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1.  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
2.  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
3.  The quality of screening colonoscopies in an office-based endoscopy clinic 
Wait times for hospital screening colonoscopy have increased dramatically in recent years, resulting in an increase in patient referrals to office-based endoscopy clinics. There is no formal regulation of office endoscopy, and it has been suggested that the quality of service in some office locations may be inferior to hospital procedures.
To compare the quality of office-based screening colonos-copies at a clinic in Oakville, Ontario, with published benchmarks for cecal intubation, withdrawal times, polyp detection, adenoma detection, cancer detection and patient complications.
Demographic information on consecutive patients and colonoscopy reports by all nine gastroenterologists at the Oakville Endoscopy Centre between August 2006 and December 2007 were prospectively obtained.
A total of 3741 colonoscopies were analyzed. The mean age of patients was 57.1 years and 51.9% were women. The cecal intubation rate was 98.98% with an average withdrawal time of 9.75 min. A total of 3857 polyps were retrieved from 1725 patients (46.11%), and 1721 adenomas were detected in 953 patients (25.47%). A total of 126 patients (3.37%) had advanced polyps and 18 (0.48%) were diagnosed with colon cancer. One patient (0.027%) had a colonic perforation and two patients had postpolypectomy bleeding (0.053%). These results meet or exceed published benchmarks for quality colonoscopy.
The Oakville Endoscopy Centre data demonstrate that office-based colonoscopies, performed by well-trained physicians using adequate sedation and hospital-grade equipment, result in outcomes at least equal to or better than those of published academic/community hospital practices and are therefore a viable option for the future of screening colonoscopy in Canada.
PMCID: PMC2695147  PMID: 19172208
Colon cancer; Office-based; Screening colonoscopy
4.  Same-day colonoscopy preparation with Senna alkaloids and bisacodyl tablets: A pilot study 
World Journal of Gastroenterology : WJG  2014;20(41):15382-15386.
AIM: To evaluate the efficacy of same-day bowel preparation with Senna alkaloids combined with bisacodyl tablets in routine colonoscopy procedures.
METHODS: Between March and June 2013, a same-day bowel preparation was implemented in our endoscopy unit. The preparation consisted of a semi-liquid, fiber-free diet one day prior to the procedure, with two bisacodyl tablets after lunch and dinner, and 250 mL of Senna alkaloid with 1.5 L of drinking water at 6 am the day of the procedure. The quality control parameters of colonoscopy were evaluated and implemented according to the guidelines of the American Society for Gastrointestinal Endoscopy. The pre-procedure, during-procedure and post-procedure patient data were collected and analyzed: (1) pre-procedure (age, gender, comorbid diseases, colonoscopy indications, complete lack of compliance with the bowel preparation protocol); (2) during-procedure (sedation dose, duration of colonoscopy, withdrawal time, cecal intubation rate, polyp detection rate, Boston Bowel Preparation Scores and presence of foam and clear liquid); and (3) post-procedure (visual analogue scale score, pain during the procedure, patient satisfaction and premature withdrawal due to the insufficient bowel preparation).
RESULTS: A total of 75 patients were included in this study with a mean age of 54.64 ± 13.29 years; 53.3% (40/75) were female and 46.7% (35/75) were male. A complete lack of compliance with the bowel preparation protocol was seen in 6.7% of patients (5/75). The mean total duration of colonoscopy was 16.12 ± 6.51 min, and the mean withdrawal time was 8.89 ± 4.07 min. The cecal intubation rate was 93.8% (61/64) and the polyp detection rate was 40% (30/75). The mean Boston Bowel Preparation Score was 7.38 ± 1.81, with the following distribution: right colon, 2.34 ± 0.89; transverse colon, 2.52 ± 0.67; left colon, 2.52 ± 0.63. The mean visual analogue scale score was 4.59 ± 1.57. Due to insufficient bowel preparation, seven patients (7/75; 9.3%) were asked to repeat the procedure. Of these, five patients had poor or modest compliance with the protocol, and two patients reported constipation. Premature withdrawal due to insufficient bowel preparation was 2.7% (2/75). The overall satisfaction with the protocol was 86.7% (65/75), with patients reporting they would prefer the same protocol in a repeat procedure.
CONCLUSION: The same-day administration of Senna alkaloids appears to be a safe and effective bowel cleansing protocol for colonoscopy procedures.
PMCID: PMC4223273  PMID: 25386088
Bisacodyl; Bowel preparation; Colonoscopy; Same-day preparation; Senna alkaloid
5.  Variation in caecal intubation rates between screening and symptomatic patients 
The caecal intubation rate (CIR) is an important quality standard for endoscopists, as well as for national bowel cancer screening programmes; however, individuals undergoing colonoscopy for bowel screening and symptomatic patients represent different groups, and their characteristics may affect colonoscopy performance.
To compare colonoscopists’ performance, as assessed by the CIR, in symptomatic patients compared to individuals undergoing colonoscopy for bowel cancer screening.
Retrospective audit of CIRs for all patients undergoing colonoscopy at our institution during the year 2008. We retrieved the data from an endoscopy reporting software database and from the local bowel cancer screening programme database. Demographic data was extracted, as well as details of known factors that may affect completion of colonoscopy, such as poor bowel preparation, presence of diverticular disease, polyps, tumour and strictures. The unadjusted CIRs for colonoscopists participating in the screening programme were compared between the bowel screening and the symptomatic patient groups.
