The effect of colonoscopy preparation quality on adenoma detection rates

Risk factors for inadequate bowel preparation before colonoscopy: A meta-analysis

OBJECTIVE

This meta-analysis aimed to comprehensively explore the risk factors for inadequate bowel preparation (IBP).

METHODS

We searched the Embase, PubMed, Web of Science, and The Cochrane Library databases up to August 24, 2023, to identify observational studies and randomized controlled trials (RCTs) that examined risk factors for IBP. A random effects model was used to pool the adjusted odds ratios and 95% confidence intervals.

RESULTS

A total of 125 studies (91 observational studies, 34 RCTs) were included. Meta-analyses of observational studies revealed that three preparation-related factors, namely, characteristics of last stool (solid or brown liquid), incomplete preparation intake, and incorrect diet restriction, were strong predictors of IBP. The other factors were moderately correlated with IBP incidence, including demographic variables (age, body mass index, male sex, Medicaid insurance, and current smoking), comorbidities (diabetes, liver cirrhosis, psychiatric disease, Parkinson's disease, previous IBP, poor mobility, inpatient, and Bristol stool form 1/2), medications (tricyclic antidepressants, opioids, antidepressants, narcotics, antipsychotics, and calcium channel blockers), and preparation-related factors (preparation-to-colonoscopy interval not within 3 to 5/6 h, nonsplit preparation, and preparation instructions not followed). No colonoscopy indications were found to be related to IBP. Meta-analyses of RCTs showed that education, constipation, stroke/dementia, and discomfort during preparation were also moderately associated with IBP. Most of the other findings were consistent with the pooled results of observational studies. However, primarily due to imprecision and inconsistency, the certainty of evidence for most factors was very low to moderate.

CONCLUSIONS

We summarized five categories of risk factors for IBP. Compared to demographic variables, comorbidities, medications, and colonoscopy indications, preparation-related elements were more strongly associated with IBP. These findings may help clinicians identify high-risk individuals and provide guidance for IBP prevention.

Evaluating the Efficacy of Resect-and-Discard and Resect-and-Retrieve Strategies for Diminutive Colonic Polyps

BACKGROUND AND OBJECTIVES

Diminutive polyps present a unique challenge in colorectal cancer (CRC) prevention strategies. This study aims to assess the characteristics and variables of diminutive polyps in a Romanian cohort, intending to develop a combined resect-and-retrieve or resect-and-discard strategy that reduces the need for an optical diagnosis.

MATERIALS AND METHODS

A prospective cohort study was conducted at two endoscopy centers in Romania from July to December 2021. Adult patients undergoing colonoscopies where polyps were identified and resected were included. Endoscopic procedures employed advanced diagnostic features, including blue-light imaging (BLI) and narrow-band imaging (NBI). Logistic regression analysis was utilized to determine factors impacting the probability of adenomatous polyps with high-grade dysplasia (HGD).

RESULTS

A total of 427 patients were included, with a mean age of 59.42 years (±11.19), predominantly male (60.2%). The most common indication for a colonoscopy was lower gastrointestinal symptoms (42.6%), followed by screening (28.8%). Adequate bowel preparation was achieved in 87.8% of cases. The logistic regression analysis revealed significant predictors of HGD in adenomatous polyps: age (OR = 1.05, 95% CI: 1.01-1.08, p = 0.01) and polyp size (>5 mm vs. ≤5 mm, OR = 4.4, 95% CI: 1.94-10.06, p < 0.001). Polyps classified as Paris IIa, Ip, and Isp were significantly more likely to harbor HGD compared to the reference group (Is), with odds ratios of 6.05, 3.68, and 2.7, respectively.

CONCLUSIONS

The study elucidates significant associations between the presence of HGD in adenomatous polyps and factors such as age, polyp size, and Paris classification. These findings support the feasibility of a tailored approach in the resect-and-discard and resect-and-retrieve strategies for diminutive polyps, potentially optimizing CRC prevention and intervention practices. Further research is warranted to validate these strategies in broader clinical settings.

Individualized intervention based on a preparation-related prediction model improves adequacy of bowel preparation: A prospective, multi-center, randomized, controlled study

AIMS

An easy-to-use preparation-related model (PRM) predicting inadequate bowel preparation (BP) was developed and proved superior to traditional models in our previous study. Here we aimed to investigate whether PRM-based individualized intervention can improve BP adequacy.

METHODS

Patients undergoing morning colonoscopy were prospectively enrolled in 5 endoscopic centers in China. After standard BP of split-dose polyethylene glycol (PEG) was completed, patients were randomized (1:1) to the individualized group or standard group. High-risk patients predicted by PRM score ≥3 were instructed to drink an additional 1.5 L PEG in the individualized group while not in standard group. The primary endpoint was the rate of adequate BP, defined by segmental Boston bowel preparation scale ≥2. Secondary outcomes included adenoma detection rate (ADR) and adverse events.

RESULTS

900 patients were randomly allocated to the individualized group (n = 449) and the control (n = 451). Baseline characteristics were similar between the two groups. The rates of high-risk patients were 19.6 % in individualized group and 19.7 % in standard group. In intention-to-treat analysis, adequate BP was 91.8 % in individualized group and 84.7 % in the standard group (p = 0.001). Among high-risk patients, adequate BP rate was 94.3 % in individualized group and 49.3 % in standard group (p < 0.001), and ADR were 40.9 % vs 16.9 %, respectively (p < 0.001). No significant differences were found regarding the adverse events and willingness to repeat BP (all p >0.05).

CONCLUSIONS

The individualized intervention using an additional dose of PEG to high-risk patients predicted by PRM, significantly improved BP quality. The intervention significantly improved ADR in high-risk patients. (ClinicalTrials.gov number: NCT04434625).

The status quo of short videos as a source of health information regarding bowel preparation before colonoscopy

Background

For high-quality colonoscopies, adequate bowel preparation is a prerequisite, closely associated with the diagnostic accuracy and therapeutic safety of colonoscopy. Although popular-science short videos can help people quickly access health information, the overall quality of such short videos as a source of health information regarding bowel preparation before colonoscopy is unclear. Therefore, we intend to conduct a cross-sectional study to investigate the quality of bowel preparation information before colonoscopy through short videos taken on TikTok and Bilibili.

Methods

The Chinese phrases "colonoscopy" and "bowel preparation" were used as keywords to search for and screen the top 100 videos in the comprehensive rankings on TikTok and Bilibili. The Global Quality Score (GQS) and the modified DISCERN score were used to assess the quality of the information provided in these short videos.

Results

A total of 186 short videos were included in this study; 56.5% of them were posted by health professionals, whereas 43.5% of them were posted by nonhealth professionals. The overall quality of these videos was unsatisfactory, with a median DISCERN score of 3 (2-4) and a median GQS of 3 (3-4). The radar maps showed that videos posted by gastroenterologists had higher completeness scores regarding outcomes, management, and risk factors, while nongastroenterologists had higher completeness scores concerning adverse effects, symptoms, and definitions of bowel preparation. Additionally, the median DISCERN score and GQS of the videos posted by gastroenterologists were 3 (3-4) and 3 (3-4), respectively, whereas the quality of the videos posted by patients was the worst, with a median DISCERN score of 2 (1-2) and a median GQS of 2 (1.25-3).

Conclusion

In conclusion, the overall quality of health information-related videos on bowel preparation before colonoscopy posted on specified short video platforms was not satisfactory. Gastroenterologists provide more information on the outcomes, management, and risk factors for bowel preparation before colonoscopy, while nongastroenterologists focus on adverse effects, symptoms, and definitions of bowel preparation.

Excellent Bowel Preparation Quality Is Not Superior to Good Bowel Preparation Quality for Improving Adenoma/Polyp Detection Rate

Background

Adequate bowel preparation quality is essential for high-quality colonoscopy according to the current guidelines. However, the excellent effect of bowel preparation on adenoma/polyp detection rate (ADR/PDR) remained controversial.

Methods

During the period from December 2020 to August 2022, a total of 1566 consecutive patients underwent colonoscopy by an endoscopist. Their medical records were reviewed. According to the Boston bowel preparation scale, patients were divided into excellent, good, and poor bowel preparation quality groups. ADR/PDR, diminutive ADR/PDR, small ADR/PDR, intermediate ADR/PDR, large ADR/PDR, and number of adenomas/polyps were compared among them. Logistic regression analyses were performed to identify the factors that were significantly associated with ADR/PDR.

Results

Overall, 1232 patients were included, of whom 463, 636, and 133 were assigned to the excellent, good, and poor groups, respectively. The good group had a significantly higher ADR/PDR (63% vs 55%, P = .015) and a larger number of adenomas/polyps (2.5 ± 3.2 vs 2.0 ± 2.8, P = .030) than the poor group. Both ADR/PDR (63% vs 55%, P = .097) and number of adenomas/polyps (2.2 ± 2.8 vs 2.0 ± 2.8, P = .219) were not significantly different between excellent and poor groups. The excellent (9% vs 4%, P = .045) and good (9% vs 4%, P = .040) groups had a significantly higher intermediate ADR/PDR than the poor group. Logistic regression analyses showed that either good (odds ratio [OR] = 1.786, 95% CI = 1.046-3.047, P = .034) or excellent (OR = 2.179, 95% CI = 1.241-3.826, P = .007) bowel preparation quality was independently associated with a higher ADR/PDR compared with poor bowel preparation quality. Excellent (OR = 1.202, 95% CI = 0.848-1.704, P = .302) bowel preparation quality was not independently associated with a higher ADR/PDR compared with good bowel preparation quality.

Conclusions

The pursuit of excellence in bowel preparation does not show an association with increased ADR/PDR and number of adenomas/polyps compared with a good level. In addition, our study further contributes to the existing evidence that poor bowel preparation compromises ADR/PDR and number of adenomas/polyps.

CCRA: A colon cleanliness rating algorithm based on colonoscopy video analysis

Objective

A Colon Cleanliness Rating Algorithm (CCRA) based on colonoscopy image analysis is proposed in this paper, in order to solve the problem that the results of Colon Cleanliness (or Bowel Preparation Quality) rating caused by manual inspection are inconsistent.

