Achieving cecal intubation in the very difficult colon

A population-based analysis on the incidence of metachronous colon cancer after endoscopic resection of advanced adenomas with high-grade dysplasia: does location matter?

BACKGROUND

Advanced adenomas (AAs) with high-grade dysplasia (HGD) represent a risk factor for metachronous neoplasia, with guidelines recommending short-interval surveillance. Although the worse prognosis of proximal (vs distal) colon cancers (CCs) is established, there is paucity of evidence on the impact of laterality on the risk of subsequent neoplasia for these AAs.

METHODS

Adults with HGD adenomas undergoing polypectomy were identified in the Surveillance, Epidemiology, and End Results database (2000-2019). Cumulative incidence of malignancy was estimated using the Kaplan-Meier method. Fine-Gray models assessed the effect of patient and disease characteristics on CC incidence.

RESULTS

Of 3199 patients, 26% had proximal AAs. A total of 65 cases of metachronous adenocarcinoma were identified after polypectomy of 35 proximal and 30 distal adenomas with HGD. The 10-year cumulative incidence of CC was 2.3%; when stratified by location, it was 4.8% for proximal vs 1.4% for distal adenomas. Proximal location was significantly associated with increased incidence of metachronous cancer (adjusted hazard ratio, 3.32; 95% CI, 2.05-5.38).

CONCLUSION

Proximal location of AAs with HGD was associated with >3-fold increased incidence of metachronous CC and shorter time to diagnosis. These data suggest laterality should be considered in the treatment and follow-up of these patients.

An intraprocedural bowel cleansing system for difficult-to-prepare patients-A multicenter prospective feasibility study

BACKGROUND

Adequate bowel preparation is a prerequisite for colonoscopy. However, up to 20% of colonoscopies remain inadequately prepared. Risk factors for inadequate bowel preparation often overlap with those of failed cecal intubation. This study aimed to assess the feasibility of an intraprocedural bowel cleansing system (BCS) in patients with a history of inadequate bowel preparation.

METHODS

Patients (n = 44) with a history of inadequate bowel preparation in the past 2 years were included. After a limited preparation with 300 mL split-dose sodium picosulfate magnesium citrate, additional cleansing during colonoscopy was performed with the BCS. The primary outcome was adequate bowel preparation using the Boston Bowel Preparation Scale (BBPS). Secondary outcomes included cecal intubation rate, procedure times, usability, and safety.

RESULTS

Median BBPS increased from 1-2-2 (IQR 1-2) to 3-3-3 (IQR) (p < 0.0001), with 31.8% and 88.6% of patients adequately prepared before and after using the BCS, respectively (p < 0.0001). Cecal intubation rate was 88.6%. Reasons for incomplete colonoscopy were looping (n = 2), technical failure (n = 1), relative stricture (n = 1), and residual feces (n = 1). In patients with complete colonoscopy, the adequate cleansing rate was 97.5%. Median total procedure time was 26 min, of which 5.3 min were spent on cleaning. General ease of use was scored with a median of 4 out of 5, representing "as good as conventional colonoscopy". No serious adverse events occurred.

CONCLUSIONS

Adequate bowel cleaning can be achieved with an intraprocedural BCS in patients with a history of inadequate bowel preparation, which may reduce repeat colonoscopies and clinical admissions for bowel preparation. However, since these patients more frequently have complicated anatomy (surgical scarring, diverticulosis, etc.), adequate patient selection is advised to avoid incomplete procedures.

Endoscopic polypectomy for malignant polyps: Should tumor location (right versus left side) guide clinical decisions?

BACKGROUND

Current guidelines consider endoscopic resection appropriate treatment for malignant colon polyps with negative margins, low-grade histology, and no lymphovascular invasion. While increasing literature demonstrates a worse prognosis for advanced stage right- versus left-sided colon cancers after curative treatment, there is paucity of data regarding prognostic effect of location in patients undergoing endoscopic resection of T1 polyps. We hypothesized the more aggressive biologic behavior observed in advanced right-sided cancers would be similarly represented in malignant polyps, and this location would be associated with lower overall survival.

METHODS

The National Cancer Database was queried for adults with T1NxMx tumors who underwent endoscopic polypectomy (2004-2017). Patients with positive margins or without follow-up information were excluded.

RESULTS

A total of 2,337 patients met inclusion criteria; 22% had right-sided polyps. Endoscopically excised proximal tumors were more common in elderly, and those with public insurance and more comorbidities (all P < .01). Among patients with complete pathologic data, there were no statistical differences between right- and left-sided polyps with 1 cm median size, >92% without lymphovascular invasion, and 100% without tumor deposits. Univariate analysis showed 73% vs 86% 5-year overall survival for right versus left polyps (P < .01). After adjustment for available confounders, right-sided location remained significantly associated with worse overall survival (hazard ratio 1.49, 95% confidence interval 1.21-1.83).

CONCLUSION

In this national cohort of patients with endoscopically excised malignant polyps, we identified right colon location as an independent prognostic factor associated with increased risk of mortality. Our data suggest polyp location should be taken into consideration when making clinical decisions regarding treatment and/or surveillance.

Prospective evaluation of the motorized spiral enteroscope for previous incomplete colonoscopy

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.

Colonoscope "Looping" During Ileo-Colonoscopy in Children is Significantly Different to that Observed in Adult Practice

OBJECTIVES

Ileo-colonoscopy (IC) can be technically challenging because of unpredictable colonoscope loop formation. Aims of this study were to assess the risk of loop formation and to attempt to understand which factors were likely to predispose to which subtype of loop.

METHODS

Prospective study conducted on children referred for an IC at Sheffield Children's Hospital. Presence and type of loop was objectively assessed using the magnetic endoscope imaging tool.

