Incomplete Colonoscopy Research Articles

The role of single-balloon colonoscopy for patients with previous incomplete standard colonoscopy: Is it worth doing it?

The rate of cecal intubation is a well-recognized quality measure of successful colonoscopy. Infrequently, the standard colonoscopy techniques fail to achieve complete examination. The role of single-balloon overtube-assisted colonoscopy (SBC) in these situations has only been sparsely studied. This prospective single-center study aimed to investigate the technical success (rate of cecal intubation) and the diagnostic gain of SBC. The study recruited consecutive patients with previous incomplete standard colonoscopy who were admitted for SBC at our tertiary center in Eastern Switzerland between February 2008 and October 2014. The primary outcome was defined as successful cecal intubation. Data on patient characteristics, indication, technical details of procedure, and outcome were collected prospectively. The Olympus enteroscope SIF-Q180 was used. The study included 100 consecutive patients (median age 70years; range 38-87years; 54% female) who were examined using a single-balloon overtube-assisted technique. The cecal intubation rate was 98% (98/100). The median time of total procedure was 54min (range 15-119min); the median time to reach the cecal pole was 27.5min (range 4-92min). Passage of the sigmoid colon was not possible in two cases with a fixed, angulated sigmoid colon. The diagnostic gain was 21% regarding adenomatous polyps in the right colon. The complication rate was 2% (2/100, minor) without need for surgery. This prospective patient cohort study shows that single-balloon colonoscopy is a safe and effective procedure to achieve a complete endoscopic examination in patients with a previous failed standard colonoscopy. A significant diagnostic and therapeutic gain in the right colon justifies additional procedure time.

P0112 Prediction of complex colonic anatomy before colonoscopy: Use of quantitative CTC data for risk stratification of patients for colon-cancer screening

Background Certain characteristics in patients have been associated with decreased endoscopic performance and outcomes. However, little objective quantitative data have been reported on differences in colonic morphology, which could explain why certain patient populations are at higher risk than others for incomplete or difficult colonoscopy. Poor performance and bad experiences in patients may negatively affect their choice for future screening for colon cancer. Knowledge before colonoscopy of patients with complex morphology could help endoscopists appropriately prepare for these particular patients. Methods Prototype quantification software was used to assess CT colonography datasets. To limit selection bias, all patients had a history of failed colonoscopy. Colonic morphology metrics were investigated, including: length, volume, tortuosity (number of acute angles), compactness (volume of box containing centreline divided by centreline length), and height of the sigmoid apex (HSA). Patient factors assessed included: sex ( n = 40), age ( n = 32), height ( n = 32), BMI ( n = 32), and hysterectomy ( n = 73). Patient groups were compared with the t -test. Distance navigated at colonoscopy was compared and relative risk was assessed. Findings Despite similar lengths, women’s colons were more tortuous and compact, less voluminous, and had lower HSA ( p 65 years), shorter ( p ⩽ 0.05) colons and demonstrated decreased distance travelled at endoscopy, although the differences were not statistically significant. Women with hysterectomy had more tortuous and less voluminous sigmoid segments with lower HSA ( p ⩽ 0.02). At endoscopy, the hysterectomy group had 46% chance of failure to pass the sigmoid segment, versus 22% in the non-hysterectomy group (relative risk 2.068, p = 0.043). Interpretation Differences in colonic morphology exist between patient populations. Factors including female sex, older age, shorter stature, thinner body habitus, and hysterectomy status show quantitative evidence of more complex colonic morphology which can make endoscopy more challenging in these patients. Consideration of these factors could help endoscopists prepare for challenging cases and provide a better screening experience.

PWE-029 Colon capsule endoscopy: a useful diagnostic modality that informs patient management: Abstract PWE-029 Table 1

