Faculty Bibliography

Colorectal cancer remains the second-leading cause of cancer death in the United States-but efforts over the past two decades have resulted in tremendous progress in understanding the biology of how this disease develops, increasing screening rates, and decreasing incidence and mortality in those age 50 years and older. The drivers of this movement have been outstanding leadership, innovation, and collaboration. As we move forward to tackle issues such as the increasing incidence of this disease in younger adults, the need to address disparities in care and outcomes, and our shared goal to reach 80% screening rates, it's important to understand and appreciate the story of our past success in order to advance our future efforts.

Background: Inadequate bowel preparation is estimated to occur in as many as 25% of colonoscopies, and can lead to adverse outcomes including prolonged examination times, missed lesions of up to 42-48% and an increased rate of complications. Adequacy of bowel preparation is recognized as an important metric when assessing quality of colonoscopy. National guidelines state that when bowel preparation for colonoscopy is considered inadequate, repeat examination should occur within one year. Our aim was to evaluate the timing of recommendation for repeat colonoscopy when inadequate bowel prep was reported using GIQuIC, the GI Quality Improvement Consortium, a large, national clinical gastroenterology data registry. Methods: We performed an analysis of all screening and surveillance colonoscopies among adults age 18-89 reported in GIQuIC during the period from 2010-2017. A standardized data collection tool captured information about bowel preparation quality. GIQuIC prospectively collects patient and procedural information on colonoscopies from over 450 sites across the US. We examined data on colonoscopy where bowel preparation was deemed to be inadequate and then evaluated recommendations for interval follow up. Results: A total of 3,773,519 colonoscopies were analyzed for this study, recorded in the registry between 2010-2017. Inadequate bowel preparation was reported in 201,804 (5.3%). Of these, 127,854 were found on examinations where the indication was screening and 74,220 where the indication was surveillance. The recommendation for follow up interval to be less than one year was made in 25.1% when all examinations were assessed. The rate was 25.6% when only looking at screening exams and 24.2% for surveillance exams. (Table 1) When assessed per physician, data was available for 3582 physicians, and mean performance to recommend follow up in less than one year when poor preparation was noted was 34.2%; median performance was 27.3%. When follow up other than within 1 year was recommended, the recommendation was for none (4.9%), 2 years (5.2%), 3 years (26.7%), 5 years (37.9%), 10 years (11.2%), and other (14.2%) (Table 2) Conclusions: The recommendation for repeat screening or surveillance colonoscopy in less than one year when the index colonoscopy has an inadequate bowel prep is a quality measure in gastroenterology. This study, using data from GIQuIC, demonstrates poor compliance with these guideline recommendations. Given the consequences of poor bowel prep in colonoscopy, including possible missed lesions, repeat examination is recommended soon after the initial procedure, and certainly within one year. Adherence to these guidelines as demonstrated here is low, and this suggests the need to understand factors behind this low adherence, as well as increased education and increased adherence to colorectal cancer screening and surveillance guidelines

Introduction: Colonoscopy is the most commonly used test for colorectal cancer screening in the US, but patients often find the oral bowel preparation difficult, inconvenient, or intolerable. Suboptimal bowel prep occurs in 20-24% of colonoscopies, leading to inadequate examinations that necessitate additional procedures. Colonic irrigation is an FDA-approved method of colon cleansing using a warm water lavage, but few studies have evaluated it as preparation for colonoscopy. The purpose of this study is to evaluate colonic irrigation as an alternative to oral bowel prep in patients undergoing screening/ surveillance colonoscopy. Methods: We conducted a single-center, single-arm feasibility study using the Hydro-San Plus system. Patients followed a low-residue diet and took 2 doses of polyethylene glycol the day before the procedure. Colonoscopy was performed immediately following colonic irrigation. Boston Bowel Prep Scale (BBPS) and adverse events were recorded. A telephone questionnaire was administered within 7 days of the procedure. Results: Of the 21 patients enrolled, 48% had at a medical risk factor for poor prep (Table 1). Eighteen patients completed irrigation, of whom 12 (67%) had an adequate bowel prep, defined as BBPS>1 in all segments (Table 2). Two irrigations were not completed due to minor adverse events (discomfort from speculum insertion and rectal abrasion) and 1 was aborted for mechanical repair. There were no major adverse events. Patients with no risk factors for poor prep were 4 times more likely to have an adequate prep, although this was not statistically significant (P=0.14). Half of the patients felt that irrigation was easy (47%) and comfortable (53%), while most felt it was tolerable (71%) and convenient (82%). Among participants who had previous a colonoscopy with oral prep, the majority felt that irrigation was easier (85%), more tolerable (77%), and more convenient (85%) than oral prep. 82% of respondents said they would ask for irrigation again and only 12% said they would refuse if it were offered. Conclusion: Colonic irrigation is a safe and moderately efficacious alternative to oral bowel prep for screening/surveillance colonoscopy. A more potent oral pre-prep, especially for patients with risk factors for poor prep, may improve efficacy. Importantly, patient satisfaction with colonic irrigation appears to be higher than with oral bowel prep. (Table Presented)

