Adenoma detection rate (ADR) is one of the most important indicators of endoscopy quality, as an increased ADR is related to reduced rates of interval cancer.
Although several new technologies have emerged as promising tools to improve ADR, evidence has demonstrated that education in the recognition of colorectal lesions helps to improve ADR
Studies evaluating techniques that improve visualization by exposing more mucosa, such as retroflexion, Third Eye Retroscope, add-on devices or wide-angle colonoscopies, report conflicting results regarding ADR improvement
Image-enhanced colonoscopes facilitate the detection and characterization of polyps, especially nonpolypoid colorectal neoplasms
Image enhancement techniques should be effective and practical to enable routine use in endoscopy units performing colorectal cancer screening.
High-quality colonoscopy is mandatory to prevent adenoma recurrence and colorectal cancer. In the past few years, technical advances have been developed with the purpose of improving adenoma detection rate (ADR), one of the most important validated colonoscopy quality benchmarks. Several techniques or devices are used to optimize visualization: observation techniques; add-on devices; auxiliary imaging devices; colonoscopes with increased field of view; and colonoscopes with an integrated inflatable reusable balloon. Image-enhanced endoscopy (IEE) facilitates the detection and characterization of polyps and especially nonpolypoid colorectal neoplasms. Indigo carmine is the most frequently used dye in colonoscopy as it deposits in depressed areas, improving detection of flat and depressed lesions. Virtual chromoendoscopy has emerged as an effective contrast enhancement technology without the limitation of preparing dyes and applying them through the colonoscope working channel. Narrow-band imaging (NBI) enhances the capillary pattern and surface of the mucosa using optical filters, and second-generation NBI provides a twofold brighter image than the previous system, yielding promising ADR results. Moreover, a second-generation blue laser imaging system, LASEREO, has been reported to improve not only polyp detection rate but also ADR, becoming a promising IEE modality. Herein, we describe technical advances in colonoscopy imaging and their effect on ADR.
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Mandel, J. S. et al. Reducing mortality from colorectal cancer by screening for fecal occult blood. N. Engl. J. Med. 328, 1365–1371 (1993).
Kronborg, O., Fenger, C., Olsen, J., Jørgensen, O. D. & Søndergaard, O. Randomised study of screening for colorectal cancer with faecal-occult-blood test. Lancet 348, 1467–1471 (1996).
Hardcastle, J. D. et al. Randomised controlled trial of faecal-occult-blood screening for colorectal cancer. Lancet 348, 1472–1477 (1996).
Schoen, R. E. et al. Colorectal-cancer incidence and mortality with screening flexible sigmoidoscopy. N. Engl. J. Med. 366, 2345–2357 (2012).
Winawer, S. J. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N. Engl. J. Med. 329, 1977–1981 (1993).
Rex, D. K. et al. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology 112, 24–28 (1997).
Heresbach, D. et al. Miss rate for colorectal neoplastic polyps: a prospective multicenter study of back-to-back video colonoscopies. Endoscopy 40, 284–290 (2008).
Martinez, M. E. et al. Adenoma characteristics as risk factors for recurrence of advanced adenomas. Gastroenterology 120, 1077–1083 (2001).
van Stolk, R. U., Beck, G. J., Baron, J. A., Haile, R. & Summers, R. Adenoma characteristics at first colonoscopy as predictors of adenoma recurrence and characteristics at follow-up: the Polyp Prevention Study Group. Gastroenterology 115, 13–18 (1998).
Lieberman, D. A. et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 143, 844–857 (2012).
Hassan, C. et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 45, 842–851 (2013).
Sanduleanu, S. et al. Definition and taxonomy of interval colorectal cancers: a proposal for standardising nomenclature. Gut 64, 1257–1267 (2015).
Bressler, B. et al. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterology 132, 96–102 (2007).
Singh, H., Nugent, Z., Demers, A. A. & Bernstein, C. N. Rate and predictors of early/missed colorectal cancers after colonoscopy in Manitoba: a population-based study. Am. J. Gastroenterol. 105, 2588–2596 (2010).
Valori, R. et al. European guidelines for quality assurance in colorectal cancer screening and diagnosis. First edition. Endoscopy 44 (Suppl. 3), SE88-105 (2012).
Singh, S., Singh, P. P., Murad, M. H., Singh, H. & Samadder, N. J. Prevalence, risk factors, and outcomes of interval colorectal cancers: a systematic review and meta-analysis. Am. J. Gastroenterol. 109, 1375–1389 (2014).
le Clercq, C. M. et al. Postcolonoscopy colorectal cancers are preventable: a population-based study. Gut 63, 957–963 (2014).
