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Background & Aims: Endoscopic mucosal resection (EMR) is standard therapy for nonpedunculated colorectal polyps ≥20 mm. It has been suggested recently that polyp resection without current (cold resection) may be superior to the standard technique using cutting/coagulation current (hot resection) by reducing adverse events (AEs), but evidence from a randomized trial is missing., Methods: In this randomized controlled multicentric trial involving 19 centers, nonpedunculated colorectal polyps ≥20 mm were randomly assigned to cold or hot EMR. The primary outcome was major AE (eg, perforation or postendoscopic bleeding). Among secondary outcomes, major AE subcategories, postpolypectomy syndrome, and residual adenoma were most relevant., Results: Between 2021 and 2023, there were 396 polyps in 363 patients (48.2% were female) enrolled for the intention-to-treat analysis. Major AEs occurred in 1.0% of the cold group and in 7.9% of the hot group (P = .001; odds ratio [OR], 0.12; 95% CI, 0.03-0.54). Rates for perforation and postendoscopic bleeding were significantly lower in the cold group, with 0% vs 3.9% (P = .007) and 1.0% vs 4.4% (P = .040). Postpolypectomy syndrome occurred with similar frequency (3.1% vs 4.4%; P = .490). After cold resection, residual adenoma was found more frequently, with 23.7% vs 13.8% (P = .020; OR, 1.94; 95% CI, 1.12-3.38). In multivariable analysis, lesion diameter of ≥4 cm was an independent predictor both for major AEs (OR, 3.37) and residual adenoma (OR, 2.47) and high-grade dysplasia/cancer for residual adenoma (OR, 2.92)., Conclusions: Cold resection of large, nonpedunculated colorectal polyps appears to be considerably safer than hot EMR; however, at the cost of a higher residual adenoma rate. Further studies have to confirm to what extent polyp size and histology can determine an individualized approach. German Clinical Trials Registry (Deutsches Register Klinischer Studien), Number DRKS00025170., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The value of lower gastrointestinal endoscopy (LGIE; colonoscopy or sigmoidoscopy) relates to its ability to detect clinically relevant findings, predominantly cancers, preneoplastic polyps or inflammatory bowel disease. There are concerns that many LGIEs are performed on low-risk patients with limited benefit., Aims: To determine the diagnostic outcomes of LGIE for common symptoms., Methods: We performed a cross-sectional study of diagnostic LGIE between March 2019 and February 2020 using the UK National Endoscopy Database. We used mixed-effects logistic regression models, incorporating random (endoscopist) and fixed (symptoms, patient age, and sex) effects upon two dependent variables (large polyp [≥10 mm] and cancer diagnosis). Adjusted positive predictive values (aPPVs) were calculated., Results: We analysed 384,510 LGIEs; 33.2% were performed on patients aged under 50 and 53.6% on women. Regarding colonoscopies, the unadjusted PPV for cancer was 1.5% (95% CI: 1.4-1.5); higher for men than women (1.9% vs. 1.1%, p < 0.01). The PPV for large polyps was 3.2% (95% CI: 3.1-3.2). The highest colonoscopy cancer aPPVs were in the over 50s (1.9%) and in those with rectal bleeding (2.5%) or anaemia (2.1%). Cancer aPPVs for other symptoms were <1% despite representing 54.3% of activity. In patients under 50, aPPVs were 0.4% for cancer and 1.6% for large polyps. Results were similar for sigmoidoscopy., Conclusions: Most colonoscopies were performed on patients with low-risk symptoms, where cancer risk was similar to the general population. Cancer and large polyp yield was highest in elderly patients with rectal bleeding or anaemia, although still fell short of FIT-based screening yields., (© 2024 The Authors. Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd.)

