Retrograde inspection vs standard forward view for the detection of colorectal adenomas during colonoscopy: A back-to-back randomized clinical trial

BACKGROUND The adenoma detection rate(ADR) is inversely associated with the incidence of interval colorectal cancer and serves as a benchmark quality criterion during screening colonoscopy. However, adenoma miss rates reach up to 26% and studies have shown that a second inspection of the right colon in retroflected view(RFV) can increase ADR.AIM To assess whether inspection of the whole colon in RFV compared to standard forward view(SFV) can increase ADR.METHODS Patients presenting for screening or surveillance colonoscopy were invited to participate in this randomized controlled trial and randomized into two arms. In RFV arm colonoscopy was initially performed with SFV, followed by a second inspection of the whole colon in RFV. In the SFV arm first withdrawal was performed with SFV, followed by a second inspection of the whole colon again with SFV. Number, size and morphology of polyps found during first and second inspection in each colonic segment were recorded and all polyps were removed and sent for histopathology in separate containers.RESULTS Two hundred and five patients were randomly assigned to the RFV(n = 101) and SFV(n = 104) arm. In the RFV arm, both polyp detection rate(PDR) and ADR were increased under second inspection in RFV(PDR 1~(st) SFV: 39.8%, PDR 2~(nd)RFV: 46.6%; ADR 1~(st) SFV: 35.2%, ADR 2~(nd) RFV: 42%). Likewise, in the SFV arm,PDR and ADR were increased under second inspection(PDR 1~(st) SFV: 37.5%, PDR 2~(nd) SFV: 46.6%; ADR 1~(st) SFV: 34.1%, ADR 2~(nd)SFV: 44.3%) with no significant differences in ADR and PDR between the SFV and RFV arm. Mean number of adenomas per patient(APP) was increased in the RFV and SFV(APP RFV arm: 1~(st) SFV: 1.71; 2~(nd) RFV: 2.38; APP SFV arm: 1~(st) SFV: 1.83, 2~(nd)SFV:2.2). The majority of adenomas additionally found during second inspection in RFV or in SFV were located in the transverse and left-sided colon and were 5 mm in size.CONCLUSION Second inspection of the whole colon leads to increased adenoma detection with no differences between SFV and RFV. Hence, increased detection is most likely a feature of the second inspection itself but not of the inspection mode.     

Do forceps biopsies truthfully reflect the nature of endoscopically uncovered polypoid lesions of the colon?

BACKGROUND: Total excision of colonic polyps is not always attainable and in some patients it is clinically contraindicated. Also, a resected polyp may be lost at any step between its endoscopic removal and its embedding in paraffin. The aim of this study was to compare the histological features of colonic polyps as analysed by the study of biopsy-forceps obtained samples with those assessed on scrutinizing the totally resected growths. PATIENTS AND METHODS: This prospective study included a cohort of 59 patients in whom, in the course of an elective colonoscopy, a total excision of a 6 mm-sized or larger polyp was called for. Sizeable biopsies were obtained by means of an Olympus Multibyte forceps prior to the total polypectomy. Subsequent to the study of the polypectomy specimens, the forceps biopsy samples were submitted for histological examination. The pathologists were blinded as to the source of the tissue they were studying. The diagnoses rendered by evaluating the biopsy samples and polypectomy specimens of each patient were contrasted with each other. RESULTS: Major discrepancies between the histological features of the fragments captured by the biopsy-forceps and the factual nature of the totally removed polyps were uncovered in 11 (18.6%) of 59 cases. Intriguingly, the grade of the tumours was underrated in all the 11 cases, as judged by contrasting the tentative diagnoses of the forceps-biopsies with the decisive diagnoses of the polypectomies. Importantly, 2 adenocarcinomas would have been missed by just looking at the forceps-retrieved sample. CONCLUSIONS: In our experience, a discordance of 18.6% is to be expected between the diagnoses rendered after examining forceps-biopsies of and totally excised colonic polyps. Nevertheless, it is advisable to procure biopsies prior to the excision of the growths, because on those occasions in which patients' growths cannot be removed or have not been retrieved for one reason or another, a small forceps-captured tissue sample correctly reflects the characteristics of the polyp in 81.4% of the cases. Finally, the biopsies may be discarded in the event that total removal was successful.     

Colonoscopy — how difficult,how painful?

