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Background: Sessile serrated adenomas/polyps (SSA/P) are an under-recognized disease with a unique malignant pathway. Improved endoscopic recognition and pathological interpretation is needed., Aims: To determine whether an educational intervention that improved adenoma detection rate (ADR) could improve SSA/P detection rate after reclassification of previously termed "hyperplastic" polyps., Methods: We reanalyzed data from a prospective randomized trial of an educational intervention aimed at increasing ADR. All hyperplastic polyps ≥6 mm reported in a previously published study were rereviewed and reclassified using standardized criteria for serrated lesions. Detection rates of sessile serrated adenomas/polyps and other clinically relevant serrated polyps were calculated in the baseline and post-training phases of the original study., Results: Of 263 available for rereview, 33 (12.5%) were reclassified as SSA/P (N = 32) or traditional serrated adenoma (TSA) (N = 1). Reclassification was more common in the right colon (18 vs. 8%, p = 0.02). Baseline SSA/P detection rate was 0.7% in the untrained group and 1.3% in the trained group. Post-training, the SSA/P detection rate increased to 2.1 and 1.5%, respectively. The clinically relevant serrated polyp detection rate at baseline was 14.2% in the untrained group and 11.3% in the trained group. After the educational intervention, the clinically relevant serrated polyp detection rates increased to 16.5 and 14.8% in the untrained and trained groups, respectively. The estimated odds of an endoscopist detecting either a SSA/P or other clinically relevant serrated polyp during colonoscopy increased by only 3% with the educational intervention (OR 1.03, 95% CI 0.61-1.74, p = 0.91)., Conclusions: Pathological re-interpretation of larger serrated polyps resulted in the reclassification of 12.5% of lesions. Quality improvement methods focused on adenoma detection did not impact SSA/P detection, and thus specific methods for serrated polyp detection are needed.

Background and Aims: Colorectal EMR for nonpolypoid neoplasia achieves better outcomes when performed by expert endoscopists. The time point at which the endoscopist achieves expert level remains to be defined. The objective of this study was to establish a learning curve of colorectal EMR for nonpolypoid neoplasia based on residual tissue on surveillance colonoscopy and adverse event rate., Methods: Five hundred seventy-eight consecutive patients underwent EMR of colorectal neoplasia by 1 of 3 primary endoscopists between December 2004 and September 2013 in a tertiary academic center. Primary analyses focused on the largest lesion for patients with more than 1 lesion (median age, 69 years; median polyp size, 30 mm; 51% en bloc resection). Data on surveillance colonoscopy were available for 74%. Learning curves were calculated for each of the 3 main outcome measurements: the presence of residual neoplasia on surveillance colonoscopy, endoscopic assessment of incomplete EMR, and the occurrence of an immediate bleeding adverse event., Results: Residual neoplasia on surveillance colonoscopy was present for 23.2% of patients, the rate of endoscopist-assessed incomplete EMR was 27.6%, and immediate bleeding adverse events occurred in 6.9% of patients. Although there was between-endoscopist variability, the overall rates of residual neoplasia and incomplete EMR decreased to below 20% to 25% after 100 EMRs; initial decreases in both rates were observed for earlier EMRs. Immediate bleeding adverse events occurred at a low frequency for each endoscopist across all EMRs. Perforation requiring surgical intervention occurred in 1 patient (0.2%)., Conclusions: This study demonstrated that an unexpectedly high number of 100 colorectal EMR procedures for large nonpolypoid colorectal neoplasia are required to achieve a plateau phase for crucial outcomes., (Copyright © 2016 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Objectives: We recently completed a randomized controlled trial of an endoscopic quality improvement program (EQUIP) that demonstrated an improved adenoma detection rate (ADR) through simple educational interventions. The aim of this study (phase III) is to examine whether the improvement in ADR in the trained endoscopists remained stable with further follow-up., Methods: We prospectively followed up 15 staff endoscopists who had previously been randomized to a quality improvement intervention. In the current study, we examined an additional 1,200 colonoscopy procedures conducted over a 5-month time period following the original study, referred to as phase III. During this time, all physicians received quarterly ADR and other quality metric feedback, and the previous control group was offered the educational intervention voluntarily. ADRs and adenoma per patient (APP) rates were estimated in the endoscopists who were and were not randomized to EQUIP training and compared with those obtained in phases I and II of the original study. The study was conducted in a tertiary care Academic Medical Center. The study sample comprised 1200 patients undergoing routine colonoscopy. The main outcome measurement was adenoma detection rate., Results: The previously observed increase in ADR in the trained group from 36% in phase I to 47% in phase II was maintained into phase III (46%). The ADR of the untrained group remained unchanged from phase I (36%) to phase II (35%); it was increased only marginally in phase III to 39%, which was still lower than the 46% ADR in the trained group. The trained group had an increase in APP, from 0.72 in Phase I to 0.87 in Phase II and 0.98 in Phase III. For the previously untrained group, there was no change in APP from phase I (0.68) to phase II (0.68), but there was possibly a small increase (to 0.74) in Phase III., Conclusions: This study provides evidence that improvements in ADR obtained through the endoscopic quality-training program can persist for at least 5 months after completion of the program. It further suggests that a focus on ADR does not lead to a "one and done" phenomenon. The limitations of this study were as follows: single-center setting, and lack of sessile polyp information/standardization.