Background and Aims: Adenoma detection rate (ADR) has been shown to correlate with interval cancers after screening colonoscopy and is commonly used as surrogate parameter for its outcome quality. ADR improvements by various techniques have been studied in randomised trials using either parallel or tandem methodololgy., Methods: A systematic literature search was done on randomised trials (full papers, English language) on tandem or parallel studies using either adenoma miss rates (AMR) or ADR as main outcome to test different novel technologies on imaging (new endoscope generation, narrow band imaging, iScan, Fujinon intelligent chromoendoscopy/blue laser imaging and wide angle scopes) and mechanical devices (transparent caps, endocuff, endorings and balloons). Available meta analyses were also screened for randomised studies., Results: Overall, 24 randomised tandem trials with AMR (variable definitions and methodology) and 42 parallel studies using ADR (homogeneous methodology) as primary outcome were included. Significant differences in favour of the new method were found in 66.7% of tandem studies (8222 patients) but in only 23.8% of parallel studies (28 059 patients), with higher rates of positive studies for mechanical devices than for imaging methods. In a random-effects model, small absolute risk differences were found, but these were double in magnitude for tandem as compared with parallel studies (imaging: tandem 0.04 (0.01, 0.07), parallel 0.02 (0.00, 0.04); mechanical devices: tandem 0.08 (0.00, 0.15), parallel 0.04 (0.01, 0.07)). Nevertheless, 94.2% of missed adenomas in the tandem studies were small (<1 cm) and/or non-advanced., Conclusions: A tandem study is more likely to yield positive results than a simple parallel trial; this may be due to the use of different parameters, variable definitions and methodology, and perhaps also a higher likelihood of bias. Therefore, we suggest to accept positive results of tandem studies only if accompanied by positive results from parallel trials., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Aims: False positive (FP) results by computer-aided detection (CADe) hamper the efficiency of colonoscopy by extending examination time. Our aim was to develop a classification of the causes and clinical relevance of CADe FPs, and to assess the relative distribution of FPs in a real-life setting., Methods: In a post-hoc analysis of a randomized trial comparing colonoscopy with and without CADe (NCT: 04079478), we extracted 40 CADe colonoscopy videos. Using a modified Delphi process, 4 expert endoscopists identified the main domains for the reasons and clinical relevance of FPs. Then, 2 expert endoscopists manually examined each FP and classified it according to the proposed domains. The analysis was limited to the withdrawal phase., Results: The 2 main domains for the causes of CADe FPs were identified as artifacts due to either the mucosal wall or bowel content, and clinical relevance was defined as the time spent on FPs and the FP rate per minute. The mean number of FPs per colonoscopy was 27.3 ± 13.1, of which 24 ± 12 (88%) and 3.2 ± 2.6 (12%) were due to artifacts in the bowel wall and bowel content, respectively. Of the 27.3 FPs per colonoscopy, 1.6 (5.7%) required additional exploration time of 4.8 ± 6.2 seconds per FP (ie, 0.7% of the mean withdrawal time). In detail, 15 (24.2%), 33 (53.2%), and 14 (22.6%) FPs were classified as being of mild, moderate, or severe clinical relevance. The rate of FPs per minute of withdrawal time was 2.4 ± 1.2, and was higher for FPs due to artifacts from the bowel wall than for those from bowel content (2.4 ± 0.6 vs 0.3 ± 0.2, P < .001)., Conclusions: FPs by CADe are primarily due to artifacts from the bowel wall. Despite a high frequency, FPs result in a negligible 1% increase in the total withdrawal time because most of them are immediately discarded by the endoscopist., (Copyright © 2020 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Interval cancers occur more frequently in the right colon. One reason could be that right-sided adenomas are frequently missed in colonoscopy examinations. We reanalyzed data from tandem colonoscopies to assess adenoma miss rates in relation to location and other factors., Methods: We pooled data from 8 randomized tandem trials comprising 2218 patients who had diagnostic or screening colonoscopies (adenomas detected in 49.8% of patients). We performed a mixed-effects logistic regression with patients as cluster effects with different independent parameters. Factors analyzed included location (left vs right, splenic flexure as cutoff), adenoma size, form, and histologic features. Analyses were controlled for potential confounding factors such as patient sex and age, colonoscopy indication, and bowel cleanliness., Results: Right-side location was not an independent risk factor for missed adenomas (odds ratio [OR] compared with the left side, 0.94; 95% CI, 0.75-1.17). However, compared with adenomas ≤5 mm, the OR for missing adenomas of 6-9 mm was 0.62 (95% CI, 0.44-0.87), and the OR for missing adenomas of ≥10 mm was 0.51 (95% CI, 0.33-0.77). Compared with pedunculated adenomas, sessile (OR, 1.82; 95% CI, 1.16-2.85) and flat adenomas (OR, 2.47; 95% CI, 1.49-4.10) were more likely to be missed. Histologic features were not significant risk factors for missed adenomas (OR for adenomas with high-grade intraepithelial neoplasia, 0.68; 95% CI, 0.34-1.37 and OR for sessile serrated adenomas, 0.87; 95% CI, 0.47-1.64 compared with low-grade adenomas). Men had a higher number of adenomas per colonoscopy (1.27; 95% CI, 1.21-1.33) than women (0.86; 95% CI, 0.80-0.93). Men were less likely to have missed adenomas than women (OR for missed adenomas in men, 0.73; 95% CI, 0.57-0.94)., Conclusions: In an analysis of data from 8 randomized trials, we found that right-side location of an adenoma does not increase its odds for being missed during colonoscopy but that adenoma size and histologic features do increase risk. Further studies are needed to determine why adenomas are more frequently missed during colonoscopies in women than men., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Outcomes of endoscopic surveillance after surgery for colorectal cancer (CRC) vary with the incidence and timing of CRC detection at anastomoses or non-anastomoses in the colorectum. We performed a systematic review and meta-analysis to evaluate the incidence of CRCs identified during surveillance colonoscopies of patients who have already undergone surgery for this cancer., Methods: We searched PubMed, EMBASE, SCOPUS, and the Cochrane Central Register of Clinical Trials through January 1, 2018 to identify studies investigating rates of CRCs at anastomoses or other locations in the colorectum after curative surgery for primary CRC. We collected data from published randomized controlled, prospective, and retrospective cohort studies. Data were analyzed by multivariate meta-analytic models., Results: From 2373 citations, we selected 27 studies with data on 15,803 index CRCs for analysis (89% of patients with stage I-III CRC). Overall, 296 CRCs at non-anastomotic locations were reported over time periods of more than 16 years (cumulative incidence, 2.2% of CRCs; 95% confidence interval [CI], 1.8%-2.9%). The risk of CRC at a non-anastomotic location was significantly reduced more than 36 months after resection compared with before this time point (odds ratio for non-anastomotic CRCs at 36-48 months vs 6-12 months after surgery, 0.61; 95% CI, 0.37-0.98; P = .031); 53.7% of all non-anastomotic CRCs were detected within 36 months of surgery. One hundred and fifty-eight CRCs were detected at anastomoses (cumulative incidence of 2.7%; 95% CI, 1.9%-3.9%). The risk of CRCs at anastomoses was significantly lower 24 months after resection than before (odds ratio for CRCs at anastomoses at 25-36 months after surgery vs 6-12 months, 0.56; 95% CI, 0.32-0.98; P = .036); 90.8% of all CRCs at anastomoses were detected within 36 months of surgery., Conclusions: After surgery for CRC, the highest risk of CRCs at anastomoses and at other locations in the colorectum is highest during 36 months after surgery-risk decreases thereafter. Patients who have undergone CRC resection should be evaluated by colonoscopy more closely during this time period. Longer intervals may be considered thereafter., (Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: A higher incidence of proximal interval cancers after colonoscopy has been reported in several follow-up studies. One possible explanation for this might be that proximally located adenomas have greater malignant potential. The aim of the present study was to assess the risk of malignancy in proximal versus distal adenomas in patients included in a large screening colonoscopy database; adenoma shape and the patients' age and sex distribution were also analyzed., Methods: Data for 2007-2012 from the German National Screening Colonoscopy Registry, including 594,614 adenomas identified during 2,532,298 screening colonoscopies, were analyzed retrospectively. The main outcome measure was the rate of high-grade dysplasia (HGD) in adenomas, used as a surrogate marker for the risk of malignancy. Odds ratios (ORs) for the rate of HGD found in adenomas were analyzed in relation to patient- and adenoma-related factors using multivariate analysis., Results: HGD histology was noted in 20,873 adenomas (3.5%). Proximal adenoma locations were not associated with a higher HGD rate. The most significant risk factor for HGD was adenoma size (OR 10.36 ≥1 cm vs <1 cm), followed by patient age (OR 1.26 and 1.46 for age groups 65-74 and 75-84 vs 55-64 years) and sex (OR 1.15 male vs female). In comparison with flat adenomas as a reference lesion, sessile lesions had a similar HGD rate (OR 1.02) and pedunculated adenomas had a higher rate (OR 1.23). All associations were statistically significant (P ≤ .05)., Conclusions: In this large screening database, it was found that the rates of adenomas with HGD are similar in the proximal and distal colon. The presence of HGD as a risk marker alone does not explain higher rates of proximal interval colorectal cancer. We suggest that certain lesions (flat, serrated lesions) may be missed in the proximal colon and may acquire a more aggressive biology over time. A combination of endoscopy-related factors and biology may therefore account for higher rates of proximal versus distal interval colorectal cancer., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Aim: To evaluate the ability of PillCamColon2 to visualize colonic segments missed by incomplete optical colonoscopy (OC) and to assess the diagnostic yield., Methods: This prospective multicentre study included 81 patients from nine centres who underwent second-generation colon capsule endoscopy (CCE) following incomplete OC performed by an experienced gastroenterologist (> 1000 colonoscopies). Patients with stenosis were excluded. According to patient preferences, CCE was performed the following day (protocol A) after staying on clear liquids and 0.75 L Moviprep in the morning or within 30 d after new split-dose Moviprep (protocol B). Boosts consisted of 0.75 L and 0.25 L Moviprep, and phospho-soda was given as a rescue if the capsule was not excreted after seven hours., Results: Seventy-four patients were analysed (51% of them in group A; 49% in group B). Bowel cleansing was adequate in 67% of cases, and CCE could visualize colonic segments missed by incomplete colonoscopy in 90% of patients under protocol A and 97% of patients under protocol B ( P = 0.35, n.s.). Significant polyps including adenocarcinoma were detected in 24% of cases. Detection rates for all polyps and significant polyps per patient were similar in both protocols. Polyps were found predominantly in the right colon (86%) in segments that were not reached by OC. Extracolonic findings - such as reflux esophagitis, suspected Barrett esophagus, upper GI-bleeding, gastric polyps, gastric erosions and angiectasia - were detected in eight patients. PillCamColon2 capsule was retained in the ileum of one patient (1.4%) without symptoms and removed during an uneventful resection for unknown Crohn's disease that was diagnosed as the cause of anemia, which was the indication for colonoscopy. CCE was well tolerated. One patient suffered from self-limiting vomiting after consuming the phospho-soda., Conclusion: Second-generation CCE using a low-volume preparation is useful after incomplete OC, and it allows for the detection of additional relevant findings, but cleansing efficiency could be improved., Competing Interests: Conflict-of-interest statement: Peter Baltes, Michael Philliper, Ingo Steinbrück, and Horst Hohn received lecture fees from Given Imaging, Jörg Albert, Martin Keuchel received study support and lecture fees from Given Imaging, Tanja Nowak was an employee of Given Imaging, the other authors have nothing to declare. The study was supported by Given Imaging, Hamburg, Germany by providing the capsules and an unrestricted grant.

