Digestive Diseases and Sciences

, Volume 57, Issue 3, pp 764–770 | Cite as

Proficiency in the Diagnosis of Nonpolypoid Colorectal Neoplasm Yields High Adenoma Detection Rates

  • Tonya Kaltenbach
  • Sarah K. McGill
  • Venkat Kalidindi
  • Shai Friedland
  • Roy Soetikno
Original Article

Abstract

Background and Aims

Current efforts to prevent colorectal cancer focus on the detection and removal of neoplasms. Nonpolypoid colorectal neoplasms (NP-CRN) have a subtle appearance that can be difficult to recognize during colonoscopy. Endoscopists must first be familiar with the patterns of NP-CRN in order to detect and diagnose them. We studied the adenoma detection rates of endoscopists who had trained to detect NP-CRN, versus endoscopists who had not.

Materials and Methods

Design: Retrospective Nested Case Control Study. Setting: Outpatient Screening Colonoscopy. Participants: Adult Veterans. Intervention: Proficiency in the features and diagnosis of NP-CRN. Main Outcomes Measurements: Adenoma detection.

Results

In total, 462 patients had screening colonoscopies—267 by colonoscopists who had trained in the features and diagnosis of NP-CRN. Patient characteristics were similar between groups—the majority were men with a mean age of 62 ± 6 years. Neoplasia was more prevalent (45.7 vs. 34.9%; p = 0.02) in patients evaluated by the trained compared to the conventionally trained group. Trained colonoscopists had a higher adenoma detection rate (0.76 vs. 0.54 adenomas per patient, p < 0.001); removed a higher proportion of neoplasia (77 vs. 35%, p < 0.001); and more frequently diagnosed NP-CRN lesions (OR 2.98, 95% CI: 1.46–6.08) compared to colonoscopists without supplemental training.

Conclusions

Endoscopists who are proficient in the detection of NP-CRN had significantly higher adenoma detection rates—of both polypoid and flat adenomas—compared to endoscopists without training, and were more specific in resection of adenomatous over hyperplastic lesions.

Keywords

Colonoscopy Endoscopy lower GI tract Adenoma detection Nonpolypoid Polyp Neoplasm Cancer 

