Publications by authors named "Douglas K Rex"

431 Publications

Adjusting detection measures for colonoscopy: how far should we go?

Authors:
Douglas K Rex

Clin Gastroenterol Hepatol 2021 Jun 8. Epub 2021 Jun 8.

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana. Electronic address:

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http://dx.doi.org/10.1016/j.cgh.2021.06.010DOI Listing
June 2021

A Pilot Randomized Trial of Polypectomy Techniques for 4 to 6 mm Colonic Polyps.

J Clin Gastroenterol 2021 Jun 11. Epub 2021 Jun 11.

Department of Internal Medicine/Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN.

Background And Goals: There is variation in polypectomy techniques for resection of small polyps. Aim was to compare techniques for 4 to 6 mm polyps for recurrent adenoma, efficiency, and adverse events and to establish methodological factors for definitive trial.

Materials And Methods: The study was a randomized controlled trial. Outpatients with ≥1, 4 to 6 mm polyps were randomized to cold forceps (CF), cold snare (CS), and hot snare (HS). Polypectomy site was marked with SPOT to assess for recurrence at the original polypectomy site during surveillance colonoscopy. To assess feasibility of a definitive trial we measured (1) rates of patient refusal, participation, ineligibility; (2) retention; (3) recurrent neoplasia; and (4) sample size for a definitive trial.

Results: Three hundred fifty-three patients were randomized to 1 of the 3 polypectomy techniques, of whom 260 (73.6%) completed the initial colonoscopy (mean age 57 y, 50.4% women), with 91, 87, and 82 patients randomized to CF, CS, and HS polypectomy, respectively. Mean time for polyp resection for CF, CS, and HS were 198.8, 58.5, and 96.8 seconds, respectively, with CS and HS requiring less time than CF (P<0.001). One hundred sixty-four (63.1%) completed surveillance colonoscopy. Polyp recurrences were 9 (14.5%) with CF, 5 (9.6%) with CS, and 0 (0%) with HS. Although the recurrence relative risks with CF and CS polypectomy were 1.84 and 1.65 as compared with HS, respectively, neither was statistically significant.

Conclusions: CS and HS polypectomy require less time than CF. HS polypectomy may have a lower risk for recurrent neoplasia. High attrition rate is a challenge in conducting randomized controlled trial with polyp recurrence as endpoint.
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http://dx.doi.org/10.1097/MCG.0000000000001571DOI Listing
June 2021

Optical diagnosis of colorectal polyps using novel Blue Light Imaging (BLI) classification among trainee endoscopists.

Dig Endosc 2021 May 30. Epub 2021 May 30.

Division of Gastroenterology, hepatology and motility, University of Kansas School of Medicine, Kansas City, Kansas, USA.

Background: Blue Light Imaging(BLI) has been shown to improve the characterization of colorectal polyps among the endoscopy experts. We aimed to determine if this technology could be taught to endoscopy trainees while maintaining high accuracy and interobserver agreement.

Methods: Twenty-one gastroenterology trainees (fellows) from 2 academic institutions participated in this prospective study. Each trainee completed a web-based learning comprising 4 modules: pre-test, didactic videos explaining the BLI Adenoma Serrated International Classification(BASIC), interactive examples, and post-test assessment. The pre- and post-test modules consisted of reviewing video images of colon polyps in high-definition white light and BLI and then applying the BASIC classification to determine if the polyps were likely to be adenomatous. Confidence in adenoma identification(rated '1' to '5'), accuracy in polyp(adenoma vs non-adenoma) identification, and agreement in characterization per BASIC criteria were derived.

Results: Trainee accuracy in the adenoma diagnosis improved from 74.7% (pretest) to 85.4% (post-test) (p<0.01). There was a trend towards higher accuracy in polyp characterization with subsequent years of training (1st year fellows: 77.4%, 2 year: 88.5%, and final year 94.0%) with consistent improvements after the e-learning across years of trainees. Overall, trainees were able to identify adenoma with a high sensitivity of 86.9%, specificity 83.9%, positive predictive value of 84.4%, and negative predictive value of 86.5%. However, their inter-observer agreement in adenoma diagnosis was moderate(k=0.52).

