Validation of same-day bowel preparation regimen using 4L polyethylene glycol: Comparison of morning and afternoon colonoscopy

Safety of cold snare resection techniques for removal of polyps in the small colon in patients taking clopidogrel and aspirin: a Korean Association for the Study of Intestinal Diseases prospective multicenter study

BACKGROUND AND AIMS

Polypectomy is a procedure associated with a high risk of bleeding. Guidelines recommend uninterrupted aspirin use during polypectomy, whereas cessation of clopidogrel 5 to 7 days before polypectomy is recommended. The cold snare resection (CSR) technique, with or without submucosal injection, is considered safer than conventional polypectomy using electrocoagulation for postpolypectomy bleeding. In this study, we compared the bleeding adverse events associated with CSR between clopidogrel and aspirin users.

METHODS

This multicenter prospective cohort study was conducted in 5 academic hospitals in Korea and included clopidogrel and aspirin users who underwent polypectomy. Antiplatelet agents were used without interruption, with ≤3 days of interruption defined as continuous use. The primary endpoint was delayed bleeding, which was defined as bleeding occurring several hours after polypectomy, whereas immediate bleeding was defined as bleeding requiring hemostasis 2 minutes after polypectomy. Risk factors for immediate bleeding were investigated for each polyp.

RESULTS

Finally, 263 patients (509 polyps) were included, including those receiving clopidogrel (n=129) and aspirin (n=134). The rates of delayed bleeding per patient in the clopidogrel and aspirin groups were .8% and .7%, respectively, meeting noninferiority (rate difference, .03%; 95% confidence interval, -2.07 to 2.13). A total of 100 cases of hemostasis (19.8%) were performed in 68 patients after polypectomy. Immediate bleeding risk factors were female sex, end-stage renal disease, submucosal injection before resection, and polyp size ≥5 mm.

CONCLUSIONS

This multicenter prospective study demonstrated the safety of CSR in patients treated with uninterrupted clopidogrel and aspirin. (Clinical trial registration number: NCT04328987.).

Effect of bowel preparation completion time on bowel cleansing efficacy: Prospective randomized controlled trial of different bowel preparation completion times precolonoscopy

OBJECTIVES

The elapse time between the completion of bowel cleansing and colonoscopy is one of the important factors for proper bowel cleansing. Although several studies have reported that a short time interval resulted in a favorable bowel cleansing, no randomized controlled trial (RCT) has been conducted to determine the effect of the elapse time. Consequently, we performed an RCT to investigate the efficacy of bowel preparation of participants who underwent colonoscopy according to the different time intervals between the completion of bowel preparation and colonoscopy.

METHODS

In this single-center RCT, study participants were randomized to complete bowel preparation either 2-4 h or 4-8 h before colonoscopy. The primary end-point was successful bowel preparation, rated using the Boston Bowel Preparation Scale (BBPS).

RESULTS

A total of 504 individuals were included (2-4 h, 255; 4-8 h, 249). The rate of successful bowel preparation in the 2-4 h group showed noninferiority compared with that of the 4-8 h group (97.6% vs. 95.2%; rate difference, 2.5% [-0.8% to 5.7%]; Pfor noninferiority < 0.001, Pfor superiority = 0.136). The rate for perfect cleansing (a BBPS score of 9) was higher in the 2-4 h group (56.5% vs. 39.8%, P < 0.001).

CONCLUSION

When bowel cleansing was finished 2-4 h before the start of colonoscopy, the overall bowel cleansing was noninferior, and perfect cleansing was superior, compared to that when cleansing was finished 4-8 h before colonoscopy.

Development and validation of a novel scoring system based on a nomogram for predicting inadequate bowel preparation

BACKGROUND AND AIMS

Adequate bowel preparation (BP) is crucial for the diagnosis of colorectal diseases. Identifying patients at risk of inadequate BP allows for targeted interventions and improved outcomes. We aimed to develop a model for predicting inadequate BP based on preparation-related factors.

METHODS

Adult outpatients scheduled for colonoscopy between May 2022 and October 2022 were enrolled. One set (N = 913) was used to develop and internally validate the predictive model. The primary predictive model was displayed as a nomogram and then modified into a novel scoring system, which was externally validated in an independent set (N = 177). Inadequate BP was defined as a Boston Bowel Preparedness Scale (BBPS) score of less than 2 for any colonic segment. The model was evaluated by the receiver operating characteristic (ROC) curve, calibration plots, and decision curve analysis (DCA).

