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High-quality Bowel Preparation Is Required for Detection of Sessile Serrated Polyps. Clin Gastroenterol Hepatol 2016; 14:1155-62. [PMID: 27060426 PMCID: PMC4955697 DOI: 10.1016/j.cgh.2016.03.044] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The effect of bowel preparation quality has been well-characterized for detection of adenomas but not for detection of sessile serrated adenomas/polyps (SSPs). We performed a prospective study to determine proportions of patients in whom SSPs were detected at different levels of bowel preparation quality, using common validated scoring systems. METHODS Our study enrolled 749 male veterans 50-75 years old undergoing screening or surveillance colonoscopy. Proportions of patients in whom SSP were detected were calculated for each level of preparation quality based on the Aronchick scale (poor = low quality, fair = intermediate quality, and good or excellent = high quality) and the Boston Bowel Preparation Scale (BBPS; scores of 0-3 for right, transverse, and left colon segments). We compared SSP detection among different levels of preparation quality using multivariate logistic regression, adjusting for age, indication, and endoscopist. Our primary hypothesis was that SSP detection would not be significantly lower with intermediate-quality than with high-quality preparations. RESULTS SSPs were detected in a significantly smaller proportion of patients with intermediate-quality preparation than high-quality preparation, for the entire colon (4.6% vs 12.0%; odds ratio [OR], 0.37; 95% confidence interval [CI], 0.15-0.87) and right colon (1.5% vs 7.9%; OR, 0.19; 95% CI, 0.05-0.81). SSPs were detected in smaller proportions of patients with total colon BBPS scores <7 than in patients with BBPS scores of 7-9 (4.7% vs 12.6%; OR, 0.36; 95% CI, 0.19-0.67). SSPs were detected in right colons of a smaller percentage of patients with BBPS scores of 2 than scores of 3 (4.7% vs 9.5%; OR, 0.50; 95% CI, 0.26-0.94). CONCLUSIONS Any bowel preparation quality below high quality is associated with a significant decrease in the detection of SSPs. Although intermediate-quality preparation and BBPS segment scores of 2 seem to be adequate for detection of adenomas, these levels of preparation quality may not be adequate for detection of SSPs.
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Sulz MC, Kröger A, Prakash M, Manser CN, Heinrich H, Misselwitz B. Meta-Analysis of the Effect of Bowel Preparation on Adenoma Detection: Early Adenomas Affected Stronger than Advanced Adenomas. PLoS One 2016; 11:e0154149. [PMID: 27257916 PMCID: PMC4892520 DOI: 10.1371/journal.pone.0154149] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/10/2016] [Indexed: 02/06/2023] Open
Abstract
Background and Aims Low-quality bowel preparation reduces efficacy of colonoscopy. We aimed to summarize effects of bowel preparation on detection of adenomas, advanced adenomas and colorectal cancer. Methods A systematic literature search was performed regarding detection of colonic lesions after normal and low-quality bowel preparation. Reported bowel preparation quality was transformed to the Aronchick scale with its qualities “excellent”, “good”, “fair”, “poor”, and “insufficient” or “optimal” (good/excellent), “suboptimal” (fair/poor/insufficient), “adequate” (good/excellent/fair) and “inadequate” (poor/insufficient). We identified two types of studies: i) Comparative studies, directly comparing lesion detection according to bowel preparation quality, and ii) repeat colonoscopy studies, reporting results of a second colonoscopy after previous low-quality preparation. Results The detection of early adenomas was reduced with inadequate vs. adequate bowel preparation (Odds Ratio (OR) 0.53, CI: 0.46–0.62, p<0.001). The advanced adenomas were affected less in comparison (0.74, CI: 0.62–0.87, p<0.001). The large number of subjects considered in the present meta-analysis resulted in smaller confidence intervals compared to earlier studies. Classifying the bowel-preparation quality as suboptimal vs. optimal led to the same qualitative conclusion (OR: 0.81, CI: 0.74–0.89, p<0.001 for early adenomas, OR: 0.94, CI: 0.87–1.01, n.s. for advanced adenomas). Bowel preparation was equally important for right-sided/ flat/ serrated vs. other lesions in most observational studies but more relevant in some repeat colonoscopy studies; data regarding carcinoma detection were insufficient. Conclusion Inadequate bowel preparation affects detection of early colonic lesions stronger than advanced lesions.
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Affiliation(s)
- Michael C. Sulz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
- Division of Gastroenterology and Hepatology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Arne Kröger
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Meher Prakash
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Christine N. Manser
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
- See-Spital Horgen, 8801, Horgen, Switzerland
| | - Henriette Heinrich
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Benjamin Misselwitz
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
- * E-mail:
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Brimhall BB, Hankins SC, Kankanala V, Austin GL. Medicare Under Age 65 and Medicaid Patients Have Poorer Bowel Preparations: Implications for Recommendations for an Early Repeat Colonoscopy. PLoS One 2016; 11:e0155208. [PMID: 27187809 PMCID: PMC4871354 DOI: 10.1371/journal.pone.0155208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 04/26/2016] [Indexed: 12/31/2022] Open
Abstract
Background/Aims Colonoscopy is performed on patients across a broad spectrum of demographic characteristics. These characteristics may aggregate by patient insurance provider and influence bowel preparation quality and the prevalence of adenomas. The purpose of this study was to evaluate the association of insurance status and suboptimal bowel preparation, recommendation for an early repeat colonoscopy due to suboptimal bowel preparation, adenoma detection rate (ADR), and advanced ADR (AADR). Methods This is a cohort study of outpatient colonoscopies (n = 3113) at a single academic medical center. Patient insurance status was categorized into five groups: 1) Medicare < 65y; 2) Medicare ≥ 65y; 3) Tricare/VA; 4) Medicaid/Colorado Indigent Care Program (CICP); and 5) commercial insurance. We used multivariable logistic or linear regression modeling to estimate the risks for the association between patient insurance and suboptimal bowel preparation, recommendation for an early repeat colonoscopy due to suboptimal bowel preparation, ADR, and AADR. Models were adjusted for appropriate covariates. Results Medicare patients < 65y (OR 4.91; 95% CI: 3.25–7.43) and Medicaid/CICP patients (OR 4.23; 95% CI: 2.65–7.65) were more likely to have a suboptimal preparation compared to commercial insurance patients. Medicare patients < 65y (OR 5.58; 95% CI: 2.85–10.92) and Medicaid/CICP patients (OR 3.64; CI: 1.60–8.28) were more likely to receive a recommendation for an early repeat colonoscopy compared to commercial insurance patients. Medicare patients < 65y had a significantly higher adjusted ADR (OR 1.50; 95% CI: 1.03–2.18) and adjusted AADR (OR 1.99; 95% CI: 1.15–3.44) compared to commercial insurance patients. Conclusions Understanding the reasons for the higher rate of a suboptimal bowel preparation in Medicare < 65y and Medicaid/CICP patients and reducing this rate is critical to improving colonoscopy outcomes and reducing healthcare costs in these populations.
