High-Volume Colonoscopy Predicts Higher Cecal Intubation Rates and Lower Perforation Risk, but Not Higher Detection or Cancer Prevention

Douglas K. Rex, MD, MASGE reviewing Forbes N, et al. Clin Gastroenterol Hepatol 2020 Mar 20.

In a systematic review and meta-analysis encompassing 27 studies with 11,276,244 colonoscopies, there was no association of procedure volume with adenoma detection rate (ADR) nor prevention of postcolonoscopy cancer. The cecal intubation rate increased with each additional 100 annual procedures (odds ratio [OR], 1.17). Overall adverse events trended lower with each 100 annual procedures (OR, 0.95; 95% confidence interval, 0.90-1.00). The risk of perforation appeared more clearly reduced, based on two large studies that had specifically examined this, with 8% and 4% risk reductions per 100 additional annual procedures.


These data indicate that cecal intubation and avoidance of perforation are technical skills that improve with higher volumes and experience. Conversely, detection appears to be a function of other endoscopist qualities and is independent of procedural volume. These data indicate that high volume is not a surrogate for good detection, and reinforce that ADR must be measured by all endoscopists. On the other hand, low-volume colonoscopists require observation to minimize complications. Individual endoscopy centers might consider limiting their exposure to screening patients, when the consequences of perforation seem disastrous, and high-risk colons. Low-volume colonoscopists might be encouraged to avoid struggling to accomplish cecal intubation and to get help early with technically complex colons.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Douglas K. Rex, MD, MASGE

Bio and Disclosures


Forbes N, Boyne DJ, Mazurek MS, et al. Association between endoscopist annual procedure volume and colonoscopy quality: systematic review and meta-analysis. Clin Gastroenterol Hepatol 2020 Mar 20. (Epub ahead of print) (