603 Quality Indicators to Enhance Adenoma Detection Rate: Should There Be Reconsideration of the Current Standard?

Quality Indicators to Enhance Adenoma Detection Rate: Should There Be Reconsideration of the Current Standard? Madhusudhan R. Sanaka, Tushar Gohel, Amareshwar Podugu, Pokala R. Kiran, Prashanthi N. Thota, Rocio Lopez, James M. Church, James W. Collins, Carol A. Burke Gastroenterology, Cleveland Clinic, Cleveland, OH Background/Aims: The quality indicators (QI) for colonoscopy published in 2006 are based on studies done in the decade prior to their publication. Colonoscopic technology has improved, yet data shows incomplete protection from colonoscopy for cancer in the right colon. We believe a reassessment of detection rates for adenomas (ADR) and sessile serrated polyps (SSPDR) in average risk individuals is warranted. Knowledge of the ADR and SSPDR according to location in the colon, may improve the quality of colonoscopy. Our study aims were to determine Overall and segmental ADR and SSPDR in average risk individuals undergoing colonoscopy. Methods: Colonoscopy reports from a total of 66 endoscopists including 41 gastroenterologists, 15 colorectal surgeons, 7 general surgeons and 3 other proceduralists during 2008-2009 were reviewed. Up to 120 procedures per endoscopist were randomly selected. Colonoscopic findings including quality of preparation, polyp size, location, morphology and pathology were retrieved. Patients with good or excellent bowel preparation were included. Patients with incomplete colonoscopy, fair or poor bowel preparation, prior colon resection, FAP, HNPCC and IBD were excluded. ADR is defined as percentage of colonoscopies with at least one adenoma detected. SSPDR is defined similarly. Proximal colon consisted of cecum, ascending and transverse colon including splenic flexure while Distal colon included descending, sigmoid and rectum. Data is presented as mean sd or N (%). Detection rates were estimated for each endoscopist and comparisons between locations were made using paired t-tests. Results: 7382 colonoscopy reports were reviewed. 3337 average risk patients were included, 2560 (77%) had standard definition colonoscopy and 777 (23%) had high definition colonoscopy. The ADR was 24.9 10.5% (30.8 10.5% in Men and 19.1 12.8% in Women). ADR was greater in the Proximal than the Distal colon (15.5 7.9% vs 12.9 5.9%, p 0.011). This was similar for both genders, Men: Proximal 19 8.8%, Distal 16.7 8.5% and Women: Proximal 12.1 10.2%, Distal 9.0 7. SSPDR was 1.7 2.3 % (Proximal 1.2 1.8%, Distal 0.5 1.1%, p 0.003. This was again similar for Men: Proximal 1.2 2.4%, Distal 0.7 1.8% and Women: Proximal 1.1 2.2%, Distal 0.4 1.2%. Conclusions: The overall ADR in average risk individuals determined in a large group of endoscopists from various specialties at a tertiary care center is consistent with previously set ADR quality indicators. We demonstrate that both the ADR and SSPDR vary significantly by location within the colon, Proximal Distal. We propose two new quality indicators for colonoscopy in average risk individuals: SSPs should be detected in at least 1%; a minimum ADR and SSPDR should be set for the Proximal colon. 604 Does Inspection During Instrument Insertion Improve Adenoma Detection At Colonoscopy? A Randomized Controlled Trial David G. Hewett, Douglas K. Rex School of Medicine, The University of Queensland, Brisbane, QLD, Australia; Department of Medicine, Indiana University Medical Center, Indianapolis, IN Polyps are often missed during colonoscopy, even with meticulous technique. Polyps seen and not removed during instrument insertion are sometimes unable to be found during withdrawal. Aim: To investigate the impact of inspection during instrument insertion on adenoma detection in sedated patients undergoing routine screening or surveillance colonoscopy. Methods: We conducted a randomized controlled trial, in which 340 patients were randomized to undergo colonoscopy with inspection only performed during instrument withdrawal or colonoscopy with some of the inspection performed during instrument insertion. Eligibility criteria were: patients aged 50 years or older, ability to give informed consent and scheduled for elective colonoscopy. Exclusion criteria were previous surgical resection of the colon or rectum, inflammatory bowel disease, polyposis syndrome, and previously incomplete colonoscopy. Colonoscopy was performed using high definition colonoscopes with carbon dioxide insufflation, and a stopwatch was used to measure insertion and inspection times, with the aim of equal total inspection times between arms. The primary outcome measure was the adenoma detection rate in the two study groups. Group comparisons were performed using Wilcoxon rank sum or chisquare tests as appropriate. Results: Background demographic characteristics of the patients in the two study groups were equivalent (Table 1: mean age 63.0, range 47-85; male 44%). Colonoscopy-related variables were also similar, including indication, quality of bowel preparation, mean total procedure time, mean total inspection time (IN: 9.63min, WD: 9.44 mins, p NS). Mean insertion time was significantly higher in the insertion group (IN: 8.4min, WD: 5.1min, p 0.001). Adenomas were detected in 187 patients; representing an overall adenoma detection rate of 55% or 1.62 adenomas per patient. Adenomas ( 1) were found in 89 (52%) patients from the insertion group, compared with 98 (59%) in the withdrawal group (p NS). The mean number of adenomas in the insertion group was 1.38 (SE 0.16) and 1.86 (SE 0.21) in the withdrawal group. There were no significant differences in other secondary outcomes, including total procedure time (IN: 24.2min, WD: 27.4, p 0.07), or postcolonoscopy abdominal pain (IN: 1.42, WD 1.22, p NS). Conclusions: Inspection during colonoscope insertion offered no additional benefit compared with an equivalent period of inspection performed entirely during withdrawal. These results do not support a role for routine inspection during colonoscope insertion. Abstracts