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Affiliation(s)
- Bryan B. Brimhall
- Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado, United States of America
| | - Sam C. Hankins
- Brody School of Medicine, East Carolina University, Greenville, North Carolina, United States of America
| | - Vineel Kankanala
- Division of Gastroenterology and Hepatology, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Gregory L. Austin
- Division of Gastroenterology and Hepatology, University of Colorado Denver, Aurora, Colorado, United States of America
- * E-mail:
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Martin D, Walayat S, Ahmed Z, Dhillon S, Asche CV, Puli S, Ren J. Impact of bowel preparation type on the quality of colonoscopy: a multicenter community-based study. J Community Hosp Intern Med Perspect 2016; 6:31074. [PMID: 27124170 PMCID: PMC4848432 DOI: 10.3402/jchimp.v6.31074] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 03/22/2016] [Indexed: 12/27/2022] Open
Abstract
Background High-quality bowel preparation is crucial for achieving the goals of colonoscopy. However, choosing a bowel preparation in clinical practice can be challenging because of the many formulations. This study aims to assess the impact the type of bowel preparation on the quality of colonoscopy in a community hospital setting. Methods A retrospective, observational study was conducted utilizing a colonoscopy screening/surveillance database in central Illinois during the period of January 1, 2010, to March 31, 2014. Patients without bowel preparation assessment were excluded from this study. Controlling for the confounders, generalized linear models were used to estimate the adjusted impact [odds ratio (OR)] of bowel preparation type on the quality of preparation (excellent, good, fair, and poor), and on the detection of advanced adenoma. The association between the time of withdrawal after insertion and the quality of preparation was also examined using a linear model. Results A total of 28,368 colonoscopies; half the patients were male, and the average age was 61±9 years. Polyethylene glycol (PEG) was used in the majority (70.2%) of bowel preparations, followed by sodium sulfate (21.4%), sodium phosphate (2.5%), magnesium sulfate (0.4%), and others. Compared with PEG, magnesium sulfate had a poorer quality of bowel preparations (OR=0.6, 95% CI 0.4–0.9; p<0.05), whereas the quality of bowel preparation was significantly improved by using sodium sulfate (OR=5.7, 95% CI 5.4–6.1; p<0.001) and sodium phosphate (OR=2.1, 95% CI 1.8–2.5; p<0.001). For those who had adequate bowel preparation, the better quality of preparation significantly increased the detection rate of advanced adenoma (5.0, 3.6, and 2.9% for excellent, good, and fair, respectively). Conclusion When possible, sodium sulfate–based preparations should be recommended in the community setting for colonoscopy because of their high quality of bowel preparation.
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Affiliation(s)
- Daniel Martin
- Department of Gastroenterology, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Saqib Walayat
- Department of Gastroenterology, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Zohair Ahmed
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Sonu Dhillon
- Department of Gastroenterology, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Carl V Asche
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA.,Center for Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, IL, USA.,Department of Pharmacy Systems, Outcomes And Policy, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Srinivas Puli
- Department of Gastroenterology, OSF Saint Francis Medical Center, Peoria, IL, USA
| | - Jinma Ren
- Department of Internal Medicine, University of Illinois College of Medicine at Peoria, Peoria, IL, USA.,Center for Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, IL, USA;
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Ravi S, Sabbagh R, Antaki F. Use of automated irrigation pumps improves quality of bowel preparation for colonoscopy. World J Gastrointest Endosc 2016; 8:295-300. [PMID: 27014425 PMCID: PMC4804187 DOI: 10.4253/wjge.v8.i6.295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 10/23/2015] [Accepted: 01/19/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the effectiveness of automated irrigation pumps (AIPs) in improving the quality of the bowel preparation and the yield of colonoscopy.
METHODS: A retrospective observational study was conducted at a single medical center. Outpatient colonoscopies performed during a 4-mo time period when AIPs were not in use, were compared to colonoscopies performed during control period. The main outcomes measured were quality of bowel preparation, procedures aborted due to poor preparation, recommendations to repeat at short interval due to sub-optimal bowel preparation and adenoma detection rates.
RESULTS: One thousand and thirty-seven colonoscopies were included. A higher proportion of cases did not achieve a satisfactory bowel preparation when AIPs were not used (24.4% vs 10.3%, P < 0.01). The number of procedures aborted due to inadequate preparation was not significantly different, however a repeat procedure at a short interval was recommended in a higher proportion of cases when AIPs were not used (21.3% vs 6.9%, P < 0.01). Good or excellent preparation was 2.91 (95%CI: 2.04-4.15) times more likely when AIPs were used. Detection of polyps and adenomas was not significantly different.
CONCLUSION: AIP use during colonoscopy results in a higher proportion of colonic preparation rated as satisfactory, although polyp detection rate is not significantly affected. Recommendations for repeat colonoscopy at shorter interval significantly decrease with the use of AIPs. This study supports the use of the irrigation pumps in endoscopy units to improve the quality of colonoscopy.
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Kang X, Zhao L, Leung F, Luo H, Wang L, Wu J, Guo X, Wang X, Zhang L, Hui N, Tao Q, Jia H, Liu Z, Chen Z, Liu J, Wu K, Fan D, Pan Y, Guo X. Delivery of Instructions via Mobile Social Media App Increases Quality of Bowel Preparation. Clin Gastroenterol Hepatol 2016; 14:429-435.e3. [PMID: 26492848 DOI: 10.1016/j.cgh.2015.09.038] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 09/09/2015] [Accepted: 09/30/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Bowel preparation is closely linked to the quality of colonoscopy. We investigated whether delivery of instructions via a social media app increases the quality of colonoscopy by improving adequacy of bowel preparation. METHODS We performed a prospective study at 3 endoscopic centers in China of 770 colonoscopy outpatients (18-80 years old) with convenient access to Wechat (a widely used mobile social media app) from May through November 2014. Patients were randomly assigned to groups that received standard education along with delivery of interactive information via Wechat (n = 387) or standard education (controls, n = 383). The primary outcome was proportion of patients with adequate bowel preparation (Ottawa score <6). Secondary outcomes included rates of adenoma detection and cecal intubation, cecal intubation time, rates of incomplete compliance with instructions, and patient willingness to repeat bowel preparation. RESULTS Demographic features were comparable between the groups. A higher proportion of patients in the group that received social media instruction had adequate bowel preparation than the control group (82.2% vs 69.5%, P < .001). Among patients with successful colonoscopies, the group that received social media instruction had lower mean total and segmental Ottawa scores (P < .05). A higher proportion of patients receiving social media instruction also had cecal intubation (97.2% vs 93.2% in controls, P = .014) and were found to have adenomas (18.6% vs 12.0% in controls, P = .012). CONCLUSIONS Instruction via a mobile social media app, in conjunction with regular instruction, increases subjective measures of adequacy of bowel preparation. Use of the app significantly increased the proportion of patients with successful cecal intubation and in whom adenomas were detected, indicating increased quality of colonoscopy. ClinicalTrials.gov number: NCT02140827.
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Affiliation(s)
- Xiaoyu Kang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Lina Zhao
- Department of Radiotherapy, Xijing Hospital, Fourth Military Medical University, Xian, China
| | - Felix Leung
- Sepulveda ACC, VA Greater Los Angeles Healthcare System, North Hill, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Hui Luo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Limei Wang
- Department of Gastroenterology, Shaanxi Second People's Hospital, Xian, China
| | - Ji Wu
- Department of Gastroenterology, Chancheng Central Hospital of Foshan, Foshan, China
| | - Xiaoyang Guo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Xiangping Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Linhui Zhang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Na Hui
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Qin Tao
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Hui Jia
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Zhiguo Liu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Zhangqin Chen
- Department of Gastroenterology, Shaanxi Second People's Hospital, Xian, China
| | - Junjun Liu
- Department of Gastroenterology, Chancheng Central Hospital of Foshan, Foshan, China
| | - Kaichun Wu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Daiming Fan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China
| | - Yanglin Pan
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
| | - Xuegang Guo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
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Aranda-Hernández J, Hwang J, Kandel G. Seeing better - Evidence based recommendations on optimizing colonoscopy adenoma detection rate. World J Gastroenterol 2016; 22:1767-1778. [PMID: 26855536 PMCID: PMC4724608 DOI: 10.3748/wjg.v22.i5.1767] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/17/2015] [Accepted: 12/01/2015] [Indexed: 02/06/2023] Open
Abstract
Colorectal cancer is one of the three most frequent causes of cancer deaths in men and women in Europe and North America. Diagnosis and resection of adenomas has convincingly demonstrated its utility in diminishing colorectal cancer incidence. Therefore, colonoscopy is now the gold standard for colorectal cancer screening. But it is also known that colonoscopy effectiveness varies among endoscopists. Among different quality indicators, the most used is the adenoma detection rate (ADR) which is the percentage of average-risk patients for colorectal cancer who are found to have at least one adenoma or adenocarcinoma during a screening colonoscopy. There is compelling evidence supporting an inverse correlation between ADR and interval colorectal cancer (cancer found after a screening colonoscopy). Many factors such as quality of precolonoscopy preparation, additional observers, manoeuvres with the endoscope (second view, retroflexion, water inflation rather than air), time spent during withdrawal, changes in patient position, fold-flattener devices, new imaging or endoscopic modalities and use of intravenous or through the scope sprayed drugs, have been studied and developed with the aim of increasing the ADR. This reviews discusses these factors, and the current evidence, to “see better” in the colon and optimize ADR.
