Predictors of failed colonoscopy in nonagenarians: a single-center experience

Safety and feasibility of colonoscopy in nonagenarians: A systematic review, meta-analysis and meta-regression analysis

AIM

The aim of this work was to evaluate the safety and feasibility of performing colonoscopy in patients aged 90 years or over.

METHOD

In compliance with PRISMA statement standards, a systematic review of studies reporting the outcomes of colonoscopy in patients aged ≥90 years was conducted. A proportional meta-analysis model was constructed to quantify the risk of outcomes and a direct comparison meta-analysis model was constructed to compare outcomes between nonagenarians and patients aged between 50 and 89 years via random-effects models.

RESULTS

Seven studies enrolling 1304 patients (1342 colonoscopies) were included. Analyses showed that complications related to bowel preparation occurred in 0.7% (95% CI 0.1%-1.6%), procedural complications in 0.6% (0.00%-1.7%), 30-day complications in 1.5% (0.6%-2.7%), procedural mortality in 0.3% (0.0%-1.1%) and 30-day mortality in 1.1% (0.3%-2.2%). Adequate bowel preparation and colonoscopy completion were achieved in 81.3% (73.8%-87.9%) and 92.1% (86.7%-96.3%), respectively. No difference was found in bowel preparation-related complications [risk difference (RD) 0.00, p = 0.78], procedural complications (RD 0.00, p = 0.60), 30-day complications (RD 0.01, p = 0.20), procedural mortality (RD 0.00, p = 1.00) or 30-day mortality (RD 0.01, p = 0.34) between nonagenarians and patients aged between 50 and 89 years. The colorectal cancer detection rate was 14.3% (9.8%-19.5%), resulting in therapeutic intervention in 65.9% (54.5%-76.6%).

CONCLUSIONS

Although the evidence is limited to a selected group of nonagenarians, it may be fair to conclude that if a colonoscopy is indicated in a nonagenarian with good performance status (based on initial less-invasive investigations), the level 2 evidence supports its safety and feasibility. Age on its own should not be a reason for failing to offer colonoscopy to a nonagenarian.

Patient Navigation Plus Tailored Digital Video Disc Increases Colorectal Cancer Screening Among Low-Income and Minority Patients Who Did Not Attend a Scheduled Screening Colonoscopy: A Randomized Trial

BACKGROUND

Up to 50% of people scheduled for screening colonoscopy do not complete this test and no studies have focused on minority and low-income populations. Interventions are needed to improve colorectal cancer (CRC) screening knowledge, reduce barriers, and provide alternative screening options. Patient navigation (PN) and tailored interventions increase CRC screening uptake, however there is limited information comparing their effectiveness or the effect of combining them.

PURPOSE

Compare the effectiveness of two interventions to increase CRC screening among minority and low-income individuals who did not attend their screening colonoscopy appointment-a mailed tailored digital video disc (DVD) alone versus the mailed DVD plus telephone-based PN compared to usual care.

METHODS

Patients (n = 371) aged 45-75 years at average risk for CRC who did not attend a screening colonoscopy appointment were enrolled and were randomized to: (i) a mailed tailored DVD; (ii) the mailed DVD plus phone-based PN; or (iii) usual care. CRC screening outcomes were from electronic medical records at 12 months. Multivariable logistic regression analyses were used to study intervention effects.

RESULTS

Participants randomized to tailored DVD plus PN were four times more likely to complete CRC screening compared to usual care and almost two and a half times more likely than those who were sent the DVD alone.

CONCLUSIONS

Combining telephone-based PN with a mailed, tailored DVD increased CRC screening among low-income and minority patients who did not attend their screening colonoscopy appointments and has potential for wide dissemination.

