Randomized, controlled trial of standard-definition white-light, high-definition white-light, and narrow-band imaging colonoscopy for the detection of colon polyps and prediction of polyp histology

doi:10.1016/j.gie.2011.04.050

Gastrointestinal Endoscopy

Volume 74, Issue 3, September 2011, Pages 593-602

Presented at Digestive Disease Week, May 1-4, 2010, New Orleans, Louisiana (Gastrointest Endosc 2010;71:AB142).

https://doi.org/10.1016/j.gie.2011.04.050 Get rights and content

Background

Missing adenomas and the inability to accurately differentiate between polyp histology remain the main limitations of standard-definition white-light (SD-WL) colonoscopy.

Objective

To compare the adenoma detection rates of SD-WL with those of high-definition white-light (HD-WL) and narrow-band imaging (NBI) as well as the accuracy of predicting polyp histology.

Design

Multicenter, prospective, randomized, controlled trial.

Setting

Two academic medical centers in the United States.

Patients

Subjects undergoing screening or surveillance colonoscopy.

Intervention

Subjects were randomized to undergo colonoscopy with one of the following: SD-WL, HD-WL, or NBI.

Main Outcome Measurements

The proportion of subjects detected with adenomas, adenomas detected per subject, and the accuracy of predicting polyp histology real time.

Results

A total of 630 subjects were included. The proportion of subjects with adenomas was 38.6% with SD-WL compared with 45.7% with HD-WL and 46.2% with NBI (P = .17 and P = .14, respectively). Adenomas detected per subject were 0.69 with SD-WL compared with 1.12 with HD-WL and 1.13 with NBI (P = .016 and P = .014, respectively). HD-WL and NBI detected more subjects with flat and right-sided adenomas compared with SD-WL (all P values <.005). NBI had a superior sensitivity (90%) and accuracy (82%) to predict adenomas compared with SD-WL and HD-WL (all P values <.005).

Limitations

Academic medical centers with experienced endoscopists.

Conclusions

There was no difference in the proportion of subjects with adenomas detected with SD-WL, HD-WL, and NBI. However, HD-WL and NBI detected significantly more adenomas per subject (>60%) compared with SD-WL. NBI had the highest accuracy in predicting adenomas in real time during colonoscopy. (Clinical Trial registration number: NCT 00614770.)

Section snippets

Study design

This was a multicenter prospective, randomized, controlled trial that was conducted at 2 tertiary referral centers. The study was approved by the local institutional review board at both centers and registered with Clinical Trials.gov (NCT 00614770).

Study population

Subjects referred and scheduled for screening or surveillance colonoscopy were prospectively enrolled between August 2008 and November 2009. Written informed consent was obtained from all subjects. Inclusion criteria were referral for screening or

Subjects

A total of 664 subjects were enrolled in the study between August 2008 and November 2009. Thirty-four subjects (5%) were excluded (Fig. 2): 5% in the SD-WL arm, 3% in HD-WL arm, and 7% in the NBI arm. Thus, a total of 630 subjects completed the study protocol, and these were included in the analysis: 210 in each study group. Table 1 shows the demographics of the subjects, indication for colonoscopy, insertion time, and withdrawal time. The mean age of subjects was statistically higher in the

Discussion

We report the results of a randomized, controlled trial comparing 3 commercially available imaging modalities (SD-WL, HD-WL, and NBI) for the detection of adenomas and prediction of polyp histology. This is the first trial to do so, all under the purview of 1 study. There was no significant difference in the proportion of subjects with adenomas (primary outcome) among SD-WL, HD-WL, and NBI. Both HD-WL and NBI detected a 7% higher proportion of subjects with adenomas compared with SD-WL, a

References (33)

D.K. Rex et al.
Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies
Gastroenterology
(1997)
D.J. Robertson et al.
Colorectal cancer in patients under close colonoscopic surveillance
Gastroenterology
(2005)
D.K. Rex
Narrow-band imaging without optical magnification for histologic analysis of colorectal polyps
Gastroenterology
(2009)
A. Rastogi et al.
Narrow-band imaging colonoscopy–a pilot feasibility study for the detection of polyps and correlation of surface patterns with polyp histologic diagnosis
Gastrointest Endosc
(2008)
A. Rastogi et al.
Recognition of surface mucosal and vascular patterns of colon polyps by using narrow-band imaging: interobserver and intraobserver agreement and prediction of polyp histology
Gastrointest Endosc
(2009)
S. Kudo et al.
Nonpolypoid neoplastic lesions of the colorectal mucosa
Gastrointest Endosc
(2008)
J.C. Anderson et al.
Association of smoking and flat adenomas: results from an asymptomatic population screened with a high-definition colonoscope
Gastrointest Endosc
(2010)
M. Pellise et al.
Impact of wide-angle, high-definition endoscopy in the diagnosis of colorectal neoplasia: a randomized controlled trial
Gastroenterology
(2008)
A.M. Buchner et al.
High-definition colonoscopy detects colorectal polyps at a higher rate than standard white-light colonoscopy
Clin Gastroenterol Hepatol
(2010)
S. Kudo et al.
Diagnosis of colorectal tumorous lesions by magnifying endoscopy
Gastrointest Endosc
(1996)

J.N. Rogart et al.

