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Song JH, Kim ER. Strategies to improve screening colonoscopy quality for the prevention of colorectal cancer. Korean J Intern Med 2024; 39:547-554. [PMID: 38247125 PMCID: PMC11236814 DOI: 10.3904/kjim.2023.334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/04/2023] [Accepted: 10/15/2023] [Indexed: 01/23/2024] Open
Abstract
The incidence and mortality of colorectal cancer (CRC) have decreased through regular screening colonoscopy, surveillance, and endoscopic treatment. However, CRC can still be diagnosed after negative colonoscopy. Such CRC is called interval CRC and accounts for 1.8-9.0% of all CRC cases. Most cases of interval CRC originate from missed lesions and incompletely resected lesions. Interval CRC can be minimized by improving the quality of colonoscopy. This has led to a growing interest in and demand for high-quality colonoscopy. It is important to reduce the risk of CRC and its associated mortality by improving the quality of colonoscopy. In this review article, we provide an overview of colonoscopy quality indicators, including bowel preparation adequacy, the cecal intubation rate, the adenoma detection rate, the colonoscopy withdrawal time, appropriate polypectomy, and complication of the procedure. Because colonoscopy is a highly endoscopist-dependent procedure, colonoscopists should be well-acquainted with quality indicators and strive to apply them in daily clinical practice for the prevention of CRC.
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Affiliation(s)
- Joo Hye Song
- Department of Medicine, Konkuk University Medical Center, Konkuk University School of Medicine, Seoul, Korea
| | - Eun Ran Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Anderson JC, Rex DK. Performing High-Quality, Safe, Cost-Effective, and Efficient Basic Colonoscopy in 2023: Advice From Two Experts. Am J Gastroenterol 2023; 118:1779-1786. [PMID: 37463252 DOI: 10.14309/ajg.0000000000002407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/05/2023] [Indexed: 07/20/2023]
Abstract
Based on published evidence and our expert experience, we provide recommendations to maximize the efficacy, safety, efficiency, and cost-effectiveness of routine colonoscopy. High-quality colonoscopy begins with colon preparation using a split or same-day dose and preferably a low-volume regimen for optimal patient tolerance and compliance. Successful cecal intubation can be achieved by choosing the correct colonoscope and using techniques to facilitate navigation through challenges such as severe angulations and redundant colons. Safety is a primary goal, and complications such as perforation and splenic rupture can be prevented by avoiding pushing through fixed resistance and avoiding loops in proximal colon. Furthermore, barotrauma can be avoided by converting to water filling only (no gas insufflation) in every patient with a narrowed, angulated sigmoid. Optimal polyp detection relies primarily on compulsive attention to inspection as manifested by adequate inspection time, vigorous probing of the spaces between haustral folds, washing and removing residual debris, and achieving full distention. Achieving minimum recommended adenoma detection rate thresholds (30% in men and 20% in women) is mandatory, and colonoscopists should aspire to adenoma detection rate approaching 50% in screening patients. Distal attachments can improve mucosal exposure and increase detection while shortening withdrawal times. Complete resection of polyps complements polyp detection in preventing colorectal cancer. Cold resection is the preferred method for all polyps < 10 mm. For effective cold resection, an adequate rim of normal tissue should be captured in the snare. Finally, cost-effective high-quality colonoscopy requires the procedure not be overused, as demonstrated by following updated United States Multi Society Task Force on Colorectal Cancer postpolypectomy surveillance recommendations.
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Affiliation(s)
- Joseph C Anderson
- Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
- Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA
- Division of Gastroenterology, Department of Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Douglas K Rex
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Al-Toma A, Oude Hergelink DM, Tenthof van Noorden J, Koornstra JJ. Prospective evaluation of the motorized spiral enteroscope for previous incomplete colonoscopy. Endosc Int Open 2022; 10:E1112-E1117. [PMID: 36238532 PMCID: PMC9552671 DOI: 10.1055/a-1869-2541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/30/2022] [Indexed: 11/23/2022] Open
Abstract
Background and study aims A significant percentage of colonoscopies remain incomplete because of failure to intubate the cecum. The motorized spiral enteroscope (MSE) technique, originally developed for deep small bowel enteroscopy, may be an effective alternative technique in cases of incomplete examination of abnormally long colons (dolichocolon). We prospectively evaluated the success rate of cecal intubation, safety and the therapeutic consequences of using MSE after incomplete conventional colonoscopy. Patients and methods A total of 36 consecutive patients with an indication for diagnostic and/or therapeutic colonoscopy were prospectively enrolled in this multicenter trial. All patients had undergone at least one incomplete colonoscopy attributed to abnormally long colons. Patients with incomplete colonoscopy due to stenosis were excluded. Results Twenty-two men and 14 women (median age 66 years, range 35-82) were enrolled. Median procedure time was 30 minutes (range 16-50). Cecal intubation rate was 100 % and median cecal intubation time was 10 minutes (range 4-30). Abnormalities, mostly neoplastic lesions, were detected in 23 of 36 patients, corresponding to a diagnostic yield of 64 %. All these findings were in the right side of the colon and had not been described by the antecedent incomplete coloscopy. No adverse events occurred. Conclusions In case of a difficult and long colon, MSE is safe and effective for diagnostic and therapeutic colonoscopy. It may provide an attractive solution to accomplish completeness of previous incomplete colonoscopies in these patients.
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Affiliation(s)
- Abdulbaqi Al-Toma
- Department of Gastroenterology and hepatology, St. Antonius hospital, Nieuwegein, the Netherlands
| | - Dorien M. Oude Hergelink
- Department of Gastroenterology & Hepatology, University Medical Centre Groningen, University of Groningen, The Netherlands
| | | | - Jan Jacob Koornstra
- Department of Gastroenterology & Hepatology, University Medical Centre Groningen, University of Groningen, The Netherlands
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Park SB, Cha JM. Quality indicators in colonoscopy: the chasm between ideal and reality. Clin Endosc 2022; 55:332-338. [PMID: 35656625 PMCID: PMC9178135 DOI: 10.5946/ce.2022.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 02/28/2022] [Indexed: 11/30/2022] Open
Abstract
Continuous measurement of quality indicators (QIs) should be a routine part of colonoscopy, as a wide variation still exists in the performance and quality levels of colonoscopy in Korea. Among the many QIs of colonoscopy, the adenoma detection rate, average withdrawal time, bowel preparation adequacy, and cecal intubation rate should be monitored in daily clinical practice to improve the quality of the procedure. The adenoma detection rate is the best indicator of the quality of colonoscopy; however, it has many limitations for universal use in daily practice. With the development of natural language processing, the adenoma detection rate is expected to become more effective and useful. It is important that colonoscopists do not strictly and mechanically maintain an average withdrawal time of 6 minutes but instead perform careful colonoscopy to maximally expose the colonic mucosa with a withdrawal time of at least 6 minutes. To achieve adequate bowel preparation, documentation of bowel preparation with the Boston Bowel Preparation Scale (BBPS) should be a routine part of colonoscopy. When colonoscopists routinely followed the bowel preparation protocols, ≥85% of outpatient screening colonoscopies had a BBPS score of ≥6. In addition, the cecal intubation rate should be ≥95% of all screening colonoscopies. The first step in improving colonoscopy quality in Korea is to apply these key performance measurements in clinical practice.
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Affiliation(s)
- Su Bee Park
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Myung Cha
- Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
- Correspondence: Jae Myung Cha Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea E-mail:
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Utano K, Nagata K, Honda T, Kato T, Lefor AK, Togashi K. Bowel habits and gender correlate with colon length measured by CT colonography. Jpn J Radiol 2022; 40:298-307. [PMID: 34633598 PMCID: PMC8891197 DOI: 10.1007/s11604-021-01204-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 09/23/2021] [Indexed: 12/26/2022]
Abstract
PURPOSE CT colonography enables three-dimensional measurement of colon length. However, previous studies using CT colonography have not examined the association with gender, age, physique, a history of laparotomy and bowel habits, all possible contributory factors to colon length. The aim of this study is to investigate factors associated with colon length. MATERIALS AND METHODS We conducted a post hoc analysis based on data obtained from a previous multi-center trial including 321 patients with positive fecal immunochemical tests who underwent CT colonography. Colon length was measured using a computer-generated center line and was divided at the iliac crest level into the distal and proximal colons. Bowel habits were classified into three groups: A-daily; B-once every 2 or 3 days; and C-less than once in 3 days. Statistical comparison was made using one-way ANOVA with Bonferroni's correction. RESULTS A total of 295 patients were analyzed. The entire colon length (cm, mean ± standard deviation) of individual patients was 150.3 ± 18.5 cm and ranged from 109.7 to 195.9 cm. The female colon was significantly longer than the male colon (154.3 ± 18.1 cm vs. 147.1 ± 18.3 cm; p = 0.022). Colon length showed trends associated with age (p = 0.18) and a history of laparotomy (p = 0.14). According to bowel habits, the entire colon measured 147.4 ± 17.9 in group A, 154.7 ± 18.5 in group B and 158.6 ± 18.3 in group C, and significant differences were observed for "A vs. C" (p = 0.002) and "A vs. B" (p = 0.014). In subgroup analysis by colon segment, the proximal colon trended similarly to the entire colon while there were no trends for the distal colon. CONCLUSIONS This study has clearly demonstrated that bowel habits and gender both correlate with the length of the entire colon measured by CT colonography, and in particular, the proximal colon. Using CT colonography, we measured the colon length in 295 patients. The entire colon length was 150.3 ± 18.5 cm on average. Females and constipated (less frequent defecation) patients have a significantly longer colon, and in particular, the proximal colon. Colon length showed trends associated with age and a history of laparotomy.
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Affiliation(s)
- Kenichi Utano
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi, Aizuwakamatsu, Fukushima, 969-3492, Japan
| | - Koichi Nagata
- Department of Gastroenterology, Fukushima Medical University, Fukushima, Japan
| | - Tetsuro Honda
- Department of Gastroenterology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Takashi Kato
- Department of Internal Medicine, Hokkaido Gastroenterology Hospital, Sapporo, Japan
| | | | - Kazutomo Togashi
- Department of Coloproctology, Aizu Medical Center, Fukushima Medical University, 21-2 Maeda, Tanisawa, Kawahigashi, Aizuwakamatsu, Fukushima, 969-3492, Japan.
