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Sa1147 Development and Validation of an Algorithm to Complete Colonoscopy Using Standard Endoscopes in a Prospective Cohort of Patients With Prior Incomplete Colonoscopy
Abstracts Table. Demographic data and colorectal endoscopic submucosal dissection results of Laterally spreading tumor-granular type (LST-G) and laterally spreading tumor-non granular type (LST-NG) [n(procedure)[230, N(case)[222]
Gender,N, Male/Female Lesion size, (median;range),mm Sample size, (median;range),mm Time of procedure,(median;range), min Dissection speed, (median;range), mm2/min En-Bloc Resection, n(%) Complete Resection, n(%) R0 Resection R1 Resection Rx Resection Complication, n Delayed bleeding Perforation Paris Classification, n 0-1s+2a 0-2a 0-2a+2c Localization, n Rectum Sigmoid colon Descending colon Splenic Flexura Transverse colon Hepatic Flexura Ascending colon Ceacum Ileocecal Valve Localization Left Colon Right Colon Pathology, n Carcinoma -Intramucosal -Sm1 invasion -Sm2 invasion Tubular Adenoma Tubulovillous Adenoma Villous Adenoma Serrated Adenoma
LST-NG (n[40)
LST-G (n[190)
p
26/9 27; 12-58 37; 15-62 58.5; 6-300 13.7; 5.23-43.96
107/80 35; 13-176 42; 20-198 59; 6-540 22.7; 2.09-79.55
0.059 <0.001* 0.005* 0.537* <0.001*
36(90)
173(91.1)
0.834 0.001
31(77.5) 9(22.5) 0(0)
173 (91.1) 10(5.3) 7 (3.7) 0.596
0 2(5.0)
2(1.1) 5(2.6)
0 (0) 21 (52.5) 19 (47.5)
126 (54.8) 53 (27.9) 11 (5.8)
14 4 2 2 8 8 2 0 0
95 30 12 4 6 12 16 11 4
22(55) 18(45)
141(74.2) 49(25.8)
22(55) 13(32.5) 1(2.5) 8(20.0) 7(17.5) 9(22.5) 1(2.5) 1(2.5)
78(41.1) 65(34.2) 3(1.6) 10(5.3) 13(6.8) 76(40.0) 3(7.4) 9(4.7)
<0.001
<0.001
more likely to be female [Table]. IC extent was sigmoid (33%), descending (12%), transverse (34%), and ascending colon (21%). Multiple endoscopes were used at IC in 20% of cases and 18% of patients had >1 prior IC. The overall repeat colonoscopy success rate was 98% (nZ172); 94% of all colonoscopies were completed using a standard endoscope. Median insertion time was 10 minutes [IQR 7.3, 15.5] and did not differ by IC reason. Adenomas were detected in 44% of patients. A single adverse event (hypoxemia requiring hospitalization) occurred. Colonoscopy could not be completed using any endoscope in 3 patients (2%, angulation in 2 patients; looping in 1 patient). In the 125 patients managed by the algorithm, the initial standard endoscope chosen was successful in 90% of patients; in 9 patients (7%), changing to a different standard endoscope (nZ5) or enteroscope (nZ4) successfully completed the procedure. Conclusions: A robust treatment algorithm was developed for patients with prior incomplete colonoscopy. Use of this algorithm resulted in complete colonoscopy with standard endoscopes in nearly all patients, with adenomas identified in 44% of patients.