Narrow-band imaging without high magnification to differentiate polyps during real-time colonoscopy: improvement with experience

Gastrointest Endosc

(2008)

Y. Sano et al.

Meshed capillary vessels by use of narrow-band imaging for differential diagnosis of small colorectal polyps

Gastrointest Endosc

(2009)

A. Ignjatovic et al.

Optical diagnosis of small colorectal polyps at routine colonoscopy (Detect InSpect ChAracterise Resect and Discard; DISCARD trial): a prospective cohort study

Lancet Oncol

(2009)

D.K. Rex et al.

Bringing new endoscopic imaging technology into everyday practice: what is the role of professional GI societies?Polyp imaging as a template for moving endoscopic innovation forward to answer key clinical questions

Gastrointest Endosc

(2010)

D.K. Rex et al.

The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps

Gastrointest Endosc

(2011)

D.K. Rex et al.

High yields of small and flat adenomas with high-definition colonoscopes using either white light or narrow band imaging

Gastroenterology

(2007)

Cited by (136)

Computer-aided detection versus advanced imaging for detection of colorectal neoplasia: a systematic review and network meta-analysis
2021, The Lancet Gastroenterology and Hepatology
Citation Excerpt :
However, these trials were included in the supplementary subanalysis investigating the individual role of each technique in increasing the adenoma detection rate (appendix pp 19–23). Thus, 50 trials involving 34 445 participants were included in our main analysis.7,25–73 Ten studies were from the USA (5799 patients),25–34 eight from China (6747 patients),35–43 six from Germany (4183 patients),44–49 five from Italy (2440 patients),7,50–53 four from Japan (2315 patients),54–57 two from South Korea (728 patients),58,59 two from Australia (1326 patients),60,61 two from the Netherlands (2402 patients),62,63 three from the UK (745 patients),64–66 and one study each from Belgium (1065 patients),67 Brazil (541 patients),68 Israel (1000 patients),69 Mexico (337 patients),70 Romania (505 patients),71 Spain (238 patients),72 and France (2058 patients).73
Computer-aided detection (CADe) techniques based on artificial intelligence algorithms can assist endoscopists in detecting colorectal neoplasia. CADe has been associated with an increased adenoma detection rate, a key quality indicator, but the utility of CADe compared with existing advanced imaging techniques and distal attachment devices is unclear.
For this systematic review and network meta-analysis, we did a comprehensive search of PubMed/Medline, Embase, and Scopus databases from inception to Nov 30, 2020, for randomised controlled trials investigating the effectiveness of the following endoscopic techniques in detecting colorectal neoplasia: CADe, high definition (HD) white-light endoscopy, chromoendoscopy, or add-on devices (ie, systems that increase mucosal visualisation, such as full spectrum endoscopy [FUSE] or G-EYE balloon endoscopy). We collected data on adenoma detection rates, sessile serrated lesion detection rates, the proportion of large adenomas detected per colonoscopy, and withdrawal times. A frequentist framework, random-effects network meta-analysis was done to compare artificial intelligence with chromoendoscopy, increased mucosal visualisation systems, and HD white-light endoscopy (the control group). We estimated odds ratios (ORs) for the adenoma detection rate, sessile serrated lesion detection rate, and proportion of large adenomas detected per colonoscopy, and calculated mean differences for withdrawal time, with 95% CIs. Risk of bias and certainty of evidence were assessed with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
50 randomised controlled trials, comprising 34 445 participants, were included in our main analysis (six trials of CADe, 18 of chromoendoscopy, and 26 of increased mucosal visualisation systems). HD white-light endoscopy was the control technique in all 50 studies. Compared with the control technique, the adenoma detection rate was 7·4% higher with CADe (OR 1·78 [95% CI 1·44–2·18]), 4·4% higher with chromoendoscopy (1·22 [1·08–1·39]), and 4·1% higher with increased mucosal visualisation systems (1·16 [1·04–1·28]). CADe ranked as the superior technique for adenoma detection (with moderate confidence in hierarchical ranking); cross-comparisons of CADe with other imaging techniques showed a significant increase in the adenoma detection rate with CADe versus increased mucosal visualisation systems (OR 1·54 [95% CI 1·22–1·94]; low certainty of evidence) and with CADe versus chromoendoscopy (1·45 [1·14–1·85]; moderate certainty of evidence). When focusing on large adenomas (≥10 mm) there was a significant increase in the detection of large adenomas only with CADe (OR 1·69 [95% CI 1·10–2·60], moderate certainty of evidence) when compared to HD white-light endoscopy; CADe ranked as the superior strategy for detection of large adenomas. CADe also seemed to be the superior strategy for detection of sessile serrated lesions (with moderate confidence in hierarchical ranking), although no significant increase in the sessile serrated lesion detection rate was shown (OR 1·37 [95% CI 0·65–2·88]). No significant difference in withdrawal time was reported for CADe compared with the other techniques.