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Abadir AP, Park N, Eng D, El Hage N, Sowa P, Samarasena J. Successful use of a novel dynamic rigidizing overtube in a patient with looping during colonoscopy. VideoGIE 2021; 6:236-238. [PMID: 34027258 PMCID: PMC8119879 DOI: 10.1016/j.vgie.2020.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Alexander Philip Abadir
- Division of Gastroenterology and Hepatology, University of California - Irvine, Irvine, California
| | - Nathan Park
- Division of Gastroenterology and Hepatology, University of California - Irvine, Irvine, California
| | - David Eng
- Division of Gastroenterology and Hepatology, University of California - Irvine, Irvine, California
| | - Nabil El Hage
- Division of Gastroenterology and Hepatology, University of California - Irvine, Irvine, California
| | - Piotr Sowa
- Division of Gastroenterology and Hepatology, University of California - Irvine, Irvine, California
| | - Jason Samarasena
- Division of Gastroenterology and Hepatology, University of California - Irvine, Irvine, California
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Impact of Tilt-Down Positioning Compared With Left Lateral Positioning on Ease of Colonoscope Insertion During Colonoscopy. J Clin Gastroenterol 2020; 54:558-560. [PMID: 32011402 DOI: 10.1097/mcg.0000000000001318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
GOALS The aim of this study was to evaluate the efficacy of tilt-down (TD) versus left lateral (LL) positioning in speed and ease of colonoscope insertion in women with risk factors for difficult colonoscopy. BACKGROUND Risk factors for difficult colonoscopy in women include pelvic surgery, diverticulosis, and thin body habitus. STUDY Female patients with body mass index (BMI) under 25, diverticulosis and history of pelvic surgery were randomized to TD or LL positioning. Five colonoscopists performed all studies at a single center. Time to splenic flexure and cecum, type and amount of medication administered, Boston Bowel Prep Score (BBPS), adverse events, and findings were recorded. The Mann-Whitney U test was used to evaluate the primary endpoint. RESULTS A total of 150 women were enrolled (81 TD, 69 LL). The mean age was 60.1 (SD 10.5) and the mean BMI was 23.9 (SD 3.5). In total 98 (65.3%) women had prior pelvic surgery, 94 (62.7%) had BMI <25 and 60 (40.0%) had diverticulosis. There was no statistically significant difference in time to the splenic flexure overall but insertion to the splenic flexure was significantly faster in the TD position as compared with the LL position in patients with diverticulosis (124 s for TD, 160 s for LL, P=0.022). In a linear regression analysis, lower BMI, diverticulosis and lower BBPS were significantly associated with a longer insertion time to the splenic flexure. There were no adverse events. CONCLUSION TD positioning represents a straightforward maneuver to facilitate advancement through the sigmoid colon and may be beneficial in women with diverticular disease.
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Parsa N, Vemulapalli KC, Rex DK. Performance of radiographic imaging after incomplete colonoscopy for nonmalignant causes in clinical practice. Gastrointest Endosc 2020; 91:1371-1377. [PMID: 32032619 DOI: 10.1016/j.gie.2020.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS CT colonography (CTC) or barium enema are commonly ordered to complete colorectal imaging after an incomplete colonoscopy. We evaluated the sensitivity of radiographic studies performed for this purpose in clinical practice outside clinical trials. METHODS Adult patients referred to an expert endoscopist for incomplete colonoscopy because of a redundant colon or a difficult sigmoid and who underwent previous radiographic imaging between July 2001 and July 2019 were identified. None of the patients had a malignant obstruction as the cause of incomplete colonoscopy. Data on polyp size, location, and pathology were obtained from colonoscopy and radiology reports. Polyps identified on imaging and colonoscopy were matched based on polyp size and location. RESULTS Among 769 patients referred for incomplete colonoscopy, we identified 65 with a radiographic examination performed within 36 months of colonoscopy at our center. Per-patient sensitivity for CTC was suboptimal (70%) and was very low for barium enema (26.7%). Per-polyp sensitivity for both CTC and barium enema was poor (23.8% and 7.6%). Quality of the examination did not seem to affect procedure sensitivity. CONCLUSIONS Radiographic imaging after incomplete colonoscopy for reasons other than malignant obstruction had poor sensitivity for polyps. Patients with incomplete colonoscopies should be considered for repeat colonoscopy by an expert.
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Affiliation(s)
- Nasim Parsa
- Division of Gastroenterology and Hepatology, University of Missouri, Columbia, Missouri, USA
| | - Krishna C Vemulapalli
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Douglas K Rex
- Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Girotra M, Sethi S, Barakat MT, Huang RJ, Friedland S, Ladabaum U, Banerjee S. When Experts Fail: Use of a Short Turning Radius Colonoscope Facilitates Successful Completion of Colonoscopy in Patients with Bowel Fixity. Dig Dis Sci 2020; 65:1429-1435. [PMID: 31630343 DOI: 10.1007/s10620-019-05882-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 10/09/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND Rates of incomplete colonoscopy in non-expert settings range up to 13%. Expert colonoscopists can complete ~ 95% colonoscopies when other endoscopists fail; however, a small number remain incomplete even in expert hands, typically due to bowel fixity. AIMS Pentax Retroview™ (EC-3490TLi) is a new slim colonoscope with a short turning radius (STR) and greater tip deflection (210°), which allows easy maneuverability across sharply angulated/fixed colonic bends. We evaluated the utility of this colonoscope for completing colonoscopies that fail even in the hands of expert colonoscopists. METHODS Retrospective chart review was performed, and main outcomes measured included cecal intubation rate, lesions detected, dosage of sedation used, and complications. RESULTS Using the STR colonoscope, complete colonoscopy to the cecum was possible in 34/37 patients (91.9%). No loss of lumen/blind advancement was necessary in any of the procedures. No adverse events occurred. Among the completed colonoscopies, 6/34 (17.6%) patients had adenomas, all proximal to the site of prior failure, including one advanced adenoma. All failures (n = 3, 8.1%) had a history of cancer surgeries, with peritoneal carcinomatosis/extensively fixed/frozen bowel (two patients) and an additional diverticular stricture with colo-vesical fistula (one patient). CONCLUSION STR colonoscope facilitates completion of a high proportion (91.9%) of colonoscopies that previously failed in expert hands. Its STR allows easy maneuverability across segments of sharp angulation with bowel fixity without need for blind advancement. The use of this colonoscope led to the detection of adenomas in 17.6% of patients, all proximal to the site of prior failed colonoscopy.
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Affiliation(s)
- Mohit Girotra
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC: 5244, Stanford, CA, 94305, USA
| | - Saurabh Sethi
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC: 5244, Stanford, CA, 94305, USA
| | - Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC: 5244, Stanford, CA, 94305, USA
| | - Robert J Huang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC: 5244, Stanford, CA, 94305, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC: 5244, Stanford, CA, 94305, USA
| | - Uri Ladabaum
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC: 5244, Stanford, CA, 94305, USA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC: 5244, Stanford, CA, 94305, USA.
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McCain JD, Stancampiano FF, Bouras EP, DeVault KR, Gilbert EL, Ryan T, Maillis A, Heckman MG, Diehl NN, Palmer WC. Creation of a score to predict risk of high conscious sedation requirements in patients undergoing endoscopy. Gastrointest Endosc 2020; 91:595-605.e3. [PMID: 31756314 DOI: 10.1016/j.gie.2019.11.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 11/03/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The administration of intravenous conscious sedation to patients undergoing GI endoscopy carries a risk of cardiopulmonary adverse events. Our study aim was to create a score that stratifies the risk of occurrence of either high-dose conscious sedation requirements or a failed procedure. METHODS Patients receiving endoscopy via endoscopist-directed conscious sedation were included. The primary outcome was occurrence of sedation failure, which was defined as one of the following: (1) high-dose sedation, (2) the need for benzodiazepine/narcotic reversal agents, (3) nurse-documented poor patient tolerance to the procedure, or (4) aborted procedure. High-dose sedation was defined as >10 mg of midazolam and/or >200 μg of fentanyl or the meperidine equivalent. Patients with sedation failure (n = 488) were matched to controls (n = 976) without a sedation failure by endoscopist and endoscopy date. RESULTS Significant associations with sedation failure were identified for age, sex, nonclonazepam benzodiazepine use, opioid use, and procedure type (EGD, colonoscopy, or both). Based on these 5 variables, we created the high conscious sedation requirements (HCSR) score, which predicted the risk of sedation failure with an area under the curve of 0.70. Compared with the patients with a risk score of 0, risk of a sedation failure was highest for patients with a score ≥3.5 (odds ratio, 17.31; P = 2 × 10-14). Estimated area under the curve of the HCSR score was 0.68 (95% confidence interval, 0.63-0.72) in a validation series of 250 cases and 250 controls. CONCLUSIONS The HCSR risk score, based on 5 key patient and procedure characteristics, can function as a useful tool for physicians when discussing sedation options with patients before endoscopy.
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Affiliation(s)
- Josiah D McCain
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Ernest P Bouras
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Kenneth R DeVault
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Emily L Gilbert
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Taylor Ryan
- CRISP Student Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Alex Maillis
- CRISP Student Program, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - William C Palmer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Shine R, Bui A, Burgess A. Quality indicators in colonoscopy: an evolving paradigm. ANZ J Surg 2020; 90:215-221. [PMID: 32086869 DOI: 10.1111/ans.15775] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 12/14/2019] [Accepted: 01/20/2020] [Indexed: 12/27/2022]
Abstract
The year 1969 marked a revolution in the diagnosis of colorectal cancer (CRC). It is when Dr Wolff developed the colonoscope and quickly realized its potential in both diagnosis and treatment of colonic neoplasms. Over the past 50 years there has been exponential increase in utilization of colonoscopy with over 1 million colonoscopies performed annually throughout Australasia. Endoscopic removal of pre-malignant lesions has been proven to reduce the incidence and mortality of colorectal. Although timing and frequency of surveillance colonoscopy plays a crucial role in risk reduction of CRC, this is dependent upon the findings of the index colonoscopy. The goal of screening colonoscopy is to detect CRC and identify and remove pre-malignant neoplasms that risk progression to CRC. With increasing uptake of bowel screening throughout Australasia, there is increasing pressure to ensure all endoscopists and endoscopy units perform at a universal high-quality. All too often high demand and constant delays compromise colonoscopy quality. Without clear and concise quality indicators with transparent measurement and audit, these flaws can quickly jeopardize screening goals and patient outcomes. This review aims to explore six key quality indicators and explore the evidence behind the current recommended standards. These key indicators include; rate of adequate bowel preparation, caecal intubation rate, adenoma detection rate, withdrawal time, complication rates and surveillance intervals.