Introduction Colon capsule endoscopy (CCE) has been demonstrated to be a feasible alternative to colonoscopy for the detection of polyps and neoplasia 1 and avoids intubation and sedation. This study evaluates the utility of CCE in routine clinical practice and its impact on patient outcomes. Method Retrospective, single-centre, including symptomatic patients attending for CCE using PillCam Colon 2 (Given Imaging, Israel). All patients with known inflammatory bowel disease (IBD) successfully passed a PillCam Patency device prior. Patient demographics, procedural data, final diagnosis and management outcomes were collected. Results 101 patients were included, mean age 43 years (range 16–95), 73 female, median follow-up 29 months (range 1–52). 48% refused colonoscopy, 29% had an incomplete colonoscopy, 17% chose CCE over colonoscopy and 6% were unfit for colonoscopy. Indication for the procedure: anaemia (24%), IBD assessment (16%) and suspected IBD (60%). The latter had predominant symptoms of diarrhoea (77%), abdominal pain (18%) or weight loss (5%). Procedure completion rate 69%, bowel preparation was adequate in 75%. There were no complications. Results are summarised in Table 1. In the anaemia group, CCE altered management in 15%: 3 further procedures (1 double balloon enteroscopy (DBE) and argon plasma coagulation, 1 catheter embolisation and 1 small bowel capsule endoscopy) and 1 altered medication. The remaining 20 were managed conservatively. In the known IBD group, CCE altered further management in 69% (7 altered medication, 2 surgery, 2 further procedures (1 DBE, 1 colonoscopy), the remaining 5 patients were managed conservatively. In those suspected as having IBD, this was identified in 7%. Other clinically significant diagnoses were made in 36%. The remaining 57% patients were thought to have functional bowel disorders and were discharged. 3 patients were excluded due to a non-diagnostic examination. Conclusion CCE may be a useful alternative for detecting clinically relevant pathology in symptomatic patients and can help guide management. An incomplete examination (i.e. distal colon not visualised) was less relevant in the 29 patients who had already had an incomplete colonoscopy beforehand or the 24 patients whose incomplete CCE was sufficient to provide a diagnosis. Although marketed as a colonic imaging device, a third of pathology identified by CCE was in the SB, serving as a reminder that it may be difficult to distinguish symptoms arising from the small or large bowel, or both. Disclosure of interest None Declared. Reference Spada C, Hassan C, Munoz-Navas M, et al . Second-generation colon capsule endoscopy compared with colonoscopy. Gastrointest Endosc 2011; 74 (3):581-89.e1

PWE-360 Outcomes of failed colonoscopy within the bowel cancer screening programme (BCSP)

<h3>Introduction</h3> The NHS BCSP uses colonoscopy as the primary colonic investigation following a positive faecal occult blood screening test. The standards for completion of colonoscopy are high within the programme and well above the target of 90%. Whilst there is clear guidance for use of a ‘second test’ to complete colonic imaging in that minority with a ‘failed’ index colonoscopy,¹little is known about the outcome of these patients. The aim of this study was to determine the outcome of patients following a failed BCSP colonoscopy. <h3>Method</h3> All patients that underwent a BCSP colonoscopy at Royal Liverpool University Hospital between 2008–2013 were identified. All cases of failed colonoscopy were fully audited with a minimum of 12 months follow up and comparisons were made with those within the BCSP with completed examinations (Chi-Squared statistical analysis). <h3>Results</h3> In the study period 2885 BCSP colonoscopies were performed, caecal intubation rate was 96%. From the 111 failed procedures, 26 (23%) were due to obstructing colorectal cancer (CRC). 108 patients underwent a second test: 67 (62%) had CT colonography, 23 (21%) had a CT abdomen, 17 (16%) had a repeat colonoscopy, 2 (2%) had a barium enema. 3 (3%) patients did not have a second test: 2 declined, and 1 died of cardiac causes post orthopaedic surgery whilst awaiting their test. Once the patients with significant positive findings on the index colonoscopy were excluded (e.g. cancer diagnosis), the risk of finding additional significant pathology on second test was 49%. Sub-categorised, the risk of CRC, extra-colonic malignancy and polyps was 2.3%, 2.3% and 44% respectively. Whilst the risk of finding CRC on the second test was similar to a completed procedure (2.3% vs. 3.2% respectively; p = 0.66), the risks of finding polyps was unsurprising lower (second test 44% vs. complete colon 61%: p &lt; 0.001). The 12-month outcome of patients with failed colonoscopy found that 53% returned to the BCSP, 19% were enrolled to BCSP surveillance and 25% were offered a definitive treatment after MDT (all CRC patients). The 12-month mortality was just 3%: 2 having died from non-GI malignancy and 1 from cardiac causes. <h3>Conclusion</h3> This study emphasises the importance of complete colonic examination within the BCSP. For those with an incomplete colonoscopy not caused by an obstructing tumour, there was a 49% chance of finding significant pathology on the second test. The lower incidence of polyps found on the second test confirms colonoscopy as the gold standard for polyp detection. Overall the outcomes are good with just 3% mortality at 12 months (unrelated to CRC) even with a diagnosis of CRC in almost a quarter of cases. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Taylor S <i>et al</i>. Guidelines for the use of imaging in the NHS Bowel Cancer Screening Programme. 2nd edition. 2012.