Methods

Firstly, CCRA intercepts images from the colonoscopy video. Secondly, each colonoscopy image's stool area is segmented by U-Net to obtain the 2-classification segmentation results. Finally, the colon cleanliness is obtained by comparing the average area of the stool area with the standard proportion.

Results

After testing, the pixel accuracy of the U-Net model is 97.02 %, IoU is 83.67 %, accuracy is 92.17 %, recall is 90.21 %, F1-Score is 90.95 %. The accuracy of CCRA is 92.45 %-99.275.

Conclusion

The experimental results show that the CCRA proposed in this paper can quickly and accurately output the colon cleanliness rating of patients without manpower.

Correlation between prescribing doctor attributes and intestinal cleanliness in colonoscopy: a study of 22522 patients

OBJECTIVE

This study aimed to analyze the correlation between different attributes of doctors who prescribe colonoscopies and the cleanliness of the intestine to guide the development of colonoscopy application protocols.

METHODS

Data on colonoscopy cases conducted in the gastroenterology department of Hangzhou First People's Hospital between April 2018 and March 2021 were collected. The gender, age, professional attributes of the prescribing doctors, and Boston Bowel Preparation Scale (BBPS) score were recorded. In addition, the correlation between the prescribing doctors' characteristics and the intestine's cleanliness was analyzed.

RESULTS

The study included 22,522 patients with a mean BBPS score of 6.83 ± 1.94. There were 16,459 male and 6,063 female doctors with similar BBPS scores (p = 0.212). The study found no significant difference in BBPS scores between 19,338 internist and 3,184 non-internist (p = 0.154). However, BBPS scores differed significantly between 18,168 gastroenterologists and 4,354 non-gastroenterologists (p = 0.016) and between 19,990 intestinal-related specialties(gastroenterology and gastrointestinal surgery) and 2,532 non-intestinal-related specialties (p = 0.000). In addition, BBPS scores were significantly different between 18,126 prescribing endoscopiests and 4,396 non-endoscopiests (p = 0.014). However, there was no significant difference in BBPS scores among doctors of different ages (p = 0.190). The study found significant differences in BBPS scores between male and female patients and those under or over 40 years (p = 0.000).

CONCLUSION

To improve colonoscopy preparation quality, priority should be given to doctors in gastroenterology, intestinal-related specialties, and endoscopiests. Their expertise may result in better education and improved bowel cleanliness.

Gastroenterologist focus of clinical practice affects adenoma detection in screening colonoscopy

Our objective was to determine whether the clinical focus of gastroenterology practice would affect screening colonoscopy quality metrics, specifically adenoma detection (AD). In a retrospective study of screening colonoscopies, gastroenterologists were categorized based on their clinical subspecialty focus into general/motility, hepatology, inflammatory bowel disease (IBD), and interventional endoscopy. The primary outcome was AD with a secondary outcome of adenoma and/or sessile serrated polyp (SSP) detection (AD + SSP). A total of 5271 (male: 49.1%) complete colonoscopies were performed between 2010 and 2020 by 16 gastroenterologists (male: 62.5%, general/motility specialists: 3, hepatologists: 3, IBD specialists: 4, interventional endoscopists: 6). The AD and AD + SSP rate between each specialty focus were 27.5% and 31.0% for general/motility, 31.4% and 35.5% for hepatology, 38.4% and 43.6% for IBD, and 37.5% and 43.2% for interventional endoscopy. In regression analysis, patient's male gender (odds ratios [OR]: 1.81, 95% CI: 1.60-2.05, P < .001), longer withdrawal time (OR: 1.16, 95% CI: 1.14-1.18, P < .001), hepatologist (OR: 1.25, 95% CI: 1.02-1.53, P = .029), IBD subspecialist (OR: 1.60, 95% CI: 1.30-1.98, P < .001), and interventional endoscopist (OR: 1.36, 95% CI: 1.13-1.64, P < .001) were independently associated with AD. Moreover, patient's male gender (OR: 1.64, 95% CI: 1.45-1.85, P < .001), acceptable bowel preparation (OR: 1.29, 95% CI: 1.06-1.56, P = .010), withdrawal time (1.20, 95% CI: 1.18-1.22, P < .001), hepatologist (OR: 1.30, 95% CI: 1.07-1.59, P = .008), IBD subspecialist (OR: 1.72, 95% CI: 1.39-2.12, P < .001), interventional endoscopist (OR: 1.44, 95% CI: 1.20-1.72, P < .001) were independent factors that improved detection of AD + SSP. Subspecialty focus of practice was an important factor in AD rate along with the male gender of the patient, bowel preparation, and withdrawal time.

Efficacy of oral sulfate tablets for bowel preparation and adenoma detection rate

BACKGROUND AND AIM

The adenoma detection rate (ADR), which is closely related to bowel preparation, is the most important factor for colonoscopy quality assessment. New oral sulfate tablets (OSTs) have been developed to improve bowel preparation compliance. This study evaluated the efficacy of OSTs in terms of the ADR and bowel preparation status.

METHODS

Medical records of subjects under the age of 65 who underwent colonoscopy from March 2019 to February 2021 were retrospectively reviewed. Polyethylene glycol with ascorbic acid (PEG-A) was used as a bowel preparation for the first half of the study period, and OSTs were used for the second half. In total, 16 971 subjects were included in the study: 9199 (54.2%) used PEG-A, and 7772 (45.8%) used OSTs. Bowel cleansing quality was assessed by the Boston Bowel Preparation Scale (BBPS).

RESULTS

The average age was 50 years. The rate of adequate bowel preparation was higher in the OST group than in the PEG-A group (97.2% vs 95.0%, P < 0.001). The mean BBPS was also higher in the OST group (8.02 vs 7.75, P < 0.001). The adenomas per colonoscopy (APC), the ADR and the sessile serrated polyp detection rate (SSPDR) were higher in the OST group than in the PEG-A group (APC 0.56 ± 1.01 vs 0.48 ± 0.91, P < 0.001; ADR 34.5% vs 30.7%, P < 0.001; SSPDR 5.2% vs 3.3%, P < 0.001).

CONCLUSIONS

Compared with PEG-A, OSTs yielded superior APC, ADRs, SSPDRs, and better bowel cleanliness. Therefore, OSTs are a good alternative for patients who have difficulty taking large-volume bowel preparation formulations.

SPLIT-DOSE BOWEL PREPARATION IS SUPERIOR TO STRAIGHT-DOSE IN HOSPITALIZED PATIENTS UNDERGOING INPATIENT COLONOSCOPY

BACKGROUND

There is a two-fold higher rate of failed colonoscopy secondary to inadequate bowel preparation among hospitalized versus ambulatory patients. Split-dose bowel preparation is widely used in the outpatient setting but has not been generally adapted for use among the inpatient population.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of split versus single dose polyethylene glycol bowel (PEG) preparation for inpatient colonoscopies and determine additional procedural and patient characteristics that drive inpatient colonoscopy quality.

METHODS

A retrospective cohort study was performed on 189 patients who underwent inpatient colonoscopy and received 4 liters PEG as either split- or straight-dose during a 6-month period in 2017 at an academic medical center. Bowel preparation quality was assessed using Boston Bowel Preparation Score (BBPS), Aronchick Score, and reported adequacy of preparation.

RESULTS

Bowel preparation was reported as adequate in 89% of the split-dose group versus 66% in the straight-dose group (P=0.0003). Inadequate bowel preparations were documented in 34.2% of the single-dose group and 10.7% of the split-dose group (P<0.001). Only 40% of patients received split-dose PEG. Mean BBPS was significantly lower in the straight-dose group (Total: 6.32 vs 7.73, P<0.001).

CONCLUSION

Split-dose bowel preparation is superior to straight-dose preparation across reportable quality metrics for non-screening colonoscopies and was readily performed in the inpatient setting. Interventions should be targeted at shifting the culture of gastroenterologist prescribing practices towards use of split-dose bowel preparation for inpatient colonoscopy.

Characteristics of Interval Colorectal Cancer: A Canadian Retrospective Population-Level Analysis from Newfoundland and Labrador

Interval colorectal cancers (I-CRCs) arise during the interval time period between scheduled colonoscopies. Predicting which patients are at risk of I-CRCs remains an elusive undertaking, but evidence would suggest that most I-CRCs arise from lesions missed on index endoscopy. The procedural factors that lead to missed lesions are numerous and lack consensus in the literature. In Canada, the province of Newfoundland and Labrador has the highest incidence of CRCs. In this study our aim was to examine I-CRCs (3-60 months after last colonoscopy) in NL through a population-level analysis covering 67% of the province from 2001-2018. We estimated the I-CRC rate to be up to 9.3%. Median age of I-CRC diagnosis was 67.1 years with an interval time of 2.9 years. About 57% of these tumors occurred proximal to the splenic flexure, with 53% presenting as local disease. No temporal differences were observed in interval time or tumor distribution. On univariate and multivariable logistical regression, risk of right-sided I-CRC did not correlate to the index colonoscopy indication, bowel preparation quality, size of largest polyp removed, colonoscopy completion rate, or stage at presentation. Improvements in synoptic reporting utilization and national registries are needed to identity risk factors and reduce I-CRC frequency.

Bowel cleansing efficacy of 1 L NER1006versus macrogol and 3 L polyethylene glycol using split-dose administration

Background and Aim

Colonoscopies are an important diagnostic technique in the detection of colorectal cancer and colonic disease. Adequate examination is dependent on the degree of mucosal visibility, with poor cleansing impeding the detection of neoplasms. These patients require shorter colonoscopy surveillance intervals, longer hospital stays, and increased healthcare costs-rendering a screening colonoscopy cost-ineffective. In Australia and the Gold Coast Hospital and Health Service (GCHHS), macrogol and 3 L of polyethylene glycol are the preferred regimen given its safety profile and efficacy. Yet, little is known locally about the use of the new low-volume bowel preparation NER1006 (Plenvu) given its recent registration with the Therapeutic Goods of Australia (TGA). The primary outcome assessed the bowel cleansing efficacy of NER1006 compared with 7 days of macrogol and 3 L of polyethylene glycol using the Boston Bowel Preparation Scale (BBPS), while also assessing the influence of notable patient characteristics such as age, gender, body mass index (BMI), and the patients Charlson comorbidity index (CCI). Secondary outcomes assessed the polyp detection rate and procedural factors including cecal intubation, scope withdrawal time, and rebooking rates.

