S697 Interventions to Improve the Quality of Screening-Related Colonoscopy: A Systematic Review and Network Meta-analysis of Randomized Controlled Trials

Introduction: There is an absence of clear evidence-based guidance to inform endoscopists on strategies aimed to improve adenoma detection rate (ADR). Given substantial endoscopist-level variability in ADR and quality metrics, there is an urgent need to systematically characterize colonoscopy quality improvement strategies. Methods: This network meta-analysis (NMA) included patients undergoing screening-related colonoscopy and interventions within pre-determined domains (pre-procedural parameters, intra-procedural techniques, endoscopy technologies, disposable assistive devices, and additive substances). Outcomes were ADR, polyp detection rate (PDR) right ADR, advanced ADR, sessile serrate ADR, adenomas per colonoscopy (APC), APC subtypes, cecal intubation rate (CIR), withdrawal time, and adverse event rates. For the NMA, we used a Bayesian random-effects model using Markov-chain Monte-Carlo simulation, with 10,000 burn-ins and 100,000 iterations. We calculated odds ratios (OR) and corresponding 95% credible intervals (CrI) and ranked the probabilities of the interventions within each domain through a plot of surface under the cumulative ranking curves (SUCRA). We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess the certainty of evidence Results: We included 118 RCTs with 93,819 unique patients evaluating 36 unique interventions. Eleven interventions were associated with improved ADR (dual observation, water exchange, iScan, linked colour imaging, computer aided detection, G-EYE, Endorings, WingCap, Endocuff Vision 1 and 2, and oral methylene blue) (Figure 1). In SUCRA analysis, dual observation (SUCRA, 0.84) and water exchange (SUCRA, 0.78) were ranked highest in the intraprocedural techniques domain, iScan (SUCRA, 0.95), LCI (SUCRA, 0.85), and CADe (SUCRA, 0.78) in the endoscopic technologies domain, G-EYE (SUCRA, 0.86), WingCap (SUCRA, 0.82), and Endocuff vision 1 (SUCRA, 77.4) in the disposable assistive devices domain, and methylene blue (SUCRA, 0.94) in the additive substances domain. Secondary outcomes are summarized in Table 1. Certainty of evidence ranged from very low to moderate. Conclusion: These results provide important information regarding the relative efficacies of interventions to improve colonoscopy quality and are relevant to endoscopy unit managers, gastrointestinal and endoscopy societies which produce clinical guidelines, and practicing endoscopists.Figure 1.: Forrest plots with odds ratios and 95% credible intervals from network meta-analysis of primary outcome of adenoma detection rate. Table 1. - Secondary Outcomes With Effect Estimates and 95% Credible Intervals Intervention PDR, OR (95% CrI) ssADR, OR (95% CrI) rADR, OR (95% CrI) aADR, OR (95% CrI) APC (MD, 95% CrI) ssAPC (MD, 95% CrI) WT (MD, 95% CrI) CIR, RR (95% CrI) Peri-procedural parameters Bisacodyl 1.17 (0.83, 1.64) - - - - - - 1.00 (0.98, 1.02) Coffee plus PEG 1.25 (0.91, 1.74) - - - - - - - Electrolyte-free PEG 0.95 (0.73, 1.27) - - - - - - - Low dose PEG 1.14 (0.93, 1.41) - - 1.42 (0.62, 3.34) - - 0.60 (−0.78, 1.99) - Low-fibre diet 1.03 (0.85, 1.21) - - 1.33 (0.75, 2.38) - - - 1.01 (0.95, 1.06) Low fibre diet and sulfate-free PEG 1.09 (0.77, 1.51) - - - - - - 1.01 (0.98, 1.04) Patient education 0.91 (0.77, 1.07) - - - - - 0.40 (−0.65, 1.40) - Simethicone 0.86 (0.65, 1.11) - - 0.92 (0.51, 1.69) - - −0.04 (−1.08, 0.99) - Single-dose