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1.  Prospective Study of the Quality of Colonoscopies Performed by Primary Care Physicians: The Alberta Primary Care Endoscopy (APC-Endo) Study 
PLoS ONE  2013;8(6):e67017.
The quality of colonoscopies performed by primary care physicians (PCPs) is unknown.
To determine whether PCP colonoscopists achieve colonoscopy quality benchmarks, and patient satisfaction with having their colonoscopy performed by a primary care physician.
Prospective multi-center, multi-physician observational study. Colonoscopic quality data collection occurred via completion of case report forms and pathological confirmation of lesions. Patient satisfaction was captured by a telephone survey.
Thirteen rural and suburban hospitals in Alberta, Canada.
Proportion of successful cecal intubations, average number of adenomas detected per colonoscopy, proportion of patients with at least one adenoma, and serious adverse event rates; patient satisfaction with their wait time and procedure, as well as willingness to have a repeat colonoscopy performed by their primary care endoscopist.
In the two-month study period, 10 study physicians performed 577 colonoscopies. The overall adjusted proportion of successful cecal intubations was 96.5% (95% CI 94.6–97.8), and all physicians achieved the adjusted cecal intubation target of ≥90%. The average number of ademonas detected per colonoscopy was 0.62 (95% CI 0.5–0.74). 46.4% (95% CI 38.5–54.3) of males and 30.2% (95% CI 22.3–38.2) of females ≥50 years of age having their first colonoscopy, had at least one adenoma. Four serious adverse events occurred (three post polypectomy bleeds and one perforation) and 99.3% of patients were willing to have a repeat colonoscopy performed by their primary care colonoscopist.
Two-month study length and non-universal participation by Alberta primary care endoscopists.
Primary care physician colonoscopists can achieve quality benchmarks in colonoscopy. Training additional primary care physicians in endoscopy may improve patient access and decrease endoscopic wait times, especially in rural settings.
PMCID: PMC3695091  PMID: 23826186
2.  Water exchange method for colonoscopy: learning curve of an experienced colonoscopist in a U.S. community practice setting 
Water exchange colonoscopy has been reported to reduce examination discomfort and to provide salvage cleansing in unsedated or minimally sedated patients. The prolonged insertion time and perceived difficulty of insertion associated with water exchange have been cited as a barrier to its widespread use.
To assess the feasibility of learning and using the water exchange method of colonoscopy in a U.S. community practice setting.
Quality improvement program in nonacademic community endoscopy centers.
Patients undergoing sedated diagnostic, surveillance, or screening colonoscopy.
After direct coaching by a knowledgeable trainer, an experienced colonoscopist initiated colonoscopy using the water method. Whenever >5 min elapsed without advancing the colonoscope, conversion to air insufflation was made to ensure timely completion of the examination.
Primary outcome
Water Method Intention-to-treat (ITT) cecal intubation rate (CIR).
Female patients had a significantly higher rate of past abdominal surgery and a significantly lower ITTCIR. The ITTCIR showed a progressive increase over time in both males and females to 85–90%. Mean insertion time was maintained at 9 to 10 min. The overall CIR was 99%.
Use of water exchange did not preclude cecal intubation upon conversion to usual air insufflation in sedated patients examined by an experienced colonoscopist. With practice ITTCIR increased over time in both male and female patients. Larger volumes of water exchanged were associated with higher ITTCIR and better quality scores of bowel preparation. The data suggest that learning water exchange by a busy colonoscopist in a community practice setting is feasible and outcomes conform to accepted quality standards.
PMCID: PMC3655367  PMID: 23805393
water exchange; colonoscopy; learning curve
3.  Gastronet survey on the use of one- or two-person technique for colonoscopy insertion 
BMC Gastroenterology  2011;11:73.
Usually, colonoscopy insertion is performed by the colonoscopist (one-person technique). Quite common in the early days of endoscopy, the assisting nurse is now only rarely doing the insertion (two-person technique). Using the Norwegian national endoscopy quality assurance (QA) programme, Gastronet, we wanted to explore the extent of two-person technique practice and look into possible differences in performance and QA output measures.
100 colonoscopists in 18 colonoscopy centres having reported their colonoscopies to Gastronet between January and December 2009 were asked if they practiced one- or two-person technique during insertion of the colonoscope. They were categorized accordingly for comparative analyses of QA indicators.
75 endoscopists responded to the survey (representing 9368 colonoscopies) - 62 of them (83%) applied one-person technique and 13 (17%) two-person technique. Patients age and sex distributions and indications for colonoscopy were also similar in the two groups. Caecal intubation was 96% in the two-person group compared to 92% in the one-person group (p < 0.001). Pain reports were similar in the groups, but time to the caecum was shorter and the use of sedation less in the two-person group.
Two-person technique for colonoscope insertion was practiced by a considerable minority of endoscopists (17%). QA indicators were either similar to or better than one-person technique. This suggests that there may be some beneficial elements to this technique worth exploring and try to import into the much preferred one-person insertion technique.
