Mastering the Difficult Colonoscopy and Polypectomy

Mastering the Difficult
Colonoscopy and
Polypectomy
Douglas K Rex
Indiana University Health
Indianapolis, Indiana
What makes a master
colonoscopist?
 Basics:
– Split or same day dosing of preps
• Adjust the volume for the patient
– High definition optics
• Increases ADR by 2-4%
• Essential to effective EMR
– Measure and prove high ADR
– CO2 in all cases
• Essential for EMR, (ESD), stent placement,
decompression of ACPO
What makes a master
colonoscopist?
 Liberal use of water immersion
– Essential for difficult sigmoids, for
redundant colons and for unsedated exams
 Mastery of serrated lesions
– Terminology, histology, recognition,
resection, identification of SPS
 Mastery of endoscopic lesion diagnosis
– Should be few surprises from path about
identification of cancer
– Should be few surprises from path about
adenoma vs serrated class lesions
What makes a master
colonoscopist?
 Should send very few benign colon polyps for surgical
resection
– Surgery has higher risk, worse complications and
higher costs
 Should be able to overcome all of the common obstacles
to effective EMR of larger colorectal lesions
– Or recognize limitations and refer to someone who
can
 Should follow the recommended screening and
surveillance intervals
Be as safe as possible
 Avoid “diagnostic” perforation
– Never push against fixed resistance
– Switch to water in difficult sigmoid
 Avoid splenic injury
– Be careful with torque in the proximal colon
 Reduce aspiration
– Anesthesia and deep sedation
 Reduce post-polypectomy bleeding
– Limit thermal injury
 Reduce missing
– Measure ADR
What makes an insertion
difficult?
 What will I do when you refer me an
incomplete colonoscopy?
– Look at the report and classify the problem:
• Redundant colon: adult scope and WI
• Angulated sigmoid: skinny scope and WI
Left hand grip on the
insertion tube
 Enables rotation and distance control
while freeing the right hand
 Optimizes tip control*
 Optimize deflection capability
 Reduce stress on the left thumb
Left hand scope grip
Left hand scope grip
What makes polypectomy and
EMR difficult?
 What will I do when you refer me a large
or difficult colon polyp?
– Large:
– Flat:
– Hard to access:
– On ICV or medial wall of the cecum:
– Scarred down:
– Not difficult: serrated lesions
Best tools and tricks for EMR:




Longer lasting injection: hydroxyethyl starch
Include contrast agent
Use stiff snare (limit to 15-20 mm size)
Use cap on ICV, medial wall of cecum (for
access)
 Use short cap technique for very flat polyp
 Limit thermal injury
 The very new:
– Avulsion (Haber)
– Underwater EMR (Binmoeller)
Approach to Large Lesions
Inspect the entire surface of
the lesion
 Look for morphologic changes of cancer
– Ulcers
– Nodules
 Look for vessel and pit pattern changes of
cancer
Limiting Thermal Injury
EMR of large lesions –
summary of key points







Usually start at distal end
Inject a lot
Get into submucosal space
Squeeze tissue tight and use more cut
Move the submucosal wave proximally
Go into retroflexion as needed
Remember coag graspers for acute
bleeding
Approach to flat lesions
Soft short cap
Cap-fitted
Avulsion – alternative to
ablation for small flat areas
Dealing with flat – summary
of key steps
 Stiff snare
 Use cap technique
 Avulse small flat areas and small fibrotic
areas
 Limit ablative methods (APC)
Approach to Difficult to
Access
Proximal Edge Injection
Access to ileo-cecal valve
Summary of tools for difficult
to access and ICV polyps
 Retroflexion
– Switch to thinner scope if necessary
 Cap on scope – adult scope preferred on
ICV
Approach to scarred down
 Can still lift if large amount of residual
polyp
 Consider underwater resection with lesion
floating
 Use stiff snare
 Ablate the margin of the new resection
and the old scar
Scarred down
Summary
 Objectively assess your own performance
 Know rules for staying safe
 Know tools for successful cecal intubation
in
– Redundant colons;angulated sigmoids
 Know tools to overcome each of the
challenges in difficult polyps
– Large, flat, hard to access, ICV, scarred
down
Technical Performance of
Water-Assisted Colonoscopy
 Water immersion
– Turn off the gas at the source
– Fill the colon with sufficient water to tell the
luminal direction
– Remove the water during withdrawal
 Water exchange
– Fill the colon with water and remove during
insertion
Water assisted colonoscopy