Conclusion: The novel BLI classification can be easily taught to gastroenterology trainees using an online module and accuracy improves with years of training reaching >90% for colorectal polyp characterization.
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http://dx.doi.org/10.1111/den.14050DOI Listing
May 2021

The role of clips in preventing delayed bleeding after colorectal polyp resection: an individual patient data meta-analysis.

Clin Gastroenterol Hepatol 2021 May 12. Epub 2021 May 12.

Department of Gastroenterology and Hepatology, Radboudumc, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.

Background & Aims: Non-pedunculated colorectal polyps are normally endoscopically removed to prevent neoplastic progression. Delayed bleeding is the most common major adverse event. Clipping the resection defect has been suggested to reduce delayed bleedings. Our aim was to determine if prophylactic clipping reduces delayed bleedings and to analyze the contribution of polyp characteristics, extent of defect closure and antithrombotic use.

Methods: An Individual Patient Data Meta-Analysis was performed. Studies on prophylactic clipping in non-pedunculated colorectal polyps were selected from PubMed, Embase, Web of Science and Cochrane database (last selection: April 2020). Authors were invited to share original study data. The primary outcome was delayed bleeding ≤30 days. Multivariable mixed models were used to determine the efficacy of prophylactic clipping in various subgroups adjusted for confounders.

Results: Data of 5,380 patients with 8,948 resected polyps were included from three RCT's, two prospective and eight retrospective studies. Prophylactic clipping reduced delayed bleeding in proximal polyps ≥20 mm (OR 0.62; 95% CI 0.44 - 0.88; Number Needed to Treat [NNT] = 32), especially with antithrombotics (OR 0.59; 95% CI 0.35 - 0.99; NNT = 23; subgroup of anticoagulants/double platelet inhibitors N=226; OR 0.40; 95% CI 0.16 - 1.01; NNT = 12). Prophylactic clipping did not benefit distal polyps ≥20 mm with antithrombotics (OR 1.41; 95% CI 0.79 - 2.52).

Conclusions: Prophylactic clipping reduces delayed bleeding after resection of non-pedunculated, proximal colorectal polyps ≥20 mm, especially in patients using antithrombotics. No benefit was found for distal polyps. Based on this study, patients can be identified who may benefit from prophylactic clipping. (PROSPERO registration number CRD42020104317).
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http://dx.doi.org/10.1016/j.cgh.2021.05.012DOI Listing
May 2021

Prioritizing an oncologic approach to endoscopic resection of pedunculated colorectal polyps.

Gastrointest Endosc 2021 Apr 27. Epub 2021 Apr 27.

Nuovo Regina Margherita Hospital, Rome, Italy.

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http://dx.doi.org/10.1016/j.gie.2021.03.003DOI Listing
April 2021

Sessile serrated lesions: Searching for the true prevalence.

Endosc Int Open 2021 Apr 15;9(4):E635-E636. Epub 2021 Apr 15.

Indiana University School of Medicine, Indianapolis, Indiana, United States.

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http://dx.doi.org/10.1055/a-1373-4825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050560PMC
April 2021

Response.

Gastrointest Endosc 2021 05;93(5):1198-1201

Division of Gastroenterolgy/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.

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http://dx.doi.org/10.1016/j.gie.2021.01.044DOI Listing
May 2021

Response.

Authors:
Douglas K Rex

Gastrointest Endosc 2021 04;93(4):991

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

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http://dx.doi.org/10.1016/j.gie.2020.12.047DOI Listing
April 2021

ACG Clinical Guidelines: Colorectal Cancer Screening 2021.

