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Serrated colorectal lesions include hyperplastic polyps (HPs) and sessile serrated adenomas (SSAs). Optical biopsy could misclassify SSAs as unimportant if they resemble HPs.To explore the narrow-band imaging (NBI) features of SSAs. We hypothesized that SSAs resemble HPs under NBI.Retrospective analysis of data from our prospective study of NBI in routine practice.Single specialty group.Patients undergoing colonoscopy.Colonoscopy.Polyp histology prediction by community gastroenterologists. Features of SSAs versus HPs and adenomas by using the Narrow-Band Imaging International Colorectal Endoscopic (NICE) Classification.Among 2388 lesions, 141 were diagnosed on pathology as SSAs, 465 as HPs, and 1546 as adenomas. Each individual NICE feature of HPs was found in 38% to 42% of SSAs, 66% to 67% of HPs, and 15% to 20% of adenomas (P.001 for each). Each individual NICE feature of adenomas was found in 57% to 62% of SSAs, 33% to 34% of HPs, and 80% to 84% of adenomas (P.001 for each). Compared with HPs, SSAs were less likely (odds ratio [OR] 0.74; 95% confidence interval [CI], 0.69-0.79) and adenomas were even less likely (OR 0.62; 95% CI, 0.59-0.64) to have all 3 NICE features of HPs. SSAs5 mm were more likely than smaller SSAs to have all 3 NICE features of adenomas. SSA location did not predict NBI features. Analyses restricted to high-confidence lesions showed similar results.The endoscopists were not NBI experts.Community gastroenterologists observed a profile of NICE features among SSAs that was intermediate to the profiles observed for HPs and adenomas. These results require confirmation by NBI experts.

Background and Aims The 6-minute withdrawal time for colonoscopy, widely considered the standard of care, is controversial. The skill and technique of endoscopists may be as important as, or more important than, withdrawal time for adenoma detection. It is unclear whether a shorter withdrawal time with good technique yields an acceptable lesion detection rate. Our objective was to evaluate a 3-minute versus a 6-minute withdrawal time by using segmental tandem colonoscopy. Methods We performed a prospective, randomized trial by using 4 expert endoscopists. Patients were randomized to a 3-minute or a 6-minute initial withdrawal, each followed by a tandem second 6-minute withdrawal. All polyps were removed. The primary outcomes were adenoma miss rates (AMRs), adenomas per colonoscopy (APC) rates, and adenoma detection rates (ADRs). Results A total of 99 and 101 patients were enrolled in the 3-minute and 6-minute withdrawal groups, respectively. The AMR was significantly higher in the 3-minute withdrawal group (48.0% vs 22.9%; P = .0001). After controlling for endoscopist, patient age and/or sex, Boston Bowel Preparation Scale score, and size and/or location and/or morphology of adenoma, the AMR remained significantly higher in the 3-minute withdrawal group (odds ratio, 2.78; 95% confidence interval, 1.35-5.15; P = .0001). The ADR was similar between both groups (39.2% vs 40.6%; P = .84). However, the mean APC rate was significantly lower in the 3-minute withdrawal group (0.55 vs 0.80; P = .0001). Conclusions The AMR was significantly higher, and the APC rate was significantly lower in the 3-minute withdrawal group versus the 6-minute withdrawal group. Despite expert technique, a shorter withdrawal time is associated with an unacceptably high AMR and low APC rate. (Clinical trial registration number: NCT01802008.)

The PIVI (Preservation and Incorporation of Valuable endoscopic Innovations) initiative is an ASGE program whose objectives are to identify important clinical questions related to endoscopy and to establish a priori diagnostic and/or therapeutic thresholds for endoscopic technologies designed to resolve these clinical questions. Additionally, PIVIs may also outline the data and or the research study design required for proving an established threshold is met. Once endoscopic technologies meet an established PIVI threshold, those technologies are appropriate to incorporate into clinical practice presuming the appropriate training in that endoscopic technology has been achieved. The ASGE encourages and supports the appropriate use of technologies that meet its established PIVI thresholds. The PIVI initiative was developed primarily to direct endoscopic technology development toward resolving important clinical issues in endoscopy. The PIVI initiative is also designed to minimize the possibility that potentially valuable innovations are prematurely abandoned due to lack of utilization and to avoid widespread use of an endoscopic technology before clinical studies documenting their effectiveness have been performed. The following document, or PIVI, is one of a series of statements defining the diagnostic or therapeutic threshold that must be met for a technique or device to become considered appropriate for incorporation into clinical practice. It is also meant to serve as a guide for researchers or those seeking to develop technologies that are designed to improve digestive health outcomes. An ad hoc committee under the auspices of the existing ASGE Technology and Standards of Practice Committees Chairs develops PIVIs. An expert in the subject area chairs the PIVI, with additional committee members chosen for their individual expertise. In preparing this document, evidence-based methodology was employed, using a MEDLINE and PubMed literature search to identify pertinent clinical studies on the topic. PIVIs are ultimately submitted to the ASGE Governing Board for approval, as is done for all Technology and Standards of Practice documents. This document is provided solely for educational and informational purposes and to support incorporating these endoscopic technologies into clinical practice. It should not be construed as establishing a legal standard of care.

