Usefulness of a small-caliber, variable-stiffness colonoscope as a backup in patients with difficult or incomplete colonoscopy

OBJECTIVES: Although variable-stiffness colonoscopes have been developed, difficult or incomplete colonoscopies occasionally occur. The aim of this study was to evaluate the usefulness of a small-caliber, variable-stiffness colonoscope (scVSC) as a backup in patients with difficult or incomplete colonoscopies. METHODS: First, we retrospectively reviewed the cecal intubation rate of colonoscopies in which an adult standard colonoscope (AC) was immediately switched to an scVSC in all patients in whom a colonoscopy with an AC was incomplete. Second, 374 consecutive patients were randomized to undergo colonoscopy with a pediatric variable-stiffness colonoscope (PVSC, n = 123), AC (n = 125), or scVSC (n = 126). The scVSC was used by the same endoscopist to reattempt colonoscopy immediately after colonoscopy with a PVSC or an AC had been assessed as difficult or incomplete. The cecal intubation rate and time and the ancillary maneuvers used were evaluated. RESULTS: Fifty-two (2.5%) of the 2,056 attempted colonoscopies with an AC did not reach the cecum. Fifty-one of the 52 patients (98.1%) had complete colonoscopies after the switch from the AC to the scVSC. The initial intubation rate and time were not statistically different among the groups: PVSC, 95% and 6.8 min; AC, 91% and 7.5 min; and scVSC, 98% and 8.2 min. Cecal intubation was achieved in all five patients (100%) and in 10 out of 11 (91%) patients, respectively, after the PVSC or AC was switched to the scVSC. CONCLUSIONS: The completion rate markedly improved after switching from an AC or PVSC to an scVSC in difficult or incomplete colonoscopies, although the scVSC does not appear to offer any distinct advantage over the AC or PVSC for routine colonoscopies.     

(Technically) Difficult colonoscope insertion – Tips and tricks

Cecal intubation is a critical aspect of effective, complete colonoscopy. Difficult colonoscopy is most often considered as one in which it is challenging or impossible to reach the cecum. It may be a common occurrence due to patient and/or endoscopist factors. Incomplete colonoscopies should be avoided, since patients in this context present an important prevalence of lesions that escape examination. The approach to successful cecal intubation should depend on characterization of the problem as redundant colon or difficult sigmoid colon. Most patients with a prior incomplete colonoscopy can be colonoscoped successfully, if careful attention is paid to technique, using a variety of scopes, colonoscopy methods and additional equipment. Sufficient time should be allotted to make the attempt.     

Quality indicators in pediatric colonoscopy: an Australian tertiary center experience

Objectives: Quality indicators for colonoscopy in adults are largely driven by colorectal cancer screening, and include cecal intubation rates, with rates of >90% recommended. In contrast, colorectal cancer is rare in childhood, with paucity of data on relevant quality indicators for pediatric colonoscopy. It is also unclear whether high rates of cecal intubation are achievable in small children. Our aim was to audit all colonoscopies performed in a tertiary pediatric center to examine clinical indications for procedure, completeness of examination with cecal and ileal intubation, significant findings, and complications.

Methods: Retrospective review of colonoscopies performed between November 2011 and October 2015 was undertaken.

Results: Total colonoscopy was performed in 652 patients, 53% male, with median age 13.0 (range 0.4–18.2) years. The most common indications for colonoscopy were assessment of inflammatory bowel disease (IBD) 57.9% (378/652), rectal bleeding 10% (68/652) and abdominal pain 10% (68/652). Trainees performed 69.8% (452/652) of procedures. Quality of bowel preparation was mentioned in 63% (410/652), of which 22% (90/410) were considered inadequate. Cecal intubation rate was 96.3% (628/652) and ileal intubation rate was 92.4% (603/652). Extent of procedure was confirmed in 99.2% of patients with photographs and/or ileal biopsy. Poor quality of bowel preparation (p?=?.001) and age <5years (p?=?.007) were inversely related to successful ileal intubation.

