qine colonoscopy-sylabus_final

QUALIT Y IN ENDOSCOPY

COLONOSCOPY & COLONIC NEOPLASMS

Berlin, Germany May 4 - 5, 2012

S Y L L A B U S

www.quality-in-endoscopy.org

Berlin, Germany QinE: Colonoscopy & colonic neoplasms www.esge.com

Bowel cleansing: The modern prep methods? Are scales necessary?Brian P. Saunders��..........Page 1

Colonoscopy and management of patients taking antiplatelet agentsChristian Boustière��......Page 4

Tricks, tools, new instruments to approach the caecum: The optimal way toacquire colonoscopy skillsSiwan Thomas-Gibson��...�Page 5

How to record success and is it necessary?Michael Bretthauer��......��...Page 6

Colorectal cancer: Different risk levelsThierry Ponchon��..��Page 7

Missed and interval carcinomas: The truthMichal F. Kaminski....................................��.....��Page 9

New lesions: Histological definitions and endoscopic patternsMichael Vieth��.....Page 11

New lesions: Histological definitions and endoscopic patternsAna Ignjatovic��..�..Page 12

Quality control: The best parameter and how to follow itRoland Valori��...��..Page 13

How to Improve Adenoma Detection � Through technologyRalf Kiesslich��...��..Page 14

How to Improve Adenoma Detection � Through better TechniqueJames East��..��..Page 15

The role of biomarkers to individualize treatment of colorectal cancerThomas Seufferlein��.��..Page 16

CT and MR colonography: Is there a future?Jaap Stoker��.��...Page 18

The new colonoscopes: Latest developmentsJames East��..��..0

Diminutive polyps: The optimal treatment?Siwan Thomas-Gibson��.��Page 21

The malignant adenoma: when to recommend surgery?Evelien Dekker��.�..Page 22

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012

Table of content

Berlin, Germany QinE: Colonoscopy & colonic neoplasms www.esge.com 2

Fig 1

Step 1: Absolute Contraindications - Gastrointestinal Obstruction or perforation Y/N- Ileus or gastric retention Y/N- Acute Intestinal or Gastric Ulceration Y/N- Severe Acute Inflammatory Bowel Disease or Toxic Megacolo Y/N- Reduced Levels of Consciousness Y/N- Hypersensitivity to any of the Ingredients Y/N- Inability to Swallow without Aspiration Y/N- Illeostomy Y/NIf YES to any of above, do not continue & patient must be discussed ASAP with ScreeningDirector or designated deputy.

Step 2: Assess Risk - Known or established renal failure Y/N - 70 years + Y/N - Significant Co-Morbidities - ASA 3+ Y/N - Antihypertensives Y/N- Diuretics Y/N- Congestive heart failure Y/N- NSAIDs Y/N- Anti-depressants Y/N- Anti-psychotics Y/N-Carbamazepine Y/NAll high risk/ radiology patients shall have a biochemistry sample taken Bloods taken for U&E�s, EGFR Y/NAdditional Bloods taken (please circle): LFT/ Clotting/ FBCBy Whom: Date:Is the patient of Afro/Caribbean origin Y/N

Step 3: Bowel Preparation Prescription This is a legal prescription & must be signed and dated.Please supply the said patient with the bowel preparation indicated below:1. 10 x Senna 7.5mg Tablets & 2 x Sachets Citramag/Picolax2. 10 x Senna 7.5mg Tablets & 3 x Sachets Citramag/Picolax3. 2x A&B Sachets of Moviprep4. Extended MoviPrep (3x A&B Sachets)5. 1x 100ml bottle Gastrografin

Dr�s Name:Dr�s Signature: Date: Colon/ VC date:

Step 4: Instructions provided to the patient Dispensed Y/N By Whom: Date:Verbal instructions given Y/N (note: inc. fluid management advice)Written instructions given Y/NAdvice given for taking regular medication Y/N N/A


Step 5: U&E�s resultseGFR result:(eGFR recalculation if Afro/Caribbean origin):Creninatie: Sodium: Pottasium:Urea: FBC/ LFT/ Clotting (if applicable) Printed & attached: Yes/No

Attach Pathology Results to formAbnormal results reviewed by:Outcome:

Stage ofkidneydisease

GFRml/min/1.73m

2

Optimal bowelpreparation

Acceptable bowelpreparation

1 >90

10 x senna7.5mg tabletsand 2 sachetsCitramag

2 60 � 89

10 x senna7.5mg tabletsand 2 sachetsCitramag

3A 45 � 59PEG / Picolax /Citramag

3B 30 - 44PEG / Picolax /Citramag

4 15 � 29PEG (if fluidstatus allows)

Picolax / Citramag

5< 15 orondialysis

PEG (if fluidstatus allows)

Picolax

Other prep required � please specify and document reasons and discussion with authorising clinician (Please note a prescription is required):

