Improving quality measures in colonoscopy and its therapeutic intervention

Abstract

Colonoscopy with polypectomy has been shown to reduce the risk of colon cancer. The critical element in the quality of colonoscopy in terms of polyp detection and removal continues to be the performance of the endoscopist, independent of patient-related factors. Improved results in terms of polyp detection and complete removal have implications regarding the development of screening and surveillance intervals and the reduction of interval cancers after negative colonoscopy. Advances in colonoscopy techniques such as high-definition colonoscopy, hood-assisted colonoscopy and dye-based chromoendoscopy have improved the detection of small and flat-type colorectal polyps. Virtual chromoendoscopy has not proven to improve polyp detection but may be useful to predict polyp pathology. The majority of polyps can be removed endoscopically. Available polypectomy techniques include cold forceps polypectomy, cold snare polypectomy, conventional polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection. The preferred choice depends on the polyp size and characteristics. Other useful techniques include colonoscopic hemostasis for acute colonic diverticular bleeding, endoscopic decompression using colonoscopic stenting, and transanal tube placement for colorectal obstruction. Here we review the current knowledge concerning the improvement of quality measures in colonoscopy and colonoscopy-related therapeutic interventions.

Keywords: Colonoscopy, Polypectomy, Hemostasis, Endoscopic decompression, Colorectal polyp, Colonic diverticular bleeding, Colorectal obstruction, Gastrointestinal endoscopy

Core tip: Achieving appropriate bowel preparation and proper luminal distention for endoscopic mucosal imaging remains the key step enabling the endoscopist to detect colorectal neoplasia and predict polyp pathology. Success improves with experience and feedback. In this review we discuss the impact of high-definition colonoscopy, hood-assisted colonoscopy, and dye-based and virtual chromoendoscopy on colorectal polyp detection and prediction. Colonoscopic polypectomy is a continuously evolving therapy and has the potential to further reduce the risk of colorectal cancer. We propose that optimal polypectomy techniques for nonpedunculated polyps should be primarily based on polyp size, and these include cold forceps polypectomy (1-3 mm), cold snare polypectomy (4-10 mm), conventional polypectomy (7-14 mm), and endoscopic mucosal resection (EMR) (15-20 mm). For polyps larger than 21 mm, piecemeal EMR or endoscopic submucosal dissection is preferred.