Conclusions: High rates of cecal and ileal intubation are achievable in pediatric colonoscopy. Ileal intubation should be considered a quality indicator since the main indicator for pediatric colonoscopy is to investigate IBD.     

An adequate level of training for technical competence in screening and diagnostic colonoscopy: a prospective multicenter evaluation of the learning curve

BACKGROUND: Various training programs in colonoscopy recommend that trainees should perform at least 100 to 200 procedures to be considered technically competent at diagnostic colonoscopy. OBJECTIVE: Our purpose was to determine the adequate level of training for technical competence in screening and diagnostic colonoscopy. DESIGN: A prospective multicenter trial. SETTING: Fifteen tertiary care academic medical centers. PATIENTS: Over 8 months we prospectively evaluated the procedures of 24 first-year GI fellows in 15 tertiary care academic medical centers. A total of 4351 colonoscopies were assessed prospectively with variable clinical factors. INTERVENTION: Cecal intubation was documented by photographing the identified cecal landmarks, including the appendiceal orifice and the ileocecal valve. MAIN OUTCOME MEASUREMENTS: Acquisition of competence (success rate) was evaluated for colonoscopic training on the basis of 2 objective criteria: (1) adjusted completion rate (>90%) and (2) cecal intubation time (<20 minutes). RESULTS: The overall success rate was 83.5% (3635/4351). The mean cecal intubation time was 9.23 +/- 4.63 minutes. The success rate significantly improved and reached the requisite standard of competence after 150 procedures (71.5%, 82.6%, 91.3%, 94.4%, 98.4%, and 98.7%, respectively, for every 50 consecutive blocks). The polyp detection rate did not improve significantly during the 8 months and was not correlated with the learning curve. In addition, mean time to cecal intubation decreased significantly, from 11.16 to 8.39 minutes, after 150 procedures. Logistic regression analysis found that prolonged cecal intubation was caused by the following factors: elderly patients, female sex, low body mass index, poor bowel preparation, poor American Society of Anesthesiologists status, abdominal pain as an indication, instructor's supervision, and low case volume. LIMITATIONS: We did not record final pathologic reports of detected polyps and withdrawal time. CONCLUSIONS: Competence in technically efficient screening and diagnostic colonoscopy generally requires experience with more than 150 cases. Also, factors associated with prolonged cecal intubation for typical trainees did not differ from those for experienced colonoscopists.     

Incomplete colonoscopy: Maximizing completion rates of gastroenterologists

BACKGROUND

Cecal intubation is one of the goals of a quality colonoscopy; however, many factors increasing the risk of incomplete colonoscopy have been implicated. The implications of missed pathology and the demand on health care resources for return colonoscopies pose a conundrum to many physicians. The optimal course of action after incomplete colonoscopy is unclear.

OBJECTIVES:

To assess endoscopic completion rates of previously incomplete colonoscopies, the methods used to complete them and the factors that led to the previous incomplete procedure.

METHODS:

All patients who previously underwent incomplete colonoscopy (2005 to 2010) and were referred to St Paul’s Hospital (Vancouver, British Columbia) were evaluated. Colonoscopies were re-attempted by a single endoscopist. Patient charts were reviewed retrospectively.

RESULTS:

