscopy or Colonography for Screening (COCOS) trial. The overall design of this invitational, population-based, colorectal cancer screening program as well as its main results (participation and diagnostic yield) have been described in detail elsewhere.12, 13 Screening participants allocated to the colonoscopy arm were included for this study. Between June 2009 and July 2010, a total of 6600 asymptomatic individuals from the Amsterdam and

Results

A total of 1426 people participated in the colonoscopy screening program, of whom 1407 (99%) underwent a complete screening colonoscopy. In this group, 1354 colonoscopies were completed by endoscopists who had performed more than 50 colonoscopies. Of the corresponding study participants, 689 (51%) were men; their median age was 60 years (interquartile range [IQR] 55-65 years). The median Ottawa bowel preparation score was 5 (IQR 3-8). The median net withdrawal time was 10 minutes (IQR 8-15

Discussion

We performed a prospective study to compare PSP detection among endoscopists and to identify patient-related and procedure-related factors associated with the detection of PSPs. PSP detection differed significantly among experienced endoscopists. In this population, we did not observe significant effects of age, sex, or quality of bowel preparation but found withdrawal time to be strongly and significantly associated with PSP detection.

To our knowledge, this is the first prospective study to

Acknowledgment

We would like to acknowledge Karin de Groot for the professional research support and the accurate recording of all colonoscopy items.

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Cited by (113)

