Afternoon Procedures Research Articles

Adenoma Detection Rate (ADR) Based on Scope Daily Volume-Does It Matter?

INTRODUCTION: The major goal of colonoscopy (C) is the detection and removal of adenomatous (A) polyps. Many factors are involved in assuring adequate adenoma detection including a clean colon, a slow colonic withdrawal and an attentive endoscopist (E). Prior studies have suggested a higher (A) detection in the morning over afternoon procedures possibly related to physician fatigue. Fatigue can also be related to other causes like work volume and time restrictions. GOAL: We thus set out to measure ADR based on scope daily volume. HYPOTHESIS: We hypothesized that ADR would be affected by the number of scopes performed in a work session with less ADR when scope volume or pressure to complete a work load was high. METHODS: ADR was evaluated retrospectively for 50 C each from three E from July 2009 to July 2010 during three procedure volumes, namely 1-5 procedures/session, 6-10 and >10 to a maximum of 15. Exclusions were age 80, C in the past 1 year, incomplete C or s/p partial colectomy. ADR was calculated by determining the number of C were at least one adenoma was found and removed. RESULTS: Age and sex were similiar between groups. A trend for a higher amount of total polyps and A were seen in the over 10 procedure group as compared to 6-10 group but no statistical difference was seen. The ADR was not different between all three categories. CONCLUSION: No difference in ADR was seen between scope daily volumes in our outpatient private practice group setting up to a maximum of 15 scopes per session.

Adenoma Detection Rate Is Not Influenced by the Timing of Colonoscopy When Performed in Half-Day Blocks

Afternoon colonoscopies have recently been reported to be associated with lower adenoma detection rate (ADR), which was attributed to physician fatigue resulting from the same endoscopist performing procedures throughout the day. The aim of our study was to assess ADR in morning compared with afternoon colonoscopy performed in half-day blocks with different physicians. We evaluated the primary hypothesis that morning and afternoon ADRs would not differ significantly when performed in half-day blocks by different endoscopists. Data on all colonoscopies performed between January 2009 and December 2009 were obtained from our endoscopy database. All patients who underwent colonoscopies in 2009 for screening, surveillance, and family history of colon cancer/polyps were included in the study. Morning colonoscopies were defined as those that were performed from 0800 to 1200 hours. Afternoon colonoscopies were defined as those that were performed from 1300 to 1700 hours. Colonoscopies in each block were performed either by different endoscopists working in half-day (morning or afternoon) block schedules or by the same endoscopist working a full-day schedule. A total of 4,665 patients were included in the study. For endoscopists working the full-day, the afternoon ADR was significantly lower than the morning ADR (21 vs. 26.1%; odds ratio (OR)=0.75; 95% confidence interval (CI) 0.59, 0.96; P=0.02). Conversely, in the half-day group, there was no significant difference in ADR between afternoon and morning (27.6 vs. 26.6%; OR=1.05; 95% CI 0.88, 1.26; P=0.56). Performing colonoscopies in half-day blocks by different endoscopists increases the detection of adenomas in afternoon procedures, probably by reducing physician fatigue.

Queue Position in the Endoscopic Schedule Impacts Effectiveness of Colonoscopy

Endoscopist fatigue potentially impacts colonoscopy. Fatigue is difficult to quantitate, but polyp detection rates between non-fatigued and fatigued time periods could represent a surrogate marker. We assessed whether timing variables impacted polyp detection rates at a busy tertiary care endoscopy suite. Consecutive patients undergoing colonoscopy were retrospectively identified. Indications, clinical demographics, pre-procedural, and procedural variables were extracted from chart review; colonoscopy findings were determined from the procedure reports. Three separate timing variables were assessed as surrogate markers for endoscopist fatigue: morning vs. afternoon procedures, start times throughout the day, and queue position, a unique variable that takes into account the number of procedures performed before the colonoscopy of interest. Univariate and multivariate analyses were performed to determine whether timing variables and other clinical, pre-procedural, and procedural variables predicted polyp detection. During the 4-month study period, 1,083 outpatient colonoscopy procedures (57.5±0.5 years, 59.5% female) were identified, performed by 28 endoscopists (mean 38.7 procedures/endoscopist), with a mean polyp detection rate of 0.851/colonoscopy. At least, one adenoma was detected in 297 procedures (27.4%). A 12.4% reduction in mean detected polyps was detected between morning and afternoon procedures (0.90±0.06 vs. 0.76±0.06, P=0.15). Using start time on a continuous scale, however, each elapsed hour in the day was associated with a 4.6% reduction in polyp detection (P=0.005). When queue position was assessed, a 5.4% reduction in polyp detection was noted with each increase in queue position (P=0.016). These results remained significant when controlled for each individual endoscopist. Polyp detection rates decline as time passes during an endoscopist's schedule, potentially from endoscopist fatigue. Queue position may be a novel surrogate measure for operator fatigue.