The BCSC must receive any dispensed Bowel prep back before re- issuing


The management of anti-platelet agents (APA) has become a frequent problem concerningabout 12% of patients undergoing an endoscopy. So ESGE has decided to achieve a verycomplete guideline published on 2011*. For colonoscopy, we know that polyps are commonand are generally resected in the same time. This situation combining a diagnostic andtherapeutic procedure with a variable bleeding risk requires considering the possibility tomodify the APA treatment after an evaluation of the thrombotic risk of the patients. Most ofthem have coronary diseases and the stents occlusion is prevented by a continuous APAtherapy using aspirin or clopidogrel and the both in high thrombotic risk conditions (recentstroke and all stents less than 6 weeks after insertion and until one year for drug elutingstents). The main point is the knowledge of both the thrombotic risk and the real bleeding riskof the endoscopic procedure. The rule is to never stop APA and particularly aspirin becausemany publications had clearly demonstrated that biopsies or polypectomies can be performedunder aspirin without increasing the bleeding events. For large polyps (>1 cm) and EMR, onemust treat all bleeding or visible vessels during the resection and widely use techniques ofprevention (clips, adrenaline injection, detachable loop) to avoid delayed post-polypectomybleeding. When patients are under dual APA for a very high thrombotic risk, the best decisionis certainly to delay colonoscopy or to replace it by a non-invasive technique if possible.Heparin or NSAID cannot be used as a substitute for APA. For patients under clopidogrelalone, it�s possible to do a switch with aspirin and to resume clopidogrel after the procedure.When APA treatement has to be stopped, 5 days of discontinuation are enough to obtain therestauration of platelet aggregability and the treatment must be resumed as soon as possibleand no later than 48 hours after the procedure. Recent publications have concluded that thebleeding risk after colonic polypectomy under aspirin or clopidogrel was similar but theseresults are a little discordant.To date, we have no published data for digestive endoscopy and the new APA: prasugrel andticagrelor , but it�s admitted that the bleeding risk is higher than the use of aspirin orclopidogrel. These new APA, always used in association with aspirin, must be discontinued 7days before.In conclusion, we recommend to never stop aspirin except for procedures with a very highbleeding risk as large EMR or ESD. It�s essential to give complete information to patients andto take cardiologist advices for all difficult cases.

References Boustiere C et al.Endoscopy and antiplatelet agents: ESGE guideline. Endoscopy 2011; 43:445-58

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: Colonoscopy and management of patients taking antiplatelet agents

Author: Christian Boustière, Saint Joseph Hospital, Marseille, France


Colonoscopy training has evolved over the years however the mainstay of training remains theapprenticeship approach.Evidence suggests that at least 300 colonoscopies are required before a trainee willconsistently achieve a 90% caecal intubation rate (CIR) and competency is reached. Ofcourse CIR is only one aspect of competency but there is a paucity of evidence to suggesthow many cases are needed to acquire the interpretive and therapeutic skills required for theindependent endoscopist.

Colonoscopy is a challenging and variable technique which is the source of both frustrationand fascination for all who practise it. As life long learners, we perhaps should assume thatone can ever master the skill completely because as technology evolves, allowing us toperform ever more complex procedures, we are required to learn the new skills involved.Training can be delivered in a number of ways:

The classic apprenticeship model requires time, dedication and trainers who are bothcompetent in the skill and in training the skill. Improvements in the latter will ensure that thosedelivering training pass on their skills in an efficient and reproducible way.

The evidence for �massed� and �distributed� practise gives us insight into how we should bestapproach skills training, with, no doubt, potential benefits for both models. �Deliberate� and�mental� practise may also allow a trainee to climb the learning curve more quickly.

A number of specific technologies have undoubtedly improved training opportunities. Virtualreality (VR) simulator training has been shown to enhance learning and accelerate skillacquisition. Newer generation simulators with a more challenging and realistic feel for insertiontechnique may make this method of training more useful.

Surely the most significant advance in helping us achieve pain free colonoscopic insertion isthe 3D imager guide. Real-time visualisation of colonic looping has accelerated learning,enhances understanding, facilitates training and allows more �intelligent� colonoscopy in mostcases.

Whether a novice or experienced endoscopist, we would do well to adopt an attitude of life-long learning. Having a recognised mentor or coach to facilitate our professional developmentwill help us on the way to the elusive goal of mastery.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: Tricks, tools, new instruments to approach the caecum: The optimal way to acquire colonoscopy skills

Author: Siwan Thomas-Gibson, St. Mark�s Hospital, Harrow, UK


Success of colonoscopy is not universally defined. Many would agree that success ofcolonoscopy means to reach the cecum, make a correct diagnosis, detect and remove alllesions, without inflicting any complications or pain and discomfort for the patient. Yourhospital administrator would probably add that success also includes holding your dailyschedule (doing the colonoscopy as quickly as possible, without jeopardising �quality�), withinthe boundaries of the available resources.From the abovementioned follows that success can be defined as adhering to a certainstandard of quality. To measure quality, a number of indicators have been evaluated forcolonoscopy. Quality indicators can be divided into process indicators (also called surrogateindicators), and outcome indicators (also called result indicators). Examples of processindicators are polyp and adenoma detection rates, or withdrawal time. Outcome indicators aremissed cancer rates, rates of interval cancer, or perforation rates.

A large number of studies have shown significant variation in quality of performedcolonoscopies, both between countries, centres, and individual endoscopists. Recently, thesevariances in performance have been shown to have imminent importance for patient health,demonstrated by the landmark study of Kaminski and co-workers on the relationship ofadenoma detection rates and interval colorectal cancer (1). Thus, there is a clear need forcolonoscopists to register performance.

To date, a minimum standard set of quality indicators should be collected during eachcolonoscopy. These indicators include in addition to patient data (such as age and sex),clinical indication, diagnosis, and surveillance strategy: Bowel cleansing regimen and quality;sedation; endoscope and equipment used; time to reach the cecum; withdrawal time; polyp,adenoma and cancer detection rates; complications and adverse events; and patientdiscomfort and satisfaction.

Quality indicators should be collected prospectively and continuously. Digital endscopy reportsystems used in endoscopy lab�s should be designed to collect quality indicators automaticallyduring/after each colonoscopy.

It is the responsibility of care provider (hospitals, health care system, or screening programme)to establish quality assurance programs and to follow-up on generated data. QA programscovering individual performance (such as for colonoscopists) must include adequate follow-upof suboptimal performance, guided by the principle �improvement, not punishment�.

References Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and the risk ofinterval cancer. N Engl J Med. 2010;362:1795-803.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: How to record success and is it necessary?

Author: Michael Bretthauer, University of Oslo, Oslo, Norway


Three levels of risk of developing a colorectal cancer are usually defined: average, high and veryhigh. At each level of risk are appropriate follow-up recommendations.