Methods

Data from all patients who underwent an outpatient colonoscopy procedure at GCHHS between 1 July 2020 and 30 September 2020 were analyzed. Patients were aged 50-74 years of age and were referred for a screening colonoscopy due to a positive fecal occult blood test (FOBT) result from the National Bowel Cancer Screening Program.

Results

Of the 238 patients who met the inclusion criteria, 108 patients received NER1006 and 130 patients received macrogol and 3 L polyethylene glycol. NER1006 achieved superior overall (P < 0.001) and right-sided colon cleansing (P = 0.016). There was an even distribution of males and females (P = 0.118), the mean age of both cohorts was <65 years of age. The macrogol and 3 L polyethylene glycol group had a statistically higher BMI (P < 0.001) and CCI (P < 0.001). Cecal intubation success was achieved in both cohorts (≥95%) and scope withdrawal time was ≥6 min, polyp detection was non-superior (P = 0.824), but superior in NER1006 when BBPS ≥6 (P = 0.002). Rebooking rates were significantly lower in the NER1006 group (P = 0.013).

Conclusion

This study demonstrated that NER1006 was superior in terms of overall and right-sided bowel cleansing as a primary endpoint. Patient factors demonstrated to be independent predictors of inadequate bowel preparation. Future studies should aim to explore the safety and tolerability of NER1006 while also assessing the bowel cleansing effectiveness in patients with a high BMI and comorbidity index.

Existing Bowel Preparation Quality Scales Are Reliable in the Setting of Centralized Endoscopy Reading

BACKGROUND

Development of bowel preparation products has been based upon colon cleansing rating by a local endoscopist. It is unclear how bowel preparation scales perform when centrally evaluated.

AIMS

To evaluate the reliability of bowel preparation quality scales when assessed by central readers.

METHODS

Four central readers evaluated 52 videos in triplicate, 2 weeks apart, during the entire endoscopic procedure (insertion/withdrawal of the colonoscope) and exclusively on colonoscope withdrawal using the Boston Bowel Preparation Scale (BBPS), Chicago Bowel Preparation scale, Harefield Cleansing Scale, Ottawa Bowel Preparation Quality Scale (OBPQS), Aronchick score, a visual analogue scale, and additional items proposed in a modified Research and Development/University of California Los Angeles appropriateness process. Reliability was assessed with intraclass correlation coefficients.

RESULTS

Intraclass correlation coefficients (95% confidence interval) for inter-rater reliability of the quality scales ranged from 0.51 to 0.65 (consistent with moderate to substantial inter-rater reliability) during the entire procedure. Corresponding intraclass correlation coefficients for intra-rater reliability ranged from 0.69 to 0.77 (consistent with substantial intra-rater reliability). Reliability was highest in the right colon and lowest in the left colon. No differences were observed in reliability when assessed for the procedure overall (insertion/withdrawal) relative to assessment on withdrawal alone.

CONCLUSION

All five bowel preparation quality scales had moderate to substantial inter-rater reliability. Panelists considered the Aronchick score too simplistic for clinical trials and recognized that assessment of residual fluid in the Ottawa Bowel Preparation Quality Scale was not amenable to central assessment.

Comparative Effectiveness of Enhanced Patient Instructions for Bowel Preparation Before Colonoscopy: Network Meta-analysis of 23 Randomized Controlled Trials

Background

Various enhanced patient instructions (EPIs) have been used for bowel preparation (BP) and our previous meta-analysis also demonstrated the efficacy of EPIs in increasing the colonic polyp and adenoma detection rates; however, the optimal method for adequate BP has not yet been developed.

Objective

We performed a network meta-analysis to determine the optimal instructions.

Methods

We searched for randomized controlled trials (RCTs) comparing the effectiveness of EPIs with each other or standard patient instructions (SPIs) for BP. We performed direct and Bayesian network meta-analyses for all instructions and used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria to appraise the quality of evidence.

Results

We included 23 RCTs (7969 patients) comparing 10 different instructions. In direct meta-analyses, most of the EPIs, except visual aids and mobile apps, increased the adequate preparation rate (APR). Network meta-analyses showed that additional explanations were superior to visual aids (odds ratio [OR] 0.35, 95% CI 0.19-0.59), telephone calls (OR 0.62, 95% CI 0.37-0.99), educational videos (OR 0.79, 95% CI 0.5-0.77), and mobile apps (OR 0.33, 95% CI 0.14-0.68) with low-to-high-quality evidence; newly designed booklets (OR 3.28, 95% CI 1.59-6.16), SMS text messaging (OR 2.33, 95% CI 1.28-3.91), telephone calls (OR 1.86, 95% CI 1.03-1.78), educational videos (OR 2.33, 95% CI 1.40-3.65), and social media applications (OR 2.42, 95% CI 1.4-3.93) were superior to visual aids and mobile apps with low-to-high-quality evidence. SMS text messaging, telephone calls, and social media applications increase adherence to and satisfaction with the BP regime. Social media applications reduce the risk of adverse events (AEs). Telephone calls and social media applications increase the polyp detection rate (PDR).

Conclusions

Newly designed booklets, telephone calls, educational videos, and social media applications can improve the quality of BP. Telephone calls and social media applications improve adherence to and satisfaction with the BP regime, reduce the risk of AEs, and increase the PDR.

Trial Registration

INPLASY (International Platform of Registered Systematic Review and Meta-analysis Protocols) INPLASY2020120103; https://inplasy.com/inplasy-2020-12-0103/

Thoughts on factors related to colonoscopy quality

With the increase in health consciousness and the prevalence of early gastrointestinal cancer screening, the number of diagnosed cases of colorectal polyps and adenomas in the Chinese general population has substantially increased. However, the overall adenoma detection rate (ADR) in China remains lower than the global standard of 30%. High quality colonoscopy is pivotal for increasing the ADR and reducing the risk of interval colon cancer. A few factors are related to the quality of colonoscopy, including preoperative evaluation of examinees, bowel preparation, techniques for intubation, use of image enhancement endoscopy, withdraw time, and prevention of adverse events.

Comprehensive evaluation of the learning curve to achieve satisfactory adenoma detection rate

BACKGROUND AND AIM

The number of colonoscopies required to reach satisfactory adenoma detection rate (ADR) is not well established. The aim of this study was to identify the appropriate number of procedures required to attain satisfactory ADR for those well-trained endoscopists who have a cecal intubation rate (CIR) ≥ 90% and start to perform colonoscopy independently.

METHODS

All endoscopists with compelete independent colonoscopy data during career in our database were enrolled. The number of procedures required to achieve ADR ≥ 20% was identified by cumulative summation (Cusum), learning curve Cusum (LC-Cusum), and moving average method. Mixed effect logistic regression model was developed to determine the relationship between endoscopist as well as patient-related factors and adenoma detection.

RESULTS

A total of 24 943 procedures and 14 endoscopists were enrolled. By Cusum analysis, the interest point was at 207 procedures. By LC-Cusum analysis, 71% (10/14) and 86% (12/14) of endoscopists had attained satisfactory ADR after 200 and 300 procedures, respectively. By moving average method, endoscopists reached a mean ADR of 20% at 216 and 261 procedures over blocks of 50 and 100 procedures, respectively. The total number of procedures, number of daily procedures, patient age and gender, bowel preparation, sedation, and diverticulosis were significantly associated with adenoma detection.

CONCLUSIONS

This is the first study to investigate the learning curve of ADR for those well-trained endoscopists who have a CIR ≥ 90% and start to perform colonoscopy independently. Two hundred procedures might be an optimal number required to reach an ADR ≥ 20%.

Smartphone Application to Reinforce Education Increases High-Quality Preparation for Colorectal Cancer Screening Colonoscopies in a Randomized Trial

BACKGROUND & AIMS

Sufficient bowel preparation is crucial for successful screening and surveillance colonoscopy. However, rates of inadequate preparation are still high. We investigated the effects of reinforced patient education using a smartphone application software (APP) for colonoscopy preparation in participants in a CRC screening program.

METHODS

We performed a prospective, endoscopist-blinded study of 500 patients undergoing split-dose bowel preparation for CRC screening or surveillance colonoscopies at multiple centers in Germany, from November 2017 through January 2019. Participants (n = 500) were given oral and written instructions during their initial appointment and then randomly assigned (1:1) to groups that received reinforced education starting 3 days before the colonoscopy (APP group) or no further education (controls). The primary outcome was quality of bowel preparation according to the Boston bowel preparation scale. Secondary outcomes included polyp and adenoma detection rates, compliance with low-fiber diet, split-dose laxative intake, perceived discomfort from the preparation procedure.

RESULTS

The mean Boston bowel preparation scale score was significantly higher in the APP-group (7.6 ± 0.1) than in the control group (6.7 ± 0.1) (P < .0001). The percentage of patients with insufficient bowel preparation was significantly lower in the APP group (8%) than in the control group (17%) (P = .0023). The adenoma detection rate was significantly higher in the APP group (35% vs 27% in controls) (P = .0324). Use of the APP was accompanied by a lower level of non-compliance with correct laxative intake (P =.0080) and diet instructions (P = .0089). The APP group reported a lower level of discomfort during preparation (P < .0001).

CONCLUSIONS

In a randomized trial, reinforcing patient education with a smartphone application optimized bowel preparation in the 3 days before colonoscopy, increasing bowel cleanliness, adenoma detection, and compliance in patients undergoing CRC screening or surveillance. ClinicalTrials.gov no: NCT03290157.

Enhanced Patient Education for Colonic Polyp and Adenoma Detection: Meta-Analysis of Randomized Controlled Trials

Background

To improve patients’ comprehension of bowel preparation instructions before colonoscopy, enhanced patient education (EPE) such as cartoon pictures or other visual aids, phone calls, mobile apps, multimedia education and social media apps have been proposed. However, it is uncertain whether EPE can increase the detection rate of colonic polyps and adenomas.

Objective

This meta-analysis aimed to evaluate the efficacy of EPE in detecting colonic polyps and adenomas.

Methods

We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from their inception to June 2019 for the identification of trials comparing the EPE with standard patient education for outpatients undergoing colonoscopy. We used a random effects model to calculate summary estimates of the polyp detection rate (defined as the number of patients with at least one polyp divided by the total number of patients undergoing selective colonoscopy), adenoma detection rate (defined as the number of patients with at least one adenoma divided by the total number of patients undergoing selective colonoscopy), advanced adenoma detection rate (defined as the number of patients with at least one advanced adenoma divided by the total number of patients undergoing selective colonoscopy), sessile serrated adenoma detection rate (defined as the number of patients with at least one sessile serrated adenoma divided by the total number of patients undergoing selective colonoscopy), cancer detection rate (defined as the number of patients with at least one cancer divided by the total number of patients undergoing selective colonoscopy), or adenoma detection rate - plus (defined as the number of additional adenomas found after the first adenoma per colonoscopy). Moreover, we conducted trial sequential analysis (TSA) to determine the robustness of summary estimates of all primary outcomes.

Results

We included 10 randomized controlled trials enrolling 4560 participants for analysis. The meta-analysis suggested that EPE was associated with an increased polyp detection rate (9 trials; 3781 participants; risk ratio [RR] 1.19, 95% CI 1.05-1.35; P<.05; I²=42%) and adenoma detection rate (5 trials; 2133 participants; RR 1.37, 95% CI 1.15-1.64; P<.001; I2=0%), which were established by TSA. Pooled result from the inverse-variance model illustrated an increase in the sessile serrated adenoma detection rate (3 trials; 1248 participants; odds ratio 1.76, 95% CI 1.22-2.53; P<.05; I²=0%). One trial suggested an increase in the adenoma detection rate - plus (RR 4.39, 95% CI 2.91-6.61; P<.001). Pooled estimates from 3 (1649 participants) and 2 trials (1375 participants) generated no evidence of statistical difference for the advanced adenoma detection rate and cancer detection rate, respectively.

Conclusions

The current evidence indicates that EPE should be recommended to instruct bowel preparation in patients undergoing colonoscopy because it can increase the polyp detection rate, adenoma detection rate, and sessile serrated adenoma detection rate. However, further trials are warranted to determine the efficacy of EPE for advanced adenoma detection rate, adenoma detection rate - plus, and cancer detection rate because of limited data.

Multidirectional Colonoscopy Quality Improvement Increases Adenoma Detection Rate: Results of the Seoul National University Hospital Healthcare System Gangnam Center Colonoscopy Quality Upgrade Project (Gangnam-CUP)

BACKGROUND

To prevent colorectal cancer, high-quality colonoscopy is advocated, undertaken by endoscopists with high adenoma detection rates (ADRs). Despite reports that various factors may impact ADRs, the significance of such factors is still unclear.

AIMS

The analysis was aimed at quality-oriented interventions for boosting ADRs.

METHODS

Study enrollees were adults subjected to screening colonoscopy between September 2013 and August 2016 at the Gangnam Center of Seoul National University Hospital Healthcare System. The investigation entailed six periods (P1-6) of 6 months each, during which serial multidirectional quality improvement efforts were instituted. In particular, we sought to further educate endoscopists, provide feedback on individual ADRs, and introduce a split-dose regimen, gauging results via the Boston Bowel Preparation Score. Changes in polyp detection rates (PDRs) and ADRs were then analyzed.

RESULTS

A total of 13,430 colonoscopies were undertaken by 15 experienced endoscopists. Overall, the ADR increased from 45.6% (P1) to 48.2% (P6, p < 0.001). The PDR, ADR, and advanced adenoma detection rate (AdvADR) showed the greatest increases between P3 and P4 [PDR 67.8% → 71.2% (p < 0.001); ADR 44.1% → 47.7% (p = 0.001); AdvADR 2.3% → 3.3% (p = 0.028)] in keeping with the introduction of a split-dose regimen. The sessile serrated adenoma detection rate (SSADR) increased substantially from 2.1% (P1) to 7.9% (P6, p < 0.001), with the largest gain between P1 and P2, just after education (p = 0.023).

CONCLUSIONS

Successful quality improvement in colonoscopy was achieved through comprehensive multidirectional efforts in education, feedback, and enhanced bowel preparation. Achieving high-level bowel preparation was paramount in ADR improvement. The SSADR was improved through education.

The importance of colonoscopy bowel preparation for the detection of colorectal lesions and colorectal cancer prevention

Background and study aims  Colonoscopy for colorectal cancer (CRC) screening has reduced CRC incidence and mortality and improved prognosis. Optimal bowel preparation and high-quality endoscopic technique facilitate early CRC detection. This review provides a narrative on the clinical importance of bowel preparation for colonoscopy and highlights available bowel preparations. Methods  A PubMed search was conducted through June 2019 to identify studies evaluating clinical outcomes, efficacy, safety, and tolerability associated with bowel preparation for CRC screening-related colonoscopy. Results  Selecting the optimal bowel preparation regimen is based on considerations of efficacy, safety, and tolerability, in conjunction with individual patient characteristics and preferences. Available bowel preparations include high-volume (4 L) and low-volume (2 L and 1 L), polyethylene glycol (PEG) solutions, sodium sulfate, sodium picosulfate/magnesium oxide plus anhydrous citric acid, sodium phosphate tablets, and the over-the-counter preparations magnesium citrate and PEG-3350. These preparations may be administered as a single dose on the same day or evening before, or as two doses administered the same day or evening before/morning of colonoscopy. Ingesting at least half the bowel preparation on the day of colonoscopy (split-dosing) is associated with higher adequate bowel preparation quality versus evening-before dosing (odds ratio [OR], 2.5; 95 % confidence interval [CI], 1.9-3.4). Conclusions  High-quality bowel preparation is integral for optimal CRC screening/surveillance by colonoscopy. Over the last 30 years, patients and providers have gained more options for bowel preparation, including low-volume agents with enhanced tolerability and cleansing quality that are equivalent to 4 L preparations. Split-dosing is preferred for achieving a high-quality preparation.

Cloud-based multi-media systems for patient education and adherence: a pilot study to explore patient compliance with colonoscopy procedure preparation

Technology based patient education and adherence approaches are increasingly utilized to instruct and remind patients to prepare correctly for medical procedures. This study examines the interaction between two primary factors: patterns of patient adherence to challenging medical preparation procedures; and the demonstrated, measurable potential for cloud-based multi-media information technology (IT) interventions to improve patient adherence. An IT artifact was developed through prior design science research to serve information, reminders, and online video instruction modules to patients. The application was tested with 297 patients who were assessed clinically by physicians. Results indicate modest potential (43.4% relative improvement) for the IT-based approach for improving patient adherence to endoscopy preparations. Purposively designed cloud-based applications hold promise for aiding patients with complex medical procedure preparation. Health care provider involvement in the design and evaluation of a patient application may be an effective strategy to produce medical evidence and encourage the adoption of adherence apps.

A Randomized Controlled Trial Comparing Colonoscopic Enema With Additional Oral Preparation as a Salvage for Inadequate Bowel Cleansing Before Colonoscopy

GOALS

The goal of this study was to evaluate the noninferiority of colonoscopic enema to additional oral preparation in salvage bowel cleansing for inadequate preparation for a morning colonoscopy.

BACKGROUND

Colonoscopic enema, administering additional cathartics into the right colon through the colonoscope accessory channel, is suggested to rescue poor bowel preparation for a colonoscopy but lacking comparative study.

STUDY

In this prospective, randomized, actively-controlled, parallel group, noninferiority trial, consecutive outpatients and health checkup recipients aged from 19 to 70 years with inappropriate bowel preparation during an elective colonoscopy were enrolled to receive either a colonoscopic enema of 1 L polyethylene glycol (PEG) (enema group) or additional oral intake of 2 L PEG (oral group). The primary endpoint was the proportion of adequate bowel preparation evaluated using the Boston Bowel Preparation Scale.

RESULTS

Overall, 131 participants were randomized. Adequate bowel preparation was achieved in 53% (35/66) of the enema group, which was significantly inferior to the oral group (81.5%; 53/67) with a difference of -28.5% (95% confidence interval, -44.1, -12.9; P=0.001). The largest difference in the proportion of adequate bowel preparation was observed in the right colon (57.8% in the enema group vs. 86.9% in the oral group; P<0.001), followed by the transverse colon (85.9% vs. 98.4%; P=0.017) and the left colon (90.6% vs. 96.7%; P=0.274).

CONCLUSIONS

The colonoscopic enema of 1 L PEG was inferior to the additional oral ingestion of 2 L PEG regarding efficacy as a salvage bowel preparation in adults with inadequate bowel cleansing for colonoscopy.

Determination of withdrawal times in individualized opportunistic screening colonoscopies

To investigate effects of bowel preparation, experience level of colonoscopists, and colonoscopy withdrawal time (CWT) on the quality of an individual opportunistic screening colonoscopy, according to adenoma detection rate (ADR).Data were retrospectively analyzed from opportunistic screening colonoscopies (n = 16,951) at 4 hospitals of various care levels in China.The ADR positively correlated with the experience level of the colonoscopist. The individualized CWT varied, depending on the quality of bowel preparation and the number of colonoscopies performed previously by the colonoscopist. In a setting of adequate bowel preparation, the mean CWT decreased with the increased experience of the colonoscopist. With poor and inadequate bowel preparation, no colonoscopist at any level of experience could obtain a satisfactory ADR.For adequately prepared colonoscopies, minimum CWTs have been determined. Repeat colonoscopy is strongly recommended for patients with poor bowel preparation, regardless of the colonoscopist's experience.