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Clark BT, Protiva P, Nagar A, Imaeda A, Ciarleglio MM, Deng Y, Laine L. Quantification of Adequate Bowel Preparation for Screening or Surveillance Colonoscopy in Men. Gastroenterology 2016; 150:396-405; quiz e14-5. [PMID: 26439436 PMCID: PMC4728019 DOI: 10.1053/j.gastro.2015.09.041] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/22/2015] [Accepted: 09/27/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Bowel preparation is defined as adequate if it is sufficient for identification of polyps greater than 5 mm. However, adequate preparation has not been quantified. We performed a prospective observational study to provide an objective definition of adequate preparation, based on the Boston Bowel Prep Scale (BBPS, which consists of 0-3 points for each of 3 colon segments). METHODS We collected data from 438 men who underwent screening or surveillance colonoscopies and then repeat colonoscopy examinations within 60 days by a different blinded endoscopist (1161 colon segments total) at the West Haven Veterans Affairs Medical Center from January 2014 to February 2015. Missed polyps were defined as those detected on the second examination of patients with the best possible bowel preparation (colon segment BBPS score of 3) on the second examination. The primary outcome was the proportion of colon segments with adenomas larger than 5 mm that were missed in the first examination. We postulated that the miss rate was noninferior for segments with BBPS scores of 2 vs those with BBPS scores of 3 (noninferiority margin, <5%). Our secondary hypotheses were that miss rates were higher in segments with BBPS scores of 1 vs those with scores of 3 or of 2. RESULTS The adjusted proportion with missed adenomas greater than 5 mm was noninferior for segments with BBPS scores of 2 (5.2%) vs those with BBPS scores of 3 (5.6%) (a difference of -0.4%; 95% confidence interval [CI], -2.9% to 2.2%). Of study subjects, 347 (79.2%) had BBPS scores of 2 or greater in all segments on the initial examination. A higher proportion of segments with BBPS scores of 1 had missed adenomas larger than 5 mm (15.9%) than segments with BBPS scores of 3 (5.6%) (a difference of 10.3%; 95% CI, 2.7%-17.9%) or 2 (5.2%) (a difference of 10.7%; 95% CI, 3.2%-18.1%). Screening and surveillance intervals based solely on the findings at the first examination would have been incorrect for 16.3% of patients with BBPS scores of 3 in all segments, for 15.3% with BBPS scores of 2 or 3 in all segments, and for 43.5% of patients with a BBPS score of 1 in 1 or more segments. CONCLUSIONS Patients with BBPS scores of 2 or 3 for all colon segments have adequate bowel preparation for the detection of adenomas larger than 5 mm and should return for screening or surveillance colonoscopy at standard guideline-recommended intervals. Colon segments with a BBPS score of 1 have a significantly higher rate of missed adenomas larger than 5 mm than segments with scores of 2 or 3. This finding supports a recommendation for early repeat colonoscopic evaluation in patients with a BBPS score of 0 or 1 in any colon segment.
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Affiliation(s)
| | - Petr Protiva
- Yale School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Anil Nagar
- Yale School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Avlin Imaeda
- Yale School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Maria M. Ciarleglio
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Loren Laine
- Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.
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Harrison NM, Hjelkrem MC. Bowel cleansing before colonoscopy: Balancing efficacy, safety, cost and patient tolerance. World J Gastrointest Endosc 2016; 8:4-12. [PMID: 26788258 PMCID: PMC4707321 DOI: 10.4253/wjge.v8.i1.4] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/15/2015] [Accepted: 11/11/2015] [Indexed: 02/05/2023] Open
Abstract
Effective colorectal cancer screening relies on reliable colonoscopy findings which are themselves dependent on adequate bowel cleansing. Research has consistently demonstrated that inadequate bowel preparation adversely affects the adenoma detection rate and leads gastroenterologists to recommend earlier follow up than is consistent with published guidelines. Poor preparation affects as many as 30% of colonoscopies and contributes to an increased cost of colonoscopies. Patient tolerability is strongly affected by the preparation chosen and manner in which it is administered. Poor tolerability is, in turn, associated with lower quality bowel preparations. Recently, several new developments in both agents being used for bowel preparation and in the timing of administration have brought endoscopists closer to achieving the goal of effective, reliable, safe, and tolerable regimens. Historically, large volume preparations given in a single dose were administered to patients in order to achieve adequate bowel cleansing. These were poorly tolerated, and the unpleasant taste of and significant side effects produced by these large volume regimens contributed significantly to patients’ inability to reliably complete the preparation and to a reluctance to repeat the procedure. Smaller volumes, including preparations that are administered as tablets to be consumed with water, given as split doses have significantly improved both the patient experience and efficacy, and an appreciation of the importance of the preparation to colonoscopy interval have produced additional cleansing.
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Murphy CJ, Jewel Samadder N, Cox K, Iqbal R, So B, Croxford D, Fang JC. Outcomes of Next-Day Versus Non-next-Day Colonoscopy After an Initial Inadequate Bowel Preparation. Dig Dis Sci 2016; 61:46-52. [PMID: 26289257 DOI: 10.1007/s10620-015-3833-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/29/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND Inadequate bowel preparation is the most common cause of failed colonoscopy, and repeat failure occurs in more than 20 % of follow-up attempts. Limited data suggest that next-day follow-up may reduce the risk for repeat inadequate preparation. OBJECTIVE Evaluate differences in prep quality with next-day follow-up after initial inadequate preparation. DESIGN Retrospective study. SETTING Academic center. PATIENTS Outpatient screening and surveillance colonoscopies between 7/2002 and 6/2007. INTERVENTION Comparison of next-day versus any other day ("non-next-day") repeat colonoscopy outcomes. MAIN OUTCOME MEASUREMENTS Aronchick scale, polyp and adenoma detection rates. RESULTS Of 20,798 initial colonoscopies, 857 (4.1 %) had inadequate preparation. 460 (54 %) were lost to follow-up. One hundred and fourteen (13 %) had next-day and 283 (33 %) had non-next-day colonoscopy with mean follow-up of 8.8 months. On follow-up examination, 29.8 % of next-day and 23.3 % of non-next-day colonoscopies had inadequate bowel preparation (p = 0.48). The adenoma detection rate for the next-day group improved from 3.5 to 38.6 % on follow-up, compared to 20.5 and 36.8 % in the non-next-day group. There was no significant difference between groups in detection of total adenoma (p = 0.73) or advanced adenomas (p = 0.20) on follow-up examinations. LIMITATIONS Retrospective design, differences in baseline colonoscopy characteristics. CONCLUSION The results confirm the need for repeat examination after a colonoscopy with inadequate bowel prep, as there was substantial increase in adenoma detection on follow-up. There were no differences in outcomes between next-day versus non-next-day colonoscopy. These data support repeating after inadequate colonoscopy within 1 year as convenient for patient and physician.
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Affiliation(s)
| | - N Jewel Samadder
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Kristen Cox
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Ronak Iqbal
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Brian So
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Daniel Croxford
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - John C Fang
- University of Utah Health Sciences Center, Salt Lake City, UT, USA.