Factors affecting the quality of bowel preparation for colonoscopy in hard-to-prepare patients: Evidence from the literature

Adequate bowel cleansing is critical for a high-quality colonoscopy because it affects diagnostic accuracy and adenoma detection. Nevertheless, almost a quarter of procedures are still carried out with suboptimal preparation, resulting in longer procedure times, higher risk of complications, and higher likelihood of missing lesions. Current guidelines recommend high-volume or low-volume polyethylene glycol (PEG)/non-PEG-based split-dose regimens. In patients who have had insufficient bowel cleansing, the colonoscopy should be repeated the same day or the next day with additional bowel cleansing as a salvage option. A strategy that includes a prolonged low-fiber diet, a split preparation regimen, and a colonoscopy within 5 h of the end of preparation may increase cleansing success rates in the elderly. Furthermore, even though no specific product is specifically recommended in the other cases for difficult-to-prepare patients, clinical evidence suggests that 1-L PEG plus ascorbic acid preparation are associated with higher cleansing success in hospitalized and inflammatory bowel disease patients. Patients with severe renal insufficiency (creatinine clearance < 30 mL/min) should be prepared with isotonic high volume PEG solutions. Few data on cirrhotic patients are currently available, and no trials have been conducted in this population. An accurate characterization of procedural and patient variables may lead to a more personalized approach to bowel preparation, especially in patients undergoing resection of left colon lesions, where intestinal preparation has a poor outcome. The purpose of this review was to summarize the evidence on the risk factors influencing the quality of bowel cleansing in difficult-to-prepare patients, as well as strategies to improve colonoscopy preparation in these patients.

Risk Factors of Inadequate Bowel Preparation for Screening Colonoscopy

The success of a colonoscopy in detecting and removing pre-cancerous and cancerous lesions depends heavily on the quality of bowel preparation. Despite efforts, 20–44% of colonoscopy participants have an inadequate bowel preparation. We aimed to assess and compare risk factors for inadequate bowel preparation and for the presence of advanced colorectal neoplasms in routine screening practice. In this cross-sectional study, among 8125 participants of screening colonoscopy in Germany with a comprehensive assessment of sociodemographic factors, lifestyle and medical history, we examined factors associated with inadequate bowel preparation and with findings of advanced neoplasms using adjusted log-binomial regression models. Among the identified risk factors assessed, three factors were identified that were significantly associated with inadequate bowel preparation: age ≥ 70 years (adjusted prevalence ratios, aPR, 1.50 95%CI 1.31–1.71), smoking (aPR 1.29 95%CI 1.11–1.50) and abdominal symptoms (aPR 1.14 95%CI 1.02–1.27). The same risk factors were also associated with the prevalence of advanced neoplasms in our study (aPR 1.72, 1.62 and 1.44, respectively). The risk factors associated with inadequate bowel preparation in this study were also associated with a higher risk for advanced neoplasms. Inadequate bowel preparation for colonoscopy might lead to missed colorectal cancer (CRC) precursors and the late diagnosis of CRC. People at high risk of advanced neoplasms are in particular need of enhanced bowel preparation.

Risk Factors Associated with Inadequate Bowel Preparation in Patients with Functional Constipation

BACKGROUND

Constipation is a common reason of poor bowel preparation, which negatively influences the quality of colonoscopy. Risk factors for inadequate bowel preparation in constipated patients remain unclear.

AIMS

This study aimed to investigate the high-risk factors that might influence the quality of bowel preparation in patients with functional constipation.

METHODS

Consecutive patients with functional constipation who underwent colonoscopy between June 2016 and April 2017 were enrolled. A standard split dose of 4 l polyethylene glycol was used for bowel preparation. Patient- and procedure-related parameters were recorded. The primary outcome was an adequate rate of bowel preparation. Risk factors for inadequate bowel preparation were screened by multivariate logistic regression analysis.

RESULTS

A total of 199 patients were included. Adequate bowel preparation was found in 62.8% (125/199) of patients. At multivariate analysis, Bristol stool form scale (BSFS) 1 [odds ratio (OR) 2.73, 95% confidence interval (CI) 1.26-5.90; P = 0.011], rectal pain score during defecation < 2 (OR 4.14, 95% CI 1.22-13.97; P = 0.022), and starting-to-defecation interval ≥ 4 h (OR 3.83, 95% CI 1.34-10.91; P = 0.012) were risk factors for inadequate bowel preparation in patients with constipation. For patients with no, 1, 2, or 3 risk factors, the rates of inadequate bowel preparation were 11%, 23%, 49%, and 65%, respectively.

