Impact of Tilt-Down Positioning Compared With Left Lateral Positioning on Ease of Colonoscope Insertion During Colonoscopy.

GOALS: The aim of this study was to evaluate the efficacy of tilt-down (TD) versus left lateral (LL) positioning in speed and ease of colonoscope insertion in women with risk factors for difficult colonoscopy. BACKGROUND: Risk factors for difficult colonoscopy in women include pelvic surgery, diverticulosis, and thin body habitus. STUDY: Female patients with body mass index (BMI) under 25, diverticulosis and history of pelvic surgery were randomized to TD or LL positioning. Five colonoscopists performed all studies at a single center. Time to splenic flexure and cecum, type and amount of medication administered, Boston Bowel Prep Score (BBPS), adverse events, and findings were recorded. The Mann-Whitney U test was used to evaluate the primary endpoint. RESULTS: A total of 150 women were enrolled (81 TD, 69 LL). The mean age was 60.1 (SD 10.5) and the mean BMI was 23.9 (SD 3.5). In total 98 (65.3%) women had prior pelvic surgery, 94 (62.7%) had BMI <25 and 60 (40.0%) had diverticulosis. There was no statistically significant difference in time to the splenic flexure overall but insertion to the splenic flexure was significantly faster in the TD position as compared with the LL position in patients with diverticulosis (124 s for TD, 160 s for LL, P=0.022). In a linear regression analysis, lower BMI, diverticulosis and lower BBPS were significantly associated with a longer insertion time to the splenic flexure. There were no adverse events. CONCLUSION: TD positioning represents a straightforward maneuver to facilitate advancement through the sigmoid colon and may be beneficial in women with diverticular disease.

Resect and discard approach to colon polyps: real-world applicability among academic and community gastroenterologists.

BACKGROUND: "Resect and discard" (RD) is a new paradigm for management of diminutive polyps. AIM: To compare concordance of surveillance interval recommendations and diagnostic performance between RD and standard of care in a hospital outpatient department with both academic and community gastroenterologists. METHODS: Prospective, observational study conducted at a single outpatient endoscopy center over 12 months. Patients with diminutive polyps on screening or surveillance colonoscopy were included. Histology predictions for all diminutive polyps (≤5 mm) were made based on endoscopic imaging. Concordance of recommended surveillance intervals and diagnostic performance of histology predictions were compared to histopathological review. RESULTS: A total of 606 diminutive polyps were found in 315 patients (mean age 62.4 years, 49 % female). Histological prediction was made in 95.7 % of polyps (97.4 % of patients), with high confidence in 74.3 %. The concordance for surveillance intervals was 82.1 % compared to histopathological review and was similar between community and academic gastroenterologists (80.2 vs. 76.3 %, p = 0.38). Overall, sensitivity, specificity, and accuracy of histological predictions made with high confidence were 0.81, 0.36, and 77.1 %. Predictions made with narrow-band imaging (NBI) had lower accuracy (73.9 % with NBI vs. 82.5 % with high-definition white light (HWDL) only, p = 0.017) as well as lower prediction confidence (score of 7.6 with NBI vs. 8.6 with HDWL only, p < 0.001). CONCLUSIONS: Our surveillance interval concordance was below the 90 % threshold deemed acceptable by the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations statement. Diagnostic performance using optical imaging to predict histology was equal between community and academic endoscopists.

CT colonography: multiobserver diagnostic performance.

PURPOSE: To prospectively evaluate multiobserver diagnostic performance and reader agreement for colorectal polyp detection in a well-characterized cohort of patients with increased number of polyps, compared with an average-risk patient, with colonoscopy as the reference standard. MATERIALS AND METHODS: A cohort of 70 patients suspected of having polyps was examined with spiral computed tomographic (CT) colonography, with colonoscopy performed the same day. After air insufflation per rectum, supine and prone images were obtained with single-detector row CT (5-mm collimation, 8-mm table increment, 2-mm reconstruction interval). Images were analyzed independently by four experienced abdominal radiologists using two-dimensional multiplanar reformation followed by selective use of three-dimensional endoscopic volume-rendered images. Data were analyzed both per polyp and per patient. RESULTS: Analysis per polyp demonstrated a pooled sensitivity of 0.68 for lesions 10 mm or larger (n = 40), with 75% agreement among the four readers. Analysis per patient demonstrated improved detection and agreement, with a pooled sensitivity of 0.88 for patients with polyps or cancers 10 mm or larger (n = 28), with 94% agreement. When sensitivity and receiver operating characteristic analyses were analyzed per polyp size threshold, results among readers converged and peaked at polyp diameters of approximately 10 mm. CONCLUSION: In this patient cohort, diagnostic performance and interobserver agreement with single-detector row CT colonography was sufficient for detection of patients with lesions 10 mm or larger, with more variable results for smaller polyps.