RESULTS

Independent factors included in the prediction model were stool frequency ≤ 5 (15 points), preparation-to-colonoscopy interval ≥ 5 h (15 points), incomplete dosage (100 points), non-split dose (90 points), unrestricted diet (88 points), no additional water intake (15 points), and last stool appearance as an opaque liquid (0-80 points). The training set exhibited the following performance metrics for identifying BP failure: area under the curve (AUC) of 0.818, accuracy (ACC) of 0.818, positive likelihood ratio (PLR) of 2.397, negative likelihood ratio (NLR) of 0.162, positive predictive value (PPV) of 0.850, and negative predictive value (NPV) of 0.723. In the internal validation set, these metrics were 0.747, 0.776, 2.099, 0.278, 0.866, and 0.538, respectively. The external validation set showed values of 0.728, 0.757, 2.10, 0.247, 0.782, and 0.704, respectively, indicating strong discriminative ability. Calibration curves demonstrated close agreement, and DCA indicated superior clinical benefits at a threshold probability of 0.73 in the training cohort and 0.75 in the validation cohort for this model.

CONCLUSIONS

This novel scoring system was developed from a prospective study and externally validated in an independent set based on 7 easily accessible variables, demonstrating robust performance in predicting inadequate BP.

Comparison of 2 L Polyethylene Glycol Plus Ascorbic Acid and 4 L Polyethylene Glycol in Elderly Patients Aged 60-79: A Prospective Randomized Study

BACKGROUND

The bowel-cleansing efficacy and safety of 2 L polyethylene glycol (PEG) with ascorbic acid (2L PEG + Asc) has rarely been studied in the elderly population. In this randomized trial, we compared the bowel cleanliness, safety, and tolerability of 2L PEG + Asc with those of 4 L PEG in an elderly population aged 60-79.

METHODS

Study participants were randomized either to 2L PEG + Asc or 4L PEG. The primary endpoint was the success rate of bowel preparation, using the Boston Bowel Preparation Scale. Before colonoscopy, all participants were questioned about adverse events and tolerability regarding purgative ingestion.

RESULTS

A total of 347 individuals were enrolled (2L PEG + Asc, 174; 4L PEG, 173). Mean age in the 2L PEG + Asc and the 4L PEG was 69.3 ± 5.6 and 69.3 ± 5.0, respectively (P = 0.917). The rate for successful bowel cleansing was comparable between the 2L PEG + Asc (92%) and the 4L PEG (96%, P = 0.118). Total ingested liquid including purgative and water was lower in the 2L PEG + Asc group (2.9 L) than in the 4L PEG group (4.2 L, P < 0.001). The tolerability of purgative was superior in the 2L PEG + Asc (overall satisfaction, P < 0.001; willingness to reuse, P < 0.001). There were no serious adverse events during the trial.

CONCLUSIONS

The bowel-cleansing efficacy of 2L PEG + Asc was comparable to that of 4L PEG. Tolerability was superior in the 2L PEG + Asc group. For older people, 2L PEG + Asc is an efficacious and safe bowel cleanser. (Clinical trial registration number: KCT0004123).

Efficacy and Tolerability of Two Different Low-Volume Split-Dose Polyethylene Glycol Electrolytes Solution Bowel Preparation for Morning Colonoscopy

METHODS

A total of 120 patients were randomized to receive either the control group (n = 64) or the experimental group (n = 65). Patients in the control group adopted the low-volume split-dose regimen one, and patients in the experimental group adopted the low-volume split-dose regimen two. Those randomized to regimen one were instructed to take 0.75 L PEG two hours after dinner the day before the colonoscopy and 1.5 L PEG 4 hours before the colonoscopy. Patients assigned to regimen two were invited to consume 1.5 L PEG two hours after dinner the day before the colonoscopy and 0.75 L PEG 4 hours before the colonoscopy. The quality of bowel preparation, rated according to a Boston Bowel Preparation Scale (BBPS), represented the primary outcome measure. Tolerability, satisfaction, and lesions detection rated were secondary outcomes.