 Roles for water assisted insertion
– Reduce pain and sedation requirements (A)
– Improved preparation quality (A)
– Detection of more adenomas (B)
– Cecal intubation in redundant colon (B)
– Passing the angulated sigmoid (C)
– Prevention of barotrauma perforation (C)
Role of CO2 in colonoscopy
 Use in all cases: reduced post-procedural
pain (A)
– For intraprocedural pain water immersion is
more effective (A)
 Selective use:
– EMR and ESD (B)
– Severe diverticular disease (prevention of
delayed barotrauma) (C)
– Decompression (C)
– Stent placement (C)
Difficult colonoscopy has 2
basic causes
 Redundant colon
– Standard colonoscope and good technique
– Water immersion
– 4 handed pressure
– Overtubes
 Angulated sigmoid
– Pediatric colonoscope, Ultrathin colonoscope, narrow push
enteroscope, balloon enteroscope (single or double)
– 4 handed pressure
– Water immersion
Detection
What doesn’t work or isn’t
practical
For seeing behind folds
 170 angle of view (A)
 Short caps* (A)
 Third-Eye Retroscope (A)
*benefit is minor
For detection of flat
lesions
 NBI (A)
 FICE (A)
 i-scan (A)
 Autofluorescence (A)
What does work
For seeing behind folds
 Endocuff (A)
 Endorings (A)
 G-EYE (A)
 Full Spectrum Endoscopy
(FUSE) (A)
For seeing flat lesions
 Chromoendoscopy (pancolonic dye-spraying)* (A)
*essential in IBD and
effective (though
impractical) in routine
screening and surveillance
Dealing with “flat”
– short cap on the tip
Endocuff
Endocuff
EndoRings
Endorings
Pentax G – Eye
™
Endoscopy
Full Spectrum
FDA cleared & CE Mark
330º Field of View
Full Spectrum Endoscopy
(FUSE)
Difficult colonoscopy and
polypectomy
 What are the best evidence based
methods?
– A: randomized controlled trials
– B: case-control, cohort, observational
– C: opinion
 Should I try something new?
Polypectomy
Cold snare polypectomy
 Reduced risk of delayed hemorrhage (B)
 More effective and more efficient than cold
forceps for polyps ≤ 5 mm (A)
 Mixed results on effectiveness compared
to hot snaring for polyps 5-10 mm
– Key is to anchor the snare tip away from the
polyp and strip normal mucosa from around
the polyp
Cold snaring
Cap for access
Underwater EMR
New tools in colonoscopy
 Difficult colonoscopy
– Water immersion
– CO2
 Difficult polypectomy
– Hydroxyethyl starch with contrast agent
– Short cap on scope
– Avulsion
– Underwater EMR
Improving the Quality of
Your Colonoscopy
Douglas K Rex
Indiana University Health
Indianapolis, IN
Bowel Preparation
Bowel preparation scales
 Aronchick
– Aronchick GIE 2004; 60: 1037-8
 Ottawa
– Rostom GIE 2004;59: 482-6
 Boston
– Lai GIE 2009; 69: 620-25
– Calderwood GIE; 2010; 72;686-92
 Chicago
– Gerard; Clinical Translational Gastroenterology
(2013) 4, e43; doi:10.1038/ctg.2013.16
Boston Bowel Preparation Scale
 Right, transverse and left colon segments
– 0 = unprepared colon segment with stool that cannot be
cleared
– 1 = portion of mucosa in segment seen after cleaning,
but other areas not seen because of retained material
– 2 = minor residual material after cleaning, but mucosa
of segment generally well seen
– 3 = entire mucosa of segment seen well after cleaning
– Total score ranges from 0 to 9
• Lai et al GIE 2009;69:620-25
Chicago Bowel Preparation
Scale
 Cleaning scores
– 0 = unprepared colon segment with stool that cannot be
cleaned (> 15% of the mucosa not seen)
– 5 = portion of mucosa in segment seen after cleaning; but up
to 15% of the mucosa not seen
– 10 = minor residual material after cleaning, but mucosa of the
segment generally well seen
– 11 = entire mucosa of segment well seen after washing
– 12 = entire mucosa of segment well seen before washing
(suctioning of liquid allowed)
 Fluid scale (not shown here)
– Gerard Clin Trans Gastroenterol (2013) 4,
e43;doi:10.1038/ctg.2013.16
Correlation with adequate
preparation
 Boston BPS
– Overall score ≥ 2 in each segment predicts
doctors will follow screening and
surveillance guideline
• Calderwood GIE; 2014; 80:269
New guidelines for bowel
preparation from the USMSTF
 Johnson, DA et al
– Gastroenterology 2014;147:903
– Gastrointestinal Endoscopy 2014;80:543
– Am J Gastroenterology 2014;109:1528
New guidelines for bowel
preparation from the USMSTF
 Adequate preparation should be achieved
in ≥ 85% of exams (per physician)
 Keys to success:
– Split or same day dosing
– Judge preparation after washing and
suctioning
– Adjust for predictors of inadequate
preparation
Why make a target for
adequate preparation?