Colonoscopy is sometimes painful for the patient and often difficult for the endoscopist, but it is hard to predict how difficult or painful the examination will be. The purpose of this study was to identify factors that influence difficulty and pain during colonoscopy.Some 1,284 consecutive patients undergoing office colonoscopy by three endoscopists were prospectively studied. A standard questionnaire was completed by the nursing staff, who assessed the degree of difficulty and pain associated with each exam on a four-point scale.There were 682 men and 551 women (sex not recorded in 51). There was no pain in 27%, mild pain in 39%, moderate pain in 25%, and severe pain in 9%. There was no difficulty in 25%, mild difficulty in 33%, moderate difficulty in 28%, and severe difficulty in 14%. Colonoscopy was significantly easier (P<0.001, chi square) and less painful (P<0.001, chi square) in patients after sigmoidectomy. It was more painful after hysterectomy (P<0.05, chi square) and more difficult and painful in women than in men (P<0.01, chi square). There were significant differences between endoscopists in the assessment of pain associated with colonoscopy.Most colonoscopies are associated with little or no pain (66%) and are easy or only mildly difficult to perform (58%). Patients who have had sigmoid resection are especially easy and painless to examine while women, especially after hysterectomy, are at higher risk of having a painful experience. Colonoscopy technique can influence the amount of pain experienced by the patient.     

Complications of surgical endoscopy

Background: This study examines the notion that gastrointestinal endoscopy performed by supervised surgical residents is safe. Methods: We reviewed all gastrointestinal endoscopic procedures performed by surgical residents with faculty supervision for complications and deaths occurring up to 30 days following the procedures. Results: The overall complication rate for 9,201 upper and lower endoscopy procedures was 1.4% and 0.42%, respectively. Overall mortality rate was 0.76% for upper endoscopy and 0.6% for lower endoscopy. No mortality was a direct result of a procedure-related complication. Intestinal perforation, drug overdose, bleeding, and aspiration were the most common procedure-related complications. Each resident completed an average of 75 upper endoscopies and 79 lower endoscopies during their training period. Conclusions: Gastrointestinal endoscopy can be performed safely by surgical residents with appropriate supervision. The higher morbidity and mortality of upper endoscopy are most likely related to the underlying disease rather than the procedure. Awareness of common complications and application of appropriate precautions and instruction are critical for minimizing complications. Received 25 March 1996/Accepted: 24 April 1996     

东营区≥45岁人群结直肠癌初筛结果分析及肠镜顺应性调查

目的 对东营区≥45岁常住居民进行结直肠癌筛查,并探讨初筛阳性者肠镜顺应性及其影响因素,为提高居民结直肠癌筛查工作提供科学依据。方法 采用方便抽样方法选择辖区内2个镇和3个街道的社区卫生服务中心作为结直肠癌筛查志愿者招募点招募≥45岁常住居民为研究对象开展结直肠癌筛查及问卷调查,对初筛阳性者进一步进行肠镜检查,采用描述性分析方法对居民结直肠筛查结果及肠镜顺应性进行分析,并对其影响因素进行单、多因素分析。结果 本研究共纳入1 201人进行分析,男662人,女539人,45~59岁372人,60~69岁495人,70~79岁334人。初筛阳性人数总计371例,其中危险因素初筛阳性154例,FOBT阳性298例,危险因素和FOBT阳性双阳性者81例,初筛阳性率为30.89%。男性（OR=3.177）、黏液血便史（OR=7.683）以及肠道息肉病史（OR=5.008）为结直肠癌初筛阳性的危险因素。371例初筛阳性者中121例完成结肠镜检查,结肠镜检查顺应率为32.61%。性别（OR=2.776）、年龄（OR=0.511、0.433）、婚姻状况（OR=4.267）、文化程度（OR=2.782、3.916）、医疗保险（OR=2.743）是结直肠癌初筛阳性者结肠镜检查顺应性的影响因素。结论 东营市东营区结直肠癌初筛阳性率较高,应加强对存在黏液血便史以及肠道息肉病史男性个体人群的结直肠癌筛查。居民结直肠镜检查顺应性较低,尤其是60岁及以上、非在婚、文化程度较低、无医保的女性个体,可特异性强化对该群体个体的健康教育,提高其结直肠镜顺应性。     

Metachronous ileal cancer after surgery for ascending colon cancer in a patient with Lynch syndrome: A case report

Introduction and importanceColorectal surveillance via colonoscopy in patients with Lynch syndrome reduces the mortality of colorectal cancer. On the other hand, it is unclear whether surveillance for other malignancies, including small bowel cancer, is beneficial. We report a patient with Lynch syndrome who developed ileal cancer after surgery for ascending colon cancer.Case presentationA 47-year-old man visited our hospital for a check-up for positive fecal occult blood. He was diagnosed with ascending colon cancer and met the clinical criteria for the diagnosis of Lynch syndrome based on his past and family history. The Bethesda markers demonstrated high-frequent microsatellite instability. Laparoscopy-assisted right hemicolectomy was performed. He received follow-up colonoscopy the next year, which revealed ileal cancer near the anastomosis. He underwent resection of the second cancer via a laparoscopic approach, and has been free from recurrence for five years.Clinical DiscussionSmall bowel cancer has a dismal prognosis because a high percentage of patients were diagnosed at advanced stages. The diagnosis of metachronous ileal cancer by the first follow-up colonoscopy after surgery for ascending colon cancer offered a long disease-free survival in our patient.ConclusionThe clinical course suggested the importance of inspecting the small bowel in Lynch syndrome patients, especially when colorectal cancer is diagnosed.     

