Prof Rupert Leong, Director of Endoscopy, Head of IBD Professor of Medicine UNSW, University of Sydney, Concord Hospital Australia IBDSydney
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1 10:30-10:50 25 Sept 2017 Monday A-PSDE / WEO Colorectal Cancer Screening Committee (CRCSC) Meeting Room S228 (2/F) Prof Rupert Leong, Director of Endoscopy, Head of IBD Professor of Medicine UNSW, University of Sydney, Concord Hospital Australia IBDSydney
2 Advisory board: AbbVie, Aspen, Ferring, Hospira, Janssen, Pfizer, Takeda Research: Shire, Endochoice, Janssen Prof Rupert Leong
3 n=88,902: 22 year 1,815 incident CRC, 474 deaths polypectomy: HR CRC 0.57 (95% CI: ) HR CRC death 0.32 ( ) Colonoscopy reduces CRC and CRC Mortality
4 adjusted hazard ratio n=136 gastroenterologists ADR: % Corley NEJM 2014 Risk of interval CRC 1% increase in ADR decrease 3% risk CRC HR: 0.77 ( ) 0.52
5 improve adenoma detection: 1. optimize patient selection 2. improve quality 3. colonoscopy technique i. optimize bowel preparation ii. withdrawal time >6 minutes iii. look again : re-insertion, retroflex, work folds iv. technology: Endocuff, Endoring, panoramic increase ADR decreases risk of CRC Corte, Leong. J Gastroenterol Hepatol 2015
6 improve adenoma detection flat behind folds blind spots fold-flattening panoramic endoscopy
7 Fold flattening devices Transparent Cap Endocuff G-Eye Balloon Aranda-Hernández World J Gastro 2016 EndoRing
8 Panoramic endoscopy FUSE Third Eye Retroscope Aranda-Hernández World J Gastro 2016 Third Eye Panoramic
9 cap: polyps RR 1.08 ( ) caecal intubation time -0.64min Ng Am J Gastroenterol 2012
10 n=1,063, n=530 Endocuff, n=533 CC surveillance, symptoms, screen, FIT ADR 52% CC vs 52% Endocuff flat adenomas 0.27/ individual vs 0.16 (P<0.01); small adenomas 0.91 vs 0.74 (P=.03) 22 failed sigmoid intubation van Doorn Gut 2015
11 reusable balloon & inflation system 0.1mm diameter straighten folds and flexures n=126 tandem colonoscopy balloon colonoscopy missed 7.5% vs 45% colonoscopy (P=0.0002) detection 81% additional adenomas Halpem Endosc 2015
12 retroflexed 2 nd camera uses up channel Prof Rupert Leong
13 n=29: +4 polyps; 11.8% increased yield n=249: +16% adenomas n=298: +11% adenomas n=349: +23% adenomas Triadafilopoulos Endosc 2008 DeMarco Gastrointest Endosc 2010 Waye Gastrointest Endosc 2010 Leuflkens Gastrointest Endosc 2011
14 CMOS, LED 300 degree viewing frees channel ICV intubation challenge lens wash reusable version Rubin World J Gastro 2015
15 n=33, screening, surveillance, diagnostic ADR 44% 100% caecal intubation; intubation time 8min Rubin World J Gastro 2015
16 170 Field of View 330
17 168cm length 12.8mm diameter high res full tip mobility 3.8mm channel
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19 20
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21 tandem colonoscopy study 18-70yo; screening, assessment, follow up conventional colonoscopy first or FUSE first Conventional Colonoscopy n=88 FUSE n=97 Adenoma miss rate 20/ 49 (41%) 5 / 67 (7%) < P Gralnek Lancet Oncol 2015
