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Objectives: The cecal intubation rate (CIR) is one of the 3 priority indicators for quality in colonoscopy. Whether continuous measurement of CIR is useful in high performers is uncertain., Methods: At an academic center, we identified 16 physicians who performed at least 50 procedures over 6 consecutive years. We analyzed all colonoscopy procedures excluding those with poor/inadequate preparation or severe colitis for CIR trend over the years. We calculated the numbers needed to establish CIR over minimum threshold levels with 95% confidence., Results: The overall CIR was 99.4%. None of the 16 physicians had a CIR <96.6% in any year. Sensitivity analyses including patients without intent to reach the cecum and inadequate bowel preparation had little impact on the results. Overall cecal photo documentation rate was 98.4%. No significant correlation was observed between procedure volume at our center and CIR (σ = -0.196, P = 0.483). Physicians with CIR ≥99% need to have only 24 examinations reviewed to establish CIR is >95%., Discussion: Continuous measurement of CIR, at least in high performers, appears to be of limited value. Very high performers need to evaluate small number of cases to demonstrate that CIR is above the recommended thresholds.

Background: The prevalence of sessile serrated adenomas and/or polyps (SSA/Ps) is uncertain., Objective: To determine the prevalence of SSA/Ps and SSA/Ps with cytologic dysplasia (SSA/P-CD) by using a colonoscopist with a high lesion detection rate and an expert in serrated lesion pathology., Design: Retrospective screening colonoscopy study., Setting: Academic endoscopy unit., Patients: A total of 1910 average risk, asymptomatic patients aged ≥50 years underwent screening colonoscopy between August 2005 and April 2012 by a single colonoscopist with a high lesion detection rate., Interventions: Slides of all lesions in the serrated class proximal to the sigmoid colon and all rectal and sigmoid colon serrated lesions >5 mm in size were reviewed by an experienced GI pathologist., Main Outcome Measurements: Prevalence of SSA/Ps, defined as the proportion of patients with ≥1 SSA/P., Results: There were 1910 patients, of whom 389 had 656 lesions in the serrated class. Review by the experienced GI pathologist determined a prevalence of SSA/Ps without cytologic dysplasia of 7.4% and SSA/Ps-CD of 0.6% (total SSA/P prevalence 8.1%). SSA/Ps and SSA/Ps-CD comprised 5.6% and 0.3%, respectively, of all resected polyps. The mean size of SSA/Ps was 7.13 mm (standard deviation [SD] 4.66), and 51 of 77 (66.2%) polyps ≥10 mm in the serrated class were SSA/Ps., Limitations: Retrospective design., Conclusion: A colonoscopist with a high lesion detection rate and an experienced pathologist identified a high prevalence (8.1%) of SSA/Ps in a screening population. SSA/Ps are more common than previously believed., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Serrated lesions are an important contributor to colorectal cancer (CRC), notably in the proximal colon. Findings in the distal colorectum are markers of advanced proximal adenomatous neoplasia. However, it is not known whether they affect the odds of advanced proximal serrated lesions., Methods: We performed a retrospective cross-sectional study of data from 1910 patients (59.3 ± 8.0 years, 53.8% female) who underwent an average-risk screening colonoscopy from August 2005 through April 2012 at Indiana University Hospital and an associated ambulatory surgery center. Colonoscopies were performed by an endoscopist with high rates of detection of adenomas and serrated polyps. Tissue samples of all serrated polyps (hyperplastic, sessile serrated adenoma/polyp [SSA/P], or traditional serrated adenoma) proximal to the sigmoid colon and serrated polyps >5 mm in the rectum or sigmoid colon were reviewed by a gastrointestinal pathologist and reclassified on the basis of World Health Organization criteria. Advanced serrated lesion (ASL) was defined as SSA/P with cytologic dysplasia, SSA/P ≥10 mm, or traditional serrated adenoma. Advanced conventional adenomatous neoplasia (ACN) was defined as tubular adenoma ≥10 mm, villous histology, high-grade dysplasia, or cancer. The prevalence of proximal ASL and ACN was calculated on the basis of distal colorectal findings. Multivariable logistic regression analysis was performed to determine the age-adjusted and sex-adjusted odds of advanced proximal adenomatous and serrated lesions. Secondary analyses were performed to examine the effect of variable ASL definitions., Results: Fifty-two patients (2.7%) had proximal ASL, and 99 (5.2%) had proximal ACN. Of the 52 patients with proximal ASL, 27 (52%) had no distal polyps. Of the 99 patients with proximal ACN, 40 (40%) had no distal polyps. Age and type of distal adenomas were significantly associated with proximal ACN. There were no significant associations between distal polyp type and proximal ASL. In secondary analyses, distal SSA/Ps (P = .008) but not distal hyperplastic polyps or conventional adenomas were associated with any proximal SSA/P., Conclusions: The findings at flexible sigmoidoscopy that traditionally serve as indications for colonoscopy (conventional adenomas) are likely to be ineffective for detection of proximal ASL. This finding, plus the observation that most patients with proximal ASL have no distal polyps, favors screening colonoscopy over sigmoidoscopy, especially in the elderly. The observation that non-advanced distal SSA/Ps are associated with any proximal SSA/P warrants further study., (Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: The adenoma detection rate (ADR) is a validated marker of colonoscopy quality. However, the optimal measurement method is unclear., Objective: The aims of our study were to (1) define benchmarks for the number of adenomas per screening colonoscopy (APC) quality metric; (2) study the association between ADRs for screening, surveillance, and diagnostic indications; and (3) explore the association of the screening ADR with an overall ADR inclusive of all colonoscopy indications., Design: Retrospective study., Setting: University hospital and associated ambulatory surgery center endoscopy units., Patients: Patients aged ≥50 years who underwent colonoscopy for screening, surveillance, or diagnostic indications by 20 endoscopists between January 1, 1999 and April 30, 2012., Intervention: Colonoscopy., Main Outcome Measurements: ADR, APC for screening, surveillance, and diagnostic indications., Results: A total of 21,766 colonoscopies were included. The indication was screening in 7434 (34.2%), surveillance in 8338 (38.3%), and diagnostic in 5994 (27.5%). The screening ADRs and APCs were significantly correlated (R = 0.91; P < .0001). For men, an ADR of 25% corresponded to an APC of 0.46 (95% confidence interval [CI], 0.35-0.57); for women, an ADR of 15% corresponded to an APC of 0.20 (95% CI, 0.13-0.27). Overall, the ADR stratified by colonoscopy indication was highest for surveillance, followed by screening, then diagnostic. For men, a screening ADR of 25% corresponded to a surveillance ADR of 31.9% (95% CI, 24.8%-38.9%); for women, an ADR of 15% corresponded to a surveillance ADR of 24.3% (95% CI, 18.3%-30.5%). The corresponding diagnostic ADRs were 17.0% (95% CI, 12.4%-21.6%) and 15.4% (95% CI, 11.5%-19.3%), respectively. There was significant correlation between screening ADR and an overall ADR inclusive of all colonoscopy indications., Limitations: External generalizability, retrospective design., Conclusion: We propose minimum screening APC detection benchmarks of 0.50 for men and 0.20 for women. ADRs for screening, surveillance, and diagnostic colonoscopy are correlated and can be used to derive a simplified overall ADR inclusive of all colonoscopy indications., (Published by Mosby, Inc.)

