Performing colonoscopy in elderly and very elderly patients: Risks, costs and benefits

Impact of Frailty on Care Burden of Hospitalized Older Adults Receiving Colonoscopy: A 2016-2020 Nationwide Inpatient Sample Analysis

BACKGROUND

Colonoscopy is a widely used diagnostic and therapeutic procedure. The impact of frailty on outcomes of hospitalized older patients undergoing colonoscopy is unclear. This study aims to evaluate associations between frailty and outcomes of hospitalized older adults undergoing colonoscopy.

METHODS

Data were extracted from the Nationwide Inpatient Sample (NIS), 2016-2020. Hospitalized patients ≥ 65 years old who underwent colonoscopy were included. Frailty was assessed using a modified frailty index (mFI), and frail was defined as mFI ≥ 0.27. The primary outcomes were in-hospital mortality, nonroutine discharge, prolonged length of stay (LOS) (≥ 75th percentile), postprocedural dysrhythmia, and other postprocedural complications.

RESULTS

A total of 142 257 hospitalized older adults were included, with 29 558 categorized as frail. The mean age was 77 years, and 54% were males. Frail patients had significantly higher in-hospital mortality (2.7% vs. 1.7%), nonroutine discharge (27.8% vs. 19.6%), prolonged LOS (33.9% vs. 24.2%), and postprocedural dysrhythmia (46.3% vs. 29.2%) compared to nonfrail patients (all, p < 0.001). After adjusting for covariates, frailty remained significantly associated with increased risks of in-hospital mortality (odds ratio [OR] = 1.60), nonroutine discharge (OR = 1.62), prolonged LOS (OR = 1.62), and postprocedural dysrhythmia (OR = 2.12). Stratified analyses by sex and age obtained the same results across all subgroups.

DISCUSSION

Frailty is significantly associated with adverse outcomes in hospitalized older adults undergoing colonoscopy. These findings highlight the importance of increased periprocedural care for frail patients to improve clinical outcomes and optimize resource utilization.

Real-world effectiveness and safety of 1L polyethylene glycol and ascorbic acid for bowel preparation in patients aged 80 years or older

Background and study aims

Clinical trials and real-world studies show a 1L polyethene glycol and ascorbic acid solution (1L PEG-ASC) to be an effective and safe bowel preparation for colonoscopy in the general population. Here, the effectiveness and safety of 1L PEG-ASC were evaluated in patients aged 80 years or older in a real-world setting.

Patients and methods

A post-hoc analysis of an observational, multicenter, retrospective study assessed the effectiveness and safety of 1L PEG-ASC on outpatients aged ≥ 80 years old undergoing colonoscopy at eight centers in Spain and Portugal. Cleansing quality was assessed using the Boston Bowel Preparation Scale, with overall scores ≥ 6 and all segmental scores ≥ 2 considered adequate colon cleansing, and overall scores ≥ 8 or 3 in the right colon considered high-quality cleansing. Cecal intubation rate, withdrawal time, polyp and adenoma detection rates (ADR), and adverse events (AEs) were also monitored.

Results

Data were analyzed from 423 patients aged ≥ 80 years; mean age 83.5 years (±3.2) and 49.2% males. The adequate colon cleansing success rate was 88.9%, with high-quality cleansing of the overall and right colon achieved in 54.1% and 46.1% of patients, respectively. Colonoscopy was complete in 94.1% of cases and the ADR was 51.3%. At least one AE was experienced by 4.5% of participants, the most frequent being mild dehydration (2.8%) and nausea (1.2%).

Conclusions

This post-hoc analysis confirms 1L PEG-ASC to be an effective and safe bowel cleansing preparation for patients aged 80 years or older in a real-world setting.

A Large Comparative Cohort Study of Colonoscopy in the Elderly: Indications, Outcomes, and Technical Aspects

Introduction  Performing colonoscopy in the elderly is associated with unique challenges, including higher rates of comorbidities, limited physiological reserve, and procedural complexities. This study aimed to evaluate the technical aspects, indications, and outcomes of colonoscopy in the elderly, with an emphasis on indication-based diagnostic yield. Methods  In this retrospective cohort study, we reviewed 35,000 consecutive colonoscopy procedures performed over a 12-year period on patients aged 50 years and older. Patients were categorized into three groups: very elderly (>80 years, n=3,434), elderly (65-80 years, n=13,783), and younger controls (50-64 years, n=17,959). Clinical and endoscopic findings were analyzed, with a focus on indication-specific outcomes. Results  The most frequent indications for colonoscopy in the very elderly and elderly groups were anemia and rectal bleeding. Both elderly groups exhibited higher rates of inpatient procedures (49.2% and 20.9% vs. 9.6%; P<0.0001), inadequate bowel preparation (18.5% and 13.5% vs. 9.1%; P<0.0001), and anesthesiologist involvement in sedation (6.0% and 3.9% vs. 2.1%; P=0.03) but required lower doses of propofol sedation (4.5% and 5.4% vs. 7.9%; P=0.026). Colorectal cancer (CRC), polyps, and diverticulosis detection increased linearly with age. Colonoscopies performed for anemia or rectal bleeding yielded higher CRC and polyp detection rates, whereas constipation was associated with the lowest diagnostic yield. Conclusion This study highlights the technical challenges associated with performing colonoscopy in elderly patients, identifies indications with the highest diagnostic yield, and underscores the necessity of tailored bowel preparation protocols and an indication-driven approach to optimize the clinical utility of colonoscopy in this population.