Outcomes of Repeat Colonoscopy in Entire Cohort of IC Referrals (n[175) Angulation (n[90)
Looping (n[57)
Gender 72 (80.%)* 26 (45.6%) Body Mass Index (SD) 26.3 (5.4) 31. (9.1)* Successful Repeat 88(97.8%) 52 (91.2%) Colonoscopy Using Standard Endoscopes Successful Repeat 88 (97.8%) 56 (98.2%) Colonoscopy Using Any Endoscope Total Insertion Time, 9.8 (6.7, 16.6) 10.5 (8.3, 14.0) min, Median (IQR) Total Procedure Time, 23.5 (18.8, 30.7) 27.85 (20.5, 32.8) min, Median (IQR) * p<0.005
Both (n[28)
All (n[175)
21 (75.0%) 27.(7.4) 25 (89.3%)
119 (68.0%) 28.3 (7.5) 165 (94.3%)
28 (100%)
172 (98.3%)
10.7 (8.1, 14.9)
10.3 (7.4, 15.2)
27.1 (21.2, 41.8) 25.2 (20.2, 32.6)
0.015
0.039
R0; deep and lateral margins were free of neoplasm, R1; tumor cells extended to deep or lateral margins, Rx; margins could not be evaluated due to coagulation artifacts or piecemeal resection, Sm1; submucosal cancer with invasion for colorectal lesion <1000 mm Sm2; submucosal cancer with invasion for colorectal lesion 1000 mm, * Mann-Whitney U test applied, p<0.05 is statistically significant Chi-square or Fisher’s test applied, p<0.05 is statistically significant
Sa1147 Development and Validation of an Algorithm to Complete Colonoscopy Using Standard Endoscopes in a Prospective Cohort of Patients With Prior Incomplete Colonoscopy Melinda Rogers*1,2, Andrew J. Gawron1, David Grande1, Rajesh N. Keswani1,2 1 Northwestern Memorial Hospital, Chicago, IL; 2Gastroenterology, University of Utah Hospital, Salt Lake City, UT Introduction: Incomplete colonoscopy (IC) may occur due to colon angulation (adhesions or diverticulosis), endoscope looping, or both. Specialty endoscopes/devices have been shown to successfully complete prior IC, but may not be widely available. The purpose of this study was to develop and validate an algorithm utilizing standard endoscopes for prior IC. Methods: This was a prospective cohort study of patients referred after IC due to angulation and/or looping over a 3-year period (2012-2015); IC due to inadequate sedation were excluded. Initially, 50 consecutive IC patients were enrolled and repeat colonoscopy was attempted using standard endoscopes (adult/pediatric colonoscope or upper endoscope). Utilizing the outcomes of these 50 patients, an algorithm (Figure) was developed to identify the standard endoscope most likely to complete colonoscopy based upon IC cause, extent, number of IC, and body mass index (BMI). This algorithm was then prospectively validated in 125 patients. Repeat colonoscopies utilized monitored anesthesia. The primary outcomes were 1) overall colonoscopy completion rate using standard endoscopes and 2) success rate of the initial standard endoscope chosen based upon the developed algorithm. Results: There were 175 total patients (69% F) referred for IC due to angulation (nZ90), looping (nZ57), or both (nZ28). Median age at time of referral was 64y (IQR 57,69) with the majority (61%) repeating colonoscopy within 1 year of IC. BMI was significantly higher in patients with IC due to looping than angulation [Table]. Patients referred for IC due to angulation were