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Suboptimal Bowel Preparation Significantly Impairs Colonoscopic Detection of Non-polypoid Colorectal Neoplasms. Dig Dis Sci 2015; 60:2294-303. [PMID: 25777260 DOI: 10.1007/s10620-015-3628-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/09/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND It is unclear whether the quality of bowel preparation affects colonoscopic detection of non-polypoid colorectal neoplasms (NP-CRNs). AIM To evaluate the impact of bowel-cleansing quality on detection of NP-CRNs. METHODS We performed a retrospective analysis of asymptomatic screening colonoscopy cases after standardized bowel preparation at an academic teaching hospital between June 2011 and May 2013. Primary outcome was a comparison of the adenoma detection rate (ADR) of non-polypoid morphology according to quality of bowel preparation. Secondary outcomes included detection prevalence of non-polypoid adenomas. RESULTS Of the enrolled 6097 screening examinations, the preparation quality was rated as adequate (excellent or good) in 5224 (85.7 %), fair in 615 (10.1 %), and poor in 258 (4.2 %) patients. The prevalence of NP-CRNs was 40.5 % (1962/4847) of all CRNs. The overall ADR of non-polypoid morphology was 12.3 % (747/6097) of all colonoscopies, but it significantly differed among participating endoscopists (all P < 0.05). The ADR of non-polypoid morphology was significantly lower with fair- or poor-quality preparation, versus adequate-quality preparation (adjusted odds ratio [aOR] 0.55, 95 % confidence interval [CI] 0.41-0.75; aOR 0.49, 95 % CI 0.30-0.79, respectively). Poor-quality preparation was also associated with impaired detection of polypoid, proximal colon, and sub-centimeter adenomas (all P < 0.05). CONCLUSIONS Suboptimal (fair or poor) bowel preparation significantly impairs colonoscopic detection of NP-CRNs. Given that the prevalence of NP-CRNs is substantial in our average-risk screening cohort, ongoing efforts to improve the preparation quality are practically valuable in increasing the detection of NP-CRNs, thereby improving the efficacy of screening colonoscopies.
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Anderson JC, Shaw RD. Update on colon cancer screening: recent advances and observations in colorectal cancer screening. Curr Gastroenterol Rep 2015; 16:403. [PMID: 25108645 DOI: 10.1007/s11894-014-0403-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
There have been many recent advances and observations regarding colorectal cancer (CRC) screening. New CRC surveillance guidelines have been published to help endoscopists with the management of important clinical issues such as serrated polyps. There have been several important large studies examining the impact of endoscopic process measures such as bowel prep, withdrawal time, and adenoma detection rate on CRC screening. In addition, there have been technical advances in CT colonography including the development of exams that do not require a bowel preparation. Other new technology such as colon capsule endoscopy may aid endoscopists in the challenge of completing the evaluation of the colon in those patients with an incomplete colonoscopy. Finally, there have been large studies which examine the performance characteristics of the so-called non-invasive CRC screening tests such as fecal immunochemical test (FIT) and fecal DNA.
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Affiliation(s)
- Joseph C Anderson
- Department of Veterans Affairs Medical Center, 215 North Main Street, White River Junction, VT, 05009, USA,
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Colon washing tips the scales toward a better prep. J Clin Gastroenterol 2015; 49:267-9. [PMID: 25626631 DOI: 10.1097/mcg.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Abstract
GOAL To determine whether Excellent bowel cleansing is superior to Good for the detection of adenomas. BACKGROUND High quality colonoscopy requires Adequate bowel preparation. However, it is unknown whether adenoma detection differs between subcategories of Adequate cleansing. STUDY We utilized a retrospective, cross-sectional study design to obtain data about patients undergoing colonoscopy at a single university center between August 31, 2011 and September 1, 2012. Primary outcome was adenoma detection rate (ADR), the percentage of patients with ≥1 adenoma. Secondary outcomes included adenomas per colonoscopy, adenoma distribution (proximal vs. distal), and detection of advanced adenomas, sessile serrated polyps (SSP), and cancer. RESULTS The electronic medical record of 5113 consecutive colonoscopies with Good or Excellent preparation was queried for preparation quality, colonoscopy indication, demographics, medical history, and history of adenoma and colon cancer. Exclusion criteria were age below 18 years, inflammatory bowel disease, or familial polyposis. Adenoma detection was not superior with Excellent cleansing as compared with Good for ADR [respectively, 26% vs. 29%, odds ratio 0.97 (0.85, 1.11), P=0.618] or adenomas per colonoscopy [respectively, 0.437 vs. 0.499, incidence rate ratio (IRR) 0.98 (0.90, 1.07), P=0.705]. Excellent cleansing demonstrated superior detection of SSPs [IRR 1.66 (1.14, 2.40), P=0.008] and advanced adenomas [IRR 1.37 (1.09, 1.72), P=0.007] but not colon cancer [odds ratio 0.286 (0.083, 0.985), P=0.0474]. CONCLUSIONS ADR is not significantly different between the Adequate subcategories of Excellent and Good. However, Excellent cleansing is associated with superior detection of advanced adenomas and SSPs. If confirmed, achieving an Excellent preparation may improve colonoscopy performance in the proximal colon where SSPs primarily occur.
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Imler TD, Morea J, Kahi C, Sherer EA, Cardwell J, Johnson CS, Xu H, Ahnen D, Antaki F, Ashley C, Baffy G, Cho I, Dominitz J, Hou J, Korsten M, Nagar A, Promrat K, Robertson D, Saini S, Shergill A, Smalley W, Imperiale TF. Multi-center colonoscopy quality measurement utilizing natural language processing. Am J Gastroenterol 2015; 110:543-52. [PMID: 25756240 DOI: 10.1038/ajg.2015.51] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 01/02/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND An accurate system for tracking of colonoscopy quality and surveillance intervals could improve the effectiveness and cost-effectiveness of colorectal cancer (CRC) screening and surveillance. The purpose of this study was to create and test such a system across multiple institutions utilizing natural language processing (NLP). METHODS From 42,569 colonoscopies with pathology records from 13 centers, we randomly sampled 750 paired reports. We trained (n=250) and tested (n=500) an NLP-based program with 19 measurements that encompass colonoscopy quality measures and surveillance interval determination, using blinded, paired, annotated expert manual review as the reference standard. The remaining 41,819 nonannotated documents were processed through the NLP system without manual review to assess performance consistency. The primary outcome was system accuracy across the 19 measures. RESULTS A total of 176 (23.5%) documents with 252 (1.8%) discrepant content points resulted from paired annotation. Error rate within the 500 test documents was 31.2% for NLP and 25.4% for the paired annotators (P=0.001). At the content point level within the test set, the error rate was 3.5% for NLP and 1.9% for the paired annotators (P=0.04). When eight vaguely worded documents were removed, 125 of 492 (25.4%) were incorrect by NLP and 104 of 492 (21.1%) by the initial annotator (P=0.07). Rates of pathologic findings calculated from NLP were similar to those calculated by annotation for the majority of measurements. Test set accuracy was 99.6% for CRC, 95% for advanced adenoma, 94.6% for nonadvanced adenoma, 99.8% for advanced sessile serrated polyps, 99.2% for nonadvanced sessile serrated polyps, 96.8% for large hyperplastic polyps, and 96.0% for small hyperplastic polyps. Lesion location showed high accuracy (87.0-99.8%). Accuracy for number of adenomas was 92%. CONCLUSIONS NLP can accurately report adenoma detection rate and the components for determining guideline-adherent colonoscopy surveillance intervals across multiple sites that utilize different methods for reporting colonoscopy findings.