CONCLUSIONS

With the standard preparation regime, > 1/3 of patients with functional constipation had inadequate bowel cleansing. BSFS 1, rectal pain score during defecation < 2, and starting-to-defecation interval ≥ 4 h were identified as independent risk factors for inadequate bowel preparation in constipated patients.

TRIAL REGISTRATION

ClinicalTrials.gov number NCT02842411.

Screening for Colon Cancer in Older Adults: Risks, Benefits, and When to Stop

Colorectal cancer (CRC) is the fourth leading cause of cancer and second leading cause of mortality from cancer in the United States. As the population ages, decisions regarding the initiation and cessation of screening and surveillance for CRC are of increasing importance. In elderly patients, the risks of CRC and the presenting signs and symptoms are similar to those in younger patients. Screening and ongoing surveillance should be considered in patients who have a life expectancy of 10 years or more. Life expectancy estimates can be calculated using online calculators. If screening is deemed appropriate, the choice of which test to use first is unclear. Currently, there are a number of modalities available to screen for CRC, including both invasive modalities (eg, colonoscopy, sigmoidoscopy, capsule colonoscopy, and computed tomographic colonography) and noninvasive modalities (fecal immunochemical test, stool DNA testing, and blood testing). Colonoscopy and other invasive testing options are considered safe, but the risks of complications of the bowel preparation, the procedure, and sedation medications are all increased in older patients. In contrast, noninvasive testing provides a safe initial test; however, it is important to consider the increased false-positive rates in the elderly, and a positive test result will usually necessitate colonoscopy to establish the diagnosis. Ongoing screening and surveillance should be a shared decision-making process with the patient based on multiple factors including the patient's morbidity and mortality risk from CRC and his or her underlying comorbidities, the patient's functional status, and the patient's preferences for screening. Ultimately, the decision to initiate or discontinue screening for CRC in older patients should be done based on a case-by-case individualized discussion.

Predictive factors for inadequate bowel preparation using low-volume polyethylene glycol (PEG) plus ascorbic acid for an outpatient colonoscopy

Low-volume polyethylene glycol (PEG) plus ascorbic acid solutions are widely used for bowel cleansing before colonoscopy. This study aimed to investigate the pre-endoscopic predictive factors for inadequate preparation in subjects receiving low-volume PEG plus ascorbic acid. A prospective study was performed at Gangnam Severance Hospital, Korea, from June 2016 to December 2016. All participants received low-volume PEG plus ascorbic acid solutions for outpatient colonoscopy. The split-dose bowel preparation was administered in subject with morning colonoscopy while same day bowel preparation was used for afternoon colonoscopy. 715 patients were enrolled (mean age 56.1 years, 54.4% male), of which 138 (19.3%) had an inadequate bowel preparation. In multivariable analysis, cirrhosis (OR 4.943, 95% CI 1.191–20.515), low (less than 70%) compliance for three-day low-residual diet (OR 2.165, 95% CI 1.333–3.515), brown liquid rectal effluent (compared with clear or semi-clear effluent) (OR 7.604, 95% CI, 1.760–32.857), and longer time interval (≥2 hours) between last defecation and colonoscopic examination (OR 1.841, 95% CI, 1.190–2.849) were found as an independent predictors for inadequate preparation. These predictive factors may be useful in guiding additional intervention to improve quality of bowel preparation.

Safety and Efficacy of Low-Volume Preparation in the Elderly: Oral Sulfate Solution on the Day before and Split-Dose Regimens (SEE SAFE) Study

Background/Aims

The use of a low-volume bowel cleansing agent is associated with a greater willingness to undergo repeat colonoscopy. Oral sulfate solution (OSS) is a recently approved low-volume agent; however, its efficacy and safety in the elderly population remain unclear. We aimed to evaluate the efficacy, safety, and acceptability of the OSS preparation, in comparison to those of a standard polyethylene glycol (PEG; 4 L) preparation, in elderly patients.

