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Digestive Diseases and Sciences

, Volume 63, Issue 10, pp 2573–2581 | Cite as

Self-Formation Assessed by Cumulative Summation Test Does Not Reach Recommended Thresholds for Optical Diagnosis of Colorectal Polyps ≤ 7 mm

  • Francisco Javier García-Alonso
  • Isabel Manzano Santamaría
  • Antonio Guardiola Arévalo
  • Rubén Pique Becerra
  • Amanda Leandro Barros
  • Noelia de Sande Rivera
  • Guillermo Moreno Casas
  • Silvia Arribas Terradillos
  • Álvaro Llerena Riofrío
  • Cristian Aitor Escolano Peco
  • Emma Alguacil Rodríguez
  • Fernando Bermejo
Original Article

Abstract

Background and Aims

Accurate optical diagnosis of diminutive polyps would allow implementing a resect and discard strategy. We evaluated the learning curve of a single training session followed by self-education in subjects with no endoscopic experience.

Methods

Learning curves were evaluated in 38 subjects employing learning curve–cumulative summation (LC‐CUSUM) tests, with each participant attending one training session regarding narrow band imaging and optical diagnosis and then individually assessing 100 lesions, receiving feedback after each diagnosis. Diagnostic accuracy was subsequently evaluated in 180 patients with lesions ≤ 7 mm. Evaluators predicted each polyp’s histology and recommended a surveillance interval. Determinants of accuracy were explored using regression analysis.

Results

According to the LC‐CUSUM curve, 20 evaluators (52.6%) reached diagnostic competence after 57 lesions (IQR 55–76.5). During the diagnostic performance assessment, 11,666 diagnoses and 6840 follow-up recommendations were generated. Considering high confidence diagnoses, accuracy was 81.3% (80.5–82.1%), negative predictive value (NPV) for rectosigmoid adenomas 78.6% (76.4–80.6%), and sensitivity for adenomas 86.6% (85.8–87.4%). Two (5.3%) evaluators reached a ≥ 90% accuracy, 3 (7.9%) presented a NPV for rectosigmoid adenomas ≥ 90%, and 18 (47.4%) a sensitivity for adenomas ≥ 90%. Multivariable logistic regression showed high confidence and size ≥ 5 mm as the strongest predictors of accuracy. Fifteen (39.5%) evaluators recommended a correct or reduced follow-up interval in over 90% of subjects.

Conclusions

Self‐formation after a single training session did not allow most evaluators to reach the required accuracy. LC-CUSUM tests did not identify competent evaluators. Despite these results, 86.7% of follow-up intervals would have been corrected or reduced.

Keywords

Colonoscopy Colonic polyps Adenomatous polyps Narrow band imaging Learning curve Cumulative summation tests 

Notes

Author’s contribution

FJGA, IMS, and FB designed the project. ALB, NdSR, GMC, SAT, ALR, CAEP, and EAR involved in acquisition of data. FJGA and RPB involved in analysis and interpretation of data. FJGA, IMS, AGA, FB drafted the article. All the authors finally approved.

Compliance with ethical standards

Conflict of interest

None of the authors has potential conflicts of interests.