PEG - - - - - −0.40 (−1.79, 0.99) - Sulfate-based prep 0.99 (0.84, 1.13) - - 0.96 (0.58, 1.60) - - 0.20 (−1.22, 1.63) 1.00 (0.97, 1.05) Sulfate-free PEG 1.17 (0.83, 1.60) - - - - - - Intraprocedural techniques Abdominal compression device 0.91 (0.63, 1.31) - - 0.90 (0.62, 1.29) 0.16 (−0.30, 0.63) - −0.91 (−6.94, 5.10) - Dual observer 1.13 (0.88, 1.49) - 1.18 (0.56, 2.49) 1.00 (0.80, 1.24) - 2.22 (−1.20, 5.72) 1.00 (0.91, 1.09) Inspection on insertion - - 1.00 (0.48, 2.09) 1.02 (0.81, 1.30) −0.01 (−0.38, 0.28) - −3.02 (−7.37, 1.17) - Prescribed positional change 0.99 (0.70, 1.42) - - - - - 0.81 (−5.12, 6.75) - Proximal colon retroflexion - - - 0.74 (0.46, 1.18) - - - - Second forward view 1.09 (0.87, 1.35) - 1.08 (0.58, 1.95) 1.14 (0.94, 1.38) - - 1.02 (−2.42, 4.48) Segmental timed withdrawal 1.16 (0.79, 1.71) - 0.63 (0.21, 1.76) 1.28 (0.81, 2.03) 0.14 (−0.33, 0.61) - 0.00 (−5.94, 5.93) 1.00 (0.95, 1.03) Short withdrawal time - - - - - - - - Water exchange 1.33 (0.92, 1.94) - 1.12 (0.69, 1.68) 1.18 (1.04, 1.35)* - −0.02 (−3.43, 3.37) 1.00 (0.93, 1.06) Water immersion - - 1.08 (0.56, 1.99) 1.03 (0.80, 1.32) - 0.57 (−3.50, 4.64) Endoscopic technologies Blue-light imaging - - - - - - - - Computer-aided detection 1.08 (0.99, 1.18) 0.91 (0.55, 1.68) 1.21 (0.73, 1.96) 1.27 (0.62, 2.63) 0.22 (−0.08, 0.52) - 0.12 (−0.28, 0.56) - Flexible spectral imaging color enhacement 0.96 (0.84, 1.09) - - - −0.01 (−0.09, 0.08) - - - iScan 1.03 (0.88, 1.21) 1.03 (0.41, 2.56) 0.98 (0.50, 2.01) - 0.09 (−0.06, 0.24) - 0.25 (−0.18, 0.79) - Linked-color imaging 1.14 (1.06, 1.23)* 1.25 (0.49, 2.81) 1.05 (0.77, 1.42) 1.03 (0.62, 1.73) 0.19 (0.09, 0.30)* - 0.26 (−0.20, 0.74) 1.00 (0.98, 1.03) Narrow-band imaging 0.99 (0.91, 1.07) 2.92 (1.27, 6.92)* 0.92 (0.69, 1.26) 1.37 (0.79, 2.32) −0.01 (−0.09, 0.07) - 0.61 (0.21, 1.01)* 1.00 (0.99, 1.01) Ultrathin colonoscope 0.87 (0.60, 1.25) - 0.26 (0.05, 0.90)* 0.46 (0.15, 1.33) - - 1.06 (0.99, 1.15) Wide-angle colonoscope 0.96 (0.87, 1.05) 0.93 (0.47, 2.04) 0.96 (0.69, 1.33) 0.96 (0.45, 2.05) −0.24 (−0.78, 0.30) - 0.26 (−0.34, 0.89) 0.99 (0.94, 1.03) Disposable assistive devices AmplifEYE 1.10 (0.84, 1.43) 1.08 (0.57, 2.07) 1.17 (0.59, 2.27) - 0.28 (−0.84, 1.42) 0.02 (−1.58, 1.63) −0.71 (−2.88, 1.35) CaP-assisted colonoscopy 1.09 (0.89, 1.33) 0.85 (0.54, 1.30) 1.09 (0.82, 1.51) 1.02 (0.84, 1.20) 0.08 (−0.39, 0.57) 0.36 (−0.43, 1.20) 0.12 (−0.92, 1.09) 1.01 (0.97, 1.04) Endocuff vision 1 1.21 (1.06, 1.42)* 1.07 (0.69, 1.71) 0.99 (0.69, 1.40) 0.78 (−0.32, 1.88) - 0.18 (−0.93, 1.31) 1.01 (0.97, 1.05) Endocuff vision 2 1.09 (0.97, 1.23) 1.15 (0.80, 1.64) 1.05 (0.81, 1.32) 1.09 (0.92, 1.26) 0.16 (−0.37, 0.71) 0.06 (−1.08, 1.21) −0.41 (−1.22, 0.30) 1.01 (0.99, 1.05) EndoRings 1.03 (0.90, 1.18) 1.09 (0.77, 1.57) 0.88 (0.53, 1.46) 1.23 (0.80, 1.91) 0.06 (−0.59, 0.77) 0.06 (−1.07, 1.20) −0.72 (−2.07, 0.60) 0.99 (0.94, 1.05) G-EYE - - - - - - - - WingCap 1.21 (0.90, 1.63) 0.54 (0.14, 1.95) 1.18 (0.45, 3.23) - 0.27 (−0.67, 1.20) - 0.37 (−1.39, 2.12) 1.00 (0.94, 1.06) Additive substances Indigo carmine - - - - - - - - Oral methylene blue - - - - - - - - Menthol - - - - - - - - aADR (Advanced Adenoma Detection Rate), APC (Adenomas Per Colonoscopy), CIR (Cecal Intubation Rate), CrI (Credible Interval), MD (Mean Difference), OR (Odds Ratio), PDR (Polyp Detection Rate), PEG (Polyethylene Glycol), rADR (Right Adenoma Detection Rate), RR (Risk Ratio), ssADR (Sessile Serrated Adenoma Detection Rate), ssAPC (Sessile Serrated Adenomas Per Colonoscopy), WT (Withdrawal Time).