Methods

A multicenter, randomized, investigator-blinded study was conducted. Participants were randomized to receive OSS or 4-L PEG with a split-dose regimen. Bowel cleansing efficacy was assessed using the Boston Bowel Preparation Scale (BBPS). Acceptance, satisfaction, and preparation-related symptoms were recorded. Additionally, blood parameters were analyzed for electrolyte abnormalities and nephrotoxicity.

Results

A total of 193 patients were analyzed. No group differences in overall bowel cleansing efficacy were observed, with “adequate” preparations achieved in 95.9% (93/97) and 94.8% (91/96) of patients in the OSS and 4L PEG groups, respectively (p=0.747). However, mean BBPS scores for the entire (p=0.010) and right colon (p=0.001) were significantly higher in the OSS group than in the 4-L PEG group. The severity of clinical adverse events and frequency of acute kidney injury were similarly low, and no clinically meaningful electrolyte changes were identified. Self-reported scores regarding amount (p<0.001) and feeling (p=0.007), as well as overall satisfaction (p=0.001) and willingness to repeat the preparation (92.8% vs 67.7%, p<0.001), were significantly better in the OSS group than in the 4-L PEG group.

Conclusions

In elderly individuals, OSS with a split-dose regimen has greater acceptability and comparable efficacy in bowel cleansing compared to 4-L PEG. (Clinical trials registration number: NCT03112967)

Colonoscopy in the very elderly

INTRODUCTION

Colonoscopy is the gold standard test for investigating lower gastrointestinal symptoms and is an important therapeutic tool for colonic polypectomy. This paper is aimed at the general physician and examines the role of colonoscopy in very elderly patients by exploring the particular risks in this population, the yield of colonoscopy and potential alternative investigations.

SOURCES OF DATA

Original research and review articles were identified through selective PubMed searches. Guidelines were identified through interrogation of national and international society websites in addition to PubMed searches.

AREAS OF AGREEMENT

Advanced age alone is not a reason to avoid investigation. The decision to perform colonoscopy in this population must take into account indication and yield, risks of the procedure and bowel preparation, physical fitness of the patient, potential alternative and the ability to consent. As a general rule, the principle of 'first doing no harm' should be applied and requires balancing of the risks of the procedure and preparation with the benefits of doing the test.

AREAS OF CONTROVERSY

There is no defined upper age limit at which colonoscopy is contraindicated, however; the National Health Service Bowel Cancer Screening Programme stops inviting patients for screening and surveillance colonoscopy at age 75.

GROWING POINTS AND AREAS TIMELY FOR DEVELOPING RESEARCH

The concepts of 'first do no harm' and shared decision-making are not new but are increasingly important, particularly in this patient group. It is crucial to provide patients with information about risks, benefits and alternative investigations to empower their decision-making.

Complications and outcomes of routine endoscopy in the very elderly

BACKGROUND AND STUDY AIMS

 In Japan, the elderly population has been increasing annually. The number of elderly patients for whom esophagogastroduodenoscopy (EGD) and colonoscopy (CS) is indicated also has been rising. The aim of this study was to evaluate the safety and efficacy of routine endoscopy in a cohort of octogenarians aged 85 years and older - defined by the World Health Organization as the very elderly.

PATIENTS AND METHODS

 A total of 5,586 patients underwent EGDs, and 2,484 patients underwent CSs performed at the Keio University Hospital from January to September 2014. One hundred eighty-five EGDs and 70 of the CS were performed in the very elderly. Six hundred nine EGDs and 262 CS were performed on younger patients (aged forties). Statistical analysis was performed by univariate and multivariate analyses.

RESULTS

 On univariate analysis, the rate of adverse events (AEs) in the very elderly was significantly higher compared to the younger group (6.3 % vs. 1.1 %; P  < 0.01). Moreover, the very elderly cohort received substantial therapeutic intervention as compared to the younger (16.9 % vs. 6.9 %; P  < 0.01). On multivariate analysis, independent risk factors of AEs included: very elderly patients (odds ratio (OR) 3.30, 95 % confidence interval (CI) 1.05 - 10.35), inpatients (OR 3.22, 95 % CI 1.34 - 7.74), and use of pethidine hydrochloride prescription (OR 3.44, 95 % CI 1.51 - 7.81).

