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Adequate bowel preparation is of paramount importance for the effectiveness of preventive colonoscopy as it allows visualization of the mucosal surface and adenomas detection, the pre-malignant lesions leading to colon cancer. Still, a considerable portion of patients fail to achieve adequate bowel cleansing, with predictors of inadequate bowel preparation being at the focal point of several studies, so far. Incorporation of these factors within predictive models has been implemented in an effort to promptly identify patients at risk for inadequate bowel preparation and thus, timely adopt practices that have the potential to improve bowel cleansing. Ultimately, this could lead to improved procedural outcomes not only in terms of neoplastic detection rate but also interval repeat procedures, expenses, patient convenience and adverse events risk. Aim of this manuscript is to present an up to date overview of all predictive scores/models addressing bowel cleansing adequacy in everyday clinical practice., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper, (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objectives: Previous meta-analysis including nonrandomized studies showed marginal benefit of underwater endoscopic mucosal resection(U-EMR) compared to conventional EMR(C-EMR) in terms of polypectomy outcomes. We evaluated U-EMR compared to C-EMR in the treatment of colorectal polyps with respect to effectiveness and safety by analyzing only randomized controlled trials(RCTs)., Material and Methods: PubMed and Cochrane Library databases were searched for RCTs published until 11/2020, evaluating U-EMR vs. C-EMR regarding en bloc resection, post-endoscopic resection adenoma recurrence, complete resection, adverse events rates and difference in resection time. Abstracts from Digestive Disease Week, United European Gastroenterology Week and ESGE Days meetings were also searched. Effect size on outcomes is presented as risk ratio(RR; 95% confidence interval[CI]) or mean difference(MD; 95%CI). The I 2 test was used for quantifying heterogeneity, while Grading of Recommendations Assessment, Development and Evaluation(GRADE) was used to assess strength of evidence., Results: Six RCTs analyzing outcomes from 1157 colorectal polypectomies(U-EMR589;C-EMR,568) were included. U-EMR associated with significant higher rate of en bloc resection compared to C-EMR [RR(95%CI):1.26(1.01-1.58); Chi² for heterogeneity=30.43, P<0.0001; I²=84%, GRADE: Very low]. This effect was more prominent regarding resection of polyps sized ≥20 mm compared to polyps <20 mm [RR(95%CI):1.64(1.22-2.20) vs. 1.10(0.98-1.23)]. Post-resection recurrence [RR(95%CI):0.52(0.28-0.94);GRADE:Low] was lower significantly in U-EMR group. In contrast, no significant difference was detected between U-EMR and C-EMR regarding complete resection [RR(95%CI): 1.06(0.91-1.24) GRADE:Very low] and adverse events occurrence[RR(95%CI):1.00 (0.72-1.39); GRADE:Low]., Conclusion: Meta-analysis of RCTs supports that U-EMR resection achieves higher rate of en bloc resection compared to conventional EMR. This effect is driven when resecting large(≥20 mm) polyps., (Copyright © 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Endocuff - a plastic device with flexible projections - mounted on the distal tip of the colonoscope, promises improved colonic mucosa inspection., Aim: To elucidate the effect of Endocuff on adenoma detection rate (ADR), advanced ADR (AADR) and mean number of adenomas per colonoscopy (MAC)., Methods: Literature searches identified randomized-controlled trials evaluating Endocuff-assisted colonoscopy (EAC) vs conventional colonoscopy (CC) in terms of ADR, AADR and MAC. The effect size on study outcomes was calculated using fixed or random effect model, as appropriate, and it is shown as relative risk (RR) [95% confidence interval (CI)] and mean difference (MD) (95%CI). The rate of device removal in EAC arms was also calculated., Results: We identified nine studies enrolling 6038 patients. All studies included mixed population (screening, surveillance and diagnostic examinations). Seven and two studies evaluated the first and the second-generation device, respectively. EAC was associated with increased ADR compared to CC [RR (95%CI): 1.18 (1.05-1.32); Ι 2 = 71%]; EAC benefits more endoscopists with ADR ≤ 35% compared to those with ADR > 35% [RR (95%CI): 1.37 (1.08-1.74); Ι 2 = 49% vs 1.10 (0.99-1.24); Ι 2 = 71%]. In terms of AADR and MAC, no difference was detected between EAC and CC [RR (95%CI): 1.03 (0.85-1.25); Ι 2 = 15% and MD (95%CI): 0.30 (-0.17-0.78); Ι 2 = 99%]. Subgroup analysis did not show any difference between the two device generations regarding all three endpoints. In EAC arms, the device had to be removed in 3% (95%CI: 2%-5%) of the cases mainly due to tortuous sigmoid or presence of diverticula along it., Conclusion: EAC increases ADR compared to CC, especially for endoscopists with lower ADR. On the other hand, no significant effect on AADR and MAC was detected., Competing Interests: Conflict-of-interest statement: All authors declare no conflict-of-interest.