RESULTS

Three hundred procedures were prospectively evaluated. Only 9% of paediatric ICs were loop-free. Alpha loops were the most common loop in children older than 5, whereas reverse alpha loops and a wider variety of complex and repetitive loops were observed in younger patients. Once a specific type of loop has formed, the risk of re-looping in a different way or in a different position of the colon is reduced. Left lateral starting position was found to increase the risk of reverse alpha loops and re-looping. Challenging loops, such as reverse alpha, were more frequent in males. Higher body mass index (BMI) was associated with an increased risk of alpha and deep transverse loops formation, while lower BMI with a higher incidence of reverse alpha and N loop. Loop formation did not prevent 100% ileal intubation.

CONCLUSIONS

This study represents the first attempt to describe loop formation according to patient characteristics in a large paediatric series. Further studies are needed in order to establish if these findings could be helpful in simplifying the execution of IC procedures in children and facilitate the learning curve during endoscopy training programs.

Efficacy and tolerability of colonoscopies in overweight and obese patients: Results from a national database on gastrointestinal endoscopic outcomes

Background and study aims  Gastroenterologists are encountering a rising number of obese patients requiring colonoscopy. Existing literature regarding colonoscopy outcomes in this population is scant and conflicting. We analyzed a nationwide cohort of patients to identify the effects of body mass index (BMI) on colonoscopy success, efficacy, and tolerability. Patients and methods  The Clinical Outcomes Research Initiative (CORI) endoscopic database was queried for all colonoscopies in adults between 2008-2014. Patients were stratified into four cohorts based on BMI classification for comparison. Multivariable analysis was performed to identify the effect of BMI on procedure outcome, efficacy and tolerability. Results  Of 41,401 procedures, 27,696 met study inclusion criteria. Of these, 49.4 % were performed for colorectal cancer screening, most commonly under anesthesia directed sedation. Patient discomfort was the reason for an incomplete colonoscopy in 18.7 % of all cases, and more frequent among the overweight and obese cohorts. An inadequate bowel preparation was most common in the class III obesity cohort. Compared to the normal BMI group, a BMI ≥ 30 and < 40 kg/m ² was associated with an increased odds of an incomplete colonoscopy ( P  = 0.001for overweight, P  = 0.0004 for class I/II obesity), longer procedure ( P  < 0.05 for all) and poorer tolerance ( P  < 0.0001 for class I/II obesity, P  = 0.016 for class III obesity). Anesthesia-administered sedation was more commonly used than endoscopist directed sedation amongst the obese cohort compared with the normal BMI cohort ( P  < 0.0001). Conclusions  Endoscopists should consider the increased odds of incomplete colonoscopy, longer procedures, and poorer tolerance when performing colonoscopy in obese patients to improve clinical management and procedural outcome.

Feasibility of salvage colonoscopy by water exchange for failed air-insufflated patients: a prospective, randomized, controlled trial

BACKGROUND

A complete colonoscopy is crucial for screening colorectal diseases and colorectal cancer. However, a failure rate of up to 43% still exists. Several studies have indicated that the water exchange method can enhance the cecal intubation rate while reducing discomfort of the patient. Water exchange colonoscopy (WEC) might be a salvage treatment for the patients who failed from air insufflation colonoscopy (AIC). We aimed to assess the feasibility of WEC as a salvage measure following the failure of conventional AIC.

METHODS

Patients willing to undergo unsedated colonoscopy at a tertiary-care referral center in China were randomly assigned 1:1 to WEC or AIC group for salvage after the initial AIC attempt failed. Patients were blinded to group assignment. The primary outcome was cecal intubation rate, the secondary outcomes included time to the cecum, maximum pain scores, and technical difficulty level.

RESULTS

Recruited 104 patients were randomized to the WEC (n = 52) or AIC (n = 52) group. WEC significantly increased the cecal intubation rate (92.3% vs 73.1%; p = .02). The maximum pain scores and technical difficulty level in the WEC group were significantly lower than the AIC group during salvage procedure (p < .001).

CONCLUSIONS

This randomized, controlled trial confirms that the WEC significantly enhanced cecal intubation rate in difficult colonoscopy in unsedated patients after the failure of standard AIC. The increased cecal intubation rate, lower pain scores and technical difficulty level suggest WEC is a good alternative for incomplete unsedated colonoscopy. Clinical trial registration number: ChiCTR2100051483.

Descending-sigmoid colon flexure - An important but surprisingly ignored landmark

BACKGROUND

In invasive examinations of the colon, e.g. colonoscopy, the tortuosity of the colon is a crucial factor for successful completion of the procedure. If adjacent segments of the colon bend at acute angles (under 90°), endoscopy may become difficult and troublesome.

METHODS

We retrospectively enroled 227 individuals (96 female, 131 male) who underwent abdominopelvic computed tomography examination. For inclusion, subjects were required to have a negative history for colonic disease and abdominopelvic surgery. We measured the angle between the descending colon and the proximal part of the sigmoid (in degrees). In addition, the position of the descending-sigmoid flexure was assessed in relation to the left anterior superior iliac spine, the median plane, and anterior aspect of the 5th lumbar vertebra (in mm). The study protocol was reviewed and approved by the local ethics committee.

RESULTS

We visualised the descending-sigmoid flexure in all 227 subjects. In one third of cases, the flexure formed an angle smaller than/or 90°. In females, this landmark (mean ± standard deviation) was located 30.2 ± 8.4 mm from the left anterior superior iliac spine, 88.6 ± 14.2 mm from the median plane, and 115.4 ± 21.4 mm from the anterior aspect of the 5th lumbar vertebra. In males, the dimensions were: 32.1 ± 12.8 mm, 97.6 ± 15.8 mm, and 123.9 ± 22.9 mm, respectively. This landmark distance remained constant from the left anterior superior iliac spine regardless of subject age, height and weight. The other measured distances were related to age, height, weight or BMI.