Am J Gastroenterol 2021 03;116(3):458-479

Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Colorectal cancer (CRC) is the third most common cancer in men and women in the United States. CRC screening efforts are directed toward removal of adenomas and sessile serrated lesions and detection of early-stage CRC. The purpose of this article is to update the 2009 American College of Gastroenterology CRC screening guidelines. The guideline is framed around several key questions. We conducted a comprehensive literature search to include studies through October 2020. The inclusion criteria were studies of any design with men and women age 40 years and older. Detailed recommendations for CRC screening in average-risk individuals and those with a family history of CRC are discussed. We also provide recommendations on the role of aspirin for chemoprevention, quality indicators for colonoscopy, approaches to organized CRC screening and improving adherence to CRC screening. CRC screening must be optimized to allow effective and sustained reduction of CRC incidence and mortality. This can be accomplished by achieving high rates of adherence, quality monitoring and improvement, following evidence-based guidelines, and removing barriers through the spectrum of care from noninvasive screening tests to screening and diagnostic colonoscopy. The development of cost-effective, highly accurate, noninvasive modalities associated with improved overall adherence to the screening process is also a desirable goal.
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http://dx.doi.org/10.14309/ajg.0000000000001122DOI Listing
March 2021

When and How To Use Endoscopic Tattooing in the Colon: An International Delphi Agreement.

Clin Gastroenterol Hepatol 2021 May 22;19(5):1038-1050. Epub 2021 Jan 22.

Servicio de Medicina Digestiva, Hospital General Universitario de Alicante, Instituto de Investigación Biomédica Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain. Electronic address:

Background & Aims: There is a lack of clinical studies to establish indications and methodology for tattooing, therefore technique and practice of tattooing is very variable. We aimed to establish a consensus on the indications and appropriate techniques for colonic tattoo through a modified Delphi process.

Methods: The baseline questionnaire was classified into 3 areas: where tattooing should not be used (1 domain, 6 questions), where tattooing should be used (4 domains, 20 questions), and how to perform tattooing (1 domain 20 questions). A total of 29 experts participated in the 3 rounds of the Delphi process.

Results: A total of 15 statements were approved. The statements that achieved the highest agreement were as follows: tattooing should always be used after endoscopic resection of a lesion with suspicion of submucosal invasion (agreement score, 4.59; degree of consensus, 97%). For a colorectal lesion that is left in situ but considered suitable for endoscopic resection, tattooing may be used if the lesion is considered difficult to detect at a subsequent endoscopy (agreement score, 4.62; degree of consensus, 100%). A tattoo should never be injected directly into or underneath a lesion that might be removed endoscopically at a later point in time (agreement score, 4.79; degree of consensus, 97%). Details of the tattoo injection should be stated clearly in the endoscopy report (agreement score, 4.76; degree of consensus, 100%).

Conclusions: This expert consensus has developed different statements about where tattooing should not be used, when it should be used, and how that should be done.
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http://dx.doi.org/10.1016/j.cgh.2021.01.024DOI Listing
May 2021

Multicentre, prospective, randomised study comparing the diagnostic yield of colon capsule endoscopy versus CT colonography in a screening population (the TOPAZ study).

Gut 2020 Dec 18. Epub 2020 Dec 18.

Indiana University School of Medicine, Indiana University Hospital, Indianapolis, Indiana, USA.

Objective: Colon capsule endoscopy (CCE) has shown promise for colorectal neoplasia detection compared with optical colonoscopy (OC), but has not been compared with other screening tests in average risk screening patients.

Design: Patients 50 to 75 years of age (African Americans, 45-75 years) were randomised to CCE or CT colonography (CTC) and subsequent blinded OC. The primary endpoint was diagnostic yield of polyps ≥6 mm with CCE or CTC. Secondary endpoints included accuracy for size and histology, examination completeness, number/proportion of subjects with polyps and adenomas ≥6 mm and ≥10 mm, subject satisfaction and safety.