Lebwohl, B. et al. The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy. Gastrointest. Endosc. 73, 1207–1214 (2011).
Chokshi, R. V., Hovis, C. E., Hollander, T., Early, D. S. & Wang, J. S. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointest. Endosc. 75, 1197–1203 (2012).
Ness, R. M., Manam, R., Hoen, H. & Chalasani, N. Predictors of inadequate bowel preparation for colonoscopy. Am. J. Gastroenterol. 96, 1797–1802 (2001).
Liu, X. et al. Telephone-based re-education on the day before colonoscopy improves the quality of bowel preparation and the polyp detection rate: a prospective, colonoscopist-blinded, randomised, controlled study. Gut 63, 125–130 (2014).
Kaminski, M. F., Regula, J. & Kraszewska, E. Quality indicators for colonoscopy and the risk of interval cancer. N. Engl. J. Med. 362, 1795–1803 (2010).
Barclay, R. L., Vicari, J. J., Doughty, A. S., Johanson, J. F. & Greenlaw, R. L. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N. Engl. J. Med. 355, 2533–2541 (2006).
Rex, D. K. Colonoscopic withdrawal technique is associated with adenoma miss rates. Gastrointest. Endosc. 51, 33–36 (2000).
Lee, R. H. et al. Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos). Gastrointest. Endosc. 74, 128–134 (2011).
Coe, S. G., Crook, J. E., Diehl, N. N. & Wallace, M. B. An endoscopic quality improvement program improves detection of colorectal adenomas. Am. J. Gastroenterol. 108, 219–226 (2013).
Kaminski, M. F. et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomised trial. Gut 65, 616–624 (2016).
Harrison, M., Singh, N. & Rex, D. K. Impact of proximal colon retroflexion on adenoma miss rates. Am. J. Gastroenterol. 99, 519–522 (2004).
Kushnir, V. M. et al. Impact of retroflexion versus second forward view examination of the right colon on adenoma detection: a comparison study. Am. J. Gastroenterol. 110, 415–422 (2015).
Ng, S. C. et al. The efficacy of cap-assisted colonoscopy in polyp detection and cecal intubation: a meta-analysis of randomized controlled trials. Am. J. Gastroenterol. 107, 1165–1173 (2012).
He, Q. et al. Cap-assisted colonoscopy versus conventional colonoscopy: systematic review and meta-analysis. Int. J. Colorectal Dis. 28, 279–281 (2013).
Westwood, D. A., Alexakis, N. & Connor, S. J. Transparent cap-assisted colonoscopy versus standard adult colonoscopy: a systematic review and meta-analysis. Dis. Colon Rectum 55, 218–225 (2012).
Biecker, E. et al. Novel endocuff-assisted colonoscopy significantly increases the polyp detection rate: a randomized controlled trial. J. Clin. Gastroenterol. 49, 413–418 (2015).
Floer, M. et al. Higher adenoma detection rates with endocuff-assisted colonoscopy — a randomized controlled multicenter trial. PLoS ONE 9, e114267 (2014).
van Doorn, S. C. et al. Adenoma detection with Endocuff colonoscopy versus conventional colonoscopy: a multicenter randomised controlled trial. Gut http://dx.doi.org/10.1136/gutjnl-2015-310097 (2016).
Chin, M., Chen, C. L. & Karnes, W. E. Improved polyp detection among high risk patients with Endocuff [abstract]. Gastrointest. Endosc. 81 (Suppl. 5), AB283 (2015).
Pioche, M. et al. Endocuff®-assisted colonoscopy increases polyp detection rate: a simulated randomized study involving an anatomic colorectal model and 32 international endoscopists. Surg. Endosc. 30, 288–295 (2016).
Triadafilopoulos, G., Watts, H. D., Higgins, J. & Van Dam, J. A novel retrograde viewing auxiliary imaging device (Third Eye Retroscope) improves the detection of simulated polyps in anatomic models of the colon. Gastrointest. Endosc. 65, 139–144 (2007).
Triadafilopoulos, G. & Li, J. A pilot study to assess the safety and efficacy of the Third Eye retrograde auxiliary imaging system during colonoscopy. Endoscopy 40, 478–482 (2008).