CONCLUSIONS

 Routine endoscopy in the very elderly incurs a significant risk of AEs, particularly when combined with pethidine hydrochloride prescription.

Predictors of Suboptimal Bowel Preparation Using 3-l of Polyethylene Glycol for an Outpatient Colonoscopy: A Prospective Observational Study

BACKGROUND

A 3-l polyethylene glycol (PEG) solution provided better bowel cleansing quality than a 2-l solution for outpatient colonoscopy. Predictors of suboptimal preparation using a 3-l PEG have not been previously reported.

AIMS

To investigate the possible predictors of suboptimal bowel preparation using 3-l of PEG.

METHODS

We analyzed a database of 1404 consecutive colonoscopies during a 27-month period at a community hospital. A split-dose PEG regimen was provided for morning colonoscopies, and a same-day PEG regimen was provided for afternoon colonoscopies. The level of bowel cleansing was prospectively scored according to the Boston Bowel Preparation Scale (BBPS). Possible predictors of suboptimal colon preparation, defined as a BBPS score <7, were analyzed using univariate statistics and multivariate logistic regression models.

RESULTS

The mean age of the study population (46.7 % men) was 52.5 years (range 20-80 years, SD 11.1 years), and the majority of patients (77.6 %) underwent morning colonoscopies. A suboptimal bowel preparation was reported in 17.2 % of the observed colonoscopies. In the multivariate regression analysis, constipation (odds ratio [OR] 1.60, 95 % confidence interval [CI] 1.15-2.22), male gender (OR 1.68, 95 % CI 1.25-2.25), obesity (OR 1.76, 95 % CI 1.29-2.41), and inadequate (<80 %) PEG consumption (OR 5.4, 95 % CI 2.67-10.89) were independent predictors of a suboptimal colon preparation.

CONCLUSIONS

This prospective study identified that constipation, male gender, obesity, and inadequate intake of PEG were significant risk factors for suboptimal bowel preparation using a 3-l PEG solution for outpatient colonoscopy. Interventions of optimized colonoscopy preparation should be targeted at these patient populations.

Colorectal cancer screening and surveillance in the elderly: updates and controversies

Colorectal cancer is common worldwide, and the elderly are disproportionately affected. Increasing age is a risk factor for the development of precancerous adenomas and colorectal cancer, thus raising the issue of screening and surveillance in older patients. Elderly patients are a diverse and heterogeneous group, and special considerations such as comorbid medical conditions, functional status and cognitive ability play a role in deciding on the utility of screening and surveillance. Colorectal cancer screening can be beneficial to patients, but at certain ages and under some circumstances the harm of screening outweighs the benefits. Increasing adverse events, poorer bowel preparation and more incomplete examinations are observed in older patients undergoing colonoscopy for diagnostic, screening and surveillance purposes. Decisions regarding screening, surveillance and treatment for colorectal cancer require a multidisciplinary approach that accounts not only for the patient’s age but also for their overall health, preferences and functional status. This review provides an update and examines the challenges surrounding colorectal cancer diagnosis, screening, and treatment in the elderly.

Fecal tag CT colonography with a limited 2-day bowel preparation following incomplete colonoscopy

PURPOSE

This study aimed to assess the feasibility and patient tolerance of a 2-day limited fecal tag bowel preparation in computed tomographic colonography (CTC) performed for incomplete conventional colonoscopy (CC) patients.

MATERIALS AND METHODS

Seventy-five patients who underwent a CTC examination fbecause of incomplete CC were included. A low-residue diet was given for 2 days before CTC. Fecal tagging (FT) was done using a barium sulfate suspension. The quality of the preparation, success of tagging and patient experience with the bowel preparation were investigated.

RESULTS

Four hundred fifty bowel segments were evaluated. The number of solid stool balls of 6-9 mm size was 284; the corresponding figure was 93 for solid stool balls ≥ 10 mm. Residual fluid was present in about one-third of the segments. The fecal tagging efficacy for ≥ 6 mm residual stool balls was 92 %. Overall, 16 (21.3 %) patients presented with colonic lesions at CTC. Three out of four colonic mass lesions had not been diagnosed with CC. Most patients reported mild discomfort.

