Colonoscopy may be weak link in organised colorectal cancer screening programme with faecal immunochemical test

Objective To evaluate the quality of colonoscopies performed after a positive faecal immunochemical test in the French colorectal cancer screening programme. Methods Retrospective analysis of all colonoscopies performed between 2015 and 2019 after a positive quantitative faecal immunochemical test in the population-based colorectal cancer screening programme organised in Alsace, part of the French programme. The following indicators were evaluated: annual colonoscopy volume, caecal intubation rate, adenoma detection rate, proximal serrated lesion detection rate and proportion of patients referred directly to surgery for benign polyp management. Endoscopists who performed <30 faecal immunochemical test positive colonoscopies were non-assessable. Results Overall, 13,455 faecal immunochemical test-positive colonoscopies performed by 116 community gastroenterologists were included, 13,067 of them by 80 assessable endoscopists. The overall caecal intubation, adenoma detection and proximal serrated lesion detection rates were 97.9%, 57.6% and 7.6%, respectively. They were <90%, <45% and <1% for 1.3%, 12.5% and 6.3% of the endoscopists, respectively. Overall, 1028 (7.9%) individuals were examined by 13 low-performing endoscopists and 328 (2.4%) individuals by 33 low-volume non-assessable endoscopists. Among 9133 individuals harbouring polyps, 155 (1.7%) had unwarranted surgery for a benign polyp. Overall, 1487 individuals (11.1%; 95% confidence interval 10.5–11.6) were not given the best possible chances, whereas 5545 individuals (41.2%; 95% confidence interval 40.4–42.0) were offered the best possible chances by 37 endoscopists. Conclusions At programme level, the key performance indicators evaluated largely exceeded the target standards. At individual level, at least one in nine individuals was not given the best possible chances during faecal immunochemical test-positive colonoscopies by a minority of poor-performing and/or low-volume endoscopists.

Of Open Pits and Valleys: Endoscopic Optical Diagnosis Juxtaposition of Pathologically Distinct Rectal Polyp Lesions

Optical diagnosis during colorectal cancer screening is instrumental in deciding whether or not to resect colorectal lesions, choose the appropriate technique and to properly communicate with the pathologist. The latter is even more important when it comes to serrated lesions with the latest WHO classification justifying a pathology diagnosis of a serrated lesion with a minimum criterion of characteristic findings in just one crypt, which may only be detectable when adequate sectioning and scrutinization is performed. Here, we present a unique case of comparatively small rectal lesions with typical endoscopic findings warranting a diagnosis of a serrated lesion (open pit pattern) and adenoma (valley sign).

Evaluation of the Serrated Lesions Detection Rate and Its Role as a Colonoscopy Quality Criteria

Objectives To evaluate the serrated lesion detection rate in colonoscopy at a specialized clinic and its role as quality criteria for endoscopic examination. Methods This is an observational cross-sectional study with all patients that underwent colonoscopy between October 2018 and May 2019, performed by an experimented physician. A questionnaire was answered before the examination by the patient, and another questionnaire after the colonoscopy was answered by the medical team. All polyps identified were removed and sent to the same pathologist for analysis. Results A total of 1,000 colonoscopies were evaluated. The average age of the patients was 58.9 years old, and most of them were female (60.6%). In 62.5% of the procedures, polyps were removed, obtaining a total of 1,730 polyps, of which 529 were serrated lesions, being 272 sessile serrated lesions (SSL). This data resulted in a serrated lesion detection rate (SDR) of 29.2%, and of 14% when considering only the SSL detection rate (SSLDR). The right colon had higher rates, with 22.3% SDR and 15.3% SSLDR. Screening colonoscopies also presented a higher serrated detection rate, of 20%, followed by diagnostics and follow-up exams. Smoking was the only risk factor associated with higher serrated detection rate. Conclusions The serrated lesion detection rate is higher than the ones already previously suggested and the have the higher rates were stablished in the right colon and on screening exams.

Importance of sessile serrated lesions in a patient with familial adenomatous polyposis

A 28-year-old male visited hospital because his mother had been diagnosed with familial adenomatous polyposis (FAP) with a pathological variant of the APC gene. Total colonoscopy showed that he has more than 100 polyps distributed throughout the colorectum, and the APC gene variant was also detected. After he was diagnosed with FAP, he received information that surgery was currently the only way to prevent the development of colorectal cancer. However, he firmly declined to undergo surgical procedures and decided to have strict follow-up with frequent endoscopic polypectomy to prevent the development of colorectal cancer. At the first endoscopy, polypectomy was performed on 52 polyps. Histological analysis of the dissected polyps showed that they were all adenomas, but adenocarcinoma was not detected. The second endoscopic polypectomy was performed after 4 months later. We found a pale 20 mm wide flat, elevated type polyp in the ascending colon with an adherent mucus cap that was resistant to washing off. After endoscopic mucosal resection, histological analysis revealed that there were two lesions in the polyps, a sessile serrated lesion (SSL) and SSL with dysplasia. SSL is a high-risk lesion for colorectal cancer, but it was reported to be rare in patients with FAP, and the existence of SSL suggested another carcinogenesis pathway in patients with FAP in addition to the adenoma-carcinoma sequence. Our report may be significant not only in consideration of the pathogenesis of FAP but also useful to raise awareness of SSL for clinicians who perform endoscopic polypectomy to prevent the development of colorectal cancer in patients with FAP.

Higher adenoma detection, sessile serrated lesion detection and proximal sessile serrated lesion detection are associated with physician specialty and performance on Direct Observation of Procedural Skills

ObjectiveAdenoma detection rate (ADR) and sessile serrated lesion detection rate (SSLDR) vary among physicians. We sought to determine physician characteristics associated with ADR and SSLDR in a population-based colon screening programme.DesignRetrospective study of 50–74 year olds with positive faecal immunochemical test and colonoscopy from 15/11/2013 to 31/12/2018. Physician characteristics included: gender, specialty, year and country of medical school graduation, colonoscopy volume and Direct Observation of Procedural Skills (DOPS) performance. Multivariable regression was performed on the following dependent variables: ADR, advanced ADR, proximal and distal ADR, SSLDR, proximal and distal SSLDR.Results104 326 colonoscopies were performed by 261 physicians. A higher ADR was associated with gastroenterology (OR for general surgery 0.87, 95% CI 0.80 to 0.95; OR for general/family/internal medicine 0.70, 95% CI 0.55 to 0.88), fewer years since graduation (OR for graduation >2000 10.48, 95% CI 1.30 to 1.69 compared with <1980) and DOPS performance (OR for lowest DOPS performance 0.64, 95% CI 0.50 to 0.82 compared with highest DOPS performance). SSLDR was associated with gastroenterology (OR for general surgery 0.89, 95%, CI 0.81 to 0.97; OR for general/family/internal medicine 0.67, 95% CI 0.49 to 0.92) and DOPS performance (OR for lowest DOPS performance 0.71, 95% CI 0.51 to 0.99 compared with highest DOPS performance). Proximal SSLDR was associated with gastroenterology (OR for general surgery 0.90, 95% CI 0.82 to 0.99; OR for general/family/internal medicine 0.69, 95% CI 0.50 to 0.97) and DOPS performance (OR for lowest DOPS performance 0.68, 95% CI 0.47 to 0.99).ConclusionHigher ADR, SSLDR and proximal SSLDR was associated with gastroenterology specialty and improved performance on DOPS.