22 Gralnek Lancet Oncol 2015 Standard colonoscopy (n=88) FUSE (n=97) Missed adenoma by 1 st procedure 20 / 49 (41%) 5 / 67 (7%) Morphology: total 20 5 Pedunculated 2 0 Sessile 18 5 Size : 10mm 1 0 Subtype Location 6-9mm 5 0 <5mm 14 5 TA (18), TVA (1) and villous (1) Tubular (5) Right 14 2 Conventional colonoscopy misses small, proximal colonic polyps Left 6 3 Finding require change in surveillance 9.1% (8/88) 0% (0/97)
23 screening +ve FIT; 7 Italian centres Conventional Colonoscopy n=330 high ADR (40%), first gen, learning curve 1 adenoma identified = ADR already met FUSE n=328 ADR n (%) 150/330 (45.5) 143/328 (43.6) Advanced ADR n (%) 23.0% 64/328 (19.5) Cesare Gut 2016
24 Adenoma Miss Rate RR: 0.35 (95%CI: ) Facciorusso J Gastro Hepatol 2017
25 Adenoma Detection Rate: 1.05 ( ) Facciorusso J Gastro Hepatol 2017
26 Total colonoscopy time Facciorusso J Gastro Hepatol 2017
27 Adenoma Detection RR (95% CI) Adenoma Miss Rate RR (95% CI) Right-sided 1.10 ( ) 0.27 ( ) Left-sided 0.92 ( ) 0.33 ( ) Size 5mm 1.09 ( ) 0.26 ( ) Size >5mm 1.01 ( ) 0.38 ( ) Flat / sessile 1.32 ( ) 0.26 ( ) Pedunculated 1.04 ( ) 0.15 ( ) FUSE: small adenomas; R & L colons ADR same Facciorusso J Gastro Hepatol 2017
28 Off On Adaptive Matrix Imaging Off High Always on capability Maintains natural colors Smart enhancement Designed to reduce distraction Gastro-esophageal Junction Off Off High On Flat Sessile Polyp Pending FDA clearance Not for sale in the US
29 Markov model cost-effectiveness of FUSE +16% increased cancer prevention: 58% to 74% gain of 9 days per person cost of cancer care decreased $90M to $57M savings $145 per person Hassan Digest Endosc 2015
30 232 degrees n=319: ADR 1.1 vs 1% (P=0.43)
31 Tandem Studies Rex 1997 Gastro n=183 Rex 2011 GI Endosc n=1,000 Adenoma Miss Rates Additional Adenomas Detected by 2 nd Procedure vs. TFV 24% 2 nd Pass 31% vs. 2 nd Pass +12% on retroflexion Siersema 2012 World J Gastro n=349 vs. TFV 31% Third Eye 46% Gralnek 2014 Lancet Oncol n=185 vs. TFV 41% FUSE 69%
32 Technology Improvement Negatives Cap flatten folds cheap - Third Eye Retroscope Third Eye Panoramic Cap Full spectrum endoscopy through working channel clip on, 3 cameras 3 cameras incorporated, LUMOS reverse view uses up channel 330 degrees intubating ileum, >25 use 330 degrees initial capital (minimal training) Endocuff flatten folds cheap intubating ileum EndoRing flatten folds cheap intubating ileum
33 what is the best measure of quality? who will benefit most from technologies? high ADRs? low ADRs? incremental gain? slow withdrawal, high quality bowel prep? negatives? learning curve, difficult intubation, use channel cost benefit? cheap cap vs FUSE
34 endoscopic technology decreases adenoma miss rate FUSE: improve CRC screening efficacy; reduces interval CRC decreased adenoma miss rates; ADR not increased other techniques: less established
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36 Where is the panda? Prof Rupert Leong
37 Gralnek Leong Cesare Population mixed IBD surveillance +ve FIT Endpoint adenoma miss rate adenoma miss rate adenoma detection rate Adenoma Miss Rate 7% FUSE vs 41% CC P= Adenoma Detection Rate P= % FUSE vs 71% CC 73% FUSE vs 27% 43.6% FUSE vs 45.5% CC
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