Background Colorectal cancer (CRC) is a major worldwide cause of cancer-related mortality. Colonoscopy programs based on guideline-recommended surveillance intervals have been put in place to reduce the morbidity and mortality associated with CRC. We were interested to evaluate clinical practice adherence to guideline-recommended surveillance intervals, the potential extent of early repeat colonoscopies, and causes of nonadherence to guideline recommendations. Methods We performed a literature search for articles reporting on guideline adherence for surveillance colonoscopies. Exclusion criteria included inflammatory bowel disease and hereditary CRC syndrome cohorts. Primary outcome was correct interval assignment in patients undergoing surveillance colonoscopy. Groups were assessed for adherence according to their respective guideline recommendations (North American or European). Results 16 studies were included in the analysis. The mean colonoscopy surveillance interval adherence rate was 48.8 % (95 % confidence interval [CI] 37.3 – 60.4). For North American guidelines, surveillance interval assignments were adherent to guideline recommendations in 44.7 % (95 %CI 24.2 – 66.3) of patients after detection of low risk lesions and in 54.6 % (95 %CI 41.4 – 67.4) after detection of high risk lesions. For European guidelines, surveillance interval assignments were adherent to recommendations in 24.4 % (95 %CI 1.1 – 63.4) of patients after detection of low risk lesions and in 73.6 % (95 %CI 35.5 – 98.8) after detection of high risk lesions. Conclusions The worldwide adherence to surveillance colonoscopy guidelines was low, with more than 50 % of patients undergoing repeat colonoscopies either too early or too late. Early repeat colonoscopies occurred with the highest frequency for patients in whom only hyperplastic polyps or low risk adenomas were found.

This article has an accompanying continuing medical education activity, also eligible for MOC credit, on page e19. Learning Objective: Upon completion of this CME activity, successful learners will be able to describe key colonoscopy quality metrics and employ proper polypectomy techniques in different clinical situations. BACKGROUND & AIMS: Incomplete resection of neoplastic colorectal polyps can result in postcolonoscopy colorectal cancer. We performed a systematic review and meta-analysis to determine the incomplete resection rate (IRR) of colorectal polyps and associated factors. METHODS: We searched MED-LINE, EMBASE, EBM Reviews, and CINAHL to identify full-text articles that reported IRRs of polyps 1 to 20 mm, published until March 2019. Exclusion criteria were studies of inflammatory bowel disease cohorts, referrals for difficult polypectomy, polyp sizes larger than 20 mm, and endoscopic submucosal resection and/or dissection as polypectomy approaches. IRRs were calculated based on findings from biopsies taken at polypectomy sites or assessments of margins of resected polyps. The primary outcome was IRR for snare removal of polyps 1 to 20 mm. Secondary outcomes included IRR for polyps 1 to 10 mm and 10 to 20 mm, IRR for hot and cold snare removal of polyps 1 to 10 mm and 10 to 20 mm, IRR of snare removal with or without submucosal injection, and IRR for forceps and cold snare removal of polyps 1 to 5 mm. RESULTS: We identified 6148 reports and used 32 studies, with a total of 9282 polyps, in our quantitative analysis. The IRR for snare removal of polyps 1 to 20 mm was 13.8% (95% confidence interval [CI] 10.3-17.3; 13 studies, 5128 polypectomies). IRRs were 15.9% for snare removal of polyps 1 to 10 mm (95% CI 9.6-22.1; 9 studies, 2531 polypectomies) and 20.8% for snare removal of polyps 10 to 20 mm (95% CI 12.9-28.8; 6 studies, 412 polypectomies). The IRR for hot snare removal of polyps 1 to 10 mm was 14.2% (95% CI 5.2-23.2) vs 17.3% for cold snare polypectomy (95% CI 14.3-20.3). The IRR for forceps removal of polyps 1 to 5 mm was 9.9% (95% CI 7.1-13.0) vs 4.4% for snare polypectomy (95% CI 2.9-6.1). CONCLUSIONS: In a systematic review and meta-analysis, we found that colorectal polyps 1 to 20 mm are frequently incompletely resected, and that risk increases for polyps 10 mm or larger. There is no difference in IRRs of cold vs hot snares for polyps 1 to 10 mm. Snare polypectomy should be used over forceps for polyps 1 to 5 mm.