Introduction: A variety of add-on devices and new-generation endoscopes have the potential to detect lesions 'hidden' behind colonic folds. We measured the effect of these new modalities on colonoscopy's lesions miss rates by a meta-analysis of data from individual studies., Materials and Methods: We performed literature searches in Medline and Cochrane Library for back-to-back randomized-controlled trials evaluating colonoscope add-on devices and new endoscopes in terms of lesions miss rates. The effect size on study outcomes is shown as relative risk (95% confidence interval)., Results: We identified nine tandem studies with 1594 patients: seven evaluating add-on devices (one with cap, two with Endocuff, one with Endorings, one with Third-Eye Retroscope, two with G-EYE endoscope) and two evaluating the full-spectrum endoscopy system (FUSE) in comparison with conventional colonoscopy (CC). Overall, adenoma miss rate (AMR) was significantly lower with add-on devices/FUSE [0.33 (0.22-0.50), P<0.00001] compared with CC, the effect being similar among the add-on devices [0.35 (0.22-0.57), P<0.0001] and the FUSE [0.26 (0.15-0.46), P<0.00001] studies, respectively. Advanced AMR and polyp miss rate (PMR) were also significantly lower using add-on devices/FUSE [0.30 (0.21-0.44), P<0.0001 and 0.31 (0.13-0.79), P=0.01, respectively]. Use of add-on devices/FUSE scope was associated with significantly lower AMR and PMR in the proximal colon and it was associated with shortening of the colonoscopy surveillance interval., Conclusion: Our meta-analysis provides evidence that AMR, advanced AMR, and PMR are significantly lower using add-on to colonoscope devices and the full-spectrum endoscopy systems compared with CC. Heterogeneity among the included studies and the small number of detected advanced adenomas call for cautious interpretation of the results.

Although colonoscopy has been proven effective in reducing the incidence of colorectal cancer through the detection and removal of precancerous lesions, it remains an imperfect examination, as it can fail in detecting up to almost one fourth of existing adenomas. Among reasons accounting for such failures, is the inability to meticulously visualize the colonic mucosa located either proximal to haustral folds or anatomic curves, including the hepatic and splenic flexures. In order to overcome these limitations, various colonoscope attachments aiming to improve mucosal visualization have been developed. All of them - transparent cap, Endocuff, Endocuff Vision and Endorings - are simply mounted onto the distal tip of the scope. In this review article, we introduce the rationale of their development, present their mode of action and discuss in detail the effect of their implementation in the detection of lesions during colonoscopy., Competing Interests: Conflict-of-interest statement: The authors declare no conflict of interest related to this publication.