Results: From 320 enrolled subjects, data from 286 (89.4%) were evaluable. The proportion of subjects with any polyp ≥6 mm confirmed by OC was 31.6% for CCE versus 8.6% for CTC (pPr non-inferiority and superiority=0.999). The diagnostic yield of polyps ≥10 mm was 13.5% with CCE versus 6.3% with CTC (pPr non-inferiority=0.9954). The sensitivity and specificity of CCE for polyps ≥6 mm was 79.2% and 96.3% while that of CTC was 26.8% and 98.9%. The sensitivity and specificity of CCE for polyps ≥10 mm was 85.7% and 98.2% compared with 50% and 99.1% for CTC. Both tests were well tolerated/safe.

Conclusion: CCE was superior to CTC for detection of polyps ≥6 mm and non-inferior for identification of polyps ≥10 mm. CCE should be considered comparable or superior to CTC as a colorectal neoplasia screening test, although neither test is as effective as OC.

Trial Registration Number: ClinicalTrials.gov no: NCT02754661.
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http://dx.doi.org/10.1136/gutjnl-2020-322578DOI Listing
December 2020

Factors associated with complete clip closure after endoscopic mucosal resection of large colorectal polyps.

Endoscopy 2020 Dec 8. Epub 2020 Dec 8.

Department of Gastroenterology, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Barcelona, Spain.

BACKGROUND AND STUDY AIM : Delayed bleeding is a common adverse event following endoscopic mucosal resection (EMR) of large colorectal polyps. Prophylactic clip closure of the mucosal defect after EMR of nonpedunculated polyps larger than 20 mm reduces the incidence of severe delayed bleeding, especially in proximal polyps. This study aimed to evaluate factors associated with complete prophylactic clip closure of the mucosal defect after EMR of large polyps. METHODS : This is a post hoc analysis of the CLIP study (NCT01936948). All patients randomized to the clip group were included. Main outcome was complete clip closure of the mucosal resection defect. The defect was considered completely closed when no remaining mucosal defect was visible and clips were less than 1 cm apart. Factors associated with complete closure were evaluated in multivariable analysis. RESULTS : In total, 458 patients (age 65, 58 % men) with 494 large polyps were included. Complete clip closure of the resection defect was achieved for 338 polyps (68.4 %); closure was not complete for 156 (31.6 %). Factors associated with complete closure in adjusted analysis were smaller polyp size (odds ratio 1.06 for every millimeter decrease [95 % confidence interval 1.02-1.08]), good access (OR 3.58 [1.94-9.59]), complete submucosal lifting (OR 2.28 [1.36-3.90]), en bloc resection (OR 5.75 [1.48-22.39]), and serrated histology (OR 2.74 [1.35-5.56]). CONCLUSIONS : Complete clip closure was not achieved for almost one in three resected large nonpedunculated polyps. While stable access and en bloc resection facilitate clip closure, most factors associated with clip closure are not modifiable. This highlights the need for alternative closure options and measures to prevent bleeding.
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http://dx.doi.org/10.1055/a-1332-6727DOI Listing
December 2020

Safety and efficacy of remimazolam in high risk colonoscopy: A randomized trial.

Dig Liver Dis 2021 Jan 23;53(1):94-101. Epub 2020 Nov 23.

Hofstra Northwell School of Medicine, Hempstead, NY, United States.

Background: Procedural sedation of ASA III/IV patients has increased risk. Remimazolam (an ultra-short-acting benzodiazepine) has proven safe and efficient for outpatient colonoscopy sedation.

Methods: A double-blind, randomized, multi-center, parallel group trial was performed, comparing remimazolam to placebo with an additional open-label arm for midazolam in procedural sedation of 79 ASA III/IV patients undergoing colonoscopy. This was the third of 3 Phase III trials for remimazolam in the procedural sedation program. The primary end point was the safety of remimazolam.