Background & Aims: During endoscopy, the resect and discard strategy, if performed with high confidence, can be used to determine histologic features of diminutive colorectal polyps (5 mm or less). These polyps can then be removed and discarded without pathology assessment. However, the complexities of real-time optical assessment and follow-up management have provided challenges to widespread use of this approach. We aimed to determine the outcomes of simple alternative strategies, in which all diminutive polyps can be resected and discarded., Methods: We collected data from 2 previous studies that used narrow-band imaging to assess polyps, performed at 5 medical centers (1658 patients with 2285 diminutive polyps; 15 endoscopists). We compared 3 resect and discard strategies: the currently used optical strategy, which relies on high confidence optical assessment of all diminutive polyps; a location-based strategy that classifies all recto-sigmoid diminutive polyps a priori as hyperplastic and all polyps proximal to the recto-sigmoid colon a priori as neoplastic; and a simplified optical strategy, in which all recto-sigmoid diminutive polyps are classified as hyperplastic unless confidently assessed as neoplastic, and all polyps proximal to the recto-sigmoid colon are classified as neoplastic unless confidently assessed as hyperplastic polyps. The primary outcome was the agreement of the surveillance interval calculated for each strategy with the surveillance interval determined by pathology analysis., Results: The proportion of surveillance intervals that agreed with pathology-based surveillance recommendations was slightly higher when the optical strategy was used compared to the location-based strategy or simplified optical strategy (94% vs 89% and 90%, respectively; P < .001). When the 5-10 year recommendations for patients with low-risk polyps were applied as a 10-year surveillance interval, all 3 strategies resulted in surveillance interval agreement compared to pathology above 90% (the quality benchmark). Use of the simplified or location-based strategy could have avoided pathology analysis for 77% of all polyps, compared to 59% if the optical strategy was used (P < .001). In addition, a higher proportion of patients could receive recommendations immediately after colonoscopy with use of the simplified or location based strategy (65%) compared to the optical strategy (40%) (P < .001)., Conclusion: A location-based and a simplified optical resect and discard strategy produced surveillance recommendations that were in agreement with those from pathology analysis for at least 90% of patients, assuming a 10-year surveillance interval for patients with low-risk polyps. These strategies could further reduce the number of pathology examinations and provide more patients with immediate surveillance recommendations. Optical assessment might be reduced or might not be required for resect and discard. Clintrials.gov no: NCT01935180 and NCT01288833., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Colonoscopy is a widely performed procedure with procedural volumes increasing annually throughout the world. Many procedures are now performed as part of colorectal cancer screening programmes. Colonoscopy should be of high quality and measures of this quality should be evidence based. New UK key performance indicators and quality assurance standards have been developed by a working group with consensus agreement on each standard reached. This paper reviews the scientific basis for each of the quality measures published in the UK standards., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background and Aim: Due to limited acceptance of colonoscopy as diagnostic and screening test alternatives are warranted. Colon capsule endoscopy (CCE) has been shown to be a possible filter test, but because of logistical issues a second bowel preparation is usually required, if consecutive colonoscopy is needed. We therefore evaluated the feasibility of a single bowel preparation for both overnight CCE and (therapeutical) colonoscopy thereafter., Methods: Patients from two university hospitals referred to undergo colonoscopy were prospectively included in a dual centre feasibility study. A polyethylene glycol (PEG) based bowel preparation-schedule with ingestion of a colon capsule endoscopy (CCE) at 10pm and subsequent colonoscopy at about 12am on the next day was investigated. The first generation PillCam colon capsule was used with 4 different preparation protocols containing several prokinetics in different compositions (i. e. metoclopramide, erythromycin, sennosoides). The main endpoint was the proportion of patients who completed both CCE and colonoscopy; secondary endpoints were capsule transit times, amount of colon seen on CCE, bowel cleanliness, sensitivity and specifity of CCE and patients' acceptance., Results: 50 patients between 18 and 75 years were included. The sequence of overnight colon capsule endoscopy and colonoscopy was successfully completed in all but one (one refused colonoscopy). The capsule was excreted during recording time in 86 % of examinations, visualization of the complete colon was possible in 60 %, but adequate colon preparation was achieved in only 45 % irrespective of the regimen used. The preparation regimen consisting of a PEG-solution, erythromycin as prokinetic drug followed by PEG-solution as boost showed the largest proportion of adequate preparations. Overall sensitivity and specificity of CCE for polyps of any size were 65 % and 76 %, respectively. 26 of 30 patients (86.7 %) returned the subjective assessment questionnaire. 23 patients (88 %) reported mild to no discomfort or embarrassment during CCE, whereas 15 patients (58 %) did during the preparation procedure. Drinking the purgative solution was the most inconvenient step in 84 % of cases, drinking the boosts during CCE the second inconvenient step (60 %)., Conclusion: Overnight CCE-procedure followed by direct capsule-reading is feasible and safe and might avoid repetitive bowel preparation for subsequent colonoscopy. The bowel preparation needs to be improved., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Colorectal cancer (CRC) is one of the most common malignancies worldwide. The aim of this study was to compare the outcomes of two different screening approaches in a small country (Montenegro, 650,000 inhabitants) with a CRC incidence lower than the European average., Methods: Two structured invitation programs were compared with respect to compliance and neoplasia yield: (i) program A focused on first-degree relatives of CRC patients diagnosed in two hospitals (n=206), inviting them for colonoscopy; (ii) program B was an invitation program for fecal occult blood testing, followed by colonoscopy if positive, conducted in University Hospital, Podgorica, Montenegro, on 2760 randomly selected average-risk persons, age 50-74 years, living in a single municipality., Results: Of 710 first-degree relatives of 206 CRC patients approached, 540 presented for colonoscopy (76.05% uptake). Overall, 31 were diagnosed with a cancer, 58 with advanced adenoma, and 151 with adenoma in general. In the general screening program, of 2760 individuals invited, 920 underwent fecal immunochemical test (33.3% uptake) and colonoscopy was performed in all 95 positive cases (10.3%); six cancers was found in five patients (one patient had two cancers), 19 patients were diagnosed with advanced adenoma, and 26 with any adenomas. The risk-targeted screening program had a significantly higher yield for cancers in both per invited (31/710 vs. 5/2760, P<0.001) and per eligible person analysis (31/540 vs. 5/920, P<0.001)., Conclusion: In a low-incidence country with limited resources, it may be advisable to start with CRC screening targeted to risk groups.