The detection of premalignant colon polyps during colonoscopy is stable throughout the workday

Recent studies have shown that colonoscopic polyp detection decreases as the workday progresses. This may reflect time-dependent factors such as colonoscopist fatigue and decreased colon cleanliness, which can be addressed through adaptations in colonoscopy practice. To test for time-of-day differences in adenomatous polyp (AP) and sessile serrated polyp (SSP) detection in a practice that uses split-dose bowel preparation and moderated daily colonoscopist procedure loads. Retrospective chart review. Community-based, group gastroenterology practice. This study involved 2439 patients undergoing surveillance or screening colonoscopy. Colonoscopy. Detection rate of all premalignant polyps (PMPs), and of APs and SSPs, individually. A total of 1183 PMPs were identified in 1486 eligible patients (mean PMP/colonoscopy = 0.80; PMP detection rate = 47%). In univariate and multivariate analyses, PMP detection as well as detection of APs or SSPs individually did not vary significantly in relation to the hour of the day. In a binary comparison of morning (am) versus afternoon (pm) procedures, the total polyp detection rate was 67% and 66%, respectively. For PMPs, APs, SSPs, and hyperplastic polyps (HPs), the am and pm detection rates were 46% and 47%, 41% and 44%, 8% and 8%, and 27% and 24%, respectively. Bowel preparation quality was independent of time of day and was rated excellent or good in 86% to 87% of cases. Retrospective, nonrandomized study. Stable PMP, AP, SSP, and HP detection rates throughout the workday occur under certain practice conditions, including the use of split-dose bowel preparation and/or moderated daily colonoscopist procedure loads.

Achieving quality in colonoscopy: bowel preparation timing and colon cleanliness

Colonoscopy is considered the gold standard for investigation of large bowel pathology. Numerous factors influence the efficacy of bowel preparation for colonoscopy. Inadequate bowel preparation can lead to missed pathology. Timing of fasting and bowel preparation, timing of procedure and possibly patient bowel habit and presence of diverticula may have an influence on the quality of the preparation. The aim of this study was to investigate the quality of cleansing of sodium picosulfate (Picoprep-3™, Pharmatel Fresenius Kabi Pty Ltd, Pymble, NSW, Australia) with different administration schedules and to evaluate whether patient's bowel patterns influence the quality of cleansing. Three hundred twenty-five patients (175 morning and 150 afternoon procedures) were interviewed prior to colonoscopy to evaluate bowel habit and timing of preparation administration. Quality of cleansing was then assessed during colonoscopy using a 5-point scale. Further factors analysed included the patient's prior bowel habit and the presence of diverticula at colonoscopy. Procedural end points evaluated included procedure total time, caecal intubation time and withdrawal times. The quality of cleansing for individual bowel segments was worse for afternoon procedures (P < 0.05 for some segments) and for patients with prior constipation (P < 0.05 for descending colon segments). Caecal intubation times were shorter for patients with diarrhoea and longer for female patients, who also had shorter withdrawal times. No correlation was found between the procedural end points (total duration, caecal intubation time and withdrawal times) and the timing of fasting. Quality of cleansing is significantly improved when bowel preparation is taken entirely the day prior to colonoscopy. Patients with prior constipation demonstrated poorer cleansing.