Background: Oral sodium phosphate solution (OSPS) has been associated with acute renal failure when used as a bowel preparation for colonoscopy., Aim: To determine whether gastroenterologists in Indiana follow recent recommendations for safe and effective use of colonoscopy., Methods: A survey of gastroenterologists in Indiana performed in mid-2006. Written instruction to patients were obtained and reviewed., Results: We received responses from 97.5% of Indiana gastroenterologists, of whom 80% reported using OSPS. All using OSPS forwarded their written instructions. None exceeded the recommended two 45 mL doses in their written instructions. Although separation of the two 45 mL doses by at least 6 to 12 hours is recommended, 35% of physicians prescribed the 2 doses at intervals less than 6 hours. Only 9.7% gave specific instructions for volumes of fluid to be taken before the first dose. Fluid prescriptions during the preparation were often suboptimal according to current recommendations. Less than 25% of physicians followed the recommendation to use carbohydrate-electrolyte solutions for hydration., Conclusions: Gastroenterologists in Indiana in mid-2006 uniformly followed recommendations for maximum doses of OSPS, but recommended intervals for the doses and gave hydration instructions that often did not follow current recommendations.

Background: There is variation between endoscopists in their detection of colorectal adenomas. There is less understanding of variation between endoscopists in detection and management of nonadenomas., Aim: To describe the removal rates of nonadenomas, variability between endoscopists, and the association of adenoma removal with nonadenoma removal., Methods: Consecutive colonoscopy reports by 9 gastroenterologists at Indiana University Hospital between January 1999 and January 2004 were obtained. Patients with inflammatory bowel disease, polyp syndromes, or who were referred for polypectomy were excluded., Results: There were 10,034 included colonoscopies. The prevalence of nonadenomatous polyps increased from 26.6% at age 30 years to 29.3% at age 70 years (P=0.02); this association was much less powerful than that of age with removal of adenomas. The range of finding > or =1 nonadenomatous polyp was 11.8% to 34.9%. The correlation between adenoma detection and nonadenoma removal by individual endoscopists for the full cohort was 0.79 and for persons age > or =50 years was 0.84., Conclusions: Detection of nonadenomatous polyps by individual endoscopists at colonoscopy is highly variable and correlates with increased removal rates of adenomatous polyps.