1) persons at average risk of colorectal cancer (sporadic cases)Men and women over 50 with no personal or family history are considered as individuals ataverage risk of developing colorectal cancer. Colorectal cancer is indeed very rare before age 40.The risk increases after age 50. The average age at diagnosis is 70 years.Monitoring is based on the establishment of an organized mass screening program. In Europe,mass screening is mainly based on guaiac or immunochemical FOBT. First-line colonoscopy orrectosigmoidoscopy are used or evaluated in some countries (such as Poland or Germany forcolonoscopy, UK or Italy for rectosigmoidoscopy)

2) persons at high risk for colorectal cancer (non syndromic familial cases, IBD):The risk is 2-5 times higher than for the average risk-population. These cases represent 10-30% ofcolorectal cancer cases. The risk increases with the number of relatives with CRC, the closer therelatives are to the patient, and with the age of CRC in family members. Individuals with a personalhistory of colorectal cancer or adenoma are also at high risk for subsequent development ofcancer. Patients with chronic inflammatory bowel disease (ulcerative colitis, Crohn�s disease) arealso at increased risk: risk factors include long duration (evolving for over 10 years) and extent ofthe disease, young age at onset, complicating sclerosing cholangitis. Risk of colorectal cancer inIBD patients is 10 to 25% over the life._______________________________________________________________________________Familial risk RR 95 % CI_______________________________________________________________________________

One first-degree relative with CRC 2.25 2.00 to 2.53< 45 y 3.87 2.40 to 6.2245-59 y 2.25 1.85 to 2.72> 59 y 1.82 1.47 to 2.25

Two or more first-degree relatives with CRC 4.25 3.01 to 6.02Only two first-degree relatives 3.76 2.56 to 5.51One second or third-degree relative with CRC 1.50Two second-degree relatives with CRC 2.30One first-degree relative with an adenoma < 60 y 1.99 1.55 to 2.55_______________________________________________________________________________RR, relative risk; CI, confidence intervalsBurt RW (Gastroenterol Clin North Am 1996;25:793-803), Johns LE, Houlston RS (Am JGastroenterol 2001;96:2992-3003), European guidelines for quality insurance in colorectal cancerscreening and diagnosis, IARC first edition.

3) persons at very high risk of colorectal cancer (syndromic familial risk)These cases represent 1-5% (mean 3%) of the colorectal cancer cases. One-third of newcases are caused by a de novo mutation. Nearly one out of two will be diagnosed withcolorectal cancer in these families. Familial adenomatous polyposis (FAP). FAP is autosomal-dominant. The risk of getting cancer is almost systematic if no preventive treatment is provided.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: Colorectal cancer: Different risk levels

Author: Thierry Ponchon, Ed. Herriot Hospital, Lyon, France


Hereditary nonpolyposis colorectal cancer (HNPCC) or Lynch syndrome. HNPCC withautosomal-dominant transmission is the most common form of syndromic familial colorectalcancer (up to 5% of the total cases of colorectal cancer) . A consensus group has established alist of criteria (the Amsterdam II criteria) that suggest the presence of the HNPCC phenotype.Other less common familial syndromes are: juvenile polyposis, Peutz�Jeghers syndrome,Cowden syndromeMonitoring is based on oncogenetic consultation, search for mutations and regularchromocoloscopies.


The title refers to colorectal cancers (CRCs) that occur in a relatively short time following a�negative� colonoscopy. In population-based studies of diagnostic colonoscopies they areusually called new or missed CRCs and defined as CRCs diagnosed between 6 months and 3years (or 5 years) from the procedure.

1,2In the screening colonoscopy setting they are called

interval CRCs and defined as CRCs diagnosed before the scheduled time of surveillancecolonoscopy.

3

Based on population-based studies 3.4% to 7.9% of CRCs diagnosed in Canada or UnitedStates were new or missed CRCs.

1,4,5Likewise, interval CRCs represented 9.2% of all CRC�s

diagnosed in a large colonoscopy screening cohort.3For the purpose of this summary, in the

next paragraphs new or missed CRCs will also be called interval CRCs.Three major reasons for the occurrence of interval CRCs are: rapid growth of CRC, incompleteremoval of polyps, or overlooked polyp or CRC.There is growing evidence that some interval CRCs result from alternative CRC pathways.Interval CRCs were more likely than non-interval CRCs to demonstrate microsatellite instability(MSI), CpG island methylator phenotype, and less likely to demonstrate KRAS mutation.

2,6,7

Still, MSI which is known to be associated with rapid transformation through theadenocarcinoma sequence, was present in no more than a third of interval CRCs.

2,7Moreover,

interval CRCs showed comparable rates of poor differentiation to non-interval CRCs.2,6It could

be therefore hypothesized that no more than a third of interval CRCs are due to rapid growth.It has been suggested that incomplete polypectomy, particularly incomplete piecemealpolypectomy of large sessile adenomas, contribute to 27-31% of interval CRCs.

8,9However,

this suggestion was based on the assumption that all interval CRCs located in thepolypectomy segment resulted from incomplete removal. Both studies did not account formissed synchronous lesions in the polypectomy segment.Indirect evidence suggests that more than 50% of interval CRCs is due to lesions overlookedat colonoscopy.

10The reasons for missing CRCs or its precursor lesions are also variable:

limited endoscopic technology, inadequate bowel cleansing, incomplete examination orinadequate visualization of colorectal mucosa.Although there is no evidence for the association between technological limitations ofcolonoscopy and the risk of interval CRCs there are several facts that make this hypothesisplausible. Modern endoscopes still miss 8-13% of the colonic surface.

11Tandem colonoscopy

study has never shown single examiner who does not miss some small adenomas.12There

must be some subtle lesions which are present on endoscopic image but are not recognizedby the examiner.

