Endoscopia Digestiva Chirurgica Università Cattolica del Sacro Cuore Policlinico “A. Gemelli” - Roma Lucio Petruzziello
<ul><ul><li>“  Removal of Adenomatous Polyps  </li></ul></ul><ul><ul><li>by Endoscopic Polypectomy  </li></ul></ul><ul><ul...
<ul><li>“  We now have clearer insight  </li></ul><ul><li>into the natural history of colorectal cancer  </li></ul><ul><li...
 
(Welch Allyn - NY)
Low-Res.:  100.000-200.000  Pixels Hi-Res.:  up to 850.000  Pixels
HD images are composed of double  the number of scanning lines (1080 vs. 576)  and horizontal resolution than used  in con...
 
 
<ul><li>After 40 years … </li></ul><ul><li>…  No alternative technique  </li></ul><ul><li>ready for clinical use </li></ul>
Zorzi M. Lo screening colorettale in Italia: survey 2007
 
<ul><li>Prospective 4 month audit: </li></ul><ul><li>9223 examinations </li></ul><ul><li>Caecal intubation rate 77% </li><...
<ul><li>13.7%  Screening colonoscopies </li></ul><ul><li>66% Specific Informed Consent  </li></ul><ul><li>44.9%  No Sedati...
Is this you ?
<ul><li>Quality of Colonoscopy  </li></ul><ul><li>to be improved: </li></ul><ul><li>Better Colonoscopy Technique </li></ul...
<ul><li>Completion Rate > 85% (acceptable) or > 90% (desirable) </li></ul><ul><li>Withdrawal time (6’-10’) </li></ul><ul><...
<ul><li>Some patients under close colonoscopic surveillance still develop CRC at short intervals </li></ul>Robertson DJ. G...
<ul><li>Fast Track cancers - MMR pathway (15-20%) </li></ul><ul><li>Inadequate Bowel Prep </li></ul><ul><li>Piecemeal remo...
van Rijn JC. Am J Gastroenterol 2006; 101
The Paris endoscopic classification of superficial neoplastic lesions Gastrointest Endosc 2003, 58, 6
<ul><li>Scarcely detected in western countries </li></ul><ul><li>Japanese endoscopists demonstrated that up to 40% of aden...
Colonoscopic withdrawal times and adenoma detection  during screening colonoscopy Barclay RL. N Engl J Med 2006;355
Narrow Band Imaging (NBI) Chromoendoscopy (Indigo Carmine 0.2%)
Sampling depth not deeper than Lamina Propria
Intraepithelial  Carcinoma  Intramucosal  Carcinoma Invasive Carcinoma (T1) or Early CR Cancer  HGD
Only to confirm unresectability (neoplastic invasion of the submucosa)
<ul><li>Adequate skill to remove polyps or NPL (flat lesions) up to 2 cm </li></ul><ul><li>Knowledge of Guidelines on Anti...
<ul><li>Stiff Monofilament Snare best for flat lesions </li></ul><ul><li>ESD skills not required </li></ul>
<ul><li>From Ileo-cecal Valve to Upper Rectum </li></ul><ul><li>For follow-up endoscopy </li></ul><ul><li>For the surgeon ...
<ul><li>How Quality of Colonoscopy  </li></ul><ul><li>can be improved: </li></ul><ul><li>Institutional Traning </li></ul><...
<ul><li>355 EGDs </li></ul><ul><li>73 Colonoscopies </li></ul><ul><li>5 ERCPs </li></ul>Bischops R. Gut 2002 Italian Resid...
<ul><li>300 EGDs </li></ul><ul><li>150 Colonoscopies </li></ul><ul><li>30 Polypectomies </li></ul>D.M. 1 agosto 2005  Rias...
 
<ul><li>Bowel preparation quality </li></ul><ul><li>Cecal intubation rate (>95%) </li></ul><ul><li>Photo documentation of ...
Imperiali G.  Endoscopy 2007 <ul><li>Routine sedation (Midazolam and Meperidine) </li></ul><ul><li>Less skilled endoscopis...
Imperiali G.  Endoscopy 2007
Retraining
S. Thomas−Gibson, Endoscopy 2007
2008   Colonoscopy Retraining Working Group G. Costamagna, MD  A. Federici, MD P. D’Argenio, MD E. Di Giulio, MD G. Minoli...
<ul><li>Held by Italian Ministry of Health </li></ul><ul><li>Managed by National Screening Observatory (ONS) </li></ul><ul...
<ul><li>In collaboration with the 3 Gastroenterological Societies (AIGO, SIED, SIGE) and with the Italian Group for CRC Sc...
Colonoscopy  “ Train the Trainers” Course Hands-on Lectures Simulator Training
<ul><li>Hands-On  One-to-Master </li></ul><ul><ul><li>(Lazio, 2005) </li></ul></ul><ul><li>Observational  </li></ul><ul><u...
<ul><li>Colonoscopy carried out within 30 days after FOBT+ in only 41.0% </li></ul><ul><li>19.7% of subjects had to wait f...
<ul><li>Post-polypectomy surveillance takes resources away from screening </li></ul><ul><li>According to  BSG ,  ACS , and...
 
Follow-up Colonoscopy: Screen more, Survey Less, and Save Waye JD. Gastrointest Endosc. 2006
 
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Petruzziello

  1. 1. Endoscopia Digestiva Chirurgica Università Cattolica del Sacro Cuore Policlinico “A. Gemelli” - Roma Lucio Petruzziello
  2. 2. <ul><ul><li>“ Removal of Adenomatous Polyps </li></ul></ul><ul><ul><li>by Endoscopic Polypectomy </li></ul></ul><ul><ul><li>is associated with a </li></ul></ul><ul><ul><li>76%-90% CRC Risk Reduction “ </li></ul></ul>
  3. 3. <ul><li>“ We now have clearer insight </li></ul><ul><li>into the natural history of colorectal cancer </li></ul><ul><li>and clinical skills </li></ul><ul><li>with which to intervene </li></ul><ul><li>and make difference for many people. </li></ul><ul><li>Colorectal cancer screening </li></ul><ul><li>has come of age ”. </li></ul>Sidney J. Winawer
  4. 5. (Welch Allyn - NY)
  5. 6. Low-Res.: 100.000-200.000 Pixels Hi-Res.: up to 850.000 Pixels
  6. 7. HD images are composed of double the number of scanning lines (1080 vs. 576) and horizontal resolution than used in conventional video systems
  7. 10. <ul><li>After 40 years … </li></ul><ul><li>… No alternative technique </li></ul><ul><li>ready for clinical use </li></ul>
  8. 11. Zorzi M. Lo screening colorettale in Italia: survey 2007
  9. 13. <ul><li>Prospective 4 month audit: </li></ul><ul><li>9223 examinations </li></ul><ul><li>Caecal intubation rate 77% </li></ul><ul><li>Perforation rate 1:769 </li></ul><ul><li>Only 17% had received supervised training </li></ul><ul><li>Only 39% had attended a course </li></ul>Bowles et al Gut 2004 UK National Intercollegiate Colonoscopy Audit
  10. 14. <ul><li>13.7% Screening colonoscopies </li></ul><ul><li>66% Specific Informed Consent </li></ul><ul><li>44.9% No Sedation </li></ul><ul><li>80.7% Completion Rate </li></ul>
  11. 15. Is this you ?
  12. 16. <ul><li>Quality of Colonoscopy </li></ul><ul><li>to be improved: </li></ul><ul><li>Better Colonoscopy Technique </li></ul><ul><li>Safe Sedation </li></ul><ul><li>Better diagnostic accuracy </li></ul><ul><li>Immediate therapy (polypectomy-EMR) </li></ul>
  13. 17. <ul><li>Completion Rate > 85% (acceptable) or > 90% (desirable) </li></ul><ul><li>Withdrawal time (6’-10’) </li></ul><ul><li>Good to Excellent bowel prep </li></ul><ul><li>Adenomas yeld in > 15% of asymptomatic pts </li></ul><ul><li>Complications Registry </li></ul><ul><li>Patient’s satisfaction questionnaire </li></ul><ul><li>Immediate polypectomy for polyps at low risk for complications (< 2 cm?) </li></ul><ul><li>Biopsy (?) and delayed polypectomy for other polyps </li></ul>Source: Italian Ministry of Health
  14. 18. <ul><li>Some patients under close colonoscopic surveillance still develop CRC at short intervals </li></ul>Robertson DJ. Gastroenterology 2005; 129
  15. 19. <ul><li>Fast Track cancers - MMR pathway (15-20%) </li></ul><ul><li>Inadequate Bowel Prep </li></ul><ul><li>Piecemeal removal of large sessile polyps </li></ul><ul><li>Fast withdrawal time </li></ul>
  16. 20. van Rijn JC. Am J Gastroenterol 2006; 101
  17. 21. The Paris endoscopic classification of superficial neoplastic lesions Gastrointest Endosc 2003, 58, 6
  18. 22. <ul><li>Scarcely detected in western countries </li></ul><ul><li>Japanese endoscopists demonstrated that up to 40% of adenomas in western hospitals are of the flat and depressed type </li></ul>Fujii T. Endoscopy 1998; 30 Saitoh Y. Gastroenterology 2001; 120 Tsuda S. Gut 2002; 51
  19. 23. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy Barclay RL. N Engl J Med 2006;355
  20. 24. Narrow Band Imaging (NBI) Chromoendoscopy (Indigo Carmine 0.2%)
  21. 25. Sampling depth not deeper than Lamina Propria
  22. 26. Intraepithelial Carcinoma Intramucosal Carcinoma Invasive Carcinoma (T1) or Early CR Cancer HGD
  23. 27. Only to confirm unresectability (neoplastic invasion of the submucosa)
  24. 28. <ul><li>Adequate skill to remove polyps or NPL (flat lesions) up to 2 cm </li></ul><ul><li>Knowledge of Guidelines on Anticoagulation and Antiplatelet Therapy management </li></ul><ul><li>Exhaustive knowledge of management of adenomas with invasive carcinoma (pathologic criteria) </li></ul>
  25. 29. <ul><li>Stiff Monofilament Snare best for flat lesions </li></ul><ul><li>ESD skills not required </li></ul>
  26. 30. <ul><li>From Ileo-cecal Valve to Upper Rectum </li></ul><ul><li>For follow-up endoscopy </li></ul><ul><li>For the surgeon (especially laparoscopic) </li></ul><ul><li>Tattoo lasts forever </li></ul><ul><li>SPOT: pure carbon suspension </li></ul>
  27. 31. <ul><li>How Quality of Colonoscopy </li></ul><ul><li>can be improved: </li></ul><ul><li>Institutional Traning </li></ul><ul><li>Audits </li></ul><ul><li>Retraining Programs </li></ul>
  28. 32. <ul><li>355 EGDs </li></ul><ul><li>73 Colonoscopies </li></ul><ul><li>5 ERCPs </li></ul>Bischops R. Gut 2002 Italian Residents Experience
  29. 33. <ul><li>300 EGDs </li></ul><ul><li>150 Colonoscopies </li></ul><ul><li>30 Polypectomies </li></ul>D.M. 1 agosto 2005 Riassetto delle Scuole di specializzazione di area sanitaria Gazz. Uff. 5 novembre 2005, n. 258, S.O. Ensuring Competence Not monitored !
  30. 35. <ul><li>Bowel preparation quality </li></ul><ul><li>Cecal intubation rate (>95%) </li></ul><ul><li>Photo documentation of cecal landmarks </li></ul><ul><li>Mean withdrawal time > 6-10 min </li></ul><ul><li>Mean Adenoma Detection Rate (M: 25% - F: 15%) </li></ul><ul><li>Adverse or unplanned events </li></ul><ul><li>Complication Rates </li></ul>Lieberman D. Gastrointest Endosc 2007 Rex DL. Am J Gastroenterology 2002
  31. 36. Imperiali G. Endoscopy 2007 <ul><li>Routine sedation (Midazolam and Meperidine) </li></ul><ul><li>Less skilled endoscopists supervised by experienced physicians </li></ul><ul><li>Greater access to endoscopy sessions for endoscopists with the lowest performance rates </li></ul><ul><li>After a failure of cecal intubation, second attempt made by another endoscopist </li></ul><ul><li>Physicians with the lowest polyp detection rates invited to slow withdrawal phase </li></ul>Corrective Measures
  32. 37. Imperiali G. Endoscopy 2007
  33. 38. Retraining
  34. 39. S. Thomas−Gibson, Endoscopy 2007
  35. 40. 2008 Colonoscopy Retraining Working Group G. Costamagna, MD A. Federici, MD P. D’Argenio, MD E. Di Giulio, MD G. Minoli, MD L. Petruzziello, MD M.E. Pirola, MD C. Senore, MD M. Zappa, MD
  36. 41. <ul><li>Held by Italian Ministry of Health </li></ul><ul><li>Managed by National Screening Observatory (ONS) </li></ul><ul><li>Region-based </li></ul><ul><li>1-2 Trainers from each Region </li></ul><ul><li>National “Train-the-Trainers” Course </li></ul><ul><li>Regional “Retraining Courses” </li></ul>Colonoscopy “Retraining Program”
  37. 42. <ul><li>In collaboration with the 3 Gastroenterological Societies (AIGO, SIED, SIGE) and with the Italian Group for CRC Screening (GISCoR) </li></ul><ul><li>2 Eds (Rome, EETC, Sept. 2007 – Campobasso, Oct. 2007) </li></ul><ul><li>23 Trainers </li></ul><ul><li>1 Master Colonoscopist (CB Williams) </li></ul><ul><li>10 Experts (epidemiology, quality, screening principles, sedation, etc.) </li></ul>Colonoscopy “ Train the Trainers” Course
  38. 43. Colonoscopy “ Train the Trainers” Course Hands-on Lectures Simulator Training
  39. 44. <ul><li>Hands-On One-to-Master </li></ul><ul><ul><li>(Lazio, 2005) </li></ul></ul><ul><li>Observational </li></ul><ul><ul><li>(Lombardia, 2008) </li></ul></ul><ul><li>Hands-On Peer-to-Peer </li></ul><ul><li>(Emilia Romagna, 2009) </li></ul><ul><li>Hands-On One-to-Master </li></ul><ul><ul><li>(Veneto, 2010) </li></ul></ul>Regional “Retraining Courses”
  40. 45. <ul><li>Colonoscopy carried out within 30 days after FOBT+ in only 41.0% </li></ul><ul><li>19.7% of subjects had to wait for more than two months </li></ul>
  41. 46. <ul><li>Post-polypectomy surveillance takes resources away from screening </li></ul><ul><li>According to BSG , ACS , and AGA guidelines, most of patients with 1-2 tubular adenomas </li></ul><ul><li>FU in 5-10 years </li></ul>
  42. 48. Follow-up Colonoscopy: Screen more, Survey Less, and Save Waye JD. Gastrointest Endosc. 2006

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