Based on the published literature, detection rates of colorectal neoplasia are higher with CADe than with other techniques such as chromoendoscopy or tools that increase mucosal visualisation, supporting wider incorporation of CADe strategies into community endoscopy services.
None.
AGA Clinical Practice Update on Endoscopic Surveillance and Management of Colorectal Dysplasia in Inflammatory Bowel Diseases: Expert Review
2021, Gastroenterology
Improvements in disease management, as well as endoscopic technology and quality, have dramatically changed the way in which we conceptualize and manage inflammatory bowel disease–related dysplasia over the past 20 years. Based on evolving literature, we propose a conceptual model and best practice advice statements for the prevention, detection, and management of colorectal dysplasia in people with inflammatory bowel disease. This expert review was commissioned and approved by the American Gastroenterological Association Institute Clinical Practice Updates Committee and the American Gastroenterological Association Governing Board to provide timely guidance on a topic of high clinical importance to the American Gastroenterological Association membership. It underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Gastroenterology.
How to Approach Small Polyps in Colon: Tips and Tricks
2021, Techniques and Innovations in Gastrointestinal Endoscopy
High-definition colonoscopy for improving adenoma detection: a systematic review and meta-analysis of randomized controlled studies
2020, Gastrointestinal Endoscopy
Citation Excerpt :
Participants’ gender (male, 45.7% vs 68%) and mean age (58.2 vs 62.5 years) were similar, and there were no significant differences in the bowel preparation quality between the 2 arms among the studies that reported on this outcome.11,13-15 No difference in withdrawal times—assessed in 4 studies11-13,16 with 2517 participants—was noted between the HD-WLE and SDC groups (MD, −0.06; 95% CI, −0.25 to 0.12; P = .50; I2 = 0%; P = .44). Histopathologic samples were analyzed according to the Vienna classification17,18 in 2 studies,14,15 World Health Organization classification19 in one study16; the other 3 studies11-13 did not provide relevant details.
Previous meta-analysis showed marginal benefit of high-definition white-light endoscopy (HD-WLE) over standard-definition colonoscopy (SDC) for adenoma detection, but with residual uncertainty due to inclusion of nonrandomized studies. We aimed to further assess the effect of HD-WLE on adenoma detection by including only randomized controlled trials (RCTs).
A literature search was performed for RCTs evaluating HD-WLE versus SDC in terms of adenoma, advanced adenoma, and serrated sessile adenoma detection rates as well as the mean number of adenomas per colonoscopy (MAC), the mean number of advanced adenomas per colonoscopy (MAAC), and the mean number of sessile serrated adenomas per colonoscopy (MSSAC). The effect size on study outcomes is presented as the risk ratio (RR; 95% confidence interval [CI]) or mean difference (MD; 95% CI). We assessed the strength of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.
Six RCTs involving 4594 individuals (HD-WLE, 2323; SDC, 2271) were included. Clinical indications were screening (1 study), positive result for fecal occult blood test, personal/family history of colorectal cancer (1 study), and mixed indications (4 studies). Withdrawal time was similar between the 2 arms (MD, −0.06; 95% CI, −0.25 to 0.12; P = .50). The adenoma detection rate was significantly higher in the HD-WLE arm compared with the SDC arm (40% vs 35%; RR, 1.13; 95% CI, 1.05-1.22; P = .001; I² = 0%; GRADE, low). This effect was consistent for advanced and sessile serrated adenoma detection rates (RR, 1.33; 95% CI, 1.03-1.72; P = .03; I² = 0%; GRADE, low; and RR, 1.55; 95% CI, 1.05-2.28; P = .03; I² = 0%; GRADE, low, respectively). In contrast, the difference was not significant for MAC, MAAC, and MSSAC.
Meta-analyses of RCT data support the use of HD-WLE in clinical practice, although the additional benefit is limited.
Endocytoscopy for the differential diagnosis of colorectal low-grade adenoma: a novel possibility for the “resect and discard” strategy
2020, Gastrointestinal Endoscopy
Endocytoscopy, a next-generation endoscopic system, facilitates observation at a maximum magnification of ×520. To our knowledge, no study has reported high-precision diagnosis of colorectal low-grade adenoma, endoscopically. We aimed to reveal which endocytoscopic findings may be used as indicators of low-grade adenoma and to assess whether a “resect and discard” strategy using endocytoscopy is feasible.