Surveillance colonoscopy findings in asymptomatic participants over 75 years of age

Background and Aim

Surveillance colonoscopy for colorectal cancer (CRC) is generally not recommended beyond 75 years of age. The study determined incidence and predictors of advanced adenoma and CRC in older individuals undergoing surveillance colonoscopy.

Methods

This was a retrospective cohort study of asymptomatic older participants (≥75 years), enrolled in a South Australian CRC surveillance program who underwent colonoscopy (2015-2020). Clinical records were extracted for demographics, personal or family history of CRC, comorbidities, polypharmacy, and colonoscopy findings. The associations between clinical variables and advanced adenoma or CRC at surveillance were assessed with multivariable Poisson regression analysis.

Results

Totally 698 surveillance colonoscopies were analyzed from 574 participants aged 75-91 years (55.6% male). The incidence of CRC was 1.6% (11/698), while 37.9% (260/698) of procedures had advanced adenoma detected. Previous CRC (incidence rate ratio [IRR] 5.9, 95% CI 1.5-22.5), age ≥85 years (IRR 5.8, 95% CI 1.6-20.1) and active smoking (IRR 4.9, 95% CI 1.0-24.4) were independently associated with CRC diagnosis, while advanced adenoma at immediately preceding colonoscopy (IRR 1.6, 95% CI 1.3-2.0) and polypharmacy (IRR 1.2, 95% CI 1.0-1.5) were associated with advanced adenoma at surveillance colonoscopy in asymptomatic older participants (≥75 years).

Conclusion

Advanced neoplasia was found in more than one third of the surveillance procedures completed in this cohort. Continuation of surveillance beyond age 75 yeasrs may be considered in participants who have previous CRC or are active smokers (provided they are fit to undergo colonoscopy). In other cases, such as past advanced adenoma only, the need for ongoing surveillance should be considered alongside participant preference and health status.

A 5-Year Statewide Analysis of Unplanned Hospital Visits for EGD, Colonoscopy, Combined EGD/Colonoscopy, and ERCP

Background and Aims

Conventional complication rates for gastrointestinal endoscopic procedures may underestimate the broader risk represented by postprocedure unplanned hospital visits (UHVs). We aimed to characterize UHVs for procedures in Maryland and the District of Columbia from 2014 to 2018.

Methods

Data for all esophagogastroduodenoscopies (EGDs), colonoscopies, combined EGDs/colonoscopies, and endoscopic retrograde cholangiopancreatographies (ERCPs) performed between 2014 and 2018 was provided by the Maryland Health Information Exchange (Chesapeake Regional Information System for our Patients'). Patient demographics, timing of UHV within 14 days postprocedure, distance traveled, facility site ("home" vs "away" institution), and International Classification of Diseases codes for the UHV were analyzed. Only UHVs potentially attributable to the endoscopic procedures were included.

Results

Among 304,786 endoscopic procedures and 3904 unplanned visits, the 14-day UHV rates were 1.7%, 0.6%, 1.3%, and 5.2% for EGD, colonoscopy, combined EGD/colonoscopy, and ERCP procedures respectively. From 2014 to 2018, the UHV rate on an annual basis remained stable for all procedure types except for ERCPs which increased. Patients who experienced UHVs were statistically different in sex, race, age, and distance traveled. UHVs most often occurred on postprocedure day 1; emergency department visits occurred most commonly. UHVs for all procedures, except ERCPs, were more likely to occur at a "home" institution. Overall, patients were more likely to be admitted postprocedure at an "away" institution.

Conclusion

Postendoscopic procedure UHV rates were generally low. However, UHV rates for EGDs and colonoscopies were significantly higher than conventional complication rates. As 30%-60% of all unplanned visits occurred at an "away" institution, endoscopists should consider a broad approach to detecting postprocedure complications and not rely on a single institution for data capture.

Trends in colorectal cancer incidence according to an increase in the number of colonoscopy cases in Korea

BACKGROUND

The incidence of colorectal cancer (CRC) and preinvasive CRC (e.g., early colon cancer and advanced adenoma) is gradually increasing in several countries.

AIM

To evaluate the trend in incidence of CRC and preinvasive CRC according to the increase in the number of colonoscopies performed in Korea.

METHODS

This retrospective cohort study enrolled Korean patients from 2002 to 2020 to evaluate the incidence of CRC and preinvasive CRC, and assess the numbers of diagnostic colonoscopies and colonoscopic polypectomies. Colonoscopy-related complications by age group were also determined.

RESULTS

The incidence of CRC showed a rapid increase, then decreased after 2012 in the 50-75 year-age group. During the study period, the rate of incidence of preinvasive CRC increased at a similar level in patients under 50 and 50-75 years of age. Since 2009, the increase has been rapid, showing a pattern similar to the increase in colonoscopies. The rate of colonoscopic polypectomy in patients aged under 50 was similar to the rate in patients over 75 years of age after 2007. The rate of complications after colonoscopy and related deaths within 3 mo was high for those over 75 years of age.

CONCLUSION

The diagnosis of preinvasive CRC increased with the increase in the number of colonoscopies performed. As the risk of colonoscopy-related hospitalization and death is high in the elderly, if early lesions at risk of developing CRC are diagnosed and treated under or at the age of 75, colonoscopy-related complications can be reduced for those aged 76 years or over.