Background: Patients undergoing high-definition white-light colonoscopy by a high adenoma detector may have a lower risk of interval adenoma detection on follow-up colonoscopy and may require less frequent follow-up but may paradoxically be assigned to more frequent surveillance when more adenomas are detected., Aims: To evaluate whether high-definition white-light colonoscopy (vs. standard-definition white-light colonoscopy) and endoscopist adenoma detection rate (ADR) at index colonoscopy are associated with increased likelihood of adenomas at follow-up., Methods: Longitudinal follow-up of prior cross-section cohort study of patients who underwent colonoscopy at baseline with at least one detected adenoma was included. Associations of type of white-light at index colonoscopy and the ADR of the endoscopist at index colonoscopy (high vs. low adenoma detector) were evaluated with various adenoma and polyp detection endpoints. Eighteen endoscopists were classified as high and low adenoma detectors based on the median ADR of 0.255., Results: There were no significant differences in subsequent interval adenoma or polyp detection endpoints with regard to whether baseline exam was performed with high-definition white-light or standard-definition white-light colonoscopy nor between high and low ADR after adjusting for multiple testing (P ≤ 0.0029 considered significant). Prior to multiple testing adjustment, there was a significantly lower detection rate of hyperplastic polyps in the left colon (24 vs. 35 %, OR: 0.56, P = 0.033) at follow-up colonoscopy when baseline exam was performed with high-definition white-light index colonoscopy., Conclusions: The results of this study do not support adjusting colonoscopy surveillance guidelines based on type of colonoscopy performed or the endoscopist's ADR.

Objectives: Adenoma detection rate (ADR) is a key measure of quality in colonoscopy. Low ADRs are associated with development of interval cancer after "negative" colonoscopy. Uncontrolled studies mandating longer withdrawal time, and other incentives, have not significantly improved ADR. We hypothesized that an endoscopist training program would increase ADRs., Methods: Our Endoscopic Quality Improvement Program (EQUIP) was an educational intervention for staff endoscopists. We measured ADRs for a baseline period, then randomly assigned half of the 15 endoscopists to undergo EQUIP training. We then examined baseline and post-training study ADRs for all endoscopists (trained and un-trained) to evaluate the impact of training. A total of 1,200 procedures were completed in each of the two study phases., Results: Patient characteristics were similar between randomization groups and between study phases. The overall ADR in baseline phase was 36% for both groups of endoscopists. In the post-training phase, the group of endoscopists randomized to EQUIP training had an increase in ADR to 47%, whereas the ADR for the group of endoscopists who were not trained remained unchanged at 35%. The effect of training on the endoscopist-specific ADRs was estimated with an odds ratio of 1.73 (95% confidence interval 1.24-2.41, P=0.0013)., Conclusions: Our results indicate that ADRs can be improved considerably through simple educational efforts. Ultimately, a trial involving a larger number of endoscopists is needed to validate the utility of our training methods and determine whether improvements in ADRs lead to reduced colorectal cancer.

Background: Previous studies examining the effect of fellow participation on adenoma detection rate in colonoscopy have yielded conflicting results, and factors such as adenoma size and location have not been rigorously evaluated., Objective: To examine whether fellow participation during screening, surveillance, or diagnostic colonoscopy affects overall, size-specific, or location-specific adenoma or polyp detection rate., Methods: This was a retrospective study of 2430 colonoscopies performed in our ambulatory surgical center between September 2006 and December 2007, comparing adenoma and polyp detection rates of colonoscopies performed by fellows with supervising staff endoscopists (n = 318) with colonoscopies performed by staff endoscopists without fellow participation (n = 2112). Study participants included patients who underwent screening, surveillance, or diagnostic colonoscopies in our GI suite. Logistic regression analysis was used to evaluate the association of fellow participation with adenoma and polyp detection., Results: There was evidence of a higher rate of small (<5 mm) adenoma detection in colonoscopies with a fellow present (25% vs 17%, P = .001). This remained significant after multiple-testing adjustment (P ≤ .003 considered significant). Findings were similar, although not significant for small polyps (36% vs 29%, P = .007). There was a trend toward increased adenoma detection in colonoscopies with a fellow present compared with those without (30% vs 26%, P = .11). Multivariable adjustment for potentially confounding variables did not alter these associations., Limitations: The study had a retrospective design, and information regarding bowel preparation was not available for 37% of patients., Conclusion: Fellow involvement was associated with increased detection rates of small adenomas, providing evidence that the presence of a fellow during colonoscopy plays a role in enhancing the effectiveness of the examination., (Copyright © 2011 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)