DeMarco, D. C. et al. Impact of experience with a retrograde-viewing device on adenoma detection rates and withdrawal times during colonoscopy: the Third Eye Retroscope study group. Gastrointest. Endosc. 71, 542–550 (2010).
Waye, J. D. et al. A retrograde-viewing device improves detection of adenomas in the colon: a prospective efficacy evaluation. Gastrointest. Endosc. 71, 551–556 (2010).
Leufkens, A. M. et al. Effect of a retrograde-viewing device on adenoma detection rate during colonoscopy: the TERRACE study. Gastrointest. Endosc. 73, 480–489 (2011).
Deenadayalu, V. P., Chadalawada, V. & Rex, D. K. 170 degrees wide-angle colonoscope: effect on efficiency and miss rates. Am. J. Gastroenterol. 99, 2138–2142 (2004).
Fatima, H. et al. Wide-angle (WA) (170° angle of view) versus standard (ST) (140°angle of view) colonoscopy [abstract]. Gastrointest. Endosc. 63, AB204 (2013).
Uraoka, T. et al. A novel extra-wide-angle-view colonoscope: a simulated pilot study using anatomic colorectal models. Gastrointest. Endosc. 77, 480–483 (2013).
Uraoka, T. et al. Feasibility of a novel colonoscope with extra-wide angle of view: a clinical study. Endoscopy 47, 444–448 (2015).
Gralnek, I. M. et al. Comparison of standard forward-viewing mode versus ultrawide-viewing mode of a novel colonoscopy platform: a prospective, multicenter study in the detection of simulated polyps in an in vitro colon model (with video). Gastrointest. Endosc. 77, 472–479 (2013).
Gralnek, I. M. et al. Standard forward-viewing colonoscopy versus full-spectrum endoscopy: an international, multicentre, randomised, tandem colonoscopy trial. Lancet Oncol. 15, 353–360 (2014).
Hasan, N. et al. A novel balloon colonoscope detects significantly more simulated polyps than a standard colonoscope in a colon model. Gastrointest. Endosc. 80, 1135–1140 (2014).
Halpern, Z. et al. Comparison of adenoma detection and miss rates between a novel balloon colonoscope and standard colonoscopy: a randomized tandem study. Endoscopy 47, 238–244 (2015).
Kariya, A., Beppu, Y. & Mizuno, M. A case of early colonic cancer type IIc associated with familial polyposis coli. Stomach Intest. 12, 1359–1364 (1977).
Kudo, S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer. Endoscopy 25, 455–461 (1993).
Muto, T. et al. Small “flat adenoma” of the large bowel with special reference to its clinicopathologic features. Dis. Colon Rectum. 28, 847–851 (1985).
Rembacken, B. J. et al. Flat and depressed colonic neoplasms: a prospective study of 1000 colonoscopies in the UK. Lancet 355, 1211–1214 (2000).
Parra-Blanco, A. et al. Risk for high-grade dysplasia or invasive carcinoma in colorectal flat adenomas in a Spanish population. Gastroenterol. Hepatol. 29, 602–609 (2006).
Soetikno, R. M. et al. Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults. JAMA 299, 1027–1035 (2008).
Chiu, H. M. et al. Prevalence and characteristics of nonpolypoid colorectal neoplasm in an asymptomatic and average-risk Chinese population. Clin. Gastroenterol. Hepatol. 7, 463–470 (2009).
Matsuda, T., Saito, Y., Hotta, K., Sano, Y. & Fujii, T. Prevalence and clinicopathological features of nonpolypoid colorectal neoplasms: should we pay more attention to identifying flat and depressed lesions? Dig. Endosc. 22 (Suppl. 1), S57–S62 (2010).
Brooker, J. C. et al. Total colonic dye-spray increases the detection of diminutive adenomas during routine colonoscopy: a randomized controlled trial. Gastrointest. Endosc. 56, 333–338 (2002).
Hurlstone, D. P., Cross, S. S., Slater, R., Sanders, D. S. & Brown, S. Detecting diminutive colorectal lesions at colonoscopy: a randomised controlled trial of pan-colonic versus targeted chromoscopy. Gut 53, 376–380 (2004).
Pohl, J. et al. Pancolonic chromoendoscopy with indigo carmine versus standard colonoscopy for detection of neoplastic lesions: a randomised two-centre trial. Gut 60, 485–490 (2011).
Brown, S. R. & Baraza, W. Chromoscopy versus conventional endoscopy for the detection of polyps in the colon and rectum. Cochrane Database Syst. Rev. 4, CD006439 (2016).