RESULTS

There was no significant difference between the transverse colon and right colon scores between the two groups (P > 0.05). The low-volume split-dose regimen two showed a higher success rate for cleansing of the right colon and overall colon (P < 0.05). For the comparison of the patients' bowel tolerance, there were no statistical differences between the two groups regarding thirst, abdominal pain or abdominal discomfort, abdominal distension, dizziness or headache, anal discomfort, and sleep disturbance (P > 0.05). However, regimen two had significantly less nausea, vomiting, and fatigue than regimen one (24.62% vs. 42.19%, P=0.034; 10.77% vs. 25.00%, P=0.035; 6.15% vs. 21.88%, P=0.010, respectively). Patient-reported satisfaction and willingness to repeat the bowel preparation were significantly higher for low-volume split-dose regimen two than for low-volume split-dose regimen one (P=0.011; P=0.015).

CONCLUSIONS

In early morning colonoscopies, the bowel-cleansing efficacy and patient tolerability of low-volume split-dose regimen two were superior to low-volume split-dose regimen one.

Effect of prophylactic clip application for the prevention of postpolypectomy bleeding of large pedunculated colonic polyps: a randomized controlled trial

BACKGROUND AND AIMS

Prophylactic application of a hemoclip has been suggested as an alternative to the use of an endoloop for the prevention of postpolypectomy bleeding (PPB) when resecting large, pedunculated colorectal polyps. Therefore, this multicenter, randomized controlled trial investigated the efficacy of prophylactic hemoclip application to reduce PPB during the resection of large pedunculated polyps.

METHODS

Large pedunculated polyps (≥10 mm in head diameter) were eligible for inclusion. Polyps were randomized into a study arm (where clips were applied before resection) and a control arm (without pretreatment). The primary outcome was the rate of PPB in each group. PPB included immediate PPB (IPPB) and delayed PPB (DPPB). IPPB was defined as blood oozing (≥1 minute) or active spurting occurring immediately after polyp resection. DPPB was defined as rectal bleeding, occurring after completion of the colonoscopy.

RESULTS

In total, 238 polyps from 204 patients were randomized into the clip arm (119 polyps) or the control arm (119 polyps). Overall bleeding adverse events were observed in 20 cases (IPPB, 16; DPPB, 4). The rate of overall PPB, IPPB, and DPPB was 8.4%, 6.7%, and 1.7%, respectively, for all polyps. The rate of overall PPB (clip 4.2% vs control 12.6%, P = .033) and IPPB (clip 2.5% vs control 10.9%, P = .017) was significantly lower in the clip arm than the control arm.

CONCLUSIONS

Prophylactic clipping before resecting large pedunculated polyps can reduce overall PPB and IPPB compared with no prior treatment. Therefore, prophylactic clipping may be considered before resection of large pedunculated polyps. (Clinical trial registration number: NCT02156193.).

Postgastrectomy gastric cancer patients are at high risk for colorectal neoplasia: a case control study

Background/Aims

Several studies have shown that colorectal neoplasms (CRN) including colorectal cancer (CRC) may be prevalent in patients with gastric cancer. However, in most of these studies, colonoscopy to investigate the prevalence of CRN was performed prior to surgery. We aimed to investigate whether CRN was more prevalent in postgastrectomy gastric cancer patients than in healthy individuals.

Methods

We reviewed the medical records of those patients within a cohort of gastric cancer patients with gastrectomy who underwent colonoscopy between 2016 and 2017. Controls age- and sex-matched with gastric cancer patients at a 2:1 ratio were identified among those who underwent colonoscopy at a health-promotion center. The frequencies of CRN, advanced CRN (ACRN), and CRC among patients with gastrectomy were compared with those in the control subjects. A total of 744 individuals (gastric cancer, 248; control, 496) were included.

Results

The rates of CRN and ACRN in the gastric cancer group were higher than those in the healthy individuals (CRN, 47.6% vs. 34.7%, P<0.001; ACRN, 16.9% vs. 10.9%, P=0.020). The rate of CRC was comparable between the 2 groups (2.0% vs. 0.6%, P=0.125). Multivariate analysis identified previous gastrectomy for gastric cancer and male sex as significant risk factors for (A)CRN.

Conclusions

CRN and ACRN were more prevalent in patients who underwent surgery for gastric cancer than in the control group. Regular surveillance colonoscopy at appropriate intervals is indicated after gastrectomy.