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Affiliation(s)
- Rebecca Shine
- General Surgery, Royal Australasian College of Surgeons, Melbourne, Victoria, Australia
| | - Andrew Bui
- Colorectal Surgery, Austin Health, Melbourne, Victoria, Australia
| | - Adele Burgess
- Colorectal Surgery, Austin Health, Melbourne, Victoria, Australia
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12
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13
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Purchiaroni F, Conti S, Valerii G, Costamagna G, Riccioni ME. Use of enteroscope without the overtube in incomplete colonoscopies. Scand J Gastroenterol 2020; 55:100-104. [PMID: 31852356 DOI: 10.1080/00365521.2019.1703034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: Colonoscopy is the gold standard diagnostic method for colorectal cancer (CRC) screening. Despite the progress in the endoscopy technology field, a small percentage of colonoscopies is still incomplete. The reasons for that are mostly associated with anatomic features, such as fixed, angulated, long and loopy colon, intra-abdominal adherences and female gender. To overcome such difficulties, the usefulness of scopes different from conventional adult colonoscope (CF), such as paediatric colonoscope (PCF), gastroscope (GIF), single and double balloon enteroscope (SBE and DBE, respectively), has been shown in literature. Our retrospective study aims to evaluate the caecal intubation rate using a SBE without the overtube in patients who previously underwent an incomplete procedure with a different scope.Methods: Patients with a previous incomplete colonoscopy with CF, PCF or GIF were retrospectively enrolled through the analysis of a dedicated database. The enteroscope used was the Olympus Enteropro Single Balloon SiF-Q180 with no overtube. Complete colonoscopy was defined as successful caecal intubation.Results: SBE was used to scope 47 adult patients, mostly female, and it led to a complete procedure in 91% of them. The most frequent reason for an incomplete procedure even with the use of SBE was a fixed and angulated colon.Conclusions: Colonoscopy performed with SBE was safe and no adverse events during and/or after the procedure occurred. Our results suggest that SBE with no overtube is a useful and valid alternative to other type of scopes in difficult cases, especially those related to fixed/angulated colon and in female gender.
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Affiliation(s)
- Flaminia Purchiaroni
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Silvia Conti
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Valerii
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Elena Riccioni
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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Comparing adenoma and polyp miss rates for total underwater colonoscopy versus standard CO 2: a randomized controlled trial using a tandem colonoscopy approach. Gastrointest Endosc 2019; 89:591-598. [PMID: 30367879 DOI: 10.1016/j.gie.2018.09.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although water exchange may improve adenoma detection compared with CO2, it is unclear whether water is a better medium to fill the lumen during withdrawal and visualize the mucosa. Total underwater colonoscopy (TUC) involves the use of water exchange with the air valve off during insertion followed by the inspection of the mucosa under water. Our goal was to compare miss rates for TUC with standard CO2 for polyps and adenomas using a tandem colonoscopy design. METHODS We randomized participants to undergo tandem colonoscopies using TUC or CO2 first. In TUC, water exchange was performed during insertion, and withdrawal was performed under water. For the CO2 colonoscopy, both insertion and withdrawal were performed with CO2. The main outcomes were miss rates for polyps and adenomas for the first examination calculated as the number of additional polyps/adenomas detected during the second examination divided by the total number of polyps/adenomas detected for both examinations. Inspection times were calculated by subtracting the time for polypectomy, and care was taken to keep the times equal for both examinations. RESULTS A total of 121 participants were randomized with 61 having CO2 first. The overall miss rate for polyps was higher for the TUC-first group (81/237; 34%) compared with the CO2-first cohort (57/264; 22%) (P = .002). In addition, the overall miss rate for all adenomas was higher for the TUC-first group (52/146; 36%) compared with the CO2 group (37/159; 23%) (P = .025). However, 1 of the 3 endoscopists had higher polyp/adenoma miss rates for CO2, but these were not statistically significant differences. The insertion time was longer for TUC than for CO2. After adjusting for times, participant characteristics, and bowel preparation, the miss rate for polyps was higher for TUC than for CO2. CONCLUSIONS We found that TUC had an overall higher polyp and adenoma miss rate than colonoscopy performed with CO2, and TUC took longer to perform. However, TUC may benefit some endoscopists, an issue that requires further study. (Clinical trial registration number: NCT03231917.).
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Nusrat S, Madhoun MF, Tierney WM. Use of diphenhydramine as an adjunctive sedative for colonoscopy in patients on chronic opioid therapy: a randomized controlled trial. Gastrointest Endosc 2018; 88:695-702. [PMID: 29689257 DOI: 10.1016/j.gie.2018.04.2342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 04/14/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Chronic opioid use increases tolerance to sedatives. Diphenhydramine is recommended for difficult-to-sedate patients during endoscopic procedures. We hypothesized that the addition of diphenhydramine to midazolam and fentanyl would improve objective and subjective measures of procedural sedation. METHODS This randomized, double-blind, placebo-controlled trial included patients on chronic opioids undergoing colonoscopy. Patients were randomized to receive 50 mg of diphenhydramine intravenously (n = 61) or placebo (n = 58), in addition to fentanyl and midazolam. Baseline characteristics, amount of fentanyl and midazolam, procedure times, and adverse events were recorded. Quality of sedation was assessed by the physician and nurse. Patients rated pain and amnesia on a 10-point scale. RESULTS There was no difference in amounts of fentanyl (125.4 ± 56.2 μg vs 126.9 ± 53.5 μg, P = .88) and midazolam (4.9 ± 2.1 mg vs 5 ± 1.9 mg, P = .79) used. The mean sedation scores from the physician (6.2 ± 1.1 vs 5.3 ± 1.2, P =.0002) and nurses (5.6 ± 1.5 vs 5.1 ± 1.4, P =.04) were statistically significant in favor of the diphenhydramine arm. Patient scores for pain (2.05 ± 2.17 vs 3.09 ± 3.95, P =.047) and amnesia (7.8 ± 3.4 vs 6.5 ± 3.8, P =.047) favored the group that received diphenhydramine. Qualitative assessment showed no significant difference between the groups. There was no difference in induction time (P = .86), procedure duration (P = .98), or recovery time (P = .16). Hypotensive episodes were more common in the placebo group (P = .027). CONCLUSIONS In patients on chronic opioid therapy, administration of diphenhydramine does not allow for lower doses of procedural sedatives but improves quality of sedation without increasing the number of adverse events. (Clinical trial registration number: NCT T01967433.).
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Affiliation(s)
- Salman Nusrat
- Department of Medicine, Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Medicine, Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
| | - Mohammed F Madhoun
- Department of Medicine, Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Medicine, Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
| | - William M Tierney
- Department of Medicine, Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA; Department of Medicine, Section of Digestive Diseases and Nutrition, Veterans Affairs Medical Center, Oklahoma City, Oklahoma, USA
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Single Balloon-assisted Colonoscopy for Placement of Colonic Manometry Catheters: Initial Experience in Children. J Pediatr Gastroenterol Nutr 2018; 67:194-197. [PMID: 29570555 DOI: 10.1097/mpg.0000000000001944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Colonic manometry is used frequently in children with long standing and difficult to manage constipation to aid in management decisions. Accurate analysis requires placement of the colonic manometry catheter in the colon without looping. This is technically difficult due to the long-standing nature of the constipation in most patients leading to sigmoid and other colonic redundancy. Single balloon colonoscopy has been successfully used in adult in cases of difficult colonoscopy. We report the first series of single balloon-assisted colonoscopy for performing difficult colonoscopy in children and placing colonic manometry catheters. METHODS Retrospective chart review was performed to identify patients undergoing the procedure. All patients had prior preparation with nasogastric golytely. RESULTS Using the single balloon technique, 36 patients underwent placement of the colonic manometry catheter (ages ranging from 3 to 16 years, weights 12 to 95 kg). Catheter placement was successful in all cases with procedure times of 20 to 105 minutes. No major complications were noted. CONCLUSIONS This is the first reported series of using single balloon-assisted colonoscopy to perform difficult colonoscopy in children and place colonic manometry catheters. It may have other therapeutic implications in children such as removal of polyps or placement of similar catheters.
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Arena M, Eusebi LH, Palamara MA, Iabichino G, Consolo P, Opocher E, Giovenzana M, Barabino M, Luigiano C. The endoscopic overtube is a safe device for removing a fistulizing esophageal metal stent: a literature review. MINERVA BIOTECNOL 2018. [DOI: 10.23736/s1120-4826.18.02406-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Razjouyan H, Brant SR, Kahaleh M. Anesthesia Assistance in Outpatient Colonoscopy. Gastroenterology 2018; 154:2278-2279. [PMID: 29746810 DOI: 10.1053/j.gastro.2018.03.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/01/2018] [Indexed: 12/02/2022]
Affiliation(s)
- Hadie Razjouyan
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Steven R Brant
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Michel Kahaleh
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Bielawska B, Hookey LC, Whitehead M, Paszat LF, Rabeneck L, Tinmouth J. Reply. Gastroenterology 2018; 154:2279-2280. [PMID: 29750910 DOI: 10.1053/j.gastro.2018.05.018] [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: 12/02/2022]
Affiliation(s)
- Barbara Bielawska
- Division of Gastroenterology, Department of Medicine, University of Toronto
| | - Lawrence C Hookey
- Gastrointestinal Diseases Research Unit, Department of Medicine, Queen's University, Kingston, Ontario
| | - Marlo Whitehead
- Institute for Clinical Evaluative Sciences, Kingston, Ontario
| | | | - Linda Rabeneck
- Prevention & Cancer Control, Cancer Care Ontario and University of Toronto
| | - Jill Tinmouth
- Sunnybrook Research Institute and Prevention & Cancer Control, Cancer Care Ontario and Department of Medicine, University of Toronto, Ontario, Canada
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Trindade AJ, Rishi A, Hirten R, Inamdar S, Sejpal DV, Colombel JF. Identification of volumetric laser endomicroscopy features of colon polyps with histologic correlation. Gastrointest Endosc 2018; 87:1558-1564. [PMID: 29477303 DOI: 10.1016/j.gie.2018.02.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 02/15/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There are limited data on the use of volumetric laser endomicroscopy (VLE) for imaging colon polyps. Our aim was to identify VLE features of colon polyps. METHODS A total of 45 patients were included; 43 underwent endoscopic mucosal resection of colorectal polyps 2 cm or greater. These polyps were then scanned with VLE immediately after resection. Two patients who underwent partial colonic resection served as controls. RESULTS Forty-three polyps were included with review of matching histology: 3 intramucosal cancer (IMCA), 5 tubular adenoma (TAs)/tubulovillous adenoma (TVA) with high-grade dysplasia (HGD), 9 TVA with only low-grade dysplasia (LGD), 5 serrated adenoma, and 21 TA with LGD. All TAs and TVAs were hyper-reflective compared with normal tissue. Effacement occurred in 82.4% (14/17) of the colonic polyps with advanced pathology (TVA with HGD/IMCA) compared with 11.6% (3/26) with non-advanced pathology (TA with LGD and serrated adenoma) (P < .0001). Forty-seven percent (8/17) of polyps with advanced pathology had greater than 5 glands on VLE compared with none in the non-advanced pathology group (P = .0001). An irregular surface mainly occurred in polyps with high-grade pathology (HGD/IMCA) versus TAs. Eighty-eight percent of polyps with HGD/IMC had an irregular surface (7/8) versus 6% (2/35) of TAs (P < .0001). CONCLUSIONS In this ex vivo clinicopathologic study, we show that there are distinct VLE features of colon polyps that may help identify polyps or features of a higher-grade lesion. This may have implications for possible in vivo application to aid in dysplasia or polyp detection.
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Affiliation(s)
- Arvind J Trindade
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Arvind Rishi
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Department of Pathology, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Robert Hirten
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
| | - Sumant Inamdar
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Divyesh V Sejpal
- Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Division of Gastroenterology, Department of Medicine, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Jean-Frederic Colombel
- Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, The Mount Sinai Hospital, New York, New York, USA
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Trindade AJ, Lichtenstein DR, Aslanian HR, Bhutani MS, Goodman A, Melson J, Navaneethan U, Pannala R, Parsi MA, Sethi A, Sullivan S, Thosani N, Trikudanathan G, Watson RR, Maple JT. Devices and methods to improve colonoscopy completion (with videos). Gastrointest Endosc 2018; 87:625-634. [PMID: 29454445 DOI: 10.1016/j.gie.2017.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/22/2017] [Indexed: 02/08/2023]
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Rogers MC, Gawron A, Grande D, Keswani RN. Development and validation of an algorithm to complete colonoscopy using standard endoscopes in patients with prior incomplete colonoscopy. Endosc Int Open 2017; 5:E886-E892. [PMID: 28924595 PMCID: PMC5595582 DOI: 10.1055/s-0043-114663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Accepted: 05/22/2017] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Incomplete colonoscopy may occur as a result of colon angulation (adhesions or diverticulosis), endoscope looping, or both. Specialty endoscopes/devices have been shown to successfully complete prior incomplete colonoscopies, but may not be widely available. Radiographic or other image-based evaluations have been shown to be effective but may miss small or flat lesions, and colonoscopy is often still indicated if a large lesion is identified. The purpose of this study was to develop and validate an algorithm to determine the optimum endoscope to ensure completion of the examination in patients with prior incomplete colonoscopy. PATIENTS AND METHODS This was a prospective cohort study of 175 patients with prior incomplete colonoscopy who were referred to a single endoscopist at a single academic medical center over a 3-year period from 2012 through 2015. Colonoscopy outcomes from the initial 50 patients were used to develop an algorithm to determine the optimal standard endoscope and technique to achieve cecal intubation. The algorithm was validated on the subsequent 125 patients. RESULTS The overall repeat colonoscopy success rate using a standard endoscope was 94 %. The initial standard endoscope specified by the algorithm was used and completed the colonoscopy in 90 % of patients. CONCLUSIONS This study identifies an effective strategy for completing colonoscopy in patients with prior incomplete examination, using widely available standard endoscopes and an algorithm based on patient characteristics and reasons for prior incomplete colonoscopy.
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Affiliation(s)
- Melinda C. Rogers
- Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States,Corresponding author Melinda Rogers, MD Gastroenterology and HepatologyNorthwestern University Feinberg School of Medicine676 N St. Claire St, Suite 1400ChicagoIllinois 60611-3008United States+1-312-695-3999
| | - Andrew Gawron
- Gastroenterology and Hepatology, University of Utah School of Medicine, Ringgold Standard Institution, Salt Lake City, Utah, United States
| | - David Grande
- Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Rajesh N. Keswani
- Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
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Despott EJ, Murino A, Nakamura M, Bourikas L, Fraser C. A prospective randomised study comparing double-balloon colonoscopy and conventional colonoscopy in pre-defined technically difficult cases. Dig Liver Dis 2017; 49:507-513. [PMID: 28314604 DOI: 10.1016/j.dld.2017.01.139] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 12/22/2016] [Accepted: 01/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUNDS AND AIM Technically 'difficult' (TD) colonoscopy is associated with incomplete colonoscopy, discomfort and longer procedures. Double-balloon colonoscopy (DBC) may facilitate TD colonoscopy. The primary outcome was to compare the time taken to achieve caecal intubation during conventional colonoscopy (CC) and DBC in patient with a TD colon. METHODS We performed a prospective, randomised study comparing DBC and CC for TD colonoscopy. Patients were screened for parameters predictive of TD colonoscopy using an original scoring system and randomised to DBC or CC. Pain, sedation dose, colonoscopy completeness, time taken for cecal intubation, procedure completion, recovery time and patient satisfaction were recorded. RESULTS Forty-four patients were recruited (DBC=22; CC=22). DBC facilitated total colonoscopy in 22 cases whereas 9 CC procedures were incomplete (P=0.019). Median pre-procedure difficulty scores were equal for both groups (4.0 vs. 4.0). Mean patient discomfort, pain scores and recovery time were significantly lower for the DBC group (2.3 vs. 5.5, P=0.001; 2.0 vs. 5.9, P=0.005; 5 vs. 20min, P=0.014 respectively). Mean time taken for cecal intubation was similar (17.5 vs. 14min, P=0.18); CONCLUSION: DBC facilitates colonoscopy completion and may be a more comfortable alternative to CC for TD cases although the time taken to achieve caecal intubation was similar.
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Affiliation(s)
- Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, Royal Free NHS Foundation Trust, London, United Kingdom; Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Imperial College London, London, United Kingdom.
| | - Alberto Murino
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, Royal Free NHS Foundation Trust, London, United Kingdom; Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Imperial College London, London, United Kingdom
| | - Masanao Nakamura
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Imperial College London, London, United Kingdom; Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Leonidas Bourikas
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Imperial College London, London, United Kingdom; Department of Gastroenterology, Creta Interclinic, Heraklion, Crete, Greece
| | - Chris Fraser
- Wolfson Unit for Endoscopy, St Mark's Hospital and Academic Institute, Imperial College London, London, United Kingdom; Department of Gastroenterology, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Abstract
BACKGROUND Diverticulosis and redundant colon are colonic conditions for which underlying pathophysiology, management and prevention are poorly understood. Historical papers suggest an inverse relationship between these two conditions. However, no further attempt has been made to validate this relationship. This study set out to assess the correlation between diverticulosis and colonic redundancy. METHODS Redundant colon, diverticulosis and patient demographics were recorded during colonoscopy. Multivariate binary logistic regression was performed with redundant colon as the dependent variable and age, gender and diverticulosis as independent variables. Nagelkerke R 2 and a receiver operator curve were calculated to assess goodness of fit and internally validate the multivariate model. RESULTS Redundant colon and diverticulosis were diagnosed in 31 and 113 patients, respectively. The probability of redundant colon was increased by female gender odds ratio (OR) 8.4 (95% CI 2.7-26, p = 0.00020) and increasing age OR 1.7 (95% CI 1.1-2.6, p = 0.017). Paradoxically, diverticulosis strongly reduced the probability of redundant colon with OR of 0.12 (95% CI 0.42-0.32, p = 0.000039). The Nagelkerke R 2 for the multivariate model was 0.29 and the area under the curve at ROC analysis was 0.81 (95% CI 0.73-0.90 p-value 3.1 × 10-8). CONCLUSIONS This study found an inverse correlation between redundant colon and diverticulosis, supporting the historical suggestion that the two conditions rarely occur concurrently. The underlying principle for this relationship remains to be found. However, it may contribute to the understanding of the aetiology and pathophysiology of these colonic conditions.
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Endoscopy Lower. J Gastroenterol Hepatol 2016; 31 Suppl 2:8-28. [PMID: 27709669 DOI: 10.1111/jgh.13516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
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Yung DE, Rondonotti E, Koulaouzidis A. Review: capsule colonoscopy-a concise clinical overview of current status. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:398. [PMID: 27867950 DOI: 10.21037/atm.2016.10.71] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The colon capsule endoscopy (CCE) was first introduced in 2007. Currently, the main clinical indications for CCE are completion of incomplete colonoscopy, polyp detection and investigation of inflammatory bowel disease (IBD). Although conventional colonoscopy is the gold standard in bowel cancer screening, incomplete colonoscopy remains a problem as lesions are missed. CCE compares favourably to computer tomography colonography (CTC) in adenoma detection and has therefore been proposed as a method for completing colonoscopy. However the data on CCE remains sparse and current evidence does not show its superiority over CTC or conventional colonoscopy in bowel cancer screening. CCE also seems to show good correlation with conventional colonoscopy when used to evaluate IBD, but there are not many published studies at present. Other significant limitations include the need for aggressive bowel preparation and the labour-intensiveness of CCE reading. Therefore, much further software and hardware development is required to enable CCE to fulfill its potential as a minimally-invasive and reliable method of colonoscopy.