Risks, indications and technical aspects of colonoscopy in elderly or frail patients. Position paper of the Societat Catalana de Digestologia, the Societat Catalana de Geriatria i Gerontologia and the Societat Catalana de Medicina de Familia i Comunitaria

Colonoscopy (CS) is an invasive diagnostic and therapeutic technique, allowing the study of the colon. It is a safe and well tolerated procedure. However, CS is associated with an increased risk of adverse events, insufficient preparation and incomplete examinations in the elderly or frail patient (PEA/F). The objective of this position paper was to develop a set of recommendations on risk assessment, indications and special care required for CS in the PEA/F. It was drafted by a group of experts appointed by the SCD, SCGiG and CAMFiC that agreed on eight statements and recommendations, between them to recommend against performing CS in patients with advanced frailty, to indicate CS only if the benefits clearly outweigh the risks in moderate frailty and to avoid repeating CS in patients with a previous normal procedure. We also recommended against performing screening CS in patients with moderate or advanced frailty.

Colonoscopy in the nonagenarian population

BACKGROUND

With increasing life expectancy, there is an increasing proportion of nonagenarians undergoing both elective and emergency surgical procedures. The decision as to whom will benefit from surgical procedures is however difficult to ascertain and still remains a challenge to clinicians. This study is aimed to evaluate the clinical outcomes of colonoscopy in the nonagenarian population, and to determine if the outcomes are acceptable for us to continue to offer such interventions.

METHODS

Retrospective study of patients of Dr. G.R (Gastroenterologist) and Dr. W.B (Colorectal Surgeon) between 1 January 2018 and 31 November 2022. All patients who were ≥90 years old and had a colonoscopy was included in the study. Exclusion criteria were patients who were less than 90 years old, had a flexible sigmoidoscopy or colonoscopy as part of their surgical procedure.

PRIMARY OUTCOME MEASURES

post-colonoscopy complications and length of stay.

SECONDARY OUTCOME MEASURES

reasons for colonoscopy, significant colonoscopy findings, 30-day morbidity and mortality.

RESULTS

Sixty patients were included in the study. Median age was 91 (90-100) years old. 33.3% of the patients were males. Seventy percent of the patients were ASA 3. Median length of hospital stay was 1 day. 11.7% of patients were found to have colorectal malignancy. There were no complications after the colonoscopy. There were no 30-day re-admission, morbidity or mortality.

CONCLUSION

Colonoscopy can be performed safely in carefully selected nonagenarian patients with acceptable low complication rates.

A retrospective study of colonoscopic surveillance in the elderly

BACKGROUND

Aotearoa New Zealand (AoNZ) guidelines suggest surveillance colonoscopy should be carefully considered after age 75. The authors noted a cluster of patients presenting in their 8th and 9th decade of life with a new colorectal cancer (CRC) having previously been declined surveillance colonoscopy.

METHODS

A 7-year retrospective analysis was performed of patients who underwent a colonoscopy aged between 71 and 75 years in the period between 2006 and 2012. Kaplan-Meier graphs were created with survival measured from the time of index colonoscopy. Log rank tests were used to determine any difference in survival distribution. Relative risk (RR) was calculated, and 95% confidence intervals (CI) reported.

RESULTS

A total of 623 patients met inclusion criteria; 461 (74%) had no indication for surveillance colonoscopy and 162 (26%) had an indication. Of the 162 patients with an indication, 91 (56.2%) underwent surveillance colonoscopies after the age of 75. Twenty-three (3.7%) patients were diagnosed with a new CRC. Eighteen (78.2%) patients diagnosed with a new CRC underwent surgery. The median survival overall was 12.9 years (95% CI 12.2-13.5). This did not differ between patients with (13.1, 95% CI 12.1-14.1) or without (12.6, 95% CI 11.2-14.0) an indication for surveillance.

CONCLUSION

This study found one quarter of patients who had a colonoscopy between the ages of 71-75 had an indication for surveillance colonoscopy. Most patients with a new CRC underwent surgery. This study suggests it may be appropriate to update the AoNZ guidelines and consider adopting a risk stratification tool to aid decision making.

Colorectal Cancer Screening and Surveillance in the Geriatric Population

PURPOSE OF THE REVIEW

Our national guidelines regarding screening and surveillance for colorectal cancer recommend individualized discussions with patients 75-85 years of age. This review explores the complex decision-making that surrounds these discussions.

RECENT FINDINGS

Despite updated guidelines for colorectal cancer screening and surveillance, the guidance for patients 75 years of age or older remains unchanged. Studies exploring the risks to colonoscopy in this population, patient preferences, life expectancy calculators and additional studies in the subpopulation of inflammatory bowel disease patients provide points of consideration to aid in individualized discussions. The benefit-risk discussion for colorectal cancer screening in patients over 75 years old warrants further guidance to develop best practice. To craft more comprehensive recommendations, additional research with inclusion of such patients is needed.

Palliative stenting for malignant colorectal stenosis in the elderly

Objectives

Self‐expandable metal stents are widely used for the treatment of malignant colorectal stenosis (MCS). In elderly individuals with MCS, self‐expandable metal stents are often used as a palliative treatment, but prophylactic stent placement is not recommended. We investigated the efficacy and safety of self‐expandable metal stents for the elderly in a palliative setting, specifically in a prophylactic setting.

Methods

Elderly patients with MCS who received a palliative stent (the stent group) or palliative stoma (the stoma group) were retrospectively enrolled between April 2017 and June 2022, and the prognosis and complication rates were assessed. Additionally, patients in the stent group were divided into symptomatic and asymptomatic subgroups, and prognosis, stent patency, and complication rates were evaluated.

Results

During the study period, 31 patients with a mean age of 85.4 years and 12 patients with a mean age of 82.0 years were enrolled in the stent and stoma groups, respectively. While overall survival and complication rates were comparable, the length of hospital stay was significantly shorter in the stent group. Of the 31 patients in the stent group, 16 asymptomatic patients received prophylactic stenting, which was not associated with increased complication rates.

