854 Adenoma Detection Rates Vary Greatly Between Gastroenterology Fellows
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positive findings only with PillCam SB2® and five only with Capsovision®. Concordance between both capsule exmination were good with k0.63 in analysable patients and k0.6 in intention to treat (including failures). Diagnostic yield was similar for both capsules in a per-patient analysis, with 29/73 positive for Capsovision versus 29/73 for PillCamSB2 (p0.79). In a per-lesion analysis, Capsovision® capsule significantly improved the number of P1/P2 lesions detected; 107 versus 85 lesions, despite this difference was essentially based on 2 patient with numerous angiectasias identified by Capsovision® (p0.01). Reading time was slightly longer for Capsovision® with a mean of 32.0 min versus 26.2 with PillCam SB2®. Conclusion : This study shows for the first time comparable efficiency of the Capsovision® and PilCam SB2® capsule system regarding the diagnostic yield and image quality. Capsovision® gave a 37.0% positive diagnostic rate versus 38.3% for the PillCam SB2® without significant difference in per patient analysis. Circumferential viewing may improve angiectasia viewing. 852 Prospective Randomized Comparison of Cold SNARE Polypectomy and Conventional Polypectomy for Small Colorectal Polyps in Patients Receiving Anticoagulation Therapy Akira Horiuchi* 1 , Yoshiko Nakayama 1,2 1 Digestive Disease Center, Showa Inan General Hospital, Komagane, Japan; 2 Department of Pediatrics, Shinshu University Hospital, Matsumoto, Japan Background: The current practice guidelines for colonoscopy in patients requiring long-term anticoagulation consider polypectomy a high-risk procedure and recommend anticoagulation be temporarily discontinued. However, the bleeding risk after cold snare polypectomy in anticoagulated patients is not known. Objective: The aim of this study was to evaluate the risk of postpolypectomy bleeding after removal of small polyps by cold snare transection without electrocautery in anticoagulated patients. Method: Anticoagulated patients with colorectal polyps up to 10 mm in diameter were randomized to polypectomy to cold snare technique (Cold group) or conventional polypectomy (Conventional group). The two techniques were performed without discontinuation of warfarin. Submucosal injection of saline solution before the removal and prophylactic clipping after the removal were not routinely performed, irrespective of the type of polypectomy. The primary outcome measure was immediate bleeding during the procedure or delayed bleeding within two weeks after polypectomy requiring endoscopic intervention. Secondary outcome measure was the complete retrieval rate of colorectal polyps based on the pathological examination. Results: 70 patients were randomized: Cold group, N35 (78 polyps) and Conventional group, N35 (81 polyps). The patients’ demographic characteristics including international normalized ratio (INR), and the number, size, and shape of polyps removed were similar between the two techniques. Procedure time was significantly shorter with cold polypectomy vs. conventional polypectomy (16 min vs. 26 min, P0.0001). Complete polyp retrieval rates were identical [94% (73/78) vs. 93% (75/81)]. Immediate bleeding during the procedure was more common with conventional polypectomy [23%(8/35)] compared with cold polypectomy [5.7% (2/35)] (P0.04). No delayed bleeding occurred in cold group whereas 5 patients (14%) required endoscopic hemostasis in conventional group (P0.02). No thromboembolic events were observed in either group. Conclusion: No delayed bleeding requiring hemostasis occurred after cold snare polypectomy despite continuation of anticoagulants suggesting that cold snare polypectomy is the preferred method for removal of small colorectal polyps in anticoagulated patients. 853 Leaving Distal Colorectal Polyps in Place Can Be Achieved With High Accuracy Using High-Definition Endoscopy With Virtual Chromoendoscopy Helmut Neumann* 1 , Michael Vieth 2 , Claudia GüNther 1 , Raja Atreya 1 , JüRgen Siebler 1 , Markus F. Neurath 1 1 Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany; 2 Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany Objectives: The ASGE PIVI statement proposed that a new technology should provide a negative predictive value (NPV) 90% for adenomatous polyp histology to leave distal diminutive colorectal polyps in place without resection. To our knowledge no prior prospective study has yet evaluated the feasibility of virtual chromoendoscopy based, real-time endoscopic prediction of polyp histology for the specific endpoint of leaving distal hyperplastic polyps in place. Aims: Prospective assessment of real-time prediction of diminutive ( 5mm) distal colorectal polyps by using virtual chromoendoscopy (i-scan). Material & Methods: 224 consecutive patients undergoing screening or surveillance colonoscopy were included. 121 distal colorectal polyps from 77 patients were evaluated in real-time by using high-definition endoscopy and i-scan. Before resection, the endoscopist described each polyp according to size, shape and surface characteristics (pit and vascular pattern, color, depression) and histology was predicted with a level of confidence (high or low). Results: The histology was predicted with high-confidence in 91.7% of polyps. The overall accuracy for adenomatous polyp histology was 90.1% with a sensitivity, specificity, positive and negative predictive value of 91.5%, 88.7%, 88.5%, and 91.7%, respectively. When the prediction was made with high-confidence, the accuracy was 96.4%. Sensitivity, specificity, positive and negative predictive value were 98.2%, 94.6%, 94.7%, and 98.2%, respectively. Conclusion: High-definition endoscopy in combination with virtual chromoendoscopy allows real-time prediction of colorectal polyp histology and is accurate enough to leave distal colorectal polyps in place without resection. This approach has therefore the potential to reduce costs and risks associated with the redundant removal of diminutive colorectal polyps. 