A total of 90 patients (29 males) with a mean (± SD) age of 58±13.2 years were included in the analysis. Thirty patients (33%) had their initial colonoscopy performed by a gastroenterologist. Indications for initial colonoscopy included surveillance or screening (23%), abdominal pain (15%), gastrointestinal bleeding (29%), change in bowel habits or constitutional symptoms (18%), anemia (7%) and chronic diarrhea (8%). Reasons for incomplete colonoscopy included poor preparation (11%), pain or inadequate sedation (16%), tortuous colon (30%), diverticular disease (6%), obstructing mass (6%) and stricturing disease (10%). Reasons for incomplete procedures in the remaining 21% of patients were not reported by the referring physician. Eighty-seven (97%) colonoscopies were subsequently completed in a single attempt at the institution. Seventy-six (84%) colonoscopies were performed using routine manoeuvres, patient positioning and a variable-stiffness colonoscope (either standard or pediatric). A standard 160 or 180 series Olympus gastroscope (Olympus, Japan) was used in five patients (6%) to navigate through sigmoid diverticular disease; a pediatric colonoscope was used in six patients (7%) for similar reasons. Repeat colonoscopy on the remaining three patients (3%) failed: all three required surgery for strictures (two had obstructing malignant masses and one had a severe benign obstructing sigmoid diverticular stricture).

CONCLUSION:

Most patients with previous incomplete colonoscopy can undergo a successful repeat colonoscopy at a tertiary care centre with instruments that are readily available to most gastroenterologists. Other modalities for evaluation of the colon should be deferred until a second attempt is made at an expert centre.     

Method of colonoscopy in 42 consecutive patients presenting after prior incomplete colonoscopy

OBJECTIVES: Cecal intubation is one of the goals of colonoscopy. We sought to describe the methodology used by a single experienced examiner to perform colonoscopy in a consecutive group of patients with challenging colons. METHODS: Records of 42 consecutive patients with one or more prior unsuccessful attempts at colonoscopy by a gastroenterologist or surgeon and referred for a repeat attempt at colonoscopy were reviewed. RESULTS: Colonoscopy was complete to the cecum in 40 of the 42 patients (95%). An array of methods was employed, including propofol sedation (n = 2), pediatric colonoscope (n = 8), an external straightener (n = 9), external straightener with pediatric colonoscope (n = 2), upper endoscope (n = 8), guidewire exchange (n = 3), and enteroscope with a colon straightener (n = 1) or an enteroscope straightener (n = 1). CONCLUSIONS: A variety of methods and instruments were employed to achieve a high cecal intubation rate during colonoscopy in a group of patients with prior incomplete colonoscopies. Others may find one or more of these methods useful in patients with challenging colons.     

Effect of hysterectomy on colonoscopy completion rate

BACKGROUND:

Several studies show that colonoscopies are technically more difficult to perform in women than men, especially in women who have undergone abdominal and gynecological surgeries. A review of the literature indicates an increased rate of noncompletion of colonoscopies in most cases; however, no studies have investigated the procedural complication rate, sedation requirements and perception of pain in colonoscopies.

OBJECTIVE:

To determine whether women who have undergone a previous hysterectomy have a higher noncompletion rate when undergoing a colonoscopy, and to assess whether there is a higher percentage of complications. Furthermore, the present study also aimed to ascertain whether these women required more sedation and whether their perception of pain is greater than that of women who did not undergo previous abdominal surgeries.

METHODS:

The present study was a prospective cohort study of women, 45 to 80 years of age, who underwent colonoscopy (n=508). A total of 229 patients were eligible for the study; they completed a questionnaire, and were subsequently divided into control and hysterectomy groups. Gastroenterologists performed all procedures. After colonoscopy, the patient and endoscopist completed a pain perception questionnaire. Cecal intubation rates were also recorded.

RESULTS:

No significant difference for cecal intubation rates were detected between the two groups (95.7% and 98.7% in hysterectomy and control groups, respectively; P=0.176). The crude OR for the success rate was 0.29 (95% CI 0.05 to 1.90). There was no significant difference between groups regarding sedation or the type of colonoscope. No correlation between the gastroenterologists’ evaluation of pain and patients’ pain was observed.

CONCLUSION:

Hysterectomy did not significantly diminish the cecal intubation rate, and there was no detectable difference in pain perception or sedative dose. Colonoscopy remains an excellent screening and diagnostic tool for all women.     