Conclusions

Palliative stents for MCS appear to be effective and safe even in the elderly, and thus, prophylactic stents can be considered for asymptomatic patients.

Yield of Surveillance Colonoscopy in Older Adults with a History of Polyps: A Systematic Review and Meta-Analysis

BACKGROUND

The benefit of surveillance colonoscopy in older adults is not well described.

AIMS

To quantify the detection of colorectal cancer (CRC) and advanced polyps during surveillance colonoscopy in older adults with a history of colon polyps.

METHODS

We conducted a systematic review (MEDLINE, Cochrane Library, Web of Science, and Embase) for all published studies through May 2020 in adults age > 70 undergoing surveillance colonoscopy. The main outcome was CRC and advanced polyps detection. We performed meta-analysis to pool results by age (>70 vs. 50-70).

RESULTS

The search identified 6239 studies, of which 569 underwent full-text review and 64 data abstraction, of which 19 were included. The risk of detecting CRC (N = 11) was higher in those >70 compared to 50-70 (risk ratio 1.5 (95% CI 1.1-2.2); risk difference 0.8% (95% CI -0.2%-1.8%)). Similarly, the risk of detecting advanced polyps (N = 8) was higher in those >70 compared to 50-70 (risk ratio 1.3 (95% CI 1.2-1.3), risk difference 2.7% (95% CI 1.3%-4.0%)). Most studies did not stratify results by baseline polyp risk.

CONCLUSIONS

The detection of CRC and advanced polyps during surveillance colonoscopy in older individuals was higher than in younger controls; however, the absolute risk increase for both was small. These differences must be weighed against competing medical problems and limited life expectancy in older adults when making decisions about surveillance colonoscopy. More primary data on the risks of CRC and advanced polyps accounting for number of past colonoscopies, prior polyp risk, and duration of time since last polyp are needed.

Practical considerations for colorectal cancer screening in older adults

Recent guidelines recommend that colorectal cancer (CRC) screening after age 75 be considered on an individualized basis, and discourage screening for people over 85 due to competing causes of mortality. Given the heterogeneity in the health of older individuals, and lack of data within current guidelines for personalized CRC screening approaches, there remains a need for a clearer framework to inform clinical decision-making. A revision of the current approach to CRC screening in older adults is even more compelling given the improvements in CRC treatment, post-treatment survival, and increasing life expectancy in the population. In this review, we aim to examine the personalization of CRC screening cessation based on specific factors influencing life and health expectancy such as comorbidity, frailty, and cognitive status. We will also review screening modalities and endoscopic technique for minimizing risk, the risks of screening unique to older adults, and CRC treatment outcomes in older patients, in order to provide important information to aid CRC screening decisions for this age group. This review article offers a unique approach to this topic from both the gastroenterologist and geriatrician perspective by reviewing the use of specific clinical assessment tools, and addressing technical aspects of screening colonoscopy and periprocedural management to mitigate screening-related complications.

Colonoscopy surveillance following adenoma removal to reduce the risk of colorectal cancer: a retrospective cohort study

BACKGROUND

Colonoscopy surveillance is recommended for some patients post polypectomy. The 2002 UK surveillance guidelines classify post-polypectomy patients into low, intermediate and high risk, and recommend different strategies for each classification. Limited evidence supports these guidelines.

OBJECTIVES

To examine, for each risk group, long-term colorectal cancer incidence by baseline characteristics and the number of surveillance visits; the effects of interval length on detection rates of advanced adenomas and colorectal cancer at first surveillance; and the cost-effectiveness of surveillance compared with no surveillance.

DESIGN

A retrospective cohort study and economic evaluation.

SETTING

Seventeen NHS hospitals.

PARTICIPANTS

Patients with a colonoscopy and at least one adenoma at baseline.

MAIN OUTCOME MEASURES

Long-term colorectal cancer incidence after baseline and detection rates of advanced adenomas and colorectal cancer at first surveillance.

DATA SOURCES

Hospital databases, NHS Digital, the Office for National Statistics, National Services Scotland and Public Health England.

METHODS

Cox regression was used to compare colorectal cancer incidence in the presence and absence of surveillance and to identify colorectal cancer risk factors. Risk factors were used to stratify risk groups into higher- and lower-risk subgroups. We examined detection rates of advanced adenomas and colorectal cancer at first surveillance by interval length. Cost-effectiveness of surveillance compared with no surveillance was evaluated in terms of incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained.

RESULTS

Our study included 28,972 patients, of whom 14,401 (50%), 11,852 (41%) and 2719 (9%) were classed as low, intermediate and high risk, respectively. The median follow-up time was 9.3 years. Colorectal cancer incidence was 140, 221 and 366 per 100,000 person-years among low-, intermediate- and high-risk patients, respectively. Attendance at one surveillance visit was associated with reduced colorectal cancer incidence among low-, intermediate- and high-risk patients [hazard ratios were 0.56 (95% confidence interval 0.39 to 0.80), 0.59 (95% confidence interval 0.43 to 0.81) and 0.49 (95% confidence interval 0.29 to 0.82), respectively]. Compared with the general population, colorectal cancer incidence without surveillance was similar among low-risk patients and higher among high-risk patients [standardised incidence ratios were 0.86 (95% confidence interval 0.73 to 1.02) and 1.91 (95% confidence interval 1.39 to 2.56), respectively]. For intermediate-risk patients, standardised incidence ratios differed for the lower- (0.70, 95% confidence interval 0.48 to 0.99) and higher-risk (1.46, 95% confidence interval 1.19 to 1.78) subgroups. In each risk group, incremental costs per colorectal cancer prevented and per quality-adjusted life-year gained with surveillance were lower for the higher-risk subgroup than for the lower-risk subgroup. Incremental costs per quality-adjusted life-year gained were lowest for the higher-risk subgroup of high-risk patients at £7821.