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Sa1148 Endocuff Increases Sessile Serrated Adenoma Detection Rates in the Right Colon Shawn Kaye*, Mohit Mittal, Katherine Kim, William E. Karnes University of California, Irvine, Orange, CA Background: Each 1.0% increase in adenoma detection rate (ADR) predicts a 3.0% decrease in the risk of interval cancer. 80% of interval cancers are presumed to arise from missed and incompletely removed precancerous lesions. Interval cancers are predominantly right-sided and have molecular features of the serrated pathway (BRAF mutations and CIMP). The putative precursors are sessile serrated adenomas (SSA), which are predominately right sided, easily missed and often incompletely removed. Endocuff (Arc Medical Designs, Leeds, United Kingdom) is a novel attachment device which has been shown to significantly increase ADR. Few studies have addressed the utility of Endocuff (EC) for the detection of SSAs. Objective: Compare SSA detection rates with and without EC. Methods: Colonoscopy quality data from sixteen gastroenterologists and colorectal surgeons was collected prospectively at our single tertiary referral center from June 2012 to November 2015. Inclusion criteria included all screening and surveillance examinations (excluding inflammatory bowel disease). SSA detection rate (SSADR) and number of SSAs detected per procedure (#SSA/Proc) were compared among three groups: 1) conventional colonoscopy prior to EC implementation (CC-Pre); 2) conventional
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB231
Gender,N, Male/Female Lesion size, (median;range),mm Sample size, (median;range),mm Time of procedure,(median;range), min Dissection speed, (median;range), mm2/min En-Bloc Resection, n(%) Complete Resection, n(%) R0 Resection R1 Resection Rx Resection Complication, n Delayed bleeding Perforation Paris Classification, n 0-1s+2a 0-2a 0-2a+2c Localization, n Rectum Sigmoid colon Descending colon Splenic Flexura Transverse colon Hepatic Flexura Ascending colon Ceacum Ileocecal Valve Localization Left Colon Right Colon Pathology, n Carcinoma -Intramucosal -Sm1 invasion -Sm2 invasion Tubular Adenoma Tubulovillous Adenoma Villous Adenoma Serrated Adenoma
LST-NG (n[40)
LST-G (n[190)
p
26/9 27; 12-58 37; 15-62 58.5; 6-300 13.7; 5.23-43.96
107/80 35; 13-176 42; 20-198 59; 6-540 22.7; 2.09-79.55
0.059 <0.001* 0.005* 0.537* <0.001*
36(90)
173(91.1)
0.834 0.001
31(77.5) 9(22.5) 0(0)
173 (91.1) 10(5.3) 7 (3.7) 0.596
0 2(5.0)
2(1.1) 5(2.6)
0 (0) 21 (52.5) 19 (47.5)
126 (54.8) 53 (27.9) 11 (5.8)
14 4 2 2 8 8 2 0 0
95 30 12 4 6 12 16 11 4
22(55) 18(45)
141(74.2) 49(25.8)
22(55) 13(32.5) 1(2.5) 8(20.0) 7(17.5) 9(22.5) 1(2.5) 1(2.5)
78(41.1) 65(34.2) 3(1.6) 10(5.3) 13(6.8) 76(40.0) 3(7.4) 9(4.7)
<0.001
<0.001
more likely to be female [Table]. IC extent was sigmoid (33%), descending (12%), transverse (34%), and ascending colon (21%). Multiple endoscopes were used at IC in 20% of cases and 18% of patients had >1 prior IC. The overall repeat colonoscopy success rate was 98% (nZ172); 94% of all colonoscopies were completed using a standard endoscope. Median insertion time was 10 minutes [IQR 7.3, 15.5] and did not differ by IC reason. Adenomas were detected in 44% of patients. A single adverse event (hypoxemia requiring hospitalization) occurred. Colonoscopy could not be completed using any endoscope in 3 patients (2%, angulation in 2 patients; looping in 1 patient). In the 125 patients managed by the algorithm, the initial standard endoscope chosen was successful in 90% of patients; in 9 patients (7%), changing to a different standard endoscope (nZ5) or enteroscope (nZ4) successfully completed the procedure. Conclusions: A robust treatment algorithm was developed for patients with prior incomplete colonoscopy. Use of this algorithm resulted in complete colonoscopy with standard endoscopes in nearly all patients, with adenomas identified in 44% of patients.