Five screening colonoscopists performed 1056 colonoscopies, of which 488 were bowel screening procedures. The overall CIR was significantly lower in the symptomatic, compared to the screening, individuals (88.5% versus 93%, P < 0.02). No significant differences were observed between the two groups for risk factors that could impair the CIR. The CIR was <90% for two of the five colonoscopists in symptomatic patients, and just under 90% for one colonoscopist in screening individuals. Multivariate analysis revealed that non-screening colonoscopy was an independent predictor for an incomplete procedure (OR 1.8; 95% CI 1.2–2.8).
The CIR, a key quality performance indicator for colonoscopy, is lower in symptomatic patients compared to individuals undergoing colorectal cancer screening. These results suggested that CIR should be monitored independently in screening and non-screening colonoscopies.
PMCID: PMC4114115  PMID: 25083287
Caecal intubation rate; colonoscopists; colonoscopy; colorectal cancer; patient type; performance assessment; quality; screening; symptomatic patients
6.  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
7.  A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? 
Gut  2004;53(2):277-283.
Aim: To study the availability and quality of adult and paediatric colonoscopy in three National Health Service (NHS) regions.
Method: A prospective four month study of colonoscopies in North East Thames, West Midlands, and East Anglia.
Patients: Subjects undergoing colonoscopy in 68 endoscopy units.
Results: A total of 9223 colonoscopies were studied. The mean number of colonoscopies performed over the four month period was 142 in district general hospitals and 213 in teaching hospitals. Intravenous sedation was administered in 94.6% of procedures, but 2.2% and 11.4% of “at risk” patients did not have continuous venous access or did not receive supplemental oxygen, respectively. Caecal intubation was recorded in 76.9% of procedures but the adjusted caecal intubation rate was only 56.9%. Reasons for failing to reach the caecum included patient discomfort (34.7%), looping (29.7%), and poor bowel preparation (19.6%). A normal colonoscopy was reported in 42.1%. The most common diagnosis was polyps (22.5%) followed by diverticular disease (14.9%). Inflammatory bowel disease was recorded in 13.9% and carcinoma in 3.8%. Only half of the patients remembered being told of possible adverse events prior to the procedure. Rectal bleeding requiring admission following colonoscopy was reported in six patients. The overall perforation rate was 1:769 and colonoscopy was considered a possible factor in six deaths occurring within 30 days of the procedure. Only 17.0% of colonoscopists had received supervised training for their first 100 colonoscopies and only 39.3% had attended a training course.
Conclusion: There is serious under provision of colonoscopy service in most NHS hospitals. Endoscopy sedation guidelines are not always adhered to and there is a wide variation in practice between units. Colonoscopy is often incomplete and does not achieve the target 90% caecal intubation rate. Serious complications of colonoscopy were comparable with previous studies. Training in colonoscopy is often inadequate and improved practice should result from better training.
PMCID: PMC1774946  PMID: 14724164
colonoscopy; colonoscopy training; screening; colorectal cancer
8.  A prospective intervention study of colonoscopy reporting among patients screened or surveilled for colorectal neoplasia 
The impact of modifying electronic colonoscopy reporting software for improving adherence to guidelines regarding quality standards documentation remains poorly characterized.
Consecutive colonoscopy reports of patients undergoing screening or surveillance for colorectal neoplasia were reviewed. Following a pre-intervention quality audit conducted in 2009, some modifications were made to the reporting software (Endoworks, Olympus Corporation, USA), including changes to field navigation, drop-down menus and visual cues, to optimize all compulsory items identified by existing guidelines in the report-generating template. Results from both audits were compared. Independent validation of 10% of all data was completed.
In 250 patient reports (mean [± SD] age 61.7±10.2 years, 51.2% female, February to May 2011) of five endoscopists (mean 11.6±7.8 years in practice), procedural indication was always present, as was informed consent. Seventy-six per cent of patients had undergone previous colonoscopy, 41% provided a previous colonoscopy date, with details on past polyp removal in 42.9%. Most procedural indicators were recorded (examination date 100%, medications given 100%, difficulty level 96.4%, preparation quality 100%). All reports noted extent of visualization (cecal intubation in 97.6%, photo documentation in 96.8%). Total procedural time was recorded in 8.2% and withdrawal time in 44%. Polyps were reported in 112 patients (44.8%), with polyp size (5.01±4.42 mm) reported in 95.5%, morphology in 88.4% and anatomical location in all. The method of polyp removal was missing in 2.7% of reports. Significant improvements were noted in the documentation of withdrawal and total time, cecal landmarks, type of bowel preparation, completeness of removal, morphology and method of polyp removal, and photo documentation compared with the 2009 audit.
These results illustrate the value of targeted modifications to an electronic colonoscopic reporting system in significantly enhancing the quality of reporting.
PMCID: PMC3472912  PMID: 23061065
Audit; Colonoscopy; Colorectal cancer; Endoscopy; Quality; Reporting; Surveillance
9.  Assessment of quality in screening colonoscopy for colorectal cancer 
The effectiveness of screening colonoscopy in decreasing the incidence of colorectal cancer (CRC) is largely dependent on the detection of polyps and the quality of the procedure. Several key quality measures have been proposed to improve the effectiveness of screening colonoscopies.
To evaluate quality indicators of screening colonoscopy in a tertiary hospital.
All CRC screening colonoscopies performed between 2005 and 2009 in a single tertiary center were reviewed for internationally accepted quality measures.