LIMITATIONS

The observational design means that we cannot assume that surveillance caused the reductions in cancer incidence. The fact that some cancer staging data were missing places uncertainty on our cost-effectiveness estimates.

CONCLUSIONS

Surveillance was associated with reduced colorectal cancer incidence in all risk groups. However, in low-risk patients and the lower-risk subgroup of intermediate-risk patients, colorectal cancer incidence was no higher than in the general population without surveillance, indicating that surveillance might not be necessary. Surveillance was most cost-effective for the higher-risk subgroup of high-risk patients.

FUTURE WORK

Studies should examine the clinical effectiveness and cost-effectiveness of post-polypectomy surveillance without prior classification of patients into risk groups.

TRIAL REGISTRATION

This trial is registered as ISRCTN15213649.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 26. See the NIHR Journals Library website for further project information.

Local Anesthesia versus Conscious Sedation among Patients Undergoing Transcatheter Aortic Valve Implantation-A Propensity Score Analysis

BACKGROUND

Conscious sedation (CS) has been used successfully to treat patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) and as such is considered the standard anesthesia method. The local anesthesia (LA) only approach may be feasible and safe thanks to improvements in operators' experience.

OBJECTIVE

To evaluate differences between LA only versus CS approaches on short- and long-term outcomes among patients undergoing TAVI.

METHODS

We performed a propensity score analysis on 1096 patients undergoing TAVI for severe AS. Two hundred and seventy-four patients in the LA group were matched in a ratio of 1:3 with 822 patients in the CS group. The primary outcome was a 1-year mortality rate. Secondary outcomes included procedural and peri-procedural complication rates and in-hospital mortality.

RESULTS

Patients in the CS group had significantly higher rates of grade 2-3 acute kidney injury and were more likely to have had new left bundle branch block and high-degree atrioventricular block. Patients who underwent TAVI under CS had significantly higher in-hospital and 1-year mortality rates compared to LA (1.6% vs. 0.0% p-value = 0.036 and 8.5% vs. 3.3% p-value = 0.004, respectively). Kaplan-Meier's survival analysis showed that the cumulative probability of 1-year mortality was significantly higher among subjects undergoing CS compared to patients LA (p-value log-rank = 0.024). Regression analysis indicated that patients undergoing CS were twice more likely to die of at 1-year when compared to patients under LA (HR 2.18, 95%CI 1.09-4.36, p-value = 0.028).

CONCLUSIONS

As compared to CS, the LA-only approach is associated with lower rates of peri-procedural complications and 1-year mortality rates.

Risk Factors Associated with Colorectal Cancer in Octogenarians Can Help Stratify the Need for Colonoscopy

Objective Colonoscopy is increasingly performed in octogenarians for the detection of colorectal cancer (CRC), but its benefits may be outweighed by its risks. The aim of the present study was to identify the risk factors for CRC in octogenarians presenting for colonoscopy to help stratify the need for this procedure.

Methods A retrospective analysis of 434 patients aged ≥ 80 years referred for a colonoscopy between January 2018 and December 2019. Comparisons were made between those with and without CRC and advanced adenoma (AA). The primary endpoint was to identify the clinical variables predictive of CRC and AA, and the secondary endpoints were complications and death 30 days after the procedure.

Results Colonoscopy was performed in 434 octogenarians, predominantly for symptoms, with CRC in 65 (15.0%) patients. Iron deficiency was associated with a higher risk of having CRC identified on colonoscopy (odds ratio [OR]: 2.33; 95% confidence interval [95%CI] =  1.36–4.00), but not symptoms such as bleeding, weight loss, or diarrhea. A colonoscopy in the last 10 years was protective, with a lower risk of CRC (OR: 0.45; 95%CI = 0.22–0.93). Patients with both normal iron stores and a colonoscopy within 10 years had a 92.5% chance of not having CRC. No variables were predictive of AA. Patients with complications, including death, were older and more likely to have underlying cardiorespiratory disease.

Conclusion Iron status and colonoscopy within 10 years can be used to predict the risk of CRC in octogenarians. Those with low predicted risk, especially if older and with cardiorespiratory disease, should be considered for non-invasive tests, such as computed tomography (CT) colonography, over colonoscopy.

Real-World Use of Colonoscopy in an Older Population: A Nationwide Standard Cohort Study Using a Common Data Model

BACKGROUNDS AND AIMS

Rapid population aging is considered to be a major factor in increased colonoscopy use in Korea. However, real-world use of colonoscopy in older populations is rarely evaluated using Korean databases.

METHODS

We conducted a retrospective, observational cohort study of individuals aged over 20 years between 2012 and 2017. We used the Health Insurance Review and Assessment-National Patient Samples database, previously converted to the standardized Observational Medical Outcomes Partnership-Common Data Model. The use of diagnostic colonoscopy and colonoscopic polypectomy was evaluated, stratified by age group and sex.

