Adenoma miss rates associated with a 3-minute versus 6-minute colonoscopy withdrawal time: a prospective, randomized trial

Published:December 05, 2016DOI:

      Background and Aims

      The 6-minute withdrawal time for colonoscopy, widely considered the standard of care, is controversial. The skill and technique of endoscopists may be as important as, or more important than, withdrawal time for adenoma detection. It is unclear whether a shorter withdrawal time with good technique yields an acceptable lesion detection rate. Our objective was to evaluate a 3-minute versus a 6-minute withdrawal time by using segmental tandem colonoscopy.


      We performed a prospective, randomized trial by using 4 expert endoscopists. Patients were randomized to a 3-minute or a 6-minute initial withdrawal, each followed by a tandem second 6-minute withdrawal. All polyps were removed. The primary outcomes were adenoma miss rates (AMRs), adenomas per colonoscopy (APC) rates, and adenoma detection rates (ADRs).


      A total of 99 and 101 patients were enrolled in the 3-minute and 6-minute withdrawal groups, respectively. The AMR was significantly higher in the 3-minute withdrawal group (48.0% vs 22.9%; P = .0001). After controlling for endoscopist, patient age and/or sex, Boston Bowel Preparation Scale score, and size and/or location and/or morphology of adenoma, the AMR remained significantly higher in the 3-minute withdrawal group (odds ratio, 2.78; 95% confidence interval, 1.35-5.15; P = .0001). The ADR was similar between both groups (39.2% vs 40.6%; P = .84). However, the mean APC rate was significantly lower in the 3-minute withdrawal group (0.55 vs 0.80; P = .0001).


      The AMR was significantly higher, and the APC rate was significantly lower in the 3-minute withdrawal group versus the 6-minute withdrawal group. Despite expert technique, a shorter withdrawal time is associated with an unacceptably high AMR and low APC rate. (Clinical trial registration number: NCT01802008.)


