Improving the quality of endoscopic polypectomy by introducing a colonoscopy quality assurance program

Background: Colonoscopy is a routine procedure in patients who present with bowel symptoms. Polyps can be identified and removed during colonoscopy. A colonoscopy quality-assurance program (CQAP) was instituted in 2003.Aim: The aim of the study was to determine the effect of instituting a CQAP on the quality of endoscopic polypectomy (EP) in our patients.Patients and methods: An Initial assessment of EP practice in 2003 showed that four patients had polyps. Cecal intubation had been achieved in only two patients and a complete polyp description (CPD) had not been documented. Polypectomy was performed in two patients but the completeness of removal and retrieval of the polyps had not been assessed and histology had not been recorded. A quality improvement process was therefore instituted. This required full colonoscopy to the cecum, CPD and polypectomy to be performed for every polyp. There should be a 90% retrieval rate of all excised polyps and follow up of all histology reports. Seventy-six patients were assessed prospectively over the period 2004–2011.Results: Cecal intubation rates increased from 65% in years 2004–2007 to 90% in years 2008–2011 (t-proportion = 2.4 & CI= 4.7, highly significant). CPD rates increased from 35% to 100% (t-proportion = 6.5 & CI= 12.7,  highly significant). EP rates increased from 59% to 100% (t-proportion = 3.5 & CI= 6.9, highly significant). Percentage of procedures in which all polyps were judged completely removed increased from 41% to 86% (t-proportion = 3.6 & CI= 7, highly significant). Polyp retrieval rates, with retrieval of P90% of all excised polyps, increased from 80% to 92% (t-proportion = 0.87 & CI= 1.7, significant). Polyp histology documentation rates increased from 41% to 88% (t-proportion =3.7 & CI= 7.3, highly significant).Conclusion: The implementation of a quality assurance and improvement program improved the quality of EP in patients with polyp(s) detected during colonoscopy.Keywords: Colonoscopy; Polypectomy; Quality assurance; Juvenile polyp

Progress and Challenges in Colorectal Cancer Screening

Although faecal and endoscopic tests appear to be effective in reducing colorectal cancer incidence and mortality, further technological and organizational advances are expected to improve the performance and acceptability of these tests. Several attempts to improve endoscopic technology have been made in order to improve the detection rate of neoplasia, especially in the proximal colon. Based on the latest evidence on the long-term efficacy of screening tests, new strategies including endoscopic and faecal modalities have also been proposed in order to improve participation and the diagnostic yield of programmatic screening. Overall, several factors in terms of both efficacy and costs of screening strategies, including the high cost of biological therapy for advanced colorectal cancer, are likely to affect the cost-effectiveness of CRC screening in the future

The Quality Improvement in Colonoscopy (QIC) Study: Improving Adenoma Detection Rates and Reducing Variation between Colonoscopists

Introduction Adenoma detection rate (ADR) is an established quality marker in colonoscopy. Significant variability in ADR exists. Withdrawal time of ≥ 6 minutes; Buscopan use; position change and rectal retroflexion have been shown to improve lesion detection. We evaluated the feasibility and clinical outcome of implementing these measures, as a ‘bundle’, into routine practice to improve ADR. Factors influencing uptake were evaluated in a qualitative study. Methodology Twelve units participated. All nominated a lead colonoscopist and nurse. Implementation combined central training, local leadership, feedback and continuous central support. The 3 months prior to implementation was compared to a 9 month period after. Colonoscopists performing ≥ 25 procedures during the baseline period were ranked in quartiles by ADR. Buscopan use was used as a surrogate marker for uptake. Changes were evaluated using a corrected Chi Squared test. For the qualitative study, units and individuals were purposively sampled to ensure a range of units were included. Semi-structured interviews were conducted until saturation was reached. Data were evaluated using thematic analysis. Results Global and quartile analyses comprised data from 118 and 68 colonoscopists performing 17, 508 and 14,193 procedures respectively. There was a significant increase in Buscopan use globally (15.8% vs. 54.4%, p<0.001) and in each quartile. The ADR also increased significantly globally (16.0% vs. 18.1%, p=0.002), with a significant reduction in variation. Interviews were conducted with 8 lead and 3 non-lead colonoscopists and 1 lead nurse. Increased emphasis on examination time, awareness of ADR as a quality marker and empowerment of endoscopy nurses to encourage the use of quality measures were positive outcomes of the intervention. Challenges included difficulty in arranging set up meetings and engaging certain speciality groups. Discussion This evidence based educational intervention resulted in a significant change in behaviour, evidenced by increased Buscopan use. A significant increase in the global ADR and reduction in variation between quartiles was observed. Other positive outcomes included increased awareness of colonoscopy quality and empowerment of endoscopy nurses to promote quality measures. This study demonstrates that simple interventions can significantly change practice and improve quality. The timing of meetings and strategies to engage speciality groups are important