Background and study aims  The Endocuff (ARC Medical Design, Leeds, UK) is a device that, when mounted on the tip of an endoscope, may assist with inspection of a greater surface of the colonic mucosa by pulling backwards, flattening, and stretching the colonic folds as the endoscope is gradually withdrawn. We aimed to compare the adenoma miss rates of Endocuff-assisted colonoscopy with those of conventional colonoscopy. Patients and methods  The included patients underwent same-day, back-to-back, (Endocuff-assisted colonoscopy as the index procedure followed by conventional colonoscopy or vice versa, randomly assigned 1:1) colonoscopies, performed by six endoscopists with documented adenoma detection rates > 35 %, in four tertiary endoscopy facilities. Results  We randomized 200 patients (mean age 61.2 years [standard deviation 9.8]; 86.5 % colorectal cancer screening surveillance cases). Overall, there were seven incomplete examinations using Endocuff and one with conventional colonoscopy ( P  = 0.03). Times for endoscope insertion (5.0 minutes [0.8 - 21.0] vs. 5.0 minutes [1.0 - 16.0]; P  = 0.49) and withdrawal (6.0 minutes [3.2 - 29.0] vs. 6.0 minutes [3.1 - 17.0]; P  = 0.06) were similar for Endocuff-assisted and conventional colonoscopy. We detected one cancer and 195 adenomas; 84 in the proximal colon. Endocuff-assisted colonoscopy showed significantly lower overall and proximal colon adenoma miss rates compared with conventional colonoscopy (14.7 % [8.0 % - 21.0 %] vs. 38.4 % [28.1 % - 48.6 %] and 10.4 % [1.8 % - 19.1 %] vs. 38.9 % [23.0 % - 54.8 %], respectively). No difference between the two arms was shown regarding advanced adenoma miss rates, either overall or in the proximal colon. There were no serious adverse events related to the procedures. Conclusions  In comparison with conventional colonoscopy, Endocuff-assisted colonoscopy has a significantly lower adenoma miss rate when performed by high-detector endoscopists. However, the incomplete colonoscopy rate with Endocuff is higher.ClinicalTrials.gov Identifier: NCT02340065., Competing Interests: Competing interests: Dr. Cesare Hassan declares consultancies for Norgine; the rest of authors have nothing to declare., (© Georg Thieme Verlag KG Stuttgart · New York.)

Colonoscopy is the gold standard for colorectal cancer prevention; however, it is still an imperfect modality. Precancerous lesions can be lost during screening examinations, thus increasing the risk of interval cancer. A variety of factors either patient-, or endoscopist dependent or even the procedure itself may contribute to loss of lesions. Sophisticated modalities including advanced technology endoscopes and add-on devices have been developed in an effort to eliminate colonoscopy's drawbacks and maximize its ability to detect potentially culprit polyps. Novel colonoscopes aim to widen the field of view. They incorporate more than one cameras enabling simultaneous image transmission. In that way the field of view can expand up to 330°. On the other hand a plethora of add-on devices attachable on the standard colonoscope promise to detect lesions in the proximal aspect of colonic folds either by offering a retrograde view of the lumen or by straightening the haustral folds during withdrawal. In this minireview we discuss how these recent advances affect colonoscopy performance by improving its quality indicators (cecal intubation rate, adenoma detection rate) and other metrics (polyp detection rate, adenomas per colonoscopy, polyp/adenoma miss rate) associated with examination's outcomes., Competing Interests: Conflict-of-interest statement: The authors declare no conflict of interest related to this publication.

Background: Recent prospective randomized controlled trials have evaluated deep convolutional neural network (CNN) based computer aided detection (CADe) of lesions in real-time colonoscopy. We conducted this meta-analysis to compare the adenoma detection rate (ADR) of deep CNN based CADe assisted colonoscopy to standard colonoscopy (SC) from randomized controlled trials (RCTs). Methods: Multiple databases were searched (from inception to May 2020) and parallel RCTs that compared deep CNN based CADe assisted colonoscopy to SC were included for this analysis. Using Mantel-Haenzel (M-H) random effects model, pooled risk ratios (RR) and mean difference (MD) were calculated. In between study heterogeneity was assessed by I2% values. Outcomes assessed included other per patient adenoma parameters. Findings: Six RCTs were included in our final analysis that utilized deep CNN based CADe system in real-time colonoscopy. Total numbers of patients assessed were 4962 (2480 in CADe and 2482 in SC group). CADe based colonoscopy demonstrated statistically higher pooled ADR, RR=1.5 (95% CI 1.3–1.72), p