Introduction: Colorectal Cancer (CRC) prevention has resulted in the implementation of screening programs worldwide in hopes to reduce the number of CRC incidences. Despite these programs' best efforts, interval cancers continue to arise from lesions missed during standard procedures. Interval cancers have been found to occur more frequently in the right colon, often developing from flat and sessile lesions. These lesions have had reported miss rates of up to 60% compared to reported miss rates of 20%-30% for polyps and adenomas. The innovative G-EYE endoscope (SMART Medical Systems Ltd, Ra'anana, Israel) includes an integral, reusable balloon that is permanently installed on the distal end of a standard endoscope. Upon withdrawal, inflation of the GEYE balloon to a partial pressure results in the centralization of endoscope optics, reduction in bowel slippage, and flattening of colon topography. The enhanced visualization provided by the G-EYE balloon can result in an increase detection of lesions. Aims & Methods: In this prospective, randomized, multicentre study, patients (age >50) referred to colonoscopy as a result of screening, surveillance, positive FOBT or change in bowel habits were randomized to either standard colonoscopy (SC) or G-EYE colonoscopy. Detected lesions were removed and sent for pathology. We compared the detection rates of G-EYE colonoscopy with that of SC in the right colon. Results: 1000 patients were enrolled in the study, of which 498 underwent SC and 502 underwent G-EYE colonoscopy. Baseline parameters were similar in both groups. The right colon was defined as the cecum, ascending colon, and hepatic flexure. Results are presented in Table 1. In addition, the G-EYEincreased the detection of both advanced and large-size adenomas by 40% in the right colon Conclusion: Our study shows that G-EYE colonoscopy has the potential to significantly improve the quality of CRC screening through improved adenoma detection rates. Special attention should be given to the significant increase in right-sided flat lesions and sessile serrated adenomas by the G-EYE, as these lesions are strongly attributed to CRC. Through increased detection of these right-sided lesions, G-EYE colonoscopy can impact the quality of CRC screening by reducing miss rates and consequently reduce the incidents of interval cancers. (Table Presented)

BACKGROUND & AIMS: The incidence and predictors of non-gastrointestinal (GI) adverse events (AEs) following colonoscopy are not well understood. We studied the effects of anti-thrombotic agents, cardiopulmonary comorbidities, and age on risk of non-GI AEs after colonoscopy. METHODS: We performed a retrospective longitudinal analysis to assess the diagnosis, procedure, and prescription drug codes in a United States commercial claims database (March 2010 - March 2012). Data from patients at increased risk (n=82,025; defined as patients with pulmonary comorbidities or cardiovascular disease requiring anti-thrombotic medications) were compared with data from 398,663 average-risk patients. In a 1:1 matched analysis, 51,932 patients at increased risk, examined by colonoscopy, were compared with 51,932 matched (based on age, sex, and comorbidities) patients at increased risk who did not undergo colonoscopy. We tracked cardiac, pulmonary, and neurovascular events 1-30 days after colonoscopy. RESULTS: Thirty days after outpatient colonoscopy, non-GI AEs were significantly higher in patients taking anti-thrombotic medications (7.3%; odds ratio [OR], 10.75; 95% CI, 10.13-11.42) or those with pulmonary comorbidities (1.8%; OR, 2.44; 95% CI, 2.27-2.62) vs average-risk patients (0.7%), and in patients 60-69 yrs old (OR, 2.21; 95% CI, 2.01-2.42) or 70 yrs or older (OR, 6.45; 95% CI, 5.89-7.06), compared to patients younger than 50 yrs. The 30-day incidence of non-GI AEs in patients at increased risk who underwent colonoscopy was also significantly higher than in matched patients at increased risk who did not undergo colonoscopy, in the anticoagulant group (OR, 2.31; 95% CI, 2.01-2.65) and in the chronic obstructive pulmonary disease group (OR, 1.33; 95% CI, 1.13-1.56). CONCLUSIONS: Increased number of comorbidities and older age (older than 60 years) are associated with increased risk of non-GI AEs after colonoscopy. These findings indicate the importance of determining comorbid risk and evaluating anti-thrombotic management prior to colonoscopy.

AIMS: Colorectal cancer (CRC) prevention by colonoscopy is often attributed to the early detection of adenomas, but lesions that go undetected can result in interval cancers. This is largely due to lesions that are hidden behind colonic folds that obscure endoscopic optics. The G-EYETM endoscope (Smart Medical Systems Ltd., Ra'anana, Israel) combines a forward-viewing endoscope with a permanently integrated balloon at the distal end, that when inflated flattens haustral folds, centralizes endoscope optics, and reduces bowel slippage. This provides improved visualization and increased detection of adenomas. Our study compares the adenoma detection rate of G-EYETM colonoscopy with that of Standard Colonoscopy.
METHOD(S): Patients (age >50) referred to colonoscopy for screening, surveillance, following positive FOBT, or due to change in bowel habits were randomized to G-EYETM colonoscopy or SC. Detected lesions were removed and sent for pathology. Adenoma detection rates were calculated.
RESULT(S): Nine hundred patients were enrolled in the study, of which 445 subjects were randomized to SC and 455 subjects were randomized to G-EYETM colonoscopy. Baseline parameters were similar in both groups. Results are presented in Table 1.
CONCLUSION(S): Our study shows that the G-EYETM endoscope has the potential to enhance the quality of CRC screening through increased adenoma detection. The G-EYETM detected not only small and diminutive adenomas, but a substantially higher number of advanced and large adenomas as well. Furthermore, increased detection by G-EYETM colonoscopy of sessile serrated adenomas, lesions strongly associated with CRC, can further reduce the incidents of interval cancers. (Table Presented)