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788 The Impact of Detection of Serrated Polyps on Surveillance Programs in Primary Colonoscopy Screening
AGA Abstracts
ranging from $2,900 to $151,800 per life-year gained; COL_40 was inefficient. CONCLUSIONS: Once-only screening with either colonoscopy or CTC yields sizable reductions in the burden of CRC. For each test, once-only screening at age 50 has an incremental costeffectiveness ratio that is lower than many well-accepted medical interventions. While onceonly colonoscopy at age 45 is the most effective of the strategies considered, with an incremental cost-effectiveness ratio of over $150,000 per life-year gained, it may be prohibitively expensive. Table. Number of CRC cases, discounted life-years gained, and discounted lifetime costs per 1000 40-year-olds, and incremental cost-effectiveness ratios for no CRC screening and once-only CTC and once-only COL screening strategies.
788 The Impact of Detection of Serrated Polyps on Surveillance Programs in Primary Colonoscopy Screening Thomas R. de Wijkerslooth, Esther M. Stoop, Patrick M. Bossuyt, Kristien M. Tytgat, Jan Dees, Elisabeth M. Mathus-Vliegen, Ernst J. Kuipers, Paul Fockens, Monique van Leerdam, Evelien Dekker Background: Colonic serrated polyps (SPs) might rapidly develop into colorectal cancer (CRC). Proximal location of SPs is associated with synchronous advanced neoplasia. This might explain the occurrence of interval CRC in colonoscopy surveillance programs. It has recently been suggested to survey serrated polyps henceforth1, but this has not been incorporated in guidelines. This advice certainly will have a burden on surveillance programs but its quantity is unknown. Aim: To calculate the impact of detection of serrated polyps on surveillance programs. Methods: Asymptomatic persons (50-75 years) were consecutively invited to participate in primary colonoscopy screening. Colonoscopies were performed by experienced endoscopists (≥ 1000 colonoscopies). All detected polyps were immediately removed. In participants with adenomas, colonoscopy surveillance advice was given according to the joint guideline of ACS, US-MSTF and ACR.2 In patients with SPs, we calculated the recommended surveillance interval by using the guideline for surveillance of SPs, as recently proposed. Surveillance intervals are summarized in Table 1. We evaluated surveillance intervals using the ACS guideline only and using both guidelines. In subjects with both adenomas and SPs the shortest surveillance interval was recommended. Proximal colon location was defined as proximal to the splenic flexure. SPs included hyperplastic polyps, sessile serrated lesions and traditional serrated lesions. We included data from endoscopists who performed more than 50 study colonoscopies. Results: 1,354 subjects underwent a complete screening colonoscopy. A total of 1,635 polyps were detected, of which 707 (43%) were adenomas and 685 (42%) were SPs. In 358 patients (26%), one or more SP were detected; at least one proximal SP was detected in 167 patients (12%). One or more adenomas were detected in 392 patients (29%). No patients were identified with serrated polyposis or with 10 or more adenomas. Surveillance interval recommendations are summarized in Table 2. Surveillance interval was shortened from 5 years to 3 years in 35 patients (2.6%) and from 10 years to 3 years in 106 patients (7.8%). Conclusion: Implementing surveillance of patients with SPs would shorten surveillance intervals in 10% of screening participants. Surveillance of serrated polyps may be necessary, but will cause a significant burden on surveillance programs. 1Terdiman JP, McQuaid KR. Gastroenterology 2010;139:1444-7. 2 Levin B et al. Gastroenterology 2008;134:1570-95. Table 1: Surveillance Intervals for Patients with Adenomas and/or Serrated Polyps
*Compared to no screening — indicates default strategy †The strategy was inefficient because it was more costly and less effective (in terms of life-years gained) than another strategy 787 Higher Detection of Serrated Polyps With CAP Assisted Colonoscopy - Results From a Prospective, Randomized Controlled Trial Amit Rastogi, Neil Gupta, Deepthi S. Rao, Sachin Wani, Prateek Sharma, Ajay Bansal Background: Colonoscopy is less effective in protecting against right sided colon cancer, a significant proportion of which arise from the serrated pathway of carcinogenesis. Serrated polyps that include proximal (proximal to splenic flexure) or large (≥1cm) hyperplastic polyps (HP), sessile serrated adenoma (SSA) and traditional serrated adenoma (TSA) are the precursor lesions for these cancers. Hence, their detection rates assume significance akin to adenoma detection rates and have been reported to be variable and operator dependant. Cap assisted colonoscopy (CAC) is a simple technique that has been shown to improve the