The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy

doi:10.1016/j.gie.2013.03.1334

Gastrointestinal Endoscopy

Volume 78, Issue 3, September 2013, Pages 510-516

https://doi.org/10.1016/j.gie.2013.03.1334 Get rights and content

Background

The impact of fair bowel preparation on endoscopists' recommendations and adenoma miss rates in average-risk patients undergoing colonoscopy is unknown.

Objective

To assess the impact of fair bowel preparation on endoscopists' interval colonoscopy recommendations and miss rates in colonoscopies performed within 3 years of the index colonoscopy in average-risk patients undergoing colorectal cancer screening.

Design

Retrospective chart review.

Setting

Tertiary-care center.

Patients

Average-risk patients undergoing index colonoscopy for colorectal cancer screening between 2004 and 2006.

Intervention

Colonoscopy.

Main Outcome Measurements

Endoscopists' interval recommendations, adenoma miss rates.

Results

A total of 16,251 colonoscopy records were reviewed over a 2-year period. Of these cases, 1943 colonoscopies were performed for the sole indication of average risk or screening. Of these, fair bowel preparation was reported in 619 patients (31.9%). A repeat colonoscopy within 5 years was recommended in 70.4% of patients. The follow-up colonoscopy compliance rate within 3 years was 55.9%. Adenoma detection rates at index and follow-up colonoscopy were 20.5% and 28.2%, respectively. Of the 39 patients with follow-up colonoscopy within 3 years, the overall adenoma miss rate was 28%. Of the patients with an adenoma identified on follow-up colonoscopy, 13.6% had normal colonoscopy results on index examination.

Limitations

Retrospective design.

Conclusion

Fair bowel preparation led to a deviation from national guidelines with early repeat colonoscopy follow-up recommendations in nearly 60% of average-risk patients with normal colonoscopy results. In patients who returned for repeat colonoscopy within 3 years, the overall adenoma miss rate was 28%. Further guidelines on timing for repeat colonoscopy for fair bowel preparation are needed.

Section snippets

Study population

We conducted a retrospective review of an endoscopic database and the electronic medical records of colonoscopies performed at the University of Michigan medical procedure unit and 2 university affiliated outpatient ambulatory surgery centers (Livonia, Michigan and Ann Arbor, Michigan). Electronic medical records of consecutive, average-risk patients aged 50 to 65 years undergoing colonoscopy between July 1, 2004 and June 30, 2006 were reviewed. Only preparation qualities rated as fair by the

Results

Between July 1, 2004 and June 31, 2006, a total of 16,251 colonoscopies were performed at the University of Michigan endoscopy units, of which 1943 colonoscopies were performed for the sole indication of average-risk or screening. Of these, 619 outpatient colonoscopies (31.9%) had a fair bowel preparation quality and were included in our study (Table 1). The mean (± standard deviation [SD]) age of the patients was 55.3 ± 4.3 years, and the mean (± SD) body mass index was 30.1 ± 6.6. The

Discussion

Fair bowel preparation limits colonoscopy visualization, leading to earlier rescheduling of procedures and missed adenomas. Our study is novel because it is the first to solely address the fair descriptor of bowel preparation that is used widely throughout endoscopy practice. Additionally, we specifically targeted the average-risk patient population, which accounts for a large percentage of colonoscopy usage. We found that in patients with fair bowel preparation, gastroenterologists recommend

References (28)

L.C. Seeff et al.
How many endoscopies are performed for colorectal cancer screening? Results from CDC's survey of endoscopic capacity
Gastroenterology
(2004)
D.A. Lieberman et al.
Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer
Gastroenterology
(2012)
F. Froehlich et al.
Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study
Gastrointest Endosc
(2005)
G.C. Harewood et al.
Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia
Gastrointest Endosc
(2003)
D.K. Rex et al.
Impact of bowel preparation on efficiency and cost of colonoscopy
Am J Gastroenterol
(2002)
B. Lebwohl et al.
The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy
Gastrointest Endosc
(2011)
R.V. Chokshi et al.
Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy
Gastrointest Endosc
(2012)
S. Winawer et al.
Colorectal cancer screening and surveillance: clinical guidelines and rationale—Update based on new evidence
Gastroenterology
(2003)
D.G. Hewett et al.
Cap-fitted colonoscopy: a randomized, tandem colonoscopy study of adenoma miss rates
Gastrointest Endosc
(2010)
Centers for Disease Control and Prevention. Vital Signs. July 2011. Available at:...

S.J. Winawer et al.

Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup

N Engl J Med

(1993)

A.G. Zauber et al.

Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths

N Engl J Med

(2012)

D.K. Espey et al.

Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska Natives

Cancer

(2007)

P.A. Mysliwiec et al.

Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy

Ann Intern Med

(2004)

Cited by (72)

Trend of the polyp and adenoma detection rate by sex and age in asymptomatic average-risk and high-risk individuals undergoing screening colonoscopy, 2012–2019
2023, Preventive Medicine Reports
Adenoma detection rate (ADR) is an imperative quality measure for colorectal cancer (CRC) screening. This retrospective observational study aimed to determine the trend of polyp detection rate (PDR) and ADR in asymptomatic average- and high-risk participants in different age groups who underwent screening colonoscopy over the seven years from April 2012 to March 2019 in a tertiary gastroenterology referral center of Iran. Of 1676 participants, 51.8 % were men (mean age 52.3 years). The overall PDR and ADR were 22.7 %, and 13.5 %, respectively. Both Polyps and adenomas were more common in age groups 51–59 and ≥60 years in high-risk patients than in the corresponding groups of average-risk patients (p < 0.05). Also, both PDR and ADR were more frequent in men than in women among all studied age groups, but it was statistically significant only for the youngest age group (16.8 % versus 10.5 %, p < 0.05) for PDR and the oldest age group (19.7 % versus 13 %, p < 0.05) for ADR, respectively. The trend of total ADR was upward over 7 years in both average-risk (6.7 % to 13.3 %) and high-risk (9.8 % to 27 %) groups and across all age groups in both sexes. Multivariable logistic regression revealed that high-risk individuals had an elevated risk of adenoma compared with average-risk patients (OR: 1.6, p = 0.006). Substantial variation in thresholds of polyp and adenoma detection by age, sex, and risk categories emphasizes the need for a risk-adapted approach to CRC screening and prevention programs.
Cystic Fibrosis Colorectal Cancer Screening Consensus Recommendations
2018, Gastroenterology
Citation Excerpt :
However, in cases with extremely high-risk findings, such as very large polyps or multiple polyps, the standard surveillance interval of 3 years may have to be shortened, potentially requiring retesting within 1 year.39 An adequate bowel preparation is necessary for a quality colonoscopy and optimal detection of colon polyps40,41; however, bowel preparation is difficult in CF patients. Groups that reported systematic results of colonoscopies in CF patients used intensive CF-specific bowel preparation regimens.9,18,19
Improved therapy has substantially increased survival of persons with cystic fibrosis (CF). But the risk of colorectal cancer (CRC) in adults with CF is 5−10 times greater compared to the general population, and 25−30 times greater in CF patients after an organ transplantation. To address this risk, the CF Foundation convened a multi-stakeholder task force to develop CRC screening recommendations.
The 18-member task force consisted of experts including pulmonologists, gastroenterologists, a social worker, nurse coordinator, surgeon, epidemiologist, statistician, CF adult, and a parent. The committee comprised 3 workgroups: Cancer Risk, Transplant, and Procedure and Preparation. A guidelines specialist at the CF Foundation conducted an evidence synthesis February−March 2016 based on PubMed literature searches. Task force members conducted additional independent searches. A total of 1159 articles were retrieved. After initial screening, the committee read 198 articles in full and analyzed 123 articles to develop recommendation statements. An independent decision analysis evaluating the benefits of screening relative to harms and resources required was conducted by the Department of Public Health at Erasmus Medical Center, Netherlands using the Microsimulation Screening Analysis model from the Cancer Innervation and Surveillance Modeling Network. The task force included recommendation statements in the final guideline only if they reached an 80% acceptance threshold.
The task force makes 10 CRC screening recommendations that emphasize shared, individualized decision-making and familiarity with CF-specific gastrointestinal challenges. We recommend colonoscopy as the preferred screening method, initiation of screening at age 40 years, 5-year re-screening and 3-year surveillance intervals (unless shorter interval is indicated by individual findings), and a CF-specific intensive bowel preparation. Organ transplant recipients with CF should initiate CRC screening at age 30 years within 2 years of the transplantation because of the additional risk for colon cancer associated with immunosuppression.
These recommendations aim to help CF adults, families, primary care physicians, gastroenterologists, and CF and transplantation centers address the issue of CRC screening. They differ from guidelines developed for the general population with respect to the recommended age of screening initiation, screening method, preparation, and the interval for repeat screening and surveillance.
Impact of WeChat guidance on bowel preparation for colonoscopy: a quasi-experiment study
2023, Scientific Reports
Evaluation of bowel preparation regimens for colonoscopy including a novel low volume regimen (Plenvu): CLEANSE study
2023, BMJ Open Gastroenterology
The impact of smartphone applications on bowel preparation, compliance with appointments, cost-effectiveness, and patients' quality of life for the colonoscopy process: A scoping revie
2023, Saudi Journal of Gastroenterology
Oral sulfate solution versus low-volume polyethylene glycol for bowel preparation: Meta-analysis of randomized controlled trials
2022, Digestive Endoscopy

View all citing articles on Scopus

: DISCLOSURE: P. Schoenfeld received grant support for the study. No other financial relationships relevant to this publication were disclosed.

: See CME section; p. 529.

View full text

Published by Mosby, Inc.

Original articleClinical endoscopyThe impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy

Background

Objective

Design

Setting

Patients

Intervention

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Study population

Results

Discussion

Gastroenterology

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Gastroenterology

Gastrointest Endosc

Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup

N Engl J Med

Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths

N Engl J Med

Annual report to the nation on the status of cancer, 1975-2004, featuring cancer in American Indians and Alaska Natives

Cancer

Are physicians doing too much colonoscopy? A national survey of colorectal surveillance after polypectomy

Ann Intern Med

Original article
Clinical endoscopy
The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy