Published online Jun 16, 2018. doi: 10.4253/wjge.v10.i6.109
Peer-review started: January 5, 2018
First decision: January 31, 2018
Revised: March 5, 2018
Accepted: April 11, 2018
Article in press: April 11, 2018
Published online: June 16, 2018
Colorectal cancer (CRC) poses a significant health burden in Australia. In 2017, it is estimated to become the second most commonly diagnosed cancer with an incidence of 16682 new cases. Colonoscopy is the gold standard screening tool for CRC, with the adenoma detection rate (ADR) as the primary quality measure. ADR is defined as the proportion of screening colonoscopies that detect at least one histologically confirmed colorectal adenoma. Meeting the standard ADR is crucial in reducing CRC incidence and minimising CRC-related mortality. The performances of gastroenterologists and colorectal surgeons in colonoscopy have been compared in the literature, with varied results.
Quality of colonoscopy is a pertinent issue, with the expansion of the National Bowel Cancer Screening program, offering free screening to Australians aged 50 to 74 years old every two years by 2020. ADR has been established as an important measure of endoscopist proficiency. At present, no study has compared the ADR between gastroenterologists and colorectal surgeons in Australia. Although both specialties have similar training requirements, they remain completely separate specialties. This study aims to compare the ADR between gastroenterologists and colorectal surgeons, and hence reflect the standards of colonoscopy of both specialties in Australia. This would propel higher quality research to be undertaken regarding ways to increase ADR in colonoscopy and hence ensure more effective prevention of CRC.
This study aims to compare the ADR between gastroenterologists and colorectal surgeons at a single centre in Melbourne, Australia.
A total of 300 colonoscopies performed by gastroenterologists and colorectal surgeons at Box Hill Hospital were retrospectively reviewed from May 2016 to June 2017. Exclusion criteria were: Patients ≤ 50 years old, colonoscopies with failure of caecal intubation, patients who previously had colon cancer and/or a colonic resection, history of polyposis syndromes or inflammatory bowel disease, or a colonoscopy within the last 10 years. Patient demographics, indications, symptoms and procedural-related outcomes were measured.
The ADR was not significantly different between gastroenterologists and colorectal surgeons (34% vs 34.67%, P = 0.90). The adjusted odds ratio correcting for gender, age, 1st degree relative with colorectal cancer, previous colonoscopy, trainee involvement and caecal or terminal ileum intubation rate was 1.19 (0.69-2.05).
Both gastroenterologists and colorectal surgeons at our institution exceed benchmark standards suggested by the GESA, ASGE and ACG. An association between endoscopist specialty and ADR was not observed, even after controlling for patient-level factors. Our study reassures clinicians and patients that high standards are upheld in colonoscopy, regardless of specialty. Ways to improve ADR has been explored, such as interventions targeted at endoscopists performance, increasing withdrawal time or observation time, technological adjuncts or add-on devices and the use of simethicone. Currently, there is a lack of high quality evidence that demonstrates increase in ADR with each of these interventions to support their routine use in colonoscopy. Despite this uncertainty, technological adjuncts such as narrow band imaging and cap cuff-assisted colonoscopy may be used with discretion in daily practice. Greater time spent examining the proximal colon could be considered.
The ADR in both specialties exceed benchmark standards reflecting the high standards of education and training in Australia. Higher quality evidence investigating patient and endoscopist-specific factors that increase ADR is warranted.