adenoma detection rates by its ability to examine colonic mucosa on the proximal aspect of folds. Aim: To compare CAC and standard high definition white light colonoscopy (SC) for the proportion of subjects detected with, and the total number of significant serrated polyps [defined as proximal HP, largeHP, SSA or TSA). Methods: Subjects referred for screening or surveillance colonoscopy were prospectively enrolled and randomized to either SC or CAC at a tertiary referral center by 3 endoscopists using a high definition colonoscope (CF-H180AL, Olympus). For the CAC procedures, a small transparent cap (Disposable Distal Attachment, Model D-201-15004, Olympus, America) was attached to the tip of the colonoscope that protrudes for about 4 mm beyond the tip of the colonoscope. All polyps detected were documented for their size, location, morphologyand sent for histopathology, each in a separate specimen bottle. The primary outcomes of this study (adenoma detection rates) have been reported previousl . We conducted a post hoc analysis to compare the detection rates of significant serrated polyps between CAC and SC by Fisher's exact test and Wilcoxon Rank Sum test. Results: 427 patients were enrolled (7 exclusions, 210 completed study in each arm, mean age 61 years, 95% male, 75% Caucasian, 67% screening . There were no significant differences in age, gender, race, smoking history, BMI, quality of bowel prep, number of screening procedures or withdrawal times between the 2 groups. CAC detected a significantly higher proportion of subjects with significant serrated polyps compared to SC - 12.8% vs 6.7% (p =0.047). CAC also detected a higher total number of significant serrated polyps compared to SC - 40 vs 20 (p = 0.03). The different types of significant serrated polyps detected in the two arms are shown in Table. Conclusions: CAC is a simple technique that helps to examine the otherwise blind mucosal areas on the proximal aspects of colonic folds, thereby overcoming a major limitation of SC. This study shows that CAC detects a higher proportion of subjects with large HP, proximal HP, SSA and TSA and thus has the potential to offer greater protection against the serrated pathway of colorectal carcinogenesis compared to SC.
AGA Abstracts
a ≥5 serrated polyps proximal to the sigmoid colon, of which 2≥10 mm or ≥20 serrated polyps of any size that are distributed throughout the colon Table 2: Surveillance intervals of all screening participants
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ranging from $2,900 to $151,800 per life-year gained; COL_40 was inefficient. CONCLUSIONS: Once-only screening with either colonoscopy or CTC yields sizable reductions in the burden of CRC. For each test, once-only screening at age 50 has an incremental costeffectiveness ratio that is lower than many well-accepted medical interventions. While onceonly colonoscopy at age 45 is the most effective of the strategies considered, with an incremental cost-effectiveness ratio of over $150,000 per life-year gained, it may be prohibitively expensive. Table. Number of CRC cases, discounted life-years gained, and discounted lifetime costs per 1000 40-year-olds, and incremental cost-effectiveness ratios for no CRC screening and once-only CTC and once-only COL screening strategies.
788 The Impact of Detection of Serrated Polyps on Surveillance Programs in Primary Colonoscopy Screening Thomas R. de Wijkerslooth, Esther M. Stoop, Patrick M. Bossuyt, Kristien M. Tytgat, Jan Dees, Elisabeth M. Mathus-Vliegen, Ernst J. Kuipers, Paul Fockens, Monique van Leerdam, Evelien Dekker Background: Colonic serrated polyps (SPs) might rapidly develop into colorectal cancer (CRC). Proximal location of SPs is associated with synchronous advanced neoplasia. This might explain the occurrence of interval CRC in colonoscopy surveillance programs. It has recently been suggested to survey serrated polyps henceforth1, but this has not been incorporated in guidelines. This advice certainly will have a burden on surveillance programs but its quantity is unknown. Aim: To calculate the impact of detection of serrated polyps on surveillance programs. Methods: Asymptomatic persons (50-75 years) were consecutively invited to participate in primary colonoscopy screening. Colonoscopies were performed by experienced endoscopists (≥ 1000 colonoscopies). All detected polyps were immediately removed. In participants with adenomas, colonoscopy surveillance advice was given according to the joint guideline of ACS, US-MSTF and ACR.2 In patients with SPs, we calculated the recommended surveillance interval by using the guideline for surveillance of SPs, as recently proposed. Surveillance intervals are summarized in Table 1. We evaluated surveillance intervals using the ACS guideline only and using both guidelines. In subjects with both adenomas and SPs the shortest surveillance