Petruzziello
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Endoscopia Digestiva ChirurgicaEndoscopia Digestiva ChirurgicaUniversità Cattolica del Sacro CuoreUniversità Cattolica del Sacro CuorePoliclinico “A. Gemelli” - RomaPoliclinico “A. Gemelli” - Roma
Lucio PetruzzielloLucio Petruzziello
“ “ Removal of Adenomatous Polyps Removal of Adenomatous Polyps by Endoscopic Polypectomy by Endoscopic Polypectomy
is associated with a is associated with a 76%-90% CRC Risk Reduction “76%-90% CRC Risk Reduction “
“ “ We now have clearer insight We now have clearer insight into the natural history of colorectal into the natural history of colorectal
cancer cancer and clinical skills and clinical skills with which to intervenewith which to interveneand make difference for many people.and make difference for many people.
Colorectal cancer screening Colorectal cancer screening has come of age ”.has come of age ”.
Sidney J. WinawerSidney J. Winawer
(Welch Allyn - NY)(Welch Allyn - NY)
Low-Res.: Low-Res.: 100.000-200.000 Pixels100.000-200.000 PixelsLow-Res.: Low-Res.: 100.000-200.000 Pixels100.000-200.000 Pixels
Hi-Res.: Hi-Res.: up to 850.000 Pixelsup to 850.000 PixelsHi-Res.: Hi-Res.: up to 850.000 Pixelsup to 850.000 Pixels
HD images are composed of double HD images are composed of double the number of scanning lines (1080 vs. 576) the number of scanning lines (1080 vs. 576)
and horizontal resolution than used and horizontal resolution than used in conventional video systemsin conventional video systems
HD images are composed of double HD images are composed of double the number of scanning lines (1080 vs. 576) the number of scanning lines (1080 vs. 576)
and horizontal resolution than used and horizontal resolution than used in conventional video systemsin conventional video systems
After 40 years …
… No alternative technique
ready for clinical use
Zorzi M. Lo screening colorettale in Italia: survey 2007
Prospective 4 month audit:
9223 examinations Caecal intubation rate 77% Perforation rate 1:769 Only 17% had received supervised training Only 39% had attended a course
Bowles et al Gut 2004Bowles et al Gut 2004
UK National Intercollegiate UK National Intercollegiate Colonoscopy AuditColonoscopy Audit
• 13.7% Screening colonoscopies
• 66% Specific Informed Consent
• 44.9% No Sedation
• 80.7% Completion Rate
Is this you ?
Quality of Colonoscopy to be improved:
Better Colonoscopy Technique
Safe Sedation
Better diagnostic accuracy
Immediate therapy (polypectomy-EMR)
• Completion Rate > 85% (acceptable) or > 90% (desirable)
• Withdrawal time (6’-10’)
• Good to Excellent bowel prep
• Adenomas yeld in > 15% of asymptomatic pts
• Complications Registry
• Patient’s satisfaction questionnaire
• Immediate polypectomy for polyps at low risk for
complications (< 2 cm?)
• Biopsy (?) and delayed polypectomy for other polyps
Source: Italian Ministry of HealthSource: Italian Ministry of Health
Some patients under close colonoscopic surveillance still develop CRC at short intervals
Robertson DJ. Gastroenterology 2005; 129Robertson DJ. Gastroenterology 2005; 129
Fast Track cancers - MMR pathway (15-20%)
Inadequate Bowel Prep
Piecemeal removal of large sessile polyps
Fast withdrawal time
van Rijn JC. Am J Gastroenterol 2006; 101van Rijn JC. Am J Gastroenterol 2006; 101
The Paris endoscopic classification of The Paris endoscopic classification of superficial neoplastic lesionssuperficial neoplastic lesions
Gastrointest Endosc 2003, 58, 6Gastrointest Endosc 2003, 58, 6
Scarcely detected in western countries Japanese endoscopists demonstrated that up to
40% of adenomas in western hospitals are of the flat and depressed type
Fujii T. Endoscopy 1998; 30Fujii T. Endoscopy 1998; 30Saitoh Y. Gastroenterology 2001; 120 Saitoh Y. Gastroenterology 2001; 120
Tsuda S. Gut 2002; 51Tsuda S. Gut 2002; 51
Colonoscopic withdrawal timesColonoscopic withdrawal timesand adenoma detection and adenoma detection during screening colonoscopyduring screening colonoscopy
Barclay RL. N Engl J Med Barclay RL. N Engl J Med 2006;3552006;355
Narrow Band Narrow Band Imaging (NBI)Imaging (NBI)
ChromoendoscopChromoendoscopyy(Indigo Carmine (Indigo Carmine 0.2%)0.2%)
Sampling depth not deeper than Lamina PropriaSampling depth not deeper than Lamina Propria
Intraepithelial Intraepithelial Carcinoma Carcinoma
Intramucosal Intramucosal CarcinomaCarcinoma
Invasive Carcinoma (T1)Invasive Carcinoma (T1)or Early CR Cancer or Early CR Cancer
HGD HGD
Only to confirm unresectabilityOnly to confirm unresectability(neoplastic invasion of the submucosa)(neoplastic invasion of the submucosa)
Adequate skill to remove polyps or NPL (flat lesions) up to 2 cm
Knowledge of Guidelines on Anticoagulation and Antiplatelet Therapy management
Exhaustive knowledge of management of adenomas with invasive carcinoma (pathologic criteria)
Stiff Monofilament Snare best for flat lesions
ESD skills not required
From Ileo-cecal Valve to Upper RectumFrom Ileo-cecal Valve to Upper Rectum
For follow-up endoscopyFor follow-up endoscopy
For the surgeon (especially laparoscopic)For the surgeon (especially laparoscopic)
Tattoo lasts foreverTattoo lasts forever
SPOT: pure carbon suspensionSPOT: pure carbon suspension
How Quality of Colonoscopy How Quality of Colonoscopy
can be improved:can be improved:
Institutional TraningInstitutional Traning
AuditsAudits
Retraining Programs Retraining Programs
Bischops R. Gut 2002Bischops R. Gut 2002
355 EGDs
73 Colonoscopies
5 ERCPs
Italian Residents ExperienceItalian Residents Experience
D.M. 1 agosto 2005 Riassetto delle Scuole di specializzazione di area sanitaria
Gazz. Uff. 5 novembre 2005, n. 258, S.O.