Comparison of bowel-cleansing efficacy of split-dose and same-day dose bowel preparation for afternoon colonoscopy in patients with gastrectomy: a prospective randomized study

BACKGROUND

A split dose (SPD) of purgative is the recommended bowel-preparation method for colonoscopy, although for colonoscopy scheduled for the afternoon, a same-day dose (SDD) of purgative is recommended. However, it has not been determined whether SPD or SDD is better in patients with gastrectomy who are at high risk of suboptimal bowel cleansing. We compared the bowel-cleansing efficacy of SPD and SDD regimens in patients with gastrectomy who underwent colonoscopy in the afternoon.

METHODS

This was a prospective, randomized, assessor-blinded study. For the SDD group, polyethylene glycol (PEG) was ingested on the day of colonoscopy starting at 7 AM. In the SPD group, 2 L PEG was ingested at 9 PM the day before colonoscopy, and the remaining 2 L from 10 AM on the day of colonoscopy. Colonoscopy was performed from 1:30 PM. Before colonoscopy, the participants completed questionnaires asking about bowel-movement kinetics, adverse events, tolerability, overall satisfaction, and willingness to reuse the protocol. The bowel-cleansing efficacy was assessed using the Boston Bowel Preparation Scale.

RESULTS

A total of 193 subjects were included (SDD, 95; SPD, 98). The rate of successful bowel cleansing was comparable between the two groups (SDD, 92.6% vs. SPD, 95.9%; P = 0.37). The incidence of adverse events (nausea, vomiting, bloating, abdominal pain, and dizziness/headache) was also comparable between the two groups. However, sleep disturbance was higher in the SPD group (SDD, 10.5% vs. SPD, 25.5%; P = 0.01). Tolerability did not differ between the SDD and SPD groups (satisfaction, P = 0.11; willingness to reuse, P = 0.29).

CONCLUSIONS

The bowel-cleansing efficacy, safety profile, and patient tolerability of SDD and SPD were comparable. Both SDD and SPD regimens are feasible bowel-preparation methods for patients with gastrectomy who undergo colonoscopy in the afternoon.

TRIAL REGISTRATION

Clinical trial registration number: KCT0002699.

Comparison of Bowel Cleansing Efficacy, Safety, Bowel Movement Kinetics, and Patient Tolerability of Same-Day and Split-Dose Bowel Preparation Using 4 L of Polyethylene Glycol: A Prospective Randomized Study

BACKGROUND

Split-dose bowel preparation is recommended for morning colonoscopy, although a same-day dose regimen is an alternative for afternoon colonoscopy. Same-day preparation for morning colonoscopy has rarely been evaluated.

OBJECTIVE

We compared the bowel cleansing efficacy, bowel movement kinetics, safety profile, and patient tolerability of split-dose and same-day preparation using 4-L polyethylene glycol.

DESIGN

This was a prospective, randomized, assessor-blinded study.

SETTINGS

This study was performed at a tertiary center in Korea.

PATIENTS

Study subjects were randomly assigned to the same-day or split-dose groups. For the same-day dose group, 4 L of polyethylene glycol were ingested on the day of colonoscopy starting at 5:00 AM for morning colonoscopy or 7:00 AM for afternoon colonoscopy. In the split-dose group, 2 L of polyethylene glycol were ingested at 9:00 PM the day before colonoscopy, and the remaining 2 L from 7:00 AM for morning colonoscopy or from 10:00 AM for afternoon colonoscopy. Colonoscopy was performed from 10:00 AM.

MAIN OUTCOME MEASURES

The efficacy of bowel cleansing was evaluated using the Boston bowel preparation scale. The participants completed questionnaires asking about adverse events, bowel movement kinetics, and tolerability of the preparation before colonoscopy.

RESULTS

A total of 339 subjects were included (same-day dose = 172; split dose = 167). One subject in each group did not undergo colonoscopy. The rate of successful cleansing did not differ between the groups (same-day dose = 98.8% vs split dose = 98.2%; p = 0.681). There were no instances of hemodynamic instability or aspiration in either group. Tolerability, including overall satisfaction and willingness to reuse, were comparable between the groups.

LIMITATIONS

This was a single-center study.

