Abstract
Objectives: The aim of this study was to compare a standard versus segmental withdrawal during screening colonoscopy and its effect on the adenoma detection rate (ADR).
Methods: We performed a single-center clinical trial of average-risk patients 50 years of age and older undergoing screening colonoscopy. Patients were randomized into four groups: a standard withdrawal of at least 6 or 8 minutes and a segmental withdrawal, in which ≥3 or ≥4 minutes were dedicated to the right side of the colon, with a minimum withdrawal time of at least 6 or 8 minutes, respectively.
Results: There were 311 patients in the study. There was no difference in ADR between the standard and segmental groups (relative ratio [RR] 0.91, P = 0.50), even after stratifying for right-sided adenomas. During standard withdrawal, an increased continuous withdrawal time was associated with a higher ADR (RR 1.08, P <0.001) and total adenomas per patient (RR 1.12, P < 0.001). A binary analysis of ≥8 minutes or <8 minutes withdrawal was associated with an increased adenomas per colonoscopy (RR 1.86, P = 0.04). These differences were not observed in the segmental group.
Conclusions: Overall, there was no benefit from a segmental withdrawal protocol on ADR, but this may have been the result of the inherent limitations in the study design. After sensitivity analysis, a segmental withdrawal protocol led to an improvement in the detection of adenomas per colonoscopy and polyps per colonoscopy. A larger sample size is needed to confirm these findings.
This content is limited to qualifying members.
If you have an existing account please login now to access this article or view purchase options.
Create a free account, then purchase this article to download or access it online for 24 hours.
Create a free account, then purchase a subscription to get complete access to all articles for a full year.
References
1. American Cancer Society. Key statistics for colorectal cancer. https://www.cancer.org/cancer/colon-rectal-cancer/about/key-statistics.html. Published 2017.
Accessed October 2, 2017.
2. US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for colorectal cancer: US Preventive Services Task Force Recommendation Statement. JAMA 2016;315:2564–2575.
3. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012;143:844–857.
4. Rex DK, Boland CR, Dominitz JA, et al. Colorectal cancer screening: recommendations for physicians and patients from the U.S. Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2017;112:1016–1030.
5. Müller AD, Sonnenberg A. Prevention of colorectal cancer by flexible endoscopy and polypectomy. A case-control study of 32,702 veterans. Ann Intern Med 1995;123:904–910.
6. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med 1993;329:1977–1981.
7. Thiis-Evensen E, Hoff GS, Sauar J, et al. Population-based surveillance by colonoscopy: effect on the incidence of colorectal cancer. Telemark Polyp Study I. Scand J Gastroenterol 1999;34:414–420.
8. Zhao S, Wang S, Pan P, et al. Magnitude, risk factors, and factors associated with adenoma miss rate of tandem colonoscopy: a systematic review and meta-analysis. Gastroenterology 2019;156:1661–1674.e11.
9. Baxter NN, Warren JL, Barrett MJ, et al. Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty. J Clin Oncol 2012;30:2664–2669.
10. Brenner H, Hoffmeister M, Arndt V, et al. Protection from right- and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst 2010;102:89–95.
11. Corley DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014;370:1298–1306.
12. Kaminski MF, Wieszczy P, Rupinski M, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology 2017;153:98–105.
13. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Am J Gastroenterol 2015;110:72–90.
14. Kaminski MF, Thomas-Gibson S, Bugajski M, et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative. Endoscopy 2017;49:378–3974.
15. Kumar S, Thosani N, Ladabaum U, et al. Adenoma miss rates associated with a 3-minute versus 6-minute colonoscopy withdrawal time: a prospective, randomized trial. Gastrointest Endosc 2017;85:1273–1280.
16. Shaukat A, Rector TS, Church TR, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology 2015;149:952–957.
17. Rex DK, Johnson DA, Anderson JC, et al. American College of Gastroenterology guidelines for colorectal cancer screening 2008. Am J Gastroenterol 2009;104:739–750.
