Quality of colonoscopy: how to measure it in practice?
Ankie Dirrix-Reumkens and Silvia Sanduleanu, Maastricht University Medical Center, The Netherlands
Colonoscopy is the most commonly used endoscopic procedure. It is performed for the diagnosis of gastrointestinal diseases, screening for colorectal cancer (CRC) and surveillance indications. Recently, the American Society for Gastrointestinal Endoscopy (ASGE)1 and the European Society of Gastrointestinal Endoscopy (ESGE)2 published updated guidelines to improve the understanding of quality indicators and facilitate the implementation of them in practice. The goal of quality guidelines is to develop an evidence-based system of benchmarks for all quality indicators 3,4. In this Scientific Update, we will briefly review key studies on quality of colonoscopy and summarize current international recommendations.
To read more about Guidelines from ESGE & ASGE in terms of Quality in Colonoscopy, please follow the links below:
What do we need to monitor?
Pre-colonoscopy quality measures. The quality and effectiveness of colonoscopy (irrespective of indication) is critically affected by the quality of bowel preparation. To increase uniformity in reporting, use of validated scores is recommended, such as the Boston Bowel Preparation Score or the Ottawa Bowel Preparation Scale. Recent clinical trials suggest that low-volume cleansing preparations used as split-dose preparation provide the most successful combination between adequate bowel preparation, patient satisfaction and the least fluid and electrolyte disturbances1,2.
Quality measures at colonoscopy. It has been shown that careful inspection and longer withdrawal times are associated with a higher adenoma detection rate (ADR), which, in turn, leads to reduction of the risk for CRC, in both men and women. A minimum target ADR of ≥25 % is recommended in the average-risk population1. All adenomas identified should be resected and ≥90 % retrieved for histological examination. Caecal intubation rates for all screening colonoscopies are recommended to be ≥90 %. Withdrawal time should be monitored, with an average target of ≥ 6 minutes in screening colonoscopies with negative results.
Post-colonoscopy quality measures. Adverse events have to be recognized and documented. Unfortunately, the occurrence of the adverse events (interval (post-colonoscopy) CRCs, perforation, bleeding, cardiorespiratory problems, and mortality) is largely underreported1,2. The Expert Working Group on Interval CRC of the CRC Screening Committee of the World Endoscopy Organization recently proposed a standardized nomenclature for interval CRC, again to improve uniformity in monitoring and reporting such events during screening and surveillance5.
What is the role of image-enhanced endoscopy (IEE) in practice?
High-definition (HD) colonoscopes have a three-fold greater pixel density compared with standard-definition (SD) colonoscopes. Furthermore, IEE (which includes both image enhancement and contrast enhancement) has the potential to improve in vivo characterization of lesions6,7. Recently, the international SCENIC consensus statement on surveillance and management of dysplasia in inflammatory bowel disease (IBD) provided evidence-based criteria for implementation of IEE in practice. In the case of IBD surveillance, HD colonoscopy is recommended rather than SD colonoscopy. Furthermore, when using HD colonoscopy, chromoendoscopy is suggested rather than white-light endoscopy8. This guideline has already been endorsed by many professional gastrointestinal societies worldwide. As a next step, there is tremendous need for training in the utilization of IEE. Promising new data by Chalifoux et al9 showed that trainees performing colonoscopy with a HD colonoscope also have a higher ADR than performing colonoscopy with an SD colonoscope. Advanced endoscopic technologies are now becoming a sine-qua-non tool for our day-to-day practice.
To read more about the Guidelines from ESGE for Advanced imaging for detection and differentiation of colorectal neoplasia, please follow the link below.
It was also interesting to read the recent Survey of Digestive Health across Europe which was published by UEG Journal regarding the impact of gastrointestinal diseases on patient mortality, morbidity and quality of life across Europe, assessing the health care costs and other economic implications, and assessing the organization and delivery of gastroenterology services across Europe
1 Rex DK, Schoenfeld PS, Cohen J, Pike IM, Adler DG, Fennerty MB, et al. Quality indicators for colonoscopy. Gastrointestinal endoscopy. 2015 Jan;81(1):31-53. PubMed PMID: 25480100. Epub 2014/12/07. eng.
