Importance Colorectal cancer (CRC) remains a significant cause of morbidity and mortality in the United States. Objective To systematically review the effectiveness, diagnostic accuracy, and harms of screening for CRC. Data Sources Searches of MEDLINE, PubMed, and the Cochrane Central Register of Controlled Trials for relevant studies published from January 1, 2008, through December 31, 2014, with surveillance through February 23, 2016. Study Selection English-language studies conducted in asymptomatic populations at general risk of CRC. Data Extraction and Synthesis Two reviewers independently appraised the articles and extracted relevant study data from fair- or good-quality studies. Random-effects meta-analyses were conducted. Main Outcomes and Measures Colorectal cancer incidence and mortality, test accuracy in detecting CRC or adenomas, and serious adverse events. Results Four pragmatic randomized clinical trials (RCTs) evaluating 1-time or 2-time flexible sigmoidoscopy (n = 458 002) were associated with decreased CRC-specific mortality compared with no screening (incidence rate ratio, 0.73; 95% CI, 0.66-0.82). Five RCTs with multiple rounds of biennial screening with guaiac-based fecal occult blood testing (n = 419 966) showed reduced CRC-specific mortality (relative risk [RR], 0.91; 95% CI, 0.84-0.98, at 19.5 years to RR, 0.78; 95% CI, 0.65-0.93, at 30 years). Seven studies of computed tomographic colonography (CTC) with bowel preparation demonstrated per-person sensitivity and specificity to detect adenomas 6 mm and larger comparable with colonoscopy (sensitivity from 73% [95% CI, 58%-84%] to 98% [95% CI, 91%-100%]; specificity from 89% [95% CI, 84%-93%] to 91% [95% CI, 88%-93%]); variability and imprecision may be due to differences in study designs or CTC protocols. Sensitivity of colonoscopy to detect adenomas 6 mm or larger ranged from 75% (95% CI, 63%-84%) to 93% (95% CI, 88%-96%). On the basis of a single stool specimen, the most commonly evaluated families of fecal immunochemical tests (FITs) demonstrated good sensitivity (range, 73%-88%) and specificity (range, 90%-96%). One study (n = 9989) found that FIT plus stool DNA test had better sensitivity in detecting CRC than FIT alone (92%) but lower specificity (84%). Serious adverse events from colonoscopy in asymptomatic persons included perforations (4/10 000 procedures, 95% CI, 2-5 in 10 000) and major bleeds (8/10 000 procedures, 95% CI, 5-14 in 10 000). Computed tomographic colonography may have harms resulting from low-dose ionizing radiation exposure or identification of extracolonic findings. Conclusions and Relevance Colonoscopy, flexible sigmoidoscopy, CTC, and stool tests have differing levels of evidence to support their use, ability to detect cancer and precursor lesions, and risk of serious adverse events in average-risk adults. Although CRC screening has a large body of supporting evidence, additional research is still needed.

/pdf/screening-for-colorectal-cancer-updated-evidence-report-and-j05wmu0j1q.pdf

Screening for Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

Background: The incidence of acute left-sided colonic diverticulitis (ACD) is increasing in the Western world. To improve the quality of patient care, a guideline

/pdf/guidelines-of-diagnostics-and-treatment-of-acute-left-sided-1po8mr4e3z.pdf

Guidelines of Diagnostics and Treatment of Acute Left-Sided Colonic Diverticulitis

Post-Colonoscopy Complications: A Systematic Review, Time Trends, and Meta-Analysis of Population-Based Studies.

Objective To perform a comprehensive audit of all colonoscopy undertaken in the UK over a 2-week period. Design Multi-centre survey. All adult (≥16 years of age) colonoscopies that took place in participating National Health Service hospitals between 28 February 2011 and 11 March 2011 were included. Results Data on 20 085 colonoscopies and 2681 colonoscopists were collected from 302 units. A validation exercise indicated that data were collected on over 94% of all procedures performed nationally. The unadjusted caecal intubation rate (CIR) was 92.3%. When adjusted for impassable strictures and poor bowel preparation the CIR was 95.8%. The polyp detection rate was 32.1%. The polyp detection rate for larger polyps (≥10mm diameter) was 11.7%. 92.3% of resected polyps were retrieved. 90.2% of procedures achieved acceptable levels of patient comfort. A total of eight perforations and 52 significant haemorrhages were reported. Eight patients underwent surgery as a consequence of a complication. Conclusions This is the first national audit of colonoscopy that has successfully captured the majority of adult colonoscopies performed across an entire nation during a defined time period. The data confirm that there has been a significant improvement in the performance of colonoscopy in the UK since the last study reported seven years ago (CIR 76.9%) and that performance is above the required national standards.