Outcomes of Repeat Colonoscopy in Entire Cohort of IC Referrals (n[175) Angulation (n[90)
Looping (n[57)
Gender 72 (80.%)* 26 (45.6%) Body Mass Index (SD) 26.3 (5.4) 31. (9.1)* Successful Repeat 88(97.8%) 52 (91.2%) Colonoscopy Using Standard Endoscopes Successful Repeat 88 (97.8%) 56 (98.2%) Colonoscopy Using Any Endoscope Total Insertion Time, 9.8 (6.7, 16.6) 10.5 (8.3, 14.0) min, Median (IQR) Total Procedure Time, 23.5 (18.8, 30.7) 27.85 (20.5, 32.8) min, Median (IQR) * p<0.005
Both (n[28)
All (n[175)
21 (75.0%) 27.(7.4) 25 (89.3%)
119 (68.0%) 28.3 (7.5) 165 (94.3%)
28 (100%)
172 (98.3%)
10.7 (8.1, 14.9)
10.3 (7.4, 15.2)
27.1 (21.2, 41.8) 25.2 (20.2, 32.6)
0.015
0.039
R0; deep and lateral margins were free of neoplasm, R1; tumor cells extended to deep or lateral margins, Rx; margins could not be evaluated due to coagulation artifacts or piecemeal resection, Sm1; submucosal cancer with invasion for colorectal lesion <1000 mm Sm2; submucosal cancer with invasion for colorectal lesion 1000 mm, * Mann-Whitney U test applied, p<0.05 is statistically significant Chi-square or Fisher’s test applied, p<0.05 is statistically significant
Sa1147 Development and Validation of an Algorithm to Complete Colonoscopy Using Standard Endoscopes in a Prospective Cohort of Patients With Prior Incomplete Colonoscopy Melinda Rogers*1,2, Andrew J. Gawron1, David Grande1, Rajesh N. Keswani1,2 1 Northwestern Memorial Hospital, Chicago, IL; 2Gastroenterology, University of Utah Hospital, Salt Lake City, UT Introduction: Incomplete colonoscopy (IC) may occur due to colon angulation (adhesions or diverticulosis), endoscope looping, or both. Specialty endoscopes/devices have been shown to successfully complete prior IC, but may not be widely available. The purpose of this study was to develop and validate an algorithm utilizing standard endoscopes for prior IC. Methods: This was a prospective cohort study of patients referred after IC due to angulation and/or looping over a 3-year period (2012-2015); IC due to inadequate sedation were excluded. Initially, 50 consecutive IC patients were enrolled and repeat colonoscopy was attempted using standard endoscopes (adult/pediatric colonoscope or upper endoscope). Utilizing the outcomes of these 50 patients, an algorithm (Figure) was developed to identify the standard endoscope most likely to complete colonoscopy based upon IC cause, extent, number of IC, and body mass index (BMI). This algorithm was then prospectively validated in 125 patients. Repeat colonoscopies utilized monitored anesthesia. The primary outcomes were 1) overall colonoscopy completion rate using standard endoscopes and 2) success rate of the initial standard endoscope chosen based upon the developed algorithm. Results: There were 175 total patients (69% F) referred for IC due to angulation (nZ90), looping (nZ57), or both (nZ28). Median age at time of referral was 64y (IQR 57,69) with the majority (61%) repeating colonoscopy within 1 year of IC. BMI was significantly higher in patients with IC due to looping than angulation [Table]. Patients referred for IC due to angulation were
www.giejournal.org
Sa1148 Endocuff Increases Sessile Serrated Adenoma Detection Rates in the Right Colon Shawn Kaye*, Mohit Mittal, Katherine Kim, William E. Karnes University of California, Irvine, Orange, CA Background: Each 1.0% increase in adenoma detection rate (ADR) predicts a 3.0% decrease in the risk of interval cancer. 80% of interval cancers are presumed to arise from missed and incompletely removed precancerous lesions. Interval cancers are predominantly right-sided and have molecular features of the serrated pathway (BRAF mutations and CIMP). The putative precursors are sessile serrated adenomas (SSA), which are predominately right sided, easily missed and often incompletely removed. Endocuff (Arc Medical Designs, Leeds, United Kingdom) is a novel attachment device which has been shown to significantly increase ADR. Few studies have addressed the utility of Endocuff (EC) for the detection of SSAs. Objective: Compare SSA detection rates with and without EC. Methods: Colonoscopy quality data from sixteen gastroenterologists and colorectal surgeons was collected prospectively at our single tertiary referral center from June 2012 to November 2015. Inclusion criteria included all screening and surveillance examinations (excluding inflammatory bowel disease). SSA detection rate (SSADR) and number of SSAs detected per procedure (#SSA/Proc) were compared among three groups: 1) conventional colonoscopy prior to EC implementation (CC-Pre); 2) conventional
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB231