EXPANDED SCOPE Physicians want tools that help them perform quality screenings during every exam.

Procedure times and cecum intubations are important to track, but polyp detection rate is the No. 1 quality indicator of colonoscopy. "Deaths from colorectal cancer simply shouldn't happen, because colon cancer is a preventable disease," says Stephen Lloyd, MD, PhD, medical director of the South Carolina Medical Endoscopy Center in Columbia. Some exciting new innovations have hit the market in recent years to give physicians better views of more areas of the colon so they can better identify pre-cancerous growths and save more lives.

1 HD and NBI
Research published by Anna M. Buchner, MD, PhD, in the journal Clinical Gastroenterology and Hepatology (tinyurl.com/n8qzw4l) was the first to definitively show that high-definition scopes increase adenoma detection rates. Other groups have backed the findings.

But HD results in a relatively small increase, says Michael B. Wallace, MD, gastroenterologist and professor of medicine at the Mayo Clinic in Jacksonville, Fla. He points to a large meta-analysis of HD studies that showed the absolute increase in detection rate was about 3%.

Studies show that adding narrow band imaging (NBI) to HD also fails to increase detection rates, according to Dr. Wallace. "There's no statistical difference between HD and HD plus NBI," he says.

However, other studies that have compared the combination of HD and NBI to older-generation scopes — standard definition models without NBI — have shown a significant reduction in adenoma miss rates when the newer technology is used.

Dr. Wallace conducted a randomized controlled trial of colonoscopies performed consecutively on the same patients with both HD-NBI scopes and standard definition scopes without NBI. He found that colonoscopies performed with HD-NBI scopes resulted in fewer missed polyps.

"All of the missed polyps were quite small and probably not of great clinical significance, but they were missed nonetheless," says Dr. Wallace.

He says a study conducted by German researchers that compared adenoma detection rates between standard definition scopes and HD-NBI scopes showed the combination resulted in much higher adenoma detection rates.

"Each incremental technology change — from HD to NBI, for example — makes a relatively small difference in polyp detection rates," says Dr. Wallace. "But combining all of the technologies, which is essentially what happens in practices using the latest endoscope designs, clearly results in improved colonoscopy screenings."

2 Scope control and accessories
Dr. Wallace prefers to use scopes with torsion control, which he says can help reduce looping, keep the channel straighter and make the scope easier to pass.

He suggests physicians learn how to carefully deflect the scope's tip or retroflex the scope to see behind folds in the colon. Scopes that provide retrograde views let physicians view both forward and backward, especially in the right colon, which may benefit docs who have problems detecting flat lesions in that sometimes hard-to-see area.

Cap-assisted colonoscopy provides distance between the scope and the colon wall to aid physicians in seeing polyps behind folds, says Dr. Lloyd. One such disposable device fits over the tip of most endoscopes to hold colon folds open during extubation, which lets physicians see more mucosas for easier polyp identification. Dr. Lloyd hasn't yet used the technology, but he says it's a intriguing concept and something he'll definitely consider in the future.

PRACTICE ADVISORY
Can Nurses Manipulate Endoscopes?

TAG TEAM As a nurse advances the scope, Dr. Lloyd can work the dials with his dominant hand.

Four-member teams perform colonoscopies at the South Carolina Medical Endoscopy Center in Columbia.

• A physician leads the screening.
• A nurse advances the endoscope.
• An anesthetist helps apply abdominal pressure.
• A documenter labels the pictures taken, keeps track of biopsies and fills out the computerized report.

"Everyone has their eyes on the screen," says Stephen Lloyd, MD, PhD, the facility's medical director. "That helps us focus and miss the minimal number of polyps."

Most gastroenterologists are taught to do the exam without assistance, but Dr. Lloyd finds that a team approach, including having a nurse advance and manipulate the scope, results in lower perforations, fewer complications and much higher polyp detection rates. Their cecum intubation rate is over 99%.

Having the nurse advance and manipulate the endoscope lets Dr. Lloyd use his dominant hand to work the up-down, left-right controls in order to make precise turns and deflections of the scope's tip. He says that helps him see more polyps and remove them with improved precision.