Colonoscopy in the elderly

An evaluation of the utility, morbidity, and patient tolerance of colonoscopy in elderly (70 years) patients was undertaken and compared to data for a similar group of younger patients (50–70 years) who underwent colonoscopy during the same 48 months. Data reviewed for both groups included demographics, indications for colonoscopy, effectiveness of bowel preparation, colonoscopy completion, endoscopic findings, and complications. The mean age of the entire 656-patient population was 69±10 years; 87 (25%) of the 354 elderly patients were greater than 80 years of age and the average age of the 302-member control group was 59.8±5.8 years. Indications for colonoscopy were the same in both groups and included rectal bleeding, 134 (20%); prior colorectal operation, 115 (18%); a history of adenomatous polyps, 82 (12%); guaiac-positive stools, 49 (8%); abnormal finding on barium enema, 19 (3%); and miscellaneous other gastrointestinal symptoms, 151 (23%). Screening colonoscopy was performed in 106 (16%). Colonoscopy was successfully completed to the cecum or the ileocolic anastomosis in 85% (555/656) of the entire population. Only 78% (275/354) of elderly patients had colonoscopy successfully completed compared to 93% (281/302) of their younger counterparts (P=0.001). Elderly patients were significantly more likely to have an abnormality than younger patients (74% vs 60%, P<0.05). Malignant colorectal neoplasia was more common in the elderly (6% vs 2%, P=0.03); however, benign neoplasia was equally present in both age groups (30% vs 27%, P=NS). Thirty percent (195/656) of all patients underwent either snare polypectomy or biopsy. There were no perforations, and postprocedural hemorrhage occurred in 2% (4/195) and was unrelated to age. Overall morbidity, including procedural-related oxygen desaturation, was no different between the two groups. There were no deaths. We conclude that colonoscopy is safe in elderly patients and that advanced age does not, by itself, confer increased risk to the procedure. The lower completion rate in elderly patients mandated additional subsequent testing to complete colonic evaluation but was offset by the significantly increased likelihood of discovering treatable pathology. These results support the continued, aggressive use of colonoscopy in the colonic evaluation of the elderly.     

结肠黑变病38例综合分析

目的:探讨结肠黑变病的致病因素及转归。方法:对经结肠镜确诊检出的38例结肠黑变病进行回顾性分析。结果:38例结肠黑变病中有30例便秘,6例大便不爽,26例(68.4%)服用泻药史。并发结肠癌3例,炎性增生性息肉3例,溃疡性结肠炎2例。结论:结肠黑变病除与便秘及长期用蒽醌类泻药有关,也可能与结肠上皮细胞凋亡及结肠癌、息肉、溃疡性结肠炎有关,治疗便秘及停用泻药能逆转结肠黑变病。     

Colorectal cancer diagnosis: Pitfalls and opportunities

Colorectal cancer (CRC) is a major health problem in the Western world. The diagnostic process is a challenge in all health systems for many reasons: There are often no specific symptoms; lower abdominal symptoms are very common and mostly related to non-neoplastic diseases, not CRC; diagnosis of CRC is mainly based on colonoscopy, an invasive procedure; and the resource for diagnosis is usually scarce. Furthermore, the available predictive models for CRC are based on the evaluation of symptoms, and their diagnostic accuracy is limited. Moreover, diagnosis is a complex process involving a sequence of events related to the patient, the initial consulting physician and the health system. Understanding this process is the first step in identifying avoidable factors and reducing the effects of diagnostic delay on the prognosis of CRC. In this article, we describe the predictive value of symptoms for CRC detection. We summarize the available evidence concerning the diagnostic process, as well as the factors implicated in its delay and the methods proposed to reduce it. We describe the different prioritization criteria and predictive models for CRC detection, specifically addressing the two-week wait referral guideline from the National Institute of Clinical Excellence in terms of efficacy, efficiency and diagnostic accuracy. Finally, we collected information on the usefulness of biomarkers, specifically the faecal immunochemical test, as non-invasive diagnostic tests for CRC detection in symptomatic patients.