RESULTS

During the study period, we captured data from the database on 240,406 patients who underwent diagnostic colonoscopy and 88,984 who underwent colonoscopic polypectomy. During the study period, use of diagnostic colonoscopy and colonoscopic polypectomy steadily increased, but both procedures were most significantly increased in the 65- to 85-year group compared to other age groups (p < 0.05). Average ages for both procedures significantly increased in the most recent 3 years (p < 0.05). Polypectomy rates for men plateaued in the 50- to 64-year age group, but rates for women steadily increased up to the 65- to 85-year group. Polypectomy rates were higher for men than for women in all index years.

CONCLUSIONS

The use of diagnostic colonoscopy and colonoscopic polypectomy significantly increased in the 65- to 85-year age group. Our findings suggest that more available colonoscopy resources should be allocated to older populations, considering the aging society in Asian countries.

Primary care clinicians' perceptions of colorectal cancer screening tests for older adults

Colonoscopy is an effective screening test for colorectal cancer but is associated with significant risks and burdens, especially in older adults. Stool tests, which are more convenient, more accessible, and less invasive, can be important tools to improve screening. How clinicians make decisions about colonoscopy versus stool tests in older patients is not well-understood. We conducted semi-structured interviews with primary care clinicians throughout Maryland in 2018-2019 to examine how clinicians considered the use of stool tests for colorectal cancer screening in their older patients. Thirty clinicians from 21 clinics participated. The mean clinician age was 48.2 years. The majority were physicians (24/30) and women (16/30). Four major themes were identified using qualitative content analysis: (1) Stool test equivalency - although many clinicians still considered colonoscopy as the test of choice, some clinicians considered stool tests equivalent options for screening. (2) Reasons for recommending stool tests - clinicians reported preferentially using stool tests in sicker/older patients or patients who declined colonoscopy. (3) Stool test overuse - some clinicians reported recommending stool tests for patients for whom guidelines do not recommend any screening. (4) Barriers to use - perceived barriers to using stool tests included lack of familiarity, un-returned stool test kits, concern for accuracy, and concern about cost. In summary, clinicians reported preferentially using stool tests in sicker and older patients and mentioned examples of potential overuse. Additional studies are needed on how to better individualize the use of different colorectal screening tests in older patients.

The Value of Family History in Colorectal Screening Decisions for Oldest Old Geriatric Populations

INTRODUCTION

Colorectal cancer (CRC) is the second most common form of cancer affecting both men and women. Extensive screening guidelines have been developed to help reduce the incidence of disease. Currently, United States Preventative Service Task Force guidelines recommend against routine screening in those 85 years and older. However, octogenarians and nonagenarians continue to be screened for CRC with no consensus on indications. The aim of this study is to examine family history of CRC as a risk factor and clinical indication for providing screening colonoscopies to the "oldest old" geriatric population, defined as aged 80 years and above.

METHODS

We conducted a retrospective review of a Veterans' Health Administration database to identify male veterans aged 80 years and older who underwent screening colonoscopy. Subsequently, we examined those who tested positive for CRC with a family history of CRC.

RESULTS

Of the 458,224 patients who are 80 years and older in the Veterans Affairs (VA) database, 17.8% underwent a screening colonoscopy; 11.42% of these individuals were further diagnosed with CRC; and 8.89% of those with diagnosed CRC had a documented family history of CRC.

CONCLUSION

Family history should not be used as an inclusionary criterion for CRC screening in the 80 years and above age group as the rate of CRC in these patients with a family history of CRC is significantly lower than that in the younger age groups with a family history of CRC.

Rectum versus colon: should malignant polyps be treated differently?

BACKGROUND

The management of malignant colorectal polyps removed at endoscopy remains controversial with patients either undergoing surgical resection or regular endoscopic surveillance. Lymph node (LN) metastases occur in 6-16% of patients with malignant polyps. This study assessed the rate of LN metastases in patients undergoing surgical resection for malignant polyps removed endoscopically to determine if there is a difference in the rate of LN metastases between colonic and rectal polyps.

METHODS

A retrospective review of a prospectively maintained database was performed from 2010 to 2018. All patients who underwent surgical resection following endoscopic removal of a malignant colorectal polyp were reviewed. Clinical data including patient demographics and tumour characteristics were examined.

RESULTS

A total of 177 patients underwent surgical resection in the study period. The median age at diagnosis was 65 years (range 22-88 years) with females comprising 52% of the patient cohort (n = 92/177). Polyps were located in the colon in 60.5% of cases with the remainder located in the rectum. The median number of LN harvested was 14 (range 0-44) with malignant LN (including a mesenteric tumour deposit) identified in 8.5% of resection specimens (n = 15/177). Malignant LNs were retrieved in 5.5% of right-sided tumours, 5.6% of left-sided tumours and 12.9% of rectal tumours (P = 0.090).

CONCLUSION

A small proportion of patients with malignant polyps removed endoscopically will have LN metastases. The results of this study suggest that the tumour location might be a useful predictive marker; however, a further study with increased patient numbers is required to properly establish this finding.

Long-term colorectal cancer incidence after adenoma removal and the effects of surveillance on incidence: a multicentre, retrospective, cohort study

OBJECTIVE

Postpolypectomy colonoscopy surveillance aims to prevent colorectal cancer (CRC). The 2002 UK surveillance guidelines define low-risk, intermediate-risk and high-risk groups, recommending different strategies for each. Evidence supporting the guidelines is limited. We examined CRC incidence and effects of surveillance on incidence among each risk group.

DESIGN

Retrospective study of 33 011 patients who underwent colonoscopy with adenoma removal at 17 UK hospitals, mostly (87%) from 2000 to 2010. Patients were followed up through 2016. Cox regression with time-varying covariates was used to estimate effects of surveillance on CRC incidence adjusted for patient, procedural and polyp characteristics. Standardised incidence ratios (SIRs) compared incidence with that in the general population.

RESULTS

After exclusions, 28 972 patients were available for analysis; 14 401 (50%) were classed as low-risk, 11 852 (41%) as intermediate-risk and 2719 (9%) as high-risk. Median follow-up was 9.3 years. In the low-risk, intermediate-risk and high-risk groups, CRC incidence per 100 000 person-years was 140 (95% CI 122 to 162), 221 (195 to 251) and 366 (295 to 453), respectively. CRC incidence was 40%-50% lower with a single surveillance visit than with none: hazard ratios (HRs) were 0.56 (95% CI 0.39 to 0.80), 0.59 (0.43 to 0.81) and 0.49 (0.29 to 0.82) in the low-risk, intermediate-risk and high-risk groups, respectively. Compared with the general population, CRC incidence without surveillance was similar among low-risk (SIR 0.86, 95% CI 0.73 to 1.02) and intermediate-risk (1.16, 0.97 to 1.37) patients, but higher among high-risk patients (1.91, 1.39 to 2.56).

CONCLUSION

Postpolypectomy surveillance reduces CRC risk. However, even without surveillance, CRC risk in some low-risk and intermediate-risk patients is no higher than in the general population. These patients could be managed by screening rather than surveillance.

Acceptance on colorectal cancer screening upper age limit in South Korea

BACKGROUND

The Korea National Cancer Screening Program currently provides screening for colorectal cancer (CRC) for adults older than 50 years with no upper age limit. In general, people are likely to only pay attention to the benefits of cancer screening and to neglect its risks. Most consider the benefits of cancer screening as being far greater than the risks and are unaware that any potential benefits and harms can vary with age.

AIM

To report acceptance of an upper age limit for CRC screening and factors associated therewith among cancer-free individuals in Korea.

METHODS

The present study analyzed data from the Korea National Cancer Screening Survey 2017, a nationally representative random sample of 4500 Korean individuals targeted for screening for the five most common types of cancer. A total of 1922 participants were included in the final analysis. The baseline characteristics of the study population are presented as unweighted numbers and weighted proportions. Both univariate and multivariate logistic regression models were developed to examine factors related with acceptance of an upper age limit for CRC screening; subgroup analysis was also applied.

RESULTS

About 80% (1554/1922) of the respondents agreed that CRC screening should not be offered for individuals older than 80 years. Specifically, those who had never been screened for CRC had the highest acceptance rate (91%). Overall, screening history for CRC [screened by both fecal occult blood test and colonoscopy, adjusted odds ratio (aOR) = 0.33, 95%CI: 0.22-0.50] and other cancers (aOR = 0.55, 95%CI: 0.34-0.87), as well as a family history of cancer (aOR = 0.66, 95%CI: 0.50-0.87), were negatively associated with acceptance of an upper age limit for CRC screening. In contrast, metropolitan residents (aOR = 1.86, 95%CI: 1.29-2.68) and people who exercised regularly (aOR = 1.42, 95%CI: 1.07-1.89) were more likely to accept an upper age limit. After subgrouping, we found gender, marital status, and lifetime smoking history among never-screened individuals and residential region, family history of cancer, and physical activity among never-screened individuals to be associated with acceptance of an upper age limit.

CONCLUSION

This study describes acceptance of an upper age limit for CRC screening and factors associated with it, and provides perspectives that should be considered, in addition to scientific evidence, when developing population-based cancer screening policies and programs.

Association of decreased variation of coefficient R-R interval with ischemic colitis and small bowel obstruction

Background

The parasympathetic nervous system exerts and controls intestinal tone. Several studies have suggested that the coefficient of the R–R intervals (CVRR) is useful for evaluating the parasympathetic nervous system.

Objectives

This study aimed to evaluate the relationship between gastrointestinal emergencies, specifically ischemic colitis (IC) and small bowel obstruction (SBO), and the autonomic nervous system.

Methods

In this retrospective study, a total of 13 patients with IC or SBO aged ≧65 years were analyzed. CVRR was measured in patients with IC and SBO and controls.

Results

CVRR averaged to 8.8% ± 2.5% in controls, 1.4% ± 0.4% in patients with IC, and 2.4% ± 1.0% in SBO groups (p < 0.001). CVRR was significantly lower in patients with IC and SBO than that in controls.

Conclusion

The results of this study demonstrate the possibility that CVRR may serve as a clinical index for assessing the functioning of the parasympathetic nervous system in patients with IC or SBO.

Second look at Streptococcus sanguinis and the colon

Although the link between Streptococcus bovis bacteraemia and colon cancer is well established, bacteraemia from other viridans group streptococci that commonly colonise colonic mucosa may also herald occult malignancy. We present a case of Streptococcus sanguinis bacteraemia in an elderly man with new anaemia that led to the detection and removal of a high-grade colon neoplasm. This case contributes to a growing body of literature contending that unexplained streptococcal bacteraemia merits a thorough workup that may include relatively invasive procedures such as endoscopy. Diagnostic colonoscopy provides an opportunity to prevent invasive malignancy that may outweigh bleeding and perforation risks in elderly patients.

Value of water enema computed tomography in elderly symptomatic patients

BACKGROUND AND STUDY AIMS

Colonoscopy remains the gold standard for the examination of the colon. However, its use in the elderly is not well tolerated, and there is often a need for general anaesthesia, thus increasing the risk, especially if there are co-morbidities. Water enema computed tomography has been suggested to be a satisfactory alternative as a non-invasive, fast and effective means for the diagnosis of colorectal supra-centimetric lesions. The aim of our study was to assess the performance of water enema computed tomography as first-line examination by calculating its negative predictive value (NPV) for the diagnosis of supra-centimetric lesions in symptomatic elderly referred to colonoscopy.