Stoffel, E. M. et al. Chromoendoscopy detects more adenomas than colonoscopy using intensive inspection without dye spraying. Cancer Prev. Res. 1, 507–513 (2008).
Kahi, C. J. et al. High-definition chromocolonoscopy versus high-definition white light colonoscopy for average-risk colorectal cancer screening. Am. J. Gastroenterol. 105, 1301–1307 (2010).
Le Rhun, M. et al. High resolution colonoscopy with chromoscopy versus standard colonoscopy for the detection of colonic neoplasia: a randomized study. Clin. Gastroenterol. Hepatol. 4, 349–354 (2006).
Lapalus, M. G. et al. Does chromoendoscopy with structure enhancement improve the colonoscopic adenoma detection rate? Endoscopy 38, 444–448 (2006).
Saitoh, Y. et al. Prevalence and distinctive biologic features of flat colorectal adenomas in a North American population. Gastroenterology 120, 1657–1665 (2001).
Rutter, M., Bernstein, C., Matsumoto, T., Kiesslich, R. & Neurath, M. Endoscopic appearance of dysplasia in ulcerative colitis and the role of staining. Endoscopy 36, 1109–1114 (2004).
Subramanian, V., Mannath, J., Ragunath, K. & Hawkey, C. J. Meta-analysis: the diagnostic yield of chromoendoscopy for detecting dysplasia in patients with colonic inflammatory bowel disease. Aliment. Pharmacol. Ther. 33, 304–312 (2011).
Lecomte, T. et al. Chromoendoscopic colonoscopy for detecting preneoplastic lesions in hereditary nonpolyposis colorectal cancer syndrome. Clin. Gastroenterol. Hepatol. 3, 897–902 (2005).
Hurlstone, D. P. et al. The role of high-magnification-chromoscopic colonoscopy in hereditary nonpolyposis colorectal cancer screening: a prospective “back-to-back” endoscopic study. Am. J. Gastroenterol. 100, 2167–2173 (2005).
Hüneburg, R. et al. Chromocolonoscopy detects more adenomas than white light colonoscopy or narrow band imaging colonoscopy in hereditary nonpolyposis colorectal cancer screening. Endoscopy 41, 316–322 (2009).
Kaminski, M. F. et al. Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 46, 435–449 (2014).
Paggi, S. et al. The impact of narrow band imaging in screening colonoscopy: a randomized controlled trial. Clin. Gastroenterol. Hepatol. 7, 1049–1054 (2009).
Kaltenbach, T., Friedland, S. & Soetikno, R. A randomised tandem colonoscopy trial of narrow band imaging versus white light examination to compare neoplasia miss rates. Gut 57, 1406–1412 (2008).
Rex, D. K. & Helbig, C. C. High yields of small and flat adenomas with high-definition colonoscopes using either white light or narrow band imaging. Gastroenterology 133, 42–47 (2007).
Adler, A. et al. A prospective randomised study on narrow-band imaging versus conventional colonoscopy for adenoma detection: does narrow-band imaging induce a learning effect? Gut 57, 59–64 (2008).
Adler, A. et al. Narrow-band versus white-light high definition television endoscopic imaging for screening colonoscopy: a prospective randomized trial. Gastroenterology 136, 410–416 (2009).
Chung, S. J. et al. Comparison of detection and miss rates of narrow band imaging, flexible spectral imaging chromoendoscopy and white light at screening colonoscopy: a randomised controlled back-to-back study. Gut 63, 785–791 (2014).
Inoue, T. et al. Comparative study of conventional colonoscopy and pan-colonic narrow-band imaging system in the detection of neoplastic colonic polyps: a randomized, controlled trial. J. Gastroenterol. 43, 45–50 (2008).
Uraoka, T. et al. Detectability of colorectal neoplastic lesions using a narrow-band imaging system: a pilot study. J. Gastroenterol. Hepatol. 23, 1810–1815 (2008).
Ikematsu, H. et al. The impact of narrow band imaging for colon polyp detection: a multicenter randomized controlled trial by tandem colonoscopy. J. Gastroenterol. 47, 1099–1107 (2012).
Nagorni, A., Bjelakovic, G. & Petrovic, B. Narrow band imaging versus conventional white light colonoscopy for the detection of colorectal polyps. Cochrane Database Syst. Rev. 1, CD008361. http://dx.doi.org/10.1002/14651858.CD008361.pub2 (2012).