https://gut.bmj.com/content/gutjnl/61/Suppl_2/A3.2.full.pdf

The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK

Das kolorektale Karzinom ist mit etwa 68 000 Neuerkrankungen bei beiden Geschlechtern die zweithäufigste Krebserkrankung. Jährlich sterben etwa 27 000 Patienten an den Folgen der Erkrankung. Wichtige Teile der S3-Leitlinie Kolorektales Karzinom sind im letzten Jahr aktualisiert worden. Im Folgenden sollen einzelne wichtige Neuerungen der Leitline vorgestellt werden.

/pdf/s3-leitlinie-kolorektales-karzinom-334qelxdrc.pdf

S3-Leitlinie – Kolorektales Karzinom.

Background
Colorectal cancer (CRC) is one of the leading causes of cancer related morbidity and death. Despite the fact that the mean age at diagnosis of CRC is lower in men, screening by colonoscopy or fecal occult blood test (FOBT) is initiated at same age in both genders. The prevalence of the common CRC precursor lesion, advanced adenoma, is well documented only in the screening population. The purpose of this study was to assess the risk of advanced adenoma at ages below screening age.

https://epub.ub.uni-muenchen.de/15422/1/fetchObject.pdf

Risk of advanced colorectal neoplasia according to age and gender.

Objective Diagnostic imaging by CT colonography and capsule endoscopy is used to detect colonic lesions. Controversy exists regarding the work-up of subcentimetric lesions. The aim of this study was to identify risk indicators for advanced neoplasia (AN) in subcentimetric polyps. Design Colonoscopies were classified on the basis of the largest lesion found. AN was defined as high-grade dysplasia, villous histology, or cancer. Logistic regression models were developed to identify risk factors for AN, and validated on separate datasets. A risk index based on the logistic regression was generated, and the number needed to screen (NNS) to detect AN was determined. Results 1 077 956 colonoscopies identified 106 270 intermediate (5–9 mm) and 198 954 diminutive (≤4 mm) lesions; 13% of intermediate and 3.7% of diminutive lesions contained AN. The risk of AN was higher in intermediate than in diminutive lesions (OR 3.1; 95% CI 3.0 to 3.3). Age ≥85 versus Conclusion This study successfully identified risk factors and established a risk index for subcentimetric lesions. This has implications for the work-up of patients with subcentimetric lesions identified on diagnostic imaging.

https://gut.bmj.com/content/gutjnl/early/2012/04/22/gutjnl-2011-300111.full.pdf

Risk factors for advanced neoplasia within subcentimetric polyps: implications for diagnostic imaging

SUMMARY Screening colonoscopy is an effective means for early detection of colorectal carcinoma. Any exhaustive evaluation of the method must take further factors into account: epidemiology of colorectal adenomas and carcinomas in the target population, acceptance by the patients, structure, process, and outcome quality, and health economics. Methods: The internet-based colonoscopy database of the Bavarian Association of Statutory Health Insurance Physicians (ASHIP) for the year 2006 includes data on 86.05% of all outpatient colonoscopies performed in Bavarian ASHIP patients, or a total of 245 263 documented examinations. Results: The rate of participation in preventive colonoscopies was low (1.5%) and showed considerable geographical variation. The rate of detection of histologically confirmed colorectal neoplasia in symptom-free screened individuals was almost 26.0%. Some 1.3% of those screened had colorectal carcinoma. In 76.31% of the participants a completely clean gut was achieved. The incidence of bleeding, perforation, and cardiorespiratory complications was 0.22%, 0.03%, and 0.06%, respectively. Discussion: The complication rate of outpatient colonoscopy is on the order of tenths of a percent, while the process quality is high. The rate of detection of colorectal adenoma and carcinoma is high and the projected benefits for public health are considerable, but the rate of participation is too low. Dtsch Arztebl Int 2008; 105(24): 434-40 DOI: 10.3238/arztebl.2008.0434

Epidemiology and quality control of 245 000 outpatient colonoscopies.