Clinically significant serrated polyp detection rates and risk for postcolonoscopy colorectal cancer: data from the New Hampshire Colonoscopy Registry
2022, Gastrointestinal Endoscopy
Higher adenoma detection rates reduce the risk of postcolonoscopy colorectal cancer (PCCRC). Clinically significant serrated polyps (CSSPs; defined as any sessile serrated polyp, traditional serrated adenoma, large [≥1 cm] or proximal hyperplastic polyp >5 mm) also lead to PCCRC, but there are no data on associated CSSP detection rates (CSSDRs). We used data from the New Hampshire Colonoscopy Registry (NHCR) to investigate the association between PCCRC risk and endoscopist CSSDR.
We included NHCR patients with 1 or more follow-up events: either a colonoscopy or a colorectal cancer (CRC) diagnosis identified through linkage with the New Hampshire State Cancer Registry. We defined our outcome, PCCRC, in 3 time periods: CRC diagnosed 6 to 36 months, 6 to 60 months, or all examinations (6 months or longer) after an index examination. We excluded patients with CRC diagnosed at or within 6 months of the index examination, with incomplete examinations, or with inflammatory bowel disease. The exposure variable was endoscopist CSSDR at the index colonoscopy. Cox regression was used to model the hazard of PCCRC on CSSDR controlling for age, sex, index findings, year of examination, personal history of colorectal neoplasia, and having more than 1 surveillance examination.
One hundred twenty-eight patients with CRC diagnosed at least 6 months after their index examination were included. Our cohort included 142 endoscopists (92 gastroenterologists). We observed that the risk for PCCRC 6 months or longer after the index examination was significantly lower for examinations performed by endoscopists with CSSDRs of 3% to <9% (hazard ratio [HR], .57; 95% confidence interval [CI], .39-.83) or 9% or higher (HR, .39; 95% CI, .20-.78) relative to those with CSSDRs under 3%.
Our study is the first to demonstrate a lower PCCRC risk after examinations performed by endoscopists with higher CSSDRs. Both CSSDRs of 9% and 3% to <9% had statistically lower risk of PCCRC than CSSDRs of <3%. These data validate CSSDR as a clinically relevant quality measure for endoscopists.
Withdrawal Time: Is Nine the New Six?
2022, Clinical Gastroenterology and Hepatology
Impact of 9-Minute Withdrawal Time on the Adenoma Detection Rate: A Multicenter Randomized Controlled Trial
2022, Clinical Gastroenterology and Hepatology
Citation Excerpt :
A notable strength of our study is the accurate recording of the WT of all colonoscopies by excluding the time for biopsy and resection and controlling and adjusting for confounders related to the colonoscopists, patients, and BPQ. The rationale for selecting 9-minute WT was based on previous findings12,13,16,17,23,25 and practical considerations. First, several retrospective studies associated 9-minute WT with the highest ADR and SDR,12,13 and WTs longer than 9 minutes did not show additional benefits for ADR (ceiling effect).23,25
Although current quality indicators of colonoscopy recommend 6 minutes as the minimum standard for withdrawal time (WT), the impact of a WT longer than 6 minutes on neoplasia detection is unclear.
A multicenter randomized controlled trial involving 1027 patients was conducted from January 2018 to July 2019. Participants were randomly divided into a 9-minute (n = 514) and 6-minute (n = 513) WT group, and a timer was used to adjust the withdrawal speed. The primary outcome was the adenoma detection rate (ADR).
Intention-to-treat analysis showed a significantly higher ADR in the 9-minute versus 6-minute WT group (36.6% vs. 27.1%, P = .001). Prolonging WT from 6 to 9 minutes significantly increased ADR of the proximal colon (21.4% vs. 11.9%, P < .001) as well as of the less experienced colonoscopists (36.8% vs. 23.5%, P = .001). Improvements were also observed in the polyp detection rate (58.0% vs. 47.8%, P < .001), and mean number of polyps and adenomas detected per colonoscopy (1.1 vs. 0.9, P = .002; 0.5 vs. 0.4, P = .008, respectively). The higher ADRs in 9-minute WT were also confirmed by the per-protocol (PP) analysis and subgroup analyses, with an increased rate of sessile serrated lesion detection in the 9-minute WT by PP analysis (4.0% vs. 1.3%, P = .04). Multivariate logistic regression demonstrated that the 9-minute WT was independently associated with increased ADR (P = .005).
Prolonging WT from 6 to 9 minutes significantly improved ADR, especially in the proximal colon and for less experienced colonoscopists. A 9-minute WT benchmark should be considered as one of the quality indicators of colonoscopy. ClinicalTrials.gov (identiﬁer, NCT03399045)
Correlation between proximal serrated polyp detection and clinically significant serrated polyps: inter-endoscopist variability
2021, Revista de Gastroenterologia de Mexico
La tasa de detección de adenomas (TDA) es el más importante indicador de calidad para la prevención del cáncer colorrectal. Sin embargo, los pólipos serratos también son lesiones precursoras de cáncer colorrectal. El objetivo del estudio fue comparar la tasa de detección de pólipos serratos proximales (PSP) y la tasa de detección de pólipos serratos clínicamente significativos (PSCS), entre endoscopistas, y analizar la relación entre estos parámetros y la TDA.
Estudio observacional, transversal y prospectivo. Se incluyeron a todos los pacientes que acudieron para colonoscopia al Policlínico Peruano Japonés entre julio del 2015 y agosto del 2016. Se utilizó regresión logística multivariada para comparar la TDA, la tasa detección de PSP y la tasa de detección de PSCS entre los endoscopistas. Se calculó la asociación entre estos parámetros mediante el coeficiente de correlación de Pearson.
Fueron incluidos 15 endoscopistas y 1,378 colonoscopias. La tasa de detección de PSP estuvo en el rango de 1.8-17% entre los endoscopistas. La tasa de detección de PSP tuvo una correlación casi perfecta con la tasa de detección de PSCS (ρ = 0.922). La tasa de detección de PSP tuvo una fuerte correlación con la TDA (ρ = 0.769).
La tasa de detección de PSP tiene gran variabilidad entre endoscopistas, y tiene una correlación casi perfecta con la tasa de detección de PSCS, así como una fuerte correlación con la TDA. Estos resultados sugieren una alta tasa de PSCS perdidos por los endoscopistas con una baja tasa de detección de PSP.