Pasha, S. F. et al. Comparison of the yield and miss rate of narrow band imaging and white light endoscopy in patients undergoing screening or surveillance colonoscopy: a meta-analysis. Am. J. Gastroenterol. 107, 363–370 (2012).
Jin, X.-F., Chai, T.-H., Shi, J.-W., Yang, X.-C. & Sun, Q.-Y. Meta-analysis for evaluating the accuracy of endoscopy with narrow band imaging in detecting colorectal adenomas. J. Gastroenterol. Hepatol. 27, 882–887 (2012).
Dinesen, L., Chua, T. J. & Kaffes, A. J. Meta-analysis of narrow-band imaging versus conventional colonoscopy for adenoma detection. Gastrointest. Endosc. 75, 604–611 (2012).
Leung, W. K. et al. Detection of colorectal adenoma by narrow band imaging (HQ190) versus high-definition white light colonoscopy: a randomized controlled trial. Am. J. Gastroenterol. 109, 855–863 (2014).
Horimatsu, T. et al. Next-generation narrow band imaging system for colonic polyp detection: a prospective multicenter randomized trial. Int. J. Colorectal Dis. 30, 947–954 (2015).
Kiriyama, S. et al. Detectability of colon polyp using computed virtual chromoendoscopy with flexible spectral imaging color enhancement. Diagn. Ther. Endosc. 2012, 596303 (2012).
Aminalai, A. et al. Live image processing does not increase adenoma detection rate during colonoscopy: a randomized comparison between FICE and conventional imaging (Berlin Colonoscopy Project 5, BECOP-5). Am. J. Gastroenterol. 105, 2383–2388 (2010).
Chung, S. J. et al. Efficacy of computed virtual chromoendoscopy on colorectal cancer screening: a prospective, randomized, back-to-back trial of Fuji Intelligent Color Enhancement versus conventional colonoscopy to compare adenoma miss rates. Gastrointest. Endosc. 72, 136–142 (2010).
Pohl, J. et al. Computed virtual chromoendoscopy versus standard colonoscopy with targeted indigocarmine chromoscopy: a randomised multicentre trial. Gut 58, 73–78 (2009).
Matsuda, T. et al. Does autofluorescence imaging videoendoscopy system improve the colonoscopic polyp detection rate? — A pilot study. Am. J. Gastroenterol. 103, 1926–1932 (2008).
Ramsoekh, D. et al. A back-to-back comparison of white light video endoscopy with autofluorescence endoscopy for adenoma detection in high-risk subjects. Gut 59, 785–793 (2010).
Takeuchi, Y. et al. Autofluorescence imaging with a transparent hood for detection of colorectal neoplasms: a prospective, randomized trial. Gastrointest. Endosc. 72, 1006–1013 (2010).
van den Broek, F. J. et al. Clinical evaluation of endoscopic trimodal imaging for the detection and differentiation of colonic polyps. Clin. Gastroenterol. Hepatol. 7, 288–295 (2009).
Kuiper, T. et al. Endoscopic trimodal imaging detects colonic neoplasia as well as standard video endoscopy. Gastroenterology 140, 1887–1894 (2011).
Hoffman, A. et al. High definition colonoscopy combined with i-SCAN is superior in the detection of colorectal neoplasias compared with standard video colonoscopy: a prospective randomized controlled trial. Endoscopy 42, 827–833 (2010).
Hong, S. N. et al. Prospective, randomized, back-to-back trial evaluating the usefulness of i-SCAN in screening colonoscopy. Gastrointest. Endosc. 75, 1011–1021.e2 (2012).
Yoshida, N. et al. Improvement in the visibility of colorectal polyps by using blue laser imaging (with video). Gastrointest. Endosc. 82, 542–549 (2015).
Ikematsu, H. et al. Detectability of colorectal neoplastic lesions using a novel endoscopic system with blue laser imaging: a multicenter randomized controlled trial. Gastrointest. Endosc. http://dx.doi.org/10.1016/j.gie.2017.01.017 (2016).
The authors acknowledge funding from the National Cancer Center Research and Development Fund, Japan (27-A-5).
The authors declare no competing financial interests.
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Matsuda, T., Ono, A., Sekiguchi, M. et al. Advances in image enhancement in colonoscopy for detection of adenomas. Nat Rev Gastroenterol Hepatol 14, 305–314 (2017) doi:10.1038/nrgastro.2017.18
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