PMCID: PMC3142529  PMID: 21672243
4.  The water method for aiding colonoscope insertion: the learning curve of an experienced colonoscopist 
The water method has promising features for colonoscopy but the learning curve to master the technique is unknown.
To describe the learning phase, and pitfalls of the water method and its impact on procedural outcomes by an experienced colonoscopist.
Review of prospectively collected data in a performance improvement project
endoscopy Unit at a VA medical center
200 consecutive veterans undergoing colonoscopy
An experienced colonoscopist examined 4 consecutive groups of 25 patients each using the water method to define the learning curve. Outcomes were compared to a historical cohort (n=100) examined by the same colonoscopist using usual air insufflation.
Main outcome measures
Intent-to-treat (ITT) cecal intubation rate.
ITT cecal intubation rate increased from 76% (first) to 96% (fourth quartile). Cecal intubation time in the first 2 quartiles was significantly longer (8.9±1.0 and 8.2±0.8 min, respectively) than that in the historical cohort (5.8±0.4 min) but decreased and became comparable to control values in the next 2 quartiles (7.2±0.9 and 6.6±0.6 min, respectively). Overall adenoma detection rate as a group (55%), compared favorably to the historical cohort (46%).
The water method is relatively easy to learn for an experienced colonoscopist. Mastery of the method resulted in cecal intubation rate and overall adenoma detection rate meeting quality performance standards.
PMCID: PMC3234692  PMID: 22163078
water method; learning curve; adenoma detection rate; colonoscopy
5.  Assessment of Quality of Colonoscopy Reports: Results from a multi-center consortium 
Gastrointestinal endoscopy  2009;69(3 Pt 2):645-653.
In order to improve colonoscopy quality, reports must include key quality indicators which can be monitored.
To determine the quality of colonoscopy reports in diverse practice settings.
The consortium of the Clinical Outcomes Research Initiative (CORI), which includes 73 gastroenterology practice sites in the United States which use a structured computerized endoscopy report generator, which includes fields for specific quality indicators.
Prospective data collection from 2004 to 2006.
Main Outcomes Measurements
Reports were queried to determine if specific quality indicators were recorded. Specific endpoints, including quality of bowel prep, cecal intubation rate and detection of polyp(s) >9mm in screening exams were compared in 53 practices with more than 100 colonoscopy procedures per year.
Of the 438,521 reports received during the study period, 13.9% did not include bowel prep quality and 10.1% did not include co-morbidity classification. The overall cecal intubation rate was 96.3%, but cecal landmarks were not recorded in 14% of reports. Missing polyp descriptors included polyp size (4.9%) and morphology (14.7%). Report of interventions for adverse events during the procedure varied from 0 to 6.5%. Among average-risk patients receiving screening exams, the detection rate of polyps >9mm, adjusted for age, gender and race, was between 4 and 10% in 81% of practices.
Bias toward high rates of reporting because of standard use of a computerized report generator.
There is significant variation in quality of colonoscopy reports across diverse practices, despite the use of a computerized report generator. Measurement of quality indicators in clinical practice can identify areas for quality improvement.
PMCID: PMC2749320  PMID: 19251005
6.  Practice Audit in Gastroenterology (PAGE) program: A novel approach to continuing professional development 
Practice audit is an important component of continuing professional development that may more readily be undertaken if it were less complex. This qualitative study assessed the use of personal digital assistants to facilitate data collection and review.
Personal digital assistants programmed with standard questionnaires related to upper gastrointestinal endoscopies (Practice Audit in Gastroenterology-Endoscopy [‘PAGE-Endo’]) and colonoscopies (PAGE-Colonoscopy [‘PAGE-Colo’]) were provided to Canadian gastroenterologists, surgeons and internists. Over a three-week audit period, participants recorded indications, and the expected (E) and reported (R) findings for each procedure. Thereafter, participants recorded compliance with reporting, the ease of use and value of the PAGE program, and their willingness to perform another audit.
Over 15 to 18 months, 173 participants completed PAGE-Endo (6168 procedures) and 111 completed PAGE-Colo (4776 procedures). Most respondents noted that PAGE was easy to use (99%), beneficial (88% to 95%), and that they were willing undertake another audit (92% to 95%). In PAGE-Endo, alarm features were prevalent (55%), but major reported findings were less common than expected: esophagitis (E 29.9%, R 14.8%), esophageal stricture (E 8.3%, R 3.6%), gastric ulcer (E 17.0%, R 4.7%), gastric cancer (E 4.3%, R 1.0%) and duodenal ulcer (E 11.5%, R 5.7%). In PAGE-Colo, more colonoscopies were performed for symptom investigation (55%) than for screening (25%) or surveillance (20%). There were marked interprovincial variations with respect to sedation, biopsies and technical aspects of colonoscopy.