13

Inadequate bowel cleansing was associated with decreased detection of small and largeadenomas,

14but its association with interval CRCs is currently uncertain.

Incomplete colonoscopy is one of the best established risk factors for interval CRCs. First,interval CRCs are more likely than non-interval CRCs located proximally.

4,5,15Second,

patients examined by endoscopists with higher ceacal intubation rates had lower risk ofdeveloping interval CRC.

15

Inadequate visualization of colorectal mucosa is among the most significantly contributingfactors to the development of interval CRCs. It has been shown that endoscopists� rate ofdetection of adenomas of 20% or more is associated with a 10-fold reduced risk for intervalCRC.

3These results were corroborated by two newer studies showing an association between

higher endoscopists� polypectomy rates and lower risk for interval CRC.4,15

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: Missed and interval carcinomas: The truth Author: Michal F. Kaminski, M. Sklodowska-Curie Institute of Oncology,

Warsaw, Poland


Moreover numerous studies have shown inverse association between gastroenterologyspecialty and the risk of interval CRC.

4,5,15

The described patterns suggest that majority of interval CRCs are due to lesions overlooked atcolonoscopy and are potentially preventable by enhanced colonoscopy performance.

References: 1. Bressler B, Paszat LF, Chen Z, et al. Rates of new or missed colorectal cancers after

colonoscopy and their risk factors: a population-based analysis. Gastroenterology.2007;132:96-102.

2. Sawhney MS, Farrar WD, Gudiseva S, et al. Microsatellite instability in interval coloncancers. Gastroenterology. 2006;131:1700-5.

3. Kaminski MF, Regula J, Kraszewska E, et al. Quality indicators for colonoscopy and therisk of interval cancer. N Engl J Med. 2010;362:1795-803.

4. Cooper GS, Xu F, Barnholtz Sloan JS, et al. Prevalence and predictors of intervalcolorectal cancers in Medicare beneficiaries. Cancer. 2011 Oct 11. doi:10.1002/cncr.26602.

5. Singh H, Nugent Z, Demers AA, Bernstein CN. Rate and predictors of early/missedcolorectal cancers after colonoscopy in Manitoba: a population-based study. Am JGastroenterol. 2010;105:2588-96.

6. Arain MA, Sawhney M, Sheikh S, et al. CIMP status of interval colon cancers: anotherpiece to the puzzle. Am J Gastroenterol. 2010;105:1189-95.

7. Shaukat A, Arain M, Anway R, et al. Is KRAS Mutation Associated with Interval ColorectalCancers? Dig Dis Sci. 2012;57:913-7.

8. Farrar WD, Sawhney MS, Nelson DB, et al. Colorectal cancers found after a completecolonoscopy. Clin Gastroenterol Hepatol. 2006;4:1259-64.

9. Pabby A, Schoen RE, Weissfeld JL, et al. Analysis of colorectal cancer occurrence duringsurveillance colonoscopy in the dietary Polyp Prevention Trial. Gastrointest Endosc.2005;61:385-91.

10. Pohl H, Robertson DJ. Colorectal cancers detected after colonoscopy frequently resultfrom missed lesions. Clin Gastroenterol Hepatol. 2010;8:858-64.

11. East JE, Saunders BP, Burling D, et al. Surface visualization at CT colonographysimulated colonoscopy: effect of varying field of view and retrograde view. Am JGastroenterol. 2007;102:2529-35.

12. Rex DK, Cutler CS, Lemmel GT, et al. Colonoscopic miss rates of adenomas determinedby back-to-back colonoscopies. Gastroenterology. 1997;112:24-8.

13. Rembacken BJ, Fujii T, Cairns A, et al. Flat and depressed colonic neoplasms: aprospective study of 1000 colonoscopies in the UK. Lancet. 2000;355:1211-4.

14. Froehlich F, Wietlisbach V, Gonvers JJ, et al. Impact of colonic cleansing on quality anddiagnostic yield of colonoscopy: the European Panel of Appropriateness ofGastrointestinal Endoscopy European multicenter study. Gastrointest Endosc.2005;61:378-84.

15. Baxter NN, Sutradhar R, Forbes SS, et al. Analysis of administrative data findsendoscopist quality measures associated with postcolonoscopy colorectal cancer.Gastroenterology. 2011 ;140:65-72.


A) Serrated lesions Since it became obvious a few years ago that the classical sequency of adenoma towards

carcinoma cannot be used for aprox. 30% of colorectal carcinoma, another precursor lesionwas identified. So called sessile serrated lesions/polyps/adenomas seem to close the gapbetween carcinoma and a prior unknown precursor lesion. Terminology is very crucial.Unfortunately, due to the confusion some years ago no clear way to name these lesions hasbeen chosen. In fact sessile serrated lesions are no polyps since these lesions are regardedas non polpyoid and are no adenomas since they lack dysplasia. The European guidelines ofcolorectal cancer screening were fully aware of these semantic problems with terminology andmade the proposal to call these lesions �sessile serrated lesion� and not polyp nor adenoma.

Other lesions such as the harmless well known hyperplastic polyp and the traditionalserrated adenoma (mostly found in the distal colon of elderly patients and a true neoplasiawith classical intestinal dysplasia) belong to the group of serrated lesions. Subdifferentiationsof hyperplastic polpys are not recommended for routine use (e.g. goblet cell rich,microvesicular, mucin poor). Mixed polyps with parts of all the above named lesions arepossible. It is not clear yet, whether mixed polpys are a true own entity rather than sessileserrated lesions complicated by classical intestinal dysplasia.