 Increased costs from repeat procedures
– 1% rule: for each 1% of preparations that
are inadequate the cost of delivering
colonoscopy increases by 1%




Lower detection of small and large polyps
Lower detection of flat lesions
Longer procedural times
Patients lost to follow-up
What is an adequate
preparation?
 MSTF: able to see polyps > 5 mm in size
– This is an operational definition of a
preparation that permits detection of
clinically significant lesions
– Adequate is accompanied by the
expectation that the screening and
surveillance guidelines will be followed
Predictors of inadequate
preparation
Medical predictors
 Prior failed preparation
 Chronic constipation
 Constipating meds
– Opioids
– tricyclics
 Obesity
 Diabetes mellitus
 Prior colon resection
Predict not following
instructions
 Medicaid insurance
 English not first language
 Lower educational
language
 Longer waiting time
between date procedure
scheduled and day of
procedure
 Low health literacy
 Low “patient activation”
Responses to medical
predictors
 Prior failed preparation
– “two-day” preparations
 Other predictors
– Standard prep “plus”
Responses to predictors of not
following instructions
 Increase education
– Closed access (require pre-procedure visit)
– Second language instructions
– Navigation
Bowel prep quality
 New target: 85% or higher rate of
adequate prep
 Key methods:
– Split or same day dosing
– Clean up and then rate the prep
– Identify predictors of failure before the
procedure
Adenoma detection rate
 % of patients age ≥ 50 years having first time
screening colonoscopy with ≥ 1 conventional
adenoma documented (Targets ≥ 25% in men and
≥ 15% in women)
– Proposed by USMSTF on Colorectal Cancer
• Rex et al Am J Gastroenterol 2002;97:1296-308
 Validated
• Kaminski et al 2010;362:1795-80
• Corley et al NEJM 2014;370:1298-306
 Expect targets to rise as result of Corley study!
Colonoscopist variation
 136 GI docs, 223,842 patients, 264,972
colonoscopies, 714 interval cancers
 Patients of docs in highest ADR quintile
had 0.52 risk of cancer compared to
lowest quintile ADR
 3% incidence and 5% mortality reduction
for each 1% increase in ADR
 ADR effects present for proximal/distal
colon, men and women, early/late stage
• Corley et al NEJM 2014;370:1298-306
Improving adenoma detection
 Measurement can help (mixed evidence)
 Education is effective!!!
– Lesion recognition
– Basic withdrawal technique
• Barclay et al CGH;2008:6:1091-8
• Coe et al Am J Gastroenterol;2013;108:219-26
 Are devices effective?