Secure, real-time data entry with review of aggregate and individual data in the PAGE program provided an acceptable, straightforward methodology for accredited practice audit activities. PAGE has considerable potential for continuing professional development in gastroenterology and other specialties.
PMCID: PMC2659923  PMID: 16779458
Colonoscopy; Continuing medical education; Continuing professional development; Endoscopy; Gastroenterology; Maintenance of certification; Personal digital assistant; Practice audit
7.  Outcomes of 1949 endoscopic procedures 
Canadian Family Physician  2009;55(2):170-175.
To examine the outcomes of endoscopic procedures performed by a family physician trained in endoscopy.
Quality assurance practice audit involving medical chart review.
Rural family practice in Peace River, Alta.
All patients who had endoscopic procedures performed by a rural family physician during the period September 24, 1999, to May 31, 2007.
Type of endoscopic procedure performed, indications for and results of the endoscopies, complication rates, referral to tertiary care physicians, and patient demographic information. Colonoscopy competency was determined by the reach-the-cecum rate and by time for colonoscopy completion.
A total of 1956 endoscopic examinations were performed; complete data were verified for 1949 procedures, including 667 gastroscopies, 1178 colonoscopies, and 104 sigmoidoscopies. Endoscopic findings with gastroscopy included 50 (7.5%) cases of peptic ulcer disease, 17 (2.5%) cases of celiac disease, and 6 (0.9%) cases of upper gastrointestinal cancer; 27 (2.1%) cases of colorectal cancer and 48 (3.7%) new cases of inflammatory bowel disease were discovered with lower gastrointestinal endoscopy. The overall adenoma detection rate was 23.7% for male patients and 15.4% for female patients; for patients 50 years and older, it was 29.8% and 18.0% for male and female patients, respectively. The adjusted reach-the-cecum rate for colonoscopies was 92.3%. There was 1 colonic perforation and 1 postpolypectomy bleed. A total of 123 (6.3%) patients required referral to tertiary care physicians, half for definitive surgical intervention.
A trained family physician can perform endoscopy competently with findings and complication rates consistent with current quality assurance guidelines for endoscopy.
PMCID: PMC2642492  PMID: 19221080
8.  Maximizing the general success of cecal intubation during propofol sedation in a multi-endoscopist academic centre 
BMC Gastroenterology  2010;10:123.
Achieving the target of 95% colonoscopy completion rate at centres conducting colorectal screening programs is an important issue. Large centres and teaching hospitals employing endoscopists with different levels of training and expertise risk achieving worse results. Deep sedation with propofol in routine colonoscopy could maximize the results of cecal intubation.
The present study on the experience of a single centre focused on estimating the overall completion rate of colonoscopies performed under routine propofol sedation at a large teaching hospital with many operators involved, and on assessing the factors that influence the success rate of the procedure and how to improve this performance, analyzing the aspects relating to using of deep sedation. Twenty-one endoscopists, classified by their level of specialization in colonoscopic practice, performed 1381 colonoscopies under deep sedation. All actions needed for the anaesthesiologist to restore adequate oxygenation or hemodynamics, even for transient changes, were recorded.
The "crude" overall completion rate was 93.3%. This finding shows that with routine deep sedation, the colonoscopy completion rate nears, but still does not reach, the target performance for colonoscopic screening programs, at centers where colonoscopists of difference experience are employed in such programs.
Factors interfering with cecal intubation were: inadequate colon cleansing, endoscopists' expertise in colonoscopic practice, patients' body weight under 60 kg or age over 71 years, and the need for active intervention by the anaesthesiologist. The most favourable situation - a patient less than 71 years old with a body weight over 60 kg, an adequate bowel preparation, a "highly experienced specialist" performing the test, and no need for active anaesthesiological intervention during the procedure - coincided with a 98.8% probability of the colonoscopy being completed.
With routine deep sedation, the colonoscopy completion rate nears the target performance for colonoscopic screening programs, at centers where colonoscopists of difference experience are employed in such programs. Organizing the daily workload to prevent negative factors affecting the success rate from occurring in combination may enable up to 85% of incomplete procedures to be converted into successful colonoscopies.
PMCID: PMC2975653  PMID: 20961451
9.  The Quality of Colonoscopy Services—Responsibilities of Referring Clinicians 
Journal of General Internal Medicine  2010;25(11):1230-1234.
Primary care clinicians initiate and oversee colorectal screening for their patients, but colonoscopy, a central component of screening programs, is usually performed by consultants. The accuracy and safety of colonoscopy varies among endoscopists, even those with mainstream training and certification. Therefore, it is a primary care responsibility to choose the best available colonoscopy services. A working group of the National Colorectal Cancer Roundtable identified a set of indicators that primary care clinicians can use to assess the quality of colonoscopy services. Quality measures are of actual performance, not training, specialty, or experience alone. The main elements of quality are a complete report, technical competence, and a safe setting for the procedure. We provide explicit criteria that primary care physicians can use when choosing a colonoscopist. Information on quality indicators will be increasingly available with quality improvement efforts within the colonoscopy community and growth in the use of electronic medical records.
PMCID: PMC2947628  PMID: 20703953
primary care clinicians; colorectal screening; endoscopist; colonoscopist
10.  Improving Quality in Cancer Screening: The Excellence Report for Colonoscopy 
The goal of this project was to create and evaluate a quality measures program for colonoscopy procedures using measures recently defined by multi-specialty groups and using resources of the Clinical Outcomes Research Initiative (CORI), a gastrointestinal endoscopy research consortium. Participants collect procedure data through an endoscopic reporting system developed by CORI. Endoscopists practicing at 35 sites in 21 communities and 16 states were included in the study. Individual quality reports with 15 measures were made available monthly to endoscopists in 2/3 of the communities. Compliance with the quality measures was captured for each endoscopist prior to and at the end of the one-year intervention period. Changes in measure compliance were small and limited by lack of pathology data and documentation as well as modifications to the computing system during the study period. This study points out the difficulties of utilizing quality report cards with data captured during clinical care.
PMCID: PMC3041296  PMID: 21347021
11.  Adenoma detection in patients undergoing a comprehensive colonoscopy screening 
Cancer Medicine  2013;2(3):391-402.
Measures shown to improve the adenoma detection during colonoscopy (excellent bowel preparation, cecal intubation, cap fitted colonoscope to examine behind folds, patient position change to optimize colon distention, trained endoscopy team focusing on detection of subtle flat lesions, and incorporation of optimum endoscopic examination with adequate withdrawal time) are applicable to clinical practice and, if incorporated are projected to facilitate comprehensive colonoscopy screening program for colon cancer prevention. To determine adenoma and serrated polyp detection rate under conditions designed to optimize quality parameters for comprehensive screening colonoscopy. Retrospective analysis of data obtained from a comprehensive colon cancer screening program designed to optimize quality parameters. Academic medical center. Three hundred and forty-three patients between the ages of 50 years and 75 years who underwent first screening colonoscopy between 2009 and 2011 among 535 consecutive patients undergoing colonoscopy. Comprehensive colonoscopy screening program was utilized to screen all patients. Cecal intubation was successful in 98.8% of patients. The Boston Bowel Preparation Scale for quality of colonoscopy was 8.97 (95% confidence interval [CI]; 8.94, 9.00). The rate of adenoma detection was 60% and serrated lesion (defined as serrated adenomas or hyperplastic polyps proximal to the splenic flexure) detection was 23%. The rate of precancerous lesion detection (adenomas and serrated lesions) was 66%. The mean number of adenomas per screening procedure was 1.4 (1.2, 1.6) and the mean number of precancerous lesions (adenomas or serrated lesions) per screening procedure was 1.6 (1.4, 1.8). Retrospective study and single endoscopist experience. A comprehensive colonoscopy screening program results in high-quality screening with high detection of adenomas, advanced adenomas, serrated adenomas, and multiple adenomas.
PMCID: PMC3699850  PMID: 23930215
Adenoma; colon; colonoscopy; detection; serrated adenoma
12.  Comparison of morning versus afternoon cecal intubation rates 
BMC Gastroenterology  2007;7:19.
Many factors impacting cecal intubation rates have been examined in detail; however, little information exists regarding the effect of the timing of the procedure. We sought to examine any difference in cecal intubation rates between morning and afternoon colonoscopies and identify factors contributing to a discrepancy.
Retrospective, single-center study comparing cecal intubation rates for colonoscopies performed in the morning (begun prior to 12 noon) and colonoscopies performed in the afternoon (begun after 12 noon) over an approximately 12 month period. Univariate and multivariate analyses were performed evaluating patient demographics, procedure indication(s), endoscopist, bowel preparation type and quality, and participation by a gastroenterology fellow.
6087 colonoscopies were evaluated in this study. Colonoscopies (n = 3729) performed in the morning were compared to colonoscopies performed in the afternoon (n = 2358). The crude completion rate to the cecum was 95.0% in the morning group while the completion rate to the cecum was 93.6% of the afternoon exams (p = 0.02). The morning colonoscopies had better bowel preparation quality (p < 0.001). The multivariate analyses demonstrated that gender, age, and bowel preparation quality impacted completion rates. After correcting for these factors, there was no significant difference in completion rates in the morning versus afternoon.
Uncorrected cecal intubation rates were lower in the afternoon compared to the morning in outpatients undergoing colonoscopy. Bowel preparation quality was worse in the afternoon compared with the morning. Efforts at improving afternoon bowel preparation may improve the outcome of afternoon colonoscopies.
