Selecting patients for flexible sigmoidoscopy. Determinants of incomplete depth of insertion

Randomized controlled trial of effects of a familiarization video and patient-controlled Entonox inhalation on patient stress levels and clinical efficacy of flexible sigmoidoscopy without analgesia or sedation for investigation of fresh rectal bleeding

BACKGROUND AND AIM

Flexible sigmoidoscopy (FS) without analgesia or sedation can be unpleasant for patients, resulting in unsatisfactory examinations. Prior familiarization videos (FVs) and intra-procedural Entonox inhalation have shown inconsistent effects. This study investigated their effects on undesirable participant factors (anxiety, stress, discomfort, pain, satisfaction, later unpleasant recall of procedure, and vasovagal reactions) and clinical effectiveness (extent of bowel seen, lesions detected, and procedural/recovery times).

METHODS

This cluster-randomized single-center study evaluated 138 participants undergoing FS. There were 46 controls, 49 given access to FV, and 43 access to both FV and self-administered Entonox. Participant factors were measured by self-administered questionnaires, independent nurse assessments, and heart rate variability (HRV) metrics.

RESULTS

Questionnaires showed that the FV group was slightly more tense and upset before FS, but knowledge of Entonox availability reduced anxiety. Nonlinear HRV metrics confirmed reduced intra-procedural stress response in the FV/Entonox group compared with controls and FV alone (P < 0.05). Entonox availability allowed more bowel to be examined (P < 0.001) but increased procedure time (P < 0.05), while FV alone had no effect. FV/Entonox participants reported 1 month after FS less discomfort during the procedure. Other comparisons showed no significant differences between treatment groups, although one HRV metric showed some potential to predict vasovagal reactions.

CONCLUSIONS

Entonox availability significantly improved clinical effectiveness and caused a slight reduction in undesirable participant factors. The FV alone did not reduce undesirable participant factors or improve clinical effectiveness. Nonlinear HRV metrics recorded effects in agreement with stress reduction and may be useful for prediction of vasovagal events in future studies.

Flexible sigmoidoscopy in the randomized prostate, lung, colorectal, and ovarian (PLCO) cancer screening trial: added yield from a second screening examination

BACKGROUND

Among randomized trials evaluating flexible sigmoidoscopy (FSG) for its effect on colorectal cancer mortality, only the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial screened its participants more than one time. We report outcomes from the PLCO screening FSG program and evaluate the increased yield produced by a second FSG.

METHODS

Participants were screened by 60-cm FSG in 10 regional screening centers at study entry and 3 or 5 years later, depending on the time of random assignment. Results from subsequent diagnostic intervention were tracked and recorded in a standardized fashion, and outcomes were compared according to sex and age. The protocol discouraged repeat FSG in persons with colorectal cancer or adenoma diagnosed after the initial FSG.

RESULTS

Of 77 447 enrollees, 67 073 (86.6%) had at least one FSG and 39 443 (50.9%) had two FSGs. Diagnostic intervention occurred in 74.9% after a positive first FSG and in 78.7% after a positive repeat FSG. The second FSG increased the screening yield by 32%: Colorectal cancer or advanced adenoma was detected in 37.8 per 1000 persons after first screening and in 49.8 per 1000 persons after all screenings. The second FSG increased the yield of cancer or advanced adenoma by 26% in women and by 34% in men. Of 223 subjects who received a diagnosis of colorectal carcinoma within 1 year of a positive FSG, 64.6% had stage I and 17.5% had stage II disease.

CONCLUSIONS

Repeat FSG increased the detection of colorectal cancer or advanced adenoma in women by one-fourth and in men by one-third. Screen-detected carcinomas were early stage (stage I or II) in greater than 80% of screened persons. Colorectal cancer mortality data from the PLCO, as the definitive endpoint, will follow in later publications.

Racial/ethnic patterns of uptake of colorectal screening, National Health Interview Survey 2000-2008

BACKGROUND

Lower access and/or utilization of colorectal screening are thought to be major contributors to the higher proportion of cancers among African Americans and Hispanics that are diagnosed at advanced stages of disease and the poorer outcomes observed among Hispanics and African Americans compared with non-Hispanic whites. We examine rates of initiation, utilization of specific screening modalities, adherence tocolorectal screening guidelines, and rate of uptake of colonoscopy among age-eligible African Americans, Hispanics and non-Hispanic whites.

METHODS

Data on 46145 African American, Hispanic, and non-Hispanic white survey respondents to the 2000 and 2005 Cancer Control Modules and the 2003 and 2008 Sample Adult Cores of the National Health Interview Surveys are examined in these analyses.