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Affiliation(s)
- Diana E Yung
- Endoscopy Unit, the Royal Infirmary of Edinburgh, Edinburgh, UK
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Abstract
A thorough and complete colonoscopy is critically important in preventing colorectal cancer. Factors associated with difficult and incomplete colonoscopy include a poor bowel preparation, severe diverticulosis, redundant colon, looping, adhesions, young and female patients, patient discomfort, and the expertise of the endoscopist. For difficult colonoscopy, focusing on bowel preparation techniques, appropriate sedation and adjunct techniques such as water immersion, abdominal pressure techniques, and patient positioning can overcome many of these challenges. Occasionally, these fail and other alternatives to incomplete colonoscopy have to be considered. If patients have low risk of polyps, then noninvasive imaging options such as computed tomography (CT) or magnetic resonance (MR) colonography can be considered. Novel applications such as Colon Capsule™ and Check-Cap are also emerging. In patients in whom a clinically significant lesion is noted on a noninvasive imaging test or if they are at a higher risk of having polyps, balloon-assisted colonoscopy can be performed with either a single- or double-balloon enteroscope or colonoscope. The application of these techniques enables complete colonoscopic examination in the vast majority of patients.
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Crockett SD, Cirri HO, Kelapure R, Galanko JA, Martin CF, Dellon ES. Use of an Abdominal Compression Device in Colonoscopy: A Randomized, Sham-Controlled Trial. Clin Gastroenterol Hepatol 2016; 14:850-857.e3. [PMID: 26767313 PMCID: PMC4875866 DOI: 10.1016/j.cgh.2015.12.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Looping is a common problem during colonoscopy that prolongs procedure time. We aimed to determine the efficacy and safety of ColoWrap, an external abdominal compression device, with respect to insertion time and other procedural outcomes. METHODS We performed a prospective study of outpatients undergoing elective colonoscopy (40-80 years old; mean age, 60.5 years) at endoscopy facilities in the University of North Carolina Hospitals from April 2013 through March 2014. Subjects were randomly assigned to groups that received either ColoWrap (n = 175) or a sham device (control, n = 175) during colonoscopy. Colonoscopists and staff were blinded to the application. The primary outcome was cecal intubation time (CIT). Secondary outcomes included use of manual pressure and position change. RESULTS The mean CIT was similar for the control and ColoWrap groups (6.69 vs 6.67 minutes; P = .98). There were no statistical differences in the frequency of manual pressure (45% for controls vs 37% for ColoWrap group, P = .13) or position changes (4% for controls vs 2% for ColoWrap group, P = .36). Among patients with body mass index between 30 and 40 kg/m(2) (n = 78), CIT was significantly lower for patients in the ColoWrap group (4.69 minutes) than controls (6.10 minutes) (P = .03). Adverse events were similar between groups. CONCLUSIONS In patients undergoing elective colonoscopy, application of an external abdominal compression device did not improve CIT or affect the frequency of ancillary maneuvers. A possible benefit was observed in patients with body mass index between 30 and 40 kg/m(2), but further studies are needed. ClinicalTrials.gov number: NCT02025504.
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Bick BL, Vemulapalli KC, Rex DK. Regional center for complex colonoscopy: yield of neoplasia in patients with prior incomplete colonoscopy. Gastrointest Endosc 2016; 83:1239-44. [PMID: 26584785 DOI: 10.1016/j.gie.2015.10.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 10/29/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Incomplete colonoscopy increases the risk of incident proximal colon cancer postcolonoscopy. Incomplete colonoscopy is often followed by barium enema or CT colonography. We sought to describe the yield of completion colonoscopy in a regional center for complex colonoscopy. METHODS This is a retrospective cohort study of 520 consecutive patients referred to a single colonoscopist over a 14-year period for completion colonoscopy after a previous incomplete examination. RESULTS Colonoscopy was completed to the cecum in 506 of 520 patients (97.3%). A total of 913 conventional adenomas was removed in 277 patients (adenoma detection rate 53.3%). There were 184 adenomas ≥ 1 cm in size or with advanced pathology. There were 525 serrated-class lesions removed in 175 patients, including 54 sessile serrated polyps in 26 patients and 41 hyperplastic polyps greater than 1 cm in 26 patients. Nine colorectal cancers were found. We estimated that approximately 57% of the conventional adenomas, 58% of the sessile serrated polyps, 27% of the hyperplastic polyps, and all 9 cancers detected by the completion colonoscopy were beyond the extent of the previous examination. CONCLUSIONS The yield of completion colonoscopy in a cohort of patients with previous failed cecal intubation was substantial. Regional centers for complex colonoscopy can provide high rates of cecal intubation in cases of incomplete colonoscopy and high yields of lesions in these cases. The regional center for complex colonoscopy is an important medical service.
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Affiliation(s)
- Benjamin L Bick
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Krishna C Vemulapalli
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Douglas K Rex
- Department of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Interval Colorectal Cancer After Colonoscopy: Exploring Explanations and Solutions. Am J Gastroenterol 2015; 110:1657-64; quiz 1665. [PMID: 26553207 DOI: 10.1038/ajg.2015.365] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Accepted: 09/21/2015] [Indexed: 02/06/2023]
Abstract
There is good evidence that colorectal cancer (CRC) screening has been successful at reducing both CRC incidence and death. Colonoscopy, utilized as either a primary screening tool or a follow-up exam when other screening tests are positive, has significantly contributed to these encouraging trends. However, it is well recognized that colonoscopy is not perfectly sensitive for the detection of neoplasia and that CRC can be diagnosed within a short interval following a colonoscopy that did not detect one. The literature surrounding these cases has rapidly expanded over the last decade. Specifically, studies aimed at understanding the frequency of these events and the likely explanations for their occurrence have been performed. This review will highlight current knowledge around the epidemiology of interval post colonoscopy CRC (PCCRC). The common explanations for these cancers including missed lesions, new lesions, and incompletely resected lesions will be reviewed and their contribution to interval PCCRC estimated. Finally, the relationship of these putative explanations to potential opportunities to prevent interval PCCRC will be explored. Current approaches to prevention largely center on consistent adherence to quality colonoscopy standards. Future approaches include advances in technology to better visualize the colon and adequately resect detected neoplasia. Finally, improvement in training as well as development of a culture of continuous quality improvement will be essential to maximize the benefits of colonoscopy in daily clinical practice.
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Jia H, Wang L, Luo H, Yao S, Wang X, Zhang L, Huang R, Liu Z, Kang X, Pan Y, Guo X. Difficult colonoscopy score identifies the difficult patients undergoing unsedated colonoscopy. BMC Gastroenterol 2015; 15:46. [PMID: 25886845 PMCID: PMC4397830 DOI: 10.1186/s12876-015-0273-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 03/23/2015] [Indexed: 12/20/2022] Open
Abstract
Background Many factors have been found to affect the difficulty of colonoscope insertion, such as age, gender, body mass index (BMI), history of abdominal surgery and operator etc. However, a scoring system may be more useful to predict the difficulty during colonoscopy. Methods The individual and procedure-related data of 616 patients undergoing colonoscopy were prospectively collected from December 2013 through February 2014 in Xijing Hospital of Digestive Diseases. Cox regression analysis was used to identify high-risk factors associated with difficulty of colonoscopy. A predicting model with the difficult colonoscopy score (DCS) was developed. Results Total cecum intubation rate was 98.9% (609/616). Advanced age, lower BMI, inexperienced operator and fair or poor sleep quality were identified as independent factors of prolonged insertion time (all p < 0.05), which were used to develop the DCS. Based on the score, patients could be divided into high-risk and low-risk groups with distinct incomplete rates within 10 min (42.0% vs. 16.5%, p < 0.001). Compared with those with DCS ≤ 1, patients with DCS > 1 had increased insertion time (10.6 ± 0.7 min vs. 6.9 ± 0.2 min, p < 0.001) and pain score (1.9 ± 1.5 vs. 1.4 ± 1.4, p = 0.002). More abdominal compression (36.9% vs. 16.8%, p < 0.001) and position change (51.4% vs. 22.6%, p < 0.001) were needed in this group of patients. Conclusion Patients with DCS > 1 had longer insertion time, higher pain score and needed more abdominal compression and position changes. DCS was useful for predicting the difficulty of colonoscope intubation. (ClinicalTrials.gov NCT02105025 05/05/2014). Electronic supplementary material The online version of this article (doi:10.1186/s12876-015-0273-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hui Jia
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
| | - Limei Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China. .,Shannxi Second People's Hospital, Xian, China.
| | - Hui Luo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
| | - Shaowei Yao
- 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.
| | - Rui Huang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
| | - Zhiguo Liu
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
| | - Xiaoyu Kang
- 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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Abstract
The successful intubation of the cecum during screening or surveillance colonoscopy is vital to ensure complete mucosal inspection of the colon on withdrawal. Even when performed by an experienced endoscopist, colonoscope insertion can sometimes be challenging. Water-aided colonoscopy can be used to assist the endoscopist in navigating colons with anatomies that may be challenging owing to severe angulation or redundancy. Water-assisted colonoscopy involves the infusion of water without air and subsequent suctioning during insertion (exchange) or withdrawal (immersion or infusion). This review discusses the technique, effectiveness, safety of water-assisted colonoscopy as well as the application in sedationless endscopy.
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Affiliation(s)
- Joseph C Anderson
- Department of Veterans Affairs Medical Center, Department of Medicine, 215 North Main Street, White River Junction, VT 05009, USA; The Geisel School of Medicine at Dartmouth Medical, Department of Medicine, Hanover, NH 03755, USA.