References

  1. 1.
    Baxter NN, Warren JL, Barrett MJ, Stukel TA, Doria-Rose VP. Association between colonoscopy and colorectal cancer mortality in a US cohort according to site of cancer and colonoscopist specialty. J Clin Oncol. 2012;30:2664–2669.CrossRefGoogle Scholar
  2. 2.
    Nishihara R, Wu K, Lochhead P, et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med. 2013;369:1095–1105.CrossRefGoogle Scholar
  3. 3.
    Corley DA, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298–1306.CrossRefGoogle Scholar
  4. 4.
    Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Engl J Med. 2003;349:2191–2200.CrossRefGoogle Scholar
  5. 5.
    Lieberman D, Moravec M, Holub J, Michaels L, Eisen G. Polyp size and advanced histology in patients undergoing colonoscopy screening: implications for CT colonography. Gastroenterology. 2008;135:1100–1105.CrossRefGoogle Scholar
  6. 6.
    Lieberman DA, Rex DK, Winawer SJ, Giardiello FM, Johnson DA, Levin TR. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844–857.CrossRefGoogle Scholar
  7. 7.
    Dekker E, Fockens P. Advances in colonic imaging: new endoscopic imaging methods. Eur J Gastroenterol Hepatol. 2005;17:803–808.CrossRefGoogle Scholar
  8. 8.
    Kudo S, Tamura S, Nakajima T, Yamano H, Kusaka H, Watanabe H. Diagnosis of colorectal tumorous lesions by magnifying endoscopy. Gastrointest Endosc. 1996;44:8–14.CrossRefGoogle Scholar
  9. 9.
    IJspeert JEG, Bastiaansen BAJ, van Leerdam ME, et al. Development and validation of the WASP classification system for optical diagnosis of adenomas, hyperplastic polyps and sessile serrated adenomas/polyps. Gut. 2016;65:963–970.CrossRefGoogle Scholar
  10. 10.
    Hewett DG, Kaltenbach T, Sano Y, et al. Validation of a simple classification system for endoscopic diagnosis of small colorectal polyps using narrow-band imaging. Gastroenterology. 2012;143:599–607.e1.CrossRefGoogle Scholar
  11. 11.
    Rex DK, Kahi C, O’Brien M, et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc. 2011;73:419–422.CrossRefGoogle Scholar
  12. 12.
    Ignjatovic A, East JE, Suzuki N, Vance M, Guenther T, Saunders BP. Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect and Discard; DISCARD trial): a prospective cohort study. Lancet Oncol. 2009;10:1171–1178.CrossRefGoogle Scholar
  13. 13.
    Kaltenbach T, Rastogi A, Rouse RV, et al. Real-time optical diagnosis for diminutive colorectal polyps using narrow-band imaging: the VALID randomised clinical trial. Gut. 2015;64:1569–1577.CrossRefGoogle Scholar
  14. 14.
    Paggi S, Rondonotti E, Amato A, et al. Resect and discard strategy in clinical practice: a prospective cohort study. Endoscopy. 2012;44:899–904.CrossRefGoogle Scholar
  15. 15.
    Ladabaum U, Fioritto A, Mitani A, et al. Real-time optical biopsy of colon polyps with narrow band imaging in community practice does not yet meet key thresholds for clinical decisions. Gastroenterology. 2013;144:81–91.CrossRefGoogle Scholar
  16. 16.
    Patel SG, Schoenfeld P, Kim HM, et al. Real-time characterization of diminutive colorectal polyp histology using narrow-band imaging: implications for the resect and discard strategy. Gastroenterology. 2016;150:406–418.CrossRefGoogle Scholar
  17. 17.
    Grupo de trabajo de la guía de práctica clínica de prevención del cáncer colorrectal. Actualización 2009. Guía de práctica clínica. Barcelona: Asociación Española de Gastroenterología, Sociedad Española de Medicina de Familia y Comunitaria, y Centro Cochr; 2009.Google Scholar
  18. 18.
    Biau DJ, Williams SM, Schlup MM, Nizard RS, Porcher R. Quantitative and individualized assessment of the learning curve using LC-CUSUM. Br J Surg. 2008;95:925–929.CrossRefGoogle Scholar
  19. 19.
    López MJ, García D, Rodríguez A, Colodrón M, Vassena R, Vernaeve V. Individualized embryo transfer training: timing and performance. Hum Reprod. 2014;29:1432–1437.CrossRefGoogle Scholar
  20. 20.
    Je S, Cho Y, Choi HJ, Kang B, Lim T, Kang H. An application of the learning curve-cumulative summation test to evaluate training for endotracheal intubation in emergency medicine. Emerg Med J. 2015;32:291–294.CrossRefGoogle Scholar
  21. 21.
    McGill SK, Evangelou E, Ioannidis JPA, Soetikno RM, Kaltenbach T. Narrow band imaging to differentiate neoplastic and non-neoplastic colorectal polyps in real time: a meta-analysis of diagnostic operating characteristics. Gut. 2013;62:1704–1713.CrossRefGoogle Scholar
  22. 22.
    Rees CJ, Rajasekhar PT, Wilson A, et al. Narrow band imaging optical diagnosis of small colorectal polyps in routine clinical practice: the Detect Inspect Characterise Resect and Discard 2 (DISCARD 2) study. Gut. 2017;66:887–895.CrossRefGoogle Scholar
  23. 23.
    Ignjatovic A, Thomas-Gibson S, East JE, et al. Development and validation of a training module on the use of narrow-band imaging in differentiation of small adenomas from hyperplastic colorectal polyps. Gastrointest Endosc. 2011;73:128–133.CrossRefGoogle Scholar
  24. 24.
    Atkin W, Valori R, Kuipers E, et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition—colonoscopic surveillance following adenoma removal. Endoscopy. 2012;44:SE151–SE163.CrossRefGoogle Scholar
  25. 25.
    Cairns SR, Scholefield JH, Steele RJ, et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut. 2010;59:666–689.CrossRefGoogle Scholar
  26. 26.
    Hassan C, Quintero E, Dumonceau J-M, et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2013;45:842–851.CrossRefGoogle Scholar
  27. 27.
    Pohl H, Bensen S, Toor A, et al. Quality of optical diagnosis of diminutive polyps and associated factors. Endoscopy. 2016;48:817–822.CrossRefGoogle Scholar
  28. 28.
    Paspatis GA, Tribonias G, Konstantinidis K, et al. A prospective randomized comparison of cold vs hot snare polypectomy in the occurrence of postpolypectomy bleeding in small colonic polyps. Color Dis. 2011;13:345–348.CrossRefGoogle Scholar
  29. 29.
    Ichise Y, Horiuchi A, Nakayama Y, Tanaka N. Prospective randomized comparison of cold snare polypectomy and conventional polypectomy for small colorectal polyps. Digestion. 2011;84:78–81.CrossRefGoogle Scholar
  30. 30.
    Kessler WR, Imperiale TF, Klein RW, Wielage RC, Rex DK. A quantitative assessment of the risks and cost savings of forgoing histologic examination of diminutive polyps. Endoscopy. 2011;43:683–691.CrossRefGoogle Scholar
  31. 31.
    Chaptini L, Chaaya A, Depalma F, Hunter K, Peikin S, Laine L. Variation in polyp size estimation among endoscopists and impact on surveillance intervals. Gastrointest Endosc. 2014;80:652–659.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Francisco Javier García-Alonso
    • 1
  • Isabel Manzano Santamaría
    • 2
  • Antonio Guardiola Arévalo
    • 2
  • Rubén Pique Becerra
    • 2
  • Amanda Leandro Barros
    • 3
  • Noelia de Sande Rivera
    • 3
  • Guillermo Moreno Casas
    • 3
  • Silvia Arribas Terradillos
    • 3
  • Álvaro Llerena Riofrío
    • 3
  • Cristian Aitor Escolano Peco
    • 3
  • Emma Alguacil Rodríguez
    • 3
  • Fernando Bermejo
    • 2
  1. 1.Gastroenterology DepartmentHospital Universitario Río HortegaValladolidSpain
  2. 2.Gastroenterology DepartmentHospital Universitario de FuenlabradaFuenlabradaSpain
  3. 3.Medicine DepartmentHospital Universitario de FuenlabradaFuenlabradaSpain

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