Outpatient Flexible Sigmoidoscopy Research Articles

The value of pre-operative outpatient flexible sigmoidoscopy in patients with deep infiltrating endometriosis.

Deep infiltrating endometriosis (DE) is a particularly severe disease which affects 10-20% of women with endometriosis. 90% of DE is rectovaginal and when suspected, some clinicians have suggested the routine use of flexible sigmoidoscopy to identify intraluminal disease. We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE, both in terms of diagnosis and planning management. We aimed to assess the value of sigmoidoscopy prior to surgery for rectovaginal DE. A retrospective case series study was performed from a consecutive cohort of patients with DE referred for outpatient flexible sigmoidoscopy between January 2010 and January 2020. All patients were under the care of a specialist endometriosis multidisciplinary team. The primary outcome measure was the incidence of luminal disease. 102 consecutive cases were analysed with no cases confirming intraluminal disease. Non-specific evidence of endometriosis such as tight angulation of the bowel was found in 36.3%. Following sigmoidoscopy 100 patients proceeded to surgery and the risk of bowel resection during surgery was 4%. Due to the low incidence of luminal endometriosis, performing sigmoidoscopy routinely is of limited benefit. We recommend the selective use of sigmoidoscopy where serious pathology such as colorectal neoplasia is considered or to determine the location of endometriosis lesions which aids subsequent resectional surgery planning. This large case series details a very low incidence of intraluminal disease and makes recommendations for the specific scenarios where flexible sigmoidoscopy should be used.

Prospective Evaluation of Outpatient Flexible Sigmoidoscopy in Patients With Deep Infiltrating Endometriosis.

To study patients' acceptability of an outpatient flexible sigmoidoscopy (FS) protocol and to assess the diagnostic value of endoscopic assessment in patients with deep endometriosis (DE). All patients with DE and suspected bowel involvement diagnosed were reviewed in the colorectal outpatient clinic before elective surgery following multidisciplinary team meeting discussion. Patients were consented for having the FS performed at the same time of the clinical consultation. Primary outcome was diagnostic value of the FS. Sixty patients were included. Fifty-eight (96.7%) patients consented for the outpatient FS, demonstrating a high rate of patients' acceptability. The sigmoidoscopy demonstrated no abnormalities in 48 patients (82.7%), diverticulosis in 5 patients (8.6%), polyps in 2 patients (3.4%) and mucosal endometriosis in 1 patient only (1.7%). Outpatient FS during the preoperative consultation with the colorectal surgeon is feasible in patients with DE affecting the bowel with a high rate of patients' acceptability but limited additional diagnostic value.

PTH-294 Missed diagnosis of bowel cancer in surgical outpatients – to refer or not to refer for whole colonic imaging? a 22-year study of 29005 patients: Abstract PTH-294 Table 1

Introduction Little is known about the rates or reasons for missing diagnosis of bowel cancer in outpatients. This study determined the number of missed cancers by flexible sigmoidoscopy (FS), barium enema (BE), colonoscopy, CT colonography (CT) and in patients not having whole colonic imaging (WCI) after a normal FS. Method Retrospective cohort analysis using clinical data collected prospectively for 22 years (1986–2007) in a colorectal outpatient clinic in Portsmouth. 29005 patients were analysed. Missed cancers were detected by referral back to clinic, local audit for NBOCAP and comparison with the regional Cancer Registry. Results 1626 patients had bowel cancer. 66.1% (19174/29005) of all patients in the study did not have WCI. 13.8% (3993) had colonoscopy, 17.9% (5206) had BE and 883 (latter 8 years) had CT. 3.9% (63/1626) of cancers were missed; 21 distal (rectum and sigmoid), 41 proximal and 1 unknown site. 1.6% (21/1333) or 1:63 of distal cancers were missed by FS. Twenty-one of all missed cancers were subsequently diagnosed within 1 year (50–358 days) of the outpatient clinic, twenty within 1–2 years and twenty-two between 2–3 years. Twenty-two proximal cancers were subsequently diagnosed with cancer after a normal FS and no WCI, which means the incidence of cancer in this group of patients was 0.1% (22/18252). View this table: Abstract PTH-294 Table 1 Conclusion A policy of outpatient FS with selective WCI resulted in a low rate of missed cancers. The replacement of BE by Colonoscopy and CT should greatly reduce the numbers of missed cancers in those having WCI. Strict diagnostic strategies are required to avoid excessive delay in diagnosis of the few with cancer without over investigation of patients with transient symptoms from benign disease. Disclosure of interest None Declared.

PWE-033 The Incidence and Cost of Unexpected Hospital Attendance Following Elective Outpatient Flexible Sigmoidoscopy

IntroductionOutpatient flexible sigmoidoscopy is an increasingly utilised investigation shown to be effective in the detection and prevention of bowel cancer. The procedure is thought to entail a low risk of...