CONCLUSION

FT-CTC performed after a limited 2-day bowel preparation seems to be a technically feasible, safe and acceptable procedure that allows a complete a colonic study in incomplete CC patients.

The 5-year outcome of patients having incomplete colonoscopy

AIM

Incomplete colonoscopy indicated for the detection of neoplasia occurs in 2-23% of patients, but there is little information on the long-term outcome of such patients.

METHOD

All patients who underwent colonoscopy over 5 years at the Royal Liverpool University Hospital with a follow-up of up to 5 years were identified.

RESULTS

The risk of colorectal cancer (CRC) was 2.9% (312/10 580) for all patients undergoing colonoscopy. For a failed colonoscopy, the risk was five-fold higher [14.3% (99/693)]. The mean age of the patients was 61 years and 58% were female. Following incomplete colonoscopy the risk of finding additional CRC, advanced colonic neoplasia and extracolonic neoplasia on subsequent investigation was 6.2%, 3.2% and 1.9%. The diagnostic yield on subsequent investigation for CRC or colonic polyps was 7% for repeat colonoscopy, 13.4% for computed tomography colonography, 10.3% for standard computed tomography and 1.8% for barium enema. In the 363 patients who were not offered a subsequent investigation, there was no further instance of CRC or CRC-related mortality over a 36-month period.

CONCLUSION

Although the risk of CRC is higher in patients who have had a failed colonoscopy, a protocol approach of subsequent investigation should not replace clinical assessment on whether another test is necessary in the light of the good outcome of patients who were not subsequently investigated.

Colorectal cancer of the elderly

OPINION STATEMENT

Colorectal cancer (CRC) disproportionately affects the elderly. Older age is a strong risk factor for both the development of precancerous adenomas and CRC, thus raising the issue of screening and surveillance in older patients. However, screening and surveillance decisions in the elderly can be complex and challenging. Elderly patients are a diverse and heterogeneous group and special considerations such as co-morbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance. Such considerations also play a role in factors related to screening modalities, such as colonoscopy, as well as CRC treatment options and regimens. This review addresses many of the unique factors associated with CRC of the elderly and critically examines many of the controversies and challenges surrounding CRC in older patients.

Endoscopy in the elderly: risks, benefits, and yield of common endoscopic procedures

There has been limited research examining the risks, benefits, and use of common endoscopic procedures in the elderly. Furthermore, gastroenterology training programs do not routinely incorporate elderly concerns when dealing with common gastrointestinal issues. There exists a broad array of endoscopic procedures with varying inherent risks that must be weighed with each elderly patient in mind. This article discusses the benefits and drawbacks of the most common procedures and indications for endoscopy including upper endoscopy, colonoscopy, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound, percutaneous endoscopic gastrostomy, and deep enteroscopy.

Colorectal cancer and the elderly

Colorectal cancer and precancerous adenomas disproportionately affect the elderly, necessitating the need for screening and surveillance in this group. However, screening and surveillance decisions in the elderly can be challenging. Special considerations such as comorbid medical conditions, functional status, and cognitive ability play a role in one's decisions regarding the utility of screening and surveillance as well as the success and safety of various screening modalities. This article explores the evidence for screening and surveillance in the elderly, and addresses key challenges unique to this population.

Current status on performance of CT colonography and clinical indications

CT colonography (CTC) is a robust and reliable imaging test of the colon. Accuracy for the detection of colorectal cancer (CRC) is as high as conventional colonoscopy (CC). Identification of polyp is size dependent, with large lesions (≥10mm) accurately detected and small lesions (6-9mm) identified with moderate to good sensitivity. Recent studies show good sensitivity for the identification of nonpolypoid (flat) lesions as well. Current CTC indications include the evaluation of patients who had undergone a previous incomplete CC or those who are unfit for CC (elderly and frail individuals, patients with underlying severe clinical conditions, or with contraindication to sedation). CTC can also be efficiently used in the assessment of diverticular disease (excluding patients with acute diverticulitis, where the exam should be postponed), before laparoscopic surgery for CRC (to have an accurate localization of the lesion), in the evaluation of colonic involvement in the case of deep pelvic endometriosis (replacing barium enema). CTC is also a safe procedure in patients with colostomy. For CRC screening, CTC should be considered an opportunistic screening test (not available for population, or mass screening) to be offered to asymptomatic average-risk individuals, of both genders, starting at age 50. The use in individuals with positive family history should be discussed with the patient first. Absolute contraindication is to propose CTC for surveillance of genetic syndromes and chronic inflammatory bowel diseases (in particular, ulcerative colitis). The use of CTC in the follow-up after surgery for CRC is achieving interesting evidences despite the fact that literature data are still relatively weak in terms of numerosity of the studied populations. In patients who underwent previous polypectomy CTC cannot be recommended as first test because debate is still open. It is desirable that in the future CTC would be the first-line and only diagnostic test for colonic diseases, leaving to CC only a therapeutic role.

Adverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis

BACKGROUND

Studies suggest that advancing age is an independent risk factor for experiencing adverse events during colonoscopy. Yet many of these studies are limited by small sample sizes and/or marked variation in reported outcomes.

OBJECTIVE

To determine the incidence rates for specific adverse events in elderly patients undergoing colonoscopy and calculate incidence rate ratios for selected comparison groups.

SETTING AND PATIENTS

Elderly patients undergoing colonoscopy.

DESIGN

Systematic review and meta-analysis.

MAIN OUTCOME MEASUREMENTS

Perforation, bleeding, cardiovascular (CV)/pulmonary complications, and mortality.

RESULTS

Our literature search yielded 3328 articles, of which 20 studies met our inclusion criteria. Pooled incidence rates for adverse events (per 1000 colonoscopies) in patients 65 years of age and older were 26.0 (95% CI, 25.0-27.0) for cumulative GI adverse events, 1.0 (95% CI, 0.9-1.5) for perforation, 6.3 (95% CI, 5.7-7.0) for GI bleeding, 19.1 (95% CI, 18.0-20.3) for CV/pulmonary complications, and 1.0 (95% CI, 0.7-2.2) for mortality. Among octogenarians, adverse events (per 1000 colonoscopies) were as follows: cumulative GI adverse event rate of 34.9 (95% CI, 31.9-38.0), perforation rate of 1.5 (95% CI, 1.1-1.9), GI bleeding rate of 2.4 (95% CI, 1.1-4.6), CV/pulmonary complication rate of 28.9 (95% CI, 26.2-31.8), and mortality rate of 0.5 (95% CI, 0.06-1.9). Patients 80 years of age and older experienced higher rates of cumulative GI adverse events (incidence rate ratio 1.7; 95% CI, 1.5-1.9) and had a greater risk of perforation (incidence rate ratio 1.6, 95% CI, 1.2-2.1) compared with younger patients (younger than 80 years of age). There was an increased trend toward higher rates of GI bleeding and CV/pulmonary complications in octogenarians but neither was statistically significant.

LIMITATIONS

Heterogeneity of studies included and not all complications related to colonoscopy were captured.

CONCLUSIONS

Elderly patients, especially octogenarians, appear to have a higher risk of complications during and after colonoscopy. These data should inform clinical decision making, the consent process, public health policy, and comparative effectiveness analyses.

Colorectal cancer screening and surveillance in the elderly patient

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Older age is associated with a rise in colorectal cancer and adenomas, necessitating the need for CRC screening in older patients. However, decisions about CRC screening and surveillance in older adults are often difficult and challenging. The decision requires an individualized assessment that incorporates factors unique to performing colonoscopy in older adults in order to weigh the risks and benefits for each patient according to their overall health and preferences. This review addresses the factors unique to colorectal cancer and performing colonoscopy in older adults that are relevant in weighing the risks and benefits of screening and surveillance in this population.

Colonoscopic splenic injuries: incidence and management

PURPOSE

Splenic injuries that occur during colonoscopies are rare. There is no available incidence of this serious complication, and the literature is limited to case reports. Our study looks at single institution experience of splenic injuries during colonoscopy to define the incidence and management of this serious complication.