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Britton EJ, Sidhu S, Geraghty J, Psarelli E, Sarkar S. The 5-year outcome of patients having incomplete colonoscopy. Colorectal Dis 2015; 17:298-303. [PMID: 25605376 DOI: 10.1111/codi.12901] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/06/2014] [Indexed: 12/16/2022]
Abstract
AIM Incomplete colonoscopy indicated for the detection of neoplasia occurs in 2-23% of patients, but there is little information on the long-term outcome of such patients. METHOD All patients who underwent colonoscopy over 5 years at the Royal Liverpool University Hospital with a follow-up of up to 5 years were identified. RESULTS The risk of colorectal cancer (CRC) was 2.9% (312/10 580) for all patients undergoing colonoscopy. For a failed colonoscopy, the risk was five-fold higher [14.3% (99/693)]. The mean age of the patients was 61 years and 58% were female. Following incomplete colonoscopy the risk of finding additional CRC, advanced colonic neoplasia and extracolonic neoplasia on subsequent investigation was 6.2%, 3.2% and 1.9%. The diagnostic yield on subsequent investigation for CRC or colonic polyps was 7% for repeat colonoscopy, 13.4% for computed tomography colonography, 10.3% for standard computed tomography and 1.8% for barium enema. In the 363 patients who were not offered a subsequent investigation, there was no further instance of CRC or CRC-related mortality over a 36-month period. CONCLUSION Although the risk of CRC is higher in patients who have had a failed colonoscopy, a protocol approach of subsequent investigation should not replace clinical assessment on whether another test is necessary in the light of the good outcome of patients who were not subsequently investigated.
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Affiliation(s)
- E J Britton
- Department of Gastroenterology and Hepatology, Royal Liverpool University Hospital, Liverpool, UK
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Hotta K, Katsuki S, Ohata K, Abe T, Endo M, Shimatani M, Nagaya T, Kusaka T, Matsuda T, Uraoka T, Yamaguchi Y, Murakami Y, Saito Y. Efficacy and safety of endoscopic interventions using the short double-balloon endoscope in patients after incomplete colonoscopy. Dig Endosc 2015; 27:95-8. [PMID: 24889819 DOI: 10.1111/den.12318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 05/26/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM We have previously reported excellent cecal intubation rates using a short double-balloon endoscope in patients with a history of incomplete colonoscopy. However, data on the endoscopic treatment of colorectal tumors using a double-balloon endoscope are limited. The aim of the present study was to evaluate the efficacy and safety of endoscopic intervention of colorectal tumors using a short double-balloon endoscope. METHODS We analyzed data from a multicenter, prospective study on 110 patients (62 men, median age 66.5 years) who underwent total colonoscopy after incomplete colonoscopy to assess the characteristics of colorectal tumors, endoscopic interventions, and complications. RESULTS In all, 113 colorectal tumors were detected in 55 patients; 109 of the tumors were adenomas (24 advanced adenomas) and two each were intramucosal and advanced cancers. Locations of the lesions were eight in the cecum, 30 in the ascending colon, 18 in the transverse colon, 12 in the descending colon, 34 in the sigmoid colon, five in the rectosigmoid and six in the rectum. Average tumor diameter was 6.8 ± 6.3 mm. Fifty-nine polypectomies, 22 endoscopic mucosal resections, four hot biopsies, and six cold biopsies were done. All endoscopic interventions were successfully completed and no complications were noted. Two advanced cancers were located in the ascending colon and only a double-balloon endoscope could reach them to take a biopsy sample. CONCLUSION Double-balloon endoscopy is effective and safe for endoscopic intervention of colorectal tumors, irrespective of the location, in patients after incomplete colonoscopy.
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Affiliation(s)
- Kinichi Hotta
- Department of Gastroenterology, Saku Central Hospital, Saku, Japan; Division of Endoscopy, Shizuoka Cancer Center, Sunto, Japan
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Development of the gastrointestinal endoscopy competency assessment tool for pediatric colonoscopy (GiECAT KIDS). J Pediatr Gastroenterol Nutr 2014; 59:480-6. [PMID: 24590220 DOI: 10.1097/mpg.0000000000000358] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Many aspects of pediatric colonoscopy differ from adult practice. To date, there is no validated measure of endoscopic competence for use in pediatrics. Using Delphi methodology, we aimed to determine expert consensus regarding items required on a checklist and global rating scale designed to assess the competence of clinicians performing colonoscopy on pediatric patients. METHODS A total of 41 North American pediatric endoscopy experts rated potential checklist and global rating items for their importance as indicators of the competence of trainees learning to perform pediatric colonoscopy. Responses were analyzed and re-sent to the panel for further ratings until consensus was reached. Items that ≥ 80% of experts rated as ≥ 4 out of 5 were included in the final instrument. Consensus items were compared with those items deemed by adult endoscopy experts as fundamental to assessing the performance of adult colonoscopy. RESULTS Five rounds of surveys were completed with response rates ranging from 76% to 100%. Seventy-five checklist and 38 global rating items were reduced to 18 checklist and 7 global rating items that reached consensus. Three pediatric checklist items differed from those considered to be critical adult indicators, whereas 4 items on the latter did not reach consensus among pediatric experts. CONCLUSIONS Delphi methodology allowed for achievement of expert consensus regarding essential items to be included in the Gastrointestinal Endoscopy Competency Assessment Tool for Pediatric Colonoscopy (GiECATKIDS), a measure of endoscopic competence specific to performing pediatric colonoscopy. Key differences in the checklist items, compared with items reaching consensus during a separate adult Delphi process using the same indicators, emphasize the need for a pediatric-specific tool.
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A patient-blinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy. Am J Gastroenterol 2014; 109:1390-400. [PMID: 24890443 DOI: 10.1038/ajg.2014.126] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/18/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Minimal sedation obviates patient recovery burdens, but intolerable pain limits success of cecal intubation. Painless or minimally uncomfortable insertion ensures success of cecal intubation, current patient satisfaction, and willingness to repeat future colonoscopy with minimal sedation. Water immersion (WI) and water exchange (WE), when separately compared with air insufflation (AI), significantly reduced insertion pain. To assess comparative effectiveness, we conducted a randomized controlled trial with head-to-head comparison of these three methods. We hypothesized that WE could produce the highest proportion of patients reporting painless insertion. METHODS This prospective patient-blinded trial (NCT01535326) enrolled minimally sedated (25 mg intramuscular meperidine) patients randomized to AI, WI, or WE (90 patients/group) to aid insertion. The previously validated primary outcome was the proportion of patients reporting painless insertion. RESULTS Painless insertion was reported by 30.0% (AI), 43.3% (WI), and 61.1% (WE) of patients (P<0.001). Multivariate logistic regression analysis revealed that, after adjusting for gender, body mass index, abdominal compression, position change, insertion time to cecum, and length of scope at cecum, only WE was significantly associated with painless insertion compared with AI (odds ratio (OR)=0.08, 95% confidence interval (CI)=0.03-0.24, P<0.001) or WI (OR=0.14, 95% CI=0.05-0.40, P<0.001). Adenoma detection rate (ADR) in the right (cecum and ascending) colon was 11.1% (AI), 14.4% (WI), and 26.7% (WE) (P=0.015). The limitations included single site study with unblinded colonoscopist and assistant. CONCLUSIONS This head-to-head comparison of AI vs. WI vs. WE confirmed that WE was superior to WI and AI, with a significantly greater proportion of patients reporting painless insertion. The significantly higher ADR in the right colon in the WE group warrants further investigations.
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Abstract
High-quality bowel preparation is essential for effective colonoscopy. Bowel preparations are judged by their safety, efficacy and tolerability. Between efficacy and tolerability, efficacy is the clinical priority because inadequate preparations are disruptive and costly. Achieving high rates of adequate preparation depends first on using split-dose or same-day dosing. Patients who have medical predictors of inadequate preparation quality (for example chronic constipation) should be prescribed more aggressive preparations and patients who have factors that predict they are less likely to follow the instructions (such as English not being their first language) should receive intensified education. On the day of the procedure, patients with persistent brown effluent should be considered for large-volume enemas or additional oral preparation before proceeding with colonoscopy. During the procedure, preparation quality should be graded after the clean-up has been completed.
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Affiliation(s)
- Douglas K Rex
- Indiana University School of Medicine, Department of Medicine, 550 University Boulevard, Indianapolis, IN 46202, USA
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Double-balloon endoscopy: an effective rescue procedure after incomplete conventional colonoscopy. Eur J Gastroenterol Hepatol 2014; 26:519-22. [PMID: 24584269 DOI: 10.1097/meg.0000000000000067] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE A significant percentage of colonoscopies remain incomplete because of a failure to intubate the caecum. By double-balloon endoscopy (DBE), originally developed for deep enteroscopy, an otherwise incomplete examination of the colon might be completed. We evaluated the success rate of caecal intubation, the reasons for its failure and the therapeutic consequences of using DBE after incomplete conventional colonoscopy. METHODS We report our single-centre experience of using DBE to complete an otherwise incomplete colonoscopy. A total of 114 consecutive patients, 45 male and 69 female, with a mean age of 64.8 years, who had undergone 116 procedures, were evaluated retrospectively by a review of their medical records. RESULTS The main causes for failed caecal intubation using a conventional colonoscope were loop formation in 70 patients (61.4%) and an adhesive angulated sigmoid in 33 (28.9%). Caecal intubation by DBE was successful in 101 patients (88.6%). The rate of failure was not associated with the cause of failure of the previous colonoscopy. In 55 patients (48.2%) a relevant new diagnosis was made in the previously inaccessible part of the colon: carcinoma (n=4; 3.5%), one or more adenomas (n=48; 42.1%) and caecal flat hyperplastic polyps (n=4; 3.5%). Endoscopic polypectomy was performed in 51 patients (44.7%); two complications occurred, both being mild postpolypectomy bleedings. In seven patients (6.1%) a subsequent surgical resection was performed. CONCLUSION Colonoscopy by DBE was useful in most patients in whom conventional colonoscopy was incomplete, irrespective of the cause of the failure. In nearly half the patients, a relevant new diagnosis was made with therapeutic consequences.