Low-volume PEG plus ascorbic acid versus high-volume PEG as bowel preparation for colonoscopy

Objective. High volumes of polyethylene glycol (PEG)-based solutions as bowel preparation for colonoscopy are effective, but often poorly tolerated. To compare a 2 l PEG-based solution combined with ascorbic acid (PEG + Asc) with 4 l PEG-based solution (PEG). Methods. In a single blind, quasi-randomized, prospective study, 350 patients undergoing colonoscopy received 2 l of PEG + Asc or 4 l of PEG. For morning procedures, the total dose of PEG + Asc was taken the evening before, for afternoon colonoscopies, PEG + Asc was given as a split dose. The 4 l PEG preparation was given as a split dose. Efficacy of preparation was scored on a five-point scale in three different colon segments. Patients' experiences were evaluated using a questionnaire. Results. From 307 patients (149 PEG + Asc, 158 PEG), results were available. Successful colon cleansing was achieved in 90.6% in the PEG + Asc group compared to 96% in the PEG group (not significant). In patients prepared with PEG + Asc, bowel cleansing was worse when patients underwent colonoscopy in the morning, compared to afternoon procedures. Side-effects and patients' experiences were similar in the PEG + Asc and PEG group. Conclusions. Low-volume PEG + ascorbic acid has comparable efficacy and tolerability as high-volume PEG solution. The cleansing results were worse if patients received the full dose PEG + Asc the evening before the procedure compared to the split dose. Our data support the administration of PEG + Asc as a split dose before the procedure.

GS23P ACHIEVING QUALITY IN COLONOSCOPY: BOWEL PREPARATION TIMING AND PROCEDURAL TECHNIQUE

Background: Colonoscopy is the gold standard for investigating pathology of the large bowel. Numerous factors influence the efficacy of bowel preparation for colonoscopy. Inadequate bowel preparation can lead to missed pathology. Timing of preparation, timing of procedure and patient bowel habit may have an influence on the quality of the preparation. The aim of this study was to investigate the quality of cleansing of sodium picosulphate with different administration schedules and to evaluate whether patient's prior bowel patterns influenced quality of cleansing.Methods: 325 patients were interviewed prior to colonoscopy to evaluate prior bowel habit and timing of preparation administration. The quality of preparation was then assessed during colonoscopy. Further patient factors evaluated included patient tolerance, compliance and adverse reactions to preparation. Procedural factors evaluated included quality of cleansing and circular muscle hypertrophy. Procedure total time, caecal intubation time and withdrawal times were also recorded. A 5‐point scale was used to assess quality of cleansing.Results: The quality of cleansing for individual bowel segments was worse for afternoon procedures (p &lt; 0.05 for all segments), and for patients with prior constipation (p &lt; 0.05 for transverse and descending segments). No correlation was found between the quality indicators (total duration, caecal intubation time, withdrawal times), colon length, circular muscle hypertrophy or presence of diverticula for cleansing quality.Conclusion: The quality of cleansing is significantly improved when bowel preparation is taken the day prior to colonoscopy. In addition patients with prior constipation demonstrated poorer cleansing.

Comparison of Cecal Intubation Rates and Quality of Bowel Preparation Between Morning and Afternoon Colonoscopies

Background/Aims: The timing of colonoscopies has been reported predictive factor of incomplete colonoscopy and poor bowel preparation. We aimed to compare the cecal intubation rates and quality of bowel preparation in morning versus afternoon procedure, and to determine the interval time between polyethylene glycol (PEG) solution starting time and colonoscopy procedure for adequate bowel preparation. Methods: A prospective, case-control, and single-center study comparing cecal intubation rates and quality of bowel preparation according to the timing of procedure were performed between May 2007 and October 2007. Outpatients in the morning and afternoon procedure were advised to drink PEG solution at 5 AM and at 8 AM on the day of colonoscopy, respectively. Quality of bowel preparation was assessed using the Ottawa bowel preparation quality scale. Results: A total of 300 outpatients were enrolled, of which 149 in the morning and 151 were in the afternoon. Several known factors of incomplete colonoscopy, such as female gender, prior hysterectomy, constipation, low body mass index, and diverticulosis were similar between two groups. Complete cecal intubation rates were 97.3% (145/149) in the morning group and 98.0% (148/151) in the afternoon group, and were not significant difference (p = 0.69). Poor bowel preparation rates in the morning versus afternoon were 14.8% versus 13.9% (p = 0.81). Subjects with interval time ≥7 hours between PEG starting time and procedure starting time had an 2.10 odds ratio (95% CI, 1.08-4.07, p <0.05) with poor preparation, compared to those with interval time 4-7 hours. Conclusions: Contrary to the previous studies, complete cecal intubation rates and bowel preparation rates are not different in the morning versus afternoon procedures. We suggest that to improve the adequate bowel preparation rate of afternoon colonoscopy, it is better to perform the colonoscopy within 4-7 hours after PEG starting time.