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Background and Aims: Accurate polyp size measurement is important for guideline conforming choice of polypectomy techniques and subsequent surveillance interval assignments. Some endoscopic tools (biopsy forceps [BF] or endoscopic rulers [ER]) exist to help with visual size estimation. A virtual scale endoscope (VSE) has been developed that allows superimposing a virtual measurement scale during live endoscopies. Our aim was to evaluate the performance of VSE when compared to ER and BF-based measurement. Methods: We conducted a preclinical randomized trial to evaluate the relative accuracy of size measurement of simulated colorectal polyps when using: VSE, ER, and BF. Six endoscopists performed 60 measurements randomized at a 1:1:1 ratio using each method. Primary outcome was relative accuracy in polyp size measurement. Secondary outcomes included misclassification of sizes at the 5, 10, and 20mm thresholds. Results: A total of 360 measurements were performed. The relative accuracy of BF, ER, and VSE was 78.9% (95%CI=76.2-81.5), 78.4% (95%CI=76.0-80.8), and 82.7% (95%CI=80.8-84.8). VSE had significantly higher accuracy compared to BF (p=0.02) and ER (p=0.006). VSE misclassified a lower percentage of polyps >5mm as ≤5mm (9.4%) compared to BF (15.7%) and ER (20.9%). VSE misclassified a lower percentage of ≥20mm polyps as <20mm (8.3%) compared with BF (66.7%) and ER (75.0%). 25.6%, 25.5%, and 22.5% of polyps ≥10mm were misclassified as <10mm with ER, BF, and VSE, respectively. Conclusions: VSE had significantly higher relative accuracy in measuring polyps compared to ER or biopsy forceps assisted measurement. VSE improves correct classification of polyps at clinically important size thresholds.

Background and study aims Optical real-time diagnosis (= resect-and-discard strategy) is an alternative to histopathology for diminutive colorectal polyps. However, clinical adoption of this approach seems sparse. We were interested in evaluating potential clinical uptake and barriers for implementation of this approach. Methods We conducted an international survey using the “Google forms” platform. Nine endoscopy societies distributed the survey. Survey questions measured current clinical uptake and barriers for implementing the resect-and-discard strategy, perceived cancer risk associated with diminutive polyps and potential concerns with using CT-colonography as follow-up, as well as non-resection of diminutive polyps. Results Eight hundred and eight endoscopists participated in the survey. 84.2 % (95 % CI 81.6 %–86.7 %) of endoscopists are currently not using the resect-and-discard strategy and 59.9 % (95 % CI 56.5 %–63.2 %) do not believe that the resect-and-discard strategy is feasible for implementation in its current form. European (38.5 %) and Asian (45 %) endoscopists had the highest rates of resect-and-discard practice, while Canadian (13.8 %) and American (5.1 %) endoscopists had some of the lowest implementation rates. 80.3 % (95 % CI 77.5 %–83.0 %) of endoscopists believe that using the resect-and-discard strategy for diminutive polyps will not increase cancer risk. 48.4 % (95 % CI 45.0 %–51.9 %) of endoscopists believe that leaving diminutive polyps in place is associated with increased cancer risk. This proportion was slightly higher (54.7 %; 95 % CI 53.6 %–60.4 %) when asked if current CT-colonography screening practice might increase cancer risks. Conclusion Clinical uptake of resect-and-discard is very low. Most endoscopists believe that resect-and-discard is not feasible for clinical implementation in its current form. The most important barriers for implementation are fear of making an incorrect diagnosis, assigning incorrect surveillance intervals and medico-legal consequences.

Objectives The virtual scale endoscope (VSE) allows projection of a virtual scale onto colorectal polyps allowing real‐time size measurements. We studied the relative accuracy of VSE compared to visual assessment (VA) for the measuring simulated polyps of different size and morphology groups. Methods We conducted a blinded randomized controlled trial using simulated polyps within a colon model. Sixty simulated polyps were evenly distributed across four size groups (1–5, >5–9.9, 10–19.9, and ≥20 mm) and three Paris morphology groups (flat, sessile, and pedunculated). Six endoscopists performed polyp size measurements using random allocation of either VA or VSE. Results A total of 359 measurements were completed. The relative accuracy of VSE was significantly higher when compared to VA for all size groups >5 mm (P = 0.004, P < 0.001, P < 0.001). For polyps ≤5 mm, the relative accuracy of VSE compared to VA was not significantly higher (P = 0.186). The relative accuracy of VSE was significantly higher when compared to VA for all morphology groups. VSE misclassified a lower percentage of >5 mm polyps as ≤5 mm (2.9%), ≥10 mm polyps as <10 mm (5.5%), and ≥20 mm polyps as <20 mm (21.7%) compared to VA (11.2%, 24.7%, and 52.3% respectively; P = 0.008, P < 0.001, and P = 0.003). Conclusion Virtual scale endoscope had significantly higher relative accuracies for every polyp size group or morphology type aside from diminutive. VSE enables the endoscopist to better classify polyps into correct size categories at clinically relevant size thresholds of 5, 10, and 20 mm.

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