Dear Colleague

Why asking when using google would be faster?

Am J Gastroenterol. 2014 Mar;109(3):417-26. doi: 10.1038/ajg.2013.442. Epub 2014 Jan 7.

Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry.

Butterly L1, Robinson CM2, Anderson JC3, Weiss JE2, Goodrich M2, Onega TL4, Amos CI2, Beach ML5.

Author information

Abstract

OBJECTIVES:

Detection and removal of adenomas and clinically significant serrated polyps (CSSPs) is critical to the effectiveness of colonoscopy in preventing colorectal cancer. Although longer withdrawal time has been found to increase polyp detection, this association and the use of withdrawal time as a quality indicator remains controversial. Few studies have reported on withdrawal time and serrated polyp detection. Using data from the New Hampshire Colonoscopy Registry, we examined how an endoscopist's withdrawal time in normal colonoscopies affects adenoma and serrated polyp detection.

METHODS:

We analyzed 7,996 colonoscopies performed in 7,972 patients between 2009 and 2011 by 42 endoscopists at 14 hospitals, ambulatory surgery centers, and community practices. CSSPs were defined as sessile serrated polyps and hyperplastic polyps proximal to the sigmoid. Adenoma and CSSP detection rates were calculated based on median endoscopist withdrawal time in normal exams. Regression models were used to estimate the association of increased normal withdrawal time and polyp, adenoma, and CSSP detection.

RESULTS:

Polyp and adenoma detection rates were highest among endoscopists with 9 min median normal withdrawal time, and detection of CSSPs reached its highest levels at 8-9 min. Incident rate ratios for adenoma and CSSP detection increased with each minute of normal withdrawal time above 6 min, with maximum benefit at 9 min for adenomas (1.50, 95% confidence interval (CI) (1.21, 1.85)) and CSSPs (1.77, 95% CI (1.15, 2.72)). When modeling was used to set the minimum withdrawal time at 9 min, we predicted that adenomas and CSSPs would be detected in 302 (3.8%) and 191 (2.4%) more patients. The increase in detection was most striking for the CSSPs, with nearly a 30% relative increase.

CONCLUSIONS:

A withdrawal time of 9 min resulted in a statistically significant increase in adenoma and serrated polyp detection. Colonoscopy quality may improve with a median normal withdrawal time benchmark of 9 min.

Took me 30secs, sorry to be a little bit harsh. But for a surgeon who claims to have experience in Gastrointestinal Surgical Oncology, in my opinion, the question is close to the limit. However, now you have some up-to-date data, 6mins have been considered the minimum for at least a decade.

Regards, Bruno

And btw. I would be interested in the annual salary of endoscopist who claim to face 'the economic pressure'. What do we gain per annum: 100k, 200k, 500k? Where is our own ethical limit?

Time examining the colonic mucosa in detail is both a surrogate for quality of examination as well as a measure of awareness of how polyps can be easily missed. There is evidence that longer examination times reduce significantly subsequent interval cancer rates and early evidence that implementing a quality improvement programme for colonoscopy which includes a longer withdrawal time will improve adenoma detection.

So far just an abstract but encouraging work from Rajasekhar, Rees and Rutter et al

A multi-centre pragmatic study of an educational intervention to improve adenoma detection at colonoscopy. PT Rajasekhar, CJ Rees, MD Rutter, BP Saunders, MG Bramble, APS Hungin, DW Wilson, JE East. European Gastroenterology Week 2013.

Dear Colleague,

Classical and yet unsolved issue. How do you find a pressure of interval cancer?

Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.

Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL.

N Engl J Med. 2006 Dec 14;355(24):2533-41.

BACKGROUND: Colonoscopy is commonly used to screen for neoplasia. To assess the

performance of screening colonoscopy in everyday practice, we conducted a study

of the rates of detection of adenomas and the amount of time taken to withdraw

the colonoscope among endoscopists in a large community-based practice.

METHODS: During a 15-month period, 12 experienced gastroenterologists performed

7882 colonoscopies, of which 2053 were screening examinations in subjects who had

not previously undergone colonoscopy. We recorded the numbers, sizes, and

histologic features of the neoplastic lesions detected during screening, as well

as the duration of insertion and of withdrawal of the colonoscope during the

procedure. We compared rates of detection of neoplastic lesions among

gastroenterologists who had mean colonoscopic withdrawal times of less than 6

minutes with the rates of those who had mean withdrawal times of 6 minutes or

more. According to experts, 6 minutes is the minimum length of time to allow

adequate inspection during instrument withdrawal.

RESULTS: Neoplastic lesions (mostly adenomatous polyps) were detected in 23.5% of

screened subjects. There were large differences among gastroenterologists in the

rates of detection of adenomas (range of the mean number of lesions per subject

screened, 0.10 to 1.05; range of the percentage of subjects with adenomas, 9.4 to

32.7%) and in their times of withdrawal of the colonoscope from the cecum to the

anus (range, 3.1 to 16.8 minutes for procedures during which no polyps were

removed). As compared with colonoscopists with mean withdrawal times of less than

6 minutes, those with mean withdrawal times of 6 minutes or more had higher rates

of detection of any neoplasia (28.3% vs. 11.8%, P

Dear Collegue,

according to my own opinion, the withdrawel time is important for beginners and for endoscopists with low experience. I performed nearly 60.000 colonoscopies, my ADR is 30% and I doubt, that a withdrawal time over 6 minutes leads to a hiegher detection rate in my praxctice.

Hi All,

The detection of polyps and reduction in interval colorectal cancer would sensibly be correlated with quality of preparation, documenting caecal/ ileal intubation with photography or biopsy, ensuring an adequate time to inspect the mucosal surface, and unique features of each bowel e.g. Mobility, propensity to loop etc. I am unsure if there have been any studies to show that an enforced prolongation of the withdrawal time correlates with a higher detection rate for an individual colonoscopist.? I will have to take a look at Rajasekhar et als paper.

I elect to measure total time of colonoscopy, and polyp ( c.f. adenoma) detection rates as part of a quality assurance measure.

Regards

Time without competence is useless. Competence without enough time is suboptimal.

Careful exploration between ascending colon's folds takes time, as does insufflation/partial sucking of a perfectly prepared colon.

I have performed only 20,000 colonoscopy, take a mean of 10 minutes for withdrawal (non counting polypectomy) and find also 30% flat polyps.

Economic pressure can't be an argument, even in France where colonoscopy fees are under 200 E.