Demonstrating that colonoscopy is high quality

Colonoscopy is the gold standard investigation for examining the lower GI tract [1]. It plays a fundamental role in investigation of symptomatic individuals and in screening for colorectal cancer (CRC) [2,3]. Colonoscopy must be high quality in order to maximize its benefit [4]. Poor-quality colonoscopy is associated with increased interval cancer rates [4]. High-quality colonoscopy involves a complete procedure that provides comprehensive inspection of colonic mucosa [5]. There are a number of markers of colonoscopy quality, [2,6,7] with cecal intubation rate (CIR) historically being the most widely reported [8]. Cecal intubation was previously confirmed by written documentation of the cecal landmarks; however, photo-documentation of the cecum is now the accepted method of confirming colonoscopy completion. The European Society of Gastrointestinal Endoscopy (ESGE) guidelines recommend that such photo-documentation includes images of both the ileocecal valve and the cecum with views of the appendiceal orifice [9]. CIR is variable and many measures have been used to improve it [10–12]. The United Kingdom has engaged in a comprehensive quality improvement program with significant improvements [10,13]. Other countries have demonstrated similar results [14]. Although CIR is an important marker of completion of a procedure, other markers of quality include adenoma detection rate (ADR), bowel preparation, rectal examination and rectal retroflexion, colonoscopy withdrawal time (CWT), polyp retrieval, and complication rates [15–21]. Furthermore, comfort scores, tattooing of suspected malignant lesions in the colon, and taking diagnostic biopsies for unexplained diarrhea are seen as quality markers in addition to the rate of postcolonoscopy colorectal cancer [22–25]. Clinician performance in each of these areas is variable, but those who perform well tend to do so across all measures [22]. Among all measures, the most important marker of colonoscopy quality is adenoma detection rate [15–17]. ADR has clearly been shown to correlate with interval cancers [4]. Patients scoped by colonoscopists with high ADRs have lower interval cancer rates [4]. Furthermore, patients scoped by colonoscopists with higher ADRs have lower CRC mortality rates [16]. Polyp detection rate (PDR) can be used as a surrogate marker of ADR [26]. The paper, “Meticulous cecal image documentation at colonoscopy is associated with improved polyp detection,” published in this edition of Endoscopy International Open, explores the link between polyp detection rates and the quality of cecal photo-documentation. The paper reports a correlation between good-quality cecal photodocumentation and higher PDRs, including rightsided polyp detection (although some of these were hyperplastic polyps). Right-sided lesions are of particular interest and it may be that failure to detect them is one reason that screening programs are not adequately preventing right-sided colorectal cancer [27,28]. The reason for the correlation between PDR and image quality may be that colonoscopists who take time to capture convincing cecal images are generally more careful in their withdrawal examination. Another explanation may be that these “meticulous” colonoscopists have better control over the endoscope, which leads to better mucosal visualization. Longer mean CWTs are associated with increased adenoma detection, and are more relevant than total procedure times, as the majority of mucosal visualisation occurs on withdrawal of the colonoscope [19,29]. Although there was no statistically significant difference in procedure duration between “meticulous” and “non-meticulous” endoscopists in this study, the