A prospective randomized single blind trial of Fleet phosphate enema versus glycerin suppositories as preparation for flexible sigmoidoscopy

This study compared the efficacy and patient acceptability of two methods of bowel preparation for flexible sigmoidoscopy. Patients attending for outpatient flexible sigmoidoscopy were prospectively randomized to receive one Fleet ready-to-use enema or 2 x 4 g glycerin suppositories, 2 h preprocedure. Patient and endoscopist questionnaires were used to compare the outcomes. From November 2000 to August 2001, 203 (male = 95; female = 108) patients were randomized. Patient data available for 163 patients (enema = 93; suppository = 70) revealed: ease of use (enema = 52; suppository = 25; P < 0.02, Fisher's exact); assistance required (enema = 19; suppository = 3; P < 0.005, Fisher's exact); grade of effectiveness (enema = 83; suppository = 44; P < 0.0001, Fisher's exact), and whether patients wished to try another preparation in future (enema = 16; suppository = 24; P = 0.016, Fisher's exact). Endoscopist data available for 151 patients (enema = 76; suppository = 75) revealed: average depth of insertion (enema = 53.6 +/- 11.6 cm; suppository 46.3 +/- 13.7 cm; P < 0.001, Student's t test); acceptable (excellent + good) quality of preparation [enema = 60 (78.9%); suppository = 34 (45.3%); P < 0.0001, Fisher's exact]. Bowel preparation for flexible sigmoidoscopy using a single Fleet enema is acceptable to patients and more effective than glycerin suppositories.

Diversion colitis presenting with massive rectal distension and bilateral ureteric obstruction

Diversion of the faecal stream with the distal colon left in situ can occur following both elective and emergency surgery for colonic disease. Whether the excluded colon is subsequently removed or continuity restored is variable. In patients undergoing subtotal colectomy for colitis, the majority will undergo a further procedure, either a restorative ileroectal anastomosis or completion proctectomy, with or without an ileoanal pouch. Amongst those patients who undergo Hartmann’s procedure, the rates of reversal varies widely, but a significant proportion will not undergo further surgery and remain with a permanent colostomy and rectal stump. In patients undergoing elective anterior resection of the rectum for adenocarcinoma, a significant proportion of patients will have a permanent stoma with distal colon in situ. Both acute and chronic complications may result from the redundant distal colon. In the acute postoperative period, such complications include pelvic sepsis resulting from rectal stump dehiscence. Chronic complications, which are more common in those in whom the original surgery was for inflammatory bowel disease, include on-going disease activity in the rectum, and in the long term, dysplastic changes and carcinoma. Where the original pathology was not inflammatory, those with a rectal stump may develop non-specific inflammatory changes in the rectum, so-called diversion colitis, as a consequence of diversion of the faecal stream. Diversion colitis may present with abdominal pain, bleeding and discharge. Here, we describe the late presentation of inflammatory change within a rectal stump resulting in massive distension of the rectum and significant haemorrhage. The rectal distension caused bladder outflow obstruction, bilateral hydronephrosis and acute renal failure requiring bilateral nephrostomies. At the age of 29, a male patient underwent investigation for life-long constipation. A barium enema showed gross colonic distension. It was decided to proceed with a subtotal colectomy, and in light of the technical difficulties anticipated as a consequence of the gross colonic distension, this was planned as a two-stage procedure. He initially underwent a difficult subtotal colectomy with an end ileostomy, though when he was readmitted for planned reversal of his stoma and an ileorectal anastomosis, the rectum was, during laparotomy, found to be distended. It was, therefore, not felt safe to perform an anastomosis; the rectum was left in place, and the ileostomy was refashioned. The patient was content not to pursue any further surgical intervention. Fifteen years later, the patient presented as an emergency complaining of rectal bleeding and anal pain. On this occasion, his symptoms settled spontaneously, and outpatient flexible sigmoidoscopy of the rectum was planned. He was readmitted in the interim complaining of abdominal distension, difficulty passing urine and further rectal bleeding. On examination, he was normotensive and pyrexial with a temperature of 41°C. His abdomen was distended, with a palpable tender bladder. He was unable to tolerate rectal examination. His blood tests revealed acute renal impairment, with a creatinine of 220, a urea of 16.7, potassium of 5.6, WCC 12.9, and CRP 166. He was catheterised and drained 1,800 ml of urine; urinalysis was positive for blood and nitrates. He was started on broad spectrum intravenous antibiotics. An ultrasound of the renal tract demonstrated bilateral hydronephrosis. He went on to have bilateral nephrostomies, with a consequent improvement in his renal function. A CT of Int J Colorectal Dis (2008) 23:1143–1144 DOI 10.1007/s00384-008-0491-3