PTH-016 Post colonoscopy colorectal cancer (pccrc) rates – a district general hospital experience

<h3>Introduction</h3> Colorectal cancer (CRC) is the second leading cause of cancer related deaths in the United Kingdom. Colonoscopy is recommended first line investigation for CRC. Most studies recommend counselling patients undergoing colonoscopy about a “miss rate” of up to 6%.¹The aim of this retrospective study was to evaluate the frequency of post colonoscopy colorectal cancer (PCCRC) in a District General Hospital. <h3>Method</h3> Data for all patients with a new diagnosis of CRC were obtained from our local colorectal cancer services between Jan 2011 to Sept 2014. We identified all patients who have had colonoscopy within 36 months of a CRC diagnosis. PCCRC was defined as those who had colonoscopy within 6–36 months of diagnosis, whereas the cancers were classified as “detected” if diagnosis was made within 6 month of preceding colonoscopy. Patients with incomplete colonoscopy were excluded. <h3>Results</h3> 494 patients were diagnosed with CRC. Of these, 161 patients had a colonoscopy within 36 months preceding diagnosis. 2.5% (4/161) patients were found to have PCCRC. 75% were male and mean age of the patients was 77 years (range 61–86 years). Bowel preparation was reported to be good in all procedures. The location of the PCCRC was sigmoid (2), descending colon (1) and transverse colon (1). The indication for colonoscopy was anaemia (2), bleeding per rectum (1) and Crohn’s colitis surveillance (1). Only 1 colonoscopy detected colonic polyp, tubulovillous adenoma with high grade dysplasia; however this was not followed up as per guidelines. The mean time between colonoscopy and definitive colon cancer diagnosis was 30 months (range 19–36 months). All patients with PCCRC died with a mean survival time of 376 days from the time of cancer diagnosis. Two of these four patients had metastatic disease at the time of diagnosis with one of the patient had extensive metastasis and died within 16 days of diagnosis. <h3>Conclusion</h3> In our study, rate of PCCRC was 2.5%, although this rate is low compared to most studies²but it has serious implications and may lead to diagnosis at an advanced stage. It is prudent to audit the miss rate of colonoscopy to improve colonoscopy quality and the rate of PCCRC occurrence should be incorporated as a quality indicator of a colonoscopy service <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Bressler B, Paszat LF, Chen Z <i>et al</i>. Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. Gastroenterology 2007;132:96–102 Morris EJ, Rutter MD, Finan PJ <i>et al</i>. Post-colonoscopy colorectal cancer (PCCRC) rates vary considerably depending on the method used to calculate them: a retrospective observational population-based study of PCCRC in the English National Health Service. <i>Gut</i>2014. doi: 10.1136/gutjnl-2014-308362

P-292 The Polyp Manager: a new tool to report polyps during colonoscopy in a complete and time-efficient way. A pilot study

Introduction: According to the CO-RADS report of the Quality Assurance Task Group of the American National Colorectal Cancer Roundtable, standardized documentation of colon polyps should include the following 7 items: location, size, morphology, method of removal, completeness of removal and retrieval and if the specimen is provided to the pathologist. In The Netherlands, a description of the mucosal aspect and packaging of each individual polyp in separate containers are considered additional quality items. Since a report is usually made after the colonoscopy it can be difficult to recall all relevant data, especially when there are many polyps to be described. Previous studies have shown that reporting of polyps is often incomplete. The Polyp Manager (PM, Olympus, Zoeterwoude, The Netherlands) is a new touchscreen operated software application that allows the endoscopist to describe polyps real-time during the colonoscopy. PM generates a uniform and complete list of all polyp characteristics that serves as input for both the colonoscopy report and pathology request. In this pilot study PM was not yet connected to a digital reporting system. We compared the PM with conventional reporting (CR) with respect to completeness of polyp documentation and potential time benefit. Methods: In two Dutch hospitals, all patients planned for a regular colonoscopy were included and randomly assigned to either PM or CR. Excluded were national screening colonoscopies, incomplete colonoscopies, patients with no polyps found and with previous colon surgery. Endoscopists measured the total duration of the colonoscopy plus the time needed to report polyps and to create a pathology request. The sum of the latter two in both groups was considered as the potential time benefit once PM would be integrated in the reporting system, provided that using PM would not prolong the colonoscopy. To evaluate completeness of polyp description, the PM-group was compared with an equally sized historical CR-group (CRH) including all patients that had colonoscopy in the month before starting the prospective study. Each of the eight polyp descriptors mentioned above (Dutch criteria) were scored for each polyp. Results: 144 colonoscopies (78 PM, 66 CR) were included prospectively with patients comparable for age, sex and number of polyps (both PM and CV 2.0 ± 2.0, p > 0.05)‡ . Duration of colonoscopy was equal in PM and CR (25:42 ± 16:20 vs 24:00 ± 16:40 minutes, p > 0.05)‡ suggesting that operating PM does not extend the procedure. Time to report polyps and provide a pathology request was 2:23 ± 3:03‡ minutes in the entire group (PM plus CR). Historical CR-reports (78 CRH) were comparable for age, sex and number of polyps with PM (CRH 2.0 ± 2.0, p > 0.05)‡. The incomplete documentation of the following items did significantly improve by using the PM: location (96% vs 82%, p = 0.01), size (95% vs 89%, p = 0.03), aspect (71% vs 36%, p < 0.001) and completeness of removal (61% vs 37%, p < 0.001). (‡= median ± interquartile range) Conclusion: This pilot study suggests that PM improves the completeness of reporting polyp characteristics and may reduce the total procedure time once PM is a fully integrated part of the reporting system. Conformational studies in such a setting are expected shortly.