Of the 1545 individuals who underwent first-time screening colonoscopy 38% were male and 62% were female. The mean age of the patients was 60.4 years and the mean difference in ages was ± 10.3 years. Cecal intubation rate was 91% (1336), however ileocecal valve photo documentation was performed in only 81% (1248) colonoscopies. The quality of bowel preparation was classified as: good 76% (1171), reasonable 11% (174), and poor 13% (200). Polyp detection rate (PDR) was 33% (503). The prevalence of polyps ≥1 cm in size was 5% (82). PDR was significantly higher in men than in women (44% [260] vs 25% [243], P = 0.0001). Other factors significantly influencing PDR were quality of bowel preparation (odds ratio [OR]: 1.28, 95% confidence interval [CI]: 0.9–1.6) and age over 50 (OR: 1.9, 95% CI: 1.3–2.9). Left colonic polyps were associated with a risk ratio of 2.3 (95% CI: 1.8–2.9) of lesions in the other colonic segments compared to no polyps in the left colon. None of the colonoscopists reported withdrawal time.
Cecal intubation rate and quality of bowel preparation were suboptimal. The polyp detection rate compares favorably to accepted standards and its main determinants are male sex, age >50 years, quality of bowel preparation, and the presence of left colonic polyps.
PMCID: PMC3254205  PMID: 22235171
colorectal cancer; screening colonoscopy; quality indicators
10.  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
11.  Rate of serious complications of colonoscopy in Quebec 
The rate of serious complications is one marker of the quality of colonoscopy services.
To estimate the rate of serious complications of colonoscopy according to colonoscopy indication and polypectomy status.
A prospective cohort study of patients scheduled for colonoscopy who were recruited from seven endoscopy facilities across Montreal (Quebec) was conducted. Before colonoscopy, patients completed a brief questionnaire and provided their health insurance numbers. Colonoscopy indication was based on patient-reported medical history. Polypectomy status was obtained from provincial physician billing records (Régie de l’assurance maladie du Québec). Diagnoses and procedures associated with hospitalization in the 30 days following colonoscopy were obtained from the provincial hospitalization database (MedEcho).
Of the 2134 patients enrolled (mean age 60.9 years, 50.1% male), 33 (1.55% [95% CI 1.06% to 2.16%]) were hospitalized within 30 days. One patient experienced bleeding following a colonoscopy that involved polypectomy and was diagnosed with carcinoma in situ of the rectum. Based on self-reported rectal bleeding in the previous six months, the colonoscopy was nonscreening. The provincial hospitalization data showed no occurrences of perforation, diverticulitis, myocardial infarction/stroke or death; thus, the rate of serious colonoscopy complications was 0.05% (95% CI 0.00% to 0.26%).
The rate of serious colonoscopy complications requiring hospitalization was low and comparable with what is reported in the literature. The serious complication occurred subsequent to polypectomy and in a nonscreening colonoscopy.
The findings support the relative safety of screening colonoscopy in persons without large bowel diseases and symptoms. However, future research to determine the rate of serious complications not requiring hospitalization is warranted to reassure decision makers of the safety of colonoscopy for colorectal cancer screening.
PMCID: PMC3441168  PMID: 22993732
Colonoscopy; Complications; Screening
12.  Quality and Safety of Screening Colonoscopies Performed by Primary Care Physicians With Standby Specialist Support 
Medical care  2010;48(8):703-709.
Expanding the population’s access to colonoscopy screening can reduce colorectal cancer disparities. Innovative strategies are needed to address the prevailing 50% colonoscopy screening gap, partly attributable to inadequate specialist workforce. This study examined the quality of colonoscopies by primary care physicians (PCPs) with standby specialist support at a licensed ambulatory surgery center.
Retrospective data on 10,958 consecutive colonoscopies performed by 51 PCPs on 9815 patients from October 2002 to November 2007 were used to calculate the rates of cecal intubation, detection of polyps, adenomas, advanced neoplasia and cancer, adverse events, and time taken for endoscope insertion and withdrawal. The center’s protocol requires a 2-person technique (using a trained technician), polyp search and removal during both scope insertion and withdrawal, and onsite expert always available for rescue assistance (either navigational or therapeutic).
Mean patient age was 58.3 (±10.9) years, 48.0% were male, and 48.1% African-American. The cecal intubation rate was 98.1%, polyp detection rate 63.1%, hyperplastic polyp 27.5%, adenoma 29.9%, advanced neoplasia 5.7%, cancer 0.63%, major adverse events 0.06% (including 2 perforations; no death). Mean insertion and withdrawal times were 14.4 (±9.3) and 10.9 (±6.8) minutes, respectively; 13.2 (±8.6) and 8.0 (±4.5) minutes without polyps found, and 15.1 (±9.6) and 12.5 (±7.3) minutes when ≥1 polyp was found.
In the largest published study of PCP-performed colonoscopies with standby specialist support, we observed performance quality indicators and lesion detection rates that are comparable to documented rates for experienced gastroenterologists. Systems that use PCPs with specialist backup support enable high-quality colonoscopy performance by PCPs.
PMCID: PMC2959169  PMID: 20613663
screening colonoscopy; primary care physicians; colorectal neoplasms; colonic polyps; adenomatous polyps; patient safety; performance quality; procedure time
13.  The water method significantly enhances proximal diminutive adenoma detection rate in unsedated patients 
Colonoscopy has been reported to fail to prevent some post screening colonoscopy incident cancers or minimize cancer mortality in the proximal colon. These reports question the effectiveness of colonoscopy in detecting all proximal adenomas. Diminutive ones which can be obscured by residual feces are particularly at risk. The water method provides salvage cleansing of sub-optimal preparations.
To test the hypothesis that the water method enhances proximal diminutive adenoma detection rate (ADR).
The data bases of two parallel RCT were combined and analyzed.
Two Veterans Affairs endoscopy units.
Patient and Methods
The water and air methods were compared in these two parallel RCT examining unsedated patients.
Main Outcome Measurements
The combined data on diminutive and overall ADR in the proximal colon, overall ADR, cecal intubation rate, withdrawal time and global bowel cleanliness score.