B) Non polypoid including LST Most authors use the term �flat� instead of �non polypoid�. It was felt by the European

guidelines of colorectal carcinoma screening that the term �flat� is too subjective. Therefore,the term �non polypoid� is recommended and defined as at least twice the mucosal height andless than 3mm in height. These lesions are difficult to detect and seem to be more ofteninvolved in so called interval carcinoma cases after a prior unremarkable endoscopy. Theselesions are not to believed to be found more often in any segment of the colon. Nevertheless,most sessile serrated lesions esp. in the right colon belong to this group.

C) Depressed carcinomas Small depressed adenomas less than 1 cm harbour in up to 80% already carcinomatous

foci. Despite the size, these lesions can cause minute and discrete changes of the colon thatare hard to detect without chromoendoscopy or other methods of contrast enhancement. Froma molecular perspective these lesions do not differ much from the classical adenoma-carcinoma sequence but seem to be able to run faster through several steps towardsmalignant transformation compared to classical adenomas that may take up to 17 years formalignant transformation

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: New lesions: Histological definitions and endoscopic patterns Author: Michael Vieth, Klinikum Bayreuth, Bayreuth, Germany


Colonoscopy with polypectomy of adenomas results in 76-90% reduction in expected incidence ofcolorectal cancer (CRC). However, colonoscopy is not fault-less, with adenoma miss rates of about22% (95% confidence interval, CI, 15-32%). Adenoma detection rate has been proposed as one ofthe quality indicators of colonoscopy has been shown to be associated with development of intervalcancer. In addition, 3-5% of patients who develop CRC would have had a colonoscopy within thepreceding 3-5 years and it appears that colonoscopy is protective for left sided cancers but not forright sided ones. This is likely to be multifactorial but tunour biology of the right sided colorectalcancers is thought to be one of the factors. These lesions often arise from relatively flat, subtlepolyps which often have �hyperplastic� appearance and are known as sessile serrated polyps.Non-polypoid colorectal neoplasms (NP-CRN), comprising flat elevated (0-IIa), flat (0-IIb) and flatdepressed (0-IIc) lesions, are intrinsically more difficult to detect without adequate expertise andtechnology. Those with a depression (true IIc component) are thought to be of particular biologicalsignificance and are more likely to harbour high-grade dysplasia or submucosal cancer whencompared to flat elevated or polypoid lesions of the same size. Originally thought to be a Japanesephenomenon, NP-CRNs have now been described worldwide. Although flat and depressed lesionsrepresented only 15% of all neoplasms, 54% of all superficial cancers (defined as intramucosal andT1 cancers) had non-polypoid morphology. Flat and flat elevated lesions are subtle and oftendifficult to detect at standard colonoscopy, particularly if mucosal visualization is sub-optimal.Enhancing mucosal contrast, either by using a dye or advanced optical imaging may improve thedetection of subtle, flat lesions. Chromoendoscopy with indigocarmine increases detection of flat ordepressed CRN. Although narrow band imaging (NBI) probably does not improve overall adenomadetection, it may be helpful when examining for non-polypoid lesions.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: New lesions: Histological definitions and endoscopic patterns Author: Ana Ignjatovic, St. Mark's Hospital, Harrow, UK


This presentation will explore the parameters that best indicate high quality colonoscopy. It willexplain how we might use inputs, outputs and outcomes and discuss their merits anddisadvantages, from the perspective of the patient, payer, hospital, unit and endoscopist. Forsome parameters an adequate sample means that they can only be reported meaningfully atunit, regional or even national level. This means that performance managing colonoscopycannot always occur at the individual level. A framework will be proposed of how we mightreport colonoscopy quality in the future and this will be used as basis for further discussion.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: Quality control: The best parameter and how to follow it Author: Roland Valori, Gloucestershire Royal Hospital, Gloucester, UK


The prognosis for patients with malignancies of the GI-tract is strictly dependent on earlydiagnosis of premalignant and malignant lesions. However, small, flat or depressed neoplasticlesions remain difficult to detect with standard endoscopic technologies thereby limiting theirvalue for cancer screening.

Screening colonoscopy is not able to significantly reduce the incidence of colorectal cancer onthe right side of the colon and a substantial amount of cancers is being missed [1-3]. Potentialexplanations are incomplete colon cleansing, overlooked flat adenomas, serrated lesions andinsufficient skills of the examiners. Thus, standard video endoscopy needs furtherimprovement to evolve as an efficient method for the detection early cancers. Ideally newendoscopic techniques should lead to a reliable diagnosis of precancerous lesions andconditions during ongoing endoscopy.

Three steps are important for proper endoscopic diagnosis: detection; characterization andconfirmation.

Detection of lesions in the gut might be improved using new intraprocedural cleaningtechniques, improved imaging modalities or new optics which provide a wider field of view ofthe mucosa (e.g. third eye imaging). Auto- and exogenous fluorescence techniques aim tounmask lesions with neoplastic potential only.

Characterization of mucosal changes by the examiner is most important, because this stepdetermines the need for endoscopic or surgical interventions. Characterization means topredict histology during ongoing endoscopy. This can be achieved by analysing the type ofcircumscribed mucosal lesion and to specify surface tissue and vessel architecture.Characterization can be eased with chromoendoscopy, virtual chromoendoscopy,spectroscopy or new software filters.

Finally, histological confirmation is needed to define whether the endoscopic intervention wasjustified and cancer or premalignant changes were present or not. This can be accomplishedtraditionally by conventional or most recently with in vivo histology (confocal laserendomicroscopy). Furthermore, functional and molecular imaging might open a new door oftailored and individualized diagnosis and targeted intervention.

References: Kiesslich R, Goetz M, Hoffman A, Galle PR. New imaging techniques and opportunities inendoscopy. Nat Rev Gastroenterol Hepatol. 2011 Sep 6;8(10):547-53.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: How to Improve Adenoma Detection � Through technology

Author: Ralf Kiesslich, University of Mainz, Mainz, Germany


It is now more than 40 years since the first total colonoscopy. Colonoscopy has become themain screening test for colorectal cancer prevention in many countries and is considered to bethe criterion standard for adenoma detection and therapy. Despite this fundamental questionsremain about the best way to perform basic technical aspects of colonoscopy to maximiseadenoma detection and so enhance cancer prevention. Flat lesions and serrated polyps whichare more challenging to detect will require optimal technique if we are to prevent especiallyright sided colon cancer effectively.