854 Adenoma Detection Rates Vary Greatly Between Gastroenterology Fellows Yark Hazewinkel*, Robert B. Klanderman, Deborah Van Den Buijs, Paul Fockens, Evelien Dekker Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands Background: The adenoma detection rate (ADR) is an independent predictor of interval cancer and varies between colonoscopists. This variability within the ADR might already start during endoscopical training. Although Dutch training guidelines prescribe 100 fully supervised procedures, in the past at our institution, fellows inspected the colon unsupervised after approximately their first 50 procedures. This setting enabled us to measure ADR levels of starting colonoscopists. Aim: To monitor ADRs of fellows withdrawing autonomously during their entire fellowship in a retrospective setting. Methods: Colonoscopies performed by 7 fellows between May 2004 and Feb 2012 were reviewed. To identify a learning curve, consecutive procedures were stratified into a “training set” (first 140 procedures) and ”post-training set” (141 till end of fellowship). For ADR analysis, emergency procedures as well as patients with IBD, polyposis and a positive faecal blood test were excluded. These procedures, however, did count as gained experience in the training set. Individual ADRs were compared with the highest-level detector, adjusted for patient’s age, gender and indication. Regression analysis was used to determine the association of training ADRs on the detection of advanced neoplasia ( 1 cm, high grade dysplasia, villous structure or CRC) during the remaining fellowship. Results: A total of 3252 colonoscopies were performed by 7 fellows. The number of procedures performed per fellow ranged from 389 to 612. After exclusion, data of 2050 procedures could be used for ADR analysis. In this cohort (mean age 59 yrs SD 15, 48% male) the overall ADR was 23% whereas individual ADRs ranged from 15% to 32%. Compared with the highest level detector, the odds for detecting 1 adenoma for individual fellows ranged from 0.73 to 0.29. None of the 7 individual ADRs increased significantly after the first 140 procedures. Fellows with a training ADR 20% (n4) detected significantly more advanced neoplasms during the remaining course of their fellowship compared to fellows with a training ADR 20% (OR 1.88 95% CI 1.33-2.66). Conclusion: The detection of adenomas varies greatly between fellows. We observed no increase in ADR levels after the first 140 colonoscopies, suggesting that adequate withdrawal technique is specifically learned during this novice-period. The significance of this finding is underlined by the observation that fellows with an ADR 20%, during this period, go on to detect more advanced neoplasms during the remaining course of their fellowship. In an effort to improve detection performance it seems therefore advisable to intensify training during the beginning of a fellowship. 855 Racial Differences in Outcome of Colonoscopy in Young Adults (<50 Years): Sub-Analysis From Colonoscopy Outcome in Minority Population (Comp) Registry Kinesh Changela, Shashideep Singhal, Manhal Olaywi*, Deepanshu Jain, Devin Lane, Sushil Duddempudi, Mojdeh Momeni, Mahesh Krishnaiah, Sury Anand Gastorenterology, The Brooklyn Hospital Center, Brooklyn, NY Background: Identification and removal of colonic adenomas is the corner stone of our colorectal cancer prevention program. There has been a concern of earlier development of colonic adenomas in adults 50 years of age especially in high risk ethnic groups. There are very limited studies done to determine the yield of colonoscopy in young minority adults. Methods: The study cohort was selected from from COMP registry at our teaching urban community hospital. Patients with age 50 years were included in the study. The demographic, endoscopic findings and pathological reports study group were analyzed to determine the yield colonic adenomas during colonoscopy. Results: Out of 4015 colonoscopies Abstracts www.giejournal.org Volume 77, No. 5S : 2013 GASTROINTESTINAL ENDOSCOPY AB174
Transcript of 854 Adenoma Detection Rates Vary Greatly Between Gastroenterology Fellows
positive findings only with PillCam SB2® and five only with Capsovision®.Concordance between both capsule exmination were good with k�0.63 inanalysable patients and k�0.6 in intention to treat (including failures). Diagnosticyield was similar for both capsules in a per-patient analysis, with 29/73 positivefor Capsovision versus 29/73 for PillCamSB2 (p�0.79). In a per-lesion analysis,Capsovision® capsule significantly improved the number of P1/P2 lesionsdetected; 107 versus 85 lesions, despite this difference was essentially based on 2patient with numerous angiectasias identified by Capsovision® (p�0.01).Reading time was slightly longer for Capsovision® with a mean of 32.0 minversus 26.2 with PillCam SB2®. Conclusion : This study shows for the first timecomparable efficiency of the Capsovision® and PilCam SB2® capsule systemregarding the diagnostic yield and image quality. Capsovision® gave a 37.0%positive diagnostic rate versus 38.3% for the PillCam SB2® without significantdifference in per patient analysis. Circumferential viewing may improveangiectasia viewing.
