Real-time Feedback Improves the Quality of Colonoscopy by Trainees: A Controlled Clinical Trial: ACG/AstraZeneca Fellow Award (2012)

Purpose: Colonoscopy is an operator-dependent procedure that provides only partial protection against colorectal cancer. Many forms of feedback to improve quality of colonoscopy have been tried; most have failed as changing endoscopist behavior has been found to be very difficult. Aim: To determine whether real-time feedback (RT-FB) to third year GI trainees during colonoscopy improves the quality of mucosal inspection compared to the colonoscopy done without RT-FB. Methods: We installed RT-FB systems in two endoscopy rooms already equipped with video capturing systems; RT-FB was based on real-time analysis of the video stream using software algorithms previously described. Endoscopy RNs were trained to activate the RT-FB system during colonoscopy using a dedicated keypad at the start of the withdrawal phase and to turn it off at the end of the procedure. After an observation phase, third year GI trainees randomly received RT-FB when assigned to colonoscopy in RT-FB rooms. For this study, RT-FB was limited to two features: (1) visual confirmation of start of withdrawal phase; and (2) effort to inspect the lateral mucosa during withdrawal as “spiral score”, initially set to zero. Each time a sector indicating a quadrant was inspected, a green triangle appeared in the corner of that quadrant using overlay; each time all four quadrants were inspected at least once - i.e., a full circumference - the spiral score was incremented by 1. All video files, de-identified, in random order and devoid of feedback, were manually annotated by two blinded investigators. Continuous variables were compared with mean, standard deviation and t-test. Results: 483 colonoscopy video files (194 with and 289 without RT-FB) from third year GI trainees (n=10) were analyzed. The mean mucosal visualization score was significantly higher with compared to without RT-FB (85.1 ± 9.5 vs. 81.5 ± 12.5%; p< 0.001). The mean debris removal score (7.8 ± 1.1 with vs. 7.5 ± 1.3 without RT-FB; p= 0.02), and the mean bowel distention score (8.1 ± 0.9 with vs. 7.8 ± 1.1 without RT-FB; p=0.01) were better with RT-FB during colonoscopy withdrawal. The mean withdrawal time was longer with RT-FB compared to without RT-FB (17.2 ± 8.6 vs. 15.3 ± 8 min, p=0.01). Conclusion: 1. The simple RT-FB feature “spiral score” significantly improved mucosal visualization by third year GI trainees. 2. Although no RT-FB was provided related to debris removal, bowel distention and withdrawal time, RT-FB significantly improved these features as well. 3. Baseline visualization scores for third year GI trainees were high yet improved further by RF-FB. 4. RT-FB can serve as a teaching tool to improve quality of colonoscopy by trainees. 5. These data call for controlled studies of RT-FB in staff endoscopists. Disclosure: The technology used for this research has been licensed to EndoMetric Inc. Drs. Piet de Groen, Wallapak Tavanapong, JungHwan Oh, Johnny Wong, and Mayo Clinic have a financial interest associated with the technology used in this research and hold an equity position in Endometric Inc. Drs. Piet de Groen, Wallapak Tavanapong, JungHwan Oh, Johnny Wong, and Mayo Clinic have received royalties of less than the federal threshold for significant financial interest from licensing of this technology and hold rights to receive future royalties.