Efficacy of cap-assisted colonoscopy according to lesion location and endoscopist training level

AIM: To evaluate the efficacy of cap-assisted colonoscopy(CAC) for detection of colorectal polyps and adenomas according to the lesion location and endoscopist training level.METHODS: Patients 20 years or older, who underwent their first screening colonoscopy in a single tertiary center from May 2011 to December 2012 were enrolled in this study. All patients underwent either CAC or standard colonoscopy(SC), and all of the procedures were performed by 11 endoscopists(8 trainees and 3 experts). All procedures were performed with highdefinition colonoscopes and narrow band imaging. The eight trainees had experiences of performing 150 to 500 colonoscopies, and the three experts had experiences of performing more than 3000 colonoscopies. A 4-mmlong transparent cap was attached to the end of a colonoscope in the CAC group. We retrospectively evaluated the number of polyps and adenomas, polyp detection rate(PDR), and the number of adenomas and adenoma detection rate(ADR) according to the lesion location and endoscopist training level between CAC and SC. We also evaluated the number of polyps and adenomas according to their size between CAC and SC.RESULTS: Overall, PDR and ADR using CAC were significantly higher than those using SC for both whole colon(48.5% vs 40.7%, P = 0.012; 35.7% vs 28.3%, P = 0.012) and right-side colon(35.3% vs 26.6%, P = 0.002; 27.0% vs 16.9%, P 0.001). The number of polyps and adenomas per patient using CAC was significantly higher than that using SC for both the whole colon(1.07 ± 1.59 vs 0.82 ± 1.31, P = 0.008; 0.72 ± 1.32 vs 0.50 ± 1.01, P = 0.003) and right-side colon(0.66 ± 1.18 vs 0.41 ± 0.83, P 0.001; 0.46 ± 0.97 vs 0.25 ± 0.67, P 0.001). In the trainee group, the PDR and ADR using CAC were significantly higher than those using SC for both the whole colon(46.7% vs 39.7%, P = 0.040; 33.9% vs 26.0%, P =0.012) and right-side colon(34.2% vs 26.5%, P = 0.015; 25.3% vs 15.9%, P = 0.001). In the expert group, the PDR and ADR using CAC were significantly higher than those using SC only for the right-side colon(42.1% vs 27.0%, P =0.035; 36.8% vs 21.0%, P = 0.020).CONCLUSION: CAC is more effective than SC for detection of colorectal polyps and adenomas, especially when performed by trainees and when the lesions are located in the right-side colon.     

Magnetic imaging-assisted colonoscopy vs conventional colonoscopy: A randomized controlled trial

AIM: To compare magnetic imaging-assisted colonoscopy (MIC) with conventional colonoscopy (CC).METHODS: Magnetic imaging technology provides a computer-generated image of the shape and position of the colonoscope onto a monitor to give visual guidance to the endoscopist. It is designed to improve colonoscopy performance and tolerability for patients by enabling visualization of loop formation and endoscope position. Recently, a new version of MIC technology was developed for which there are limited data.To evaluate this latest generation of MIC among experienced rather than inexperienced or trainee endoscopists, a prospective randomized trial was performed using only gastroenterologists with therapeutic endoscopy training. Consecutive patients undergoing elective outpatient colonoscopy were randomized to MIC or CC, with patients blinded to their group assignment. Endoscopic procedural metrics and quantities of conscious sedation medications were recorded during the procedures. The procedure was classified as “usual” or “difficult” by the endoscopist at the conclusion of each case based on the need for adjunctive maneuvers to facilitate endoscope advancement. After more than one hour post-procedure, patients completed a 10 cm visual analogue pain scale to reflect the degree of discomfort experienced during their colonoscopy. The primary outcome was patient comfort expressed by the visual analogue pain score. Secondary outcomes consisted of endoscopic procedural metrics as well as a sedation score derived from standardized dose increments of the conscious sedation medications.RESULTS: Two hundred fifty-three patients were randomized and underwent MIC or CC between September 2011 and October 2012. The groups were similar in terms of the indications for colonoscopy and patient characteristics. There were no differences in cecal intubation rates (100% vs 99%), insertion distance-to-cecum (82 cm vs 83 cm), time-to-cecum (6.5 min vs 7.2 min), or polyp detection rate (47% vs 52%) between the MIC and CC groups. The primary outcome of mean pain score (1.0 vs 0.9 out of 10, P = 0.41) did not differ between MIC and CC groups, nor did the mean sedation score (8.2 vs 8.5, P = 0.34). Within the subgroup of cases considered more challenging or difficult, time-to-cecum was significantly faster with MIC compared to CC, 10.1 min vs 13.4 min respectively (P = 0.01). Sensitivity analyses confirmed a similar pattern of overall findings when each endoscopist was considered separately, demonstrating that the mean results for the entire group were not unduly influenced by outlier results from any one endoscopist.CONCLUSION: Although the latest version of MIC resulted in faster times-to-cecum within a subgroup of more challenging cases, overall it was no better than CC in terms of patient comfort, sedation requirements and endoscopic procedural metrics, when performed in experienced hands.     