PWE-355 Ct-colonography use in incomplete colonoscopy and frail patients

<h3>Introduction</h3> CT-colonography (CTC) is a valid alternative to standard colonoscopy in colorectal cancer (CRC). In the context of screening, it is employed only in unsuitable colonoscopy candidates or when colonoscopy is incomplete. With rising numbers in both categories, the use of CTC within our NHS Board has increased over 300% in the last 5 years. <h3>Method</h3> 198 consecutive patients who underwent CTC between January 2013–October 2013 were retrieved from a prospectively collected radiology database. Patient who had a CTC were allocated into one of two groups; (1) patients who were “frail,” with cardiovascular, pulmonary, renal impairment or generalised poor mobility or (2) they had an “incomplete” colonoscopy. We analysed the characteristics of the two groups, colonic findings and follow-up rates. Statistical analysis of categorical variables was performed using Chi-square. Differences in mean were sought with the t-test. A p-value &lt;0.05 was considered significant. <h3>Results</h3> 116 patients were allocated in the “incomplete” group (M/F: 49/67) and 82 in the “frail” group (M/F: 42/40) (p = 0.27). Mean age was 71 (SD±10) for the “incomplete” group and 72 (SD±12) in the “frail” group (p = 0.51). Isolated and multiple polyps were found in 22 “incomplete” colonoscopy and 14 “frail” patients (11.2% and 7.1%)(p = 0.91): The polyp size was recorded as: 13 cases (6.6%) were &lt;5mm (diminutive), 20 cases (10.1%) between 6–9mm (small) and 13 cases were ≥ 10mm (large). There was no association between polyp size and patient group (p = 0.6, 1.0 and 0.7) and no age difference for polyp sizes (p = 0.89, 0.45, 0.36). 20 colonoscopies (10.1% of total) were subsequently performed after the CTC in the “failed” group and 17 (8.6%) in the “frail” group, with no difference between the groups (p = 0.66). <h3>Conclusion</h3> There are no significant difference in lesion and polyp yield between those who “failed” to complete optical colonoscopy and those deemed too “frail” to undergo the endoscopic investigation. The increasing trend for referral for CTC reflects the wider requirement to investigate the elderly and frail population by an established and refined technique. We have increased the use of CTC in our Board, due to a continued decease in use of barium enemas, the need to rule out cancer in patients who are too frail to undergo surgery and an increased confidence in the technique by referrers, after evidence of the equivalence of CTC with colonoscopy. Whilst optical colonoscopy numbers are still climbing significantly as a result of bowel screening, a similar trend for CTC-based screening might be observed in the next years. In our groups of patients, there was no difference in the colonoscopy rate after CTC. <h3>Disclosure of interest</h3> None Declared.

OC-050 Panenteric capsule endoscopy: whole gut visualisation without intubation

Introduction Capsule endoscopy (CE) is a well-tolerated, first line small bowel (SB) investigative modality. A specifically adapted version is available to image the colon, thus providing an option for non-invasive, single visit imaging of the entire gastrointestinal tract. This study evaluates a novel panenteric protocol utilised to investigate patients with symptoms which could originate from the SB, large bowel or both sites. Method Retrospective, single centre, involving consecutive patients attending for panenteric CE between July 2008 and December 2014. PillCam SB (Given Imaging, Israel) or MiroCam (Intromedic, Korea) and PillCam Colon 2 (Given Imaging) were used. All patients with known inflammatory bowel disease (IBD) successfully passed a PillCam Patency device prior. Patient demographics, procedural data, final diagnosis and outcomes were collected. Results 108 procedures were performed, mean age 41.5 years (range 16–95), 72 female, median follow up 27 months (range 2–79). 41 patients had known IBD (37 Crohn’s, 4 ulcerative colitis (UC)) and were undergoing disease re-assessment after 12 months of anti-TNF therapy (12), or due to relapse in symptoms (29). The remaining 67 patients had suspected IBD with predominant symptoms of diarrhoea (33), abdominal pain (15), iron deficiency anaemia (8), weight loss (6) and gastrointestinal bleeding (5). 51 patients refused colonoscopy, 37 chose CE over colonoscopy, 17 had an incomplete colonoscopy and 3 were unfit for colonoscopy. Panenteric capsule endoscopy completion rate (CECR) was 60.1% (65/108), SB CECR 86.1% (93/108) and colon CECR 71.3% (77/108). Colon CE bowel preparation was graded as good or excellent in 61.8%. 2 patients were excluded due to prolonged gastric retention of the colon capsule, 1 subsequently diagnosed with narcotic bowel syndrome. No complications were encountered. In the IBD group, 25 patients (61.0%) had evidence of active disease, leading to medication alterations in 21, surgery in 1 and conservative management in 3. Of the 16 patients in whom mucosal healing had been achieved, medication regimens were downgraded in 10 patients. In the suspected IBD group, this was identified in 13.4% (7 Crohns, 2 UC). Clinically relevant alternative findings included colon polyps (16), diverticular disease (9 colonic, 1 SB), angioectasia (6 SB, 1 colonic), and a small bowel carcinoid (1). The remaining 24 patients were diagnosed with functional bowel disorders and discharged. Of all the 34 patients with IBD identified, 22 had ileitis alone, 5 had ileocolonic disease and 7 had colonic disease alone. Conclusion Panenteric capsule endoscopy is feasible and can be performed safely in patients known to have IBD. It can be used to guide management without resorting to conventional endoscopy and identifies pathology in all areas of the GI tract. Disclosure of interest None Declared.