METHODS

All patients from 1980 through June 2008 sustaining a splenic injury during colonoscopy were reviewed.

RESULTS

Four patients (of 296,248 colonoscopies) sustained a splenic injury directly from colonoscopy performed at our institution (incidence 0.001%). Three additional patients were treated at our tertiary referral center after splenic injury from colonoscopy performed elsewhere. The mean age at the time of colonoscopy was 54 years (range 40-70 years). The most common presenting symptom was abdominal pain (n = 4) with a mean decrease in hemoglobin of 6.5 g/dl (range 4.5-8.5 g/dl). Splenic injury was diagnosed by computed tomography in five patients. Six patients received a mean of 5.5 U of packed red blood cells (range 2-14 U). All patients were managed with splenectomy, six patients within 24 h of the index colonoscopy, and one patient presented more than 24 h after initial colonoscopy. There was no evidence of preexisting splenic disease in any of the patients by surgical pathology, and there were no postoperative complications or deaths. The mean duration of stay was 10 days (range 7-15 days). All patients are alive at a median follow up of 22 months (range 1-164 months).

CONCLUSION

Splenic injury occurring during colonoscopy is a rare but serious complication. Patients presented with abdominal pain and a precipitous decrease in hemoglobin and have all required emergent splenectomy.

High-dose bisacodyl plus water lavage compared with oral sodium phosphate as bowel preparation for outpatient colonoscopy

BACKGROUND

The aim of this prospective study was to compare the efficacy and patient compliance of an oral high dose of bisacodyl plus water lavage and oral sodium phosphate in adults undergoing elective colonoscopy.

METHODS

A total of 276 patients were randomized to receive an oral high-dose bisacodyl preparation (6 tablets of 5mg bisacodyl) plus water lavage (2 L of water) or an oral sodium phosphate (NaP) preparation (90 mL in divided doses). All endoscopic procedures were conducted in the afternoon. The endoscopist was blinded to the preparation the patient had received and graded the quality of colon cleansing as excellent, good, fair, poor, or failed. Patients' demographic data, indications for the procedure, and colonoscopic findings were recorded and compared.

RESULTS

Significantly improved (p < 0.001) bowel preparation after NaP compared with bisacodyl plus water lavage was reported. The completion rate of colonoscopy was significantly lower (p < 0.001) in the bisacodyl group (70.6%) than in the NaP group (92.9%). The detection of polyps was significantly increased (p = 0.017) in the NaP group (43.1%) compared with the bisacodyl group (27.1%). A procedural indication of constipation was an independent predictor of failed preparation in the bisacodyl group (odds ratio, 4.8; 95% confidence interval, 1.9-12.0; p < 0.001).

CONCLUSION

The quality of bowel preparation with oral NaP was better than that with bisacodyl plus water lavage.

CT colonography with reduced bowel preparation after incomplete colonoscopy in the elderly

We prospectively assessed the feasibility and acceptance of computerized tomographic colonography (CTC) without bowel cathartic preparation in elderly patients after incomplete colonoscopy. A total of 136 patients underwent CTC without cathartic preparation. The time delay between conventional colonoscopy and CTC ranged between 3 and 20 days, depending on the clinical situation. Before CTC, fecal tagging was achieved by adding diatrizoate meglumine and diatrizoate sodium to regular meals. CTCs were interpreted using a primary two-dimensional (2D) approach and 3D images for further characterization. Patients were interviewed before and 2 weeks after CTC to assess preparation acceptance. CTC was feasible and technically successful in all the 136 patients. Fecal tagging was judged as excellent in 113 (83%) patients and sufficient in 23 (17%). Average CT image interpretation time was 14.8 min. Six (4.4%) cases of colorectal cancer and nine (6.6%) large polyps were detected, as well as 23 (11.3%) extracolonic findings of high clinical importance. No major side effect occurred, although 25% patients reported minor side effects, especially diarrhea. Overall, 76/98 patients replied that they would be willing to repeat the test if necessary. CTC without cathartic preparation is a technically feasible and safe procedure to complete a colonic study in the elderly, prompting its use in clinical practice.