Gastroenterology trainee miss-rate for colon polyps: A prospective study of tandem colonoscopic examinations
Background: Determination of a safe follow-up period following identification of adenomatous polyps is critically dependent on the quality and thoroughness of the first colonoscopy. We performed a prospective study examining the miss-rate of colonoscopy for polyps as performed by gastroenterology fellows in the setting of an academic training program. Methods: Consecutive eligible outpatients presenting for colonoscopy to the GI Clinic were asked to consent to the study. Those agreeing underwent colonoscopy in the usual fashion: the exam was performed by a senior gastroenterology fellow with attending supervision. Supervision was generally observational only. Polypectomies were performed in the standard manner. One out of 4 pts were then randomized to undergo a second exam. The second procedure was performed immediately by a study attending who was blinded to the results of the first colonoscopy. Any additional detected polyps were removed. Results: 287 patients (pts) were offered enrollment over an 11 month period. 151 pts consented to the study, and 32 underwent a second exam. In 10 cases (31%), additional polyps were detected. A total of 21 polyps were missed, ranging in size from 1.5-8mm, with an average size of 3.7mm. Only 5 polyps (24%) were larger than 4mm. The number of missed polyps on individual exams ranged from 1 to 7. No missed polyp had advanced histology (villous component or cancer). In only 1 case did the study attending's findings alter the plan for the pt (the finding of an additional 6mm polyp changed f/u plan from 5 years to 3). Ten fellows participated in the study. Average fellow experience was 360 colonoscopies with a range of 72 to 647. In cases in which polyps were missed, average fellow experience was 332. Fellows who had performed < 250 colonoscopies were no more likely to miss polyps than more experienced fellows (Fisher's exact test). Conclusions: Our prospective study demonstrated a miss-rate of 31% in colonoscopies performed by senior trainees in an academic setting. However, no large polyps or polyps with advanced histology were missed. At our institution, senior fellows, with observational attending supervision, perform adequate and thorough colonoscopic exams.
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