Cecal intubation time in screening colonoscopy

Factors predict prolonged colonoscopy before the procedure: prospective registry study

BACKGROUND

Colonoscopy difficulty and procedure time can vary between cases, posing challenges for daily scheduling in endoscopy units. In the literature, cecal intubation time (CIT) is commonly used to assess colonoscopy difficulty, yet there is debate regarding the factors influencing CIT. This prospective observational study aimed to evaluate the factors influencing CIT.

METHODS

In this single-center, prospective, observational study, 915 patients who underwent colonoscopy between July 2023 and April 2024 were evaluated. Failure to achieve cecal intubation due to poor bowel preparation and a history of colorectal surgery were considered as exclusion criteria. Patients with a CIT ≥ 11 min or those with technically failed cecal intubation were categorized into the prolonged CIT subgroup, while those with a CIT < 11 min were analyzed in the normal CIT subgroup. Patients were evaluated based on demographic characteristics, clinical parameters, and colonoscopy results.

RESULTS

A total of 902 patients included in the final analysis. The median age was 55 years and 55.4% of them were women. The cecal intubation rate was 97.5% (892 patients). The polyp, adenoma, and malignancy detection rate were 27.4, 20.7, and 1.9%, respectively. Median cecal intubation time (CIT) was 6 min (Interquartile range: 4-8). In multivariate analysis, body mass index ≤ 18.5, previous abdominal surgery, increased Wexner Constipation Score, and lesser endoscopist experience were associated with prolonged CIT.

CONCLUSIONS

BMI, previous abdominal surgery, severity of constipation, and the experience of endoscopist may affect CIT. Considering these factors during daily planning in the endoscopy unit can lead to more efficient facility utilization.

MorphGI: A Self-Propelling Soft Robotic Endoscope Through Morphing Shape

Colonoscopy is currently the best method for detecting bowel cancer, but fundamental design and construction have not changed significantly in decades. Conventional colonoscope (CC) is difficult to maneuver and can lead to pain with a risk of damaging the bowel due to its rigidity. We present the MorphGI, a robotic endoscope system that is self-propelling and made of soft material, thus easy to operate and inherently safe to patient. After verifying kinematic control of the distal bending segment, the system was evaluated in: a benchtop colon simulator, using multiple colon configurations; a colon simulator with force sensors; and surgically removed pig colon tissue. In the colon simulator, the MorphGI completed a colonoscopy in an average of 10.84 min. The MorphGI showed an average of 77% and 62% reduction in peak forces compared to a CC in high- and low-stiffness modes, respectively. Self-propulsion was demonstrated in the excised tissue test but not in the live pig test, due to anatomical differences between pig and human colons. This work demonstrates the core features of MorphGI.

G-EYE Improves Polyp, Adenoma, and Serrated Polyp Detection Rates in Colonoscopy: A Systematic Review and Meta-analysis

BACKGROUND

Colonoscopy is the gold-standard test to decrease mortality from colorectal cancer (CRC). G-EYE is an inflated balloon on the bending section of the scope with the ability to flatten the folds to improve the adenoma detection rate (ADR). We performed this meta-analysis to evaluate the efficacy of G-EYE in improving ADR and other quality indicators of colonoscopy.

METHODS

A literature search was performed through March 21, 2023, on databases including Embase, Medline, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, KCI-Korean Journal Index, and Global Index Medicus. Core concepts of G-EYE, colonoscopy, ADR, polyp detection rate (PDR), serrated polyp detection rate (SPDR), and withdrawal time were searched. Statistical analysis was performed with OpenMeta[Analyst]. The odds ratio (OR) for the proportional variable and mean difference for the continuous variable along with 95% CI was used with a P-value <0.05 considered statistically significant. We used the DerSimonian-Laird method and random effects model for pooling data.

RESULTS

The search strategy yielded a total of 143 articles. Three studies with 3868 total colonoscopies were finalized. The pooled ADR, PDR, and SPDR showed statistical improvement with G-EYE (OR: 1.744, 95% CI: 1.534-1.984, P<0.001; OR: 1.766, 95% CI: 1.547-2.015, P<0.001; and OR: 1.603, 95% CI: 1.176-2.185, P=0.003). The withdrawal time was also noted to be higher in the G-EYE group (mean difference: 0.114, CI: 0.041-0.186, P=0.002).

CONCLUSIONS

This meta-analysis suggests that G-EYE can improve ADR, PDR, and SPDR. Further studies are needed to evaluate the effect of G-EYE on interval CRC and mortality rate.

