1	La qualita’ nella colonscopia di screening Renato Fasoli Gastroenterologia Ospedale Santa Chiara, Trento
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3	Messaggio telefonico reale (f.b., femmina, 44 anni, milano) asintomatica; sottoposta a colonscopia per screening familiare/personale Mi hanno trovato un polipo al colon. Ora aspetto la biopsia e poi mi fanno un intervento in day hospital per toglierlo. In piu’ – e questa è la parte orribile – controlli ogni anno. Ps. esame dolorosissimo (mi hanno dato solo un po’ di Valium)
4	Esistono delle peculiarità nella colonscopia di screening ? Particolare attenzione a: Consenso informato Storia personale e familiare Trattamento anticoagulante e anti-aggregante (alta probabilità di operatività) Condizioni a rischio di batteriemia Gestione pacemaker e defibrillatori Preparazione (aspetti organizzativi) Ottimizzazione della resa diagnostica Know-how nelle polipectomie Gestione insuccessi diagnostici e terapeutici Refertazione e documentazione fotografica Informazioni successive all’esame (follow-up. consulti multidisciplinari)
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6	La colonscopia non è infallibile ! L’utente del programma di screening si aspetta un’esistenza libera dal CCR, ma… …1/110 sviluppa CCR entro 3 anni dalla colonscopia…..
7	"Colorectal cancer developing after colonoscopy..." Colorectal cancer developing after colonoscopy is more frequently right-sided than its incidence in the general population. In a population-based study of right-sided cancer, at least 6% of patients had colonoscopy 6 to 36 months before diagnosis, suggesting that the endoscopist missed the cancer.
8	Why would colonoscopy be less effective in preventing death from right-sided CRC? 1) Some "complete" colonoscopies do not evaluate the entire right colon. 2) Bowel preparation may be worse in the right colon. 3) Right and left colonic neoplasia may differ biologically.
9	POLYP MISS RATE DETERMINED BY TANDEM COLONOSCOPY: A SYSTEMATIC REVIEW 1.2-5.0 media polipi/paziente 98% CS completa
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11	Adenoma detection rate Percentage of patients undergoing colonoscopy in whom a histologically proven adenoma is found In asymptomatic patients > 50 years of age
12	Adenoma detection rate Required values Diagnosis of adenomas in subjects> 50 years of age: > 25% in males > 15% in females 20-40% in subjects with family history
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14	Withdrawal times and adenoma detection rates (Illinois, USA) 11.8 vs 28.3% of detection rate o any neoplasia (also advanced adenomas) Large differences among gastroenterologists (9.4-32.7%) Seemingly linear relationship
15	What could be done to improve adenoma detection Timer during withdrawal (stopwatch, es. Indiana University Hospital) Emphasis on withdrawal in teaching New technologies (chromoendoscopy, NBI? High definition)
16	New Technologies Developments for improved detection of flat lesions Chromoendoscopy NBI High definition Autofluorescence Developments for exposing more mucosa Cap fitted colonoscopy Third eye retroscope Wide angle-colonoscopy Colonoscopy in retroflexion
17	Quality factors Generally independent on « technology » Colonoscopy withdrawal time: 6-10 minutes Percentage of resected colonic polyps recovered for pathologic examination>95% Possibly dependent on « technology » Caecal intubation rate: >95% Adenoma detection rate in males over 50 years of age: > 25% Adenoma detection rate in females over 50 years of age: > 15% Always try to remove endoscopically polyps of any kind if < 2 cm in size
18	Other tricks for quality in screening colonoscopy Split preparation (improved vision in the right colon) Light sedation Warm water Antispasmodics Carbon dioxide Position changes Judicious retroflexion
19	Colonscopia di screening Trento YES NO
20	Quality in (screening) colonoscopy In the past Reach the caecum most often and fastest Remove difficult polyps Sedation Nowadays Reach the anus as slow as possible Adenoma detection Patient satisfaction
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