CONCLUSIONS

The descending-sigmoid flexure is an important landmark in large intestine morphology situated approximately width of two fingers (3 cm) from the left anterior superior iliac spine and one hand width (9-10 cm) from the median plane. In approximately one third of the subjects, the flexure formed an angle of less than/or 90°, which can cause a problem during colonoscopy.

Performance of radiographic imaging after incomplete colonoscopy for nonmalignant causes in clinical practice

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.

(Technically) Difficult colonoscope insertion - Tips and tricks

Cecal intubation is a critical aspect of effective, complete colonoscopy. Difficult colonoscopy is most often considered as one in which it is challenging or impossible to reach the cecum. It may be a common occurrence due to patient and/or endoscopist factors. Incomplete colonoscopies should be avoided, since patients in this context present an important prevalence of lesions that escape examination. The approach to successful cecal intubation should depend on characterization of the problem as redundant colon or difficult sigmoid colon. Most patients with a prior incomplete colonoscopy can be colonoscoped successfully, if careful attention is paid to technique, using a variety of scopes, colonoscopy methods and additional equipment. Sufficient time should be allotted to make the attempt.

The large intestine from fetal period to adulthood and its impact on the course of colonoscopy

The human large intestine in the living adult has a total length of about 1300 mm, ranging from 1100 to 2108 mm. The development of the gut continues after birth, up to the age 4-5. The large intestine ascends at the beginning in the right abdominal quadrant, then it traverses the abdominal cavity, and finally it descends to the anus. The left and right colic flexures are the basic flexions between the transverse, ascending and descending colon, respectively. Additionally, there are secondary bendings between intestinal segments. The angles between the neighbouring parts can vary between examined subjects. Most of the angulations can be found in the transverse (range 2-9) and sigmoid colon (range 1-9), making them the most troublesome parts to pass with a colonoscope. Colonoscopy (usually performed in the left lateral or supine position) is one of the most important examination of the large intestine mucus membrane. During this procedure the endoscope is passed through the colon into the cecum or terminal ilium. The individual anatomical features (tortuosity, supernumerary loops and elongation) may slow down or interfere with the progress of the scope. We summarize current knowledge on the human large intestine from the fetal period to adulthood and carve out some aspects that are currently less known to colonoscopists.

Difficult colonoscopy: air, carbon dioxide, or water insufflation?

Background/Aims

This study aimed to compare tolerance to air, carbon dioxide, or water insufflation in patients with anticipated difficult colonoscopy (young, thin, obese individuals, and patients with prior abdominal surgery or irradiation).

Methods

Patients with body mass index (BMI) less than 18 kg/m² or more than 30 kg/m², or who had undergone previous abdominal or pelvic surgeries were randomized to air, carbon dioxide, or water insufflation during colonoscopy. The primary endpoint was cecal intubation with mild pain (less than 5 on visual analogue scale [VAS]), without use of sedation.

Results

The primary end point was achieved in 32.7%, 43.8%, and 84.9% of cases with air, carbon dioxide and water insufflation (P<0.001). The mean pain scores were 5.17, 4.72, and 3.93 on the VAS for air, carbon dioxide, and water insufflation (P<0.001). The cecal intubation rate or procedure time did not differ significantly between the 3 groups.

Conclusions

Water insufflation was superior to air or carbon dioxide for pain tolerance. This was seen in the subgroups with BMI <18 kg/m² and the post-surgical group, but not in the group with BMI >30 kg/m².

Double-Balloon Endoscopy after Incomplete Colonoscopy and Its Comparison with Computed Tomography Colonography

BACKGROUND/AIMS

Because of the national screening program for colorectal carcinoma in The Netherlands, the number of colonoscopies has increased. In case of incomplete colonoscopy, computed tomography colonography (CTC) and double-balloon colonoscopy (DBc) are alternative options. This study evaluated cecal intubation rate and pathology detection rate in the previously unexplored part of the colon, complication rate of DBc, and CTC results after incomplete colonoscopy.

METHODS

Retrospective observational study in a tertiary referral hospital regarding DBc and CTC reports from cases with incomplete colonoscopy.

RESULTS

Sixty-three DBcs were performed after incomplete colonoscopy. Cecal intubation rate was 95%. Detection rate was 58% (5% carcinoma and 3% high-grade dysplastic adenoma). CTC preceded 54% of DBcs and 62% of CTC findings were confirmed. In 16%, a biopsy was taken, and in 60%, an intervention (mostly polypectomy) was performed. One major complication (1.5%) occurred, i.e., arterial bleeding due to polypectomy necessitating right hemicolectomy. CTC (n=213) showed a possible lesion in 35%, and could be confirmed by follow-up endoscopy or surgery in 65%.

CONCLUSIONS

DBc is effective and safe for completion of colon inspection in incomplete colonoscopy. In patients with a high likelihood of pathology, DBc is preferred over CTC.

A prospective randomised study comparing double-balloon colonoscopy and conventional colonoscopy in pre-defined technically difficult cases

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.

Ultrathin versus pediatric instruments for colonoscopy in older female patients: A randomized trial

BACKGROUND AND AIM

Small-caliber endoscopes such as gastroscopes or pediatric colonoscopes are occasionally required to negotiate fixed or angulated colons. However, the use of a new ultrathin instrument (diameter 7.0 mm) narrower than other conventional colonoscopes has not been evaluated. The aim of the present study was to compare the use compare the use of an ultrathin colonoscope (UTC) with a pediatric colonoscope (PDC) for colonoscopy in older female patients.