18. Bressler B, Paszat LF, Chen Z, et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterology 2007;132:96–102.
19. Klein JL, Okcu M, Preisegger KH, Hammer HF. Distribution, size and shape of colorectal adenomas as determined by a colonoscopist with a high lesion detection rate: influence of age, sex and colonoscopy indication. United European Gastroenterol J 2016;4:438–448.
20. Moher D, Hopewell S, Schulz KF, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Int J Surg 2012;10:28–55.
21. Clark BT, Rustagi T, Laine L. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate. Am J Gastroenterol 2014;109:1714–1724.
22. Othman MO, Zhang D, Elhanafi S, et al. Cap-assisted colonoscopy increases detection of advanced adenomas and polyps. Am J Med Sci 2017;353:367–373.
23. Lieberman D, Moravec M, Holub J, et al. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography. Gastroenterology 2008;135:1100–1105.
24. Schoen RE, Weissfeld JL, Pinsky PF, et al. Yield of advanced adenoma and cancer based on polyp size detected at screening flexible sigmoidoscopy. Gastroenterology 2006;131:1683–1689.
25. Lee TJW, Blanks RG, Rees CJ, et al. Longer mean colonoscopy withdrawal time is associated with increased adenoma detection: evidence from the Bowel Cancer Screening Programme in England. Endoscopy 2013;45:20–26.
26. Aniwan S, Orkoonsawat P, Viriyautsahakul V, et al. The secondary quality indicator to improve prediction of adenoma miss rate apart from adenoma detection rate. Am J Gastroenterol 2016;111:723–729.
27. Brand EC, Wallace MB. Strategies to increase adenoma detection rates. Curr Treat Options Gastroenterol 2017;15:184–212.
28. Castaneda D, Popov VB, Verheyen E, et al. New technologies improve adenoma detection rate, adenoma miss rate, and polyp detection rate: a systematic review and meta-analysis. Gastrointest Endosc 2018;88:209–222.e11.
29. Chaptini L, Laine L. Can I improve my adenoma detection rate? J Clin Gastroenterol 2015;49:270–281.
30. Facciorusso A, Triantafyllou K, Murad MH, et al. Compared abilities of endoscopic techniques to increase colon adenoma detection rates: a network meta-analysis. Clin Gastroenterol Hepatol 2019;17:2439–2454.e25.
31. Repici A, Wallace MB, East JE, et al. Efficacy of per-oral methylene blue
formulation for screening colonoscopy. Gastroenterology 2019;156:2198–2207.e1.
32. Shirin H, Shpak B, Epshtein J, et al. G-EYE colonoscopy is superior to standard colonoscopy for increasing adenoma detection rate: an international randomized controlled trial (with videos). Gastrointest Endosc 2019;89:545–553.
33. Rex DK, Repici A, Gross SA, et al. High-definition colonoscopy versus Endocuff versus EndoRings versus full-spectrum endoscopy for adenoma detection at colonoscopy: a multicenter randomized trial. Gastrointest
Endosc 2018;88:335–344.e2.
34. Cohen J, Grunwald D, Grossberg LB, et al. The effect of right colon retroflexion on adenoma detection: a systematic review and meta-analysis. J Clin Gastroenterol 2017;51:818–824.
35. Desai M, Bilal M, Hamade N, et al. Increasing adenoma detection rates in the right side of the colon comparing retroflexion with a second forward view: a systematic review. Gastrointest Endosc 2019;89:453–459.e3.
36. Kushnir VM, Oh YS, Hollander T, et al. Impact of retroflexion vs. second forward view examination of the right colon on adenoma detection: a comparison study. Am J Gastroenterol 2015;110:415–422.
37. 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.
38. Avalos DJ, Zuckerman MJ, Dwivedi A, Dodoo C, Satiya J, Castro FJ. Differences in prevalence of large polyps between Hispanic Americans from Mexican- and non-Mexican-predominant states. Dig Dis Sci 2019;64:232–240.
39. Jung Y, Joo Y-E, Kim HG, et al. Relationship between the endoscopic withdrawal time and adenoma/polyp detection rate in individual colonic segments: a KASID multicenter study. Gastrointest Endosc 2019;89:523–530.