852Prospective Randomized Comparison of Cold SNAREPolypectomy and Conventional Polypectomy for SmallColorectal Polyps in Patients Receiving Anticoagulation TherapyAkira Horiuchi*1, Yoshiko Nakayama1,2
1Digestive Disease Center, Showa Inan General Hospital, Komagane,Japan; 2Department of Pediatrics, Shinshu University Hospital,Matsumoto, JapanBackground: The current practice guidelines for colonoscopy in patientsrequiring long-term anticoagulation consider polypectomy a high-risk procedureand recommend anticoagulation be temporarily discontinued. However, thebleeding risk after cold snare polypectomy in anticoagulated patients is notknown. Objective: The aim of this study was to evaluate the risk ofpostpolypectomy bleeding after removal of small polyps by cold snaretransection without electrocautery in anticoagulated patients. Method:Anticoagulated patients with colorectal polyps up to 10 mm in diameter wererandomized to polypectomy to cold snare technique (Cold group) orconventional polypectomy (Conventional group). The two techniques wereperformed without discontinuation of warfarin. Submucosal injection of salinesolution before the removal and prophylactic clipping after the removal were notroutinely performed, irrespective of the type of polypectomy. The primaryoutcome measure was immediate bleeding during the procedure or delayedbleeding within two weeks after polypectomy requiring endoscopic intervention.Secondary outcome measure was the complete retrieval rate of colorectal polypsbased on the pathological examination. Results: 70 patients were randomized:Cold group, N�35 (78 polyps) and Conventional group, N�35 (81 polyps). Thepatients’ demographic characteristics including international normalized ratio(INR), and the number, size, and shape of polyps removed were similar betweenthe two techniques. Procedure time was significantly shorter with coldpolypectomy vs. conventional polypectomy (16 min vs. 26 min, P�0.0001).Complete polyp retrieval rates were identical [94% (73/78) vs. 93% (75/81)].Immediate bleeding during the procedure was more common with conventionalpolypectomy [23%(8/35)] compared with cold polypectomy [5.7% (2/35)](P�0.04). No delayed bleeding occurred in cold group whereas 5 patients (14%)required endoscopic hemostasis in conventional group (P�0.02). Nothromboembolic events were observed in either group. Conclusion: No delayedbleeding requiring hemostasis occurred after cold snare polypectomy despitecontinuation of anticoagulants suggesting that cold snare polypectomy is thepreferred method for removal of small colorectal polyps in anticoagulatedpatients.
853Leaving Distal Colorectal Polyps in Place Can Be Achieved WithHigh Accuracy Using High-Definition Endoscopy With VirtualChromoendoscopyHelmut Neumann*1, Michael Vieth2, Claudia GüNther1, Raja Atreya1,JüRgen Siebler1, Markus F. Neurath1
1Department of Medicine 1, University of Erlangen-Nuremberg,Erlangen, Germany; 2Institute of Pathology, Klinikum Bayreuth,Bayreuth, GermanyObjectives: The ASGE PIVI statement proposed that a new technology shouldprovide a negative predictive value (NPV) �90% for adenomatous polyphistology to leave distal diminutive colorectal polyps in place without resection.To our knowledge no prior prospective study has yet evaluated the feasibility ofvirtual chromoendoscopy based, real-time endoscopic prediction of polyphistology for the specific endpoint of leaving distal hyperplastic polyps in place.Aims: Prospective assessment of real-time prediction of diminutive (� 5mm)distal colorectal polyps by using virtual chromoendoscopy (i-scan). Material &Methods: 224 consecutive patients undergoing screening or surveillancecolonoscopy were included. 121 distal colorectal polyps from 77 patients were
evaluated in real-time by using high-definition endoscopy and i-scan. Beforeresection, the endoscopist described each polyp according to size, shape andsurface characteristics (pit and vascular pattern, color, depression) and histologywas predicted with a level of confidence (high or low). Results: The histologywas predicted with high-confidence in 91.7% of polyps. The overall accuracy foradenomatous polyp histology was 90.1% with a sensitivity, specificity, positiveand negative predictive value of 91.5%, 88.7%, 88.5%, and 91.7%, respectively.When the prediction was made with high-confidence, the accuracy was 96.4%.Sensitivity, specificity, positive and negative predictive value were 98.2%, 94.6%,94.7%, and 98.2%, respectively. Conclusion: High-definition endoscopy incombination with virtual chromoendoscopy allows real-time prediction ofcolorectal polyp histology and is accurate enough to leave distal colorectalpolyps in place without resection. This approach has therefore the potential toreduce costs and risks associated with the redundant removal of diminutivecolorectal polyps.