METHODS

A prospective, randomized, controlled trial was conducted in a single academic endoscopy unit. A total of 77 female patients aged ≥70 years undergoing unsedated colonoscopy were randomized to colonoscopy with a UTC (n = 39) or PDC (n = 38). Primary outcome measurement was the degree of pain using a numerical rating scale, and secondary outcomes were cecal intubation rate, ileal intubation rate, time to cecum and adenoma detection rate.

RESULTS

There was a significant difference in reported pain using the numerical rating scale (median, UTC 1 vs PDC 4, P < 0.0001). Cecal intubation rates were 97.4% in UTC and 92.1% in PDC (P = 0.36), and ileal intubation rates were 82.0% and 89.4% (P = 0.76), respectively. However, median times to cecum were significantly longer using UTC compared with PDC (15.2 min vs 11.1 min, P = 0.022). Adenoma detection rates were 30.7% in UTC and 26.3% in PDC (P = 0.80).

CONCLUSIONS

Colonoscopy using UTC was almost equivalent to that of PDC in older female patients, with significantly less pain compared with PDC. UTC may be an alternative to PDC for the difficult colon.

Left-colon water exchange preserves the benefits of whole colon water exchange at reduced cecal intubation time conferring significant advantage in diagnostic colonoscopy - a prospective, randomized controlled trial

OBJECTIVES

Whole-colon water exchange (WWE) reduces insertion pain, increases cecal intubation success and adenoma detection rate, but requires longer insertion time, compared to air insufflation (AI) colonoscopy. We hypothesized that water exchange limited to the left colon (LWE) can speed up insertion with equivalent results.

METHODS

This prospective, randomized controlled study (NCT01735266) allocated patients (18-80 years) to WWE, LWE or AI group (1:1:1). The primary outcome was cecal intubation time.

RESULTS

Three hundred subjects were randomized to the WWE (n = 100), LWE (n = 100) or AI group (n = 100). Ninety-four to ninety-five per cent of patients underwent diagnostic colonoscopy. Baseline characteristics were balanced. The median insertion time was shorter in LWE group (4.8 min (95%CI: 3.2-6.2)) than those in WWE (7.5 min (95%CI: 6.0-10.3)) and AI (6.4 min (95%CI: 4.2-9.8)) (both p < 0.001) groups. The cecal intubation rates in unsedated patients of the two water exchange methods (WWE 99%, LWE 99%) were significantly higher than that (89.8%) in AI group (p = 0.01). The final success rates were comparable among the three groups after sedation was given. Maximum pain scores and number of patients needing abdominal compression between WWE and LWE groups were comparable, both lower than those in AI group (p < 0.05). No significant difference was observed regarding PDR, although the PDR in right colon tended to be higher in WWE group.

CONCLUSION

By preserving the benefits of WWE and reducing insertion time, LWE is appropriate for diagnostic colonoscopy, especially in settings with tight scheduling of patients. The higher PDR in the right colon in WWE group deserves to be further investigated.

Colon capsule endoscopy

Colon capsule endoscopy (CCE) is a minimally invasive technique specifically designed to explore the colon without sedation and air insufflation. CCE may overcome some of the limitations of colonoscopy. Second-generation CCE (CCE-2) was proved accurate in detecting colonic neoplastic lesions when used in average-risk individuals. The evidence to date supports the use of CCE-2 in cases of colonoscopy failure, in patients unwilling to undergo colonoscopy, and when colonoscopy is contraindicated. Other potential applications, such as colorectal cancer screening or diagnostic surveillance of inflammatory bowel disease, require clarification.

Colon capsule endoscopy: What we know and what we would like to know

Colonoscopy is usually perceived as an invasive and potentially painful procedure, being also affected by a small, but definite, risk of major complications (cardiopulmonary complications, perforation, hemorrhage) and even mortality. To improve both acceptability and safety, PillCam Colon Capsule Endoscopy (CCE) (Given Imaging Ltd, Yoqneam, Israel) has been developed. CCE represents a non-invasive technique that is able to explore the colon without sedation and air insufflation. The Second Generation of Colon Capsule Endoscopy (PillCam Colon 2) (CCE-2) was proven to be an accurate tool to detect colonic neoplastic lesions when used in average risk individuals. To date, the evidence supports the use of CCE-2 in case of colonoscopy failure, in patients unwilling to perform colonoscopy and when colonoscopy is contraindicated. Other potential applications, such as colorectal cancer screening or diagnostic surveillance of inflammatory bowel disease need to be clarified. In this paper, the current “state of the art”, potential application of CCE and future needs are evaluated.

Magnetic imaging-assisted colonoscopy vs conventional colonoscopy: A randomized controlled trial

AIM: To compare magnetic imaging-assisted colonoscopy (MIC) with conventional colonoscopy (CC).

METHODS: Magnetic imaging technology provides a computer-generated image of the shape and position of the colonoscope onto a monitor to give visual guidance to the endoscopist. It is designed to improve colonoscopy performance and tolerability for patients by enabling visualization of loop formation and endoscope position. Recently, a new version of MIC technology was developed for which there are limited data.To evaluate this latest generation of MIC among experienced rather than inexperienced or trainee endoscopists, a prospective randomized trial was performed using only gastroenterologists with therapeutic endoscopy training. Consecutive patients undergoing elective outpatient colonoscopy were randomized to MIC or CC, with patients blinded to their group assignment. Endoscopic procedural metrics and quantities of conscious sedation medications were recorded during the procedures. The procedure was classified as “usual” or “difficult” by the endoscopist at the conclusion of each case based on the need for adjunctive maneuvers to facilitate endoscope advancement. After more than one hour post-procedure, patients completed a 10 cm visual analogue pain scale to reflect the degree of discomfort experienced during their colonoscopy. The primary outcome was patient comfort expressed by the visual analogue pain score. Secondary outcomes consisted of endoscopic procedural metrics as well as a sedation score derived from standardized dose increments of the conscious sedation medications.