PMCID: PMC1906788  PMID: 17559669
13.  Colonoscopy at a combined district general hospital and specialist endoscopy unit: lessons from 505 consecutive examinations 
Provisional reports from the Intercollegiate British Society of Gastroenterology National Colonoscopy audit show completion rates of 57-77% for the procedure and poor levels of training and supervision. We prospectively audited all aspects of colonoscopy performed at a combined district general hospital and specialist endoscopy unit. Details of referral, examination, endoscopist, complications and follow-up were recorded and patients were sent questionnaires for long-term follow-up.
505 patients (246 male) underwent colonoscopy by 27 different endoscopists. Their median age was 57 years (range 13-92) and 93% were outpatients. 64% patients were symptomatic and 36% were having surveillance or follow-up colonoscopy. The overall caecal intubation rate was 93%, with little difference between surgeons, physicians and experienced trainees (89%, 92%, 94%) and specialist endoscopists (98%). In only one case was an inexperienced trainee (<100 procedures) unsupervised. Pain scores estimated by the endoscopist were well matched with those given by the patient—medians 29 and 26 (maximum 100) respectively. Median satisfaction score was 96 (maximum 100). Polyp pick-up rate was 26.9% and there were 11 new cancers. 16 (3%) minor immediate complications were recorded—5 oversedation, 6 vasovagal attacks, 3 polypectomy haemorrhages and 2 mucosal injuries (neither requiring treatment). 3 patients died within 6 months of follow-up but no death was colonoscopy related.
Completion rates in this setting were adequate for all endoscopists studied. Patient satisfaction with the procedure was high and very few immediate or long-term complications were encountered.
PMCID: PMC1279514  PMID: 11934910
14.  High success rate of repeat colonoscopy with standard endoscopes in patients referred for prior incomplete colonoscopy 
BMC Gastroenterology  2014;14:56.
In patients with incomplete colonoscopy, cecal intubation is sometimes unsuccessful due to a redundant or tortuous colon. Repeat colonoscopy may be successful with the use of alternate endoscopes or careful attention to technique but limited outcomes data is available. The aim of this study was to describe the technique, success rate and outcomes of consecutive patients referred for previous incomplete colonoscopy.
We conducted a retrospective chart review of incomplete colonoscopy procedures in patients age 18-90 at an academic teaching hospital referred to an endoscopist specializing in difficult colonoscopy.
Cecal intubation was successful in 96 of 100 repeat colonoscopies and 83 procedures were completed with a standard endoscope (adult, pediatric, or gastroscope). The adenoma detection rate was 28% for successful repeat colonoscopies; a majority of these patients had no adenomas identified on incomplete exam. In 69.4% of cases, an endoscope was used to successfully complete colonoscopy that was not used in the incomplete colonoscopy. The median insertion time was significantly less for the complete colonoscopy (10.6 min) compared to the incomplete colonoscopy (18.8 min, P = 0.004).
Repeat colonoscopy has a high success rate and identified a significant number of new adenomas. Use of all available endoscopes should be considered prior to procedure termination in patients with a tortuous colon. Repeat colonoscopy can often be accomplished using a standard endoscope and is not attributed to increased endoscope insertion time.
PMCID: PMC3986859  PMID: 24679009
Incomplete colonoscopy; Enteroscopes; Endoscopy; Difficult colonoscopy
15.  Evaluation of colonoscopy technical skill levels by use of an objective kinematic-based system 
Gastrointestinal endoscopy  2010;73(2):315-321.e1.
Colonoscopy requires training and experience to ensure accuracy and safety. Currently, no objective, validated process exists to determine when an endoscopist has attained technical competence. Kinematics data describing movements of laparoscopic instruments have been used in surgical skill assessment to define expert surgical technique. We have developed a novel system to record kinematics data during colonoscopy and quantitatively assess colonoscopist performance.
To use kinematic analysis of colonoscopy to quantitatively assess endoscopic technical performance.
Prospective cohort study.
Tertiary-care academic medical center.
This study involved physicians who perform colonoscopy.
Application of a kinematics data collection system to colonoscopy evaluation.
Main Outcome Measurements
Kinematics data, validated task load assessment instrument, and technical difficulty visual analog scale.
All 13 participants completed the colonoscopy to the terminal ileum on the standard colon model. Attending physicians reached the terminal ileum quicker than fellows (median time, 150.19 seconds vs 299.86 seconds; p < .01) with reduced path lengths for all 4 sensors, decreased flex (1.75 m vs 3.14 m; P = .03), smaller tip angulation, reduced absolute roll, and lower curvature of the endoscope. With performance of attending physicians serving as the expert reference standard, the mean kinematic score increased by 19.89 for each decrease in postgraduate year (P < .01). Overall, fellows experienced greater mental, physical, and temporal demand than did attending physicians.
Small cohort size.
Kinematic data and score calculation appear useful in the evaluation of colonoscopy technical skill levels. The kinematic score appears to consistently vary by year of training. Because this assessment is nonsubjective, it may be an improvement over current methods for determination of competence. Ongoing studies are establishing benchmarks and characteristic profiles of skill groups based on kinematics data.
PMCID: PMC3113705  PMID: 21111413
16.  Colonoscopy Practice in Lagos, Nigeria: A Report of an Audit 
Background. Colonoscopy effectiveness depends on the quality of the examination. Community-based report of quality of colonoscopy practice in a developing country will help in determining standard and also serve as a stimulus for improvement in service. Aim. To review the quality of colonoscopy practice and document pattern of colonic disease including polyp detection rate in Lagos, Nigeria. Method. A protocol that captured the patients' demographics, indication, and some quality indices of colonoscopy was developed and sent to all the identified colonoscopy units in Lagos to complete for all procedures performed between January 2011 and June 2012. All data were collated and analyzed. The quality indices studied were compared with guideline standard. Results. Twelve colonoscopy centers were identified but only nine centers responded. The gastroenterologist/endoscopists were physicians (3) and surgeons (5). Six hundred and seven colonoscopy procedures were performed during this period (M : F = 333 : 179) while the sex was not disclosed in 95 subjects. The examination indications were lower GI bleeding (24.2%), altered bowel habits (9.2%), lower abdominal pain (9.1%), screening for CRC (4.3%) and unspecified (46.8%). Conscious sedation was generally used while bowel preparation (good in 81.4%) was done with low residue diet and stimulant laxatives. Caecal intubation rate was 81.2%. Common endoscopic findings were haemorrhoids (43.2%), polyps/masses (13.4%), diverticulosis (11.1%), and no abnormality (23.4%). Polyp was detected in 6.8% of cases. Conclusion. Colonoscopy utilization is low, and the quality of practice is suboptimal; although limited resources could partly explain this, however it is not clear if the low rate of polyp detection is due to missed lesions or low population incidence.
PMCID: PMC3600188  PMID: 23533321
17.  What are the risk factors of colonoscopic perforation? 
BMC Gastroenterology  2009;9:71.
Knowledge of the factors influencing colonoscopic perforation (CP) is of decisive importance, especially with regard to the avoidance or minimization of the perforations. The aim of this study was to determine the incidence and risk factors of CP in one of the endoscopic training centers accredited by the World Gastroenterology Organization.
The prospectively collected data were reviewed of all patients undergoing either colonoscopy or flexible sigmoidoscopy at the Faculty of Medicine Siriraj Hospital, Bangkok, Thailand between January 2005 and July 2008. The incidence of CP was evaluated. Eight independent patient-, endoscopist- and endoscopy-related variables were analyzed by a multivariate model to determine their association with CP.
Over a 3.5-year period, 10,124 endoscopic procedures of the colon (8,987 colonoscopies and 1,137 flexible sigmoidoscopies) were performed. There were 15 colonic perforations (0.15%). Colonoscopy had a slightly higher risk of CP than flexible sigmoidoscopy (OR 1.77, 95%CI 0.23-13.51; p = 1.0). Patient gender, emergency endoscopy, anesthetic method, and the specialty or experience of the endoscopist were not significantly predictive of CP rate. In multivariate analysis, patient age of over 75 years (OR = 6.24, 95%CI 2.26-17.26; p < 0.001) and therapeutic endoscopy (OR = 2.98, 95%CI 1.08-8.23; p = 0.036) were the only two independent risk factors for CP.
The incidence of CP in this study was 0.15%. Patient age of over 75 years and therapeutic colonoscopy were two important risk factors for CP.
PMCID: PMC2760570  PMID: 19778446
18.  Magnetic endoscope imaging (ScopeGuide) elucidates the mechanism of action of the pain-alleviating impact of water exchange colonoscopy - attenuation of loop formation 
The explanation why water exchange colonoscopy produces a significant reduction of pain during colonoscopy is unknown. A recent editorial recommended use of magnetic endoscope imaging (MEI) to elucidate the explanation.
In unselected patients to show that MEI documents less frequent loop formation when water exchange is used.
Observational, performance improvement.
Veterans Affairs outpatient endoscopy.
Routine colonoscopy cases.
Colonoscopy using air or water exchange method was performed as previously described. The MEI equipment (ScopeGuide, Olympus) with built-in magnetic sensors displays the configuration of the colonoscope inside the patient. During sedated colonoscopy the endoscopist was blinded to the ScopeGuide images which were recorded and subsequently reviewed.
Main outcome measures
Loop formation based on a visual guide provided by Olympus.
There were 41 and 32 cases in the water exchange and air group, respectively. The sigmoid N loop was most common, followed by the sigmoid alpha loop, and exaggeration of scope curvature at the splenic flexure/transverse colon. Of these, 20/32 vs. 9/41 patients (p=0.0007) had sigmoid looping, and 17/32 vs. 9/41 patients (p=0.0007) had sigmoid/splenic looping when the scope tip was in the transverse colon, in the air and water exchange group, respectively.
Colonoscopy method was not blinded and non randomized.
MEI data objectively demonstrated significantly fewer loops during water exchange colonoscopy, elucidating its mechanism of pain alleviation - attenuation of loop formation. Since MEI feedback enhances cecal intubation by trainees, the role of MEI combined water exchange in speeding up trainee learning curves deserves further evaluations.
PMCID: PMC3655371  PMID: 23805397
colorectal cancer screening; optical colonoscopy; water method; magnetic endoscopic imaging
19.  Back-to-Back Comparison of Auto-Fluorescence Imaging (AFI) Versus High Resolution White Light Colonoscopy for Adenoma Detection 
BMC Gastroenterology  2012;12:75.
Some patients under close colonoscopic surveillance still develop colorectal cancer, thus suggesting the overlook of colorectal adenoma by endoscopists. AFI detects colorectal adenoma as a clear magenta, therefore the efficacy of AFI is expected to improve the detection ability of colorectal adenoma. The aim of this study is to determine the efficacy of AFI in detecting colorectal adenoma.
This study enrolled 88 patients who underwent colonoscopy at Asahikawa Medical University and Kushiro Medical Association Hospital. A randomly selected colonoscopist first observed the sigmoid colon and rectum with conventional high resolution endosopy (HRE). Then the colonoscopist changed the mode to AFI and handed to the scope to another colonoscopist who knew no information about the HRE. Then the second colonoscopist observed the sigmoid colon and rectum. Each colonoscopist separately recorded the findings. The detection rate, miss rate and procedural time were assessed in prospective manner.
The detection rate of flat and depressed adenoma, but not elevated adenoma, by AFI is significantly higher than that by HRE. In less-experienced endoscopists, AFI dramatically increased the detection rate (30.3%) and reduced miss rate (0%) of colorectal adenoma in comparison to those of HRE (7.7%, 50.0%), but not for experienced endoscopists. The procedural time of HRE was significantly shorter than that of AFI.
AFI increased the detection rate and reduced the miss rate of flat and depressed adenomas. These advantages of AFI were limited to less-experienced endoscopists because experienced endoscopists exhibited a substantially high detection rate for colorectal adenoma with HRE.
PMCID: PMC3444423  PMID: 22726319
Autofluorescence imaging; Colorectal adenoma; Detection rate; Flat and depressed adenoma; Less-experienced endoscopist; High-resolution colonoscope
20.  Incomplete colonoscopy: Maximizing completion rates of gastroenterologists 
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.
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.
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.
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).
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.
PMCID: PMC3441163  PMID: 22993727
Barium enema; Colonoscopy; CT colonography; Double-balloon enteroscopy; Incomplete colonoscopy
21.  Bowel preparations as quality indicators for colonoscopy 
Colonoscopy is the principal investigative procedure for colorectal neoplasms because it can detect and remove most precancerous lesions. The effectiveness of colonoscopy depends on the quality of the examination. Bowel preparation is an essential part of high-quality colonoscopies because only an optimal colonic cleansing allows the colonoscopist to clearly view the entire colonic mucosa and to identify any polyps or other lesions. Suboptimal bowel preparation not only prolongs the overall procedure time, decreases the cecal intubation rate, and increases the costs associated with colonoscopy but also increases the risk of missing polyps or adenomas during the colonoscopy. Therefore, a repeat examination or a shorter colonoscopy follow-up interval may be suitable strategies for a patient with suboptimal bowel preparation.
PMCID: PMC3961991  PMID: 24659866
Colonoscopy; Colorectal neoplasm; Bower preparation; Quality
22.  CO2 insufflation for potentially difficult colonoscopies: Efficacy when used by less experienced colonoscopists 
AIM: To clarify the effectiveness of CO2 insufflation in potentially difficult colonoscopy cases, particularly in relation to the experience level of colonoscopists.
METHODS: One hundred twenty potentially difficult cases were included in this study, which involved females with a low body mass index and patients with earlier abdominal and/or pelvic open surgery or previously diagnosed left-side colon diverticulosis. Patients receiving colonoscopy examinations without sedation using a pediatric variable-stiffness colonoscope were divided into two groups based on either CO2 or standard air insufflation. Both insufflation procedures were also evaluated according to the experience level of the respective colonoscopists who were divided into an experienced colonoscopist (EC) group and a less experienced colonoscopist (LEC) group. Study measurements included a 100-mm visual analogue scale (VAS) for patient pain during and after colonoscopy examinations, in addition to insertion to the cecum and withdrawal times.
RESULTS: Examination times did not differ, however, VAS scores in the CO2 group were significantly better than in the air group (P < 0.001, two-way ANOVA) from immediately after the procedure and up to 2 h later. There were no significant differences between either insufflation method in the EC group (P = 0.29), however, VAS scores for CO2 insufflation were significantly better than air insufflation in the LEC group (P = 0.023) immediately after colonoscopies and up to 4 h afterwards.