First phase polyp detection
tools and devices
Mucosal exposure
 170-230 angle of view
 Cap-fitted *
 Third-Eye
Highlighting flat lesions
 Chromoendoscopy*
 High definition*
 Narrow band imaging
 FICE
 i-scan
 Autofluorescence
* some benefit
* some benefit
Third Eye Panoramic Device
 Two side-viewing cameras supplement
colonoscope’s forward view to create
panoramic video image displayed on
single monitor
 Clips onto the exterior of any standard
pediatric or adult colonoscope
– Keeps working channel
free to allow full suction
and passage of instruments
– No major capital expense for new
scopes & systems
 Can be disinfected & reused
multiple times, significantly
reducing cost per procedure
This device is currently under 510(k) review by the FDA, not available for sale in United States
Third Eye Panoramic Device
 Feasibility study with 25
patients showed:
– Cecum was
reached in
all subjects
– No interference with
mobility, tip
deflection,
retroflexion,
polypectomy
– Side views enabled
detection of
additional lesions
– No adverse events
This device is currently under 510(k) review by the FDA, not available for sale in United States
Second Phase Devices




FUSE
Endocuff
Endorings
G-EYE
Full Spectrum Endoscopy
(FUSE)
Second phase devices
Tandem studies
Technology
Author
Number
of
patients
Technology
adenoma
miss rate
(per lesion)
Standard
colonoscop
y adenoma
miss rate
p
FUSE
(3 CCD 330
angle of view
scope)
Gralnek
185
7%
41%
<0.0001
G-EYE
(balloon –
Pentax only)
Gross
112
4%
44%
<0.0001
Endorings
(OTS fold
straightener)
Dik
71
15%
48%
<0.0001
Endocuff RCTs
Author
With
Endocuff
No Endocuff
P
Biecker
J Clin Gastro
2014
36%
28%
.043
Total
Biecker
adenomas per J Clin Gastro
patient (APC) 2014
2.0
1.0
.002
Total
Floer
adenomas per UEGW 2014
patient (APC)
0.90
0.54
.014
Patients with
≥ 1 adenoma
(ADR)
Serrated lesion detection
 All of the same issues apply
 No targets for serrated lesions yet
Cecal intubation documentation
Right Colon Documentation
Intervals
 Still no evidence for 5 year intervals in
average-risk screenees – should be 10
years
 Cost-effective cancer protection related to
adequate rates of preparation and
adequate ADR
Easier measurement
 Registry participation
– GIQuIC (GI Quality Improvement
Consortium); ACG and ASGE
– DHOR (Digestive Health Outcome
Registry); AGA
Potpourri
Potpourri
 High definition
– Small gains in detection
– Essential to modern EMR
– Essential to real-time “optical biopsy”
 Insufflate with CO2
– Best to use for all cases
– Essential for large EMRs
 Water immersion
– Difficult sigmoids
– Unsedated examinations
– Redundant colons
Quality in Colonoscopy
 4 Basic Measures
– Bowel preparation
– Detection
– Documentation of cecal intubation
– Screening and surveillance intervals
 Recommended essentials
– High definition
– CO2
– Water immersion in selected cases
Polypectomy
Two common issues in
polypectomy
 Cold snaring
– Strip out normal mucosa
 Serrated lesions > 1 – 1.5 cm in size
– Inject with a contrast agent
Bowel preparation scales
Scale
Validated Considers retained
fluid
Aronchick
Yes
Yes
Ottawa
Yes
Yes
Boston
Yes
No
Score of ≥ 2 in each
segment
Chicago
Yes
Yes
Score of ≥ 25 defines a
preparation that allows
≥ 95% of mucosa to be
seen
“Modified
Chicago”
No
Predicts an adequate
preparation
Rex assessment
Standard
Olympus
colonoscopy
FUSE
Endocuff
Endorings
Insertability
+++++
++++
++++
+++
Image quality
+++++
++++
+++++
+++++
+++++
++++
+++++
Fold exposure +++
4 Key Colonoscopy Quality
Measures
 Adenoma detection rate
– Males: 30%
– Females: 20%
 Cecal intubation rate
– Overall 90%
– Screening: 95%
 Adherence to screening and surveillance
intervals: 90%
 % of cases with adequate bowel
preparation: 85%
Keys to optimal bowel
preparation in colonoscopy
 Split or same day dosing (A)
 Adjust the prep strength for predictors of failure (C)
– Opioids, tricyclics, chronic constipation, prior colon
resection, diabetes, obesity, prior failed prep
 Rate the preparation after clean-up
– Boston or Chicago scales
 If the prep is adequate follow the screening and
surveillance guidelines
– Target for success of 85%