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A prospective RCT comparing combined chromoendoscopy with water exchange (CWE) vs water exchange (WE) vs air insufflation (AI) in adenoma detection in screening colonoscopy.
Leung, JW, Yen, AW, Jia, H, Opada, C, Melnik, A, Atkins, J, Feller, C, Wilson, MD, Leung, FW
United European gastroenterology journal. 2019;(4):477-487
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BACKGROUND A low adenoma detection rate (ADR) increases risks of interval cancers (ICs). Proximal colon flat polyps, e.g. serrated lesions (SLs), are difficult to find. Missed proximal colon flat lesions likely contribute to IC. AIMS We compared chromoendoscopy with water exchange (CWE), water exchange (WE) and air insufflation (AI) in detecting adenomas in screening colonoscopy. METHODS After split-dose preparation, 480 veterans were randomized to AI, WE and CWE. RESULTS Primary outcome of proximal ADR (55.6% vs 53.4% vs 52.2%, respectively) were similar in all groups. Adenoma per colonoscopy (APC) and adenoma per positive colonoscopy (APPC) were comparable. Detection rate of proximal colon SLs was significantly higher for CWE and WE than AI (26.3%, 23.6% and 11.3%, respectively, p = 0.002). Limitations: single operator; SLs only surrogate markers of but not IC. CONCLUSIONS When an endoscopist achieves high-quality AI examinations with overall ADR twice (61.6%) the recommended standard (30%), use of WE and CWE does not produce further improvement in proximal or overall ADR. Comparable APC and APPC confirm equivalent withdrawal inspection techniques. WE alone is sufficient to significantly improve detection of proximal SLs. The impact of increased detection of proximal SLs by WE on prevention of IC deserves to be studied. This study is registered at ClinicalTrial.gov (NCT#01607255).
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Detection rates of premalignant polyps during screening colonoscopy: time to revise quality standards?
Ross, WA, Thirumurthi, S, Lynch, PM, Rashid, A, Pande, M, Shafi, MA, Lee, JH, Raju, GS
Gastrointestinal endoscopy. 2015;(3):567-74
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BACKGROUND Standards for the detection of adenomas during screening colonoscopy are widely used to measure examination quality. No such standards exist for sessile serrated adenomas (SSAs). OBJECTIVE To measure both the adenoma detection rate (ADR) and SSA detection rate (SSADR) during screening colonoscopy before and after quality improvement/financial incentive measures. DESIGN Retrospective determination of baseline ADR/SSADR by the endoscopist, followed by prospective collection of data after informing physicians of baseline detection rates. SETTING Tertiary cancer center with a large cancer screening program. PATIENTS A total of 2833 average-risk colorectal cancer screening patients 50 to 75 years of age undergoing initial colonoscopy. DATA COLLECTION Electronic medical records for indication and demographics, endoscopy report, and pathology report. MAIN OUTCOME MEASUREMENTS Detection rates of adenomas and SSAs by sex. RESULTS The overall ADR in male and female patients was 50.6% and 36.6%, respectively. The overall detection rate of advanced adenomas in male and female patients was 12.4% and 6.5%, respectively. The overall SSADR in male and female patients was 10.1% and 7.1%, respectively. In 108 patients (3.8% of entire group), SSAs were the only premalignant lesions found. Detection rates of both types of premalignant polyps improved over time but did not reach statistical significance. LIMITATIONS Single-center experience with limited sample size and small group of endoscopists. CONCLUSION ADRs far in excess of current standards are achievable. Cecal withdrawal time is associated with the ADR. Prevalence of SSA rivals that of advanced adenomas and is greater than current medical literature suggests. The combination of monitoring and financial incentives did not result in statistically significant improvement in ADRs.
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Immediate unprepared hydroflush colonoscopy for severe lower GI bleeding: a feasibility study.
Repaka, A, Atkinson, MR, Faulx, AL, Isenberg, GA, Cooper, GS, Chak, A, Wong, RC
Gastrointestinal endoscopy. 2012;(2):367-73
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BACKGROUND Urgent colonoscopy is not always the preferred initial intervention in severe lower GI bleeding because of the need for a large volume of oral bowel preparation, the time required for administering the preparation, and concern regarding adequate visualization. OBJECTIVE To evaluate the feasibility, safety, and outcomes of immediate unprepared hydroflush colonoscopy for severe lower GI bleeding. DESIGN Prospective feasibility study of immediate colonoscopy after tap-water enema without oral bowel preparation, aided by water-jet pumps and mechanical suction devices in patients admitted to the intensive care unit with a primary diagnosis of severe lower GI bleeding. SETTING Tertiary referral center. MAIN OUTCOME MEASUREMENTS Primary outcome measurement was the percentage of colonoscopies in which the preparation permitted satisfactory evaluation of the entire length of the colon suspected to contain the source of bleeding. Secondary outcome measurements were visualization of a definite source of bleeding, length of hospital and intensive care unit (ICU) stays, rebleeding rates, and transfusion requirements. RESULTS Thirteen procedures were performed in 12 patients. Complete colonoscopy to the cecum was performed in 9 of 13 patients (69.2%). However, endoscopic visualization was thought to be adequate for definitive or presumptive identification of the source of bleeding in all procedures, with no colonoscopy repeated because of inadequate preparation. A definite source of bleeding was identified in 5 of 13 procedures (38.5%). The median length of ICU stay was 1.5 days; of hospital stay, 4.3 days. Recurrent bleeding during the same hospitalization, requiring repeated endoscopy, surgery, or angiotherapy, was seen in 3 of 12 patients (25%). LIMITATIONS Uncontrolled feasibility study of selected patients. CONCLUSION Immediate unprepared hydroflush colonoscopy in patients with severe lower GI bleeding is feasible with the hydroflush technique.
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Efficacy of bowel preparation with the use of a prepackaged, low fibre diet with a low sodium, magnesium citrate cathartic vs. a clear liquid diet with a standard sodium phosphate cathartic.
Delegge, M, Kaplan, R
Alimentary pharmacology & therapeutics. 2005;(12):1491-5
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BACKGROUND A colon free of faecal residue is required for accurate diagnostic colonoscopy. Patient tolerance of his/her colonoscopy cathartic regimen affects patient compliance and willingness to undergo repeated examinations. AIM: To determine whether a meal could be consumed during standard bowel preparation. METHODS This was a randomized, endoscopists' blinded comparison of the tolerability and efficacy of a prepackaged, low-residue diet (NutraPrep) combined with the LoSo Prep bowel cleansing system, which contains magnesium citrate, bisocodyl tablets and a bisocodyl suppository (NP-LS regimen), compared with a clear liquid diet and a double-dose sodium phosphate (Fleet Phospho-soda) regimen (2F regimen). Outcome measures included efficacy of bowel preparation, patient preparation tolerability, side-effects and patient safety. RESULTS A total of 506 patients completed the study, 222 randomized to 2F and 284 to NP-LS. The NP-LS regimen resulted in significantly better colon cleansing in terms of the proportion with good or excellent results (P = 0.025) and in significantly better patient tolerance and willingness to repeat the cathartic preparation (P < 0.01). CONCLUSION The NP-LS regimen proved superior to the 2F regimen.
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Pulmonary scintigraphy for diagnosis of aspiration during intravenous propofol anaesthesia for colonoscopy.
Rezaiguia-Delclaux, S, Streich, B, Bouleau, D, Delchier, JC, Dhonneur, G, Meignan, M, Duvaldestin, P
British journal of anaesthesia. 2001;(2):204-6
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A specific technique for detection of pulmonary aspiration during the perioperative period is lacking. In this study, we developed a scintigraphic method for its diagnosis. Technetium 99m sulphur colloid was given orally 2 h before an i.v. infusion of propofol in patients undergoing elective colonoscopy. During the procedure, patients were spontaneously breathing 100% oxygen via a face mask. After recovery from anaesthesia, patients had a chest scinti-scan. As a control group, 10 healthy men were studied. The lung scan was considered positive if any tracer activity greater than background level was detected in the lung field. Among 96 patients studied, three patients had a positive chest scinti-scan. One of the three patients developed pneumonia while the other two remained asymptomatic. In none of the control asymptomatic group was tracer detected in the chest. We suggest that this technique is specific and can be used as a tool to assess the risk of pulmonary aspiration during different anaesthetic procedures.
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A novel tableted purgative for colonoscopic preparation: efficacy and safety comparisons with Colyte and Fleet Phospho-Soda.
Aronchick, CA, Lipshutz, WH, Wright, SH, Dufrayne, F, Bergman, G
Gastrointestinal endoscopy. 2000;(3):346-52
Abstract
BACKGROUND Currently available aqueous purgatives used before colonoscopy are poorly tolerated. We designed a tableted sodium phosphate purge that we believe will yield much greater patient acceptance. METHODS A total of 305 outpatients undergoing routine diagnostic colonoscopy were randomized to one of three preparation groups: Colyte (100 patients), Fleet Phospho-Soda (106 patients), or sodium phosphate tablets (99 patients). Endoscopists were blinded to the type of preparation administered and answered a questionnaire regarding preparation quality. Patients answered a questionnaire designed to analyze tolerability. Adverse events were closely followed and recorded. RESULTS There were no significant differences in quality of preparation across the groups (80% excellent or good, 4% repreparation). Although hypocalcemia (4 of 71), hypokalemia (18 of 68), and hyperphosphatemia (39 of 69) were observed in patients receiving the tablets, no adverse events occurred. Patients preferred taking the tablets over Colyte and Fleet Phospho-Soda. CONCLUSION The evaluation of a novel delivery system of a sodium phosphate purge is described. Intended for use before colonoscopy, it circumvents the poor taste and excessive volume of ingestion that are aversive to patients. The tableted purgative is equally effective, safe, and greatly preferred over the existing aqueous preparations. This may improve patient compliance with recommendations for screening colonoscopy.