CONCLUSIONS

The bowel cleansing efficacy, safety profile, and tolerability of same-day dosing with polyethylene glycol were comparable with those of split dose. Therefore, same-day dosing with 4 L of polyethylene glycol is a feasible bowel preparation method. See Video Abstract at http://links.lww.com/DCR/B44. COMPARACIÓN DE LA EFICACIA DE LA LIMPIEZA INTESTINAL, LA SEGURIDAD, LA CINÉTICA DEL MOVIMIENTO INTESTINAL Y LA TOLERABILIDAD DEL PACIENTE DE LA PREPARACIÓN INTESTINAL EN EL MISMO DÍA Y EN DOSIS DIVIDIDAS UTILIZANDO 4 L DE POLIETILENGLICOL: UN ESTUDIO PROSPECTIVO ALEATORIZADO: Se recomienda la preparación del intestino en dosis divididas para la colonoscopia de la mañana, aunque un régimen de una sola dosis el mismo día es una alternativa para la colonoscopia en la tarde. La preparación de una sola dosis el mismo día para la colonoscopia matutina rara vez se ha evaluado.Comparamos la eficacia de la limpieza intestinal, la cinética del movimiento intestinal, el perfil de seguridad y la tolerabilidad del paciente de la dosis dividida y la preparación el mismo día utilizando 4 L de polietilenglicol.Este fue un estudio prospectivo, aleatorizado, cegado por el evaluador.Este estudio se realizó en un centro terciario en Corea.Los sujetos del estudio fueron asignados aleatoriamente a el grupo de una dosis en el mismo día o al grupo de dosis dividida. Para el grupo de dosis del mismo día, se ingirieron 4 L de polietilenglicol el día de la colonoscopia a partir de las 5 a.m. para la colonoscopia de la mañana o las 7 a.m. para la colonoscopia de la tarde. En el grupo de dosis dividida, se ingirieron 2 L de polietilenglicol a las 9 p.m. el día anterior a la colonoscopia, y los otros 2 L restantes a partir de las 7 a.m. para la colonoscopia de la mañana o desde las 10 a.m. para la colonoscopia de la tarde. La colonoscopia se realizó a partir de las 10 a.m.La eficacia de la limpieza intestinal se evaluó mediante la escala de preparación intestinal de Boston. Los participantes completaron cuestionarios preguntando sobre los eventos adversos, la cinética del movimiento intestinal y la tolerabilidad de la preparación antes de la colonoscopia.Se incluyeron un total de 339 sujetos (dosis el mismo día, 172; dosis dividida, 167). Un sujeto en cada grupo no se sometió a colonoscopia. La tasa de limpieza exitosa no difirió entre los grupos (dosis el mismo día, 98.8% versus dosis dividida, 98.2%; p = 0.681). No hubo casos de inestabilidad hemodinámica o aspiración en ninguno de los grupos. La tolerabilidad, incluida la satisfacción general y la voluntad de reutilización, fueron comparables entre los grupos.Este fue un estudio de centro único.La eficacia de la limpieza intestinal, el perfil de seguridad y la tolerabilidad de la dosificación en el mismo día con polietilenglicol fueron comparables con los de la dosis dividida. Por lo tanto, la dosificación en el mismo día con 4 L de polietilenglicol es un método factible de preparación intestinal. Vea el video del resumen en http://links.lww.com/DCR/B44.

Risk factors for peritonitis in patients on continuous ambulatory peritoneal dialysis who undergo colonoscopy: a retrospective multicentre study

BACKGROUND

Colonoscopy is associated with a risk of peritonitis in patients on peritoneal dialysis. However, no study has yet described the risk factors in play.

METHODS

This was a retrospective multicentre study. The medical records of patients on continuous ambulatory peritoneal dialysis (CAPD) who underwent colonoscopy from January 2003 to December 2012 were analysed. We recorded demographic characteristics, colonoscopic factors, use of prophylactic antibiotics, and development of peritonitis. Colonoscopy-related peritonitis was defined as peritonitis developing within 1 week after colonoscopy. Demographic and clinical characteristics were compared between patients who did and those who did not develop peritonitis.

RESULTS

During the study period, 236 patients on CAPD underwent colonoscopy, of whom 9 (3.8%) developed peritonitis. The rates of polypectomy/endoscopic mucosal resection were significantly higher in the peritonitis group than in the no peritonitis group (66.7 vs. 23.4%, p = 0.009). Prophylactic antibiotics were prescribed before colonoscopy in 65 patients; none developed peritonitis. No patient who developed peritonitis received prophylactic antibiotics (p = 0.067).

CONCLUSIONS

Advanced procedures including polypectomy or endoscopic mucosal resection increase colonoscopy-related peritonitis in patients on CAPD. Randomized controlled trials to investigate whether prophylactic antibiotics are needed to prevent peritonitis in all CAPD patients are warranted.