CONCLUSION: CO2 insufflation reduced patient pain after colonoscopy in potentially difficult cases when performed by LECs.
PMCID: PMC2773898  PMID: 19891018
CO2 insufflation; Colonoscopy; Difficult colonoscopy; Experienced colonoscopist; Training
23.  Endoscopist-related factors contributing to high-quality colonoscopy: results of a Delphi survey 
Education and competency assessment in gastrointestinal endoscopy is important. Concerning colonoscopy, it is not completely clear what the best way is to learn this procedure, what defines competency in colonoscopy, and which factors define a high-quality colonoscopy. The aim of this study was to determine the endoscopist-related factors that define a high-quality colonoscopy. A three-round Delphi survey among expert endoscopists was carried out. In round 1, the panel was invited to identify factors essential for a good colonoscopy. The listed factors were to be ranked during the second round. In the third round, a 5-point Likert scale was added. A reference panel was invited to assess the items as well. 14 expert endoscopists from the Netherlands were invited, of whom eight participated (57 %). A list of 30 items important for colonoscopy was formulated. After the following rounds, consensus was reached on 16 items. Validation was conducted among eight trainees and eight experienced endoscopists (response 100 %). The groups agreed on the importance of all but one factor (p = 0.001). This Delphi survey has made explicit the endoscopist-related factors that are important for optimal colonoscopy. This might provide trainers more support regarding concrete competency assessment of trainees in endoscopy.
PMCID: PMC3890001  PMID: 24307400
Assessment; Gastrointestinal endoscopist; Delphi; Training
24.  Endoscopist Specialty Is Associated with High-Quality Endoscopy in Korea 
Yonsei Medical Journal  2012;53(2):310-317.
The present study was aimed to determine whether endoscopist specialty is associated with high-quality endoscopy.
Materials and Methods
We prospectively collected endoscopy quality related data based on the Endoscopy Quality Rating Scale (EQRS) of 277 endoscopy units in a hospital setting from the National Cancer Screening Program of Korea in 2009. Gastroenterology medical professors (n=154) from university hospitals visited each endoscopy unit and graded the unit according to the EQRS. The scores from the EQRS were analyzed and compared in relation to endoscopy training during residency and endoscopy subspecialist certification.
After excluding data from 3 endoscopy units, EQRS data from 274 endoscopy units were analyzed: 263 esophagogastroduodenoscopy (EGD) screening units and 90 colonoscopy screening units. There were no significant differences in the scores of EQRS with respect to endoscopy training during residency (p=no significance), except for scores of EGDs for "Facility and Equipment" (p=0.030). However, EQRS scores were significantly higher in the endoscopy units where endoscopy subspecialists performed the endoscopies than those where Endoscopy Subspecialists did not perform the endoscopies (p<0.05, except p=0.08 for the "Process" criteria of EGD).
Endoscopist specialty is an important determinant of high-quality endoscopy in Korea.
PMCID: PMC3282978  PMID: 22318818
Endoscopy; Endoscopy Quality Rating Scale (EQRS); endoscopist; quality; specialty
25.  Water-aided methods for colonoscopy - a review of VA experience 
Over the past 10 years, investigators at four Veterans Affairs Medical Centers in the United States devoted considerable expertise refining the method of water immersion colonoscopy. During that period, and through collective, accumulated experience, the technique evolved to its current iteration - water exchange colonoscopy. Water immersion is characterized by suction removal of infused water predominantly during the withdrawal phase of colonoscopy and has a long history of acceptance by colonoscopists. Water exchange is characterized by suction removal of infused water predominantly during endoscope insertion to minimize distention of the colonic lumen. Acquisition of a novel set of skills is necessary for its proper implementation, and its acceptance by practicing colonoscopists is uncertain. The initial goal was to develop a less painful method to accomplish cecal intubation in scheduled unsedated patients. A serendipitous observation revealed that adenoma detection rate was higher in the water exchange group. Accumulating data support the hypothesis that compared with air insufflation the water immersion and water exchange methods both significantly reduce pain during colonoscopy, and water exchange is superior to water immersion in minimizing pain and enhancing adenoma detection. Observations confirm that water exchange is efficacious in potentially difficult colonoscopy (unsedated colonoscopy in patients with a history of abdominal surgery). Combined with other adjuncts (indigo carmine or cap) water exchange further enhances adenoma detection. Limited cost benefit analysis data favor water exchange compared to air insufflation. The role of water exchange in training novice endoscopists is still being explored. Whether the option of scheduled unsedated colonoscopy facilitated by water exchange will have benefits in minimizing no shows due to unavailability of escort or in optimizing resource utilization by obviating the need for nursing staff for monitoring and recovery remain to be further studied.
PMCID: PMC3791523  PMID: 24147228
colonoscopy; water-aided method; discomfort; pain; adenoma detection rate; water immersion; water exchange

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