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Affiliation(s)
- Timothy D Imler
- 1] Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA [2] Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA [3] Department of Biomedical Informatics, Regenstrief Institute, LLC, Indianapolis, Indiana, USA
| | - Justin Morea
- 1] Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA [2] Department of Biomedical Informatics, Regenstrief Institute, LLC, Indianapolis, Indiana, USA
| | - Charles Kahi
- 1] Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA [2] Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA [3] Center of Innovation, Health Services Research and Development, Richard L, Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | | | - Jon Cardwell
- Center of Innovation, Health Services Research and Development, Richard L, Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Cynthia S Johnson
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Huiping Xu
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dennis Ahnen
- Division of Gastroenterology, University of Colorado, Denver, Colorado, USA
| | - Fadi Antaki
- Division of Gastroenterology, Wayne State University, Detroit, Michigan, USA
| | - Christopher Ashley
- Division of Gastroenterology, Albany Medical College, Albany, New York, USA
| | - Gyorgy Baffy
- Department of Medicine, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Ilseung Cho
- Division of Gastroenterology, New York University School of Medicine, New York, New York, USA
| | - Jason Dominitz
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jason Hou
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA
| | - Mark Korsten
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Bronx, New York, USA
| | - Anil Nagar
- Division of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Kittichai Promrat
- Division of Gastroenterology, Brown Medical School, Providence, Rhode Island, USA
| | - Douglas Robertson
- Division of Gastroenterology, The Dartmouth Institute, Lebanon, New Hampshire, USA
| | - Sameer Saini
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Amandeep Shergill
- Division of Gastroenterology, University of California at San Francisco, San Francisco, California, USA
| | - Walter Smalley
- Division of Gastroenterology, Vanderbilt University, Nashville, Tennessee, USA
| | - Thomas F Imperiale
- 1] Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA [2] Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA [3] Center of Innovation, Health Services Research and Development, Richard L, Roudebush VA Medical Center, Indianapolis, Indiana, USA [4] Health Services Research, Regenstrief Institute, Indianapolis, Indiana, USA
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Nusrat S, Mahmood S, Bitar H, Tierney WM, Bielefeldt K, Madhoun MF. The impact of chronic opioid use on colonoscopy outcomes. Dig Dis Sci 2015; 60:1016-23. [PMID: 25822037 DOI: 10.1007/s10620-015-3639-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2014] [Accepted: 03/20/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Endoscopic procedures are frequently performed on patients chronically on opioids, raising concerns about the safety and efficacy of conventional sedation. AIMS We hypothesized that chronic opioid use is associated with longer procedure times, higher dosages of sedation medications, and an increase in adverse effects. METHODS This is a retrospective review from June 2012 to June 2013. Patients on chronic opioids (opioids use ≥ 12 weeks) were compared to randomly selected patients matched for age, race, and sex. Multivariate regression analysis was performed to identify factors that were independently predictive of longer procedure times. RESULTS Patients on chronic opioids required higher doses of fentanyl (122.0 ± 45.3 vs. 105.8 ± 47.2 µg; P < 0.0001) and midazolam (5.3 ± 5.3 vs. 4.4 ± 2 mg; P = 0.0037) and were more likely to receive diphenhydramine (42.8 vs. 22.6 %; P < 0.001). The induction period (11.3 ± 8.8 vs. 7.5 ± 4.0 min), duration of procedure (39.1 ± 17.5 vs. 33.4 ± 14.1 min), and recovery times (38.7 ± 15.3 vs. 33.8 ± 12.1 min) were significantly longer for patients on chronic opioids. In the multivariate regression analysis, opioid use was an independent predictor of longer procedure duration (P < 0.05). Hypotensive episodes did not differ between groups (2.8 vs. 2.7 %; P = 0.8). However, patients on chronic opioids experienced more pain (13.4 vs. 5.9 %; P 0.001) and hypertensive episodes (8.1 vs. 2.8 %; P 0.002). CONCLUSION Patients on chronic opioids represent a high-risk population with longer procedural times and more discomfort, despite higher dosages of sedative agents. Prospective studies are required to define the risks and benefits of more costly alternative sedation strategies for patients on chronic opioids.
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Affiliation(s)
- Salman Nusrat
- Section of Digestive Diseases, Department of Internal Medicine, University of Oklahoma Health Sciences Center, 920 Stanton Young Blvd. WP 1345, Oklahoma City, OK, 73104, USA,
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Abstract
Adenoma detection rate (ADR) has emerged as a key quality metric for colonoscopy. Despite limitations, its major strength is based on its proven correlation with interval colorectal cancer. This has prompted extensive efforts to identify factors and interventions that improve ADR. Potentially modifiable factors that may influence ADR can be patient related (eg, bowel preparation), endoscopist related (eg, withdrawal time, quality of mucosal inspection, additional observers), or procedure related (eg, water infusion, additional examination of right colon, change in position, antispasmodics, colonoscopic equipment, and accessories). Providing endoscopists with educational material and/or feedback also seems to improve ADR.
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Predicting inadequate bowel preparation for colonoscopy in participants receiving split-dose bowel preparation: development and validation of a prediction score. Gastrointest Endosc 2015; 81:665-72. [PMID: 25600879 DOI: 10.1016/j.gie.2014.09.066] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2014] [Accepted: 09/29/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adequate bowel preparation is important for optimal colonoscopy. It is important to identify patients at risk for inadequate bowel preparation because this allows taking precautions in this specific group. OBJECTIVE To develop a prediction score to identify patients at risk for inadequate bowel preparation who may benefit from an intensified bowel cleansing regimen. DESIGN Patient and colonoscopy data were prospectively collected, whereas clinical data were retrospectively collected for a total of 1996 colonoscopies in participants who received split-dose bowel preparation. Multivariate logistic regression analyses were conducted in a random two-thirds of the cohort to develop a prediction model. Validation and evaluation of the discriminative power of the prediction model were performed within the remaining one-third of the cohort. SETTING Four centers, including one academic and three medium-to-large size nonacademic centers. PATIENTS Consecutive colonoscopies in November and December 2012. Mean age was 57.3 ± 15.9 years, 45.8% were male and indications for colonoscopy were screening and/or surveillance (27%), abdominal symptoms and/or blood loss and/or anemia (60%), inflammatory bowel disease (9%), and others (4%). INTERVENTIONS Colonoscopy. MAIN OUTCOME MEASUREMENTS Inadequate bowel preparation defined as Boston Bowel Preparation Scale score <6. RESULTS A total of 1331 colonoscopies were included in the development cohort, of which 172 (12.9%) had an inadequate bowel preparation. Independent factors included in the prediction model were American Society of Anesthesiologists Physical Status Classification System score ≥3, use of tricyclic antidepressants, use of opioids, diabetes, chronic constipation, history of abdominal and/or pelvic surgery, history of inadequate bowel preparation, and current hospitalization. The discriminative ability of the scale was good, with an area under the curve of 0.77 in the validation cohort. LIMITATIONS Study design partially retrospective, no data on patient compliance. CONCLUSION We developed a validated, easy-to-use prediction scale that can be used to identify subjects with an increased risk of inadequate bowel preparation with good accuracy.