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Cap-assisted gastroscope versus cap-assisted colonoscope for examination of difficult sigmoid colons in a nonsedated Asian population: a randomized study. Gastrointest Endosc 2014; 79:790-7. [PMID: 24210653 DOI: 10.1016/j.gie.2013.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Accepted: 09/19/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Studies have estimated that cecal intubation failure occurs with conventional colonoscopy in about 10% of cases. Various methods have been adopted to improve the cecal intubation rate, including a transparent cap and special colonoscopes. OBJECTIVE To assess the efficacy of using a cap-assisted gastroscope (E-cap) compared with a cap-assisted colonoscope (C-cap) for the complete examination of the colon in nonsedated patients with technically difficult sigmoid colons. DESIGN Randomized, controlled study. SETTING Tertiary-care referral center. PATIENTS One hundred thirty-nine patients with technically difficult sigmoid colons were studied. INTERVENTION Colonoscopy with either an E-cap (n = 69) or a C-cap (n = 70). MAIN OUTCOME MEASUREMENTS Cecal intubation rate, cecal intubation time, patient-assessed pain score, and endoscopist-assessed pain score. RESULTS The cecal intubation rate was significantly higher in the E-cap (65/69, 94.2%) than in the C-cap group (50/70, 71.4%; P < .0001). Patient-assessed pain (moderate to severe) was more frequently reported in the C-cap (14/70, 20.0%) than in the E-cap group (5/69, 7.2%; P = .029). Endoscopist-assessed pain (moderate to severe) was more frequently reported in the C-cap (13/70, 18.6%) than in the E-cap group (3/69, 7.2%; P = .009). For patients with a low body mass index (≤ 22 kg/m(2)), the cecal intubation rate was significantly higher in the E-cap (37/38, 97.4%) than in the C-cap group (15/29, 51.7%; P < .0001). LIMITATIONS Single-center experience, lack of a gastroscope control group without a cap. CONCLUSION The cap-assisted gastroscope is more tolerable and effective than cap-assisted colonoscope for the complete examination of the colon in patients with technically difficult sigmoid colons. ( CLINICAL TRIAL REGISTRATION NUMBER KCT0000744.).
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Gawron AJ, Veerappan A, Keswani RN. High success rate of repeat colonoscopy with standard endoscopes in patients referred for prior incomplete colonoscopy. BMC Gastroenterol 2014; 14:56. [PMID: 24679009 PMCID: PMC3986859 DOI: 10.1186/1471-230x-14-56] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 03/21/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In patients with incomplete colonoscopy, cecal intubation is sometimes unsuccessful due to a redundant or tortuous colon. Repeat colonoscopy may be successful with the use of alternate endoscopes or careful attention to technique but limited outcomes data is available. The aim of this study was to describe the technique, success rate and outcomes of consecutive patients referred for previous incomplete colonoscopy. METHODS We conducted a retrospective chart review of incomplete colonoscopy procedures in patients age 18-90 at an academic teaching hospital referred to an endoscopist specializing in difficult colonoscopy. RESULTS Cecal intubation was successful in 96 of 100 repeat colonoscopies and 83 procedures were completed with a standard endoscope (adult, pediatric, or gastroscope). The adenoma detection rate was 28% for successful repeat colonoscopies; a majority of these patients had no adenomas identified on incomplete exam. In 69.4% of cases, an endoscope was used to successfully complete colonoscopy that was not used in the incomplete colonoscopy. The median insertion time was significantly less for the complete colonoscopy (10.6 min) compared to the incomplete colonoscopy (18.8 min, P = 0.004). CONCLUSIONS Repeat colonoscopy has a high success rate and identified a significant number of new adenomas. Use of all available endoscopes should be considered prior to procedure termination in patients with a tortuous colon. Repeat colonoscopy can often be accomplished using a standard endoscope and is not attributed to increased endoscope insertion time.
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Affiliation(s)
| | | | - Rajesh N Keswani
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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Reply to: 10.1007/s00464-013-3134-x: colonic architectural changes after the use of psychotropic drugs: looking at the egg while forgetting the hen? Surg Endosc 2013; 28:348-9. [PMID: 24048814 DOI: 10.1007/s00464-013-3181-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 08/05/2013] [Indexed: 10/26/2022]
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The new view of colon cancer screening: forwards and backwards. Gastrointest Endosc Clin N Am 2013; 23:647-61. [PMID: 23735108 DOI: 10.1016/j.giec.2013.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Many different techniques for colon cancer screening are available. The fecal immunochemical test is best for fecal-based screening, although the DNA investigation may be more specific when further developed. Computed tomographic colonography is as good as colonoscopy for detecting colon cancer and is almost as good as colonoscopy for detecting advanced adenomas, but has limitations. The flexible sigmoidoscopic examination markedly decreases the incidence of cancer in the visualized segments, but colonoscopy is currently the best procedure for evaluating the large bowel. Techniques for retroflexion or backward view of the colon have been investigated, with all showing increased polyp detection.
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Impact of an incomplete colonoscopy referral program on recommendations after incomplete colonoscopy. Dig Dis Sci 2013; 58:1849-55. [PMID: 23456503 DOI: 10.1007/s10620-013-2605-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 02/14/2013] [Indexed: 01/14/2023]
Abstract
BACKGROUND There are limited data on recommendations and adherence to complete colon evaluation (CCE) after incomplete colonoscopy (IC). AIMS Our objectives were to (1) identify recommendations and adherence to recommendations after IC, (2) determine the diagnostic yield of CCE after IC, and (3) determine the effect of an IC referral program on recommendations for CCE. METHODS We conducted a retrospective review of IC procedures at a teaching hospital over two time periods (January 1 to May 1 2004 and July 1 to November 1 2010). A referral process for repeat colonoscopy after IC was instituted in April 2009. Outcomes included (1) recommendations (2) adherence, and (3) yield of CCE after IC. RESULTS A total of 222 patients underwent at least one IC (overall rate of 2.5 %). In 120 patients (54.1 %), CCE was recommended within 1 year; the rate did not change from 2004 to 2010. Patients with IC due to poor preparation were more likely to have specific CCE recommendations (85.5 vs. 72.2 %, P = 0.03) and recommendations of endoscopic follow-up (76.3 vs. 10.4 %, P < 0.0001) than those with IC due to difficult anatomy. When IC was due to difficult colonoscopy, there was increase in endoscopic follow-up recommended (16.3 vs. 2.8 %, P = 0.01) in 2010 compared to 2004. Adherence to recommendations was similar regardless of modality recommended, inpatient/outpatient status, polyps on initial exam, or extent of initial exam. Polyp detection rate was greater utilizing colonoscopy than barium enema (34.3 vs. 3.6 %, P < 0.0001). CONCLUSIONS There is a lack of consensus in management strategies for patients after IC. Implementation of a referral program has had minimal impact on provider recommendations.
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Sato K, Shigiyama F, Ito S, Kitagawa T, Tominaga K, Suzuki T, Maetani I. Colonoscopy using a small-caliber colonoscope with passive-bending after incomplete colonoscopy due to sharp angulation or pain. Surg Endosc 2013; 27:4171-6. [PMID: 23722893 DOI: 10.1007/s00464-013-3016-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Accepted: 05/04/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND We evaluated the performance of a newly developed small-caliber (SC) colonoscope (PCF-PQ260L). This colonoscope (diameter 9.2 mm) is designed with passive-bending and high-force transmission. The SC colonoscope was used for rescue colonoscopy following incomplete colonoscopy with a standard (SD) colonoscope caused by sharp angulation, loop formation, or pain. METHODS Records of SC colonoscopy given to patients following an incomplete colonoscopy with the SD colonoscope and in the same session were analyzed. Cecal intubation rate, pain using a visual analog scale (0 = none, 100 = extremely painful) in the first and second colonoscopy, total time, new lesions detected with the SC colonoscopy, dosage of sedation used, and any complications were assessed. Examinations that could not be completed, because the colonoscope was not long enough to reach the cecum due to a redundant colon were excluded. RESULTS The records of 43 patients who were given SC colonoscopy following incomplete examinations using the SD colonoscope were reviewed. In 97.7 % of cases (42/43), cecal intubation was achieved with the SC colonoscope in the same session. The mean pain score during colonoscopy was significantly lower for the second SC colonoscopy than for the first SD colonoscopy (40.6 ± 14.1 vs. 74.5 ± 10.8, P < 0.001). Lesions were detected with the SC colonoscope in 41.8 % of cases (18/43). CONCLUSIONS When a colonoscopy with SD colonoscope failed due to sharp angulations, loop formation, or pain, subsequent colonoscopy with a SC colonoscope increased cecal intubation and lesion detection rates and decreased severity of reported pain.
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Affiliation(s)
- Koichiro Sato
- Division of Gastroenterology, Department of Internal Medicine, Toho University Ohashi Medical Center, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan,
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Abstract
BACKGROUND Computed tomography-colonography is a diagnostic modality that can be used when the colon is not completely intubated during colonoscopy. It may have the additional advantage that information on extracolonic lesions can be obtained. OBJECTIVE The aim of this study was to investigate the yield of CT-colonography of relevant intra- and extracolonic findings in patients after incomplete colonoscopy. DESIGN This was an observational, retrospective study. DATA SOURCES Data were be obtained from standardized radiology and endoscopy reports and electronic medical records. STUDY SELECTION In total, 136 consecutive CT-colonographies performed after incomplete colonoscopy were evaluated. MAIN OUTCOME MEASURES All intra- and extracolonic findings on CT-colonography were recorded and interpreted for clinical relevance, and it was determined whether further diagnostic and/or therapeutic workup was indicated. RESULTS Major indications for colonoscopy included iron-deficiency anemia (25.7%), hematochezia (20.6%), change in bowel habits (18.4%), and colorectal cancer screening or surveillance (11.0%). Major reasons for incomplete colonoscopy were a fixed colon (34.6%) and strong angulation of the sigmoid colon (17.6%). Introduction of the colonoscope was limited to the left-sided colon in 53.7% of cases. Incomplete colonoscopy detected colorectal cancer in 12 (8.8%) patients and adenomatous polyps in 27 (19.9%) patients. CT-colonography after incomplete colonoscopy additionally revealed 19 polyps in 15 (11.0%) and a nonsynchronous colorectal cancer in 4 (2.9%) patients. CT-colonography also detected extracolonic findings with clinical consequences in 8 (5.9%) patients, including fistulizing diverticulitis (n = 3), gastric tumor (n = 2), liver abscess (n = 1), osteomyelitis (n = 1), and an infected embolus in both renal arteries (n = 1). LIMITATIONS This study was limited by the lack of confirmation of intraluminal CT-colonography findings in a subset of patients. CONCLUSIONS Computed tomography-colonography can be of added value in patients with incomplete colonoscopy, because it revealed 27 relevant additional (both intra- and extracolonic) lesions in 19.1% of patients. In cases where CT-colonography detected colorectal cancer after incomplete colonoscopy, it can also be used for staging purposes.