Effect of Body Mass Index on Cecal Intubation Time During Unsedated Colonoscopy: Variation Across the Learning Stages of an Endoscopist

BACKGROUND Body mass index (BMI) and endoscopists' experiences can be associated with cecal intubation time (CIT), but such associations are controversial. This study aimed to clarify the association between BMI and CIT during unsedated colonoscopy at 3 learning stages of a single endoscopist. MATERIAL AND METHODS A total of 1500 consecutive patients undergoing unsedated colonoscopy by 1 endoscopist at our department from December 11, 2020, to August 21, 2022, were reviewed. They were divided into 3 learning stages according to the number of colonoscopies performed by 1 endoscopist, including intermediate (501-1000 colonoscopies), experienced (1001-1500 colonoscopies), and senior stages (1501-2000 colonoscopies). Variables that significantly correlated with CIT were identified by Spearman rank correlation analyses and then included in multiple linear regression analysis. RESULTS Overall, 1233 patients were included. Among them, 392, 420, and 421 patients were divided into intermediate, experienced, and senior stages, respectively. Median CIT was 7.83, 6.38, and 5.58 min at intermediate, experienced, and senior stages, respectively (P.

Predictors of inadequate bowel preparation in older patients undergoing colonoscopy: A systematic review and meta-analysis

BACKGROUND

Factors that predict the quality of bowel preparation in older adults are unclear, and current guidelines do not provide specific recommendations.

OBJECTIVE

This meta-analysis aimed to identify risk factors for inadequate bowel preparation in older patients.

METHODS

PubMed, Embase, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang, and VIP databases were searched from their inception to February 2023. Cohort and cross-sectional studies exploring the risk factors for inadequate bowel preparation were included in this systematic review. Odds ratio (OR) values from individual studies were pooled using fixed-effects and random-effects models. In addition, a sensitivity analysis and assessment of publication bias were performed.

RESULTS

This meta-analysis included six studies (n = 1553) on previous abdominal surgery, six studies (n = 1494) on constipation, seven studies (n = 1505) on diabetes, eight studies (n = 2093) on non-compliance with the diet regimen, seven studies (n = 1350) on incomplete intake of laxative, and nine studies (n = 2163) on inadequate exercise during preparation. The pooled analysis showed that history of abdominal surgery (OR = 2.72; 95 % confidence interval, CI: 2.07 to 3.56), constipation (OR = 3.56, 95 % CI: 2.41 to 5.25), diabetes (OR = 2.54, 95 % CI: 1.81 to 3.57), non-compliance with the diet regimen (OR = 2.51, 95 % CI: 1.96 to 3.21), incomplete intake of laxative (OR = 2.43, 95 % CI: 1.60 to 3.67), and inadequate exercise during preparation (OR = 3.13, 95 % CI: 2.39 to 4.11) were independent risk factors for inadequate bowel preparation in older patients undergoing colonoscopy.

CONCLUSIONS

Three comorbid factors and three behavioral factors were significantly associated with inadequate bowel preparation in older adults. This meta-analysis provides valuable information for developing predictive models of poor bowel preparation.

High volume, low volume, or pills, which way should we go? a review of bowel preparation for colonoscopy

PURPOSE OF REVIEW

Colorectal cancer (CRC) is the second leading cause of adult cancer-related deaths in the United States. Colonoscopy is the gold standard for CRC screening. Adequate bowel preparation prior to colonoscopy is essential for good visualization, which results in higher polyp detection rates and shorter procedural times. Achieving adequate preparation prior to colonoscopy is accomplished approximately 75% of the time. This review covers current recommendations and recent updates in bowel preparation for colonoscopy.

RECENT FINDINGS

Split-dose bowel preparation is recommended, but recent studies show that same day, low-volume preparations are noninferior. Low-volume polyethylene glycol with electrolytes + ascorbic acid can achieve high-quality bowel preparation and 1-day, low-residue diets prior to colonoscopy, particularly prepackaged low-residue diets, can lead to better outcomes. Utilizing visual aids and artificial intelligence in the form of smartphone applications and quality prediction systems can also lead to higher rates of bowel preparation adequacy.

SUMMARY

An individualized approach should be used to decide on the best preparation option for patients. Lower volume, same day preparations are available and lead to better patient tolerability and compliance, along with less stringent precolonoscopy diets. Smartphone applications and artificial intelligence will allow us to better educate and guide patients with regards to following preparation instructions.

Retrograde colon imaging through colonic transendoscopic enteral tubing helps to confirm the cause of difficult colonoscopy: a case report

Numerous factors can contribute to a difficult colonoscopy, potentially leading to an incomplete procedure and overlooked lesions. Alternative strategies for handling difficult and incomplete colonoscopies should be considered. We present the case of an 85-year-old male who underwent a difficult colonoscopy, during which two expert endoscopists spent 1.5 h attempting various techniques but failed to intubate the cecum. Subsequently, colonic transendoscopic enteral tubing (TET) was performed. Abdominal plain film revealed tortuosity of the TET tube in the left abdomen corresponding to the distribution of the descending colon. Retrograde colon imaging was conducted by injecting a mixture of contrast medium and air into the colon via the TET tube. X-ray demonstrated well-developed visualization of the entire colon and terminal ileum. And evident elongation and tortuosity of the descending colon resembled an N-type folding pattern. The final diagnosis was determined as descending colon redundancy. Colonic TET combined with retrograde colon imaging through the TET tube may serve as an effective supplementary approach for identifying causes of difficult colonoscopy and improving diagnostic accuracy for bowel diseases when complete visualization is not achieved.

Factors of easy and difficult cecal intubation during unsedated colonoscopy

BACKGROUND AND AIMS

difficulty of cecal intubation should be a main indicator for the need of sedated colonoscopy and skilled endoscopists. The present study aimed to explore the factors associated with easy and difficult cecal intubation in unsedated colonoscopy.

METHODS

all consecutive patients who underwent unsedated colonoscopy at our department by the same endoscopist from December 3, 2020 to August 30, 2022 were retrospectively collected. Age, gender, body mass index (BMI), reasons for colonoscopy, position change, Boston Bowel Preparation Scale score, cecal intubation time (CIT) and major colonoscopic findings were analyzed. CIT < 5 min, CIT 5-10 min and CIT > 10 min or failed cecal intubation were defined as easy, moderate and difficult cecal intubation, respectively. Logistic regression analyses were performed to identify independent factors associated with easy and difficult cecal intubation.

RESULTS

overall, 1,281 patients were included. The proportions of easy and difficult cecal intubation were 29.2 % (374/1,281) and 27.2 % (349/1,281), respectively. Multivariate logistic regression analysis found that age ≤ 50 years, male, BMI > 23.0 kg/m2 and the absence of position change were independently associated with easy cecal intubation, and that age > 50 years, female, BMI ≤ 23.0 kg/m2, position change, and insufficient bowel preparation were independently associated with difficult cecal intubation.

CONCLUSIONS

some convenient factors independently associated with easy and difficult cecal intubation have been identified, which will be potentially helpful to determine whether a colonoscopy should be sedated and a skilled endoscopist should be selected. The current findings should be further validated in large-scale prospective studies.

A Systematic Review of Exercise Therapy for Bowel Preparation: Evidence to Guide Practice

This systematic review aims to evaluate (1) the effectiveness of exercise therapy in bowel preparation for colonoscopy, and (2) the characteristics of exercise programs for bowel preparation. Systematic searches were done in PubMed, EMBASE, the Cochrane Library, Web of Science, and CINAHL from inception to November 2022. Randomized controlled trials and quasi-experimental studies assessing the efficacy of exercise during bowel preparation were included in this review. Two reviewers independently assessed the methodological quality using a modified Downs and Black checklist. A narrative synthesis was conducted. A total of five studies (1,109 participants) were included in this review. In all eligible studies, the characteristics of the exercise programs varied and included mainly two types of exercise (walking and yoga), various amount of exercise (3,000-10,000 steps or 0.5-1.9 hours), and two exercise timing (during and 1 hour after taking the laxative). Available evidence indicated that exercise therapy is effective in improving the quality of bowel preparation. However, there was insufficient high-quality evidence to conclude the effects on procedure-related indicators, adverse events, and willingness to repeat preparation. Exercise should be recommended as an important part of routine bowel preparation for patients undergoing colonoscopy to improve the quality of bowel preparation. More rigorous studies focusing on the effects on procedure-related indicators, adverse events, and willingness to repeat preparation are needed. To ensure the effectiveness and safety of the intervention, it is critical to establish a standard, well-structured exercise program for bowel preparation.

Strategies to manage the difficult colonoscopy

During endoscopy, an endoscopist is inevitably faced with the occasional “difficult colonoscopy,” in which the endoscopist finds it challenging to advance the endoscope to the cecum. Beyond optimization of technique, with minimized looping, minimal insufflation, sufficient sedation, and abdominal splinting when needed, sometimes additional tools may be needed. In this review, we cover available techniques and technologies to help navigate the difficult colonoscopy, including the ultrathin colonoscope, rigidizing overtube, balloon-assisted colonoscopy and the abdominal compression device.