Background & Aims: The adenoma detection rate (ADR) is an important quality indicator of screening colonoscopy; it is inversely associated with risk of interval cancers and colorectal cancer mortality. We assessed trends in the ADR in the first 10 years of the German screening colonoscopy program., Methods: We calculated age-adjusted and age-specific detection rates of nonadvanced adenomas and advanced adenomas for each calendar year based on 4.4 million screening colonoscopies conducted from 2003 through 2012 and reported to the German screening colonoscopy registry., Results: We observed a steady and strong increase in rate of detection of nonadvanced adenomas in both sexes and all age groups. Age-adjusted rates of detection of nonadvanced adenomas increased from 13.3% to 22.3% among men and from 8.4% to 14.9% among women. This increase was mostly due to an increase in detection rates of adenomas <0.5 cm, and it is partly explained by an innovation effect (higher ADRs among incoming colonoscopists than among leaving colonoscopists, and relatively stable ADRs among continuing colonoscopists). Only modest increases were observed in detection rates of advanced adenomas (from 7.4% to 9.0% among men, and from 4.4% to 5.2% among women) and colorectal cancer. In 2012, overall ADR reached 31.3% and 20.1% in men and women, respectively., Conclusions: We observed a strong increase in ADRs from 2003 through 2012 in Germany. Although we cannot exclude the effects of secular trends in colorectal neoplasm prevalence, the observed increase was mainly the result of a steady increase in detection of nonadvanced adenomas (especially adenomas <0.5 cm). Further research should address potential implications for defining screening and surveillance intervals., (Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background & Aims: We investigated rates of detection of proximal serrated lesions in a cohort of average-risk patients undergoing screening colonoscopies., Methods: We reviewed results from screening colonoscopies performed by attending gastroenterologists at 32 endoscopy centers from 2008-2010. Pathology slides were interpreted at the individual centers. For this analysis, serrated lesions included hyperplastic polyps larger than 10 mm, those interpreted as sessile serrated adenomas (or sessile serrated polyp), and traditional serrated adenomas. Rates of detection for conventional adenomas and serrated lesions were compared among centers., Results: A total of 5778 lesions were detected in 7215 screening colonoscopies. Of the 5548 lesions with pathology results, 3008 (54.2%) were conventional adenomas, 350 (6.3%) were serrated, and 232 (4.2%) were proximal serrated. The proportion of colonoscopies with at least 1 proximal serrated lesion was 2.8% (range among centers, 0%-9.8%). The number of serrated lesions per colonoscopy ranged from 0.00-0.11 (average, 0.05 ± 0.25). Overall lesion detection rates correlated with proximal serrated lesion detection rates (R = 0.91, P < .0001); conventional adenoma and proximal serrated lesion detection rates also correlated (R = .43, P = .025). The detection rate of proximal serrated lesions differed significantly among centers (P < .0001); odds ratios for detection ranged from 0-0.79. Some centers' pathologists never identified proximal serrated lesions as sessile serrated adenomas/polyps., Conclusions: In an average-risk screening cohort, detection of proximal serrated lesions varied greatly among endoscopy centers. There was also substantial variation among pathologists in identification of sessile serrated adenomas/polyps. Nationally, a significant proportion of proximal serrated lesions may be missed during colonoscopy examination or incorrectly identified during pathology assessment. ClinicalTrials.gov Number: NCT00855348., (Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: As screening colonoscopy becomes more widespread, the costs for histopathological assessment of resected polyps are rising correspondingly. Reference centres have published highly accurate results for endoscopic polyp classification. Therefore, it has been proposed that, for smaller polyps, the differential diagnosis that guides follow-up recommendations could be based on endoscopy alone., Objective: The aim was to prospectively assess whether the high accuracy for endoscopic polyp diagnosis as reported by reference centres can be reproduced in routine screening colonoscopy., Design: Ten experienced private practice endoscopists had initial training in pit patterns. Then they assessed all polyps detected during 1069 screening colonoscopies. Patients (46% men; mean age 63 years) were randomly assigned to colonoscopy with conventional or latest generation HDTV instruments. The main outcome measure was diagnostic accuracy of in vivo polyp assessment (adenomatous vs hyperplastic). Secondary outcome measures were differences between endoscopes and reliability of image-based follow-up recommendations; a blinded post hoc analysis of polyp photographs was also performed., Results: 675 polyps were assessed (461 adenomatous, 214 hyperplastic). Accuracy, sensitivity and specificity of in vivo diagnoses were 76.6%, 78.1% and 73.4%; size of adenomas and endoscope withdrawal time significantly influenced accuracy. Image-based recommendations for post-polypectomy surveillance were correct in only 69.5% of cases. Post hoc analysis of polyp photographs did not improve accuracy., Conclusions: In everyday practice, endoscopic classification of polyp type is not accurate enough to abandon histopathological assessment and use of latest generation colonoscopes does not improve this. Image-based surveillance recommendations after polypectomy would consequently not meet guideline requirements., Trialregno: NCT01297712.