Data in the water (n=92) and the air (n=90) groups were assessed. The water method yielded a significantly higher proximal diminutive ADR, 28.3% vs. 14.4% (p=0.0298); cecal intubation rate, 99% vs. 90% (p=0.0091); mean withdrawal time 19 (10) vs. 15 (8) min (p=0.0065) and mean global bowel cleanliness score during withdrawal, 2.6 (0.7) vs. 2.3 (0.6) (p=0.0032). Increase in proximal overall ADR in the water group approached significance, 29.3% vs. 16.7% (p=0.0592).
Small number of predominantly male veterans.
The significantly higher cecal intubation rate, longer mean withdrawal time and better mean global bowel cleanliness score favor the outcome of significantly enhanced proximal diminutive ADR in the water group.
PMCID: PMC3109471  PMID: 21686106
colorectal cancer screening; colonoscopy; water method; adenoma detection
14.  Quality indicators for colonoscopy: Current insights and caveats 
Colonoscopy is the diagnostic modality of choice for investigation of symptoms suspected to be related to the colon and for the detection of polyps and colorectal cancer (CRC). Colonoscopy with removal of detected polyps has been shown to reduce the incidence and mortality of subsequent CRC. In many countries, population screening programs for CRC have been initiated, either by selection of patients for colonoscopy with fecal occult blood testing or by offering colonoscopy directly to average-risk individuals. Several endoscopy societies have formulated quality indicators for colonoscopy. These quality indicators are almost always incorporated as process indicators, rather than outcome measures. This review focuses on the quality indicators bowel preparation, cecal intubation rate, withdrawal time, adenoma detection rate, patient comfort, sedation and complication rate, and discusses the scientific evidence supporting them, as well as their potential shortcomings and issues that need to be addressed. For instance, there is still no clear and generally accepted definition of adequate bowel preparation, no robust scientific evidence is available supporting a cecal intubation rate ≥ 90% and the association between withdrawal time and occurrence of interval cancers has not been clarified. Adenoma detection rate is currently the only quality indicator that has been shown to be associated with interval colorectal cancer, but as an indicator it does not differentiate between subjects with one or more adenoma detected.
PMCID: PMC4265954  PMID: 25512766
Colonoscopy; Quality indicators; Bowel preparation; Cecal intubation; Withdrawal time; Adenoma detection rate; Screening; Complication; Interval colorectal cancer; Post-colonoscopy colorectal cancer
15.  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
16.  Endoscopist specialty is associated with colonoscopy quality 
BMC Gastroenterology  2013;13:78.
Some studies have shown that endoscopist specialty is associated with colorectal cancers missed by colonoscopy. We sought to examine the relationship between endoscopist specialty and polypectomy rate, a colonoscopy quality indicator. Polypectomy rate is defined as the proportion of colonoscopies that result in the removal of one or more polyps.
A cross-sectional study was conducted of endoscopists and their patients from 7 Montreal and 2 Calgary endoscopy clinics. Eligible patients were aged 50–75 and covered by provincial health insurance. A patient questionnaire assessed family history of colorectal cancer, history of large bowel conditions and symptoms, and previous colonoscopy. The outcome, polypectomy status, was obtained from provincial health administrative databases. For each city, Bayesian hierarchical logistic regression was used to estimate the odds ratio for polypectomy comparing surgeons to gastroenterologists. Model covariates included patient age, sex, family history of colorectal cancer, colonoscopy indication, and previous colonoscopy.
In total, 2,113 and 538 colonoscopies were included from Montreal and Calgary, respectively. Colonoscopies were performed by 38 gastroenterologists and 6 surgeons in Montreal, and by 31 gastroenterologists and 5 surgeons in Calgary. The adjusted odds ratios comparing surgeons to gastroenterologists were 0.48 (95% CI: 0.32–0.71) in Montreal and 0.73 (95% CI: 0.43–1.21) in Calgary.
An association between endoscopist specialty and polypectomy was observed in both cities after adjusting for patient-level covariates. Results from Montreal suggest that surgeons are half as likely as gastroenterologists to remove polyps, while those from Calgary were associated with a wide, non-significant Bayesian credible interval. However, residual confounding from patient-level variables is possible, and further investigation is required.
PMCID: PMC3646699  PMID: 23638769
Colonoscopy quality; Polypectomy; Adenoma detection rate; Specialty
17.  Split-dose vs same-day reduced-volume polyethylene glycol electrolyte lavage solution for morning colonoscopy 
World Journal of Gastroenterology : WJG  2014;20(39):14488-14494.
AIM: To compare same-day whole-dose vs split-dose of 2-litre polyethylene glycol electrolyte lavage solution (PEG-ELS) plus bisacodyl for colon cleansing for morning colonoscopy.
METHODS: Consecutive adult patients undergoing morning colonoscopy were allocated into two groups i.e., same-day whole-dose or split-dose of 2-litre PEG-ELS. Investigators and endoscopists were blinded to the allocation. All patients completed a questionnaire that was designed by Aronchick and colleagues to assess the tolerability of the bowel preparation regime used. In addition, patients answered an ordinal five-value Likert scale question on comfort level during bowel preparation. Endoscopists graded the quality of bowel preparation using the Boston bowel preparation scale (BBPS). In addition, endoscopists gave an overall grading of the quality of bowel preparation. Cecal intubation time, withdrawal time, total colonoscopy time, adenoma detection rate and number of adenomas detected for each patient were recorded. Sample size was calculated using an online calculator for binary outcome non-inferiority trial. Analyses was based upon intent-to-treat. Significance was assumed at P-value < 0.05.
