ESGE/ESDO quality in endoscopy: colonoscopy and colonic neoplasms symposium reports.

copy (ESGE) and the European Society of Digestive Oncology (ESDO) joined forces for this second symposium in the Quality in Endoscopy series and invited leaders in the field of colonoscopy and colonic neoplasms, alongside young rising stars. Sixty-seven abstracts were submitted and 30 were finally accepted. Over 200 endoscopists attended the symposium. The meeting took place in a modern and very convenient location with high-quality video facilities, which allowed excellent illustration of the case presentations and stimulated the debates. All participants and the survey responses indicated that the meeting fulfilled its aim of providing state-of-the-art knowledge of quality in colonoscopy through lectures, case discussion, and interactive participation. The different aspects of quality in colonoscopy were covered from A (bowel cleansing) to Z (stenting), and the social networking was also very fruitful. Indeed, the meeting was so active and productive that it is hard to summarize. One particularly striking feature was the number of young women working as experts in this field and contributing excellent presentations. Starting at A, then, the initial session focused on patient preparation and, of course, first on bowel cleansing. According to Brian Saunders, the basic principles for successful bowel cleansing are clear instructions, dietary restriction for at least 24 hours, a policy of enema administration in the endoscopy unit prior to the procedure in cases of “failed preparation,” and, if necessary, mechanical bowel preparation with “jet wash” devices. While the type of preparation required should be tailored to the individual, a split administration regimen with the patient continuing to drink clear fluids until close to the time of the procedure results in a bowel preparation that is better tolerated andmore effective. Scoring systems for bowel preparation, such as the Boston Bowel Preparation Scale, are useful for intermittent monitoring of quality, but are probably not necessary routinely outside of clinical trials. Christian Boustiere then summarized the 2011 ESGE guideline on the management of patients taking antiplatelet agents, and we can only encourage readers to refer to the guideline itself (Endoscopy 2011; 43; 445–458). The key factors are the patient’s thrombotic risk and the bleeding risk associated with the procedure. New antiplatelet agents were presented and discussed: the bleeding risk associated with their use is higher than with aspirin and clopidogrel and these new drugs must be discontinued 7 days prior to the procedure. Siwan Thomas-Gibson had the task of recalling the basics of performing colonoscopy and emphasized the need for dedicated training and trainers. While the mainstay of training remains the apprenticeship approach, recent technological innovations have been shown to enhance training. These include not only virtual reality simulators but, above all, the 3D imager guide. Michael Bretthauer addressed the hot topic of quality indicators. He distinguished between process indicators (such as polyp and adenoma detection rates, or withdrawal time) and outcome indicators (for example, rates of missed cancer, of interval cancer, or perforation rates). Numerous studies have shown significant variation in the quality of colonoscopies performed, between countries, between centers, and between individual endoscopists, and there is a clear need for colonoscopists to measure and record performance. To date, a minimum standard set of quality indicators should be collected during each colonoscopy. In addition to patient data, clinical indication, diagnosis, and surveillance strategy, these indicators include: bowel cleansing regimen and quality; sedation; endoscope and equipment used; time to reach the cecum; withdrawal time; polyp, adenoma, and cancer detection rates; complications and adverse events; and patient discomfort and satisfaction. Very importantly, Michael Bretthauer stated that the responsibility of care providers in terms of follow-up quality assurance programs should be guided by the principle “improvement, not punishment.” To clarify terms before the Great Debate on mass screening for colorectal cancer, Thierry Ponchon stratified the risks of colorectal cancer. Persons at average risk of colorectal cancer (sporadic cases) should be monitored within an organized mass screening program. Those at high risk of colorectal cancer (nonsyndrome familial cases, irritable bowel disease) represent 10%–30% of colorectal cancer cases and should be followed up directly by colonoscopy. For those at very high risk of colorectal cancer (familial syndromerelated risk: familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer), who represent 3% of cases, monitoring is based on oncogenetic consultation, the search for mutations, and regular chromocolonoscopy. The speakers in the Great Debate on mass screening were Jaroslaw Regula, Adam Haycock, and Thomas Seufferlin. In Europe, mass screening is mainly based on guaiac or, increasingly, immunochemical fecal occult blood testing. First-line colonoscopy or rectosigmoidoscopy are used or under evaluation in some countries (such as Poland and Germany for colonoscopy, UK and Italy for rectosigmoidoscopy). New biological tests are also under evaluation and, provided they are less expensive, could be in use in a few years’ time. Michal Kaminski was charged with telling the truth about the limitations of diagnostic colonoscopy. Missed colorectal cancers represent 3.4%– 7.9% of all colorectal cancers. Three reasons could explain these interval colorectal cancers: rapid growth of colorectal cancer, incomplete removal of polyps, or overlooked polyp or colorectal cancer. Rapid cancer growth could result from alternative colorectal cancer pathways (such as microsatellite instability). Incomplete endoscopic resection could contribute one-third of missed colorectal cancers and explain why missed lesions occur more frequently in polypectomy segments. However, overlooking lesions at colonoscopy is the major factor, even with the more recent endoscopes. It has been shown that a higher rate of detection of adenomas is associated with a reduced risk for interval colorectal cancer. Polyp location behind folds, subtle lesions that are unrecognized or unfamiliar, poor bowel preparation, and incomplete colonoscopy are the factors that contributemost significantly to the overlooking of lesions. Picking up the thread, Michael Vieth and Ana Ignjatovic described the histological and macroscopic features of some of the “new lesions” which can easily be overlooked: sessile serrated lesions, lateral spreading tumors, depressed carcinomas. In his lecture on quality control, Roland Valori was emphatic that some parameters of quality control can only be reported at regional or national levels, thus underlining the role of care providers in establishing quality assurance programs on a regional or national basis such as in the UK. Since everybody in the audience was convinced that we should detect adenomas better, the question was how to do it: through better technology, as suggested by Ralph Kiesslich, or simply through better technique, as suggested by James East? In the large majority of studies, up to now, new technologies have not been demonstrated to be effective in improving the adenoma detection rate. On the other hand, operator performance varies 10-fold for adenomas of all sizes and threeto four-fold for advanced adenomas. So it appears obvious that operator technique should be optimized before new technology is added. James East focused on bowel preparation, withdrawal time (although its exact role is debated), position changes, use of antispasmodics, and rectal retroflexion. In conclusion, with regard to adenoma and colorectal cancer detection, priority should be given to better technique and to quality control programs. Whereas technology has not been demonstrated to be effective in improving adenoma detection, its role in the characterization of polyps has been highlighted, and was especially so during the second Great Debate, “I characterize” versus “I remove,” spoken to by Ana Ignjatovic and Raf Bisschops. On the one hand, either of these approaches to diminutive polyps–whether “diagnose and discard” or “diagnose and leave behind”– has the potential to reduce the cost of histopathological analysis and to save time. One reason for this is that the clinical significance of diminutive polyp (high-grade dysplasia rate) is very low. First studies have shown that invivo optical diagnosis could be an acceptable strategy to assess surveillance intervals without histopathology. On the other hand, though, the discard policy has some limitations, especially in the case of sessile serrated lesions. Thus, the discard strategy should be applied with caution in patients with polyps 6– 9mm in size and in those with right-side lesions, because of their malignant potential. Some time during the meeting was given to new advances in the management of advanced colorectal cancer. Thomas Seufferlein summarized the emerging role of targeted therapies. Systemic treatment of colorectal cancer has made considESGE Newsletter