PWE-288 Is computed tomographic colonography more useful than colonoscopy in 2 week wait patients?

<h3>Introduction</h3> CT colonography (CTC) is now widely available as the radiological imaging test for the colon, replacing barium enema. It is recommended that regular audit processes should be in place to audit the quality of CTC service provision against internationally agreed standards. This is especially important when considering the national bowel cancer screening programme with reference to FOB positive patients unfit for a colonoscopy and/or with incomplete colonoscopic examinations. The other advantage of CTC is the ability to detect extra colonic lesions at the same time as evaluating the colon. We aimed to audit our CTC practice with reference to endoscopic findings and to determine the value of any extra colonic lesions found on CTC, especially in our 2 week wait and bowel cancer screening patients. <h3>Method</h3> All patients who had a CTC performed over a period of 13 months were evaluated against the electronic record of endoscopic procedures. Of 264 patients who had a CTC, 78 also had a contemporaneous flexible sigmoidoscopy or colonoscopy performed. <h3>Results</h3> The main indications for an investigation of the colon were altered bowel habit (45%), anaemia (11%), abdominal pain (6.8%) and cancer/ polyp follow up (7.9%). The most common indication for CTC in the 264 patients reviewed was exclusion of synchronous colonic tumours in patients who had an incomplete colonoscopy (112 patients); 140 patients had been deemed unfit to have a colonoscopy and 12 patients declined one. 11 BCSP underwent CTC, 5 due to an incomplete scope and 6 were deemed unfit for colonoscopy. 68% of the CTC and endoscopic findings were in agreement. 19/78 endoscopic abnormalities were not picked up on CTC (24%). No cancers were missed on CTC. The most common positive findings were diverticular disease (24%) and polyps (14%). We found that 37.5% of patients had extra colonic abnormalities. There were no recorded complications. <h3>Conclusion</h3> It is essential to audit the quality of CTC service provision against standards set by the International CT Colonography Standards Collaboration and the NHS Bowel Cancer Screening Programme. In our institution, the correlation of CTC and endoscopic findings was reassuring. In addition, a large number of extra colonic abnormalities were detected using CTC, some of which were significant – this is especially important in the 2 week wait patients. Colonoscopy, however, still remains the gold standard investigation for the detection of colon related pathology. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Johnson CD, Chen MH, Toledano AY <i>et al</i>. Accuracy of CT colonography for detection of large adenomas and cancer. NEJM. 2008;359:1207–17 Burling D. Effect of Directed training on reader performance for CT colonography: multicenter study. Radiology. 2007;242:152–61 NICE guidelines CT Colonography. http://guidance.nice.org.uk/IPG129;2009

PWE-375 A significant proportion of patients still require colonoscopy after ct colonography within the nhs bowel cancer screening programme