Artificial intelligence and computer-aided diagnosis in colonoscopy: current evidence and future directions

Computer-aided diagnosis offers a promising solution to reduce variation in colonoscopy performance. Pooled miss rates for polyps are as high as 22%, and associated interval colorectal cancers after colonoscopy are of concern. Optical biopsy, whereby in-vivo classification of polyps based on enhanced imaging replaces histopathology, has not been incorporated into routine practice because it is limited by interobserver variability and generally only meets accepted standards in expert settings. Real-time decision-support software has been developed to detect and characterise polyps, and also to offer feedback on the technical quality of inspection. Some of the current algorithms, particularly with recent advances in artificial intelligence techniques, match human expert performance for optical biopsy. In this Review, we summarise the evidence for clinical applications of computer-aided diagnosis and artificial intelligence in colonoscopy

Endoscopic Polyp Segmentation Using a Hybrid 2D/3D CNN

Colonoscopy is the gold standard for early diagnosis and pre-emptive treatment of colorectal cancer by detecting and removing colonic polyps. Deep learning approaches to polyp detection have shown potential for enhancing polyp detection rates. However, the majority of these systems are developed and evaluated on static images from colonoscopies, whilst applied treatment is performed on a real-time video feed. Non-curated video data includes a high proportion of low-quality frames in comparison to selected images but also embeds temporal information that can be used for more stable predictions. To exploit this, a hybrid 2D/3D convolutional neural network architecture is presented. The network is used to improve polyp detection by encompassing spatial and temporal correlation of the predictions while preserving real-time detections. Extensive experiments show that the hybrid method outperforms a 2D baseline. The proposed architecture is validated on videos from 46 patients. The results show that real-world clinical implementations of automated polyp detection can benefit from the hybrid algorithm

Quality Assessment of Colonoscopy Reporting: Results from a Statewide Cancer Screening Program

This paper aimed to assess quality of colonoscopy reports and determine if physicians in practice were already documenting recommended quality indicators, prior to the publication of a standardized Colonoscopy Reporting and Data System (CO-RADS) in 2007. We examined 110 colonoscopy reports from 2005-2006 through Maryland Colorectal Cancer Screening Program. We evaluated 25 key data elements recommended by CO-RADS, including procedure indications, risk/comorbidity assessments, procedure technical descriptions, colonoscopy findings, specimen retrieval/pathology. Among 110 reports, 73% documented the bowel preparation quality and 82% documented specific cecal landmarks. For the 177 individual polyps identified, information on size and morphology was documented for 87% and 53%, respectively. Colonoscopy reporting varied considerately in the pre-CO-RADS period. The absence of key data elements may impact the ability to make recommendations for recall intervals. This paper provides baseline data to assess if CO-RADS has an impact on reporting and how best to improve the quality of reporting

The impact of Endocuff Vision on adenoma detection rates in colonoscopy

Background One of the problems with colonoscopy is its imperfection due to variation in operator dependent adenoma detection rates. Low adenoma detection rates are linked to increased interval colorectal cancer rates and reduced cancer survival. Devices to enhance mucosal visualisation and improve adenoma detection rates such as Endocuff Vision have been developed. The primary aim of this study was to compare adenoma detection rates between Endocuff Vision-assisted colonoscopy and standard colonoscopy. Methods A multicentre, randomised controlled trial in seven hospitals in the United Kingdom was undertaken. Patients aged 18 and above referred for colonoscopy due to symptoms, colonoscopy surveillance, or as part of the Bowel Cancer Screening Programme following a positive screening faecal occult blood test were invited to the study. Patients with a suspicion of bowel obstruction, known colon cancer, polyposis syndromes, known strictures, active colitis, on anticoagulant therapy during the procedure, pregnant, attending for a therapeutic procedure or assessment of a known lesion were excluded. Findings One thousand, seven hundred and seventy-two patients (57% male, mean age 62) were recruited from November 2014 until February 2016. Patient characteristics were comparable between trial arms. Endocuff Vision increased adenoma detection rates by 4.7% (p=0.02). This was largely driven by an increase in adenoma detection rates in screening patients from 50.9% to 61.7% (p<0.001). Endocuff Vision-assisted colonoscopy also detected more mean adenomas per procedure, left sided adenomas, sessile serrated adenomas, diminutive adenomas, small adenomas and cancers. Cuff removal rate was 4.1%. Median intubation time was one minute quicker with Endocuff Vision- assisted colonoscopy (p=0.001). Anal intubation was rated as more uncomfortable with Endocuff Vision-assisted colonoscopy. There were no significant cuff-related adverse events. Endocuff Vision- assisted colonoscopy was non-inferior to SC in other markers of comfort and procedure time. Conclusion Endocuff Vision significantly improved ADR driven by an improvement in the faecal occult blood test positive screening population. Endocuff Vision-assisted colonoscopy was non-inferior in all aspects other than discomfort on anal intubation