The adenoma detection rate (ADR) is the most important quality indicator for the prevention of colorectal cancer but serrated polyps are also precursor lesions of the disease. The aim of our study was to compare the detection rate of proximal serrated polyps (PSPs) and that of clinically significant serrated polyps (CSSPs) between endoscopists and analyze the relation of those parameters to the ADR.
An observational, prospective, cross-sectional study was conducted on all patients that underwent colonoscopy at the Policlínico Peruano Japonés within the time frame of July 2015 and August 2016. The ADR and PSP and CSSP detection rates between endoscopists were compared through multivariate logistic regression and the association between those parameters was calculated through the Pearson correlation coefficient.
The study included 15 endoscopists and 1,378 colonoscopies. The PSP detection rate ranged from 1.8-17% between endoscopists and had an almost perfect correlation with the CSSP detection rate (p = 0.922), as well as strongly correlating with the ADR (p = 0.769).
There was great variability in the PSP detection rate between endoscopists. It also had an almost perfect correlation with the CSSP detection rate and strongly correlated with the ADR. Those results suggest a high CSSP miss rate at endoscopy and a low PSP detection rate.
Serrated polyps of the colon and rectum: a concise review
2021, Revista de Gastroenterologia de Mexico
«Pólipos serrados» es el término utilizado para describir lesiones epiteliales del colon y recto que demuestran un patrón de «dientes de sierra» de la superficie y epitelio de las criptas. La llamada vía serrada describe la progresión de adenomas serrados sésiles y adenomas serrados tradicionales a cáncer colorrectal. Esta vía está bien reconocida como un mecanismo de carcinogénesis alternativo, el cual representa el 15-30% de los casos de cáncer colorrectal, explicando además una proporción significativa de los casos de cáncer colorrectal de intervalo. Por tal motivo, debido a su comportamiento incierto y usualmente agresivo, los pólipos serrados son un tema de suma relevancia en el cribado de cáncer colorrectal. Nuestro objetivo fue revisar la historia, nomenclatura actual, fisiopatología, características morfológicas, tratamiento y vigilancia de los pólipos serrados.
“Serrated polyps” is the term used for epithelial lesions of the colon and rectum that have a “sawtooth” pattern on the polyp's surface and crypt epithelium. The so-called serrated pathway describes the progression of sessile serrated adenomas and traditional serrated adenomas to colorectal cancer. Said pathway is well recognized as an alternative mechanism of carcinogenesis and accounts for 15-30% of the cases of colorectal cancer. It also explains a large number of the cases of interval colorectal cancer. Thus, due to their usually aggressive and uncertain behavior, serrated polyps are of the utmost importance in colorectal cancer screening. Our aim was to review the history, current nomenclature, pathophysiology, morphology, treatment, and surveillance of serrated polyps.
Prevalence and Clinical Features of Sessile Serrated Polyps: A Systematic Review
2020, Gastroenterology
Sessile serrated polyps (SSPs) could account for a substantial proportion of colorectal cancers. We aimed to increase clarity on SSP prevalence and clinical features.
We performed a systematic review of MEDLINE, Web of Science, Embase, and Cochrane databases for original studies published in English since 2000. We included studies of different populations (United States general or similar), interventions (colonoscopy, autopsy), comparisons (world regions, alternative polyp definitions, adenoma), outcomes (prevalence, clinical features), and study designs (cross-sectional). Random-effects regression was used for meta-analysis where possible.
We identified 74 relevant colonoscopy studies. SSP prevalence varied by world region, from 2.6% in Asia (95% confidence interval [CI], 0–5.9) to 10.5% in Australia (95% CI, 2.8–18.2). Prevalence values did not differ significantly between the United States and Europe (P = .51); the pooled prevalence was 4.6% (95% CI, 3.4–5.8), and SSPs accounted for 9.4% of polyps with malignant potential (95% CI, 6.6–12.3). The mean prevalence was higher when assessed through high-performance examinations (9.1%; 95% CI, 4.0–14.2; P = .04) and with an alternative definition of clinically relevant serrated polyps (12.3%; 95% CI, 9.3–15.4; P < .001). Increases in prevalence with age were not statistically significant, and prevalence did not differ significantly by sex. Compared with adenomas, a higher proportion of SSPs were solitary (69.0%; 95% CI, 45.9–92.1; P = .08), with diameters of 10 mm or more (19.3%; 95% CI, 12.4–26.2; P = .13) and were proximal (71.5%; 95% CI, 63.5–79.5; P = .008). The mean ages for detection of SSP without dysplasia, with any or low-grade dysplasia, and with high-grade dysplasia were 60.8 years, 65.6 years, and 70.2 years, respectively. The range for proportions of SSPs with dysplasia was 3.7%–42.9% across studies, possibly reflecting different study populations.
In a systematic review, we found that SSPs are relatively uncommon compared with adenoma. More research is needed on appropriate diagnostic criteria, variations in detection, and long-term risk.

View all citing articles on Scopus

: DISCLOSURE: The study was funded by The Netherlands Organization for Health Research and Development of the Dutch Ministry of Health (ZonMW 120720012) and by the Center for Translational Molecular Medicine (CTMM DeCoDe-project). Norgine (Amsterdam, The Netherlands) provided the bowel preparation for colonoscopy. No other financial relationships relevant to this publication were disclosed.

: See CME section; p. 636.

: If you would like to chat with an author of this article, you may contact Dr Dekker at [email protected].

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Original articleClinical endoscopyDifferences in proximal serrated polyp detection among endoscopists are associated with variability in withdrawal time

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Study population

Results

Discussion

Acknowledgment

Clin Gastroenterol Hepatol

Gastroenterology

Gastroenterology

Gastroenterology

Clin Gastroenterol Hepatol

Lancet Oncol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

American College of Gastroenterology guidelines for colorectal cancer screening 2009 [corrected]

Am J Gastroenterol

Association of colonoscopy and death from colorectal cancer

Ann Intern Med

Original article
Clinical endoscopy
Differences in proximal serrated polyp detection among endoscopists are associated with variability in withdrawal time