<h3>Introduction</h3> Patients within the Bowel Cancer Screening Programme (BCSP) who are unsuitable for or decline colonoscopy are instead usually offered CT colonography (CTC). Whereas patients with a normal CTC are either discharged or returned back to biennial screening, colonoscopy is usually indicated if CTC demonstrates a suspected colorectal cancer (CRC) or large polyp/s (&gt;10mm). Patients who have intermediate-sized polyps (6–9mm) or multiple diminutive polyps (&lt;5mm) either proceed to colonoscopy (flexible sigmoidoscopy for left-sided polyps) or interval CTC. We investigated the number of patients who required colonoscopy after CTC within the BSCP. We hypothesised that a significant proportion of patients still require colonoscopy, thus questioning the utility of CTC in patients in the BCSP. <h3>Method</h3> Patients who had a CTC within the BCSP at UCLH between September 2007–14 were identified retrospectively. All CTC examinations were performed using faecal tagging with laxatives wherever possible with or without intravenous contrast. <h3>Results</h3> of CTC were classified as normal, low-risk (1–2 polyps both &lt;10mm), intermediate-risk (3–4 polyps &lt;10mm or at least one ≥10mm), high-risk (≥5 small polyps or ≥3 intermediate-sized polyps with at least one ≥10mm) and suspected CRC. <h3>Results</h3> In total, 319 CTCs were performed in 292 patients. 39 patients (13%) had CTC after incomplete colonoscopy and were excluded. 253 patients (136 male, median age 70 years) underwent CTC as their primary investigation and their outcomes analysed. 98 patients (39%) proceeded to having a colonoscopy after their CTC. There was no significant difference in the reported study quality between those patients requiring a colonoscopy (good 44%, poor 10%) and not (good 52% poor 7%). 57 patients (92%) who had either intermediate/high-risk polyps or suspected CRC on CTC underwent colonoscopy. Of these 57 patients, 15 (26%) had either low-risk polyps (n = 9) or no abnormality at colonoscopy (n = 6). 37 patients (20%) whose CTC was either normal (n = 10) or revealed low-risk polyps (n = 27) were also referred for colonoscopy. No patient had their CTC diagnosis upstaged after colonoscopy. The median time from CTC to colonoscopy was 35 days (5–1852 days). 72 patients (74%) had their colonoscopy within 3 months of their index CTC. <h3>Conclusion</h3> A significant proportion of patients who undergo CTC within the BCSP will still require a colonoscopy. Although the sensitivity of polyp detection between CTC and colonoscopy is comparable, CTC confers a not insignificant radiation burden. It is essential that all patients be counselled with this information upon entrance into the BCSP and in doing so, may reduce the number of CTCs as the primary investigation within the BCSP. <h3>Disclosure of interest</h3> None Declared.

Comparison of polyethylene glycol vs sodium picosulphate vs sodium biphosphonate by efficacy in bowel cleansing and patients' tolerability: a randomised trial.

Adequate bowel preparation is necessary for a complete colonoscopy. Polyethylene glycol-electrolyte oral solution (PEG-EOS), sodium picosulphate (SS) and sodium biphosphonate (SP) are the three most commonly used purgative agents. We aimed to determine their efficacy and tolerability compared to each other in a randomised study. 313 patients were randomly assigned to receive either PEG-EOS, SS or SP. Patients completed a tolerability score pre-colonoscopy. A cleanliness score was used to document adequacy of bowel preparation. A separate group of patients completed taste scores for the three cathartic agents before and after addition of flavour. PEG-EOS was the worst-tolerated regimen but achieved the highest rates of right colonic cleansing and the lowest rate of incomplete colonoscopies. There were no statistical differences in the rates of rectosigmoid and mid-gut cleansing among the three agents. SS was by far the preferred purgative in the taste assessment study. Addition of flavour increased significantly taste scores for PEG-EOS. For adequate bowel cleansing PEG-EOS is the most effective but is the least tolerated and least preferred among patients. Addition of flavour increases significantly patients' acceptance of PEG-EOS.

Simulated colonoscopy training using a low-cost physical model improves responsiveness of surgery interns.

Surgery residents are required to become proficient in colonoscopy before completing training. The aim of this study was to evaluate the responsiveness of surgery interns to simulated colonoscopy training. Interns, defined as postgraduate year 1 residents without exposure to endoscopy, underwent training in a physical model including colonoscopy, synthetic anatomy trays with luminal tattoos and a hybrid simulator. After baseline testing and mentored training, final testing was performed using five predetermined proficiency criteria. Content-valid metrics defined by the extent of departure from clinical reality were evaluated by two blinded assessors. Responsiveness was defined as change in performance over time and assessed comparing baseline testing with nonmentored final testing. Twelve interns (eight male, mean age 26, 80% right-handed) performed 48 colonoscopies each over 1year. Improvement was seen in the overall procedure time (24min 46s vs 20min 54s; P=0.03), passing the splenic flexure (20min 33s vs 10min 45s; P=0.007), passing the hepatic flexure (23min 31s vs 12min 45s; P=0.003), caecal intubation time (23min 38s vs 13min 26s; P=0.008), the duration of loss of view of the lumen (75% vs 8.3%; P=0.023), incomplete colonoscopy (100% vs 33.3%; P=0.042), colonoscope withdrawal <6min (16.7% vs 8.3%; P=0.052). Tattoo identification time (9min 16s vs 12min 25s; P=0.50), colon looped time (2min 12s vs 1min 45s; P=0.50) and rate of colon perforation (8.3% vs 8.3%; P=1) remained unchanged. Interrater reliability was 1.0 for all measures. Simulated colonoscopy training in a low-cost physical model improved the performance of surgery interns with decreased procedure time, increased rates of complete colonoscopy and appropriate scope withdrawal.