Background and Study Aims: The German screening colonoscopy program is accompanied by a central registry that records the main outcome quality indicators, namely colonoscopy completion rate, adenoma detection rate (ADR), and complication rate. The aim of the present study was to assess the quality of these registry data by comparing them with data from a prospective quality assurance study based on a self-reporting audit and patient feedback of screening colonoscopy., Patients and Methods: The completeness of registry information was analyzed by comparing it with prospective data gathered by audit and patient feedback in a previous quality assurance study (ClinicalTrials.gov registration number: NCT00860665) between October 2006 and March 2008. The main outcome parameters were colonoscopy completion rate, ADR, and complication rate. Complications were recorded in three steps in the audit study using case report forms (immediate and subsequent documentation by physicians [CRF-1 and CRF-2], and patient follow-up [CRF-3]), but were documented in the registry without differentiation., Results: A total of 12 134 individuals (mean age 64.5 years; 47 % men) who underwent screening colonoscopy at 19 private practices in Berlin over the 18-month period were included in the audit study. Patient feedback was obtained for 90.1 %. A total of 12 150 cases had been recorded in the registry by the same private practices during the same period. Colonoscopy completion rate and ADR data were comparable in the audit study and registry (completion rate 98.2 % vs. 97.7 %; ADR 21.0 % vs. 20.5 %). However, compared with the registry data, the complication rate was 3.1-fold higher in the audit (0.46 % vs. 0.15 %; P < 0.001), and double (0.33 % vs. 0.15 %; P < 0.05) when patient feedback was not included., Conclusions: Of the screening colonoscopy quality parameters, colonoscopy completion rate and ADR, but not complication rates, were reliably documented in the German national screening colonoscopy registry. Data on complications need to be appropriately standardized and audited in order to be used for credentialing and benchmarking purposes., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Screening colonoscopy effectiveness is hampered by limited adherence by the general population. The present prospective study was performed to evaluate whether adding capsule colonoscopy to the endoscopic screening options increases uptake., Methods: Invitation letters were sent to 2150 persons above the age of 55 insured with a German medical insurance company in the area of Rinteln, Lower Saxony with a baseline spontaneous annual screening colonoscopy uptake of 1 %. Both capsule or conventional colonoscopy were offered. Interested persons were given information about the two screening options by four local gastroenterologists and examinations were then performed according to screenees' final choice., Results: 154 persons sought further information, and 34 and 90 underwent conventional and capsule colonoscopy, respectively. Colonoscopy uptake was thus increased by the invitation process by 60 % (1.6 % vs. 1 %; p = 0.075), while the option of capsule endoscopy led to a fourfold increase of screening uptake (4.2 % vs. 1 %, p < 0.001). Despite similar age distribution in both sex groups, uptake in men was significantly higher (5.6 % vs. 2.8 %, p = 002). However, overall adenoma yield was not different in both groups., Conclusions: The present study suggests that offering the option of capsule colonoscopy increases uptake of endoscopic colorectal cancer screening. However, capsule endoscopy sensitivity for adenoma detection needs to be improved.