Operator performance for adenoma detection varies 10 fold for adenomas of all sizes and 3-4fold for advanced adenomas, suggesting �technique� has a large part to play independent ofthe �technology� used. Indeed the difference between the worst and best performingendoscopists exceeds the difference achievable with any currently available technologyenhancement. Therefore operator technique should be optimised prior to adding newtechnology.

Five core elements may be considered:

1. Bowel preparation. Adenoma detection is impossible without adequate bowel preparation.Worse bowel preparation reduces polyp and adenoma detection. No data exist to suggest thatone bowel preparation improves adenoma detection over another; however splitting the doseimproves prep scores. The endoscopists can further improve on this through vigorous washingand comprehensive suctioning of fluid pools to maximise visualisation.2. Withdrawal time. Longer withdrawal time has been found to correlate with improvedadenoma detection. Six minutes was initially suggested as a minimum in US guidelines;however lengthening withdrawal time does not automatically lead better adenoma detection,the extra time has to be used for more meticulous inspection.3. Position changes. The use of dynamic position changes to distend the lumen, and movedebris and fluid away to dependant areas came from experience with barium enema.Colonoscopic data suggests that changing position during withdrawal to supine for thetransverse and right lateral for splenic and descending colon improves adenoma detection inthese areas. Adenoma detection was correlated with luminal distension.4. Anti-spasmodics. Two recent large randomised controlled trials have provided conflictingresults on this issue. Logically by reducing spasm and flattening haustral folds anti-spasmodics should enhance polyp and adenoma detection, with one trial suggesting benefitbut the other no difference. Patients with obvious spasm appear to benefit.5. Rectal retroflexion. Conflicting data from case series, a small detection benefit may exist,and it is difficult to be sure of a truly comprehensive examination without this manoeuvre.

Investment in operator performance is likely to yield greater benefit than technology given thesize of differences in detection seen in routine practice. Nevertheless it is unclear ifestablished operators can be re-trained to modify their technique to perform at the level of thebest.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: How to Improve Adenoma Detection � Through better Technique

Author: James East, John Radcliffe Hospital, Oxford, UK


Systemic treatment of colorectal cancer has made considerable progress over the last 20years. This is partly due to the introduction of chemotherapeutic agents like oxaliplatin andirinotecan, but also due to the advent of the so called �targeted therapies�. These agents wereinitially proposed to only address tumor-specific properties and should hence confer no harmto non tumorous tissues. The new compounds were backed up by strong preclinical in vitroand in vivo data and therefore considered to be extremely promising. The clinical practicerevealed that for metastatic colorectal cancer some of these compounds are of substanialbenefit to a subgroup of patients, but not to all patients in the clinical trials. This applies toagents targeting the EGF receptor tyrosine kinase, the vascular endothelial growth factor and,more recently, also to multi-kinase inhibitors. Since these compounds are also rather costlythere is a definite need to define markers that allow to select those patients up front who willbenefit from a particular targeted treatment. This optimizes the treatment, saves costs and isthe prerequisite for a so called �personalized cancer treatment�.

Various markers -either predictive or prognostic- have been identified so far and some of themhave found their way in the clinical setting, particularly the assessment of the K-ras mutationstatus. K-ras mutations in colorectal cancer should be examined prior to the start of an anti-EGFR antibody treatment. K-ras is a small GTPase that regulates a plethora of intracellularsignaling events. In about 40% of colorectal cancers there is a mutation within the K-ras genethat renders the G protein constitutively active. There is clear evidence that tumors bearing aK-ras mutation do not respond to anti-EGFR antibodes such as cetuximab and panitumumab.Currently it is unclear whether K-ras mutations are all alike or whether tumors with specific K-ras mutations might still respond to an anti-EGFR treatment (e.g. tumors bearing a K-rasG13D mutation). Colorectal cancers with N-ras mutations (about 5% of the colorectal cancers)are also not likely to respond to an anti-EGFR treatment, but these data are still preliminary. Itis as yet unclear whether the K-ras mutation in a tumor also confers a worse prognosis to apatient.

Mutations in the B-raf gene that encodes for a serine threonine kinase, are found in 4-10% ofcolorectal cancers depending on the tumor stage. The V600E mutation is the most frequentand this mutation leads also to the constitutive activation of the kinase. Data suggest that inthe metastatic setting, this mutation is associated with a dismal prognosis and an impairedresponse to chemotherapy. However, the B-raf mutation does not seem to be predictive for ananti-EGFR treatment.There are also markers that correlate with a better prognosis: Tumor overexpression and/oramplification of epiregulin and amphiregulin, two ligands of the EGFR, is associated with abetter prognosis for the patients.

In contrast to anti-EGFR agents there is little data on prognostic/predictive markers forantiangiogenic strategies. A certain pattern of cytokines such as PlGF, PDGF or bFGF thatemerges during an anti-VEGF treatment may indicate tumor progression in patients treatedwith a combination of chemotherapy plus bevacizumab. However, the data are as yet notrobust enough to use this pattern for clinical decision making and it has to be evaluated in aclinical trial. In addition, preliminary data on a large trial evaluating the treatment beyondprogress with bevacizumab in patients with metastatic colorectal cancer suggest that uponprogress on a combination chemotherapy regimen plus bevacizumab patients do benefit morewhen only chemotherapy is changed but bevacizumab is still added. It will be interesting to

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: The role of biomarkers to individualize treatment of colorectal cancer

Author: Thomas Seufferlein, University of Ulm, Ulm, Germany


learn the molecular mechanisms behind this phenomenon and also to establish markers thatmay allow to differentiate between resistance of a tumor to chemotherapy, to a targeted agentor both.