Abbreviation

NP-CRN

Nonpolypoid colorectal neoplasm

References

  1. 1.
    Soetikno RM, Kaltenbach T, Rouse RV, et al. Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults. JAMA. 2008;299:1027–1035.PubMedCrossRefGoogle Scholar
  2. 2.
    Lieberman DA, Weiss DG, Bond JH, Ahnen DJ, Garewal H, Chejfec G. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs cooperative study group 380. N Engl J Med. 2000;343:162–168.PubMedCrossRefGoogle Scholar
  3. 3.
    Neugut AI, Lebwohl B. Colonoscopy versus sigmoidoscopy screening: getting it right. JAMA. 2010;304:461–462.PubMedCrossRefGoogle Scholar
  4. 4.
    Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362:1795–1803.PubMedCrossRefGoogle Scholar
  5. 5.
    Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2006;101:873–885.PubMedGoogle Scholar
  6. 6.
    Rex DK. Maximizing detection of adenomas and cancers during colonoscopy. Am J Gastroenterol. 2006;101:2866–2877.PubMedCrossRefGoogle Scholar
  7. 7.
    Inadomi J. Editorial: interval cancers after colonoscopy: the importance of training. Am J Gastroenterol. 2010;105:2597–2598.PubMedCrossRefGoogle Scholar
  8. 8.
    Lieberman D. Nonpolypoid colorectal neoplasia in the United States: the parachute is open. JAMA. 2008;299:1068–1069.PubMedCrossRefGoogle Scholar
  9. 9.
    Kudo S, Kashida H, Nakajima T, Tamura S, Nakajo K. Endoscopic diagnosis and treatment of early colorectal cancer. World J Surg. 1997;21:694–701.PubMedCrossRefGoogle Scholar
  10. 10.
    Soetikno R, Friedland S, Kaltenbach T, Chayama K, Tanaka S. Nonpolypoid (flat and depressed) colorectal neoplasms. Gastroenterology 2006;130:566–576; quiz 588–589.Google Scholar
  11. 11.
    McCarney R, Warner J, Iliffe S, van Haselen R, Griffin M, Fisher P. The Hawthorne effect: a randomised, controlled trial. BMC Med Res Methodol. 2007;7:30.PubMedCrossRefGoogle Scholar
  12. 12.
    Kudo S. Early colorectal cancer. Igaku-Shoin; 1996.Google Scholar
  13. 13.
    Fujii T, Shimoda T. National cancer center hospital atlas of magnifying colonoscopic diagnosis. Tokyo: Igaku-Shoin Ltd.; 2004.Google Scholar
  14. 14.
    Ellis G. Veterans Affairs Palo Alto Hospital. High-Definition Endoscopy and Sharing the Knowledge in HD: Apple Inc., 2007.Google Scholar
  15. 15.
    Soetikno RM, Fujii T, Friedland S, Barro J, Matsui S, Rouse RV. Diagnosis of flat and depressed colorectal neoplasms—an educational DVD. Chicago, IL: American Society Gastrointestinal Endoscopy; 2004.Google Scholar
  16. 16.
    Hamilton S, Altonen L. Tumours of the digestive system. World Health Organization Classification of Tumours. International Agency for Research on Cancer, 2000.Google Scholar
  17. 17.
    Yasutomi M, Baba S, Hojo K, et al. Japanese classification of colorectal carcinoma. Tokyo: Kanehara & Co., LTD.; 1997.Google Scholar
  18. 18.
    Church JM, Muto T, Appau K. Flat lesions of the colorectal mucosa: differences in recognition between Japanese and American endoscopists. Dis Colon Rectum. 2004;47:1462–1466.PubMedCrossRefGoogle Scholar
  19. 19.
    Ignjatovic A, East JE, Suzuki N, Vance M, Guenther T, Saunders BP. Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect and Discard; DISCARD trial): a prospective cohort study. Lancet Oncol. 2009;10:1171–1178.PubMedCrossRefGoogle Scholar
  20. 20.
    Hassan C, Pickhardt PJ, Rex DK. A resect and discard strategy would improve cost-effectiveness of colorectal cancer screening. Clin Gastroenterol Hepatol. 2010;8:865–869, 869 e1-3.Google Scholar
  21. 21.
    Tanaka S, Kaltenbach T, Chayama K, Soetikno R. High-magnification colonoscopy (with videos). Gastrointest Endosc. 2006;64:604–613.PubMedCrossRefGoogle Scholar
  22. 22.
    Kaltenbach T, Friedland S, Maheshwari A, et al. Short- and long-term outcomes of standardized EMR of nonpolypoid (flat and depressed) colorectal lesions > or = 1 cm (with video). Gastrointest Endosc. 2007;65:857–865.PubMedCrossRefGoogle Scholar
  23. 23.
    Fu KI, Sano Y, Kato S, et al. Chromoendoscopy using indigo carmine dye spraying with magnifying observation is the most reliable method for differential diagnosis between non-neoplastic and neoplastic colorectal lesions: a prospective study. Endoscopy. 2004;36:1089–1093.PubMedCrossRefGoogle Scholar
  24. 24.
    Eisen GM, Kim CY, Fleischer DE, et al. High-resolution chromoendoscopy for classifying colonic polyps: a multicenter study. Gastrointest Endosc. 2002;55:687–694.PubMedCrossRefGoogle Scholar
  25. 25.
    Pohl J, Schneider A, Vogell H, Mayer G, Kaiser G, Ell C. Pancolonic chromoendoscopy with indigo carmine versus standard colonoscopy for detection of neoplastic lesions: a randomised two-centre trial. Gut. 2011;60:485–490.PubMedCrossRefGoogle Scholar
  26. 26.
    Kahi CJ, Anderson JC, Waxman I, et al. High-definition chromocolonoscopy vs. high-definition white light colonoscopy for average-risk colorectal cancer screening. Am J Gastroenterol. 2010;105:1301–1307.PubMedCrossRefGoogle Scholar
  27. 27.
    Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med. 2006;355:2533–2541.PubMedCrossRefGoogle Scholar
  28. 28.
    Lee RH, Tang RS, Muthusamy VR, et al. Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos). Gastrointest Endosc. 2011;74:128–134.PubMedCrossRefGoogle Scholar
  29. 29.
    Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rates. Gastrointest Endosc. 2000;51:33–36.PubMedCrossRefGoogle Scholar
  30. 30.
    Overholt BF, Brooks-Belli L, Grace M, et al. Withdrawal times and associated factors in colonoscopy: a quality assurance multicenter assessment. J Clin Gastroenterol. 2010;44:e80–e86.PubMedCrossRefGoogle Scholar
  31. 31.
    Sanduleanu S, Rondagh EJ, Masclee AA. Development of expertise in the detection and classification of non-polypoid colorectal neoplasia: experience-based data at an academic GI unit. Gastrointest Endosc Clin N Am. 2010;20:449–460.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC (Outside the USA) 2011

Authors and Affiliations

  • Tonya Kaltenbach
    • 1
  • Sarah K. McGill
    • 1
  • Venkat Kalidindi
    • 1
  • Shai Friedland
    • 1
  • Roy Soetikno
    • 1
  1. 1.Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Division of GastroenterologyStanford University School of MedicinePalo AltoUSA

Personalised recommendations