Endoscopia Digestiva ChirurgicaEndoscopia Digestiva ChirurgicaUniversità Cattolica del Sacro CuoreUniversità Cattolica del Sacro CuorePoliclinico “A. Gemelli” - RomaPoliclinico “A. Gemelli” - Roma

Lucio PetruzzielloLucio Petruzziello

“ “ Removal of Adenomatous Polyps Removal of Adenomatous Polyps by Endoscopic Polypectomy by Endoscopic Polypectomy

is associated with a is associated with a 76%-90% CRC Risk Reduction “76%-90% CRC Risk Reduction “

“ “ We now have clearer insight We now have clearer insight into the natural history of colorectal into the natural history of colorectal

cancer cancer and clinical skills and clinical skills with which to intervenewith which to interveneand make difference for many people.and make difference for many people.

Colorectal cancer screening Colorectal cancer screening has come of age ”.has come of age ”.

Sidney J. WinawerSidney J. Winawer

(Welch Allyn - NY)(Welch Allyn - NY)

Low-Res.: Low-Res.: 100.000-200.000 Pixels100.000-200.000 PixelsLow-Res.: Low-Res.: 100.000-200.000 Pixels100.000-200.000 Pixels

Hi-Res.: Hi-Res.: up to 850.000 Pixelsup to 850.000 PixelsHi-Res.: Hi-Res.: up to 850.000 Pixelsup to 850.000 Pixels

HD images are composed of double HD images are composed of double the number of scanning lines (1080 vs. 576) the number of scanning lines (1080 vs. 576)

and horizontal resolution than used and horizontal resolution than used in conventional video systemsin conventional video systems

HD images are composed of double HD images are composed of double the number of scanning lines (1080 vs. 576) the number of scanning lines (1080 vs. 576)

and horizontal resolution than used and horizontal resolution than used in conventional video systemsin conventional video systems

After 40 years …

… No alternative technique

ready for clinical use

Zorzi M. Lo screening colorettale in Italia: survey 2007

Prospective 4 month audit:

9223 examinations Caecal intubation rate 77% Perforation rate 1:769 Only 17% had received supervised training Only 39% had attended a course

Bowles et al Gut 2004Bowles et al Gut 2004

UK National Intercollegiate UK National Intercollegiate Colonoscopy AuditColonoscopy Audit

• 13.7% Screening colonoscopies

• 66% Specific Informed Consent

• 44.9% No Sedation

• 80.7% Completion Rate

Is this you ?

Quality of Colonoscopy to be improved:

Better Colonoscopy Technique

Safe Sedation

Better diagnostic accuracy

Immediate therapy (polypectomy-EMR)

• Completion Rate > 85% (acceptable) or > 90% (desirable)

• Withdrawal time (6’-10’)

• Good to Excellent bowel prep

• Adenomas yeld in > 15% of asymptomatic pts

• Complications Registry

• Patient’s satisfaction questionnaire

• Immediate polypectomy for polyps at low risk for

complications (< 2 cm?)

• Biopsy (?) and delayed polypectomy for other polyps

Source: Italian Ministry of HealthSource: Italian Ministry of Health

Some patients under close colonoscopic surveillance still develop CRC at short intervals

Robertson DJ. Gastroenterology 2005; 129Robertson DJ. Gastroenterology 2005; 129

Fast Track cancers - MMR pathway (15-20%)

Inadequate Bowel Prep

Piecemeal removal of large sessile polyps

Fast withdrawal time

van Rijn JC. Am J Gastroenterol 2006; 101van Rijn JC. Am J Gastroenterol 2006; 101

The Paris endoscopic classification of The Paris endoscopic classification of superficial neoplastic lesionssuperficial neoplastic lesions

Gastrointest Endosc 2003, 58, 6Gastrointest Endosc 2003, 58, 6

Scarcely detected in western countries Japanese endoscopists demonstrated that up to

40% of adenomas in western hospitals are of the flat and depressed type

Fujii T. Endoscopy 1998; 30Fujii T. Endoscopy 1998; 30Saitoh Y. Gastroenterology 2001; 120 Saitoh Y. Gastroenterology 2001; 120

Tsuda S. Gut 2002; 51Tsuda S. Gut 2002; 51

Colonoscopic withdrawal timesColonoscopic withdrawal timesand adenoma detection and adenoma detection during screening colonoscopyduring screening colonoscopy

Barclay RL. N Engl J Med Barclay RL. N Engl J Med 2006;3552006;355

Narrow Band Narrow Band Imaging (NBI)Imaging (NBI)

ChromoendoscopChromoendoscopyy(Indigo Carmine (Indigo Carmine 0.2%)0.2%)

Sampling depth not deeper than Lamina PropriaSampling depth not deeper than Lamina Propria

Intraepithelial Intraepithelial Carcinoma Carcinoma

Intramucosal Intramucosal CarcinomaCarcinoma

Invasive Carcinoma (T1)Invasive Carcinoma (T1)or Early CR Cancer or Early CR Cancer

HGD HGD

Only to confirm unresectabilityOnly to confirm unresectability(neoplastic invasion of the submucosa)(neoplastic invasion of the submucosa)