Multicentre endoscopist-blinded randomised clinical trial to compare two bowel preparations after a colonoscopy with inadequate cleansing: a study protocol

INTRODUCTION

Inadequate bowel preparation is common and negatively impacts colonoscopy quality. The objective of this study is to compare two bowel preparation regimens in cleansing the colon after an index colonoscopy with failed bowel preparation.

METHODS AND ANALYSIS

This is a phase III, multicentre, randomised clinical trial comparing two bowel preparation regimens after failure to adequately cleanse at the index colonoscopy. Regimen A consists of 4 L split-dose polyethylene glycol electrolyte solution (PEG-ELS) and Regimen B consists of 6 L split-dose PEG-ELS, both preceded by 15 mg of bisacodyl the day before the procedure along with a low-fibre diet 3 and 2 days before the procedure followed by a clear fluid diet starting the day before the procedure. The primary outcome is adequate bowel preparation, defined as a Boston Bowel Preparation Scale (BBPS) score of ≥6 with each segment score ≥2. Secondary outcomes include mean BBPS score, bowel preparation adequacy using the US Multi-Society Task Force on Colorectal Cancer definition, detection rate by polyp subtype, caecal intubation rate, mean Validated Patient Tolerability Questionnaire for Bowel Preparation score, subject willingness to repeat the preparation and faecal incontinence rate.

ETHICS AND DISSEMINATION

The study will be conducted in accordance with Good Clinical Practice guidelines and local institutional standards. Study findings will be disseminated at an international gastroenterology conference and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT02976805; Pre-results.

Efficacy and safety of a ready-to-drink bowel preparation for colonoscopy: a randomized, controlled, non-inferiority trial

BACKGROUND

We performed a randomized, controlled, assessor-blinded, multicenter, non-inferiority (NI) study to compare the safety and efficacy of a ready-to-drink formulation of sodium picosulfate, magnesium oxide, and citric acid (SPMC oral solution) with a powder formulation (P/MC powder) for oral solution.

METHODS

Eligible participants (adults undergoing elective colonoscopy) were randomized 1:1 to split-dose SPMC oral solution or P/MC powder. The primary efficacy endpoint assessed overall colon-cleansing quality with the Aronchick Scale (AS), and the key secondary efficacy endpoint rated quality of right colon cleansing with the Boston Bowel Preparation Scale (BBPS). Assessments were performed by a treatment-blinded endoscopist. Tolerability was assessed using the Mayo Clinic Bowel Prep Tolerability Questionnaire. Safety assessments included adverse events and laboratory evaluations.

RESULTS

The study included 901 participants: 448 for SPMC oral solution; 453 for P/MC powder. SPMC oral solution demonstrated non-inferiority to P/MC powder {87.7% (393/448) responders versus 81.5% (369/453) responders [difference (95% confidence interval): 6.3% (1.8, 10.9)]}. The key secondary efficacy objective assessing the right colon was also met. According to the prespecified hierarchical testing, after meeting the primary and key secondary objectives, SPMC oral solution was tested for superiority to P/MC powder for the primary endpoint (p = 0.0067). SPMC oral solution was well tolerated. Most common adverse events were nausea (3.1% versus 2.9%), headache (2.7% versus 3.1%), hypermagnesemia (2.0% versus 5.1%), and vomiting (1.3% versus 0.7%) for SPMC oral solution and P/MC powder, respectively.

CONCLUSIONS

Ready-to-drink SPMC oral solution showed superior efficacy of overall colon cleansing compared with P/MC powder, with similar safety and tolerability.[ClinicalTrials.gov identifier: NCT03017235.].

Usefulness of Personal Bowel Habits as a Predictive Factor for Inadequate Bowel Preparation for Colonoscopy: A Prospective Questionnaire-Based Observational Study

Background/Aims

The quality of bowel preparation is important for optimal colonoscopy. It is influenced by medical and personal factors. We aimed to evaluate the effect of bowel habit on the quality of bowel preparation and to identify predictors of inadequate bowel preparation among bowel habit factors.

Methods

From June 2017 to September 2017, 90 volunteers were enrolled in this study. Each participant answered a questionnaire consisting of multiple questions about personal bowel habits, including stool form, frequency of bowel movements per week, duration, and degree of straining for bowel movement. Then, all volunteers underwent colonoscopic exam. Eleven endoscopists performed colonoscopies and used the Boston Bowel Preparation Scale (BBPS) as the index for bowel preparation. Two expert endoscopists simultaneously reviewed all colonoscopic images to confirm the final BBPS. Univariate and multivariate logistic regression analyses were performed to verify the correlation between bowel preparation adequacy and bowel habit.

Results

Among the 90 participants, 20 (22.2%) had inadequate bowel preparation (total BBPS ≤6 or any segmental BBPS ≤1). In univariate analysis, infrequent bowel movement (0–2/week) (odds ratio [OR], 12.60; 95% confidence interval [CI], 1.22 to 129, p=0.03) and moderate straining (more than 1/4 of defecations) (OR, 4.40; 95% CI, 1.44 to 13.39; p=0.01) were significantly associated with inadequate bowel preparation. However, only moderate straining was significantly associated with inadequate bowel preparation in multivariate analysis (OR, 3.99; 95% CI, 1.26 to 12.65; p=0.02).

Conclusions

Straining is a significant predictor for inadequate bowel preparation. For patients with straining during bowel movements, an intensified preparation regimen should be considered.

Adenoma detection rates in colonoscopies for positive fecal immunochemical tests versus direct screening colonoscopies

BACKGROUND AND AIMS

Recent guidelines propose higher adenoma detection rate (ADR) benchmarks for colonoscopies performed for positive results for fecal immunochemical tests (FIT), but this is based on low-quality evidence. We aimed to compare ADR, advanced ADR (AADR), and number of adenomas per colonoscopy (APC) in direct screening colonoscopy (DSC) versus FIT-positive colonoscopy (FITC) in a multicenter Asia-Pacific cohort to justify differential targets.

METHODS

Asymptomatic average-risk patients ≥50 years of age who underwent screening colonoscopy directly or as follow-up for positive OC-Sensor FIT results were identified from 8 sites across the Asia-Pacific region. Overall, sex-specific ADR, overall AADR, and overall APC were compared between the 2 screening methods. Multivariable logistic regression was performed to adjust for confounding by differences in patient characteristics. Linear regression was used to correlate ADR with APC and to propose APC benchmarks.

RESULTS

A total of 2901 (mean age, 60.1 years; 57% men) individuals had DSC, and 2485 (mean age, 62.8 years; 57% men) underwent FITC. Overall ADR (53.6% vs 37.5%; odds ratio [OR], 1.93; P < .001), male-specific ADR (61.6% vs 44.6%; OR, 2; P < .001), female-specific ADR (43.2% vs 28.2%; OR, 1.94; P < .001) and overall AADR (29.9% vs 4.9%; OR, 8.2; P < .001) in FITC were significantly higher than the corresponding values for DSC. Differences remained significant after adjustment for patient characteristics. ADR was strongly and positively correlated to APC, with an ADR of 45% and 35% correlating to an APC of ∼1 and ∼0.65.

CONCLUSIONS

Results from this international multicenter cohort study provide early evidence that newly proposed higher ADR targets are justified as quality indicators for FITC.

Improving the quality and acceptance of colonoscopy preparation by reinforced patient education with short message service: results from a randomized, multicenter study (PERICLES-II)

BACKGROUND AND AIMS

Sufficient bowel preparation is crucial for successful screening and surveillance colonoscopy. However, the rates of inadequate preparation are still high. We investigated the effects of reinforcing patient education and guidance by using the short message service (SMS).

METHODS

In this prospective, endoscopist-blinded, multicenter study, standard instructions pertaining to split-dose preparation were provided in a verbal and written format to all patients during the initial appointment. Patients were randomly assigned (1:1) to a group that received reinforced education starting 4 days before the colonoscopy (SMS group) or to the control group which did not receive further education. The primary outcome was the percentage of insufficient preparation results (Boston Bowel Preparation Scale [BBPS] score <6). The secondary outcomes included quality of bowel preparation according to the BBPS, polyp and adenoma detection rates, and patients' perceived discomfort in the preparation procedure.

RESULTS

The percentage of patients with insufficient bowel preparation was significantly lower in the SMS group (9%) than in the control group (19%) (P = .0013). The mean BBPS score was significantly higher in the SMS group (7.4 ± 0.1) than in the control group (6.5 ± 0.1) (P < .0001). Each colon segment had significantly higher BBPS scores in the SMS group. The adenoma detection rate and number of detected adenomas in the right segment of the colon were higher in the SMS group. SMS messages were accompanied by a lower level of discomfort during preparation (numeric rating scale) (5.2 SMS vs 5.8 controls) (P = .0042).

CONCLUSIONS

Reinforced patient education by using SMS messages during the 4 days before colonoscopy increased bowel cleanliness, adenoma detection in the right segment of the colon, and reduced discomfort. (Clinical trial registration number: NCT02272036.).

No Interval Cancers in Endoscopic Practice

Colonoscopy is long time the most preferred method for CRC screening along with diagnosis and treatment for a range of colon diseases. Based on its difficulty in visualizing precursor CRC lesions, mostly those located on the right colon, this method can be subject of improvement. The colonoscopy quality can be influenced by many factors such as colon preparation, retraction time, the colonoscopists medical training and knowledges as well as the performance of endoscopy equipment. The bad quality of colonoscopy will result in the emergence of interval cancers defined, based on the author, as cancers that appear at 3-5 years up to 10 years from the colonoscopy procedure. Interval cancers have predominantly incriminated both the colonoscopy quality and the clinician competences and less the tumor biology. Subsequently there were set quality indicators of colonoscopy in order to raise the quality of the exploration. Among the important indicators, proving their utility in studies, the ADR (adenoma detection rate) is most commonly used along with PDR (polyp detection rate) and APC (adenoma per colonoscopy). Following the purpose of obtaining a higher colonoscopy quality the medical units should keep in check all indicators. Furthermore, there should be an active involvement in an additional training of non-conforming medical personnel or even restrain of practice, given the medical legal actions that have interval cancers as a main cause.