RESULTS: Two hundred fifty-three patients were randomized and underwent MIC or CC between September 2011 and October 2012. The groups were similar in terms of the indications for colonoscopy and patient characteristics. There were no differences in cecal intubation rates (100% vs 99%), insertion distance-to-cecum (82 cm vs 83 cm), time-to-cecum (6.5 min vs 7.2 min), or polyp detection rate (47% vs 52%) between the MIC and CC groups. The primary outcome of mean pain score (1.0 vs 0.9 out of 10, P = 0.41) did not differ between MIC and CC groups, nor did the mean sedation score (8.2 vs 8.5, P = 0.34). Within the subgroup of cases considered more challenging or difficult, time-to-cecum was significantly faster with MIC compared to CC, 10.1 min vs 13.4 min respectively (P = 0.01). Sensitivity analyses confirmed a similar pattern of overall findings when each endoscopist was considered separately, demonstrating that the mean results for the entire group were not unduly influenced by outlier results from any one endoscopist.

CONCLUSION: Although the latest version of MIC resulted in faster times-to-cecum within a subgroup of more challenging cases, overall it was no better than CC in terms of patient comfort, sedation requirements and endoscopic procedural metrics, when performed in experienced hands.

Patient-posture and Ileal-intubation during colonoscopy (PIC): a randomized controlled open-label trial

BACKGROUND AND AIMS

Patient's posture change is commonly employed by a colonoscopist to achieve complete examination. We studied whether patient's posture (left-lateral decubitus vs supine) influenced the success rate of ileal intubation.

PATIENTS AND METHODS

In this prospective open-label randomized study performed in the Endoscopy Suite of a tertiary-care center, all adult outpatients referred for colonoscopy, in whom cecal intubation was achieved and who satisfied predefined inclusion criteria, were randomized to undergo ileal intubation in either of the above two postures. Colonoscopy (EC-201 WL, Fujinon) was performed after overnight poly-ethylene-glycol preparation, under conscious sedation and continuous pulse-oxymetry monitoring. After confirming cecal intubation, patients were randomized for ileal intubation. Success was defined by visualization of ileal mucosa or villi (confirmed by digital photography) and was attempted until limited by pain and/or time of ≥ 6 min.

RESULTS

Of 320 eligible patients, 217 patients (150 males) were randomized, 106 to left-lateral decubitus and 111 to supine posture. At baseline, the two groups were evenly matched. Successful ileal intubation was achieved in 145 (66.8 %) patients overall, significantly higher in the supine posture (74.8 % versus 58.5 %; P = 0.014). On multivariate analysis, supine posture (P = 0.02), average/good right-colon preparation (P < 0.01), non-thin-lipped ileocecal (IC) valve (P < 0.001) and younger age (P = 0.02) were independent predictors of success. Positive ileal findings were recorded in 13 (9 %) patients.

CONCLUSION

Ileoscopy is more successful in supine than in left-lateral decubitus posture. Age, bowel preparation and type of IC valve also determine success.

Robotics in Colonoscopy

Colorectal cancer is the second leading cause of mortality in men and women in the United States. While there is a definite advantage regarding the use of colonoscopies in screening, there is still a lack of widespread acceptance of colonoscopy use in the general public. This is evident by the fact that up to 75% of patients diagnosed with colorectal cancer present with locally advanced disease. In order to make colonoscopy and in turn colorectal cancer screening a patient friendly and a comfortable test some changes in tool are necessary. The conventional colonoscope has not changed much since its development. There are several new advances in colorectal screening practices. One of the most promising new advances is the advent of robotic endoscopic techniques.

Double-balloon endoscopy: an effective rescue procedure after incomplete conventional colonoscopy

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.

Cap-assisted gastroscope versus cap-assisted colonoscope for examination of difficult sigmoid colons in a nonsedated Asian population: a randomized study

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.).

[Does endoscopist fatigue play a role in incomplete colonoscopies and detection of polypoid lesions?]

INTRODUCTION

Nowadays, the possible effect of endoscopist fatigue on the results of colonoscopies is under discussion. We aimed to analyze possible differences in cecal intubation and the polyp and adenoma detection rate, depending on whether colonoscopies were performed at the beginning or at the end of the daily endoscopy session and to analyze the influence of the queue position on the detection rate.

PATIENTS AND METHODS

A retrospective study was performed with 1,000 ambulatory and consecutive colonoscopies, divided into 2 groups: «early» and «late» procedures. A total of 95 colonoscopies were excluded due to poor colon cleansing. After confirming that patient characteristics were homogenous in the two groups, we compared the frequency of complete colonoscopies and the polyp and adenoma detection rate. Possible differences between the 2 groups in the polyp detection rate according to the colonoscopy schedule were analyzed.

RESULTS

The overall polyp and adenoma detection rates were 44.2 and 30.5%, respectively, with no significant differences among 13 different endoscopists; polyps: p = 0.21; adenomas: p=0.63. No significant differences were found between the «early group» (n= 532) and the «late group» (n = 373) in the rates of complete colonoscopies [97.2 vs 99.4% (p=0.92)], the polyp detection rate [45.9 vs 41.8% (p=0.23)], the adenoma detection rate [30.8 vs 30% (p=0.80)] or the serrated adenoma rate [2.1% vs 1.6% (p=0.62)]. The lesion detection rate did not vary in relation to the «queue position»: polyps [p = 0.60, and adenomas: p = 0.83.