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Calderwood AH, Thompson K, Schroy PC, Lieberman DA, Jacobson BC. Good is better than excellent: bowel preparation quality and adenoma detection rates. Gastrointest Endosc 2015; 81:691-699.e1. [PMID: 25708756 PMCID: PMC4339796 DOI: 10.1016/j.gie.2014.10.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 10/24/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inadequate bowel cleansing is associated with missed lesions, yet whether polyp and adenoma detection rates (PDR, ADR) increase at the highest levels of bowel cleanliness is unknown. OBJECTIVE To evaluate the association between bowel preparation quality by using the Boston Bowel Preparation Scale (BBPS) and PDR and ADR among colonoscopies with adequate preparation. DESIGN Cross-sectional analysis. SETTING Boston Medical Center (BMC) and the Clinical Outcomes Research Initiative (CORI). PATIENTS Average-risk ambulatory patients attending screening colonoscopy with adequate bowel preparation defined as BBPS score ≥6. INTERVENTIONS Colonoscopy. MAIN OUTCOME MEASUREMENTS PDR and ADR stratified by BBPS score. RESULTS Among the 3713 colonoscopies at BMC performed by 19 endoscopists, the PDR, ADR, and advanced ADR were 49.8%, 37.7%, and 6.0%, respectively. Among the 5532 colonoscopies in CORI performed by 85 endoscopists at 41 different sites, the PDR was 44.5%, and the PDR for polyps >9 mm (surrogate for advanced ADR) was 6.2%. The PDR associated with total BBPS scores of 6, 7, and 8 were higher than those associated with a BBPS score of 9 at BMC (BBPS 6, 51%; BBPS 7, 53%; BBPS 8, 52% vs BBPS 9, 46%; P = .002) and CORI (BBPS 6, 51%; BBPS 7, 48%; BBPS 8, 45% vs BBPS 9, 40%; P < .0001). This trend persisted after we adjusted for age, sex, and race and/or ethnicity and was observed for ADR and advanced ADR. PDR was higher among good compared with excellent preparations at BMC (odds ratio [OR] 1.3; 95% confidence interval [CI], 1.0-1.5) and CORI (OR 4.7; 95% CI, 3.1-7.1). LIMITATIONS Retrospective study. CONCLUSION The PDR and ADR decreased at the highest levels of bowel cleanliness. Endoscopists finding a pristine bowel preparation should avoid a sense of overconfidence for polyp detection during the inspection phase of screening colonoscopy and still perform a careful evaluation for polyps. Furthermore, endoscopists expending additional effort to maximize cleansing of the bowel should never sacrifice on their inspection technique or inspection time.
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Affiliation(s)
| | | | - Paul C. Schroy
- Section of Gastroenterology, Boston Medical Center, Boston, MA
| | - David A. Lieberman
- Division of Gastroenterology, Oregon Health & Science University, Portland, OR
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Zhao ZY, Gao YJY, Li BR, Shan YQ, Yan FH, Wang H, Lou Z, Fu CG, Yu ED. Rate and reasons for colonoscopic cecal intubation failure in an average risk population of colorectal cancer. Shijie Huaren Xiaohua Zazhi 2015; 23:1011-1016. [DOI: 10.11569/wcjd.v23.i6.1011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To get the knowledge regarding the rate of colonoscopic cecal intubation failure in an average risk population of colorectal cancer and analyze the reasons for failed intubation.
METHODS: A retrospective analysis was performed of the data for patients who underwent colonoscopy at Changhai Hospital from January 2008 to September 2010. Average risk patients were selected according to their indications and divided into either a successful intubation group or a failed intubation group according to whether cecal intubation was achieved. Total cecal intubation rate (CIR) was calculated. The t test and χ2 test were used to compare age, gender composition, bowel preparation status and polyp detection rate (PDR) between the two groups.
RESULTS: A total of 10164 subjects received colonoscopy, of which 613 (6.0%) did not complete the colonic examination. Compared with the success group, the failure group had greater mean age, poorer bowel preparation and higher PDR (P < 0.05), although gender composition was similar. The main reasons for intubation failure was stricture due to occupying lesions, followed by poor bowel preparation. A total of 253 (41.27%) cases of infiltrative cancer were found in the failure group.
CONCLUSION: Advanced age, poor bowel preparation and suffering from infiltrative cancer are associated with failed cecal intubation. The detection rate of advanced colorectal cancer is high in the Chinese average risk populations.
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Anderson JC, Butterly LF. Colonoscopy: quality indicators. Clin Transl Gastroenterol 2015; 6:e77. [PMID: 25716302 PMCID: PMC4418496 DOI: 10.1038/ctg.2015.5] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 01/26/2015] [Indexed: 02/06/2023] Open
Abstract
Effective endoscopic screening for colorectal cancer (CRC), one of the few preventable cancers, is dependent on the adequate detection and removal of potentially precancerous lesions. However, observed variation in colonoscopy performance in practice and outcomes has highlighted the need for consistent quality measures. Quality indicators or measures are tools that help to quantify health-care processes and can aid in providing high-quality health care. The primary colonoscopy quality indicator is the adenoma detection rate (ADR), which is defined as the proportion of an endoscopist's screening colonoscopies in which one or more adenomas have been detected. The risk of post-colonoscopy CRC is inversely correlated with an endoscopist's ADR. However, ADR is dependent on other quality measures, including cecal intubation rates, withdrawal times, and quality of bowel preparation. Achieving suggested benchmarks for these other quality measures will aid the endoscopist in achieving the recently updated ADR benchmark of 25% in their practice. In addition, beyond ensuring adequate ADRs, endoscopists should have high compliance rates with guideline-recommended and evidence-based screening and surveillance intervals. Compliance with quality measures will ensure effective and safe CRC prevention and better patient outcomes.
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Affiliation(s)
- Joseph C Anderson
- Department of Veterans Affairs Medical Center, White River Junction, VT and The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Lynn F Butterly
- 1] Section of Gastroenterology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA [2] The Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Rai T, Navaneethan U, Gohel T, Podugu A, Thota PN, Kiran RP, Lopez R, Sanaka MR. Effect of quality of bowel preparation on quality indicators of adenoma detection rates and colonoscopy completion rates. Gastroenterol Rep (Oxf) 2015; 4:148-53. [PMID: 25680361 PMCID: PMC4863185 DOI: 10.1093/gastro/gov002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2014] [Accepted: 01/09/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND AIM Adequate bowel preparation is important for safe and effective colonoscopy. Quality indicators (QI) for colonoscopy include achieving at least 95% completion rate and an adenoma detection rate (ADR) of at least 25% in average-risk men and 15% in average-risk women aged over 50. Our aim was to investigate the impact of bowel preparation on ADR and colonoscopy completion rates. METHODS This retrospective cohort study included patients who underwent colonoscopy between January 2008 and December 2009. The main outcome measurements were ADR and colonoscopy completion rates to the cecum. RESULTS A total of 2519 patients was included; 1030 (41.0%) had excellent preparation, 1145 (45.5%) good-, 240 (9.5%) fair-, and 104 (4.1%) poor preparation. Colonoscopy completion rates were significantly lower in patients with poor or fair preparation (72.1% and 75.4%, respectively) than in those with good and excellent preparation (99.7% and 99.9%, respectively; P < 0.001), and significantly lower than the QI of 95% (P < 0.001). ADR in men and women combined was similar in all four grades of preparation (excellent, good, fair and poor) at 24.2% vs. 26.8% vs. 32.1% vs. 22.1%, respectively; P = 0.06. All the groups had ADR above the QI (25% for men and 15% for women) with evidence of significantly higher ADR in the women with excellent or good preparation and in men with excellent, good or fair preparation. On multivariate analysis, male gender was significantly associated with increased ADR (P < 0.001), while the quality of bowel preparation did not influence ADR. CONCLUSIONS Patients with fair and poor standards of preparation have significantly lower colonoscopy completion rates than those with excellent and good preparation. However, there was no difference in ADR between the different grades of preparation.