Impact of Colonoscopy Bowel Preparation Quality on Follow-up Interval Recommendations for Average-risk Patients With Normal Screening Colonoscopies: Data From the New Hampshire Colonoscopy Registry

BACKGROUND AND AIMS

National guidelines for colonoscopy screening and surveillance assume adequate bowel preparation. We used New Hampshire Colonoscopy Registry (NHCR) data to investigate the influence of bowel preparation quality on endoscopist recommendations for follow-up intervals in average-risk patients following normal screening colonoscopies.

METHODS

The analysis included 9170 normal screening colonoscopies performed on average risk individuals aged 50 and above between February 2005 and September 2013. The NHCR Procedure Form instructs endoscopists to score based on the worst prepped segment after clearing all colon segments, using the following categories: excellent (essentially 100% visualization), good (very unlikely to impair visualization), fair (possibly impairing visualization), and poor (definitely impairing visualization). We categorized examinations into 3 preparation groups: optimal (excellent/good) (n=8453), fair (n=598), and poor (n=119). Recommendations other than 10 years for examinations with optimal preparation, and >1 year for examinations with poor preparation, were considered nonadherent.

RESULTS

Of all examinations, 6.2% overall received nonadherent recommendations, including 5% of examinations with optimal preparation and 89.9% of examinations with poor preparation. Of normal examinations with fair preparation, 20.7% of recommendations were for an interval <10 years. Among those examinations with fair preparation, shorter-interval recommendations were associated with female sex, former/nonsmokers, and endoscopists with adenoma detection rate ≥20%.

CONCLUSIONS

In 8453 colonoscopies with optimal preparations, most recommendations (95%) were guideline-adherent. No guideline recommendation currently exists for fair preparation, but in this investigation into community practice, the majority of the fair preparation group received 10-year follow-up recommendations. A strikingly high proportion of examinations with poor preparation received a follow-up recommendation greater than the 1-year guideline recommendation. Provider education is needed to ensure that patients with poor bowel preparation are followed appropriately to reduce the risk of missing important lesions.

Bowel preparation quality scales for colonoscopy

Colorectal cancer (CRC) is the third most common cancer and second leading cause of cancer-related death in the United States. Colonoscopy is widely preferred for CRC screening and is the most commonly used method in the United States. Adequate bowel preparation is essential for successful colonoscopy CRC screening. However, up to one-quarter of colonoscopies are associated with inadequate bowel preparation, which may result in reduced polyp and adenoma detection rates, unsuccessful screens, and an increased likelihood of repeat procedure. In addition, standardized criteria and assessment scales for bowel preparation quality are lacking. While several bowel preparation quality scales are referred to in the literature, these differ greatly in grading methodology and categorization criteria. Published reliability and validity data are available for five bowel preparation quality assessment scales, which vary in several key attributes. However, clinicians and researchers continue to use a variety of bowel preparation quality measures, including nonvalidated scales, leading to potential confusion and difficulty when comparing quality results among clinicians and across clinical trials. Optimal clinical criteria for bowel preparation quality remain controversial. The use of validated bowel preparation quality scales with stringent but simple scoring criteria would help clarify clinical trial data as well as the performance of colonoscopy in clinical practice related to quality measurements.

Bowel preparation quality scales for colonoscopy

Colorectal cancer (CRC) is the third most common cancer and second leading cause of cancer-related death in the United States. Colonoscopy is widely preferred for CRC screening and is the most commonly used method in the United States. Adequate bowel preparation is essential for successful colonoscopy CRC screening. However, up to one-quarter of colonoscopies are associated with inadequate bowel preparation, which may result in reduced polyp and adenoma detection rates, unsuccessful screens, and an increased likelihood of repeat procedure. In addition, standardized criteria and assessment scales for bowel preparation quality are lacking. While several bowel preparation quality scales are referred to in the literature, these differ greatly in grading methodology and categorization criteria. Published reliability and validity data are available for five bowel preparation quality assessment scales, which vary in several key attributes. However, clinicians and researchers continue to use a variety of bowel preparation quality measures, including nonvalidated scales, leading to potential confusion and difficulty when comparing quality results among clinicians and across clinical trials. Optimal clinical criteria for bowel preparation quality remain controversial. The use of validated bowel preparation quality scales with stringent but simple scoring criteria would help clarify clinical trial data as well as the performance of colonoscopy in clinical practice related to quality measurements.

Patient Characteristics Associated With Quality of Colonoscopy Preparation: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Some features of patients are associated with inadequate bowel preparation, which reduces the effectiveness of colonoscopy examination. We performed a systematic review and meta-analysis of the association between patients' sociodemographic characteristics, health conditions, and medications with inadequate bowel preparation.

METHODS

We searched the PubMed, Scopus, and Cochrane Review databases for randomized controlled trials cohort (prospective and retrospective), case-control, and cross-sectional studies published through March 2016. We collected information on study design, study population, and bowel preparation. For each factor, we obtained the odds ratio (OR) for inadequate bowel preparation. We conducted the meta-analyses using the random-effects approach and investigated any identified heterogeneity and publication bias via graphical methods, stratification, and meta-regression.

RESULTS

We performed a meta-analysis of 67 studies, comprising 75,818 patients. The estimated pooled OR for inadequate bowel preparation was small for sociodemographic characteristics: 1.14 for age, and 1.23 for male sex (excluding studies in Asia, which had substantial heterogeneity and publication bias), and 1.49 for low education. The effect of high body mass index differed significantly in studies with mostly female patients (OR, 1.05) vs those with mostly male patients (OR, 1.30) (P = .013 for the difference). ORs for constipation and cirrhosis were heterogeneous; adjusted ORs were larger than unadjusted ORs (1.97 vs 1.29 for constipation and 3.41 vs 1.36 for cirrhosis). Diabetes (OR, 1.79), hypertension (OR, 1.25), stroke or dementia (OR, 2.09), and opioid use (OR, 1.70) were associated with inadequate bowel preparation. History of abdominal surgery (OR, 0.99) did not associate with inadequate bowel preparation. Use of tricyclic antidepressants had a larger effect on risk of inadequate bowel preparation in studies of mostly female patients (OR, 2.62) than studies of mostly male patients (OR, 1.42) (P = .085 for the difference).

CONCLUSIONS

In a systematic review and meta-analysis, we found no single patient-related factor to be solely associated with inadequate bowel preparation. Health conditions and use of some medications appear to be stronger predictors than sociodemographic characteristics.

A safe and effective multi-day colonoscopy bowel preparation for individuals with spinal cord injuries

CONTEXT/OBJECTIVE

Colonoscopy with polypectomy is associated with a reduced risk of colorectal cancer (CRC), but poor bowel cleansing limits the diagnostic yield of the procedure. Patients with spinal cord injury (SCI) frequently have suboptimal bowel cleansing with standard pre-colonoscopy bowel preparation regimens. We aimed to assess the safety, tolerability, and efficacy of a multi-day inpatient bowel preparation regimen in a population of patients with SCI.

DESIGN

Retrospective case series.

SETTING

VA Puget Sound SCI Center.

PARTICIPANTS

All patients with SCI (n = 53) who underwent inpatient colonoscopy at the VA Puget Sound from July 12, 2013 to February 12, 2015.

OUTCOME MEASURES

Patient characteristics, tolerance of full bowel preparation, pre- and post-bowel preparation electrolyte values, adverse events, and adequacy of bowel cleansing were abstracted.

RESULTS

Sixty-eight percent of patients had a cervical level of injury and the majority were either American Spinal Injury Association Impairment Scale A (41%) or D (43%). The full bowel preparation was tolerated by 91% of inpatients. In those with pre- and post-bowel preparation laboratory testing, there were small, but statistically significant decreases in serum calcium and phosphate. No patient had symptoms associated with electrolyte abnormalities or required treatment. Five out of 53 inpatients experienced autonomic dysreflexia (AD) during bowel preparation. Eighty-nine percent of patients had adequate bowel cleansing at colonoscopy.

CONCLUSIONS

We demonstrate a safe and effective inpatient bowel preparation regimen in a SCI population. The regimen was associated with mild, asymptomatic hypophosphatemia and hypocalcemia. AD was an uncommon event, predominantly occurring in patients who experienced frequent AD episodes at baseline.

Split-dose bowel preparation improves adequacy of bowel preparation and gastroenterologists’ adherence to National Colorectal Cancer Screening and Surveillance Guidelines

AIM

To quantify the impact of split-dose regimen on endoscopists’ compliance with guideline recommendations for timing of repeat colonoscopy in patients with normal colonoscopy or 1-2 small polyps (< 10 mm).

METHODS

A retrospective chart review of all endoscopy reports was undertaken in average-risk individuals > 50 years old with a normal screening colonoscopy and 1-2 small polyps. Data were abstracted from two time periods, pre and post-split-dose bowel preparation institution. Main outcome measurements were recommendation for timing of repeat colonoscopy and bowel preparation quality. Bivariate analysis by χ² tests and Student’s t-tests were performed to assess differences between the two cohorts. Multivariable logistic regression was used with guideline consistent recommendations as the dependent variables and an indicator for 2011 cohort as the primary predictor.

RESULTS

Four thousand two hundred and twenty-five patients were included in the study; 47.0% (1987) prior to the institution of split dose bowel preparation, and 53.0% (2238) after the institution of split dose bowel preparation. Overall, 82.2% (n = 3472) of the colonoscopies were compliant with guideline recommendations, with a small but significantly increased compliance rate in year 2011 (83.7%) compared to year 2009 (80.4%, P = 0.005), corresponding to an unadjusted odds ratio of 1.25 (95%CI: 1.07-1.47; P = 0.005). Colonoscopies with either “Adequate” or “Excellent” had increased from 30.6% in year 2009 to 39.6% in year 2011 (P < 0.001). However, there was no significant difference in poor/inadequate category of bowel preparation as there was a mild increase from 4.6% in year 2009 to 5.1% in year 2011 (P = 0.50).