Lesions diagnosable with endocytoscopy were examined retrospectively between May 2005 and July 2017. A normal pit-like structure in endocytoscopic images was considered a normal pit (NP) sign and used as an indicator of low-grade adenoma. The primary outcome was the diagnostic accuracy of the NP sign for low-grade adenoma. We evaluated agreement rates between endocytoscopic and pathologic diagnosis for surveillance colonoscopy interval recommendation (SCIR) and performed a validation study to verify the agreement rates.
For 748 lesions in 573 cases diagnosed as colorectal adenoma using endocytoscopy, the results were as follows: sensitivity of the NP sign for low-grade adenoma, 85.0%; specificity, 90.7%; positive predictive value, 96.6%; negative predictive value, 66.1%; accuracy, 86.4%; and positive likelihood ratio, 9.2 (P < .001). The agreement rate between endocytoscopic and pathologic diagnosis for SCIR was 94.4% (95% confidence interval [CI], 92.2%-96.1%; P < .001) under United States guidelines and 96.3% (95% CI, 94.5%-97.7%; P < .001) under European Union guidelines. All inter- and intraobserver agreement rates for expert and nonexpert endoscopists had κ values ≥0.8 except one nonexpert pair.
Endocytoscopy is an effective modality in determining the differential diagnosis of colorectal low-grade adenoma. (University Hospital Medical Information Network Clinical Trials database registration number: UMIN000018623.)
Impact of linked-color imaging on colorectal adenoma detection
2019, Gastrointestinal Endoscopy
Linked-color imaging (LCI) is a new technology that emphasizes changes in mucosal color by providing clearer and brighter images, thus allowing red and white areas to be visualized more clearly. We investigated whether LCI increases the detection of colorectal adenomas compared with white-light imaging (WLI) and blue-laser imaging (BLI)-bright.
Consecutive patients undergoing colonoscopy were randomized (1:1:1) into examination by WLI, BLI-bright, or LCI during withdrawal of the colonoscope. The adenoma detection rate (ADR), mean number of adenomas per patient, and withdrawal time were evaluated. The lesions were evaluated according to size, morphology, location, and histology.
A total of 379 patients were randomized, and 412 adenomas were detected. The ADR was 43.2%, 54.0%, and 56.9% for WLI, BLI-bright, and LCI, respectively, and was significantly higher in the LCI group than in the WLI group (P = .03). No significant difference was observed between LCI and BLI-bright (P = .71) or BLI-bright and WLI (P = .09). The mean number of adenomas per patient was 0.82, 1.06, and 1.38 for WLI, BLI-bright, and LCI, respectively, with a significant difference between LCI and WLI (P = .03). Withdrawal time did not differ among the groups. A total of 102 adenomas were detected by WLI, 131 by BLI-bright, and 179 by LCI. LCI provided a higher rate of detection of adenomas ≤5 mm in size than WLI (P = .02), with a borderline significance for a higher detection of sessile serrated adenomas (P = .05). Nonpolypoid adenomas were more commonly located in the right colon segment and polypoid adenomas in the left colon segment, with a significant difference only between BLI-bright (P < .01) and LCI (P = .03).
Our findings show that LCI increases the detection of colorectal adenomas during colonoscopy. (Clinical trial registration number: RBR-9xg6dx.)

View all citing articles on Scopus

: Dr Rastogi was supported by a research grant from Olympus America Inc.

: DISCLOSURE: The following authors disclosed financial relationships relevant to this publication: Dr Rastogi: research grant from Olympus America Inc; Dr Edmundowicz: consultant to, honorarium from, and member of the advisory board of Olympus America Inc; Dr Sharma: grant support from Olympus America Inc. The other authors disclosed no financial relationships relevant to this publication. Dr Rastogi is the recipient of the Michael V. Sivak Jr. MD Endoscopic Research Award from the American Society for Gastrointestinal Endoscopy.

: See CME section; p. 634.

: If you would like to chat with an author of this article, you may contact Dr. Rastogi at [email protected].

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Original articleClinical endoscopyRandomized, controlled trial of standard-definition white-light, high-definition white-light, and narrow-band imaging colonoscopy for the detection of colon polyps and prediction of polyp histology

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusions

Section snippets

Study design

Study population

Subjects

Discussion

Gastroenterology

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Lancet Oncol

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Original article
Clinical endoscopy
Randomized, controlled trial of standard-definition white-light, high-definition white-light, and narrow-band imaging colonoscopy for the detection of colon polyps and prediction of polyp histology