But are nurses allowed to advance and manipulate endoscopes during exams? Yes, according to a position statement (see "Manipulation of Endoscopes During Endoscopic Procedures" at tinyurl.com/m4l7ko2) released by the Society of Gastroenterology Nurses and Associates. The document states nurses can advance or withdraw endoscopes under direct supervision of endoscopists as long as they have knowledge of endoscope manipulation techniques and understand the complications associated with endoscopy. "Manipulation refers only to the act of advancing or withdrawing the endoscope under the direct supervision of the endoscopist," reads the statement.

Nurses must have full views of the colon's lumen on a video screen throughout procedures and be able to identify symptoms of complications and initiate appropriate interventions under the direction of the endoscopist, says the SGNA.

— Daniel Cook

THRICE AS NICE Dr. Lloyd loves the 330 ? field of view provided by his facility's new colonoscopy platform.

3 Analytics
Physicians at the South Carolina Medical Endoscopy Center are obsessed with maintaining their already impressive adenoma detection rate. An important part of their obsession is allowing enough time to perform complete exams, which is easier said than done in a volume-driven specialty.

"Our average case takes 27 minutes to complete, which is a bit higher than average," says Dr. Lloyd. "And our adenoma detection rate is averaging about 30%. We're not missing a whole lot of polyps, but everyone misses some."

They employ a computer-based, automated analysis tool for endoscopic procedures developed by the Mayo Clinic's Piet de Groen, MD. The device attaches to colonoscopy equipment, analyzes the image output and provides a quality number that indicates how well colonoscopies are performed. It measures the percentage of the colon's surface physicians see, how much of discovered polyps they remove and how well they irrigate and flush the bowel prep.

"Every doctor has good days and bad days," says Dr. Lloyd, emphasizing that physicians also have different techniques and different adenoma detection rates. "We're trying to get everyone's to be as high as possible."

If a physician's detection rate is lagging, Dr. Lloyd is armed with objective data to encourage him to take a little bit more time, use better technique or talk to patients about the importance of following bowel prep guidelines.

4 Peripheral views
We talked to Dr. Lloyd on the day he and his physicians first used a new endoscope platform that's generating buzz by providing a 330 ? field of view — compared to the 170 ? views of traditional scopes — in front and behind the scope during extubation. It features a 3-monitor setup: one straight-ahead screen for conventional forward viewing and 2 screens mounted at 45 ? angles to the center screen for behind-the-fold views of the colon.

Dr. Lloyd says the new technology improves his views inside the cecum, at the flexors and inside folds of the colon. "It's not a device to make colonoscopy faster, but you can see everything," he explains, referencing the platform's near-panoramic views of the colon's surface. "It's almost enough to make you dizzy. You need to pop a Dramamine before procedures."

Although working from 3 monitors takes some getting used to, Dr. Lloyd is very impressed with the system's intuitive controls and how case times haven't increased. He and his partners reached the cecum during each of the 16 cases performed with the platform on Day 1.

He's excited by the technology's potential. "I think our polyp detection rates will be a bit better than they are now, and our rates are already pretty high."

TECHNICAL SUPPORT Innovation is nice, but physicians must also commit to performing careful examinations.

5 Insufflation improvement
Using CO2 instead of air to insufflate the colon dramatically improves patients' post-procedure comfort, allows for better screenings and improves overall efficiencies, says Dr. Lloyd. "During extubation, we used to remove as much air as possible because patients would be in extreme discomfort if we didn't," he explains. "Now we're able to leave the quick-dissolving CO2 in longer for better views of the colon's walls. Plus, patients are feeling better afterward, are able to resume their regular diets much faster and are ready for timelier discharges."

Tools or technique?
"The techniques and technologies we're employing help all of our doctors provide the highest quality colonoscopy every time," says Dr. Lloyd, who values the developments that help him perform more complete exams, but cautions against relying too heavily on innovative endoscope designs. "I'm not sure it's the ultimate answer," he says. "Effective colonoscopy also depends on how carefully and conscientiously you look."