Background: Pain and bloating following colonoscopy are an underestimated problem, with 30 - 60 % of patients complaining of such symptoms. The use of CO₂ has been shown to significantly decrease pain after colonoscopy in academic hospital-based studies. The aim of the present study was to evaluate whether such an effect can also be seen during private practice routine colonoscopy., Patients and Methods: In a prospective double-blind randomized trial, one experienced colonoscopist (> 12,000 examinations) used either air or CO₂ insufflation for diagnostic or screening colonoscopy in consecutive patients presenting for diagnostic and screening colonoscopy in private practice. Outcome parameters were occurrence and duration of pain and bloating after colonoscopy based on a patient questionnaire., Results: Of 180 randomized patients, 156 replies were analyzed (43.3 % male, mean age 61.7 ± 9.7 years). There were no significant differences between the two groups with respect to age and sex distribution, indication, sedation, examination times and polypectomy rates. Both pain and abdominal bloating were significantly lower in the CO₂ group. Abdominal pain and bloating in the CO₂ vs. air group were absent in 84.4 vs. 64.6 % (p = 0.005) and 66.2 vs. 32.9 % (p < 0.001). Moderate/strong symptoms were also significantly lower with CO₂., Conclusions: The use of CO₂ appears to be as effective in daily routine in private practice colonoscopy as reported in previous hospital-based studies., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background & Aims: Improvements to endoscopy imaging technologies might improve detection rates of colorectal cancer and patient outcomes. We compared the accuracy of the latest generation of endoscopes with older generation models in detection of colorectal adenomas., Methods: We compared data from 2 prospective screening colonoscopy studies (the Berlin Colonoscopy Project 6); each study lasted approximately 6 months and included the same 6 colonoscopists, who worked in private practice. Participants in group 1 (n = 1256) were all examined by using the latest generation of wide-angle, high-definition colonoscopes that were manufactured by the same company. Individuals in group 2 (n = 1400) were examined by endoscopists who used routine equipment (a mixture of endoscopes from different companies; none of those used to examine group 1). The adenoma detection rate was calculated on the basis of the number of all adenomas/number of all patients., Results: There were no differences in patient parameters or withdrawal time between groups (8.0 vs 8.2 minutes). The adenoma detection rate was significantly higher in group 1 (0.33) than in group 2 (0.27; P = .01); a greater number of patients with least 1 adenoma were identified in group 1 (22.1%) than in group 2 (18.2%; P = .01). A higher percentage of high-grade dysplastic adenomas were detected in group 1 (1.19%) than in group 2 (0.57%), but this difference was not statistically significant (P = .06)., Conclusions: The latest generation of wide-angle, high-definition colonoscopes improves rates of adenoma detection by 22%, compared with mixed, older technology endoscopes used in routine private practice. These findings might affect definitions of quality control parameters for colonoscopy screening for colorectal cancer., (Copyright © 2012 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objectives: The acceptability of colonoscopy as a screening test is limited by several factors including patient discomfort. A new self-propelled colonoscope, the Invendo SC20 (Invendo Medical GmbH), may be helpful in reducing sedation. It consists of a sheathed endoscope contained within an "inverted sleeve," and having an instrument channel and an electrohydraulic bendable tip; it is steered using a handheld device and propelled by a motorized drive unit. This study assessed the safety and efficacy of this new endoscope in volunteers undergoing colorectal cancer (CRC) screening., Methods: Paid healthy volunteers aged 50-70 years and eligible for screening colonoscopy were included. Total colonoscopy using carbon dioxide insufflation or water instillation on demand was attempted, with all procedures being started without sedation. The main outcome parameters were safety and the cecal intubation rate., Results: A total of 61 volunteers participated (34 men and 27 women; mean age 57.5 years). The cecum was reached in 60 volunteers (cecal intubation rate of 98.4%). The median time to reach the cecum was 15 min (range 7-53.5). Sedation was given in three individuals (4.9%). On withdrawal (median time 15 min), the material for histological evaluation was obtained from 33 polyps (mean size 4.8 mm) in 23 people by biopsy forceps or snare. No device-related complications were encountered., Conclusions: A new computer-assisted colonoscope, controlled using a handheld device, showed excellent cecal intubation rates during screening examinations, with sedation required in only ~ 5% of screenees. Further clinical and comparative studies are warranted.

Objectives: Fujinon intelligent chromoendoscopy (FICE) is a post-processing imaging technique for increasing contrast of mucosa and mucosal lesions that might lead to improvement in colonic adenoma detection during colonoscopy. Previous studies on similar contrast-enhancing techniques as well as on dye staining have yielded variable and conflicting results. This large randomized trial was undertaken to determine whether FICE technology enhances adenoma detection rate (ADR)., Methods: In a prospective study performed in a multicenter private practice and hospital setting, involving 8 examiners with substantial lifetime experience (>10,000 colonoscopies each), 1,318 patients (men 46.7%, women 53.3%; mean age 59.05 years) were randomly assigned to colonoscopy with either FICE or white light imaging on instrument withdrawal. Of the colonoscopies, 68% were screening and 32% were diagnostic examinations. The primary outcome measure was the ADR (i.e., number of adenomas/total number of patients)., Results: There was no difference between the two groups in terms of general ADR (0.28 in both groups), the total number of adenomas (184 vs. 183), or detection of subgroups of adenomas. The rate of identification of hyperplastic polyps was also the same in both groups (127 vs. 121; P=0.67). The results were the same for both the screening and the diagnostic colonoscopy subgroups. Withdrawal time was the same in both groups (8.4 vs. 8.3 min, P=0.55)., Conclusions: This large randomized trial could not show any objective advantage of the FICE technique over conventional high-resolution endoscopy in terms of improved ADR.