Background/Aims: Surveillance colonoscopy is recommended after polypectomy of adenoma and surgery for colorectal cancer. The purpose of this study was to assess the frequency of advanced adenoma and cancer in colonoscopies performed for surveillance compared to screening colonoscopies. Methods: Analysis of relative frequencies of findings in colonoscopies performed for post-adenoma surveillance (post-ad), post-cancer surveillance (post-crc), screening, and follow-up of a positive fecal occult blood test (FOBT). Logistic regression was used to identify the risk for advanced adenoma (adenoma ≥10 mm, containing high-grade dysplasia, or villous histology) and cancer. Results: 324,912 colonoscopies were included in the analysis: 81,877 post-ad, 26,896 post-crc, 178,305 screening, 37,834 positive FOBT. Advanced adenoma (cancer) was diagnosed in 8.0% (0.4%) of post-ad, 5.0% (1.0%) of post-crc, 7.4% (1.1%) of screening, and 11.7% (3.6%) of positive FOBT colonoscopies. Compared to screening, the odds ratios for finding advanced adenoma were 0.93 (95% CI 0.88-0.98) for post-ad, 0.96 (0.86-1.08) for post-crc, and 1.18 (1.09-1.28) for positive FOBT colonoscopies. The odds ratios for the diagnosis of cancer were 0.29 (0.24-0.36) for post-ad, 0.81 (0.61-1.07) for post-crc, and 2.77 (2.43-3.17) for positive FOBT. Conclusion: Colonoscopy for post-ad surveillance but not colonoscopy for post-crc surveillance is associated with a lower risk of diagnosis of advanced adenoma and cancer.

/pdf/a-direct-comparison-of-the-prevalence-of-advanced-adenoma-qshiy2p9e9.pdf

A Direct Comparison of the Prevalence of Advanced Adenoma and Cancer between Surveillance and Screening Colonoscopies

S creeningkoloskopien sind ein wirksames Mittel zur Früherkennung kolorektaler Karzinome und ihrer Vorstufen. Ihre Überlegenheit gegenüber anderen Screeningmethoden erklärt sich aus ihrer hohen Sensitivität und Spezifität sowie der Möglichkeit der Polypektomie beziehungsweise Biopsie (1). Eine bevölkerungsmedizinische Bewertung muss die folgenden Aspekte berücksichtigen. Akzeptanz: Seit 2002 haben Mitglieder der Gesetzlichen Krankenversicherung im Alter ab 55 Jahren Anrecht auf zwei Früherkennungskoloskopien in zehnjährigem Abstand. Idealerweise sollten jährlich 10 % einer Altersdekade die Maßnahme nutzen. Epidemiologie kolorektaler Neoplasien: Je höher die A-priori-Wahrscheinlichkeit ist, desto höher sind die Entdeckungsraten und der Anteil richtig positiver Verdachtsbefunde. Es kann sinnvoll sein, das Screening auf Ältere oder Hochrisikogruppen zu beschränken. Screeningstrategien können nicht unkritisch von anderen Populationen übernommen werden. Strukturqualität: In der Krankenversorgung akzeptable Unannehmlichkeiten, Unzulänglichkeiten und Risiken sind bei präventiven Maßnahmen untragbar. Da Screening sich an beschwerdefreie und mehrheitlich gesunde Klienten richtet, folgt eine ethische Verpflichtung zur systematischen Qualitätssicherung. Strukturelle Aspekte, wie Qualifikation und apparative Ausstattung, sind in Deutschland in der Qualitätssicherungsvereinbarung zur Koloskopie vom 24. 7. 2006 geregelt (www.kvb.de/rechtsquel len/2500.html). Prozessqualität: Trotz intakter Strukturen können Prozesse suboptimal ablaufen. Seit 2002 ist daher die Vergütung für Screeningkoloskopien an die standardisierte Dokumentation und epidemiologische Auswertung aller Screeninguntersuchungen gebunden (3). Entscheidend ist die Patientensicherheit. Bei bevölkerungsweiter Durchführung einer im Einzelfall wenig riskanten Maßnahme können viele Komplikationen auftreten, die den Nutzen konterkarieren. Ergebnisqualität: Surrogatkriterien für den Erfolg des Programms sind die Entdeckungsraten sowie die Dignität der entdeckten Neubildungen. Langfristig ist der bevölkerungsbezogene Nachweis eines Rückgangs der Inzidenz kolorektaler Karzinome sowie der darmkrebsbedingten Mortalität zu fordern. Gesundheitsökonomie: Stehen Kosten und Risiken in einem vernünftigen Verhältnis zum Nutzen? ORIGINALARBEIT

Bilanz der Qualitätssicherung ambulanter Koloskopien nach 245000 Untersuchungen

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