      ADR (adenoma detection rate), AMR (adenoma miss rate), APC (adenomas per colonoscopy), SSA (sessile serrated adenoma)
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        • Group USCSW
        United States Cancer Statistics: 1999-2009 Incidence and Mortality Web–based Report.
        U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute, Atlanta2013
        • Winawer S.J.
        • Zauber A.G.
        • Ho M.N.
        • et al.
        The National Polyp Study.
        Eur J Cancer Prev. 1993; 2: 83-87
        • Zauber A.G.
        • Winawer S.J.
        • O'Brien M.J.
        • et al.
        Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths.
        N Engl J Med. 2012; 366: 687-696
        • Shaukat A.
        • Mongin S.J.
        • Geisser M.S.
        • et al.
        Long-term mortality after screening for colorectal cancer.
        N Engl J Med. 2013; 369: 1106-1114
        • Nishihara R.
        • Wu K.
        • Lochhead P.
        • et al.
        Long-term colorectal-cancer incidence and mortality after lower endoscopy.
        N Engl J Med. 2013; 369: 1095-1105
        • Harewood G.C.
        • Lieberman D.A.
        Colonoscopy practice patterns since introduction of medicare coverage for average-risk screening.
        Clin Gastroenterol Hepatol. 2004; 2: 72-77
        • Prajapati D.N.
        • Saeian K.
        • Binion D.G.
        • et al.
        Volume and yield of screening colonoscopy at a tertiary medical center after change in medicare reimbursement.
        Am J Gastroenterol. 2003; 98: 194-199
        • Hixson L.J.
        • Fennerty M.B.
        • Sampliner R.E.
        • et al.
        Prospective blinded trial of the colonoscopic miss-rate of large colorectal polyps.
        Gastrointest Endosc. 1991; 37: 125-127
        • Rex D.K.
        • Cutler C.S.
        • Lemmel G.T.
        • et al.
        Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies.
        Gastroenterology. 1997; 112: 24-28
        • Heresbach D.
        • Barrioz T.
        • Lapalus M.G.
        • et al.
        Miss rate for colorectal neoplastic polyps: a prospective multicenter study of back-to-back video colonoscopies.
        Endoscopy. 2008; 40: 284-290
        • Ahn S.B.
        • Han D.S.
        • Bae J.H.
        • et al.
        The miss rate for colorectal adenoma determined by quality-adjusted, back-to-back colonoscopies.
        Gut Liver. 2012; 6: 64-70
        • Pohl H.
        • Robertson D.J.
        Colorectal cancers detected after colonoscopy frequently result from missed lesions.
        Clin Gastroenterol Hepatol. 2010; 8: 858-864
        • Robertson D.J.
        • Lieberman D.A.
        • Winawer S.J.
        • et al.
        Colorectal cancers soon after colonoscopy: a pooled multicohort analysis.
        Gut. 2014; 63: 949-956
        • Rex D.K.
        • Bond J.H.
        • Winawer S.
        • et al.
        Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer.
        Am J Gastroenterol. 2002; 97: 1296-1308
        • Barclay R.L.
        • Vicari J.J.
        • Doughty A.S.
        • et al.
        Colonoscopic withdrawal times and adenoma detection during screening colonoscopy.
        N Engl J Med. 2006; 355: 2533-2541
        • Simmons D.T.
        • Harewood G.C.
        • Baron T.H.
        • et al.
        Impact of endoscopist withdrawal speed on polyp yield: implications for optimal colonoscopy withdrawal time.
        Aliment Pharmacol Ther. 2006; 24: 965-971
        • Barclay R.L.
        • Vicari J.J.
        • Greenlaw R.L.
        Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy.
        Clin Gastroenterol Hepatol. 2008; 6: 1091-1098
        • Overholt B.F.
        • Brooks-Belli L.
        • Grace M.
        • et al.
        Withdrawal times and associated factors in colonoscopy: a quality assurance multicenter assessment.
        J Clin Gastroenterol. 2010; 44: e80-e86
        • Shaukat A.
        • Rector T.S.
        • Church T.R.
        • et al.
        Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy.
        Gastroenterology. 2015; 149: 952-957
        • Rex D.K.
        • Petrini J.L.
        • Baron T.H.
        • et al.
        Quality indicators for colonoscopy.
        Am J Gastroenterol. 2006; 101: 873-885
        • Sawhney M.S.
        • Cury M.S.
        • Neeman N.
        • et al.
        Effect of institution-wide policy of colonoscopy withdrawal time > or = 7 minutes on polyp detection.
        Gastroenterology. 2008; 135: 1892-1898
        • Moritz V.
        • Bretthauer M.
        • Ruud H.K.
        • et al.
        Withdrawal time as a quality indicator for colonoscopy—a nationwide analysis.
        Endoscopy. 2012; 44: 476-481
        • Rex D.K.
        Colonoscopic withdrawal technique is associated with adenoma miss rates.
        Gastrointest Endosc. 2000; 51: 33-36
        • Lee R.H.
        • Tang R.S.
        • Muthusamy V.R.
        • et al.
        Quality of colonoscopy withdrawal technique and variability in adenoma detection rates (with videos).
        Gastrointest Endosc. 2011; 74: 128-134
        • Lieberman D.A.
        • Rex D.K.
        • Winawer S.J.
        • et al.
        Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer.
        Gastroenterology. 2012; 143: 844-857
        • Lee T.J.
        • Blanks R.G.
        • Rees C.J.
        • et al.
        Longer mean colonoscopy withdrawal time is associated with increased adenoma detection: evidence from the Bowel Cancer Screening Programme in England.
        Endoscopy. 2013; 45: 20-26
        • Butterly L.
        • Robinson C.M.
        • Anderson J.C.
        • et al.
        Serrated and adenomatous polyp detection increases with longer withdrawal time: results from the New Hampshire Colonoscopy Registry.
        Am J Gastroenterol. 2014; 109: 417-426