PATIENTS AND METHODS

This was a prospective study including 57 symptomatic patients older than 65 years. All patients were explored by water enema computed tomography at first, followed by colonoscopy, and responded to a questionnaire on the tolerance to the preparation and both procedures.

RESULTS

The mean age of patients was 73 years. The M:F sex ratio was 1.59. The most frequent indication for colonoscopy was bowel disorders associated with abdominal pain (30%). Water enema computed tomography allowed the diagnosis of tumours (n = 2), polyps (n = 6), diverticulosis (n = 7), inflammatory wall thickening (n = 1) and extra-colic lesions (n = 28). NPV of water enema computed tomography for supra-centimetric lesions was 96.5%. Sensitivity and specificity were 87.3% and 98%, respectively. However, for sub-centimetric lesions, water enema computed tomography had a low sensitivity estimated at 6%, specificity at 89.9%, positive predictive value at 91.9% and NPV at 27.7%.

CONCLUSION

Water enema computed tomography has proven to be a valuable and non-invasive method indicated as a first-line examination in case of colonic symptoms in the elderly to diagnose supra-centimetric lesions.

Results of total colonoscopy in the diagnosis of polyps. Case studies in Villavicencio, Colombia

Introducción. Cualquier levantamiento por encima del plano normal de la mucosa colónica es considerada proyección polipoidea. A mayor edad es más probable encontrar pólipos; además, los >1 cm de diámetro tienen mayor potencial de desarrollar neoplasia maligna.Objetivo. Establecer la frecuencia de lesiones polipósicas del colon, su tamaño, su localización y los grupos de edades donde están presentes en pacientes a quienes se les realizó colonoscopia en el Hospital Departamental de Villavicencio en el periodo 2009-2014.Materiales y métodos. Se analizaron los resultados de 411 colonoscopias diagnósticas. La recolección de datos y descripción estadística se hizo con el software SPPSS 2011.Resultados. Del total de la muestra, 43 (10.46%) pólipos fueron ≤1cm de diámetro, 16 (4% 3.89%) estuvieron entre 1cm y 2cm, no se encontraron pólipos >2cm y en el resto de resultados no se hallaron estas anomalías. En el grupo de edad de 41 a 50 años se presentaron pólipos en todos los segmentos del colon, pero el de mayor porcentaje (11%) fue el de 71 a 80 años. En el colon izquierdo se presentó el 69% de los pólipos >1cm y el 67% de los <1cm.Conclusión. En grupos de poblaciones <40 años de edad, los hallazgos de pólipos son bajos en colon izquierdo y muy bajos en colon derecho.

Management of Inflammatory Bowel Disease in the Elderly Patient: Challenges and Opportunities

The population of older patients with inflammatory bowel disease (IBD) continues to grow, partly reflecting the aging global population in general. The debilitating effects of IBD compound age-related decrements in health and functional capacity, and make the medical management of older patients with Crohn's disease and ulcerative colitis distinctly challenging to clinicians. Here, we review the recent literature describing the pharmacologic management of IBD in this population, with focus on the safety, tolerability, and efficacy of common treatment options, such as steroids, immunomodulators, tumor necrosis factor-α antagonists, and integrin antagonists; surgical interventions in older patients are also discussed. Few studies have systematically and prospectively evaluated the clinical challenges in the medical management of IBD in this patient population, leaving a limited evidence base to which clinicians can turn to for guidance. Treatment patterns may thus be suboptimal. For example, prolonged steroid use in the elderly was found to be common, causing significant morbidity from side effects in a particularly vulnerable population. Finally, within the context of a limited evidence base, we discuss common treatment scenarios to define the parameters within which physicians can individualize care for older patients with IBD. Overall, older patients with IBD are at higher risk of adverse events and less treatment responsiveness compared with younger patients, underscoring the need for future studies to fully characterize appropriate treatment courses for this population.

Bowel Preparation Is Associated with Reduced Morbidity in Elderly Patients Undergoing Elective Colectomy

BACKGROUND

Bowel preparation in elderly patients is associated with physiologic derangements that may result in postoperative complications. The aim of this study is to determine the impact of bowel preparation on postoperative outcomes in elderly patients.

METHODS

Patients age 75 years and older who underwent elective colectomy were identified from the 2012-2014 American College of National Surgical Quality Improvement Program (ACS-NSQIP database). Patients were grouped into no bowel preparation, mechanical bowel preparation (MBP), oral antibiotic preparation (OABP), or combined MBP + OABP. Logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes.

RESULTS

There were 4829 patients included in the analysis. Morbidity was 34.3% in no bowel prep, 32.4% in MBP, 24.8% in OABP, and 24.6% in MBP + OABP groups (p < 0.001). The MBP + OABP group compared with no bowel prep was associated with reduced rates of anastomotic leak, ileus, superficial surgical site infection (SSI), organ space SSI, respiratory compromise, and reduced length of stay. There was no difference in the rate of acute kidney injury between the groups.

CONCLUSION

MBP + OABP was associated with reduced morbidity compared with no bowel preparation in elderly patients undergoing elective colorectal resection. MBP alone was not associated with differences in outcomes compared with no bowel preparation. The use of MBP + OABP is safe and effective in elderly patients undergoing elective colectomy.