Introduction: A minimum withdrawal time for screening colonoscopy of 6 minutes has been proposed, based on an observational study. The 6-minute withdrawal time remains controversial and has not been compared in a standardized fashion to alternate withdrawal times. Aim: To perform a prospective, randomized trial to compare adenoma miss rates (AMR) associated with withdrawal times of 6 minutes vs. 3 minutes. Methods: Consecutive patients undergoing colonoscopy at Stanford University and Palo Alto Veterans Administration Hospital were randomized to undergo either a 3-minute or 6-minute withdrawal (1st pass), followed immediately by a tandem 6-minute withdrawal (2nd pass). AMR was defined as the number of adenomas detected on the 2nd pass divided by total number of adenomas found. A chi-square statistic was used to directly compare AMR. A z-statistic was used to determine effect of polyp size/location on AMR. A mixed-effects logistic regression model was then created to compare AMR, controlling for endoscopist, size/location of adenoma, and patient. Finally, a Cochrane-Armitage test for trend was used to evaluate the trend of adenoma detection associated with increasing withdrawal time. Results: 200 subjects were enrolled (99 in the 3-minute group, 101 in the 6-minute group). Demographics and indications for colonoscopy were similar between the two groups (Table 1). AMR was significantly higher in the 3-minute withdrawal group compared to the 6-minute withdrawal group (48.5% vs 21.8%; p≤0.0001). Adenomas were significantly more likely to be missed in the 3-minute withdrawal group in all 3 locations of the colon (right, transverse and left colon). AMR was higher in the 3-minute withdrawal group among adenomas that were ≤5mm; there was no significant difference in AMR for adenomas that were 6-9mm or ≥10mm. After controlling for endoscopist, size/location of the polyp/adenoma, and the patient, AMR remained significantly higher in the 3-minute withdrawal group compared to the 6-minute withdrawal group (OR 2.92, 95% CI=1.54-5.55) (Table 1). Adenoma detection rate (ADR) was similar between both 3 and 6 minute withdrawal groups (38.4% vs 40.6%, p=0.75); however, this study was not powered to detect differences in ADR. There was a significant trend towards higher total number of adenomas detected as withdrawal time increased (52 at 3 minutes, 87 at 6 minutes, 101 at 9 minutes, and 111 at 12 minutes; p

Background: The role of endoscopy in the evaluation of constipation is controversial. The aim of this study was to clarify the yield of lower endoscopy in patients with constipation. Methods: Endoscopic databases from 3 diverse hospitals were searched for procedures with constipation as an indication. Detection of neoplasia was the main outcome of interest. Results: Among 19,764 sigmoidoscopies or colonoscopies, constipation was a procedure indication for 563 patients (mean age 61 [16] years, 52% women); 58% had procedure indications in addition to constipation. Colorectal cancer was diagnosed in 8 (1.4%), adenomas in 82 (14.6%), and advanced lesions (cancer or adenoma with malignancy, high-grade dysplasia, villous features, or size ≥10 mm) in 24 (4.3%). In the 358 patients who underwent colonoscopy, cancer was detected in 1.7%, adenomas in 19.6%, and advanced lesions in 5.9%. Two patients with cancer were less than 50 years of age. In as many as 6 patients with cancer, the tumor may have caused partial obstruction. Conclusions: The range of neoplasia in patients with constipation evaluated with lower endoscopy was comparable with what would be expected in asymptomatic subjects undergoing colorectal cancer screening. Although chronic constipation alone may not be an appropriate indication for lower endoscopy, age-appropriate colorectal cancer screening should be pursued when patients with constipation seek medical care. (Gastrointest Endosc 2002;56:325-32.)

Mo1559 Evaluating the Optimal Time for Colonoscopy Withdrawal: a Prospective Randomized Comparison of 3 Minute Versus 6 Minute Withdrawal Sheila Kumar*, Rajan Kochar, Shai Friedland, Uri Ladabaum, Ann M. Chen, Subhas Banerjee Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Palo Alto, CA Introduction: A minimum withdrawal time for screening colonoscopy of 6 minutes has been proposed, based on an observational study, and has become the de-facto standard of care. The 6-minute withdrawal time remains controversial and has not been compared in a standardized fashion to alternative withdrawal times. Aims: To perform a prospective randomized study to compare Polyp Miss Rates, Adenoma Miss Rates and Adenoma Detection Rates in patients undergoing colonoscopy with a 3-minute versus a 6-minute withdrawal time. Methods: Consecutive patients undergoing colonoscopy at Stanford University and the Palo Alto Veterans Administration Hospital were enrolled. Patients were prospectively randomized to undergo colonoscopy with either a 3-minute or 6minute withdrawal time during the 1st pass. A second pass was then performed with a 6-minute withdrawal in both groups to determine Polyp Miss Rates and Adenoma Miss Rates. The Adenoma Detection Rate (#colonoscopies where at least 1 adenoma was detected on the first pass/total #colonoscopies) was also determined for both groups. Results: 107 patients (73 men, 24 women) have been enrolled. 52 underwent 3-minute withdrawal and 55 underwent 6-minute withdrawal. Indications and baseline characteristics for both groups were similar (Table 1). The Polyp Miss Rate was significantly higher in the 3-minute withdrawal group compared to the 6-minute withdrawal group (57% vs. 26%, p 0.0012). The Adenoma Miss Rate was also significantly higher in the 3-minute withdrawal group compared to the 6-minute withdrawal group, (57% vs. 33%, p 0.013) (Table 2). The Adenoma Detection Rates were similar in both groups (31% vs. 24%, p NS). Conclusion: The Polyp Miss Rate and Adenoma Miss Rate were significantly higher in the 3-minute withdrawal group compared to the 6minute withdrawal group, suggesting that a 3-minute withdrawal may be inadequate and that a 6-minute withdrawal may be more appropriate for colorectal cancer screening. No significant difference was noted in the Adenoma Detection Rate between the two groups, which may be due to inadequate sample size.