RESULTS: Data for 295 patients were analysed. Mean age was 62.0 ± 14.4 years old and consisted of 50.2 % male. There were 143 and 152 patients in the split-dose and whole-dose group, respectively. Split-dose was as good as whole-dose for quality of bowel preparation. The total BBPS score was as good in the split-dose group compared to the whole-dose group [6 (6-8) vs 6 (6-7), P = 0.038]. There was no difference in cecal intubation rate, cecal intubation time, withdrawal time, total colonoscopy time and adenoma detection rate. Median number of adenoma detected was marginally higher in the split-dose group [2 (1-3) vs 1 (1-2), P = 0.010]. Patients in the whole-dose group had more nausea (37.5% vs 25.2%, P = 0.023) and vomiting (16.4% vs 8.4%, P = 0.037), and were less likely to complete the bowel preparation (94.1% vs 99.3%, P = 0.020). Patients in the split-dose group were less likely to refuse the same bowel preparation regime (6.3% vs 13.8%, P = 0.033) and less likely to want to try another bowel preparation regime (53.8% vs 78.9%, P < 0.001).
CONCLUSION: Splitting reduced-volume PEG-ELS for morning colonoscopy is as effective as taking the whole dose on the same morning but is better tolerated and preferred by patients.
PMCID: PMC4202378  PMID: 25339836
Bowel preparation; Colonoscopy; Split-dose; Polyethylene glycol electrolyte lavage solution
18.  Colometer: A real-time quality feedback system for screening colonoscopy 
AIM: To investigate the performance of a new software-based colonoscopy quality assessment system.
METHODS: The software-based system employs a novel image processing algorithm which detects the levels of image clarity, withdrawal velocity, and level of the bowel preparation in a real-time fashion from live video signal. Threshold levels of image blurriness and the withdrawal velocity below which the visualization could be considered adequate have initially been determined arbitrarily by review of sample colonoscopy videos by two experienced endoscopists. Subsequently, an overall colonoscopy quality rating was computed based on the percentage of the withdrawal time with adequate visualization (scored 1-5; 1, when the percentage was 1%-20%; 2, when the percentage was 21%-40%, etc.). In order to test the proposed velocity and blurriness thresholds, screening colonoscopy withdrawal videos from a specialized ambulatory colon cancer screening center were collected, automatically processed and rated. Quality ratings on the withdrawal were compared to the insertion in the same patients. Then, 3 experienced endoscopists reviewed the collected videos in a blinded fashion and rated the overall quality of each withdrawal (scored 1-5; 1, poor; 3, average; 5, excellent) based on 3 major aspects: image quality, colon preparation, and withdrawal velocity. The automated quality ratings were compared to the averaged endoscopist quality ratings using Spearman correlation coefficient.
RESULTS: Fourteen screening colonoscopies were assessed. Adenomatous polyps were detected in 4/14 (29%) of the collected colonoscopy video samples. As a proof of concept, the Colometer software rated colonoscope withdrawal as having better visualization than the insertion in the 10 videos which did not have any polyps (average percent time with adequate visualization: 79% ± 5% for withdrawal and 50% ± 14% for insertion, P < 0.01). Withdrawal times during which no polyps were removed ranged from 4-12 min. The median quality rating from the automated system and the reviewers was 3.45 [interquartile range (IQR), 3.1-3.68] and 3.00 (IQR, 2.33-3.67) respectively for all colonoscopy video samples. The automated rating revealed a strong correlation with the reviewer’s rating (ρ coefficient= 0.65, P = 0.01). There was good correlation of the automated overall quality rating and the mean endoscopist withdrawal speed rating (Spearman r coefficient= 0.59, P = 0.03). There was no correlation of automated overall quality rating with mean endoscopists image quality rating (Spearman r coefficient= 0.41, P = 0.15).
CONCLUSION: The results from a novel automated real-time colonoscopy quality feedback system strongly agreed with the endoscopists’ quality assessments. Further study is required to validate this approach.
PMCID: PMC3436041  PMID: 22969189
Colonoscopy; Quality assurance; Quality improvement; Withdrawal time; Colon cancer; Bowel preparation
19.  The water method significantly enhances detection of diminutive lesions (adenoma and hyperplastic polyp combined) in the proximal colon in screening colonoscopy - data derived from two RCT in US veterans 
Emerging data indicate a colonoscopist-controlled method is needed to avoid missing proximal colon pre-malignant lesions. Screening colonoscopy does not prevent all proximal colon cancers. Even diminutive lesions in the proximal colon harbor dysplasia. In addition to adenomas (presumptive cancer precursors), recent proposals to reevaluate proximal colon hyperplastic polyps as serrated polyps which could be pre-malignant or harbingers of interval neoplasia dramatize the importance of attending to these lesions. The finding that the water method increased yield of proximal diminutive adenomas prompted assessment of the hypothesis that the water method increases yield of all proximal diminutive lesions (adenoma and hyperplastic polyp) in screening cases.
Two RCT assessed the water method with primary outcome of completion of unsedated colonoscopy when the option of scheduled, unsedated or sedation on demand was used. Diminutive (<10 mm) lesions proximal to the splenic flexure were tracked.
In screening cases, 31% and 6% of the water and air group had at least one proximal diminutive lesion (p=0.0012). Regression analysis revealed withdrawal time, method and volume of water used were significant predictors of proximal diminutive lesions. Effect of the water method on detection of proximal diminutive lesions was independent of age, body mass index, endoscopist, sedation, cecal intubation rate, bowel cleanliness score on withdrawal and total procedure time.
Male subject predominance, analysis of secondary outcomes of pooled RCT data.
The hypothesis that the water method effectively enhances proximal diminutive lesion detection in screening colonoscopy in diverse clinical settings should be tested.