Results: Of 79 patients randomized at 3 US sites, 77 underwent sedation and colonoscopy (31 received remimazolam, 16 placebo and 30 midazolam). Incidence and frequency of treatment emergent adverse events (TEAEs) were comparable in all three treatment arms, and independent of ASA status. One TEAE leading to discontinuation and one serious TEAE were reported; both in the open label midazolam arm. The efficacy endpoint was achieved for remimazolam, placebo, and midazolam in 87.1%, 0%, and 13.3% of patients (p<0.00001 for remimazolam versus placebo and versus midazolam, respectively).

Conclusions: Remimazolam is safe and efficient in procedural sedation of high risk ASA patients undergoing colonoscopy, showing a safety profile comparable to that in low risk ASA.
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http://dx.doi.org/10.1016/j.dld.2020.10.039DOI Listing
January 2021

Recurrence After Endoscopic Mucosal Resection: Early and Late Incidence, Treatment Outcomes, and Outcomes in Non-Overt (Histologic-Only) Recurrence.

Gastroenterology 2021 Feb 29;160(3):949-951.e2. Epub 2020 Oct 29.

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana. Electronic address:

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http://dx.doi.org/10.1053/j.gastro.2020.10.039DOI Listing
February 2021

Colorectal EMR outcomes in octogenarians versus younger patients referred for removal of large (≥20 mm) nonpedunculated polyps.

Gastrointest Endosc 2021 03 17;93(3):699-703. Epub 2020 Oct 17.

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Background And Aims: Data are limited on safety and outcomes of colorectal EMR in octogenarians (≥80 years old). We sought to review outcome data for patients aged ≥80 in a prospectively collected database of patients referred for large polyp removal.

Methods: We retrospectively evaluated a database of patients referred for large (≥20 mm) nonpedunculated polyp removal. From 2000 to 2019, we compared the rates of follow-up, recurrence, adverse events, and synchronous neoplasia detection between younger patients and patients aged ≥80.

Results: There were 167 patients aged ≥80 years and 1686 <80 years. Patients in the elderly group returned for surveillance less often (67.1% vs 75.1%, P = .024), had greater first follow-up recurrence rates (27.5% vs 13.8%, P < .001), but had similar adverse event rates (1.8% vs 2.8%, P = .619) compared with younger patients. Rates of synchronous neoplasia were similar and high in both groups.

Conclusions: EMR is safe and well tolerated for large polyp removal in patients over 80 years old. Patients aged ≥80 years are less likely to present for follow-up after EMR. They had a higher recurrence rate and a similarly high prevalence of synchronous precancerous lesions. Follow-up after EMR should be encouraged in the elderly, and an attempt to clear the colon of synchronous disease at the time of the initial EMR may be warranted.
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http://dx.doi.org/10.1016/j.gie.2020.10.014DOI Listing
March 2021

Narrowing the Set of Target Lesions for Colorectal Endoscopic Submucosal Dissection.

Clin Gastroenterol Hepatol 2020 Sep 19. Epub 2020 Sep 19.

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.

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http://dx.doi.org/10.1016/j.cgh.2020.09.031DOI Listing
September 2020

Adverse events and residual lesion rate after cold endoscopic mucosal resection of serrated lesions ≥10 mm.

Gastrointest Endosc 2021 03 3;93(3):654-659. Epub 2020 Sep 3.

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Background And Aims: Cold EMR is being increasingly used for large serrated lesions. We sought to measure residual lesion rates and adverse events after cold EMR of large serrated lesions.

Methods: In a single academic center, we retrospectively examined a database of serrated class lesions ≥10 mm removed with cold EMR for safety and efficacy.

Results: Five hundred sixty-six serrated lesions ≥10 mm in size were removed from 312 patients. We successfully contacted 223 patients (71.5%) with no reported serious adverse events that required hospitalization, repeat endoscopy, or transfusion. The residual lesion rate per lesion at first follow-up colonoscopy was 18 of 225 (8%; 95% confidence interval, 5-12.1). Lesions with residual were larger at polypectomy compared with lesions without recurrence (median, 23 mm versus 16 mm, P = .017).

Conclusion: Cold EMR appears to be safe and effective for the removal of large serrated lesions.
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http://dx.doi.org/10.1016/j.gie.2020.08.032DOI Listing
March 2021

Double high-level disinfection versus liquid chemical sterilization for reprocessing of duodenoscopes used for ERCP: a prospective randomized study.

Gastrointest Endosc 2021 04 31;93(4):927-931. Epub 2020 Jul 31.

Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Background And Aims: The potential for transmission of pathogenic organisms is a problem inherent to the current reusable duodenoscope design. Recent outbreaks of multidrug-resistant pathogenic organisms transmitted via duodenoscopes has brought to light the urgency of this problem. Microbiologic culturing of duodenoscopes and reprocessing with repeat high-level disinfection (HLD) or liquid chemical sterilization (LCS) have been offered as supplemental measures to enhance duodenoscope reprocessing by the U.S. Food and Drug Administration. This study aims to compare the efficacy of reprocessing duodenoscopes with double HLD (DHLD) versus LCS.

Methods: We prospectively evaluated 2 different modalities of duodenoscope reprocessing from October 23, 2017 to September 24, 2018. Eligible duodenoscopes were randomly segregated to be reprocessed by either DHLD or LCS. Duodenoscopes were randomly cultured after reprocessing for surveillance based on an internal protocol.

Results: During the study period, there were 878 post-reprocessing surveillance cultures (453 in the DHLD group and 425 in the LCS group). Of all cultures, 17 were positive for any organism (1.9%). There was no significant difference of positive cultures when comparing the duodenoscopes undergoing DHLD (8 positive cultures, 1.8%) with duodenoscopes undergoing LCS (9 positive cultures, 2.1%; P = .8). Both groups had 2 cultures that grew high-concern organisms (.5% vs .5%, P=1.0). No multidrug-resistant organisms, including carbapenem-resistant enterobacteriaceae, were detected.

Conclusions: DHLD and LCS both resulted in a low rate of positive cultures, for all organisms and for high-concern organisms. However, neither process completely eliminated positive cultures from duodenoscopes reprocessed with 2 different supplemental reprocessing strategies.
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http://dx.doi.org/10.1016/j.gie.2020.07.057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8101057PMC
April 2021

Performance of artificial intelligence in colonoscopy for adenoma and polyp detection: a systematic review and meta-analysis.

Gastrointest Endosc 2021 01 26;93(1):77-85.e6. Epub 2020 Jun 26.

Endoscopy Unit, Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy; Department of Biomedical Sciences, Humanitas University, Rozzano, Italy.

Background And Aims: One-fourth of colorectal neoplasia are missed at screening colonoscopy, representing the main cause of interval colorectal cancer. Deep learning systems with real-time computer-aided polyp detection (CADe) showed high accuracy in artificial settings, and preliminary randomized controlled trials (RCTs) reported favorable outcomes in the clinical setting. The aim of this meta-analysis was to summarize available RCTs on the performance of CADe systems in colorectal neoplasia detection.

Methods: We searched MEDLINE, EMBASE, and Cochrane Central databases until March 2020 for RCTs reporting diagnostic accuracy of CADe systems in the detection of colorectal neoplasia. The primary outcome was pooled adenoma detection rate (ADR), and secondary outcomes were adenoma per colonoscopy (APC) according to size, morphology, and location; advanced APC; polyp detection rate; polyps per colonoscopy; and sessile serrated lesions per colonoscopy. We calculated risk ratios (RRs), performed subgroup and sensitivity analyses, and assessed heterogeneity and publication bias.