CONCLUSIONS

In our series, endoscopist fatigue at the end of the day had no influence on the complete colonoscopy rate or on the polyp and adenoma detection rate. There were no differences in the number of polypoid lesions detected according to the timing of the colonoscopy schedule.

Water immersion simplifies cecal intubation in patients with redundant colons and previous incomplete colonoscopies

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.

International digestive endoscopy network to strengthen network for lower gastrointestinal diseases including inflammatory bowel disease and colorectal cancer

The International Digestive Endoscopy Network 2012 organized by Korean Society of Gastrointestinal Endoscopy was held at Seoul, Korea on June 9 to 10, 2012, during which invited lectures of world renowned experts on the lower gastrointestinal (GI) tract were given with a wide range of the latest knowledge and novel imaging of inflammatory bowel disease (IBD) and colorectal endoscopic submucosal dissection (ESD). There were very informative five sessions in the lower GI part consisting of: Colonoscopy in IBD; what can we do in 2012?; A look into the bowel beyond colon in IBD; How to estimate the invasion depth of early GI cancer?; No more no man's land: small bowel exploration; and colorectal ESD: can it be a popular procedure?

Transparent-cap-fitted colonoscopy shows higher performance with cecal intubation time in difficult cases

AIM: To investigate the efficacy of cap-fitted colonoscopy (CFC) with regard to cecal intubation time.

METHODS: Two hundred and ninety-five patients undergoing screening colonoscopy at Gospel Hospital, Kosin University College of Medicine were enrolled in this randomized controlled trial between January and December 2010. Colonoscopies were conducted by a single endoscopist. Patient characteristics including age, sex, body mass index, history of abdominal surgery, quality of preparation, and the presence of diverticulosis were recorded.

RESULTS: One hundred and fifty patients were allocated into a CFC group and 145 into a non-CFC (NCF) group. Cecal intubations were achieved in all patients. Cecal intubation time in the CFC group was significantly shorter than in the NCF group for specific conditions: age ≥ 60 years, prior abdominal surgery, and poor bowel preparation. The number of detected adenomas was higher in the CFC group than in the NCF group (P = 0.040).

CONCLUSION: CFC facilitated shortening of the cecal intubation time in difficult cases, and was more sensitive for detecting adenomas than was NCF.

Colon capsule endoscopy: Advantages, limitations and expectations. Which novelties?

Since the first reports almost ten years ago, wireless capsule endoscopy has gained new fields of application. Colon capsule endoscopy represents a new diagnostic technology for colonic exploration. Clinical trials have shown that colon capsule endoscopy is feasible, accurate and safe in patients suffering from colonic diseases and might be a valid alternative to conventional colonoscopy in selected cases such as patients refusing conventional colonoscopy or with contraindications to colonoscopy or when colonoscopy is incomplete. Despite the enthusiasm surrounding this new technique, few clinical and randomized controlled trials are to be found in the current literature, leading to heterogeneous or controversial results. Upcoming studies are needed to prove the substantial utility of colon capsule endoscopy for colon cancer screening, especially in a low prevalence of disease population, and for other indications such as inflammatory bowel disease. Possible perspectives are critically analysed and reported in this paper.

A randomized comparison of ultrathin and standard colonoscope in cecal intubation rate and patient tolerance

BACKGROUND

Complete colonoscopy examination cannot be performed in as many as 10% of cases. The new 9.2-mm ultrathin colonoscope (UTC) with an extra bending section may improve procedure tolerance and allow improvement in colonoscopy completion rate compared with a 12.9-mm standard colonoscope (SC).

OBJECTIVE

To compare the performance of the 9.2-mm UTC with that of the 12.9-mm SC.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Academic endoscopic unit.

PATIENTS

Subjects 18 years and older undergoing their first colonoscopy.

INTERVENTION

Subjects were randomized to either the UTC or SC group.

MAIN OUTCOME MEASUREMENTS

First and rescue successful cecal intubation rates, subject satisfaction scores, and sedation requirements were compared.

RESULTS

A total of 1121 patients (56% women, mean age 53.6 years) were randomized to the UTC group (n = 551) or the SC group (n = 570). There was no statistically significant difference in the first successful cecal intubation rate between the UTC and SC groups (98.9% vs 97.4%, P = .057). The mean (standard deviation) dose of midazolam and pethidine used was significantly lower in the UTC group (2.65 [0.65] mg vs 2.82 [0.85] mg, P < .001 and 27.6 [7.4] mg vs 29.7 [9.6] mg, P < .001, respectively). The mean (standard deviation) patient satisfaction score was similar between groups (6.99 [2.89] vs 7.04 [3.06], P = .762). Of the 21 patients (1.9%) with an incomplete initial colonoscopy (6 in the UTC group and 15 in the SC group), all 6 in the UTC group had their procedure completed with an SC. Eleven of 15 patients in the SC group had their procedures completed with a UTC in the same session.

LIMITATIONS

Low failure rate may mask any difference between the 2 colonoscopes as a rescue instrument.

CONCLUSIONS

The 9.2-mm UTC has performance characteristics similar to those of an SC in Chinese subjects undergoing their first colonoscopy performed by experienced and trainee endoscopists. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT01142167.).