2 Kaminski MF, Hassan C, Bisschops R, Pohl J, Pellise M, Dekker E, et al. Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2014 May;46(5):435-49. PubMed PMID: 24639382. Epub 2014/03/19. eng.
3 Rizk MK, Sawhney MS, Cohen J, Pike IM, Adler DG, Dominitz JA, et al. Quality indicators common to all GI endoscopic procedures. Gastrointestinal endoscopy. 2015 Jan;81(1):3-16. PubMed PMID: 25480102. Epub 2014/12/07. eng.
4 Cohen J, Pike IM. Defining and measuring quality in endoscopy. Gastrointestinal endoscopy. 2015 Jan;81(1):1-2. PubMed PMID: 25480098. Epub 2014/12/07. eng.
5 Sanduleanu S, le Clercq CM, Dekker E, Meijer GA, Rabeneck L, Rutter MD, et al. Definition and taxonomy of interval colorectal cancers: a proposal for standardising nomenclature. Gut. 2014 Sep 5. PubMed PMID: 25193802. Epub 2014/09/07. eng.
6 Neumann H, Fujishiro M, Wilcox CM, Monkemuller K. Present and future perspectives of virtual chromoendoscopy with i-scan and optical enhancement technology. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society. 2014 Jan;26 Suppl 1:43-51. PubMed PMID: 24373000. Epub 2014/01/01. eng.
7 Basford PJ, Longcroft-Wheaton G, Higgins B, Bhandari P. High-definition endoscopy with i-Scan for evaluation of small colon polyps: the HiSCOPE study. Gastrointestinal endoscopy. 2014 Jan;79(1):111-8. PubMed PMID: 23871094. Epub 2013/07/23. eng.
8 Laine L, Kaltenbach T, Barkun A, McQuaid KR, Subramanian V, Soetikno R. SCENIC International Consensus Statement on Surveillance and Management of Dysplasia in Inflammatory Bowel Disease. Gastroenterology. 2015 Mar;148(3):639-51 e28. PubMed PMID: 25702852. Epub 2015/02/24. eng.
9 Chalifoux SL, Rao DS, Wani SB, Sharma P, Bansal A, Gupta N, et al. Trainee participation and adenoma detection rates during screening colonoscopies. Journal of clinical gastroenterology. 2014 Jul;48(6):524-9. PubMed PMID: 24440932. Epub 2014/01/21. eng.
10 Anderson P, Dalziel K, Davies E, Fitzsimmons D, Hale J, Hughes A, et al. Survey of digestive health across Europe: Final report. Part 2: The economic impact and burden of digestive disorders. United European gastroenterology journal. 2014 Dec;2(6):544-6. PubMed PMID: 25436111. Pubmed Central PMCID: PMC4245305. Epub 2014/12/02. eng.
11 Farthing M, Roberts SE, Samuel DG, Williams JG, Thorne K, Morrison-Rees S, et al. Survey of digestive health across Europe: Final report. Part 1: The burden of gastrointestinal diseases and the organisation and delivery of gastroenterology services across Europe. United European gastroenterology journal. 2014 Dec;2(6):539-43. PubMed PMID: 25452850. Pubmed Central PMCID: PMC4245304. Epub 2014/12/03. eng.
12 Park WG, Shaheen NJ, Cohen J, Pike IM, Adler DG, Inadomi JM, et al. Quality Indicators for EGD. The American journal of gastroenterology. 2015 Jan;110(1):60-71. PubMed PMID: 25448872. Epub 2014/12/03. eng.
13 Adler DG, Lieb JG, 2nd, Cohen J, Pike IM, Park WG, Rizk MK, et al. Quality indicators for ERCP. Gastrointestinal endoscopy. 2015 Jan;81(1):54-66. PubMed PMID: 25480099. Epub 2014/12/07. eng.
14 Wani S, Wallace MB, Cohen J, Pike IM, Adler DG, Kochman ML, et al. Quality indicators for EUS. Gastrointestinal endoscopy. 2015 Jan;81(1):67-80. PubMed PMID: 25480097. Epub 2014/12/07. eng.
Feel free to contact our editorial staff with any questions or suggestions concerning the newsletter. We look forward to receiving your feedback: firstname.lastname@example.org