Transparent-cap-fitted colonoscopy shows higher performance with cecal intubation time in difficult cases

AIM:To investigate the efficacy of cap-fitted colonoscopy(CFC) with regard to cecal intubation time.METHODS:Two hundred and ninety-five patients undergoing screening colonoscopy at Gospel Hospital,Kosin University College of Medicine were enrolled in this randomized controlled trial between January and December 2010.Colonoscopies were conducted by a single endoscopist.Patient characteristics including age,sex,body mass index,history of abdominal surgery,quality of preparation,and the presence of diverticulosis were recorded.RESULTS:One hundred and fifty patients were allocated into a CFC group and 145 into a non-CFC(NCF) group.Cecal intubations were achieved in all patients.Cecal intubation time in the CFC group was significantly shorter than in the NCF group for specific conditions:age ≥ 60 years,prior abdominal surgery,and poor bowel preparation.The number of detected adenomas was higher in the CFC group than in the NCF group(P = 0.040).CONCLUSION:CFC facilitated shortening of the cecal intubation time in difficult cases,and was more sensitive for detecting adenomas than was NCF.     

Colorectal cancer after surveillance colonoscopy

PURPOSE: Colonoscopy is the preferred method for colorectal cancer surveillance of high-risk patients. Despite its high sensitivity, polyps or cancers may be undetected by colonoscopy and later attributed to an accelerated adenoma-carcinoma sequence. This study assesses how the characteristics of colorectal cancers found at intervals between surveillance relate to the adenoma-carcinoma sequence and its prevention. METHODS: The records of 557 patients with colorectal cancer that were diagnosed from January 1, 1990, to December 31, 1996, were reviewed to identify those patients who had prior colonoscopic surveillance within 60 months of their diagnosis. RESULTS: There were 29 (5.2 percent) patients who had one or more colonoscopies before diagnosis of their colorectal cancer. Mean interval between diagnosis and prior colonoscopy was 23 (range, 4–59) months. The distribution of cancers included nine cecum, two ascending, three hepatic flexure, five transverse, one splenic flexure, three descending, two sigmoid, three rectum, and one anal canal. The mean tumor size was 4.4 cm for the cecum and 2.4 cm for all other locations. There were 7 Tis, 6 T1, 4 T2, and 12 T3 lesions. Six patients with T3 lesions had prior colonoscopies within 24 months of the diagnosis. Three of four patients with lymphatic metastases had tumors in the cecum. Twenty tumors (69 percent) were well or moderately differentiated. Mean follow-up was 41 (range, 7–95) months with two local recurrences and two unrelated deaths. CONCLUSIONS: Size, differentiation, and stage of colorectal cancer in addition to the interval to diagnosis suggest that the majority of cancers found during surveillance colonoscopy followed prior false-negative examinations. Because cecal landmarks are most constant, prior photographic documentation may help to prove or disprove fast growth of cancers found in the cecum during surveillance colonoscopy.Read at the meeting of The American Society of Colon and Rectal Surgeons, San Antonio, Texas, May 2 to 7, 1998.     

The polyp detection rate of colonoscopy: a national study of Medicare beneficiaries

National-level data on the proportion of colonoscopies in routine practice that result in polyp detection are limited. Our goal was to determine the diagnostic yield of colonoscopy among population subgroups. We reviewed Medicare claims data for all fee-for-service beneficiaries 65 years or older who underwent colonoscopy in 1999. With the use of diagnosis and procedure codes, the proportion of procedures with polyps was estimated. Three different criteria for polyp detection were used. Approximately 1.8 million colonoscopy procedures were identified. Depending on the specific criteria used, 23.9% to 35.7% of examinations noted polyps. The detection rate was highest in younger patients, men, and whites. The apparent yield of colonoscopy in terms of polyp detection is at least 24%. These data may be informative in predicting resource allocation for therapeutic procedures associated with colonoscopy. Future studies should determine the use and yield of serial colonoscopies for polyp surveillance.     

Bowel preparation for colonoscopy using standard vs reduced doses of sodium phosphate: A single-blind randomized controlled study

AIM: To evaluate the efficacy of a colonoscopy prepa-ration that utilizes a reduced dose of sodium phosphate(NaP) and an adjunct.METHODS: Sixty-two patients requiring screening colonoscopies were studied. Each patient was randomly allocated to receive either 50 NaP tablets(50 g) or 30 NaP tablets(30 g) with 10 mL of 0.75% sodium pico-sulfate for bowel preparation. NaP was administered at a rate of five tablets(5 g) or three tablets(3 g) every 15 min with 200 mL of water, beginning five to six hours before colonoscopy. The sodium picosulfate was administered with 200 mL of water on the night before the procedure. Both groups were compared in term of the efficacies of colonic cleansing, the time required for completion of the bowel preparation, and acceptability of the preparation.RESULTS: Sixty patients(n = 30 for each group) were analyzed. The cleansing efficacy tended to be higher in the 30 g NaP plus sodium picosulfate group as as-sessed by the mean total Ottawa scale score(50 g NaP6.70 ± 1. 42 vs 30 g NaP plus sodium picosulfate 6.17 ± 1.18 P = 0.072). The mean time for bowel prepara-tion tended to be shorter in the 30 g NaP plus sodium picosulfate group(50 g NaP 189.9 ± 64.0 min vs 30 g NaP plus sodium picosulfate 161.8 ± 57.6 min, P = 0.065). There were no significant differences between the two groups in the acceptability of the preparations(50 g NaP 83.3% vs 30 g NaP plus sodium picosulfate 86.7%, P = 0.500). There were no adverse events re-lated to bowel preparation in either of the groups.CONCLUSION: The colonoscopy preparation that uti-lized 30 g NaP with sodium picosulfate was comparable to that utilizing 50 g NaP. This novel bowel preparation might be useful before colonoscopy.     

Music for colonoscopy: A single-blind randomized controlled trial

Background

Several methods have been reported to minimize patient discomfort during colonoscopy, none are currently recommended by clinical practice guidelines. We performed a single-blind randomized controlled trial to assess the efficacy of music for colonoscopy.

Methods

109 patients were randomized to music-delivering or mute headphones before and during colonoscopy. Physicians were blinded to the trial. Sedation was given on demand. Primary outcome was pain measured on linear analogue scale from 0 to 10. Secondary endpoints were the difficulty of the procedure, need of sedation, overall patient satisfaction and willingness to repeat the procedure.

Results

Mean pain score was 5.9 ± 2.2 in the control group vs. 3.8 ± 1.9 in the music group (p < 0.00001); correspondingly overall satisfaction and willingness to repeat the procedure were significantly improved by music and the difficulty perceived by physicians was significantly reduced. Total administered midazolam was 36 mg in the control group vs. 13 in the music group (p < 0.007), pethidine was 860 mg vs. 465 mg (p = 0.07) and patients requiring sedation were 22 vs. 9, respectively (p = 0.003). A multivariable analysis to adjust treatment effect for potential confounding factors confirmed the significant beneficial effect of music.