Time of Day As a Risk Factor for Incomplete Colonoscopy: An Australian Tertiary Referral Hospital Experience

Background: One time colonoscopy with polypectomy has a significant reduction on expected colorectal cancer mortality. Identifying and addressing the factors that affect quality of colonoscopy are paramount. Risk factors for incomplete colonoscopy including age, gender, bowel preparation adequacy and diverticular disease have been characterised. Whether having an afternoon vs. morning colonoscopy is an independent risk for not achieving caecal intubation is less clearly defined. Questions have been raised wether proceduralist fatigue or just inadequacy of bowel preparation for afternoon procedures accounts for decreased caecal intubation rates. Methods: Retrospective single centre study of all colonoscopies performed at the John Hunter Hospital Australia from 1/1/2006 until 31/12/2006. Results: A total of 1367 colonoscopies performed. 83 colonoscopies were excluded due to patients having previous colon resection. A further 14 colonoscopies were excluded as the reason for termination of colonoscopy was obstructing tumour. There were 644 morning colonoscopies and 626 afternoon colonoscopies. There were 150 unsuccessful colonoscopies giving a caecal intubation rate of 88.1%. 43.3% of unsuccessful colonoscopies were in the morning verse 56.7% after midday (p < 0.05). 42.7% of unsuccessful colonoscopies only extended to the sigmoid or descending colon. 64.7% unsuccessful colonoscopies were in women and 35.3% in males (p < 0.05). Poor bowel preparation was reported in 41.3% of unsuccessful colonoscopies vs. 13.1% of successful colonoscopies (p < 0.05). 25% of unsuccessful colonoscopies vs. 26% successful colonoscopies had a diagnosis of diverticular disease.(P > 0.05). Multivariate analysis demonstrated that the independent risk factors for unsuccessful colonoscopy were poor bowel preparation, gender, and time of day of procedure. There was no significant interaction between these variables (P > 0.05), suggesting that time of day is an independent risk factor for failed colonoscopy. Conclusion: Time of day is an independent risk factor for not achieving caecal intubation at colonoscopy. Priority booking of colonoscopy to the beginning of procedure lists may improve this outcome and warrants prospective investigation in the Australian setting.

Afternoon Colonoscopies Have Higher Failure Rates Compared to Morning Colonoscopies

Background: There are several predictors of incomplete colonoscopy including poor bowel preparation, female gender, prior hysterectomy and diverticulosis. In addition, higher rates of poor bowel preparation in afternoon colonoscopies compared to morning have been reported. However, the impact of afternoon scheduling of colonoscopies compared to morning on completion rates is not well studied. Aims: To determine the influence of scheduling colonoscopies in the afternoon versus morning (before 12 noon) on completion rates of colonoscopy. Methods: Retrospective chart review of colonoscopies performed by 10 trainees under attending supervision and 8 attending physicians from November 2003 to October 2004 in the division of Gastroenterology at Metro Health Medical Center. Patient demographics, indications for procedure and colonoscopic findings were reviewed. Majority of our patients receive PEG-electrolyte based bowel preparation in the evening prior to the day of scheduled colonoscopy. Results: Inadequate bowel preparation was found in 182 out of 1114 (16%) colonoscopies in the morning and 259 out of 1174 (22%) in the afternoon (p 0.0005). Patients were similar with regards to risk factors predictive of incomplete colonoscopy except poor bowel preparation precluding completion. Incompletion rate was significantly higher in afternoon procedures compared to morning procedures (8.1% versus 4.4%; p 0.0003), odds ratio for incompletion was 1.83 (CI 1.28-2.61). After excluding incomplete colonoscopies due to poor bowel preparation and colonic pathology precluding completion, incompletion rate was still higher in afternoon procedures (4.3% versus 2.8%). Odds ratio for incompletion was 1.56 (CI 0.99-2.48) but this did not reach statistical significance (p 0.068). Conclusions: Scheduling of colonoscopies in the afternoon compared to morning is an independent predictor of incomplete colonoscopy, much of this is due to poor bowel preparation. Even after adjusting for poor bowel preparation there is a trend towards higher incompletion rates in the afternoon compared to morning. Scheduling of colonoscopies only in the morning would avoid inadequate procedures in 6% of patients and also the need for unnecessary repeat colonoscopy in 3.7% of patients. This results in cost-savings and also improvement in quality of life for the patients. Background: There are several predictors of incomplete colonoscopy including poor bowel preparation, female gender, prior hysterectomy and diverticulosis. In addition, higher rates of poor bowel preparation in afternoon colonoscopies compared to morning have been reported. However, the impact of afternoon scheduling of colonoscopies compared to morning on completion rates is not well studied. Aims: To determine the influence of scheduling colonoscopies in the afternoon versus morning (before 12 noon) on completion rates of colonoscopy. Methods: Retrospective chart review of colonoscopies performed by 10 trainees under attending supervision and 8 attending physicians from November 2003 to October 2004 in the division of Gastroenterology at Metro Health Medical Center. Patient demographics, indications for procedure and colonoscopic findings were reviewed. Majority of our patients receive PEG-electrolyte based bowel preparation in the evening prior to the day of scheduled colonoscopy. Results: Inadequate bowel preparation was found in 182 out of 1114 (16%) colonoscopies in the morning and 259 out of 1174 (22%) in the afternoon (p 0.0005). Patients were similar with regards to risk factors predictive of incomplete colonoscopy except poor bowel preparation precluding completion. Incompletion rate was significantly higher in afternoon procedures compared to morning procedures (8.1% versus 4.4%; p 0.0003), odds ratio for incompletion was 1.83 (CI 1.28-2.61). After excluding incomplete colonoscopies due to poor bowel preparation and colonic pathology precluding completion, incompletion rate was still higher in afternoon procedures (4.3% versus 2.8%). Odds ratio for incompletion was 1.56 (CI 0.99-2.48) but this did not reach statistical significance (p 0.068). Conclusions: Scheduling of colonoscopies in the afternoon compared to morning is an independent predictor of incomplete colonoscopy, much of this is due to poor bowel preparation. Even after adjusting for poor bowel preparation there is a trend towards higher incompletion rates in the afternoon compared to morning. Scheduling of colonoscopies only in the morning would avoid inadequate procedures in 6% of patients and also the need for unnecessary repeat colonoscopy in 3.7% of patients. This results in cost-savings and also improvement in quality of life for the patients.