Results: Overall, 5 randomized controlled trials (4354 patients) were included in the final analysis. Pooled ADR was significantly higher in the CADe group than in the control group (791/2163 [36.6%] vs 558/2191 [25.2%]; RR, 1.44; 95% confidence interval [CI], 1.27-1.62; P < .01; I = 42%). APC was also higher in the CADe group compared with control (1249/2163 [.58] vs 779/2191 [.36]; RR, 1.70; 95% CI, 1.53-1.89; P < .01; I = 33%). APC was higher for ≤5-mm (RR, 1.69; 95% CI, 1.48-1.84), 6- to 9-mm (RR, 1.44; 95% CI, 1.19-1.75), and ≥10-mm adenomas (RR, 1.46; 95% CI, 1.04-2.06) and for proximal (RR, 1.59; 95% CI, 1.34-1.88), distal (RR, 1.68; 95% CI, 1.50-1.88), flat (RR, 1.78; 95% CI, 1.47-2.15), and polypoid morphology (RR, 1.54; 95% CI, 1.40-1.68). Regarding histology, CADe resulted in a higher sessile serrated lesion per colonoscopy (RR, 1.52; 95% CI, 1.14-2.02), whereas a nonsignificant trend for advanced ADR was found (RR, 1.35; 95% CI, .74-2.47; P = .33; I = 69%). Level of evidence for RCTs was graded as moderate.

Conclusions: According to available evidence, the incorporation of artificial intelligence as aid for detection of colorectal neoplasia results in a significant increase in the detection of colorectal neoplasia, and such effect is independent from main adenoma characteristics.
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http://dx.doi.org/10.1016/j.gie.2020.06.059DOI Listing
January 2021

Response.

Authors:
Douglas K Rex

Gastrointest Endosc 2020 07;92(1):232-233

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

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http://dx.doi.org/10.1016/j.gie.2020.03.3847DOI Listing
July 2020

If Surgeons Embrace Adenoma Detection Rate Measurement and Improvement, Cancers Will Be Prevented and Lives Will Be Saved.

Authors:
Douglas K Rex

Dis Colon Rectum 2020 07;63(7):867-869

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana.

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http://dx.doi.org/10.1097/DCR.0000000000001703DOI Listing
July 2020

Room temperature water infusion during colonoscopy insertion induces rectosigmoid colon mucus production.

Endoscopy 2020 12 20;52(12):1118-1121. Epub 2020 May 20.

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA.

Background: Water filling during colonoscopy improves several colonoscopy outcomes. We evaluated an anecdotal observation that room temperature water filling during colonoscope insertion results in mucus production in the left colon, which may impair mucosal visualization during withdrawal.

Methods: We performed 55 colonoscopies with either water or saline filling during insertion, and video recorded the examinations. Three blinded observers scored the amount of mucus visible on the video recordings.

Results: 29 patients had water filling and 26 patients had saline filling during insertion. Demographic features, procedure indications, volume of infused fluid, and insertion time to the cecum were similar in the two groups. All three blinded observers rated the mucus as greater after water filling than after saline (median 3 out of 5 vs. 1 out of 5;  < 0.001), with a kappa value for interobserver agreement of 0.364 ( < 0.001).

Conclusion: Room temperature water filling is associated with mucus production by the rectosigmoid colon, requiring additional cleansing during withdrawal.
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http://dx.doi.org/10.1055/a-1182-5211DOI Listing
December 2020

Colorectal Cancer Screening.

Authors:
Douglas K Rex

Gastrointest Endosc Clin N Am 2020 Jul;30(3):xv-xvi

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100, Indianapolis, IN 46202, USA. Electronic address:

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http://dx.doi.org/10.1016/j.giec.2020.04.001DOI Listing
July 2020

The Case for High-Quality Colonoscopy Remaining a Premier Colorectal Cancer Screening Strategy in the United States.