RESULTS

There was a modest increase in the initiation of colorectal screening among non-Hispanic whites, only and racial/ethnic disparities colorectal screening utilization persisted. The proportion of respondents for whom colonoscopy was the most complete guideline consistent exam received increased over time, while use of other modalities decreased among all racial/ethnic groups.

CONCLUSION

More effort must be made to increase colorectal screening among the U.S. population in general but particularly among racial/ethnic minority populations. With the increased attention on prevention, there is also a need to increase knowledge of the strengths and limitations of specific screening modalities and the need to receive screening exams within recommended time intervals among both patients and providers making screening recommendations.

Effect of hysterectomy on colonoscopy completion rate

BACKGROUND

Several studies show that colonoscopies are technically more difficult to perform in women than men, especially in women who have undergone abdominal and gynecological surgeries. A review of the literature indicates an increased rate of noncompletion of colonoscopies in most cases; however, no studies have investigated the procedural complication rate, sedation requirements and perception of pain in colonoscopies.

OBJECTIVE

To determine whether women who have undergone a previous hysterectomy have a higher noncompletion rate when undergoing a colonoscopy, and to assess whether there is a higher percentage of complications. Furthermore, the present study also aimed to ascertain whether these women required more sedation and whether their perception of pain is greater than that of women who did not undergo previous abdominal surgeries.

METHODS

The present study was a prospective cohort study of women, 45 to 80 years of age, who underwent colonoscopy (n=508). A total of 229 patients were eligible for the study; they completed a questionnaire, and were subsequently divided into control and hysterectomy groups. Gastroenterologists performed all procedures. After colonoscopy, the patient and endoscopist completed a pain perception questionnaire. Cecal intubation rates were also recorded.

RESULTS

No significant difference for cecal intubation rates were detected between the two groups (95.7% and 98.7% in hysterectomy and control groups, respectively; P=0.176). The crude OR for the success rate was 0.29 (95% CI 0.05 to 1.90). There was no significant difference between groups regarding sedation or the type of colonoscope. No correlation between the gastroenterologists' evaluation of pain and patients' pain was observed.

CONCLUSION

Hysterectomy did not significantly diminish the cecal intubation rate, and there was no detectable difference in pain perception or sedative dose. Colonoscopy remains an excellent screening and diagnostic tool for all women.

"Scoping-around" a sigmoidorectal intussusception: a pitfall of flexible sigmoidoscopy

A 66-year-old woman presented with 3-month history of progressive constipation and occasional bright red per-rectal bleeding. An urgent flexible sigmoidoscopy (FS) showed an abnormal lesion within the anal canal and biopsy showed tubulovillous adenoma with low-grade dysplasia. She mentioned "no" response to a preparatory enema given before FS. The patient presented 4 days after FS with absolute constipation and passing a "jelly-like" substance since the procedure. A large soft tissue lump with "currant jelly" mucus discharge was noted on per-rectal examination. An abdominal x ray was suggestive of distal large bowel obstruction and a water-soluble contrast enema suggested sigmoidorectal intussusception. The intussusception was irreducible with rigid sigmoidocopy and therefore the patient underwent sigmoid resection and Hartmann's procedure, which showed a distal sigmoid polyp as a lead point for the intussusception. Retrospectively looking into the case, the intussusception was present during FS, but was scoped-around and therefore lesion was considered to be in the anal canal.

Factors related to incomplete flexible sigmoidoscopy among adult Chinese in Taiwan

BACKGROUND

Sigmoidoscopy is effective in colorectal cancer screening, but incomplete examinations may overlook colonic pathologies and delay diagnosis. This study aimed to explore risk factors for incomplete insertions of flexible sigmoidoscopy among Taiwanese.

METHODS

Healthy adults participating in health check-up in a tertiary medical center were invited for study. Subjects were recruited when they had fully consented and agreed to participate. Factors related to incomplete insertions of flexible sigmoidoscopy were evaluated and multivariate logistic regression was used to determine independent risk factors. A predictive model was generated by the risk factors identified.