With the advent of many more novel �targeted� therapeutic strategies for colorectal cancer,e.g. multi kinase inhibitors such as regorafenib, it will be paramount, but also challenging todevelop companion markers to be able to select patients who benefit most from these targetedagents.


CT colonography

Meta-analyses on CT colonography in symptomatic patients showed that CT is a goodalternative to colonoscopy. Sensitivity for colorectal cancer (94.7%) is similar to colonoscopy whilefor polypoid lesions !10mm, per patient sensitivity is 90% and specificity 97% (for !6mm 70-86%and 86-93%, respectively). However, CT colonography can not discriminate betweenadenomatous and non-adenomatous polyps and therefore colonoscopy with biopsy is required. AsCT colonography is a triaging technique, it is most suited for populations with a relatively lowincidence of relevant lesions or in those in whom colonoscopy can not be performed. CTcolonography has proved to be very useful in patients with incomplete colonoscopy. Forsurveillance, CT colonography is also an alternative to colonoscopy; although - given theseemingly higher prevalence of flat lesions and the lower accuracy for flat lesions (approximately70%) � the technique has limitations. In patients with Lynch or FAP, CT colonography is not apreferred technique given the importance of finding diminutive lesions (< 6mm).

The test characteristics of CT colonography make it a potential important screeningtechnique. A comparable yield for advanced adenomas to colonoscopy was found in a study ofover 3,000 CT colonography participants. A systematic review of screening studies found that CTcolonography detected 82.9% of participants with adenomas of 6 mm and larger and 87.9% ofparticipants with adenomas of 10 mm and larger. Corresponding specificities were 91.4% and97.6%, respectively. These results show that CT-colonography has a high sensitivity for thedetection of adenomas of 10 mm and larger. An invitational screening program RCT ofcolonoscopy and CT colonography demonstrated that the participation rate of CT colonography issignificantly higher than of colonoscopy (35% vs 22%). In that study, the yield of colonoscopy foradvanced lesions was significantly higher for colonoscopy (8.7 versus 6.1 per 100 participants; CTcolonography surveillance results not available yet). The differences in participation rate anddiagnostic yield per participant more or less cancelled out in the diagnostic yield per invitee:advanced neoplasia was detected in 1.9 per 100 colonoscopy invitees and in 2.1 per 100 CTCinvitees. Although CT colonography is often reported as less burdensome than colonoscopy, thiswas not confirmed in this screening RCT. Further research concerning costs and costeffectiveness should facilitate comparison of CT colonography to all other CRC screeningtechniques. Further developments of CT colonography include bowel preparation and imageprocessing techniques.

MR colonography The technique of MR colonography is less well established than for CT colonography and thenumber of series is rather limited. A meta analysis of 1285 patients showed that the per-patient summary sensitivity and specificity estimates for polyps 10 mm and larger are 88% and99%, respectively. These results are comparable to CT colonography, but the data for 6-9mmpolyps was very heterogeneous precluding meta analysis. Although MR colonography can beconsidered as an alternative for CT colonography, the largest potential of the technique is apossible future use for molecular imaging (i.e. differentiating between adenomas that willdevelop into cancer and those that will not develop into cancer and can be left in situ).

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: CT and MR colonography: Is there a future? Author: Jaap Stoker, Academic Medical Center, Amsterdam,

The Netherlands


Conclusions There is definite role for CT colonography as alternative to colonoscopy, such as in lowprevalence populations, patients in whom colonoscopy can not be performed or in incompletecolonoscopy. CT colonography has clear potential as screening technique. The technique isless suited in high prevalence populations and in case diminutive lesions are important. MRcolonography can replace CT colonography for large lesions but is still primarily a researchtool.


Colonoscopes have remained fundamentally similar for the last 40 years with the exception ofelectronic video endoscopy which removed the need to look directly into the instrument. Theyconsist of optics at the instrument tip, an insertion tube with a biopsy channel and light guides,and wheels at the instrument head to control tip angulation, that require reprocessing aftereach procedure. Therapy consists of what can be achieved via the biopsy channel. Safe andcomprehensive colonoscopy with these instruments requires considerable skill and dexterityachieved after a long training period. Despite our long experience, looping with patient painand technically difficult examinations to complete confront us every day.

Recently a number of aspects of �push� colonoscopy have been challenged by new devicesand instruments. Perhaps the simplest of these is to abandon colonoscopes for colonoscopy.Balloon enteroscopy has been successful for previously failed procedures by allowing betterfixation of the instrument tip and a longer more flexible instrument. The concept of avoiding�push� from the bottom and instead advancing from the tip is also used in the Invendoscopedevice which unfurls from just behind the tip as an �inverted sleeve�. By not needing to push,loops are not stretched nor do they need reduction improving comfort. An alternative approachto looping is the Neoguide device in which articulated segments follow each other in a �follow-the-leader� style around colonic angulations meaning again loops do not stretch. Finally theAer-O-scope has abandoned the shaft altogether having an optical head in a balloon that ispushed around the colon by gas pressure.

As well as changes to the shaft, most novel colonoscopy systems have adjusted the controlsfor the instrument to become a handset often with a joystick, meaning that minimal manualdexterity is needed to operate the instrument. Other advantages include disposability of atleast part of the instrument, and use of LEDs in the tip to avoid the need for light guides.Alterations to optics might also improve visualisation and hence detection with Aer-O-scopeproviding a 360 degree view of the colonic surface.

Therapeutic instruments may also be changing with dedicated therapeutic platformsdeveloped out of the needs of Natural Orifice Translumenal Endoscopic Surgery (NOTES)research programmes that may give superior tissue manipulation including surgicaltriangulation compared to current instruments within the colonic lumen.

