Becker's ASC Review

5 Gastroenterologist Thought Leadership Question: How has the practice of per- forming colonoscopy changed since your first entered the medical field? Walter Coyle, MD, Scripps Clinic (San Di- ego): I finished my GI training in 1993. At that time, flexible sigmoidos- copy was still the major form of colorectal cancer screening. But, from that time to the early 2000s there was a move to- wards colonoscopy. That push came from the GI so- cieties and the U.S. Preventative Services Task Force. We had data; colonoscopy saves lives. Now, the prob- lem is getting everyone who needs it to be screened. David Johnson, MD, MACG, FASGE, FACP, division chief, gas- troenterology, East- ern Virginia Medical School (Norfolk): Colo- noscopy has changed in a number of ways; but one of the most impor- tant is in its availability. Now it is a preventative test used to recognize and remove cancerous polyps, but initially colonosco- py couldn't be used for screening, as this was not covered by insurance. The scientific literature has clearly shown this is the most effective colon cancer prevention test we have. The emergence of avail- ability and payers' willingness to cover colonoscopy as a colorectal cancer screening test has really de- veloped over the last couple of decades. William Katkov, MD, Providence Saint John's Health Center (Santa Monica, Ca- lif.): Among the most important changes in colonoscopy over the past 20 years is the emergence of widely accepted quality mea- sures. These have served to generally raise the standard of care. Metrics include adenoma detec- tion rates, cecal intubation rates and withdrawal time. Equally important has been the develop- ment of evidence-based guidelines for appropri- ate intervals between colonoscopies. Landmark longitudinal studies that firmly es- tablished the essential role of colonoscopy in the prevention of colon cancer, as well as the reduc- tion of deaths due to colon cancer, were extremely important. These studies established, beyond any doubt, that colonoscopy is the standard against which all other screening modalities must be measured. JoAnn Kwah, MD, Montefiore Medical Center, Albert Einstein College of Medicine (New York): Though I have only been in prac- tice for a few years, the practice of colonoscopy already has undergone many changes. One of the several things that come to mind is the technological advances that have made it easier to detect polyps and subtle mucosal abnormali- ties, which include chromoendoscopy and virtual chromoendoscopy techniques. Also, anesthesia now plays a significant role in as- sisting in sedating our patients undergoing endos- copy or colonoscopy, which seems to have increased patient satisfaction with their procedures. Finally, there is now an even greater emphasis on quality indicators and benchmarks for colonoscopy, which will definitely raise the standard of care and patient outcomes for all patients undergoing colonoscopy. Walter Park, MD, pancreas clinic medi- cal director, Stanford (Calif.) Health Care: The decreasing inci- dence and associated mortality of colon can- cer has been primarily attributed to the value of colon cancer screen- ing, for which colonoscopy is considered the gold standard. Although first performed in hospital set- tings, the practice of colonoscopy has expanded to be performed in several settings – the hospital out- patient department, the ambulatory surgical center and in some practices in the office. Along with that, advances in colonoscopy technology have made the procedure both easier (for the patient and provider), while offering more sensitivity in detecting smaller colon polyps. This technology has enabled us to bet- ter identify more types of colon polyps, such as the flat colon polyp and the serrated sessile polyps. Cynthia Rudert, MD, Celiac Disease Foun- dation (Atlanta): The procedure itself hasn't changed much, but what has been very welcome is the increase in anesthesia options for patients. These options have made colonoscopy a much more tolerable procedure for the patient. The preps over the past 25 years have also become much more tolerable. Richard Zelner, MD, Orange Coast Memo- rial Medical Center (Fountain Valley, Calif.): I have been in practice over 25 years. Initially, colonoscopy was performed when a patient was symptom- atic, not for screening purposes. Colon cancer screening was largely done with flexible sigmoidoscopy and hemoccult testing. This was the mainstay of screening until approximately the year 2000 when two studies confirmed the limitations of flexible sigmoidos- copy, which evaluates only the left side of the co- lon. Failure to evaluate the right colon results in 50 percent significant missed lesions that would be detected by colonoscopy. Following these two studies colonoscopy essentially became the gold standard for screening. The utilization of colo- noscopy greatly increased. In terms of technique there have been minimal changes. The instruments have become more flexible, making them easier to manipulate. As a result, time required for colonoscopy has dimin- ished. Physicians have become more adept at per- forming the procedure. Some physicians have de- creased the time allotted for the procedure from one hour to half an hour. The knowledge gained from performing colo- noscopy has also changed. Thus, guidelines for screening and surveillance have changed with greater knowledge of natural history of polyps, colon cancer and other disease processes. Moni- toring of the procedure has also evolved. In 2015 my biggest concern is that colonoscopies are being done too rapidly. Quality is directly related to time spent looking at the colon. The minimal with- drawal time is six minutes, but in my mind that isn't enough time. There is a push to get more done in less time in the name of efficiency. I have concern for possible missed lesions due to the rapid rate in which exams are being performed. The dramatic decrease in reimbursement for colonoscopy gives incentive for rapid colonoscopy not quality. Q: What have been a few of the biggest technological advanced in the colonos- copy field? DJ: We've had wonderful technological advances in colonoscopy. We can use smaller scopes and stiffen the scope as we advance it. Optical imaging has been the other great advance. We now have direct transmission of images to a screen and the resolution is much better. With the advent of high resolution imaging and magnification, there have been tremendous improvements in the field. Nar- row band imaging and use of chromoendoscopy has allowed for much more robust and accurate definition of lesions. JK: Two of the biggest technological advances in the colonoscopy field include the use of high definition endoscopes and enhancements in im- aging techniques to better visualize subtle lesions and small polyps. High definition has increased the pixel count on the video display allowing for much greater detail and a clearer picture for the viewer. This also with the use of enhancements in imaging techniques such as narrow band imaging (Olympus) or i-scan (Pentax) or FICE (FUJIF- ILM) allows for differentiation of subtle abnor- malities and polyps that might have been missed with standard white light endoscopy. WK: Most of the technological changes and re- finements have been made in imaging. Advances in this area have improved our ability to detect small polyps, as well as early high-risk lesions. The Evolution of Colonoscopy: The Past, Present and Future of GI's Mainstay Procedure (continued from cover)

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