William B. Hale

Conscious or unconscious: The impact of sedation choice on colon adenoma detection

AIM To determine if anesthesiologist-monitored use of propofol results in improved detection of adenomas when compared with routine conscious sedation. METHODS This retrospective study was conducted at two separate hospital-based endoscopy units where approximately 12,000 endoscopic procedures are performed annually, with one endoscopy unit exclusively using anesthesiologist-monitored propofol. Three thousand two hundred and fifty-two patients underwent initial screening or surveillance colonoscopies. Our primary end point was the adenoma detection rate, defined as the number of patients in whom at least one adenoma was found, associated with the type of sedation. RESULTS Three thousand two hundred and fifty-two outpatient colonoscopies were performed by five selected endoscopists. At least one adenoma was detected in 27.6% of patients (95% CI = 26.0-29.1) with no difference in the detection rate between the anesthesiologist-propofol and group and the gastroenterologist-midazolam/fentanyl group (28.1% vs 27.1%, P = 0.53). CONCLUSION The type of sedation used during colonoscopy does not affect the number of patients in whom adenomatous polyps are detected.

Colonoscopy in the diagnosis and management of diverticular disease.

This review examines the role of colonoscopy in the evaluation of asymptomatic diverticulosis, segmental diverticular disease-associated colitis and acute diverticulitis. Asymptomatic acute diverticulitis, discovered during screening colonoscopy, is also discussed. In addition, the use of colonoscopy, both diagnostic and therapeutic, is compared to standard radiology studies for the management of acute diverticular bleeding.

346 Anesthesia Provider Type Effect on Adenoma Detection Rate and Adenoma Under the Curve

Purpose: Adenoma detection rate (ADR) is a quality indicator used to benchmark endoscopists. A new metric was recently proposed, the AUC (adenomas under the curve), that subsumes ADR and provides additional quality information by looking at frequency and the number of adenomas detected on screening colonoscopy. As part of a quality improvement project we compared the impact of type of sedation, either conscious sedation or deep sedation (propofol) on ADR and AUC. Methods: A retrospective analysis using data mining techniques identified colonoscopies performed at our hospital from 2/2001 to 10/2011. We computed ADR and AUC for each year based on the type of anesthesia provided, conscious sedation or deep sedation.We reviewed 65684 colonoscopies and 39236 associated pathology reports; 41669 were screening colonoscopies for colorectal cancer; 51192 had conscious sedation and 13645 deep sedation. Our population was 51.91% female, with a mean age of 59.25 years and 84.19% were Caucasian. ADR was defined as the number of adenomas divided to the number of screening colonoscopies performed in the analyzed subgroup. AUC was computed by using the trapezoid method for determination of area under a curve in the same way used by the AUC authors, by summing the frequency of cases multiplied with the total number of adenomas. In order to take into account the upgrades in colonoscopy equipment during the duration of the study we performed a year to year comparison of ADR in both groups. Results: The percentage of screening colonoscopies performed with deep sedation increased from 0.67% in 2001 to 71.17% in 2011 (figure 1). However, a year by year ADR comparison did not emphasize a consistent statistical difference between the types of sedation used (table 1). Despite this finding, ADR for screening colonoscopies performed under deep sedation was overall 27.16, statistically significant when compared to ADR 20.28 for screening colonoscopies performed with conscious sedation (p<0.0001). The same effect was visible by comparing AUC, with colonoscopies provided with deep sedation (AUC = 66.52) slightly more likely to have detected 2-4 adenomas, compared to colonoscopies with conscious sedation (AUC = 62.74). Conclusion: In our population, a retrospective analysis of screening colonoscopies showed a better ADR and AUC with deep sedation. However, the presence of an anesthesiologist did not consistently improve ADR in each year of our study. Further prospective studies are needed to isolate confounders and the effect of anesthesia type on ADR. AUC seems to describe slightly better the intermediate risk subpopulation (with 3-4 polyps, 3 years recommended surveillance period), however it still needs to be prospectively validated. TABLE 1 ADR per year according to anesthesia provider type

Should Colorectal Cancer Screening Start at Age 45 for Everyone? A Community Hospital Experience

Purpose: It has been suggested African Americans(AA) begin screening for colorectal cancer screening at age 45 by the ASGEs and the American College of Gastroenterology. Previous studies have shown that blacks have greater mortality risk from colorectal cancer, younger age at presentation, a higher proportion of cancers presenting before age 50, lower screening rates than whites and more advanced cancer at diagnosis. We evaluated the adenoma detection rate by ethnicity in the age group younger then age 50. Methods: In a retrospective study evaluating 60,802 colonoscopies (84.44% Caucasians, 7.17% AA, 5.55% Hispanics, 0.82% Asians) performed between Jan 1, 2001 Oct 30, 2010 with (84.44% Caucasians, 7.17% AA, 5.55% Hispanics, 0.82% Asians) we analyzed the adenoma detection rate in sub-groups distributed according to ethnicity and age in 5 year increments. We queried the Oracle database powering our EMR system (Cerner Powerchart) for all the colonoscopy reports available for patient demographics as well as adenoma detection and colon cancer. Results: In the 45-50 years old group 5063 (8.32%) colonoscopies were performed (83.3% Caucasians, 6.67 % AA, 6.39% Hispanics, 1.22% Asians). The overall adenoma detection rate (ADR) was 12.87%, for Caucasians 12.94%, for AA 11.53%, for Hispanics 13.58% and for Asians 12.9%. In the group over 50 years ADR was for Caucasians 21.62%, for AA 20.96%, for Hispanics 19.21% and for Asians 21.67% (Table 1). Chi square analysis of ADR in the 45-50 years age group revealed no statistical significant difference between Caucasians AA (p=0.5109), Caucasians Hispanics (p=0.8073) or AA Hispanics (p= 0.4815). Also no statistical difference (p=0.901) was seen in regards to the incidence of colon cancer between Caucasians (26 cases) and AA (2 cases). Conclusion: The findings in our population having a colonoscopy performed at our hospital for any indication suggest the recommendations earlier screening starting at 45 years for African Americans or Hispanics could be extended also to Caucasians. Future prospective studies are needed to validate these findings.