Authors:
Douglas K Rex

Gastrointest Endosc Clin N Am 2020 Jul 9;30(3):527-540. Epub 2020 Apr 9.

Division of Gastroenterology/Hepatology, Indiana University School of Medicine, 550 North University Boulevard, Suite 4100, Indianapolis, IN 46202, USA. Electronic address:

Most colorectal cancer screening in the United States occurs in the opportunistic setting, where screening is initiated by a patient-provider interaction. Colonoscopy provides the longest-interval protection, and high-quality colonoscopy is ideally suited to the opportunistic setting. Both detection and colonoscopic resection have improved as a result of intense scientific investigation. Further improvements in detection are expected with the introduction of artificial intelligence programs into colonoscopy platforms. We may expect recommended intervals or colonoscopy after negative examinations performed by high-quality detectors to expand beyond 10 years. Thus, high-quality colonoscopy remains an excellent approach to colorectal cancer screening in the opportunistic setting.
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http://dx.doi.org/10.1016/j.giec.2020.02.006DOI Listing
July 2020

Most Patients Are Willing to Undergo Elective Endoscopic Procedures During the Reopening Period of the Coronavirus 2019 Pandemic.

Gastroenterology 2020 Sep 16;159(3):1173-1175.e4. Epub 2020 May 16.

Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.

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http://dx.doi.org/10.1053/j.gastro.2020.05.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229738PMC
September 2020

Endoscopy Staff Are Concerned About Acquiring Coronavirus Disease 2019 Infection When Resuming Elective Endoscopy.

Gastroenterology 2020 Sep 16;159(3):1167-1169.e3. Epub 2020 May 16.

Division of Gastroenterology/Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.

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http://dx.doi.org/10.1053/j.gastro.2020.05.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229713PMC
September 2020

Designs of colonoscopic adenoma detection trials: more positive results with tandem than with parallel studies - an analysis of studies on imaging techniques and mechanical devices.

Gut 2021 Feb 14;70(2):268-275. Epub 2020 May 14.

Gastrozentrum Hirslanden, Zurich, Switzerland.

Background And Aims: Adenoma detection rate (ADR) has been shown to correlate with interval cancers after screening colonoscopy and is commonly used as surrogate parameter for its outcome quality. ADR improvements by various techniques have been studied in randomised trials using either parallel or tandem methodololgy.

Methods: A systematic literature search was done on randomised trials (full papers, English language) on tandem or parallel studies using either adenoma miss rates (AMR) or ADR as main outcome to test different novel technologies on imaging (new endoscope generation, narrow band imaging, iScan, Fujinon intelligent chromoendoscopy/blue laser imaging and wide angle scopes) and mechanical devices (transparent caps, endocuff, endorings and balloons). Available meta analyses were also screened for randomised studies.

Results: Overall, 24 randomised tandem trials with AMR (variable definitions and methodology) and 42 parallel studies using ADR (homogeneous methodology) as primary outcome were included. Significant differences in favour of the new method were found in 66.7% of tandem studies (8222 patients) but in only 23.8% of parallel studies (28 059 patients), with higher rates of positive studies for mechanical devices than for imaging methods. In a random-effects model, small absolute risk differences were found, but these were double in magnitude for tandem as compared with parallel studies (imaging: tandem 0.04 (0.01, 0.07), parallel 0.02 (0.00, 0.04); mechanical devices: tandem 0.08 (0.00, 0.15), parallel 0.04 (0.01, 0.07)). Nevertheless, 94.2% of missed adenomas in the tandem studies were small (<1 cm) and/or non-advanced.

Conclusions: A tandem study is more likely to yield positive results than a simple parallel trial; this may be due to the use of different parameters, variable definitions and methodology, and perhaps also a higher likelihood of bias. Therefore, we suggest to accept positive results of tandem studies only if accompanied by positive results from parallel trials.
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http://dx.doi.org/10.1136/gutjnl-2020-320984DOI Listing
February 2021