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Kobayashi K, Mukae M, Ogawa T, Yokoyama K, Sada M, Koizumi W. Clinical usefulness of single-balloon endoscopy in patients with previously incomplete colonoscopy. World J Gastrointest Endosc 2013; 5:117-121. [PMID: 23515370 PMCID: PMC3600547 DOI: 10.4253/wjge.v5.i3.117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 12/04/2012] [Accepted: 01/24/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the clinical usefulness of single-balloon endoscopy (SBE) in patients in whom a colonoscope was technically difficult to insert previously.
METHODS: The study group comprised 15 patients (8 men and 7 women) who underwent SBE for colonoscopy (30 sessions). The number of SBE sessions was 1 in 7 patients, 2 in 5 patients, 3 in 1 patient, 4 in 1 patient, and 6 in 1 patient. In all patients, total colonoscopy was previously unsuccessful. The reasons for difficulty in scope passage were an elongated colon in 6 patients, severe intestinal adhesions after open surgery in 4, an elongated colon and severe intestinal adhesions in 2, a left inguinal hernia in 2, and multiple diverticulosis of the sigmoid colon in 1. Three endoscopists were responsible for SBE. The technique for inserting SBE in the colon was basically similar to that in the small intestine. The effectiveness of SBE was assessed on the basis of the success rate of total colonoscopy and the presence or absence of complications. We also evaluated the diagnostic and treatment outcomes of colonoscopic examinations with SBE.
RESULTS: Total colonoscopy was successfully accomplished in all sessions. The mean insertion time to the cecum was 22.9 ± 8.9 min (range 9 to 40). Abnormalities were found during 21 sessions of SBE. The most common abnormality was colorectal polyps (20 sessions), followed by radiation colitis (3 sessions) and diverticular disease of the colon (3 sessions). Colorectal polyps were resected endoscopically in 15 sessions. A total of 42 polyps were resected endoscopically, using snare polypectomy in 32 lesions, hot biopsy in 7 lesions, and endoscopic mucosal resection in 3 lesions. Fifty-six colorectal polyps were newly diagnosed on colonoscopic examination with SBE. Histopathologically, these lesions included 2 intramucosal cancers, 42 tubular adenomas, and 2 tubulovillous adenomas. The mean examination time was 48.2 ± 20.0 min (range 25 to 90). Colonoscopic examination or endoscopic treatment with SBE was not associated with any serious complications.
CONCLUSION: SBE is a useful and safe procedure in patients in whom a colonoscope is technically difficult to insert.
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Incomplete colonoscopy: maximizing completion rates of gastroenterologists. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2013; 26:589-92. [PMID: 22993727 DOI: 10.1155/2012/353457] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cecal intubation is one of the goals of a quality colonoscopy; however, many factors increasing the risk of incomplete colonoscopy have been implicated. The implications of missed pathology and the demand on health care resources for return colonoscopies pose a conundrum to many physicians. The optimal course of action after incomplete colonoscopy is unclear. OBJECTIVES To assess endoscopic completion rates of previously incomplete colonoscopies, the methods used to complete them and the factors that led to the previous incomplete procedure. METHODS All patients who previously underwent incomplete colonoscopy (2005 to 2010) and were referred to St Paul's Hospital (Vancouver, British Columbia) were evaluated. Colonoscopies were re-attempted by a single endoscopist. Patient charts were reviewed retrospectively. RESULTS A total of 90 patients (29 males) with a mean (± SD) age of 58 ± 13.2 years were included in the analysis. Thirty patients (33%) had their initial colonoscopy performed by a gastroenterologist. Indications for initial colonoscopy included surveillance or screening (23%), abdominal pain (15%), gastrointestinal bleeding (29%), change in bowel habits or constitutional symptoms (18%), anemia (7%) and chronic diarrhea (8%). Reasons for incomplete colonoscopy included poor preparation (11%), pain or inadequate sedation (16%), tortuous colon (30%), diverticular disease (6%), obstructing mass (6%) and stricturing disease (10%). Reasons for incomplete procedures in the remaining 21% of patients were not reported by the referring physician. Eighty-seven (97%) colonoscopies were subsequently completed in a single attempt at the institution. Seventy-six (84%) colonoscopies were performed using routine manoeuvres, patient positioning and a variable-stiffness colonoscope (either standard or pediatric). A standard 160 or 180 series Olympus gastroscope (Olympus, Japan) was used in five patients (6%) to navigate through sigmoid diverticular disease; a pediatric colonoscope was used in six patients (7%) for similar reasons. Repeat colonoscopy on the remaining three patients (3%) failed: all three required surgery for strictures (two had obstructing malignant masses and one had a severe benign obstructing sigmoid diverticular stricture). CONCLUSION Most patients with previous incomplete colonoscopy can undergo a successful repeat colonoscopy at a tertiary care centre with instruments that are readily available to most gastroenterologists. Other modalities for evaluation of the colon should be deferred until a second attempt is made at an expert centre.
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Vemulapalli KC, Rex DK. Water immersion simplifies cecal intubation in patients with redundant colons and previous incomplete colonoscopies. Gastrointest Endosc 2012; 76:812-7. [PMID: 22901988 DOI: 10.1016/j.gie.2012.05.033] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/23/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Interest in effective ways to complete colon examinations in patients who had previously undergone failed colonoscopies has increased recently. OBJECTIVE To determine whether water immersion decreased the need for ancillary equipment to achieve cecal intubation in patients who had previously undergone incomplete colonoscopies. DESIGN Retrospective cohort study. SETTING Tertiary academic center. PATIENTS A total of 345 consecutive patients referred to a tertiary center for the indication of a previous incomplete colonoscopy. INTERVENTIONS Colonoscopy with or without water immersion insertion. MAIN OUTCOME MEASUREMENTS Cecal intubation rates, type of equipment, and maneuvers used. RESULTS Cecal intubation was achieved in 332 of 345 patients (96.2%) and was similar in those with and without water immersion (170/178, 95.5% vs 162/167, 97%, P = .58). An external straightening device was used in 6 of 178 cases with water immersion (3.4%) compared with 25 of 168 cases with air insufflation (15%) (P < .0001). Among patients with a redundant colon as the sole cause of previously incomplete examinations, water immersion required an external straightener in 7% compared with 37% with air insufflation during insertion (P < .0001), and position change was required in 5% of those with water immersion compared with 22% with air insufflation (P = .01). LIMITATIONS Retrospective review; single-center, single-endoscopist study. CONCLUSION Water immersion decreases the need for external straightening devices and position change maneuvers in patients with redundant colons and previously incomplete colonoscopies.
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Affiliation(s)
- Krishna C Vemulapalli
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Dzeletovic I, Harrison ME, Pasha SF, Crowell MD, Decker GA, Gurudu SR, Leighton JA. Comparison of single- versus double-balloon assisted-colonoscopy for colon examination after previous incomplete standard colonoscopy. Dig Dis Sci 2012; 57:2680-6. [PMID: 22615017 DOI: 10.1007/s10620-012-2227-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 04/30/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Colonoscopy fails to achieve cecal intubation in 5-10 % of cases. Many of these cases can be completed using balloon-assisted colonoscopy, either with the single-balloon colonoscopy (SBC) or the double-balloon colonoscopy (DBC) techniques. AIM To compare the completion rates of SBC and DBC in patients with previous incomplete conventional colonoscopy. METHODS Between August 2009 and July 2011 either SBC or DBC was performed in 53 patients in whom previous conventional colonoscopy did not achieve cecal intubation. The medical records of these 53 patients were reviewed retrospectively for details regarding (1) indication for the initial colonoscopy, (2) patient characteristics, (3) data from the initial colonoscopy, and (4) details on both SBC and DBC. RESULTS SBC was successful in intubating the cecum in 100 % (26/26) of patients and DBC was successful in 93 % (25/27) of patients. The median (range) time to reach the cecum was 17 (9-43) min in the SBC group and 20 (7-58) min in the DBC group (P = 0.37). The presence of polyps was an entirely new finding in 35 % (9/26) of patients in the SBC group and 30 % (8/27) of patients in DBC group. Therapeutics were performed in 73 % (19/26) of patients in SBC group and 67 % (18/27) of patients in DBC group. CONCLUSION For patients with incomplete conventional colonoscopy, SBC and DBC offer high cecal intubation rates as well as detection of additional polyps and therapeutic capability. Either SBC or DBC can be considered after incomplete conventional colonoscopy.
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Affiliation(s)
- Ivana Dzeletovic
- Division of Gastroenterology and Hepatology, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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Nonanesthesiologist-administered propofol sedation for colonoscopy is safe and effective: a prospective Spanish study over 1000 consecutive exams. Eur J Gastroenterol Hepatol 2012; 24:787-92. [PMID: 22517241 DOI: 10.1097/meg.0b013e328353fcbc] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND STUDY AIMS Propofol is increasingly being used in sedated colonoscopy. This paper assesses the safety and efficacy of nonanesthesiologist-administered propofol in a large series of colonoscopies. PATIENTS AND METHODS A prospective registry of consecutive American Society of Anesthetics (ASA) class I and II outpatients undergoing colonoscopy was carried out. Propofol, administered by a nurse under an endoscopist's supervision, was the sole sedative agent used. RESULTS Of the 1000 patients (563 women/437 men, mean age 57, range 8-89 years) included in the study, 57.4% showed ASA I and 42.6% ASA II characteristics. The cecal intubation rate was 96.9%. 48.2% of the procedures were for therapeutic purposes. The mean propofol dose was 177 mg (range 50-590 mg). Doses correlated inversely with patient age (r=-0.38; P<0.001) and were lower in ASA II patients (P<0.001) and in diagnostic (rather than therapeutic) exams (P<0.001). The average recovery time (from extracting the colonoscope to patient discharge) was 18.6 min (range 4-75) and longer in ASA II patients (P=0.05). A pulse oximetry saturation of less than 90% and a decrease in systolic blood pressure of more than 20 mmHg were observed in 24 (2.4%) and 385 (35.8%) patients, respectively. Both events were more frequent in patients older than 65 years (P<0.05); the latter was more common in ASA II patients. CONCLUSION Colonoscopy under endoscopist-controlled propofol sedation in low-risk patients is safe and effective, allowing for a complete exploration, although patients at least 65 years old and/or classified as ASA II are more likely to present a decrease in blood pressure and have a prolonged recovery time.
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