CONCLUSION

Split-dose bowel regimen increases endoscopists’ compliance to guidelines in average-risk patients with normal colonoscopy or 1-2 small polyps.

Is the level of cleanliness using segmental Boston bowel preparation scale associated with a higher adenoma detection rate?

Background

The impact of Boston bowel preparation scale (BBPS) scores on the adenoma detection rate (ADR) in each segment has not been adequately addressed. The aim of this study was to determine the association between segmental or overall ADR and serrated polyp detection rate (SDR) with segmental and total BBPS scores.

Methods

All outpatient screening colonoscopies with documented BBPS scores were retrospectively reviewed at a tertiary institution from January to December 2013. Chi-square tests and logistic regression were used to analyze the detection rates of adenomas and serrated polyps with bowel prep scores. Odds ratios were calculated using logistic regression that controlled for withdrawal time, age, body mass index, diabetes status and sex.

Results

We analyzed 1991 colonoscopies. The overall ADR was 37.5% (95% confidence interval [CI], 35.3-39.6). There was a significant difference in the overall ADR, and in SDR across all bowel category groups, with total BBPS scores of 8 and 9 having lower detection rates than scores of 5, 6 and 7. As the quality of bowel preparation increased, there was a statistical decrease in the ADR (odds ratio [OR] 0.79 [CI 0.66-0.94], P=0.04) of the right colon, while in the left colon, there was a statistical decrease in SDR (OR 0.78, [CI 0.65-0.92] P=0.019).

Conclusion

Segmental ADR and SDR both decreased as prep scores increased, decreasing notably in patients with excellent prep scores of 8 and 9. A possible explanation for this unexpected discrepancy may be related to longer and better visualization of the mucosa when cleansing and suctioning is necessary.

Bowel preparation quality between hospitalized patients and outpatient colonoscopies

BACKGROUND/AIMS

Optimal bowel preparation is essential for a complete high-quality colonoscopy. We sought to determine whether an inpatient, as opposed to an ambulatory setting, would affect the quality of bowel preparation.

PATIENTS AND METHODS

A retrospective chart review was conducted in a tertiary care university hospital. We collected demographic data from consecutive patients who underwent a colonoscopy for any reason between August 2007 and April 2012.

RESULTS

A total of 2999 patients were included in the study with a mean age of 50.36 (95%CI; 49.79-50.94). Males comprised 58.12%. Ambulatory patients had a higher rate of good bowel preparations (67.23% vs. 56.64%, P value < 0.01), a lower rate of poor bowel preparations (18.22% vs. 27.14%, P value < 0.01), and a higher rate of colonoscopy completion (86.79% vs. 77.59%, P value < 0.01). There was no difference between the rates of polyps detected (18.90% vs. 20.83%, P value = 0.22). The univariabe modeling factors associated with a sub-optimal bowel preparation were age OR 1.02 (95% CI, 1.01 to 1.02), chronic kidney disease OR 2.34 (95% CI, 1.12 to 4.88), diabetes mellitus OR 2.00 (95% CI, 1.50 to 2.68), hypertension OR 1.48 (95% CI, 1.11 to 1.97), anemia OR 1.81 (95% CI, 1.33 to 2.47), and weight loss OR 1.41 (95% CI, 1.01 to 1.96). Better bowel preparation was associated with colonoscopies performed in the outpatient setting OR 0.63 (95% CI, 0.54 to 0.73).

CONCLUSION

Bowel preparation quality is affected by the setting in which it is performed. This result suggests that, when appropriate, colonoscopies should be performed on an outpatient basis. Further studies are required to replicate this finding.

Correlation Between Bowel Preparation and the Adenoma Detection Rate in Screening Colonoscopy

PURPOSE

The adenoma detection rate is commonly used as a measure of the quality of colonoscopy. This study assessed both the association between the adenoma detection rate and the quality of bowel preparation and the risk factors associated with the adenoma detection rate in screening colonoscopy.

METHODS

This retrospective analysis involved 1,079 individuals who underwent screening colonoscopy at the National Cancer Center between December 2012 and April 2014. Bowel preparation was classified by using the Aronchick scale. Individuals with inadequate bowel preparations (n = 47, 4.4%) were excluded because additional bowel preparation was needed. The results of 1,032 colonoscopies were included in the analysis.

RESULTS

The subjects' mean age was 53.1 years, and 657 subjects (63.7%) were men. The mean cecal intubation time was 6.7 minutes, and the mean withdrawal time was 8.7 minutes. The adenoma and polyp detection rates were 28.1% and 41.8%, respectively. The polyp, adenoma, and advanced adenoma detection rates did not correlate with the quality of bowel preparation. The multivariate analysis showed age ≥ 60 years (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.02-1.97; P = 0.040), body mass index ≥ 25 kg/m² (HR, 1.56; 95% CI, 1.17-2.08; P = 0.002) and current smoking (HR, 1.44; 95% CI, 1.01-2.06; P = 0.014) to be independent risk factors for adenoma detection.

CONCLUSION

The adenoma detection rate was unrelated to the quality of bowel preparation for screening colonoscopy. Older age, obesity, and smoking were independent risk factors for adenoma detection.

Evaluation of Clensia®, a new low-volume PEG bowel preparation in colonoscopy: Multicentre randomized controlled trial versus 4L PEG

BACKGROUND

Success of colonoscopy is linked to the adequacy of bowel cleansing. Polyethylene glycol 4L (PEG 4L) solutions are widely used for colonic cleansing but with limitations concerning tolerability and acceptability.

AIM

To demonstrate the equivalence of a new low-volume PEG containing citrates and simeticone (Clensia) versus a standard PEG 4L.

METHODS

In this, multicentre, randomised, observer-blind trial, patients received either Clensia 2L or PEG 4L solution. Primary endpoint was the proportion of patients with colon cleansing evaluated as excellent or good.

RESULTS

422 patients received Clensia (n=213) or PEG 4L (n=209). Rate of excellent/good bowel cleansing was 73.6% and 72.3% in Clensia and PEG 4L group respectively. Clensia was demonstrated to be equivalent to PEG 4L. No SAEs were observed. Clensia showed better gastrointestinal tolerability (37.0% vs 25.4%). The acceptability was significantly better with Clensia in terms of proportion of subjects who felt no distress (Clensia 72.8% vs PEG 4L 63%, P=0.0314) and willingness-to-repeat (93.9% vs 82.2%, P=0.0002). The rate of optimal compliance was similar with both formulations (91.1% for Clensia vs 90.9% for PEG 4L, P=0.9388).

CONCLUSIONS

The low-volume Clensia is equally effective and safe in bowel cleansing compared to the standard PEG 4L, with better gastrointestinal tolerability and acceptability.

Water Exchange Method Significantly Improves Adenoma Detection Rate: A Multicenter, Randomized Controlled Trial

OBJECTIVES

Adenoma detection rate (ADR) is a key colonoscopy quality indicator in Western clinical literature. Our low ADR prompted us to assess novel methods to improve performance. Western retrospective reports suggested that water exchange (WE) could increase ADR. However, most of these studies used pain score or intubation rate as the primary outcome. Here we test the hypothesis that WE significantly increases ADR among Chinese colonoscopists and design a prospective randomized controlled trial using ADR as our primary outcome.

METHODS

This prospective, randomized controlled trial was performed at six centers in China. Screening, surveillance, and diagnostic cases were randomized to be examined by WE or traditional air insufflation (AI) method. The primary outcome was ADR.

RESULTS

From April 2014 to July 2015, 3,303 patients were randomized to WE (n=1,653) and AI (n=1,650). The baseline characteristics were comparable. Overall ADR was 18.3% (WE) and 13.4% (AI) (relative risk 1.45, 95% confidential interval: 1.20-1.75, P<0.001). ADR in screening patients using AI was 25.8% (male) and 15.7% (female). ADR in screening patients aged >50 years old was 29.4% (WE) and 22.9% (AI) (relative risk 1.09, 95% confidential interval: 1.00-1.19, P=0.040). The increase by WE was reproducibly observed in all indication categories, and significant in screening and diagnostic cases. The limitation imposed by the unblinded investigators was mitigated by comparable inspection times in cases without polyps, similar adenoma per positive colonoscopy, and reproducible enhancement of ADR and adenoma per colonoscopy by WE across all eight investigators.

CONCLUSIONS

This prospective study confirms Western retrospective data that WE significantly improves ADR among Chinese colonoscopists. WE may be superior to AI for screening colonoscopy in China. Colonoscopists elsewhere with low ADR might consider evaluating WE for performance improvement.

Is a split-dose regimen of 2 L polyethylene glycol plus ascorbic acid tolerable for colonoscopy in an early morning visit to a comprehensive medical check-up?

AIM

To evaluate the effectiveness and tolerability of a split-dose 2 L polyethylene glycol (PEG)/ascorbic acid (AA) regimen for healthy examinees who visited for comprehensive medical check-up in the early morning.

METHODS

From February 2015 to March 2015, examinees of average risk who were scheduled for a colonoscopy in the morning were retrospectively enrolled.

RESULTS

The 189 examinees were divided into split-dose and non-split-dose groups. The adequacy of bowel preparation for the split-dose group vs the non-split-dose group was 96.8% vs 85.2%, respectively, P < 0.001, and the compliance of the last meal restriction was 74.6% vs 58.2%, respectively, P < 0.001. The sleep disturbance (P < 0.001) was more prevalent in the split-dose group, however the willingness to repeat the same preparation method (P = 0.243) was not different in both groups. The split-dose regimen was the most important factor influencing adequate bowel preparation in multivariate analysis (HR = 10.89, 95%CI: 6.53-18.17, P < 0.001).