300 EGDs
150 Colonoscopies
30 Polypectomies
Ensuring CompetenceEnsuring Competence
Not Not monitored !monitored !
Bowel preparation quality
Cecal intubation rate (>95%)
Photo documentation of cecal landmarks
Mean withdrawal time > 6-10 min Mean Adenoma Detection Rate (M: 25% - F:
15%)
Adverse or unplanned events
Complication RatesLieberman D. Gastrointest Endosc 2007Lieberman D. Gastrointest Endosc 2007
Rex DL. Am J Gastroenterology 2002Rex DL. Am J Gastroenterology 2002
Imperiali G. Endoscopy 2007Imperiali G. Endoscopy 2007
Routine sedation (Midazolam and Meperidine)Routine sedation (Midazolam and Meperidine)
Less skilled endoscopists supervised by Less skilled endoscopists supervised by experienced physiciansexperienced physicians
Greater access to endoscopy sessions for Greater access to endoscopy sessions for endoscopists with the lowest performance ratesendoscopists with the lowest performance rates
After a failure of cecal intubation, second After a failure of cecal intubation, second attempt made by another endoscopistattempt made by another endoscopist
Physicians with the lowest polyp detection Physicians with the lowest polyp detection rates invited to slow withdrawal phaserates invited to slow withdrawal phase
Corrective MeasuresCorrective Measures
Imperiali G. Endoscopy 2007Imperiali G. Endoscopy 2007
RetrainingRetraining
S. Thomas−Gibson, Endoscopy 2007S. Thomas−Gibson, Endoscopy 2007
20082008 Colonoscopy Retraining Working GroupColonoscopy Retraining Working Group
G. Costamagna, MD G. Costamagna, MD
A. Federici, MDA. Federici, MD
P. D’Argenio, MDP. D’Argenio, MD
E. Di Giulio, MDE. Di Giulio, MD
G. Minoli, MDG. Minoli, MD
L. Petruzziello, MDL. Petruzziello, MD
M.E. Pirola, MDM.E. Pirola, MD
C. Senore, MDC. Senore, MD
M. Zappa, MDM. Zappa, MD
Held by Italian Ministry of Health
Managed by National Screening Observatory (ONS)
Region-based
1-2 Trainers from each Region
National “Train-the-Trainers” Course
Regional “Retraining Courses”
Colonoscopy “Retraining Program”Colonoscopy “Retraining Program”
In collaboration with the 3 Gastroenterological Societies (AIGO, SIED, SIGE) and with the Italian Group for CRC Screening (GISCoR)
2 Eds (Rome, EETC, Sept. 2007 – Campobasso, Oct. 2007)
23 Trainers 1 Master Colonoscopist (CB Williams)
10 Experts (epidemiology, quality, screening principles, sedation, etc.)
Colonoscopy Colonoscopy ““Train the Trainers” CourseTrain the Trainers” Course
Colonoscopy Colonoscopy ““Train the Trainers” Train the Trainers” CourseCourse
Hands-onHands-on
LecturesLecturesSimulator TrainingSimulator Training
Hands-On One-to-Master(Lazio, 2005)
Observational (Lombardia, 2008)
Hands-On Peer-to-Peer
(Emilia Romagna, 2009)
Hands-On One-to-Master(Veneto, 2010)
Regional “Retraining Regional “Retraining Courses”Courses”
Colonoscopy carried out within 30 days after FOBT+ in only 41.0%
19.7% of subjects had to wait for more than two months
Post-polypectomy surveillance takes resources away from screening
According to BSG, ACS, and AGA guidelines, most of patients with 1-2 tubular adenomas
FU in 5-10 years
Follow-up Colonoscopy:Follow-up Colonoscopy:
Screen more,Screen more,
Survey Less,Survey Less,
and Saveand Save
Waye JD. Gastrointest Endosc. 2006Waye JD. Gastrointest Endosc. 2006