PMCID: PMC3136853  PMID: 21776425
colonoscopy; water method; proximal colon; hyperplastic polyp; adenoma
20.  Endoscopic innovations to increase the adenoma detection rate during colonoscopy 
Up to a quarter of polyps and adenomas are missed during colonoscopy due to poor visualization behind folds and the inner curves of flexures, and the presence of flat lesions that are difficult to detect. These numbers may however be conservative because they mainly come from back-to-back studies performed with standard colonoscopes, which are unable to visualize the entire mucosal surface. In the past several years, new endoscopic techniques have been introduced to improve the detection of polyps and adenomas. The introduction of high definition colonoscopes and visual image enhancement technologies have been suggested to lead to better recognition of flat and small lesions, but the absolute increase in diagnostic yield seems limited. Cap assisted colonoscopy and water-exchange colonoscopy are methods to facilitate cecal intubation and increase patients comfort, but show only a marginal or no benefit on polyp and adenoma detection. Retroflexion is routinely used in the rectum for the inspection of the dentate line, but withdrawal in retroflexion in the colon is in general not recommended due to the risk of perforation. In contrast, colonoscopy with the Third-Eye Retroscope® may result in considerable lower miss rates compared to standard colonoscopy, but this technique is not practical in case of polypectomy and is more time consuming. The recently introduced Full Spectrum Endoscopy™ colonoscopes maintains the technical capabilities of standard colonoscopes and provides a much wider view of 330 degrees compared to the 170 degrees with standard colonoscopes. Remarkable lower adenoma miss rates with this new technique were recently demonstrated in the first randomized study. Nonetheless, more studies are required to determine the exact additional diagnostic yield in clinical practice. Optimizing the efficacy of colorectal cancer screening and surveillance requires high definition colonoscopes with improved virtual chromoendoscopy technology that visualize the whole colon mucosa while maintaining optimal washing, suction and therapeutic capabilities, and keeping the procedural time as low and patient discomfort as optimal as possible.
PMCID: PMC3942825  PMID: 24605019
Colonoscopy; Endoscopic innovations; Adenoma detection; Polyp detection; Gastrointestinal endoscopy
21.  Fecal Occult Blood Test for Colorectal Cancer Screening 
Executive Summary
The colorectal cancer (CRC) screening project was undertaken by the Medical Advisory Secretariat (MAS) in collaboration with the Cancer Care Ontario (CCO).
In November 2007, the Ontario Health Technology Advisory Committee (OHTAC) MAS to conduct an evidence-based analysis of the available data with respect to colorectal cancer diagnosis and prevention. The general purpose of the project was to investigate the effectiveness, cost effectiveness, and safety of the various methods and techniques used for colorectal cancer screening in average risk people, 50 years of age and older.
The options currently offered for colorectal cancer screening were reviewed and five technologies were selected for review:
Computed tomographic (CT) colonography
Magnetic resonance (MR) colonography
Wireless capsule endoscopy (PillCam Colon)
Fecal occult blood test (FOBT)
Flexible sigmoidoscopy
In this review, colonoscopy was considered as the “gold standard” technique by which the effectiveness of all other modalities could be evaluated. An economic analysis was also conducted to determine cost-effectiveness of different screening modalities.
Evidence-based analyses have been prepared for each of these technologies, as well as summary document that includes an economic analysis, all of which are presented at the MAS Web site:
The objective of this evidence review is to examine the effectiveness and cost-effectiveness of fecal occult blood testing (FOBT), including guaiac FOBT (gFOBT) and immunochemical FOBT (iFOBT), for use in colorectal cancer (CRC) screening in asymptomatic, average-risk adults.
Is the use of gFOBT or iFOBT associated with a reduction in CRC and overall mortality?
What are the sensitivity and specificity of gFOBT and iFOBT for the detection of 1) CRC and 2) large polyps (≥ 1 cm)?
Clinical Need
CRC is the most common cause of non-tobacco related cancer death in Canada. It has been estimated that in 2007, 7,800 people were diagnosed with CRC in Ontario and 3,250 died from the disease, making the province’s incidence and mortality rate of CRC amongst the highest in the world.
Description of Technology/Therapy
There are two general types of FOBT that are categorized according to the analyte detected: guaiac FOBT (gFOBT) and immunochemical FOBT (iFOBT). Blood in the stool is a nonspecific finding but may originate from CRC or larger (>1 cm) polyps (small adenomatous polyps do not tend to bleed). Bleeding from cancers and larger polyps may be intermittent and not always detectable in a single sample. The FOBT thus requires regular testing that consists of collecting specimens from consecutive bowel movements. A positive gFOBT or iFOBT involves a diagnostic workup with colonoscopy to examine the entire colon in order to rule out the presence of cancer or advanced neoplasia.
Methods of Evidence-Based Analysis
A literature search was conducted from January 2003 to June 2008 that included OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, the Cumulative Index to Nursing & Allied Health Literature (CINAHL), The Cochrane Library, and the International Agency for Health Technology Assessment/Centre for Review and Dissemination.
Inclusion Criteria
Patients at average risk for CRC
All patients must be at least 50 years of age
Biennial FOBT as a screening modality and use of colonoscopy as the reference standard
Systematic reviews and randomized controlled trials (RCTs)
Outcomes: CRC mortality, overall mortality, sensitivity, specificity, adverse effects
Exclusion Criteria
Studies involving fewer than 100 patients
Studies that do not report sufficient data for analysis
Comparisons of Interest
Evidence exists for these comparisons of interest:
gFOBT compared with the reference “gold standard” colonoscopy (or double-contrast barium enema where colonoscopy is incomplete or contraindicated)
iFOBT compared with the reference gold standard colonoscopy (or DCBE where colonoscopy is incomplete or contraindicated)
gFOBT compared with iFOBT
The quality of the diagnostic studies was examined according to the ‘GRADE Working Group criteria’ for grading quality of evidence and strength of recommendations for diagnostic tests and strategies.