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Affiliation(s)
- Tarun Rai
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, OH, USA
| | | | - Tushar Gohel
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Amareshwar Podugu
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, OH, USA
| | | | - Ravi P Kiran
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, OH, USA
| | - Rocio Lopez
- Digestive Disease Institute, The Cleveland Clinic, Cleveland, OH, USA
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Clark BT, Rustagi T, Laine L. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection rate. Am J Gastroenterol 2014; 109:1714-23; quiz 1724. [PMID: 25135006 PMCID: PMC4423726 DOI: 10.1038/ajg.2014.232] [Citation(s) in RCA: 178] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 06/03/2014] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Current guidelines recommend early repeat colonoscopy when bowel preparation quality is inadequate, defined as inability to detect polyps >5 mm, but no data link specific bowel preparation categories or scores to this definition. Nevertheless, most physicians use a shortened screening/surveillance interval in patients with intermediate-quality preparation. We determined whether different levels of bowel preparation quality are associated with differences in adenoma detection rates (ADRs: proportion of colonoscopies with ≥1 adenoma) to help guide decisions regarding early repeat colonoscopy-with primary focus on intermediate-quality preparation. METHODS MEDLINE and Embase were searched for studies with adenoma or polyp detection rate stratified by bowel preparation quality. Preparation quality definitions were standardized on the basis of Aronchick definitions (excellent/good/fair/poor/insufficient), and primary analyses of ADR trichotomized bowel preparation quality: high quality (excellent/good), intermediate quality (fair), and low quality (poor/insufficient). Dichotomized analyses of adequate (excellent/good/fair) vs. inadequate (poor/insufficient) were also performed. RESULTS Eleven studies met the inclusion criteria. The primary analysis, ADR with intermediate- vs. high-quality preparation, showed an odds ratio (OR) of 0.94 (0.80-1.10) and absolute risk difference of -1% (-3%, 2%). ADRs were significantly higher with both intermediate-quality and high-quality preparation vs. low-quality preparation: OR=1.39 (1.08-1.79) and 1.41 (1.21-1.64), with absolute risk increases of 5% for both. ADR and advanced ADR were significantly higher with adequate vs. inadequate preparation: OR=1.30 (1.19-1.42) and 1.30 (1.02-1.67). Studies did not report other relevant outcomes such as total adenomas per colonoscopy. CONCLUSIONS ADR is not significantly different with intermediate-quality vs. high-quality bowel preparation. Our results confirm the need for early repeat colonoscopy with low-quality bowel preparation, but suggest that patients with intermediate/fair preparation quality may be followed up at standard guideline-recommended surveillance intervals without significantly affecting quality as measured by ADR.
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Affiliation(s)
- Brian T. Clark
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tarun Rustagi
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Loren Laine
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA,VA Connecticut Healthcare System, West Haven, Connecticut, USA
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Johnson DA, Barkun AN, Cohen LB, Dominitz JA, Kaltenbach T, Martel M, Robertson DJ, Boland CR, Giardello FM, Lieberman DA, Levin TR, Rex DK. Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US multi-society task force on colorectal cancer. Gastroenterology 2014; 147:903-24. [PMID: 25239068 DOI: 10.1053/j.gastro.2014.07.002] [Citation(s) in RCA: 265] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | - Alan N Barkun
- McGill University Health Center, McGill University, Montreal, Canada
| | - Larry B Cohen
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jason A Dominitz
- VA Puget Sound Health Care System and University of Washington, Seattle, Washington
| | - Tonya Kaltenbach
- Veterans Affairs Palo Alto, Stanford University School of Medicine, Palo Alto, California
| | - Myriam Martel
- McGill University Health Center, McGill University, Montreal, Canada
| | - Douglas J Robertson
- VA Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, White River Junction, Vermont
| | | | | | | | | | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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75
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Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2014; 109 Suppl 2:S39-59. [PMID: 25223578 DOI: 10.1038/ajg.2014.272] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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76
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Optimizing adequacy of bowel cleansing for colonoscopy: recommendations from the U.S. multi-society task force on colorectal cancer. Gastrointest Endosc 2014; 80:543-562. [PMID: 25220509 DOI: 10.1016/j.gie.2014.08.002] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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77
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Anderson JC, Butterly L, Robinson CM, Goodrich M, Weiss JE. Impact of fair bowel preparation quality on adenoma and serrated polyp detection: data from the New Hampshire colonoscopy registry by using a standardized preparation-quality rating. Gastrointest Endosc 2014; 80:463-70. [PMID: 24818550 PMCID: PMC4134990 DOI: 10.1016/j.gie.2014.03.021] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 03/15/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The effect of colon preparation quality on adenoma detection rates (ADRs) is unclear, partly because of lack of uniform colon preparation ratings in prior studies. The New Hampshire Colonoscopy Registry collects detailed data from colonoscopies statewide, by using a uniform preparation quality scale after the endoscopist has cleaned the mucosa. OBJECTIVE To compare the overall and proximal ADR and serrated polyp detection rates (SDR) in colonoscopies with differing levels of colon preparation quality. DESIGN Cross-sectional. SETTING New Hampshire statewide registry. PATIENTS Patients undergoing colonoscopy. INTERVENTIONS We examined colon preparation quality for 13,022 colonoscopies, graded by using specific descriptions provided to endoscopists. ADR and SDR are the number of colonoscopies with at least 1 adenoma or serrated polyp (excluding those in the rectum and/or sigmoid colon) detected divided by the total number of colonoscopies, for the preparation categories: optimal (excellent and/or good), fair, and poor. MAIN OUTCOME MEASUREMENTS Overall/proximal ADR/SDR. RESULTS The overall detection rates in examinations with fair colon preparation quality (SDR 8.9%; 95% confidence interval [CI], 7.4-10.7, ADR 27.1%; 95% CI, 24.6-30.0) were similar to rates observed in colonoscopies with optimal preparation quality (SDR 8.8%; 95% CI, 8.3-9.4, ADR 26.3%; 95% CI, 25.6-27.2). This finding also was observed for rates in the proximal colon. A logistic regression model (including withdrawal time) found that proximal ADR was statistically lower in the poor preparation category (odds ratio 0.45; 95% CI, 0.24-0.84; P < .01) than in adequately prepared colons. LIMITATIONS Homogeneous population. CONCLUSION In our sample, there was no significant difference in overall or proximal ADR or SDR between colonoscopies with fair versus optimal colon preparation quality. Poor colon preparation quality may reduce the proximal ADR.
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Affiliation(s)
- Joseph C. Anderson
- Department of Veterans Affairs Medical Center, White River Junction, VT and The Geisel School of Medicine at Dartmouth, Hanover NH
| | - Lynn Butterly
- Dartmouth Hitchcock Medical Center, Section of Gastroenterology, Lebanon, NH,The Geisel School of Medicine at Dartmouth, Department of Community and Family Medicine, Hanover, NH
| | - Christina M. Robinson
- The Geisel School of Medicine at Dartmouth, Department of Community and Family Medicine, Hanover, NH
| | - Martha Goodrich
- The Geisel School of Medicine at Dartmouth, Department of Community and Family Medicine, Hanover, NH
| | - Julia E. Weiss
- The Geisel School of Medicine at Dartmouth, Department of Community and Family Medicine, Hanover, NH
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78
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Imperiale TF, Juluri R, Sherer EA, Glowinski EA, Johnson CS, Morelli MS. A risk index for advanced neoplasia on the second surveillance colonoscopy in patients with previous adenomatous polyps. Gastrointest Endosc 2014; 80:471-8. [PMID: 24890416 DOI: 10.1016/j.gie.2014.03.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/24/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Predicting the risk of advanced colorectal neoplasia on the second surveillance colonoscopy could help tailor surveillance. OBJECTIVE To derive and validate a risk index for advanced neoplasia on the second surveillance colonoscopy. DESIGN Retrospective cohort. SETTING Single-specialty practice; Veterans Affairs Medical Center. PATIENTS A total of 965 patients with baseline adenomatous polyps, 2 surveillance colonoscopies, and no reported family history of colorectal cancer; validation cohort of 372. INTERVENTIONS Multivariable logistic regression including demographics and previous colonoscopy results; derivation and validation of a risk index. MAIN OUTCOME MEASUREMENTS Advanced adenoma (≥1 cm in size, villous histology, or high-grade dysplasia) on the second surveillance colonoscopy. RESULTS Mean age was 57.8 ± 9.8 years, 62% were men, and 36% had an advanced adenoma on the index colonoscopy. Associated with advanced adenoma on the second surveillance colonoscopy were age at index colonoscopy (scored 0 for younger than 55 years of age, 1 for 55-59 years of age, 2 for 60-64 years of age, and 3 for older than 65 years of age) and previous findings (non-neoplastic, nonadvanced, advanced [scored 0, 1, and 2, respectively]) on index colonoscopy and the first surveillance colonoscopy, with scores ranging from 1 to 7. Risks of advanced adenoma on the second surveillance colonoscopy with scores of 5 or less and more than 5 were 4.8% (95% confidence interval, 3.5%-6.4%) and 14.9% (95% confidence interval, 7.4%-25.7%), respectively, comprising 93% and 7%, respectively, of the cohort. Corresponding results in the validation cohort were 5.6% and 19.2%, respectively, comprising 86.1% and 13.9%, respectively, of the cohort. LIMITATIONS Retrospective study with potential for selection bias. CONCLUSION This index stratifies the risk of advanced adenoma on the second surveillance colonoscopy. If validated independently, it may be useful for tailoring surveillance.
