LANDMARK ARTICLE - Required reading

 Winawer SJ, Stewart ET, Zauber AG, et al.  A comparison of colonoscopy and double-contrast barium enema for surveillance after polypectomy.  N Engl J Med 2000;342:1766-1772.

Fletcher RH.  The end of barium enemas? (editorial)  N Engl J Med 2000;342

 Major Findings

 --    Paired colonoscopy and barium enema were performed in 580 patients as part of the surveillance program for patients with recently diagnosed colon adenomas.  Endoscopists were not aware of the results of the barium enema.

---   Barium enema demonstrated a polyp in only 139 of the 392 cases in which polyps were found by colonoscopy for a rate of detection of polyps of 35%

---   The accuracy of ACBE was dependent on polyp size.  32% of polyps <0.5cm , 53% of those 0.6 to 1 cm, and 48% for those >1 cm in diameter.

--- 139 patients had a positive ACBE and a negative colonoscopy.  These underwent colonoscopy a second time, and 19 additional polyps were identified.  Thus the rate of missed adenomas with colonoscopy was 20%, none were >1cm.

 FACTS TO REMEMBER FOR BOARDS

 The “miss rate” for detection of clinically significant lesions (adenomas >1cm) after one colonoscopy is 3%-6%

As many as 25% of adenomas <1cm can be missed on initial colonoscopy

False positive rate of well done ACBE is 14% (finding polyps that are not there)

The rate of complete colonoscopy (reaching the cecum) ranges from 80% to 95%, most well trained gastroenterologists should average 95% or higher.

 Clinical Application

 Colonoscopy is clearly the test of choice for surveillance in patients with recently diagnosed colon adenomas

 This article is crucial when negotiating with managed care organizations that may attempt to make BE the test of choice for polyp surveillance.

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