Summary of Findings
Single-Test Studies
There is limited direct/indirect evidence that iFOBT has sensitivity/specificity superior to that of unrehydrated gFOBT for CRC detection:
sensitivity for gFOBT:
pooled iFOBT sensitivity:
There is evidence that iFOBT and gFOBT have lower sensitivities for adenoma detection than for CRC detection:
sensitivity for rehydrated gFOBT
pooled iFOBT sensitivity
Repeated-Test Studies
No trials have examined CRC mortality outcomes after repeated testing of iFOBT.
Two RCTs from the United Kingdom and Denmark showed significant reduction in CRC mortality using unrehydrated gFOBT biennially
Relative risk reductions of 13% (UK trial) and 16% (Danish trial); absolute difference of 0.1% (UK trial) and 0.2% (Danish trial).
No significant reduction in overall mortality
Interval cancers (CRC that develop in the intervals between routine screening)
United Kingdom trial: 236 CRCs detected by positive test, 236 interval CRCs after negative test
Danish trial: 120 CRCs detected by positive test, 146 interval CRCs after negative test
Unrehydrated gFOBT has low sensitivity for CRC detection (45% in the UK trial and 54% in the Danish trial).
true positive rate
false positive rate
true negative rate
false negative rate
Guaiac FOBT – GRADE Quality of Evidence for Interventions
CRC indicates colorectal cancer; FOBT, fecal occult blood test; GRADE, Grading of Recommendations Assessment, Development and Evaluation; RCT, randomized controlled trial.
Unlikely to be an important uncertainty.
GRADE Quality of Evidence for Diagnostic Tests: Implications of Testing Focusing on Accuracy
Benefit from diagnosis and treatment after confirmatory colonoscopy
Small risk of bowel perforation during colonoscopy
Benefit of reassurance
Anxiety/worry leading up to confirmatory colonoscopy
Small risk of bowel perforation during confirmatory colonoscopy
Detriment from delayed diagnosis
Some uncertainty (until after confirmatory colonoscopy)
No Uncertainty
FOBT indicates fecal occult blood test; GRADE, Grading of Recommendations Assessment, Development and Evaluation.
Immunochemical FOBT – GRADE Quality of Evidence for Diagnostic Studies
FN indicates false negative; FOBT, fecal occult blood test; FP, false positive; Development and Evaluation; TN, true negative; TP, true positive.
Uncertainty until after confirmatory colonoscopy
Stress/worry for patient until confirmatory colonoscopy
Detrimental effects due to delayed diagnosis.
For these 3 reasons, downgrade quality from High to Moderate.
For these 3 reasons, downgrade quality from Moderate to Low.
Considerations for the Ontario Health System
Executive Summary Table 4 shows the potential system pressures and benefit/risk analysis for the use of FOBT and colonoscopy to screen for CRC in average-risk adults, ages 50 and over in Ontario.
Summary of Potential System Pressures for FOBT Screening
Prevent and detect
Every 10 years
Must repeat at regular intervals
Every 2 years
Must repeat at regular intervals
Observational studies
Used as gold standard in studies
Intervention GRADE quality: High (gFOBT)
Diagnostic GRADE quality: Low (iFOBT)
No RCTs examining the effectiveness of repeated iFOBT on CRC mortality reduction were identified
Limited direct/indirect evidence that iFOBT has superior sensitivity/specificity to unrehydrated gFOBT for detection of CRC
0.1% risk of serious bleeding and perforation requiring surgery
0.3% risk of serious complications (stroke/bleeding requiring hospitalization/ myocardial infarction)
High interval cancer rate
The small benefit in CRC mortality reduction (absolute difference 0.1% to 0.2%) also coincides with a 0.3% risk of serious complications.
No food 1 day prior to exam
Office/hospital visit
Complete bowel preparation
Eliminate citrus fruit and juices and vitamin C from diet for 3 days prior to/during stool collection.
Person applies 2 samples per bowel movement (each occurring on 3 different days) onto test areas of FOBT cards.
Increased demand for colonoscopies and colonoscopists or nurses who perform colonoscopies.
Patient receives kit from family physician, pharmacist
Patients mail completed FOBT kit to participating laboratory
Results sent back to patient
Increased demand for colonoscopies for positive patients
Removal of polyp during colonoscopy or surgery
Referral to colonoscopy
2nd of 5 choices in a patient survey study
5th of 5 choices in a patient survey study
FOBT indicates fecal occult blood test;; gFOBT, guaiac FOBT; GRADE, Grading of Recommendations Assessment, Development and Evaluation; iFOBT, immunochemical FOBT; RCT, randomized controlled trial.
PMCID: PMC3377532  PMID: 23074514
22.  Prospective randomized controlled trial evaluating cap-assisted colonoscopy vs standard colonoscopy 
AIM: To study the significance of cap-fitted colonoscopy in improving cecal intubation time and polyp detection rate.
METHODS: This study was a prospective randomized controlled trial conducted from March 2008 to February 2009 in a tertiary referral hospital at Sydney. The primary end point was cecal intubation time and the secondary endpoint was polyp detection rate. Consecutive cases of total colonoscopy over a 1-year period were recruited. Randomization into either standard colonoscopy (SC) or cap-assisted colonoscopy (CAC) was performed after consent was obtained. For cases randomized to CAC, one of the three sizes of cap was used: D-201-15004 (with a diameter of 15.3 mm), D-201-14304 (14.6 mm) and D-201-12704 (13.0 mm). All of these caps were produced by Olympus Medical Systems, Japan. Independent predictors for faster cecal time and better polyp detection rate were also determined from this study.