A prospective randomized single-blind comparison of three methods of bowel preparation for outpatient flexible sigmoidoscopy

Preparation for outpatient flexible sigmoidoscopy using a self-administered phosphate enema is the standard practice in our unit, but it provides acceptable bowel preparation in only 80% of patients. This study compared two methods of bowel preparation with the current standard in an attempt to improve efficacy and acceptability. From January to September 2003, patients scheduled for out-patient flexible sigmoidoscopy were prospectively randomized to 3 groups: group 1: one Fleet enema 2 h pre-procedure; group 2: two Fleet enemas, one on the evening prior to sigmoidoscopy and one 2 h pre-procedure; group 3: lactulose 30 ml orally 48 and 24 h prior to sigmoidoscopy, plus a single Fleet enema 2 h pre-procedure. A patient questionnaire was used to assess side effects and tolerance. The endoscopists questionnaire assessed the indication for the procedure, quality of preparation, depth of insertion, and pathological findings identified. Power calculations were based on the 80% acceptable preparation rate obtained using a single enema. For this study, 305 patients were randomized to the three groups. Patient data were available for 261 patients (group 1 = 105; group 2 = 81; group 3 = 75), and endoscopist data were available for 251 patients (group 1 = 97; group 2 = 79; group 3 = 75). No difference was noted between the groups with regard to age, gender, procedure indication, grade of endoscopist, or patient acceptability variables (ease of use: p = 0.09; assistance required: p = 0.11; cramps experienced: p = 0.84; alternative method: p = 0.25). There was no significant difference between the groups in terms of depth of insertion (p = 0.42-chi-squared test) or abnormalities noted (p = 0.34-chi-squared test). Nor was there any difference in the quality of preparation of patients in group 1 versus group 2 (p = 0.39-Fishers exact test) or group 1 versus group 3 (p = 0.13-Fishers exact). However, lactulose + Fleet resulted in significantly fewer patients with acceptable preparation compared with those who administered two Fleet enemas (p = 0.02- Fishers exact test). The addition of a Fleet enema or oral lactulose over and above a single Fleet enema gives no significant improvement in the acceptability or efficacy of bowel preparation.

A Prospective Randomised Single Blind Comparison of Three Methods of Bowel Preparation for Out-patient Flexible Sigmoidoscopy

Introduction: Flexible Sigmoidoscopy is becoming the minimum standard for the investigation of colorectal symptoms. Preparation for out-patient sigmoidoscopy using one self-administered phosphate enema is the standard practice in our unit but provides acceptable bowel preparation in only 80% of patients. This study compared two methods of bowel preparation with the current standard in an attempt to improve efficacy and acceptability. Methods: From January-September 2003, patients attending for out-patient flexible sigmoidoscopy were randomised to three groups: - Group 1: One Fleet enema two hours pre-procedure; Group 2: Two Fleet enemas, one on the evening prior to sigmoidoscopy and one two hours pre-procedure; Group 3: Lactulose 30mls orally 48 and 24 hours prior to sigmoidoscopy plus a single Fleet enema two hours pre-procedure. A patient questionnaire was used to assess side effects and tolerance. Endoscopists, who were blinded to the preparation used, completed questionnaires regarding procedure indication, preparation quality (excellent, good, fair, poor), depth of insertion, and findings. Power calculations were based on the 80% acceptable preparation rate obtained by using a single enema. An 80% probability of detecting a 10% difference in the quality of bowel preparation required a minimum of 70 patients per group. Results: 261 patients (Group 1: n=105; Group 2:n=81; Group 3:n=75) were included; endoscopist data was obtained in 96%. No difference was noted between the groups with regards age, gender, procedure indication, or grade of endoscopist. There was no difference between the groups in any of the patient acceptability variables examined (see table). There was no difference in the quality of preparation of patients in Group 1 vs. Group 2 (p=0.392) or Group 1 vs. Group 3 (p=0.132). However, lactulose + Fleet resulted in significantly fewer patients with acceptable preparation compared with two Fleet enemas (p=0.022). There was no difference between the groups in terms of depth of insertion or abnormalities noted. Conclusions: The addition of a Fleet enema or oral lactulose over and above a single fleet enema gives no significant improvement in the acceptability or efficacy of bowel preparation. 1 Chi-squared; 2Fishers exact

Enema or Picolax as preparation for flexible sigmoidoscopy?

Two preparations for outpatient flexible sigmoidoscopy, Picolax and Klyx enemas, have been compared in a randomized controlled trial. There was no difference in efficacy between the two preparations, but patients preferred Picolax.