A prospective study of factors that determine cecal intubation time at colonoscopy

BACKGROUND: For outpatient colonoscopy, the time required to intubate the cecum is variable. The aim of this study was to determine factors associated with cecal intubation time. METHODS: A total of 693 consecutive outpatient colonoscopies performed from January to October 2002 at a tertiary care medical center were studied prospectively. Data gathered included time required to reach the cecum; patient age, gender, and body mass index; history of abdominal surgery; quality of bowel preparation; presence/absence of diverticula; and endoscopist experience. RESULTS: Complete data were available for 587 patients. Mean age was 59 years, 48% were men, and mean body mass index was 28. Median cecal intubation time was 9 minutes. Linear regression analysis was performed. Cecal intubation time is prolonged by the following factors: older patient age, female gender, lower body mass index, poor bowel preparation, and lower endoscopist annual case volume. CONCLUSIONS: This large, prospective study identified 5 factors that prolong the time required for cecal intubation at colonoscopy. These factors may be used to individualize scheduling of colonoscopy according to the time required.     

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres

OBJECTIVE: The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). MATERIAL AND METHODS: A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. RESULTS: There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p < 0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p < 0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO2 insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50-99 registered colonoscopies. CONCLUSIONS: In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.     

Unsedated Colonoscopy Introduced to Ensure Access is Acceptable to a Subgroup of Veterans

Background Nurses for monitoring and recovery are required for sedated colonoscopy. A nursing shortage necessitated discontinuation of sedated colonoscopy at a VA academic training program. Aim Elements of a case series that documented acceptance of unsedated colonoscopy are reviewed to raise awareness of the feasibility of this option. Method The pros and cons of sedation and no sedation were summarized. After discussion, patients who chose the unsedated option were scheduled for examination locally while those who desired sedation were scheduled at another VA site. Colonoscopy was performed by supervised trainees. Results From September 2002 to June 2005 scheduled unsedated colonoscopy was accepted by 145 of 483 veterans. Cecal intubation was achieved in 81%. Thus, of the cohort 30% had local access to and 24% completed unsedated colonoscopy. Implementation of unsedated colonoscopy obviated the need for two registered nurses previously required for sedated colonoscopy. Conclusion Unsedated colonoscopy offered as an option to ensure access was acceptable to a subgroup of our veteran patients. Implementation required less nursing resources. Techniques to enhance the cecal intubation rate of unsedated colonoscopy performed by supervised trainees deserves to be assessed in future studies.     

Significance of a normal surveillance colonoscopy in patients with a history of adenomatous polyps

PURPOSE: The aim of this study was to determine the appropriate surveillance for patients with a history of adenomatous polyps whose last colonoscopic examination was normal. METHODS: This was a retrospective review of a database of 7,677 colonoscopies (1990 to 1996). In patients under colonoscopic surveillance, we reviewed cases of patients who had received three colonoscopies (an index (initial) colonoscopy positive for adenomas and 2 follow-up colonoscopies (interim and final)). The risk of adenomas and cancers at final follow-up colonoscopy was compared between patients having a normal interim colonoscopy and those with a positive interim colonoscopy. The risk at final colonoscopy was also stratified by time interval and the size and number of adenomas at the initial index colonoscopy. RESULTS: Two hundred four patients undergoing surveillance for adenomas met inclusion criteria. At index colonoscopy the median polyp size was 1 cm and median frequency was three polyps. At all follow-up colonoscopies, we detected 493 adenomas and one cancer (median follow-up, 55 months). At 36 months patients with a normal interim colonoscopy (n = 91) had significantly fewer polyps than patients with a positive interim colonoscopy (n = 113; 15 vs. 40 percent; P = 0.0001). By 40 months, adenomas were detected in more than 40 percent of patients in both groups. The risk after a normal interim colonoscopy was not affected by time interval or number or size of polyps. Adenomas found subsequent to a normal interim colonoscopy were dispersed throughout the colon in 28 patients and isolated to the rectosigmoid in 6 patients. CONCLUSIONS: In patients with a history of adenomas, a normal follow-up colonoscopy is associated with a statistically but not clinically significant reduction in the risk of subsequent colonic neoplasms. These patients require follow-up surveillance colonoscopy at a four-year to five-year interval.     