Conclusions

Music significantly reduces discomfort and should be routinely offered to patients undergoing colonoscopy.     

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.     

Increasing prevalence of advanced colonic polyps in young patients undergoing colonoscopy in a referral academic hospital in Hong Kong

AIM： To investigate the distribution and frequency of advanced polyps over eight years.
METHODS：6424 colonoscopies were reviewea aunng the study period 1998 to 2005. The study period was subdivided into period I ： 1998 to 2001 and period 11： 2002-2005.
RESULTS： 1856 polyps （33% advanced polyps） and 328 CRCs were detected. The mean ages of the patients with advanced polyps and cancer were 69.2 ± 12.0 and 71.6± 13.8 years, respectively. Advanced polyps were mainly lerc sided （59.5%）. Advanced polyps were found in patients ≤60 years from 17.7% in period Ⅰto 26.3% in period Ⅱ（P 〈 0.05）, especially in male subjects ≤60 years （21.6% vs 31.6%, P 〈 0.05）. Advanced tubuloviUous polyps rose from 21.5% in period I to 29.5% in period Ⅱ （P 〈 0.05）. Whereas cancers in male patients ≤ 60 years were similar in both periods： 23.2% vs 16.5% （P 〉 0.05）.
CONCLUSION： Advanced polyps increased significantly in the younger male group in the most recent period and there seems to be a shiE towards a proximal location.     

注水法在婴幼儿结肠镜检查中的应用

目的比较注气法和注水法在婴幼儿结肠镜检查中的达盲时间、麻醉药物剂量等,探索注水法结肠镜检查在婴幼儿中的应用价值。 方法收集2019年1月至2020年9月经吉林大学第一医院小儿消化科行无痛结肠镜检查的71例患儿,年龄为月龄≤72个月,其中,观察组为注水法35例,对照组为同期行传统注气法36例。应用SPSS统计学软件分析比较两组患者的达盲率、达盲时间、达盲时丙泊酚用量等差异,并探讨注水法中注水量的影响因素。 结果观察组的达盲率为100%,对照组的达盲率为94.4%,差异无统计学意义;观察组的达盲时间(8.66±4.20)min,显著少于对照组达盲时间(16.69±9.22)min(P<0.05);观察组达盲时丙泊酚用量(64.00±18.50)mg显著少于对照组丙泊酚用量(83.33±25.72)mg(P<0.05)。对注水法结肠镜注水量的相关因素分析中,发现肠道准备程度与注水量之间具有显著相关性(P<0.05)。 结论注水法在婴幼儿结肠镜中安全、可靠,适合在临床推广、应用。     

Quality monitoring in colonoscopy: Time to act

Colonoscopy is the gold standard test for colorectal cancer screening. The primary advantage of colonoscopy as opposed to other screening modalities is the ability to provide therapy by removal of precancerous lesions at the time of detection. However, colonoscopy may miss clinically important neoplastic polyps. The value of colonoscopy in reducing incidence of colorectal cancer is dependent on many factors including, the patient, provider, and facility level. A high quality examination includes adequate bowel preparation, optimal colonoscopy technique, meticulous inspection during withdrawal, identification of subtle flat lesions, and complete polypectomy. Considerable variation among institutions and endoscopists has been reported in the literature. In attempt to diminish this disparity, various approaches have been advocated to improve the quality of colonoscopy. The overall impact of these interventions is not yet well defined. Implementing optimal education and training and subsequently analyzing the impact of these endeavors in improvement of quality will be essential to augment the utility of colonoscopy for the prevention of colorectal cancer.     

The role of routinely given hyoscine-N-butylbromide in colonoscopy: a double-blind,randomized, placebo-controlled,clinical trial

Objective: Hyoscine-N-butylbromide (HBB) has been proposed to ease colonoscopy and improve mucosal visualization, yet the results from previous studies are conflicting. In our prospective, double-blind, placebo-controlled, randomized study we aimed at evaluating whether routine administration of HBB, before and during colonoscopy, ease the procedure or increase the detection rate for polyps. Material and methods: One hundred fifty outpatients scheduled for an elective colonoscopy were randomized to receive intravenous injections of either 10?mg hyoscine-N-butylbromide or saline before insertion and at cecum. Patient tolerance and technical ease of colonoscopy were evaluated by visual analogue scale (VAS). Procedure times were recorded. Number of detected polyps per patient was evaluated as well. Heart rate was monitored with a pulse oximetry. Results: HBB did not improve patient tolerance or technically ease the procedure as evaluated by VAS. However, HBB led to faster ileal intubation (1.5 vs 2.0 min, p?p?=?0.03). Patients who received HBB also needed less often external abdominal pressure (48.6 vs 66.7%, p?=?0.03). HBB did not improve polyp detection rate (0.89 vs 0.91, p?=?0.90). HBB induced a significant rise in heart rate (p?p?Conclusions: Routine administration of HBB before and during colonoscopy yields only limited improvement in the technical performance of the examination compromised by high incidence of tachycardia.     

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.     

Achieving competence in colonoscopy: Milestones and the need for a new endoscopic curriculum in gastroenterology training

Colonoscopy is considered to be the most effective tool for reducing colorectal cancer (CRC) morbidity and mortality. As a result, certifying trainee competence in the performance of colonoscopy is critical to maximizing CRC screening and prevention efforts. Guidelines on training and accreditation around the world have been revised to emphasize the attainment of milestones in the technical and cognitive skills necessary to perform the procedure. To meet this challenge, new evaluation systems have been developed to measure trainee competence through all aspects of colonoscopy training. These changes stem from increased recognition that procedural numbers alone do not necessarily guarantee trainees’ proficiency in the performance of colonoscopy. Variability in endoscopic practice and in CRC screening outcomes also point to deficiencies in the current approach towards colonoscopy instruction. However, technological innovations hold great promise in training endoscopists to perform high quality colonoscopy. Furthermore, potential advances in the use of feedback as a training tool provide new avenues for research. This review summarizes the latest evidence on the effort to define, evaluate and promote the achievement of competence in colonoscopy among trainees.     

Electrolyte changes after bowel preparation for colonoscopy:A randomized controlled multicenter trial

AIM:To investigate the electrolyte changes between 2-L polyethylene glycol with ascorbic acid 20 g(PEGAsc) and 4-L PEG solutions.METHODS:From August 2012 to February 2013,a total of 226 patients were enrolled at four tertiary hospitals.All patients were randomly allocated to a PEG-Asc group or a 4-L PEG.Before colonoscopy,patients completed a questionnaire to assess bowel preparation-related symptoms,satisfaction,and willingness.Endoscopists assessed the bowel preparation using the Boston Bowel Preparation Scale(BBPS).In addition,blood tests,including serum electrolytes,serum osmolarity,and urine osmolarity were evaluated both before and after the procedure.RESULTS:A total of 226 patients were analyzed.BBPS scores were similar and the adequate bowel preparation rate(BBPS≥6)was not different between the two groups(PEG-Asc vs 4-L PEG,73.2%vs 76.3%,P=0.760).Bowel preparation-related symptoms also were not different between the two groups.The taste of PEG-Asc was better(41.1%vs 16.7%,P0.001),and the willingness to undergo repeated bowel preparation was higher in the PEG-Asc group(73.2%vs 59.3%,P=0.027)than in 4-L PEG.There were no significant changes in serum electrolytes in either group.CONCLUSION:In this multicenter trial,bowel preparation with PEG-Asc was better than 4-L PEG in terms of patient satisfaction,with similar degrees of bowel preparation and electrolyte changes.