RESULTS: There were 200 cases in each group. There was no significant difference in terms of demographic characteristics between the two groups. CAC, when compared to the SC group, had no significant difference in terms of cecal intubation rate (96.0% vs 97.0%, P = 0.40) and time (9.94 ± 7.05 min vs 10.34 ± 6.82 min, P = 0.21), or polyp detection rate (32.8% vs 31.3%, P = 0.75). On the subgroup analysis, there was no significant difference in terms of cecal intubation time by trainees (88.1% vs 84.8%, P = 0.40), ileal intubation rate (82.5% vs 79.0%, P = 0.38) or total colonoscopy time (23.24 ± 13.95 min vs 22.56 ± 9.94 min, P = 0.88). On multivariate analysis, the independent determinants of faster cecal time were consultant-performed procedures (P < 0.001), male patients (P < 0.001), non-usage of hyoscine (P < 0.001) and better bowel preparation (P = 0.01). The determinants of better polyp detection rate were older age (P < 0.001), no history of previous abdominal surgery (P = 0.04), patients not having esophagogastroduodenoscopy in the same setting (P = 0.003), trainee-performed procedures (P = 0.01), usage of hyoscine (P = 0.01) and procedures performed for polyp follow-up (P = 0.01). The limitations of the study were that it was a single-center experience, no blinding was possible, and there were a large number of endoscopists.
CONCLUSION: CAC did not significantly different from SC in term of cecal intubation time and polyp detection rate.
PMCID: PMC2923764  PMID: 20712051
Cap; Hood; Cecum; Colonoscopy; Cecal intubation; Colonic polyps
23.  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
24.  Recommendations for Post-Polypectomy Surveillance in Community Practice 
Digestive diseases and sciences  2011;56(9):2623-2630.
After colon cancer screening, large numbers of persons discovered with colon polyps may receive post-polypectomy surveillance with multiple colonoscopy examinations over time. Decisions about surveillance interval are based in part on polyp size, histology, and number.
To learn physicians’ recommendations for post-polypectomy surveillance from physicians’ office charts.
Among 322 physicians performing colonoscopy in 126 practices in N. Carolina, offices of 152 physicians in 55 practices were visited to extract chart data, for each physician, on 125 consecutive persons having colonoscopy in 2003. Subjects included persons with first-time colonoscopy and no positive family history or other indication beyond colonoscopy findings that might affect postpolypectomy surveillance recommendations. Data were extracted about demographics, reason for colonoscopy, family history, symptoms, bowel prep, extent of examination, and features of each polyp including location, size, histology. Recommendations for post-polypectomy surveillance were noted.
Among 10,089 first-time colonoscopy examinations, hyperplastic polyps were found in 4.5% of subjects, in whom follow-up by 4–6 years was recommended in 24%, sooner than recommended in guidelines. Of the 6.6% of persons with only small adenomas, 35% were recommended to return in 1–3 years (sooner than recommended in some guidelines) and 77% by 6 years. Surveillance interval tended to be shorter if colon prep was less than “excellent.” Prep quality was not reported for 32% of examinations.
Surveillance intervals after polypectomy of low-risk polyps may be more aggressive than guidelines recommend. The quality of post-polypectomy surveillance might be improved by increased attention to guidelines, bowel prep, and reporting.
PMCID: PMC3199324  PMID: 21698368
Colonoscopy screening; Colon cancer surveillance; Colonoscopy guidelines; Colonoscopy quality
25.  The water method colonoscopy in routine unsedated colonoscopy examinations: a randomized controlled trial in diagnostic cases in Indonesian patients 
A proof-of-principle randomized controlled trial (RCT) by a US colonoscopist with limited experience in scheduled unsedated colonoscopy showed that water exchange produced significant patient-centered benefits at the expense of prolonged procedural times.
To determine if a colonoscopist experienced in scheduled unsedated colonoscopy in Indonesia can reproduce the beneficial effects without negative procedural outcomes.
Prospective, RCT (NCT01341847)
Single center, in and outpatients of Sardjito General Hospital
110 consecutive symptomatic patients meeting inclusion criteria
In the water-aided (study) method the air pump was turned off; water at room temperature was infused to aid colonoscope advancement. Residual colonic air was bypassed. Except for cleansing the infused water was suctioned during withdrawal. In the air (control) method air insufflation was used during insertion.
Main Outcome Measurements
The discomfort during insertion (primary outcome) was scored by the patient (visual analog scale: 0=none, 10=most severe) shortly after completion of colonoscopy. Secondary outcomes included patient and procedural measures.
57 and 53 patients were randomized to the control or study method, respectively. Air vs. water-aided method comparisons revealed: mean discomfort score (±SD), 6.4±2.4 vs. 4.1±2.6 (p<0.001, t-test); willingness to repeat, 62.7% vs. 83.7% (p=0.024, Fisher's exact test); cecal intubation time 12.9±7.1 vs.11.9±5.5 minutes (p=0.38); cecal intubation rate, 89.5% vs. 92.4% (p=0.74). Discomfort score was not correlated with duration of examination.
Unblinded study
Experience in scheduled unsedated colonoscopy permitted replication of patient-centered benefits of water-aided method in Indonesian patients without adverse impacts on colonoscopist-centered procedural outcomes.
PMCID: PMC3791534  PMID: 24147221
colonoscopy; unsedated; air method; water-aided method; discomfort score

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