Outpatient Laparoscopic Cholecystectomy

Outpatient laparoscopic cholecystectomy has become nearly mandatory in the current health care economic environment. This study determined the opinions of patients and their nurses regarding disability and pain after laparoscopic cholecystectomy. Using a 14-point questionnaire, 32 consecutive patients who underwent inpatient LC were surveyed. The nurses caring for these patients were surveyed with a nine-point questionnaire. Seventy-one percent of patients believed that they could not have been discharged the day of surgery; the nurses reported that 81% of the patients could not have gone home. Nausea and vomiting were common. Pain was rated as 9 or 10 in 19% of patients. Nurses reported that 56% of postoperative patients were not receptive to discharge teaching. Morning (16) versus afternoon (16) procedures were not different. Successful programs of outpatient LC must: 1) ensure adequate home support because patient capability will be limited, 2) optimize pain control, 3) minimize nausea and vomiting, and 4) deliver patient education preoperatively.

Role of Beta-Endorphins in Analgesia Associated with Reactive Hyperemia

The role of plasma rhythm of beta-endorphin (beta-E) levels during reactive hyperemia was investigated in patients undergoing aortofemoral arteriography (n = 24). Two groups of patients were studied; one undergoing morning (AM; n = 15) and the other, afternoon (PM; n = 9) procedures. Arterial blood samples for assay of plasma beta-E were obtained during the following time intervals: baseline or prior to vascular occlusion (T1); after 2 1/2 minutes of vascular occlusion (T2), and 1 (T3) and 2 minutes (T4) after release of the pressure cuffs. Baseline beta-E levels of each group were elevated over nonstressed individuals and no significant difference occurred over the course of the procedure with either the AM or PM groups. Examination of changes in beta-E levels in individual patients yielded a different pattern. In the AM group, nine patients doubled their plasma beta-E levels from T1 to T2 (P less than .05) and remained elevated during T3 and T4 (P less than .05). Other members of the group n = 6 also had high baseline levels of beta-E and these levels declined from T2 to T4 (P less than .05). In the PM group, baseline beta-E levels were elevated in comparison with normals in five patients who exhibited similar increment in beta-E levels from T1 to T2 as the AM group, but the results were not significant. Other members of the group (n = 4) also had high baseline beta-E levels and the levels declined from T2 to T4 as in the AM group.(ABSTRACT TRUNCATED AT 250 WORDS)