Background & Aims: Narrow-band imaging (NBI) has been implemented in gastrointestinal endoscopy to improve the contrast of endoluminal pathologic structures, one of the aims being to increase colonic adenoma detection. Previous studies from referral centers have yielded variable and conflicting results with regard to improvement in adenoma detection rates by using NBI. The present large randomized trial was designed to finally settle this issue., Methods: In a prospective study performed exclusively in a multicenter private practice setting involving 6 examiners with substantial lifetime experience (>10,000 colonoscopies), 1256 patients (men:women, 47%:53%; mean age, 64.4 y) were randomized to HDTV screening colonoscopy with either NBI or white-light imaging on instrument withdrawal. The primary outcome measure was the adenoma detection rate (ie, number of adenomas/total number of patients)., Results: There was no difference between the 2 groups in terms of the general adenoma detection rate (0.32 vs 0.34), the total number of adenomas (200 vs 216), or in detection in subgroups of adenomas. This was despite a minimal, but significantly longer, withdrawal time in the NBI group (8.5 vs 7.9 min; P < .05). Only hyperplastic polyps were found more frequently in the NBI group (P = .03)., Conclusions: This large randomized trial in a homogeneous private practice screening setting could not show any objective advantage of the NBI technique over white-light high definition television imaging in terms of improved adenoma detection rate. Contrast enhancement therefore likely will not contribute to a reduction in adenoma miss rates among experienced colonoscopists.

Background: Several new instruments have been developed in the effort to improve the acceptance of colonoscopy for colorectal cancer screening. A new colonoscope, the Invendoscope, is presented here. It consists of an endoscopic sheath with an inverted sleeve, instrument channel, and an electrohydraulic deflecting tip. The instrument is steered by a hand-held device and propelled by a motorized drive unit., Objective: Our purpose was to evaluate the feasibility of the new Invendoscope SC40., Design: Prospective single-arm pilot study over 2 time periods using 2 different instrument prototypes (170 and 180/200 cm)., Patients: Thirty-four healthy volunteers (19 men, mean age 49.7 years). Technical instrument defects led to premature termination in 5 additional volunteers during the 2 study periods (4 in phase 1, 1 in phase 2), who were excluded from further analysis., Interventions: Total colonoscopy was attempted, with all procedures being performed without sedation., Main Outcome Measurements: Cecal intubation rate., Results: The cecum was reached in 82% of the 34 cases (95% CI, 66%-92%), with better results in period 2 than in period 1 (90% vs 79%); of the 6 incomplete examinations, 4 reached the mid transverse colon or beyond and 2 were stopped in the sigmoid colon because of pain. The volunteer rating showed a mean score of 1.96 (range 1-6; 1 = no discomfort). No complications were encountered., Limitations: No data regarding diagnostic accuracy and no data comparing the instrument with conventional colonoscopy are available as yet., Conclusions: This pilot proof-of-principle study of a new motor-driven colonoscope showed promising cecal intubation rates and an absence of pain in 92% of cases. Further clinical and comparative studies are warranted.

Background and Aims: Colonoscopy is an established method of colorectal cancer screening, but has an adenoma miss rate of 10-20%. Detection rates are expected to improve with optimised visualisation methods. This prospective randomised study evaluated narrow-band imaging (NBI), a new technique that may enhance image contrast in colon adenoma detection., Methods: Eligible patients presenting for diagnostic colonoscopy were randomly assigned to undergo wide-angle colonoscopy using either conventional high-resolution imaging or NBI during instrument withdrawal. The primary outcome parameter was the difference in the adenoma detection rate between the two techniques., Results: A total of 401 patients were included (mean age 59.4 years, 52.6% men). Adenomas were detected more frequently in the NBI group (23%) than in the control group (17%) with a number of 17 colonoscopies needed to find one additional adenoma patient; however, the difference was not statistically significant (p = 0.129). When the two techniques were compared in consecutive subgroups of 100 study patients, adenoma rates in the NBI group remained fairly stable, whereas these rates steadily increased in the control group (8%, 15%, 17%, and 26.5%, respectively). Significant differences in the first 100 cases (26.5% versus 8%; p = 0.02) could not be maintained in the last 100 cases (25.5% versus 26.5%, p = 0.91)., Conclusions: The increased adenoma detection rate means of NBI colonoscopy were statistically not significant. It remains speculative as to whether the increasing adenoma rate in the conventional group may have been caused by a training effect of better polyp recognition on NBI.

Purpose: The introduction of reimbursement for screening colonoscopy in Germany more than one year ago raised concerns that the consequent workload might lead to underuse of diagnostic colonoscopy for symptomatic patients. Available appropriateness criteria for diagnostic colonoscopy have been rarely tested in a realistic outpatient setting. This study was designed to test current appropriateness criteria for diagnostic colonoscopy to better select patients and potentially provide more capacity for screening cases. Secondary goals were yield and quality control in both the diagnostic and screening cases., Methods: A prospective study was initiated in 39 private-practice offices to collect data on consecutive colonoscopies conducted during a 6-day study period. A detailed questionnaire was developed to define indications and symptoms, and all findings at colonoscopy were recorded. Colonoscopies were further analyzed and stratified into a screening and a diagnostic group. In the diagnostic group, indications were assessed according to the current guidelines for appropriateness (American Society for Gastrointestinal Endoscopy, European Panel for the Appropriateness of Gastrointestinal Endoscopy), and the results were correlated with the percentage of relevant findings (tumors, inflammatory conditions)., Results: During the study period, 1,397 colonoscopies (57 percent screening, 43 percent diagnostic) were analyzed (male/female ratio = 39/61 percent; mean age, 61 years). Fourteen percent and 37 percent, respectively, of the 605 diagnostic colonoscopies were regarded as inappropriate relative to the criteria of the American Society for Gastrointestinal Endoscopy and the European Panel for the Appropriateness of Gastrointestinal Endoscopy. However, the percentage of relevant inflammatory and neoplastic findings (polyps, cancer, inflammatory bowel disease, benign strictures) was only 5 to 10 percent higher in the appropriate group than in the inappropriate group. On the basis of these data, a hypothetical model for selecting appropriate indications was developed: if patients older than aged 50 years with pain, bleeding, and diarrhea, but not constipation, are regarded as having an appropriate indication, such an approach would save 20 percent of colonoscopies in these main indication groups (bleeding, pain, diarrhea, constipation), with a hypothetical miss rate for relevant findings (as defined above) of 5 percent., Conclusions: Currently used appropriateness criteria for diagnostic colonoscopy increase the yield of relevant findings but lead to a miss rate for relevant findings in the range of 10 to 15 percent. Simple selection criteria based on age and symptoms could be more suitable and should be tested in a larger group of patients.

Background and Study Aims: Some colorectal polyps cannot be adequately viewed using forward-viewing colonoscopes because of their location behind mucosal folds or bends in the bowel. We performed polypectomy using side-viewing duodenoscopes for these problematic polyps in order to avoid incomplete polypectomy or the need for surgical intervention., Patients and Methods: Between April 2000 and August 2003, polypectomy with a side-viewing endoscope was intended in 15 patients (seven men, eight women; mean age 63.7 years, median age 59 years, range 38-88 years) at our institution. In all these patients, polypectomy had been attempted previously with a forward-viewing colonoscope by at least one experienced endoscopist without success. The duodenoscope was advanced with slight bending of the tip to achieve a sloped forward view., Results: Colorectal polyps were macroscopically completely removed in 11/15 patients. One polyp near the ileocecal valve could only be partially removed with the side-viewing endoscope; and one large flat rectal adenoma, one recurrent rectal polyp (after a previous incomplete conventional polypectomy), and one polyp near the ileocecal valve could not be removed. We observed no procedure-related complications. Endoscopic follow-up was possible in seven of the 11 patients in whom the polyps were successfully resected, with no evidence of recurrence (mean follow-up 27 months)., Conclusions: Polypectomy with the side-viewing duodenoscope is a safe and effective method. It is a therapeutic option when polyps are not adequately accessible using a conventional approach.

Background and Study Aims: Screening colonoscopy with polypectomy has been shown to reduce the morbidity and mortality associated with colorectal cancer. However, there is a lack of large and systematic prospective studies of the complications of polypectomy., Patients and Methods: Data on all snare polypectomies performed in 13 institutions (six hospitals and seven gastroenterology offices) were recorded prospectively during a 20-month period, including data on a 30-day follow-up period. The primary end points of the study were polypectomy complications, which were classed as "major" or "minor". Risk factors for complications were analyzed for both patient characteristics and polyp parameters., Results: A total of 3976 snare polypectomies in 2257 patients (mean age 64.5 years) were included in the study. The mean polyp size was 1.1 cm, and 72% were sessile. Complications occurred in 9.7% of patients (6.1% of polyps); 75% of these complications were minor; and the mortality rate was zero. Multivariate regression analysis revealed polyp size as the main risk factor, both for complications overall (odds ratio 6.56, 95%CI 4.45-9.67) and for major complications (odds ratio 31.01, 95%CI 7.53-128.1). Right-sided polyp location was a significant risk factor for major complications (odds ratio 2.40, 95%CI 1.34-4.28). Setting a cut-off value of 3% as an acceptable rate for major complications, polyps larger than 1 cm in the right colon or 2 cm in the left colon, and multiple polyps carried an increased risk., Conclusions: Colonoscopic polypectomy is associated with a 10% rate of complications, but three-quarters of these are of minor clinical significance. More than 90% of the complications can be managed conservatively if adequate endoscopic expertise is available. Guidelines for intensified follow-up after polypectomy should be based on the size, location, and number of a patient's polyps.

Endosonography of the colon has until recently been limited to examination of the rectum. Rigid and flexible instruments are currently available which allow for detailed images of the rectal wall. Comparative studies suggest that endosonography may be more accurate than computed tomography in the preoperative staging of rectal carcinoma. Recently, an ultrasound colonoscope has been developed which allows for visual examination, biopsy, and endosonography throughout the colon. Experience with this technique is limited and its role in the evaluation of colonic disease has not yet been determined. Further comparative trials are needed to more fully define the role of endosonography in the diagnosis of colorectal disease.

"Golytely", a lavage solution for colonoscopic preparation, has been in clinical use since 1980. Patients usually drink all the fluid (4-61 "Golytely") the morning before colonoscopy. However, clinical observation shows that many, especially elderly, patients have difficulty tolerating these large volumes. We therefore compared two methods of drinking "Golytely" in 36 patients: One group of 18 patients underwent a two-stage lavage preparation (in the evening and the following morning before the examination), the other group drank all the fluid in the early morning before colonoscopy. Patients tolerated the two-stage method significantly better-in terms of nausea (p less than 0.05) and their willingness to repeat the procedure (p less than 0.001). In both groups the bowel was equally clean and the amount of fluid required for preparation did not differ. We conclude that this new method of drinking "Golytely" is far more convenient for the patient and does not reduce the effectiveness of bowel preparation.

The article presents the 19th United European Gastroenterology Week (UEGW) 2011 report on gastrointestinal endoscopy. Topics of the report include the advacement of traditional endoscopic mucosal resection (EMR) to tissue resection by endoscopic submucosal dissection (ESD), factors that may have an impact of ESD outcome, and screening and surveillance colonoscopy for the diagnosis of colorectal cancer.

Colonoscopy has been established as a screening tool for colorectal cancer and precursors in some countries. Efforts to improve instrument performance as well as patient comfort, safety and compliance have led to modifications of existing endoscopes as well as to the development of new scopes with different working mechanisms, including the colon capsule. While the former have not substantially changed performance, the true value of new scopes – partially single use and/or self propelling – can not be fully assessed, since they are either still under development and/or tested only in animals and in small groups of patients or volunteers. The colon capsule holds promise but has a too complicated preparatory regimen and too low a sensitivity at the moment. Future developments and further studies will show which of these techniques may complement or even replace traditional screening colonoscopy. Copyright © 2007 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]