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Affiliation(s)
- Thomas F Imperiale
- Division of Gastroenterology and Hepatology, Department of Medicine, Indianapolis University School of Medicine, Indianapolis, Indiana, USA; Regenstrief Institute, Inc, Indianapolis, Indiana, USA; Center of Excellence for Implementation of Evidence-based Practice, Roudebush VA Medical Center, Indianapolis, Indiana, USA
| | - Ravi Juluri
- Division of Gastroenterology and Hepatology, Department of Medicine, Indianapolis University School of Medicine, Indianapolis, Indiana, USA
| | - Eric A Sherer
- Department of Chemical Engineering, Louisiana Tech University, Ruston, Louisiana, USA
| | - Elizabeth A Glowinski
- Indianapolis Gastroenterology Research Foundation, Indianapolis University School of Medicine, Indianapolis, Indiana, USA
| | - Cynthia S Johnson
- Department of Biostatistics, Indianapolis University School of Medicine, Indianapolis, Indiana, USA
| | - Michael S Morelli
- Indianapolis Gastroenterology Research Foundation, Indianapolis University School of Medicine, Indianapolis, Indiana, USA
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79
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Tutticci N, Bourke MJ. Advances in colonoscopy. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2014; 12:119-139. [PMID: 24615389 DOI: 10.1007/s11938-014-0009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Colonoscopy with polypectomy has been established as the major prevention and detection strategy for colorectal cancer for over a decade. Over this period advances in colonoscopic imaging, polyp detection, prediction of histopathology and polypectomy techniques have all been seen; however, the true magnitude of the limitations of colonoscopy has only recently been widely recognized. The rate and location of missed or interval cancers after complete colonoscopy appears to be influenced by the operator-dependency of colonoscopy and failure of conventional practices to detect and treat adenomatous, and possibly more importantly, non-adenomatous colorectal cancer precursors. Consequently, studies that expand our understanding of these factors and advances that aim to improve colonoscopy, polypectomy, and cancer protection are of critical importance.
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Affiliation(s)
- Nicholas Tutticci
- Department of Gastroenterology and Hepatology, Westmead Hospital, 106A/151 Hawkesbury Road, Westmead, NSW, 2145, Australia,
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80
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Landreneau SW, Di Palma JA. Colon cleansing for colonoscopy 2013: current status. Curr Gastroenterol Rep 2014; 15:341. [PMID: 23852571 DOI: 10.1007/s11894-013-0341-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Colonoscopy requires adequate bowel cleansing to be safe and effective. There are a variety of options available. This review will focus on highlighting new products, administration techniques emphasizing the value of split-dose and same-day regimens, safety, and options for inadequate cleansing.
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Affiliation(s)
- Stephen W Landreneau
- Section of Gastroenterology, Louisiana State University School of Medicine, 1542 Tulane Avenue, New Orleans, LA 70112, USA.
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81
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Abstract
Adequate bowel preparation is essential for optimal colonoscopy. Suboptimal bowel preparation occurs in 25% to 40% of cases and is associated with canceled procedures, prolonged procedure time, incomplete examination, increased cost, and missed pathology. There are several effective formulations for colon cleansing with a good safety profile. Split dosing should be implemented whenever possible in an effort to enhance tolerance and adherence, and improve mucosal visibility and overall quality of the examination. In this review, modern bowel preparations are discussed including their mechanism of action, mode of use, safety, and how to optimize outcomes.
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Affiliation(s)
- Ala I Sharara
- Division of Gastroenterology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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82
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Advanced adenoma detection rate is independent of nonadvanced adenoma detection rate. Am J Gastroenterol 2013; 108:1286-92. [PMID: 23711625 DOI: 10.1038/ajg.2013.149] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Accepted: 04/16/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Adenoma detection rate (ADR) is the accepted rate marker in colonoscopy quality. Advanced adenomas detected at index colonoscopy, while less frequent than nonadvanced adenomas, carry greater risk for future advanced neoplasia during surveillance colonoscopy. This study aimed to determine the effect of the colonoscopist and other factors on advanced ADR and to define the correlation of advanced and nonadvanced ADRs among colonoscopists. METHODS An observational study of a cohort of patients undergoing first-time colorectal cancer screening colonoscopy was conducted. Patient characteristics and colonoscopic findings were collected. Adenoma, advanced adenoma, and nonadvanced ADRs were calculated. Logistic regression was used to determine variable effects on advanced adenoma detection, and Spearman's rank-order correlation was used to evaluate the relationship between advanced and nonadvanced ADRs. RESULTS A total of 1,944 patients had first-time screening colonoscopies by 14 colonoscopists. All colonoscopists had adequate (>20%) ADRs. The variability in the colonoscopist ranges of detection was 22.22 to 44.66% for adenomas and 2.00 to 18.18% for advanced adenomas. Logistic regression showed that increasing patient age (odds ratio (OR) 1.16 per 5-year increase, 95% confidence interval (CI) 1.05-1.28, P=0.008) and male gender (OR 2.15, 95% CI 1.51-3.06, P<0.0001) were variables associated with advanced adenoma detection. Colonoscopists were significantly different in detecting advanced adenomas by random effects model (P=0.002), adjusting for patient age, gender, race, year of colonoscopy, gastroenterology fellow participation during colonoscopy, and nonadvanced adenomas. Spearman's rank-order correlation coefficient of -0.42 (95% CI -0.77 to 0.14, P=0.13) was not significant and showed no correlation between advanced and nonadvanced adenoma detection by the group of colonoscopists. CONCLUSIONS Advanced ADR is variable among colonoscopists with acceptable ADRs. Colonoscopists' advanced ADRs are independent of their nonadvanced ADRs.
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83
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Young PE, Womeldorph CM. Colonoscopy for colorectal cancer screening. J Cancer 2013; 4:217-26. [PMID: 23459594 PMCID: PMC3584835 DOI: 10.7150/jca.5829] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 02/08/2013] [Indexed: 02/07/2023] Open
Abstract
Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Many, if not most, cases arise from premalignant lesions (adenomas) which may be identified and removed prior to becoming frankly malignant. For over a decade, colonoscopy has been the preferred modality for both CRC screening and prevention in the US. Early reports suggested that colonoscopic screening imparted a 90% risk reduction for colorectal cancer. Subsequent studies showed that estimate to be overly optimistic. While still an outstanding CRC screening and detection tool, colonoscopy has several important limitations. Some of these limitations relate to the mechanics of the procedure such as the risk of colonic perforation, bleeding, adverse consequences of sedation, and the inability to detect all colonic polyps. Other limitations reflect issues with patient perception regarding colonoscopy which, at least in part, drive patient non-adherence to recommended testing. This review examines the literature to address several important issues. First, we analyze the effect of colonoscopy on CRC incidence and mortality. Second, we consider the patient-based, periprocedural, and intraprocedural factors which may limit colonoscopy as a screening modality. Third, we explore new techniques and technologies which may enhance the efficacy of colonoscopy for adenoma detection. Finally, we discuss the short and long-term future of colonoscopy for CRC screening and the factors which may affect this future.
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Affiliation(s)
- Patrick E Young
- 1. Fellowship Director, National Capital Consortium Gastroenterology Fellowship, Walter Reed National Military Medical Center, Bethesda, MD 20889, Associate Professor of Medicine, Uniformed Service University of Health Sciences, Bethesda, MD, USA
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