EQUIP Training session 1 Improving polyp/adenoma detection

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

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

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

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)

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

Flat and depressed lesions 1819 VA patients 9.3% prevalence 15% of all neoplasms 54% of superficial carcinomas (OR 11.1; 95%CI, 4.98-24.8) 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

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

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

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.

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

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

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

NBI of same small adenoma.

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

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

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

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

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).

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

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

“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)!

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

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

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<0.001 ADR 30.5 vs 37.5 p<0.018; Lee et al, Endoscopy 2006;38:739-742 Kondo N=684, total time 11.5 vs. 13.0 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; 30:444-447 Horiuchi A, Nakayama, Am J. Gastro 2008;103:341-345 Dafnis GM. Endoscopy 2000;32:381-384 (Technical considerations and patient confort…” Horiuchi et al. CGH 2010;8:379

Clear caps

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

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