Factors affecting cecal intubation time during colonoscopy

In recent years, the morbidity and mortality of colorectal cancer (CRC) have increased significantly in China, and it has become one of the major malignancies that threaten the health of residents. Colonoscopy is the gold standard for the diagnosis of CRC. High-quality colonoscopy can effectively reduce the mortality of CRC. Cecal intubation time (CIT) is one of the indicators to reflect the quality of colonoscopy. Studies have found that many factors can affect CIT. This paper reviews the literature to identify the factors that affect CIT, such as those related to doctors, patients, assistive technologies, and equipment, in order to improve the quality of colonoscopy performed by endoscopists.

Negative effect of prolonged cecal intubation time on adenoma detection in female patients

Background and Aim

Withdrawal time of the colonoscope is associated with adenoma detection. However, the association between cecal intubation time and adenoma detection remains unclear. This study aimed to evaluate the association between cecal intubation time and adenoma detection.

Methods

This retrospective study analyzed prospectively collected data from a randomized controlled trial on female patients who underwent colonoscopy in an academic hospital. The primary outcome was the mean number of all adenomas detected per patient. Secondary outcomes included the mean number of advanced, diminutive, small/large, right-sided colonic, and left-sided colonic adenomas detected per patient. Furthermore, the detection rates of all categories of adenoma were evaluated.

Results

The analysis included 216 female patients aged ≥20 years. The correlation analysis did not reveal a significant relationship (P = 0.473) between cecal intubation and withdrawal times. The mean number of all adenomas detected per patient declined by approximately 30% (1.05-0.70) from the fastest to the slowest insertion time quartile. Adjusted regression analysis showed a significant decrease in the mean number of all adenomas detected per patient with increased intubation time (relative risk, RR = 0.87; 95% confidence interval, 0.76-0.99, P = 0.045), whereas the mean number of other categories of adenomas detected per patient and the detection rates of all categories of adenoma were not associated with the cecal intubation time.

Conclusions

This study showed a significant association between prolonged cecal intubation time and decreased adenoma detection. The cecal intubation time may be a significant quality indicator for colonoscopy.

Safety, Efficacy and High-Quality Standards of Gastrointestinal Endoscopy Procedures in Personalized Sedoanalgesia Managed by the Gastroenterologist: A Retrospective Study

Performing GI endoscopy under sedoanalgesia improves the quality-indices of the examination, in particular for cecal intubation and adenoma detection rates during colonoscopy. The implementation of procedural sedoanalgesia in GI endoscopy is also strongly recommended by the guidelines of the major international scientific societies. Nevertheless, there are regional barriers that prevent the widespread adoption of this good practice. A retrospective monocentric analytic study was performed on a cohort of 529 patients who underwent EGDS/Colonoscopy in sedoanalgesia, with personalized dosage of Fentanyl and Midazolam. ASA class, age and weight were collected for each patient. The vital parameters were recorded during, pre- and post-procedure. The rates of cecal intubation and of procedure-related complications were entered. The VAS scale was used to evaluate the efficacy of sedoanalgesia, and the Aldrete score was used for patient discharge criteria. No clinically significant differences were found between vital signs pre- and post-procedure. Both anesthesia and endoscopic-related complications occurring were few and successfully managed. At the end of examination, both the mean Aldrete score (89.56), and the VAS score (<4 in 99.1%) were suitable for discharge. For the colonoscopies, the cumulative adenoma detection rate (25%) and the cecal intubation rate in the general group (98%) and in the colorectal cancer screening group (100%) were satisfying. Pain control management is an ethical and medical issue aimed at increasing both patient compliance and the quality of the procedures. The findings of this work underscore that in selected patients personalized sedoanalgesia in GI endoscopy can be safely managed by gastroenterologists.

Diagnostic Yields and Clinical Impacts of Capsule Endoscopy

Observing the entire small bowel is difficult due to the presence of complex loops and a long length. Capsule endoscopy (CE) provides a noninvasive and patient-friendly method for visualizing the small bowel and colon. Small bowel capsule endoscopy (SBCE) has a critical role in the diagnosis of small bowel disorders through the direct observation of the entire small bowel mucosa and is becoming the primary diagnostic tool for small bowel diseases. Recently, colon capsule endoscopy (CCE) was also considered safe and feasible for obtaining sufficient colonic images in patients with incomplete colonoscopy, in the absence of bowel obstruction. This review article assesses the current status of CE in terms of the diagnostic yield and the clinical impact of SBCE in patients with obscure gastrointestinal bleeding, who have known or suspected Crohn's disease, small bowel tumor and inherited polyposis syndrome, celiac disease, and those who have undergone CCE.