The water method is effective in difficult colonoscopy - it enhances cecal intubation in unsedated patients with a history of abdominal surgery

BACKGROUND: Colonoscopy in unsedated patients in the US is considered to be difficult. Success rate of cecal intubation is limited by discomfort. Colonoscopy in patients with a history of abdominal surgery is also considered to be difficult due to adhesion-related bowel angulations. The water method has been shown to significantly reduce pain during colonoscopy. OBJECTIVE: To test the hypothesis that the water method enhances the completion of colonoscopy in unsedated patients with a history of abdominal surgery. DESIGN: The data bases of two parallel RCT were combined and analyzed. SETTING: Two Veterans Affairs endoscopy units. PATIENT AND METHODS: The water and air methods were compared in these two parallel RCT examining unsedated patients. Those with a history of abdominal surgery were selected for evaluation. MAIN OUTCOME MEASUREMENTS: Completion of unsedated colonoscopy. RESULTS: Among patients with a history of abdominal surgery, the proportion completing unsedated colonoscopy in the water group (19 of 22) was significantly higher than that (11 of 22) in the air group (p=0.0217, Fisher's exact test). LIMITATIONS: Small number of predominantly male veterans, unblinded colonoscopists, not all types of abdominal surgery (e.g. hysterectomy, gastrectomy) predisposing to difficult colonoscopy were represented. CONCLUSION: This proof-of-principle assessment confirms that in patients with a history of abdominal surgery the water method significantly increases the proportion able to complete unsedated colonoscopy. The water method deserves to be evaluated in patients with other factors associated with difficult colonoscopy.

Push enteroscopy has a 96% cecal intubation rate in colonoscopies that failed because of redundant colons

BACKGROUND

Performing a complete colonoscopy to the cecum is important for ruling out malignancy and other lesions, but failure rates are significant with a standard colonoscope. A previous study using a push enteroscope for failed colonoscopies had a completion rate of 68.7%.

OBJECTIVE

To improve the cecal intubation rate by using a newer version of a push enteroscope.

DESIGN

Retrospective study at first, then a prospective study.

SETTING

Single-center veterans health care system.

PATIENTS

A total of 47 patients in whom the cecum was not reached with a regular adult colonoscope between January 2007 and December 2010 were included. Those with poor bowel preparation were excluded.

INTERVENTIONS

Repeat colonoscopy using a new version of a push enteroscope.

MAIN OUTCOME MEASUREMENTS

The rate of cecal intubation and additional pathological findings.

RESULTS

The cecum or terminal ileum was reached in 45 patients (96%). Additional significant pathological findings in the previously unexamined colon were seen in 18 patients (38%).

LIMITATIONS

Small sample size, lack of comparison with other endoscopes.

CONCLUSIONS

Colonoscopy with a push enteroscope could be advanced to either the terminal ileum or cecum in 96% of patients, which is one of the highest known completion rates in patients in whom colonoscopy failed. Clinical management changed in all patients with additional findings.

Issues related to colorectal cancer and colorectal cancer screening practices in women

Studies have shown that colorectal cancer (CRC) incidence is equal between men and women. However, several studies have demonstrated lower adenoma detection rates in women than in men. Many questions arise about differences in adenomas, CRC, and screening practices between men and women: should screening be the same for both sexes, are there differences in risk factors in the formation of colon cancer, should special groups of women be screened differently from the general population, are colonoscopies tolerated differently in women and why, and what determines if a woman will undergo colonoscopy? This article reviews these issues.

Magnifying gastroscopy using a soft black hood for difficult colonoscopy

BACKGROUND

Various methods are reported as aids to cecal intubation for cases in which colonoscopy is difficult. This study aimed to investigate prospectively whether a gastroscope with magnification function, narrow-band imaging (NBI), and a soft black hood can aid insertion in cases of difficult colonoscopy and facilitate both accurate diagnosis and safe treatment.

METHODS

This prospective study recruited 177 patients. All were examined with a magnifying gastroscope. A commercially available soft black hood was attached to the gastroscope during insertion and magnification. Difficult colonoscopy was anticipated before colonoscopy in cases of patients with at least one of the following factors: low BMI (<20 kg/m(2)), adhesion due to previous surgery, or previous colonoscopy that could not reach to the cecum. The success rate and duration of cecal intubation then were assessed. All detected lesions were evaluated by magnifying NBI and then classified as non-neoplastic or neoplastic for endoscopic diagnosis. Subsequently, all the lesions were removed and examined histologically for comparison.

RESULTS

The overall success rate of cecal intubation was 100% (177/177), and the mean time taken to reach the cecum was 5.9 min. A total of 156 lesions were detected endoscopically, and the overall diagnostic accuracy of NBI with magnification was 98.7%. No associated complications occurred.

CONCLUSION

Magnifying gastroscopy using a soft black hood and NBI is useful for cecal intubation in cases wherein colonoscopy is difficult, facilitating accurate diagnosis and safe treatment.

Spiral overtube-assisted colonoscopy after incomplete colonoscopy in the redundant colon

BACKGROUND

A redundant colon can lead to incomplete colonoscopy. A variety of tools and techniques are available to complete colonoscopy but have limitations.

OBJECTIVE

To determine the feasibility and safety of using a spiral overtube to complete a difficult colonoscopy.

DESIGN

Retrospective review of a prospectively collected database.

SETTING

Single tertiary institution.

PATIENTS

Twenty-four patients with incomplete colonoscopy because of redundant colons underwent 26 procedures. The median age was 68 years, and 58% were men.

INTERVENTIONS

All patients underwent colonoscopy performed with a 90-cm flexible threaded overtube and a variable-stiffness pediatric colonoscope. Four individuals (18%) required exchanging the colonoscope for an enteroscope.

MAIN OUTCOME MEASUREMENTS

Successful cecal intubation, polyp identification and removal, time to reach the cecum, sedation needed, and complications.

RESULTS

Cecal intubation was achieved in 22 patients (92%). Failures occurred in 2 patients with large hernias. The median time from insertion of the colonoscope to reaching the cecum was 14.5 minutes. All procedures were performed by using conscious sedation with midazolam (median dose 7 mg) and fentanyl (median dose 150 μg). Significant findings were encountered in 17 of 22 patients (77%) including 1 cancer and 2 advanced polyps. A median of 3 polyps was removed from each patient who had polyps. All noncancerous polyps were removed during the procedure. There were no complications.