RESULTS

In total, 1,252 subjects (mean age, 53.9 13.1 years; age range, 2187 years; male/female,780/472) were enrolled, and 278 (22.2%) incomplete insertions were recorded. Multivariate analysis showed that female gender (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.562.73; p < 0.001), age >or= 60 years (OR, 1.68; 95% CI, 1.262.23; p < 0.001), inadequate bowel preparation (OR, 1.66; 95% CI, 1.212.16; p = 0.001), history of constipation (OR, 2.43; 95% CI, 1.045.69; p = 0.042), and body mass index (BMI) < 25 kg/m2 (OR, 1.41; 95% CI, 1.051.89; p = 0.024) were all independent risk factors. The probability of incomplete insertion was significantly associated with the sum of the aforementioned risk factors (p < 0.001). Compared with subjects with no risk factors, the risks of incomplete insertions increased significantly among subjects bearing 1 risk factor (OR, 2.57; 95% CI, 1.474.49; p = 0.001), 2 risk factors (OR, 4.41; 95% CI, 2.527.39; p < 0.001), 3 risk factors (OR, 6.40; 95% CI, 3.5611.52; p < 0.001) and >or= 4 risk factors (OR, 10.00; 95% CI, 3.8925.70; p < 0.001).

CONCLUSION

Female sex, age >or= 60 years, BMI < 25 kg/m2, history of constipation, and inadequate bowel preparation were independent risk factors for incomplete insertion of flexible sigmoidoscopy. Subjects with multiple risk factors may consider alternative modalities for colonic examination.

Extended flexible sigmoidoscopy performed by colonoscopists for colorectal cancer screening: a pilot study

BACKGROUND

Caecal intubation can be achieved by extended flexible sigmoidoscopy in 32% of patients.

AIM

To assess the feasibility of extended flexible sigmoidoscopy performed by colonoscopists for colorectal cancer screening.

METHODS

We enrolled 41 patients referred for screening flexible sigmoidoscopy. After purging, examination was performed with a colonoscope. All patients completed sigmoidoscopy (success in meeting referral goal); 93% and 71% had examination to the transverse or ascending colon, and caecum, respectively. Overall yield and right-sided polyps was 56% and 27%, respectively. Caecal intubation and complete examination with polypectomy took 6.0 +/- 2.5 and 18.3 +/- 5.1 min, respectively; with no complications. Twelve patients requested colonoscope withdrawal because of discomfort. Although 46% reported moderate to severe discomfort, 39% and 36%, respectively, were definitely or probably willing to repeat flexible sigmoidoscopy.

RESULTS

Unsedated colonoscopy introduced as extended flexible sigmoidoscopy emphasizes the benefits of added yield rather than the negative image of withholding of discomfort relief. The patient can choose to accept the equivalent of an unsedated colonoscopy or reject the option based on perceived discomfort during extended flexible sigmoidoscopy performed by the colonoscopist.

CONCLUSION

Extended flexible sigmoidoscopy is a feasible option in carefully selected patients, fully prepared and by an experienced colonoscopist.

Outcomes among African-Americans and Caucasians in colon cancer adjuvant therapy trials: findings from the National Surgical Adjuvant Breast and Bowel Project

BACKGROUND

African-Americans generally have lower survival rates from colon cancer than Caucasian Americans. This disparity has been attributed to many sources, including diagnosis at later disease stage and other unfavorable disease features, inadequate treatment, and socioeconomic factors. The randomized clinical trial setting ensures similarity in disease stage and a uniform treatment plan between blacks and whites. In this study, we evaluated survival and related end points for African-American and Caucasian patients with colon cancer participating in randomized clinical trials of the National Surgical Adjuvant Breast and Bowel Project (NSABP) to determine whether outcomes were less favorable for African-Americans.

METHODS

The study included African-American (n = 663) or Caucasian (n = 5969) patients from five serially conducted, randomized clinical trials of the NSABP. We compared recurrence-free survival, disease-free survival (recurrence, new primary cancer, or death), and survival (death from any cause) between blacks and whites by using statistical modeling to account for differences in patient and disease characteristics between the groups. Statistical tests were two-sided.

RESULTS

Dukes' stage and number of positive lymph nodes were remarkably similar between African-American and Caucasian patients in each trial. Over all trials combined, an 8% (95% confidence interval [CI] = -6% to 25%; P =.27) excess risk of colon cancer recurrence that was not statistically significant was observed for blacks. A greater disparity in survival was seen, with blacks experiencing a statistically significant 21% (95% CI = 6%-37%; P =.004) greater risk of death. Treatment efficacy appeared similar between the groups.

CONCLUSIONS

While the overall survival prognosis was less favorable for African-Americans compared with Caucasians in these trials, other outcomes measured were considerably more similar than those seen in the population at large, suggesting that earlier detection and adjuvant therapy could appreciably improve colon cancer prognosis for African-Americans. Continued investigations into causes of the deficits noted are warranted.