DOES A FITTED ABDOMINAL CORSET MAKES COLONOSCOPY MORE TOLERABLE?

Background and Aim: The present study evaluated the usefulness of a fitted abdominal corset for colonoscopy, enabling proper compression of the abdomen during the entire examination. Methods: Patients undergoing colonoscopy were subjected to either traditional methods or to using a fitted abdominal corset. Two hundred and sixteen patients were divided into two groups: group 1 (conventional colonoscopy) and group 2 (colonoscopy with abdominal corset). Cecal intubation rate and time need for manual compression and change of position were recorded. At the end of each colonoscopic examination, the patient evaluated pain by an 11‐point visual analog scale from 0 to 10 (0: no pain, 10: worst pain). Results: Cecal intubation time was shorter, the need for extra manual compression and change of position decreased and patients felt less pain during the procedure as denoted by lower visual analog scale scores in the group using a fitted abdominal corset, when compared to the group without a corset, in a statistically proven manner. Conclusion: Our data confirm the usefulness of the abdominal corset in decreasing the degree of patient pain and it makes colonoscopy easier and quicker with less manipulation, so we propose using a fitted abdominal corset during routine colonoscopic procedures.     

Underutilisation of the gastroscope for total colonoscopy in adults: a survey of two European countries

Background and study aims

High caecal intubation success rates have been reported with the gastroscope in adults. We surveyed the current use of the gastroscope for total colonoscopy in adults in the UK and Greece.

Methods

A questionnaire was e-mailed to 952 members of the British Society of Gastroenterology (UK) and 478 members of the Hellenic Society of Gastroenterology (GR), enquiring as to access to a paediatric colonoscope, use of gastroscope for total colonoscopy and estimate of caecal intubation success rate.

Results

Valid replies were 17.4% from UK and 19.7% from GR. The paediatric colonoscope was available to 106/138 (77%) UK and to only 18/86 (21%) GR respondents (p?=?0.0002). Of all the UK and GR respondents, 109/138 (79%) and 68/86 (79%), respectively, did not use the gastroscope for total colonoscopy. For the use of the gastroscope for total colonoscopy, 26/29 (89%) UK and 9/18 (50%) GR users did so, while a paediatric colonoscope was also available (p?=?0.001), and 3/29 (10.3%) UK and 9/18 (50%) GR users did so, whilst they had no access to a paediatric colonoscope (p?=?0.001). Estimated gastroscope caecal intubation success rate was 69% (SD 0.26) UK and 46% (SD 0.36) GR, p?=?0.008. Only 37% UK and 28% GR respondents used the gastroscope to examine the left colon.

Conclusions

The gastroscope is underutilised for total colonoscopy in both the UK and Greece. Use of the gastroscope does not appear to be related to lack of access to a paediatric colonoscope in the UK but may be in GR. Gastroscope caecal intubation success rate justifies its use where the colonoscope fails.     

Sedation-Free Colonoscopy

PURPOSE The administration of sedative drugs at colonoscopy has its drawbacks, such as increasing the rate of complications and the cost. There are a number of potential advantages to performing colonoscopy without sedation. The aim of this study is to evaluate patient tolerance and acceptance during sedation-free colonoscopy.METHODS Pain during sedation-free colonoscopy was evaluated in consecutive series of 675 patients in a prospective manner from January 1, 2003, to February 18, 2004. We recorded the degree of patient pain during colonoscopy, willingness to undergo sedation-free colonoscopy in the future, the complication rate, and the intubation time. The assisting endoscopy nurses and patients independently assessed the pain level immediately after the procedure using a four-point pain scale (nil, mild, moderate, severe).RESULTS Almost all colonoscopies (99.6 percent: 672/675) were successful. There were four complications related to colonoscopy (bleeding after polypectomy). Patients and nurses rated pain by a four-point pain scale as follows. For the patients: nil, 69.6 percent (470/675); mild, 28.0 percent (189/675); moderate, 2.2 percent (15/675); severe, 0.1 percent (1/675). For the nurses: nil, 76.1 percent (514/675); mild, 22.7 percent (153/675); moderate, 0.9 percent (6/675); severe, 0.3 percent (2/675). Patients rarely suffered from severe pain during carefully performed colonoscopies. The pain level of almost all colonoscopies was acceptable by patients, with only six patients (1.0 percent) stating that they would never undergo a colonoscopy without sedation in the future because of unbearable pain.CONCLUSIONS This study suggests that carefully performed sedation-free colonoscopy rarely causes complications and is well accepted by most patients. Sedation-free colonoscopy is more cost-effective, may be safer, and should be offered as an alternative to colonoscopy with sedation.     

Factors that predict incomplete colonoscopy

PURPOSE AND METHODS: Certain factors in a patient's history, such as prior abdominal surgery or complicated diverticular disease, have been reported to hinder cecal intubation during colonoscopy. Over a 16-month period, 1,047 consecutive colonoscopies were prospectively evaluated to determine whether these factors were indeed clinically relevant. RESULTS: Of the 90 patients (9 percent) who had incomplete intubation of the colon, there were significantly more women (66 percent) than men (34 percent) (P <0.001). Women with a history of abdominal hysterectomy had a significantly lower cecal intubation rate (P < 0.01). A history of diverticulitis did not alter the cecal intubation rate. In patients with incomplete colonic intubation, the most proximal extent of intubation was the sigmoid colon in women (31 percent) and the right colon in men (68 percent). Sixty-seven percent of patients with incomplete intubation of the colon had a prior colonoscopy completed to the cecum (67 percent women, 67 percent men), whereas 50 percent had a follow-up colonoscopy completed to the cecum (56 percent women, 40 percent men). CONCLUSIONS: Women, especially those with a history of abdominal hysterectomy, had a significantly lower cecal intubation rate usually because of an impassable sigmoid colon. Prior inability to complete colonoscopy to the cecum does not necessarily forecast future failure.Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995.     

Involvement of trainees in routine unsedated colonoscopy: review of a pilot experience

BACKGROUND: Unsedated colonoscopy is not required by the Accreditation Council of Graduate Medical Education in the curriculum of GI trainees. OBJECTIVE: We describe our pilot experience with trainee participation in unsedated colonoscopy. DESIGN: A retrospective review of a performance improvement program to provide access to colonoscopy. SETTING: A Veteran's Affair ambulatory care facility that discontinued sedated colonoscopy because of a nursing shortage. PATIENTS: A total of 145 of 483 patients who chose unsedated colonoscopy after both sedated and unsedated options were discussed. INTERVENTIONS: GI fellows performed unsedated colonoscopy under the supervision of the attending physician. MAIN OUTCOME MEASUREMENTS: Cecal intubation rate, patient assessment of the reasons for the choice, the unsedated experience, willingness to have another colonoscopy, and the rate of return for unsedated colonoscopy among eligible patients. RESULTS: Cecal intubation was achieved in 112 of 145 patients. The adjusted success rate (excluding inadequate bowel preparation and an obstructing lesion) was 81%. The most frequently acknowledged reason for the choice was the ability to communicate with the colonoscopist. Eighty-six patients reported a good experience and were likely to accept another unsedated colonoscopy. To date, all 8 patients eligible for 3-year follow-up successfully completed another unsedated examination. LIMITATION: An uncontrolled, nonrandomized review in predominantly male older veterans. CONCLUSIONS: An unsedated colonoscopy might be acceptable to some populations, particularly when communication with clinicians and procedural convenience are highly valued. Involvement of trainees is feasible. Randomized controlled comparisons of sedated and unsedated options in terms of safety (eg, sedation and procedure-related complications) and cost in settings with and without a nursing shortage deserve to be considered.     

The performance indicator of colonic intubation (PICI) in a FIT-based colorectal cancer screening program

Abstract

Objective: Cecal intubation rate (CIR) is known to be inversely associated with interval colorectal cancer (CRC) risk. Cecal intubation may be achieved by the use of force and sedation jeopardizing patient safety. The Performance Indicator of Colonic Intubation (PICI) is defined as the proportion of colonoscopies achieving cecal intubation with use of ≤2?mg midazolam and no-mild patient-experienced discomfort. We aimed (i) to measure the variation of PICI between colonoscopists and colonoscopy units; (ii) to assess the correlation between the individual components of PICI; and (iii) to evaluate the association between PICI and commonly used performance indicators.

Materials and methods: For the period 1 July 2015 through 30 June 2017 of the prevalent round of the Danish FIT-based CRC screening program, we included colonoscopies performed at four units in the Central Denmark Region within 60?days after a positive FIT-test. The PICI variation was evaluated using rates and ranges. Correlations between individual PICI components were assessed using Pearson correlation coefficients. Polyp detection rate (PDR), Adenoma detection rate (ADR), Polyp retrieval rate (PRR) and Withdrawal time (WT) were assessed within PICI quartiles.

Results: The overall PICI was 78.7% with substantial variation between colonoscopists (40.0–91.9%) and units (72.6–82.0%). CIR was significantly correlated with patient-experienced comfort (r?=?0.49, n?=?73, p?0001) and we observed that colonoscopists with a PICI between 79.9% and 84.3%) had the highest ADR.

Conclusion: We found a substantial variation in PICI between colonoscopists and between colonoscopy units, which may reflect potential for quality improvements.     

Improvement in caecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: a randomized trial of patients referred for colonoscopy

OBJECTIVE: Use of magnetic endoscope imaging (MEI) during colonoscopy has the potential to ease caecal intubation and patient discomfort and to reduce dependence on sedation and/or analgesics (SAs). However, pain reduction by using MEI has not been demonstrated so far, probably because of the liberal use of SAs. The aim of the present study was to evaluate the effect of MEI on caecal intubation and patient pain during unsedated colonoscopy performed by experienced and inexperienced colonoscopists. MATERIAL AND METHODS: A consecutive series of outpatients referred for colonoscopy were randomly allocated to examination with (imager group) or without (standard group) the use of MEI. Patients agreeing to SAs being given only on demand were included in the study. End-points were caecal intubation and pain, the latter to be graded by category on a form to be completed on the day after the examination. RESULTS: The proportion of colonoscopies performed without SAs was similar when comparing imager and standard groups and experienced with inexperienced colonoscopists; altogether 367(88%) out of 419 colonoscopies. The caecal intubation rate was higher in the imager group (190/212 (90%)) than in the standard group (153/207(74%)) (p<0.001), both collectively and separately for experienced and inexperienced colonoscopists. A pain-reducing effect of MEI was shown only when performed by experienced colonoscopists, with severe pain in 10/137 patients (7.3%) in the imager group and 21/132 patients (16%) in the standard group (p=0.03). CONCLUSIONS: In colonoscopy without the routine use of SAs, MEI significantly improves the caecum intubation rate and reduces pain during the procedure.     

Appropriateness of Colonoscopy in the Era of Colorectal Cancer Screening: A Prospective,Multicenter Study in a Private-Practice Setting (Berlin Colonoscopy Project 1, BECOP 1)

Purpose The introduction of reimbursement for screening colonoscopy in Germany more than one year ago raised concerns that the consequent workload might lead to underuse of diagnostic colonoscopy for symptomatic patients. Available appropriateness criteria for diagnostic colonoscopy have been rarely tested in a realistic outpatient setting. This study was designed to test current appropriateness criteria for diagnostic colonoscopy to better select patients and potentially provide more capacity for screening cases. Secondary goals were yield and quality control in both the diagnostic and screening cases. Methods A prospective study was initiated in 39 private-practice offices to collect data on consecutive colonoscopies conducted during a 6-day study period. A detailed questionnaire was developed to define indications and symptoms, and all findings at colonoscopy were recorded. Colonoscopies were further analyzed and stratified into a screening and a diagnostic group. In the diagnostic group, indications were assessed according to the current guidelines for appropriateness (American Society for Gastrointestinal Endoscopy, European Panel for the Appropriateness of Gastrointestinal Endoscopy), and the results were correlated with the percentage of relevant findings (tumors, inflammatory conditions). Results During the study period, 1,397 colonoscopies (57 percent screening, 43 percent diagnostic) were analyzed (male/female ratio = 39/61 percent; mean age, 61 years). Fourteen percent and 37 percent, respectively, of the 605 diagnostic colonoscopies were regarded as inappropriate relative to the criteria of the American Society for Gastrointestinal Endoscopy and the European Panel for the Appropriateness of Gastrointestinal Endoscopy. However, the percentage of relevant inflammatory and neoplastic findings (polyps, cancer, inflammatory bowel disease, benign strictures) was only 5 to 10 percent higher in the appropriate group than in the inappropriate group. On the basis of these data, a hypothetical model for selecting appropriate indications was developed: if patients older than aged 50 years with pain, bleeding, and diarrhea, but not constipation, are regarded as having an appropriate indication, such an approach would save 20 percent of colonoscopies in these main indication groups (bleeding, pain, diarrhea, constipation), with a hypothetical miss rate for relevant findings (as defined above) of 5 percent. Conclusions Currently used appropriateness criteria for diagnostic colonoscopy increase the yield of relevant findings but lead to a miss rate for relevant findings in the range of 10 to 15 percent. Simple selection criteria based on age and symptoms could be more suitable and should be tested in a larger group of patients. *For members participating in this study, see the Appendix. Supported by unrestricted grants from Olympus Co. Europe/Hamburg and Falk Foundation/Freiburg, Germany.     

Colonoscopy in the Elderly: Low Risk, Low Yield in Asymptomatic Patients

Purpose Current colonoscopy guidelines do not address the issue of when to stop performing screening and surveillance colonoscopy in the elderly. We reviewed our experience and results of colonoscopy in patients aged 80 years and older to assess the risks and diagnostic yield in this population. Methods We reviewed retrospectively the endoscopic and pathologic reports from consecutive colonoscopies performed on patients aged 80 years and older at a single, high-volume endoscopy center between August 1999 and May 2003. Patient characteristics, indications for examination, findings at colonoscopy, and complications were recorded and analyzed. Results A total of1,199 colonoscopic examinations were performed on 1,112 patients. Average age was 83.1 (range, 80–100) years. Male:female distribution was 1:1.7. Leading exclusive indications for colonoscopy included: polyp surveillance, 227 (19 percent); altered bowel habits, 168 (14 percent); iron-deficiency anemia, 132 (11 percent); and cancer follow-up, 108 (9 percent). Eighty-six examinations (7 percent) were performed solely for an indication of colorectal cancer screening. Twenty-two percent of patients had more than one indication for colonoscopy. Forty-five malignancies were found (3.7 percent). No cancers were found in the screening group, and two malignancies (0.7 percent) were detected in patients undergoing colonoscopy for polyp surveillance. There were eight (0.6 percent) reported major complications. Conclusions Colonoscopy can be performed safely in patients aged 80 years and older. However, the diagnostic yield is low, particularly in patients undergoing routine screening or surveillance examinations. Colonoscopy should for the most part be limited to elderly patients with symptoms or specific clinical findings. Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, May 2 to 5, 2005.