Adequate skill to remove polyps or NPL (flat lesions) up to 2 cm

Knowledge of Guidelines on Anticoagulation and Antiplatelet Therapy management

Exhaustive knowledge of management of adenomas with invasive carcinoma (pathologic criteria)

Stiff Monofilament Snare best for flat lesions

ESD skills not required

From Ileo-cecal Valve to Upper RectumFrom Ileo-cecal Valve to Upper Rectum

For follow-up endoscopyFor follow-up endoscopy

For the surgeon (especially laparoscopic)For the surgeon (especially laparoscopic)

Tattoo lasts foreverTattoo lasts forever

SPOT: pure carbon suspensionSPOT: pure carbon suspension

How Quality of Colonoscopy How Quality of Colonoscopy

can be improved:can be improved:

Institutional TraningInstitutional Traning

AuditsAudits

Retraining Programs Retraining Programs

Bischops R. Gut 2002Bischops R. Gut 2002

355 EGDs

73 Colonoscopies

5 ERCPs

Italian Residents ExperienceItalian Residents Experience

D.M. 1 agosto 2005 Riassetto delle Scuole di specializzazione di area sanitaria

Gazz. Uff. 5 novembre 2005, n. 258, S.O.

300 EGDs

150 Colonoscopies

30 Polypectomies

Ensuring CompetenceEnsuring Competence

Not Not monitored !monitored !

Bowel preparation quality

Cecal intubation rate (>95%)

Photo documentation of cecal landmarks

Mean withdrawal time > 6-10 min Mean Adenoma Detection Rate (M: 25% - F:

15%)

Adverse or unplanned events

Complication RatesLieberman D. Gastrointest Endosc 2007Lieberman D. Gastrointest Endosc 2007

Rex DL. Am J Gastroenterology 2002Rex DL. Am J Gastroenterology 2002

Imperiali G. Endoscopy 2007Imperiali G. Endoscopy 2007

Routine sedation (Midazolam and Meperidine)Routine sedation (Midazolam and Meperidine)

Less skilled endoscopists supervised by Less skilled endoscopists supervised by experienced physiciansexperienced physicians

Greater access to endoscopy sessions for Greater access to endoscopy sessions for endoscopists with the lowest performance ratesendoscopists with the lowest performance rates

After a failure of cecal intubation, second After a failure of cecal intubation, second attempt made by another endoscopistattempt made by another endoscopist

Physicians with the lowest polyp detection Physicians with the lowest polyp detection rates invited to slow withdrawal phaserates invited to slow withdrawal phase

Corrective MeasuresCorrective Measures

Imperiali G. Endoscopy 2007Imperiali G. Endoscopy 2007

RetrainingRetraining

S. Thomas−Gibson, Endoscopy 2007S. Thomas−Gibson, Endoscopy 2007

20082008 Colonoscopy Retraining Working GroupColonoscopy Retraining Working Group

G. Costamagna, MD G. Costamagna, MD

A. Federici, MDA. Federici, MD

P. D’Argenio, MDP. D’Argenio, MD

E. Di Giulio, MDE. Di Giulio, MD

G. Minoli, MDG. Minoli, MD

L. Petruzziello, MDL. Petruzziello, MD

M.E. Pirola, MDM.E. Pirola, MD

C. Senore, MDC. Senore, MD

M. Zappa, MDM. Zappa, MD

Held by Italian Ministry of Health

Managed by National Screening Observatory (ONS)

Region-based

1-2 Trainers from each Region

National “Train-the-Trainers” Course

Regional “Retraining Courses”

Colonoscopy “Retraining Program”Colonoscopy “Retraining Program”

In collaboration with the 3 Gastroenterological Societies (AIGO, SIED, SIGE) and with the Italian Group for CRC Screening (GISCoR)

2 Eds (Rome, EETC, Sept. 2007 – Campobasso, Oct. 2007)

23 Trainers 1 Master Colonoscopist (CB Williams)

10 Experts (epidemiology, quality, screening principles, sedation, etc.)

Colonoscopy Colonoscopy ““Train the Trainers” CourseTrain the Trainers” Course

Colonoscopy Colonoscopy ““Train the Trainers” Train the Trainers” CourseCourse

Hands-onHands-on

LecturesLecturesSimulator TrainingSimulator Training

Hands-On One-to-Master(Lazio, 2005)

Observational (Lombardia, 2008)

Hands-On Peer-to-Peer

(Emilia Romagna, 2009)

Hands-On One-to-Master(Veneto, 2010)

Regional “Retraining Regional “Retraining Courses”Courses”

Colonoscopy carried out within 30 days after FOBT+ in only 41.0%

19.7% of subjects had to wait for more than two months

Post-polypectomy surveillance takes resources away from screening

According to BSG, ACS, and AGA guidelines, most of patients with 1-2 tubular adenomas

FU in 5-10 years

Follow-up Colonoscopy:Follow-up Colonoscopy:

Screen more,Screen more,

Survey Less,Survey Less,

and Saveand Save

Waye JD. Gastrointest Endosc. 2006Waye JD. Gastrointest Endosc. 2006