Frequency and efficacy of additional investigations following incomplete colonoscopies: A population-based analysis

BackgroundLimited data are available on the follow-up of patients with incomplete colonoscopy following positive faecal occult blood testing. Our study aimed to determine the proportion of and reasons for incomplete colonoscopies, the proportion of patients who completed colonic evaluations, the methods used and the subsequent findings. MethodsA total of 9483 colonoscopies performed after positive testing in a colorectal cancer screening programme setting were included. The study was prospective for index colonoscopy findings and partly retrospective for follow-up. ResultsOverall 297 colonoscopies were incomplete (3.2%). A secondary colonic evaluation was deemed necessary in 245 patients, of which 126 underwent an additional examination (51.4%). Radiology was the primary method used for complete colonic evaluation, whereas a repeat colonoscopy was performed in only 6.4%; the examination was normal in 119 patients (94.4%). A mucosal high-grade neoplasia was removed in 1, and multiple (≥3) adenomas were removed in 2 patients. ConclusionsThe present screening programme with biennial faecal occult blood testing revealed a high colonoscopy completion rate, a low rate of secondary colonic evaluation, infrequent use of colonoscopy for completion, and a low detection rate of significant neoplasia.

Su1695 Feasibility of Same-Day Colon Capsule Endoscopy for Incomplete Colonoscopy

Su1695 Feasibility of Same-Day Colon Capsule Endoscopy for Incomplete Colonoscopy

Quality of bowel cleansing in hospitalized patients undergoing colonoscopy: A multicentre prospective regional study

BackgroundQuality of bowel cleansing in hospitalized patients undergoing colonoscopy is often unsatisfactory. No study has investigated the inpatient or outpatient setting as cause of inadequate cleansing. AimsTo assess degree of bowel cleansing in inpatients and outpatients and to identify possible predictors of poor bowel preparation in the two populations. MethodsProspective multicentre study on consecutive colonoscopies in 25 regional endoscopy units. Univariate and multivariate analysis with odds ratio estimation were performed. ResultsData from 3276 colonoscopies were analyzed (2178 outpatients, 1098 inpatients). Incomplete colonoscopy due to inadequate cleansing was recorded in 369 patients (11.2%). There was no significant difference in bowel cleansing rates between in- and outpatients in both colonic segments. In the overall population, independent predictors of inadequate cleansing both at the level of right and left colon were: male gender (odds ratio, 1.20 [1.02–1.43] and 1.27 [1.05–1.53]), diabetes mellitus (odds ratio, 2.35 [1.68–3.29] and 2.12 [1.47–3.05]), chronic constipation (odds ratio, 1.60 [1.30–1.97] and 1.55 [1.23–1.94]), incomplete purge intake (odds ratio, 2.36 [1.90–2.94] and 2.11 [1.68–2.65]) and a runway time >12h (odds ratio, 3.36 [2.40–4.72] and 2.53 [1.74–3.67]). ConclusionsWe found no difference in the rate of inadequate bowel preparation between hospitalized patients and outpatients.

Fecal tag CT colonography with a limited 2-day bowel preparation following incomplete colonoscopy.

This study aimed to assess the feasibility and patient tolerance of a 2-day limited fecal tag bowel preparation in computed tomographic colonography (CTC) performed for incomplete conventional colonoscopy (CC) patients. Seventy-five patients who underwent a CTC examination fbecause of incomplete CC were included. A low-residue diet was given for 2 days before CTC. Fecal tagging (FT) was done using a barium sulfate suspension. The quality of the preparation, success of tagging and patient experience with the bowel preparation were investigated. Four hundred fifty bowel segments were evaluated. The number of solid stool balls of 6-9 mm size was 284; the corresponding figure was 93 for solid stool balls ≥ 10 mm. Residual fluid was present in about one-third of the segments. The fecal tagging efficacy for ≥ 6 mm residual stool balls was 92 %. Overall, 16 (21.3 %) patients presented with colonic lesions at CTC. Three out of four colonic mass lesions had not been diagnosed with CC. Most patients reported mild discomfort. FT-CTC performed after a limited 2-day bowel preparation seems to be a technically feasible, safe and acceptable procedure that allows a complete a colonic study in incomplete CC patients.

The 5-year outcome of patients having incomplete colonoscopy.

Incomplete colonoscopy indicated for the detection of neoplasia occurs in 2-23% of patients, but there is little information on the long-term outcome of such patients. All patients who underwent colonoscopy over 5years at the Royal Liverpool University Hospital with a follow-up of up to 5years were identified. The risk of colorectal cancer (CRC) was 2.9% (312/10580) for all patients undergoing colonoscopy. For a failed colonoscopy, the risk was five-fold higher [14.3% (99/693)]. The mean age of the patients was 61years and 58% were female. Following incomplete colonoscopy the risk of finding additional CRC, advanced colonic neoplasia and extracolonic neoplasia on subsequent investigation was 6.2%, 3.2% and 1.9%. The diagnostic yield on subsequent investigation for CRC or colonic polyps was 7% for repeat colonoscopy, 13.4% for computed tomography colonography, 10.3% for standard computed tomography and 1.8% for barium enema. In the 363 patients who were not offered a subsequent investigation, there was no further instance of CRC or CRC-related mortality over a 36-month period. Although the risk of CRC is higher in patients who have had a failed colonoscopy, a protocol approach of subsequent investigation should not replace clinical assessment on whether another test is necessary in the light of the good outcome of patients who were not subsequently investigated.

