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Abstract

We thank Jain et al for their interest in our article1Calderwood A.H. Thompson K.D. Schroy 3rd, P.C. et al.Good is better than excellent: bowel preparation quality and adenoma detection rates.Gastrointest Endosc. 2015; 81: 691-699Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar and for sharing their comments and the results of their recent publication.2Jain D. Momeni M. Krishnaiah M. et al.Importance of reporting segmental bowel preparation scores during colonoscopy in clinical practice.World J Gastroenterol. 2015; 21: 3994-3999Crossref PubMed Scopus (7) Google Scholar We agree that endoscopists and endoscopy units should continue to strive to improve bowel preparation quality to optimize adenoma detection. We would like to emphasize that we interpret the findings of our article as a cautionary tale: Endoscopists should remain vigilant in their inspection of the colon even when the bowel preparation is excellent. Our results may differ from those of Jain et al2Jain D. Momeni M. Krishnaiah M. et al.Importance of reporting segmental bowel preparation scores during colonoscopy in clinical practice.World J Gastroenterol. 2015; 21: 3994-3999Crossref PubMed Scopus (7) Google Scholar because we compared polyp findings for individual total Boston Bowel Preparation Scale (BBPS) scores of 6, 7, and 8 versus 9, finding that polyp detection rates decreased at scores of 9 compared with scores of 6, 7, and 8.1Calderwood A.H. Thompson K.D. Schroy 3rd, P.C. et al.Good is better than excellent: bowel preparation quality and adenoma detection rates.Gastrointest Endosc. 2015; 81: 691-699Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar In contrast, Jain et al compared composite groups of total scores (4-6 vs 7-9), and this categorization over a broad range of scores likely accounts for differences in their findings. In particular, the group of total scores of 4 to 6 should not be considered as adequate cleanliness because many of these examinations include segment scores of 0 and 1. Furthermore, our previous work has shown that total BBPS scores of 4 and 5 are associated with much lower rates of polyp and adenoma detection,3Lai E.J. Calderwood A.H. Doros G. et al.The Boston Bowel Preparation Scale: a valid and reliable instrument for colonoscopy-oriented research.Gastrointest Endosc. 2009; 69: 620-625Abstract Full Text Full Text PDF PubMed Scopus (665) Google Scholar, 4Calderwood A.H. Jacobson B.C. Comprehensive validation of the Boston Bowel Preparation Scale.Gastrointest Endosc. 2010; 72: 686-692Abstract Full Text Full Text PDF PubMed Scopus (244) Google Scholar and so it is not surprising that total scores of 4 to 6 had lower adenoma detection rates (ADRs) and advanced ADRs than scores of 7 to 9. In the study they reference by Tholey et al,5Tholey D.M. Shelton C.E. Francis G. et al.Adenoma detection in excellent versus good bowel preparation for colonoscopy.J Clin Gastroenterol. 2015; 49: 313-319Crossref PubMed Scopus (12) Google Scholar ADR was higher in good compared with excellent preparations (29% vs 25%), although this was not statistically significant (P = .62). We did in fact consider body mass index and diabetes mellitus in the subset of patients from Boston Medical Center in our study. Because body mass index and diabetes mellitus were not associated with both polyp detection and bowel cleanliness (shown in our Supplemental Table 1),1Calderwood A.H. Thompson K.D. Schroy 3rd, P.C. et al.Good is better than excellent: bowel preparation quality and adenoma detection rates.Gastrointest Endosc. 2015; 81: 691-699Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar they were not considered confounders of the relationship between ADR and bowel cleanliness, and therefore we did not include them in our adjusted models. We agree that withdrawal time and even knowledge of time spent cleaning, inspecting, and performing maneuvers would have been useful variables, as we acknowledge in our section on limitations; however, we did not have access to these times and, as stated in our article, withdrawal time alone is not necessarily a robust quality indicator. The concept of endoscopists with lower ADRs reporting higher BBPS scores as suggested by Jain et al is interesting. Although we were not able to control for this in our study, behavioral factors around reporting bowel cleanliness certainly merit further exploration. Factors affecting bowel preparation and adenoma detection: patient or the doctorGastrointestinal EndoscopyVol. 82Issue 3PreviewWe read with interest the study by Calderwood et al,1 who reported a decrease in the polyp detection rate (PDR) and adenoma detection rate (ADR) with improvement in bowel preparation (BP) from good to excellent. The results are contrary to those of several other reports.2,3 The retrospective study design and lack of inclusion of several confounding factors are likely responsible for the results. Full-Text PDF