854Adenoma Detection Rates Vary Greatly BetweenGastroenterology FellowsYark Hazewinkel*, Robert B. Klanderman, Deborah Van Den Buijs,Paul Fockens, Evelien DekkerGastroenterology and Hepatology, Academic Medical Center,Amsterdam, NetherlandsBackground: The adenoma detection rate (ADR) is an independent predictor ofinterval cancer and varies between colonoscopists. This variability within theADR might already start during endoscopical training. Although Dutch trainingguidelines prescribe 100 fully supervised procedures, in the past at ourinstitution, fellows inspected the colon unsupervised after approximately theirfirst 50 procedures. This setting enabled us to measure ADR levels of startingcolonoscopists. Aim: To monitor ADRs of fellows withdrawing autonomouslyduring their entire fellowship in a retrospective setting. Methods: Colonoscopiesperformed by 7 fellows between May 2004 and Feb 2012 were reviewed. Toidentify a learning curve, consecutive procedures were stratified into a “trainingset” (first 140 procedures) and ”post-training set” (141 till end of fellowship). ForADR analysis, emergency procedures as well as patients with IBD, polyposis anda positive faecal blood test were excluded. These procedures, however, didcount as gained experience in the training set. Individual ADRs were comparedwith the highest-level detector, adjusted for patient’s age, gender and indication.Regression analysis was used to determine the association of training ADRs onthe detection of advanced neoplasia (� 1 cm, high grade dysplasia, villousstructure or CRC) during the remaining fellowship. Results: A total of 3252colonoscopies were performed by 7 fellows. The number of proceduresperformed per fellow ranged from 389 to 612. After exclusion, data of 2050procedures could be used for ADR analysis. In this cohort (mean age 59 yrsSD � 15, 48% male) the overall ADR was 23% whereas individual ADRs rangedfrom 15% to 32%. Compared with the highest level detector, the odds fordetecting � 1 adenoma for individual fellows ranged from 0.73 to 0.29. None ofthe 7 individual ADRs increased significantly after the first 140 procedures.Fellows with a training ADR �20% (n�4) detected significantly more advancedneoplasms during the remaining course of their fellowship compared to fellowswith a training ADR �20% (OR 1.88 95% CI 1.33-2.66). Conclusion: Thedetection of adenomas varies greatly between fellows. We observed no increasein ADR levels after the first 140 colonoscopies, suggesting that adequatewithdrawal technique is specifically learned during this novice-period. Thesignificance of this finding is underlined by the observation that fellows with anADR �20%, during this period, go on to detect more advanced neoplasmsduring the remaining course of their fellowship. In an effort to improve detectionperformance it seems therefore advisable to intensify training during thebeginning of a fellowship.
855Racial Differences in Outcome of Colonoscopy in Young Adults(<50 Years): Sub-Analysis From Colonoscopy Outcome inMinority Population (Comp) RegistryKinesh Changela, Shashideep Singhal, Manhal Olaywi*,Deepanshu Jain, Devin Lane, Sushil Duddempudi, Mojdeh Momeni,Mahesh Krishnaiah, Sury AnandGastorenterology, The Brooklyn Hospital Center, Brooklyn, NYBackground: Identification and removal of colonic adenomas is the corner stoneof our colorectal cancer prevention program. There has been a concern of earlierdevelopment of colonic adenomas in adults � 50 years of age especially in highrisk ethnic groups. There are very limited studies done to determine the yield ofcolonoscopy in young minority adults. Methods: The study cohort was selectedfrom from COMP registry at our teaching urban community hospital. Patientswith age � 50 years were included in the study. The demographic, endoscopicfindings and pathological reports study group were analyzed to determine theyield colonic adenomas during colonoscopy. Results: Out of 4015 colonoscopies
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www.giejournal.org Volume 77, No. 5S : 2013 GASTROINTESTINAL ENDOSCOPY AB174