It seems likely that new instruments will remove the need for dexterity for insertion, makecomprehensive mucosal visualisation easier, avoid the need for sedation and stopreprocessing. Complex therapy such as en bloc resection of large polyps may become simplerand faster. These changes could potentially improve colonoscopic screening acceptability,availability, and effectiveness, but perhaps at the cost of moving much colonoscopy out of thehands of highly skilled doctors.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: The new colonoscopes: Latest developments

Author: James East, John Radcliffe Hospital, Harrow, UK


How common are diminutive polyps? Bowel cancer is responsible for the secondcommonest cancer death in England with the average person having a lifetime risk of 1:20.The majority of these cancers are spontaneous and are attributed to the adenoma-carcinomasequence. The English bowel cancer screening population finds an adenoma in 46.5% caseswith a wide range between screening colonoscopists and an even wider range of adenomarate. This range is likely to be due largely to differences in detecting diminutive and smallpolyps. What risk do they carry? Evidence demonstrates that diminutive polyps rarely harbouradvanced pathology however, large and advanced polyps are derived from diminutive polyps.The risk of removing a diminutive polyp is diminutive compared to the risks of removing largepolyps and therefore we have an opportunity to safely interrupt the pathway to malignanttransformation at the earliest phase. Determining future risk and surveillance interval dependson the number (and size) of polyps and therefore pathological confirmation (either optical orhistological) is important How can we best detect and characterise them? The optimal method for detecting andcharacterising diminutive polyps will be discussed elsewhere. Surely there is little debate as towhether we should remove them or not, the question is how best to remove them safely andcompletely. What are the options for removing them? Though small, there are still multiple therapeuticoptions for the removal of diminutive polyps. The decision may be made by familiarity andavailability of kit as well as the relevance of that polyp to the individual patient. Hot biopsy hasgone out of vogue in the UK and certainly proximal to the splenic flexure due to the risk ofdelayed bleeding and perforation. These complications are likely to be due to sub-optimaltechnique but nevertheless there are well recognised safer options. Polyps less than 3mm canbe removed using cold forceps, but care should be taken to remove the entire polyp. Slightlylarger polyps can be removed by cold or hot snare, with or without lifting solution and thechoice will partly depend on the polyp morphology and site in the colon.

Retrieving Tissue. In �pre-optical biopsy� times it is important but often frustratingly difficult toretrieve the histological sample from a diminutive snare polypectomy. Tips for retrieval will bedemonstrated.

Words of caution. Complications can arise from sup-optimal technique and although small,polypectomy of diminutive polyps must be performed safely and completely. All colonoscopists should be trained to competency in removing polyps up 10mm in size.Competency assessment must be part of the certification process and not assumed from theirdiagnostic ability. A validated, structured assessment tool can be used to determine this.

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: Diminutive polyps: The optimal treatment? Author: Siwan Thomas-Gibson, St. Mark�s Hospital, Harrow, UK


When introducing colorectal cancer screening, more and more presymptomatic advancedadenomas and early cancers will be encountered. Detection of these lesions offers anopportunity for definitive endoscopic treatment by endoscopic polypectomy. However, if thelesion appears to be malignant there is a chance of residual disease and these patients mightrequire surgery to prevent recurrent and metastatic disease.

Risk factors for residual disease after endoscopic polypectomy include a positive orunknown resection margin, non-peduculated morphology, deep submucosal invasion (beyondsm1), poor tumour differentiation and lymphovascular invasion. However, even in thepresence of one or more risk factors, residual disease is only present in the minority of cases.As colorectal surgery has significant morbidity and also mortality, for each individual personthe risk of residual disease should be weighed against the risks of the surgical procedure.

If an adenoma appears to contain cancer at histopathologic assessment, the pathologistshould report on all individual risk factors for presence of residual disease so the treatingphysician can advise the patient on the possibility and need for further treatment. However,ideally the endoscopist recognizes the possible invasive character of the adenoma upondetecting it, thus before making a decision on therapy. This will also offer the opportunity totattoo the location of the polyp when suspicious for malignancy.

The endoscopist has several tools to diagnose invasive growth of a colonic lesion: friabilityand tendency to bleed, excavation, ulceration and a Kudo V (irregular) pit pattern. Biopsying alesion for histopathologic assessment does not exclude cancer and might even hindersubsequent endoscopic therapy by fibrosis at the biopsy site. When performing polypectomy,the non-lifting sign is suggestive for invasive growth but can also have been caused byprevious histologic sampling by a biopsy-forceps or previous partial treatment.

Careful endoscopic assessment and recognition of specific features of invasive growthshould prevent performing a useless polypectomy with the accompanying risk ofcomplications. Furthermore, it offers the opportunity to mark the location of a lesion by a tattooto guide either the endoscopist at a next endoscopy to assess the resection-site or thesurgeon during operation.

References: 1. Kudo, GI Clin N Am 19972. Walsh, GIE 19923. Binmoeller, GIE 19964. Kanamori, GIE 19965. Doniec, Dis Colon Rect 20036. Boenicke, Int J Colorectal Dis 20107. Choi, Dis Colon Rect 20098. Tominaga, Dis Colon Rectum 20059. Butte, Dis Colon Rect 2012

Quality in Endoscopy: Colonoscopy & colonic neoplasms May 4 - 5, 2012 Title: The malignant adenoma: when to recommend surgery?

Author: Evelien Dekker, Academic Medical Center, Amsterdam, The Netherlands

G O L D P A R T N E R

S I L V E R P A R T N E R

P A R T N E R

www.quality-in-endoscopy.org

WE WOULD LIKE TO THANK OUR CORPORATE PARTNERS

qine colonoscopy-sylabus_final

Documents