Various endoscopic resection techniques have been proposed for the treatment of nonpedunculated colorectal polyps sized 6–20 mm, however the optimal technique still remains unclear. A comprehensive literature review was conducted for randomized controlled trials (RCTs), investigating the efficacy of endoscopic treatments for the management of 6–20 mm nonpedunculated colorectal polyps. Primary outcomes were complete and en bloc resection rates and adverse event rate was the secondary. Effect size on outcomes is presented as risk ratio (RR; 95% confidence interval [CI]). Fourteen RCTs (5219 polypectomies) were included. Endoscopic mucosal resection(EMR) significantly outperformed cold snare polypectomy(CSP) in terms of complete [(RR 95%CI): 1.04(1.00–1.07)] and en bloc resection rate [RR:1.12(1.04–1.21)]. EMR was superior to hot snare polypectomy (HSP) [RR:1.04(1.00–1.08)] regarding complete resection, while underwater EMR (U-EMR) achieved significantly higher rate of en bloc resection compared to CSP [RR:1.15(1.01–1.30)]. EMR yielded the highest ranking for complete resection(SUCRA-score 0.81), followed by cold-snare EMR(CS-EMR,SUCRA-score 0.76). None of the modalities was different regarding adverse event rate compared to CSP, however EMR and CS-EMR resulted in fewer adverse events compared to HSP [RR:0.44(0.26–0.77) and 0.43(0.21–0.87),respectively]. EMR achieved the highest performance in resecting 6–20 mm nonpedunculated colorectal polyps, with this effect being consistent for polyps 6–9 and ≥10 mm; findings supported by very low quality of evidence. [ABSTRACT FROM AUTHOR]

The effect of fellow involvement on colonoscopy outcomes is controversial. Thus, we evaluated this effect on adenoma detection rate (ADR) and on other colonoscopy quality indicators. MEDLINE and Cochrane central register of controlled trials were searched up to September 2018 for studies evaluating fellow-involved colonoscopies vs. attending physicians-only examinations in terms of colonoscopy outcomes. Primary outcome was ADR, while advanced ADR (AADR), mean number of adenomas per colonoscopy (MAC), cecum intubation rate (CIR) and adverse events rate comprised the secondary outcomes. The effect size on study outcomes was calculated using random-effects model and it is presented as Odds Ratio (OR) or Mean Difference (MD) with 95% confidence interval (CI). Nineteen observational studies involving 34,059 patients (fellow-involved 16,875, attending physician-only 17,184) were included. Compared to the attending physician-only group, fellow involvement marginally increased ADR [OR (95%CI) = 1.12 (1.00–1.26); p = 0.06, I2 = 76%]. Attending physicians with low-to-moderate ADR (<35%) benefited most from fellow's participation [OR (95%CI): 1.26 (1.13–1.40) vs. 1.12 (1.00–1.26); p = 0.03 when ADR < 35% and OR (95%CI): 1.29 (1.13–1.46) vs. 0.95 (0.78–1.16); p = 0.01 when ADR < 30%, respectively]. Moreover, fellow-involved group had higher MAC compared to attending-only group [MD (95%CI) = 0.12 (0.04–0.20); p = 0.002, I2 = 53%]. No benefit from fellow involvement was detected either for AADR, CIR or adverse events rate. Fellow involvement during colonoscopy is associated with more adenomas detected per procedure and with higher ADR when the attending physician-only group ADR is less than 35%. [ABSTRACT FROM AUTHOR]