CONCLUSION

A split-dose regimen of 2 L PEG/AA for an early morning colonoscopy was more effective and showed better compliance for diet restriction without any difference in satisfaction and discomfort. Introducing a split-dose regimen of 2 L PEG/AA to morning colonoscopy examinees is effective and tolerable in a comprehensive medical check-up setting.

Randomized trial comparing oral sulfate solution with 4-L polyethylene glycol administered in a split dose as preparation for colonoscopy

BACKGROUND AND AIM

The present study aimed to evaluate the non-inferiority of low-volume oral sulfate solution (OSS) to 4-L polyethylene glycol (PEG) solutions administered in a split-dose regimen as bowel preparation for colonoscopy. The safety and tolerability were also compared between the two regimens.

METHODS

In this prospective, randomized, single-blind, active-control, parallel group, and non-inferiority trial, consecutive outpatients and health checkup recipients aged 19-65 years undergoing elective colonoscopy were enrolled to receive OSS or 4-L PEG in a split-dose regimen. The quality of bowel preparation was evaluated using the Boston Bowel Preparation Scale. The occurrence of any adverse events, acceptance, compliance, and satisfaction during bowel preparation were evaluated by participant interviews.

RESULTS

Overall, 210 participants were randomized, and 199 were administered by the study agents. Adequate bowel preparation was achieved in 98.0% (97/99) of the OSS group, which was non-inferior to the PEG group (96%; 96/100) with a difference of +2.8% (95% confidence interval; -2.8, +6.8). There were no differences in the incidence of adverse events except for abdominal pain, which was more frequent in the OSS (7.1%, 7/99) than in the PEG (1.0%, 1/100; P = 0.035) group. Acceptance, compliance, and satisfaction were significantly higher in the OSS than in the PEG group (all P < 0.05).

CONCLUSIONS

Split-dose OSS was non-inferior to split-dose 4-L PEG with regard to bowel preparation efficacy before colonoscopy in adult outpatients or screening colonoscopy recipients aged ≤65 years with acceptable safety and superior tolerability.

Enhanced instructions improve the quality of bowel preparation for colonoscopy: a meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

The success of a colonoscopy is highly dependent on the quality of bowel preparation (BP). Many patients have poor BP due to non-compliance with regular instructions. Reports concerning the effects of enhanced instructions on BP quality are inconsistent. The aim of this meta-analysis was to compare BP quality between patients receiving enhanced instructions in addition to regular instructions and those who received regular instructions only.

METHODS

MEDLINE, EMBASE, Web of Science, and the Cochrane Library were searched to identify relevant studies published for August 2015. The quality of BP (adequate/inadequate), adenoma detection rate, polyp detection rate, willingness to repeat preparation, and adverse events were estimated by using odds ratios (OR) and 95% confidence intervals (CI) with random effects models.

RESULTS

Eight randomized controlled trials (n = 3795) were included. Patients who received enhanced instructions showed significantly better BP quality than those receiving only regular instructions (OR, 2.35; 95% CI, 1.65-3.35; P < .001). Subgroup analysis showed that the beneficial effects of enhanced instructions on BP quality were consistent among patients receiving different purgative types, administration methods, or diet restriction (all P < .05). Patients in the enhanced instructions group showed more willingness to repeat the preparation (OR, 1.91; 95% CI, 1.20-3.04; P = .006).

CONCLUSIONS

Enhanced instructions significantly improved the quality of BP and willingness to repeat the preparation in patients undergoing colonoscopy. Factors related to patient instructions appear to be as important as the preparation method itself in improving BP quality.

Cirrhotic Patients Have Worse Bowel Preparation at Screening Colonoscopy than Chronic Liver Disease Patients without Cirrhosis

BACKGROUND

Cirrhosis has been shown in small studies to be a predictor of suboptimal bowel preparation at screening colonoscopy. It has yet to be established whether patients with chronic liver disease in the absence of cirrhosis experience equally poor colon cleansing. Intestinal dysmotility related to cirrhosis might impair bowel preparation in this population more than those with chronic liver disease without cirrhosis.

OBJECTIVE

This study compared the quality of bowel preparation in cirrhotic and non-cirrhotic patients with chronic liver disease and determined whether this influenced polyp detection rate.

METHODS

A retrospective study of patients with chronic liver disease, both cirrhotic and non-cirrhotic, who underwent screening colonoscopy was performed. Patient characteristics, concomitant medication use, adequacy of bowel preparation, and the total number and types of polyps found were compared between cirrhotic and non-cirrhotic groups.

RESULTS

330 patients fulfilled inclusion criteria; 36% (n = 120) were cirrhotic. Cirrhotic patients had significantly worse bowel preparation scores compared with non-cirrhotics (mean 3.4 ± 1.1 vs. 3.7 ± 0.9, P = 0.003). Worse bowel preparation scores in cirrhotics vs. non-cirrhotics persisted despite controlling for age, sex, and concomitant diabetes mellitus (DM) (P = 0.0027). Among the cirrhotics, 48% had the lowest preparation scores compared with 30% of non-cirrhotics. No difference in polyp detection rate was found between cirrhotics and non-cirrhotics. Severity of cirrhosis as assessed by the MELD score did not predict worse bowel preparation.

CONCLUSIONS

Cirrhotics have significantly worse bowel preparation scores compared to non-cirrhotics with chronic liver disease. No correlation between MELD score and bowel preparation score was observed in the cirrhotic cohort.

A randomized controlled trial of pre-procedure simethicone and N-acetylcysteine to improve mucosal visibility during gastroscopy - NICEVIS

Background and study aims: Mucosal views can be impaired by residual bubbles and mucus during gastroscopy. This study aimed to determine whether a pre-gastroscopy drink containing simethicone and N-acetylcysteine improves mucosal visualisation. Patients and methods: We conducted a randomized controlled trial recruiting 126 subjects undergoing routine gastroscopy. Subjects were randomized 1:1:1 to receive: A-pre-procedure drink of water, simethicone and N-acetylcysteine (NAC); B-water alone; or C-no preparation. Study endoscopists were blinded to group allocation. Digital images were taken at 4 locations (lower esophagus/upper gastric body/antrum/fundus), and rated for mucosal visibility (MV) using a 4-point scale (1 = best, 4 = worst) by 4 separate experienced endoscopists. The primary outcome measure was mean mucosal visibility score (MVS). Secondary outcome measures were procedure duration and volume of fluid flush required to achieve adequate mucosal views. Results: Mean MVS for Group A was significantly better than for Group B (1.35 vs 2.11, P < 0.001) and Group C (1.35 vs 2.21, P < 0.001). Mean flush volume required to achieve adequate mucosal views was significantly lower in Group A than Group B (2.0 mL vs 31.5 mL, P = 0.001) and Group C (2.0 mL vs 39.2 mL P < 0.001). Procedure duration did not differ significantly between any of the 3 groups. MV scores at each of the 4 locations demonstrated significantly better mucosal visibility in Group A compared to Group B and Group C (P < 0.0025 for all comparisons). Conclusions: A pre-procedure drink containing simethicone and NAC significantly improves mucosal visibility during gastroscopy and reduces the need for flushes during the procedure. Effectiveness in the lower esophagus demonstrates potential benefit in Barrett's oesophagus surveillance gastroscopy.

Controlled Dietary Restriction With a Prepackaged Low-Residue Diet Before Colonoscopy Offers Better-Quality Bowel Cleansing and Allows the Use of a Smaller Volume of Purgatives: A Randomized Multicenter Trial

BACKGROUND

Bowel preparation is burdensome, and less-demanding preparation procedures are needed. Few studies have investigated the effects of low-residue diet and prepackaged low-residue diet in combination with low-volume polyethylene glycol-electrolyte lavage solution during colonoscopy preparation.

OBJECTIVE

We compared self-prepared low-residue diets with prepackaged low-residue diets in combination with low-volume polyethylene glycol.

DESIGN

This was a single-blinded, 3-arm, multicenter, randomized controlled trial.

SETTING

Colonoscopies were conducted in outpatient settings at 3 centers in Taiwan.

PATIENTS

The study included 180 patients (age range, 20-75 years) who were scheduled for colonoscopy.

INTERVENTIONS

Three groups were compared: group A included self-prepared, 1-day, low-residue diets with a same-day 2.0-L single-dose of polyethylene glycol; group B included prepackaged low-residue diets plus 2.0 L of polyethylene glycol; and group C included prepackaged low-residue diets plus 1.5 L of polyethylene glycol.

MAIN OUTCOME MEASURES

The outcome measures were adherence, bowel-cleansing level, and patient satisfaction.

RESULTS

One third of the subjects in group A, but none in the prepackaged low-residue diets groups, violated the dietary restrictions. The proportion of right-segment preparation failure was 15.0%, 1.7%, and 6.7% (p = 0.025). Accordingly, treatment B was superior to A (p = 0.008). Among subjects violating the low-residue diets guideline, the right-segment preparation failure rate was 25%. According to a multivariate analysis, low-residue diet compliance (adjusted OR = 6.55 (95% CI, 1.83-23.43)) and BMI were predictors of right-sided preparation adequacy, but the volume of polyethylene glycol ingested was not a predictor. Compared with group A, a greater proportion of subjects in groups B and C reported satisfaction.

LIMITATIONS

Patients with high BMI and severe constipation were excluded from this study. This study included only an Asian population.

CONCLUSIONS

The prepackaged low-residue diet provides excellent adherence, better bowel cleansing, and a better experience than a self-prepared low-residue diet. With good dietary compliance, 1.5 L of polyethylene glycol provides effective preparation.

Successful endoscopic closure of a colonic perforation one day after endoscopic mucosal resection of a lesion in the transverse colon

A 73-year-old man underwent endoscopic mucosal resection (EMR) of a 20-mm flat elevated lesion on the transverse colon. The morning after the procedure, he started to have severe right upper quadrant pain after his first meal. A computed tomography scan revealed free air and a stomach filled with food. He was diagnosed to have delayed post-EMR intestinal perforation. He underwent emergent colonoscopy and clipping of the perforated site. He was discharged 8 d after the endoscopic closure without the need for surgical intervention. The meal was not the cause of the colon transversum perforation.