LIMITATIONS

Retrospective design, no control group, single center.

CONCLUSION

Spiral overtube-assisted colonoscopy can enable cecal intubation in the majority of patients in whom standard colonoscopy fails because of a redundant colon.

The impact of advances in instrumentation and techniques of colonoscopy from 1988 to 2008 on inpatient colonoscopy performance at a high volume endoscopy unit in the United States: significantly shorter procedure time, higher completion rate, performance on sicker inpatients, and near disappearance of flexible sigmoidoscopy

BACKGROUND AND AIMS

Colonoscopy instrumentation and technique have improved from 1988 to 2008. We analyze whether these improvements have resulted in improved colonoscopy performance.

METHODS

This was a retrospective study of 50 consecutive inpatients in 1988 vs. 1998 vs. 2008 undergoing intended colonoscopy at a teaching hospital. Patient APACHE score, cecal and terminal ileal intubation rates, procedure time, and colonoscopic diagnoses were compared for the three different years.

RESULTS

Changes in practice of inpatient colonoscopy in 2008 from 1988 include (1) remarkably sicker inpatients undergoing colonoscopy in 2008, as indicated by: significantly higher mean APACHE II score (11.0 ± 6.6 vs. 5.9 ± 4.1, P < 0.00001), significantly more frequent monitored bed status (58% vs. 10%, OR = 12.4; 95%-ORCI: 4.31-35.4, P < 0.00001), and significantly higher rates of several chronic diseases (e.g. CHF, 24% vs. 6%, P = 0.02); (2) significantly higher colonoscopy completion rate in 2008 (88% vs. 64%; OR = 4.13, 95%-ORCI: 1.51-11.2, P = 0.009); (3) significantly higher terminal ileum intubation rate in 2008 (44% vs. 14%, OR = 4.83, 95%-ORCI: 1.85-12.5, P = 0.002); and (4) significantly shorter mean procedure time in 2008 (26.3 ± 7.9 min vs. 48.0 ± 20.3 min, P < 0.00001). The ratio of intended colonoscopy/flexible sigmoidoscopy was significantly higher in 2008 vs. 1988 (OR = 7.50, 95%-ORCI: 2.56-21.8, P < 0.00001). Internal hemorrhoids were significantly more frequently diagnosed by colonoscopy in 2008 (44% vs. 12%, OR = 5.76, 95%-ORCI: 2.12-15.5, P = 0.001), attributed to increased rectal retroflexion.

CONCLUSIONS

Due to improved instrumentation and technique, colonoscopy has dramatically changed from 1988 to become a clinically more valuable test in 2008 as manifested by a higher completion rate, greater clinical applicability, and shorter procedure time. Colonoscopy is supplanting flexible sigmoidoscopy.

Complications of colonoscopy: magnitude and management

Although complications of colonoscopy are rare, they are potentially serious and life threatening. In addition, less serious adverse events may occur frequently and may have an impact on a patient's willingness to undergo future procedures. This article reviews the magnitude of and risk factors for major and minor colonoscopy complications, discusses management of complications, and suggests ways to design quality improvement programs to reduce the risk of complications.

Observational study of the frequency of use and perceived usefulness of ancillary manoeuvres to facilitate colonoscopy completion

BACKGROUND

A paucity of information exists regarding the frequency of use and usefulness of ancillary manoeuvres such as applying abdominal pressure and changing patient position to successfully complete colonoscopy. This information would be useful to understand and improve colonoscopy technique.

AIM

We sought to determine the frequency, type and perceived success of ancillary manoeuvres used when performing colonoscopy during routine clinical practice.

PATIENTS AND METHODS

A prospective, observational study was conducted at an outpatient endoscopy centre with a diverse group of colonoscopists. Our hypothesis was that ancillary manoeuvres would be used frequently by endoscopists of varying levels of experience and would be helpful in achieving successful caecal intubation. Information collected included patient and staff characteristics, procedural information and use of ancillary manoeuvres. Additional descriptive information was obtained when a manoeuvre was performed.

RESULTS

One thousand three hundred and twenty-seven patients participated (691 women; mean age 62.5+/-12.3). The caecum was reached in 94% of cases. One or more ancillary manoeuvres were used in 73% of cases. Whilst one or two manoeuvres were helpful to achieve caecal intubation, increased manoeuvres were associated with an increased risk of incomplete colonoscopy.

CONCLUSION

These data suggest that ancillary manoeuvres are used frequently but are not necessarily predictive of successful caecal intubation. Additional data from prospective, randomised studies are needed to address the overall utility and optimal application of individual manoeuvres.

Colonoscopy: Art or science?

The focus on colorectal neoplasia has led to an exponential increase in the use of colonoscopy in many countries. Although colonoscopy facilitates the diagnosis and treatment of colonic disease, there are public health issues that include access, training, diagnostic accuracy, complications and additions to health-care costs. Because of this, colonoscopists have a responsibility to ensure that the procedure is appropriate, safe and of high-quality. This article addresses the issue of variation in technical skills that is known to exist within the endoscopic community, even among individuals with similar experience. While some of this variation reflects innate manual dexterity, another aspect is variation in the adoption of technical manoeuvers that facilitate various aspects of the procedure including rates for cecal intubation. Although technical manoeuvers are difficult to evaluate in controlled trials, there is persuasive data that high cecal intubation rates can be achieved by minimizing inflation and looping in the sigmoid colon and by the appropriate use of positional changes and abdominal pressure. In difficult settings, there is also benefit from the use of non-standard endoscopes and various accessories including overtubes.