Predictive factors for colonoscopy complications.

To determine factors predicting complications caused by colonoscopy. Prospective cohort study. A private hospital in Hong Kong. All patients undergoing colonoscopy in the Endoscopy Centre of the Hong Kong Sanatorium & Hospital from 1 June 2011 to 31 May 2012 were included. Immediate complications were those that were recorded by nurses during and up to the day after the examination, while delayed complications were gathered 30 days after the procedure by way of consented telephone interview by trained student nurses. Data were presented as frequency and percentage for categorical variables. Logistic regression was used to fit models for immediate and systemic complications with related factors. A total of 6196 patients (mean age, 53.7 years; standard deviation, 12.7 years; 3143 women) were enrolled and 3657 telephone interviews were completed. The incidence of immediate complications was 15.3 per 1000 procedures (95% confidence interval, 12.3-18.4); 50.5% were colonoscopy-related, including one perforation and other minor presentations. Being female (odds ratioadjusted=1.6), use of monitored anaesthetic care (odds ratioadjusted=1.8), inadequate bowel preparation (odds ratioadjusted=3.5), and incomplete colonoscopy (odds ratioadjusted=4.5) were predictors of risk for all immediate complications (all predictors had P<0.05 by logistic regression). The incidence of delayed complications was 1.6 per 1000 procedures (95% confidence interval, 0.3-3.0), which comprised five post-polypectomy bleeds and one post-polypectomy inflammation. The overall incidence of complications was 17.8 per 1000 procedures (95% confidence interval, 13.5-22.1). The incidences of complications were among the lower ranges across studies worldwide. Inadequate bowel preparation and incomplete colonoscopy were identified as factors that increased the risk for colonoscopy-related complications. Colonoscopy-related complications occurred as often as systemic complications, showing the importance of monitoring.

Accuracy of Capsule Colonoscopy in Detecting Colorectal Polyps in a Screening Population

Capsule colonoscopy is a minimally invasive imaging method. We measured the accuracy of this technology in detecting polyps 6 mm or larger in an average-risk screening population. In a prospective study, asymptomatic subjects (n= 884) underwent capsule colonoscopy followed by conventional colonoscopy (the reference) several weeks later, with an endoscopist blinded to capsule results, at 10 centers in the United States and 6 centers in Israel from June 2011 through April 2012. An unblinded colonoscopy was performed on subjects found to have lesions 6 mm or larger by capsule but not conventional colonoscopy. Among the 884 subjects enrolled, 695 (79%) were included in the analysis of capsule performance for all polyps. There were 77 exclusions (9%) for inadequate cleansing and whole-colon capsule transit time fewer than 40 minutes, 45 exclusions (5%) before capsule ingestion, 15 exclusions (2%) after ingestion and before colonoscopy, and 15 exclusions (2%) for site termination. Capsule colonoscopy identified subjects with 1 or more polyps 6 mm or larger with 81% sensitivity (95% confidence interval [CI], 77%-84%) and 93% specificity (95% CI, 91%-95%), and polyps 10 mm or larger with 80% sensitivity (95% CI, 74%-86%) and 97% specificity (95% CI, 96%-98%). Capsule colonoscopy identified subjects with 1 or more conventional adenomas 6 mm or larger with 88% sensitivity (95% CI, 82%-93) and 82% specificity (95% CI, 80%-83%), and 10 mm or larger with 92% sensitivity (95% CI, 82%-97%) and 95% specificity (95% CI, 94%-95%). Sessile serrated polyps and hyperplastic polyps accounted for 26% and 37%, respectively, of false-negative findings from capsule analyses. In an average-risk screening population, technically adequate capsule colonoscopy identified individuals with 1 or more conventional adenomas 6 mm or larger with 88% sensitivity and 82% specificity. Capsule performance seems adequate for patients who cannot undergo colonoscopy or who had incomplete colonoscopies. Additional studies are needed to improve capsule detection of serrated lesions. Clinicaltrials.gov number: NCT01372878.

Colon PillCam: why not just take a pill?

This review article deals with the clinical value of capsule endoscopy for visualization of the colon. Since its introduction in 2006, the colon capsule endoscopy underwent major technological improvements. The improved performance of colon capsule endoscopy is reviewed based on three multicenter prospective studies. Screening patients for colonic adenomatous polyps is reasonable in patients who are unwilling to undergo conventional colonoscopy. Another prospective study proved that colon capsule endoscopy is effective in incomplete colonoscopy. Colon capsule endoscopy was shown to be superior to virtual colonography in the evaluation of patients with incomplete colonoscopy. Further improvements are expected in colon capsule endoscopy.