interval was recommended. Proximal colon location was defined as proximal to the splenic flexure. SPs included hyperplastic polyps, sessile serrated lesions and traditional serrated lesions. We included data from endoscopists who performed more than 50 study colonoscopies. Results: 1,354 subjects underwent a complete screening colonoscopy. A total of 1,635 polyps were detected, of which 707 (43%) were adenomas and 685 (42%) were SPs. In 358 patients (26%), one or more SP were detected; at least one proximal SP was detected in 167 patients (12%). One or more adenomas were detected in 392 patients (29%). No patients were identified with serrated polyposis or with 10 or more adenomas. Surveillance interval recommendations are summarized in Table 2. Surveillance interval was shortened from 5 years to 3 years in 35 patients (2.6%) and from 10 years to 3 years in 106 patients (7.8%). Conclusion: Implementing surveillance of patients with SPs would shorten surveillance intervals in 10% of screening participants. Surveillance of serrated polyps may be necessary, but will cause a significant burden on surveillance programs. 1Terdiman JP, McQuaid KR. Gastroenterology 2010;139:1444-7. 2 Levin B et al. Gastroenterology 2008;134:1570-95. Table 1: Surveillance Intervals for Patients with Adenomas and/or Serrated Polyps
*Compared to no screening — indicates default strategy †The strategy was inefficient because it was more costly and less effective (in terms of life-years gained) than another strategy 787 Higher Detection of Serrated Polyps With CAP Assisted Colonoscopy - Results From a Prospective, Randomized Controlled Trial Amit Rastogi, Neil Gupta, Deepthi S. Rao, Sachin Wani, Prateek Sharma, Ajay Bansal Background: Colonoscopy is less effective in protecting against right sided colon cancer, a significant proportion of which arise from the serrated pathway of carcinogenesis. Serrated polyps that include proximal (proximal to splenic flexure) or large (≥1cm) hyperplastic polyps (HP), sessile serrated adenoma (SSA) and traditional serrated adenoma (TSA) are the precursor lesions for these cancers. Hence, their detection rates assume significance akin to adenoma detection rates and have been reported to be variable and operator dependant. Cap assisted colonoscopy (CAC) is a simple technique that has been shown to improve the adenoma detection rates by its ability to examine colonic mucosa on the proximal aspect of folds. Aim: To compare CAC and standard high definition white light colonoscopy (SC) for the proportion of subjects detected with, and the total number of significant serrated polyps [defined as proximal HP, largeHP, SSA or TSA). Methods: Subjects referred for screening or surveillance colonoscopy were prospectively enrolled and randomized to either SC or CAC at a tertiary referral center by 3 endoscopists using a high definition colonoscope (CF-H180AL, Olympus). For the CAC procedures, a small transparent cap (Disposable Distal Attachment, Model D-201-15004, Olympus, America) was attached to the tip of the colonoscope that protrudes for about 4 mm beyond the tip of the colonoscope. All polyps detected were documented for their size, location, morphologyand sent for histopathology, each in a separate specimen bottle. The primary outcomes of this study (adenoma detection rates) have been reported previousl . We conducted a post hoc analysis to compare the detection rates of significant serrated polyps between CAC and SC by Fisher's exact test and Wilcoxon Rank Sum test. Results: 427 patients were enrolled (7 exclusions, 210 completed study in each arm, mean age 61 years, 95% male, 75% Caucasian, 67% screening . There were no significant differences in age, gender, race, smoking history, BMI, quality of bowel prep, number of screening procedures or withdrawal times between the 2 groups. CAC detected a significantly higher proportion of subjects with significant serrated polyps compared to SC - 12.8% vs 6.7% (p =0.047). CAC also detected a higher total number of significant serrated polyps compared to SC - 40 vs 20 (p = 0.03). The different types of significant serrated polyps detected in the two arms are shown in Table. Conclusions: CAC is a simple technique that helps to examine the otherwise blind mucosal areas on the proximal aspects of colonic folds, thereby overcoming a major limitation of SC. This study shows that CAC detects a higher proportion of subjects with large HP, proximal HP, SSA and TSA and thus has the potential to offer greater protection against the serrated pathway of colorectal carcinogenesis compared to SC.
AGA Abstracts
a ≥5 serrated polyps proximal to the sigmoid colon, of which 2≥10 mm or ≥20 serrated polyps of any size that are distributed throughout the colon Table 2: Surveillance intervals of all screening participants
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