The onus is on us to complete it," he said. The study "confirms why we need to be thorough, if you will. The investigators analyzed data from a prospective database that captured information on 25, colonoscopies performed by colorectal surgeons at the Cleveland Clinic between and A total of patients were identified as having an incomplete initial colonoscopy.
The leading reasons for an incomplete procedure were presence of stool, pain, and tortuosity, with the reason varying according to the anatomic extent of the procedure.
Of the 32 polyps identified 21 located beyond the extent of the initial incomplete colonoscopy , 9 were advanced adenomas. Patients whose indication for the initial colonoscopy was a personal history of polyps or cancer were more likely than those with other indications — a family history, symptoms, or screening — to have lesions on their completion study.
True or False. In a recent study, gallstones and alcohol consumption were the most common causes of pancreatitis among patients with COVID infection. Skip to main content. Completion study key after incomplete colonoscopy. David Vargas. Next Article: Physicians' adenoma detection rate predicts risk of interval colorectal cancers. In The median insertion time was significantly less for the complete colonoscopy Repeat colonoscopy has a high success rate and identified a significant number of new adenomas.
Use of all available endoscopes should be considered prior to procedure termination in patients with a tortuous colon. Repeat colonoscopy can often be accomplished using a standard endoscope and is not attributed to increased endoscope insertion time.
Peer Review reports. Colonoscopy is a well-established procedure utilized for the evaluation of lower gastrointestinal tract diseases including the screening for colorectal polyps and cancer CRC [ 1 ].
Optical colonoscopy is performed via inserting a flexible tube retrograde through the rectum and the goal of a complete procedure is the advancement of the endoscope to the cecum. Professional societies and The U. Radiology has traditionally been used to facilitate complete colon evaluation in these patients, though barium studies are suboptimal in evaluating the colon for pathology [ 5 ]. CT colonography, while promising, has limitations in that it requires radiation exposure, may not detect flat polyps adequately, and is not widely available [ 6 ].
There are a variety of factors that contribute to an incomplete colonoscopy including prior abdominal surgeries resulting in adhesions, severe diverticular disease, inadequate bowel cleansing, and patient discomfort [ 4 , 7 ]. Inadequate bowel cleansing can be corrected with an alteration in bowel preparation and patient discomfort can be addressed by modifying the anesthesia used.
Difficult colon anatomy often requires the use of alternate techniques or screening modalities [ 8 — 17 ] when cecal intubation is unsuccessful due to a redundant excessive looping or tortuous excessive angulation colon. Endoscopic modalities include the use of smaller caliber colonoscopes, overtubes, fluoroscopy, or single and double balloon colonoscopy.
There have been numerous studies reporting successful colonoscopy with specialty endoscopes in patients with a previous incomplete colonoscopy [ 11 — 16 , 18 ]. However, modalities used in clinical practice vary based upon the individual patient and are often limited based on available institutional expertise. We have recently shown that an incomplete colonoscopy referral program had only a modest impact on provider recommendations at our institution [ 19 ].
There is limited data on the outcomes of attempts at repeating colonoscopy with standard endoscopes after an incomplete procedure. Prior studies have shown that a variety of endoscopes and techniques can be used to achieve cecal intubation after prior incomplete colonoscopy but there has been little comparative data to the initial incomplete study [ 10 , 20 , 21 ].
The objectives of this study were to describe the technique, success rate and outcomes of consecutive patients referred for repeat colonoscopy and compare endoscopes used and procedure time to the previous incomplete colonoscopy. We conducted a retrospective chart review using administrative and manually extracted data at the Feinberg School of Medicine at Northwestern University.
Patients referred for repeat colonoscopy over a month time period April to May were eligible for the study. Patients with an incomplete colonoscopy due solely to inadequate preparation or sedation were excluded.
All incomplete procedures were performed using conscious sedation. All repeat procedures were performed by a single endoscopist RK using monitored anesthesia care. The choice of initial endoscope on repeat colonoscopy was not standardized. However, in general if the cause of the incomplete procedure was tortuousity acute angulation of the colon , a pediatric colonoscope or upper endoscope was used. If the cause of the incomplete procedure was colon redundancy elongation causing excessive looping , an adult colonoscope was used.
The cause of the incomplete procedure as either due to colon tortuousity or redundancy was determined by review of the procedure report. Data extracted from the chart review included patient demographics age, gender , BMI, history of prior surgeries, history of barium enemas, and prior incomplete colonoscopy characteristics indication, number of prior colonoscopies, extent of prior colonoscopy, procedure duration, documented reasons for incomplete colonoscopy, and endoscopes used during the procedure.
The same procedural measures were extracted for the repeat colonoscopy procedure. Adult and pediatric colonoscopes had variable stiffness capability allowing for adjustment of insertion tube flexibility and all endoscope had an auxiliary water channel.
Pathology records were reviewed to determine the number of adenomas and cancers that were detected or removed at each procedure. The primary outcome was defined as the proportion of patients with a successful repeat complete colonoscopy after prior incomplete colonoscopy. Secondary outcomes included the number of times endoscopes were changed for each procedure incomplete vs.
Adenoma detection rates for incomplete and complete procedures are also reported. Descriptive statistics were calculated for each measure and are reported as medians continuous variables and proportions categorical variables of the total patient sample. The primary outcome is reported as a proportion of the total patient sample.
Secondary outcomes are reported as proportions for categorical variables and medians for continuous variables. Differences in procedure times between the complete and incomplete procedures were determined using the Wilcoxon signed rank test. Median endoscope insertion times of documented redundant and tortuous colons were compared using the Wilcoxon rank-sum test.
Over the study period, 32, colonoscopies were performed at our institution. A total of patients with prior incomplete colonoscopy were referred to a single endoscopist for repeat colonoscopy attempt during the defined study time period. The median BMI was Incomplete colonoscopy characteristics are also shown in Table 1. The majority of procedures were for a screening or surveillance indication. A total of 12 patients had more than one incomplete procedure with a single patient having 4 incomplete procedures prior to referral.
The extent of the most recent incomplete procedure was to the left colon in The majority of patients There were no procedural complications among the study sample. A total of 59 procedures In patients with an incomplete colonoscopy attributed to a tortuous colon, successful colonoscopy was completed in the majority of patients using a standard smaller caliber endoscope pediatric colonoscope or gastroscope not used in the initial procedure Figure 1.
In the 17 patients requiring an enteroscope or who had an otherwise unsuccessful repeat procedure, the reason for the prior incomplete procedure was more often due to redundancy Patients with a documented tortuous colon required an endoscope that was not used for the previous incomplete colonoscopy Endoscopes used to complete colonoscopy compared to endoscopes used for prior incomplete colonoscopy.
In the subgroup of patients with repeat colonoscopy within 1 year of incomplete exam, the adenoma detection rate was Among these patients, Of note, a single cecal adenocarcinoma was detected in a patient with an unremarkable barium study 2 days prior to the exam. For patients in whom complete time data was available for both procedures the median insertion time was significant less for the complete colonoscopy The total procedure times for incomplete and complete procedures were A sizable number of adenomas were found on repeat procedure.
Furthermore, a majority of patients required use of an endoscope that was not used in the prior incomplete procedure. In particular, patients with a tortuous colon more often had a repeat complete procedure with a standard endoscope that was not used in the prior incomplete procedure. Our data also suggest that incomplete procedures due to colonic redundancy may more often require referral for use of balloon enteroscopes to complete the procedure.
While incomplete studies due to inadequate bowel preparation or sedation can be rectified with modified sedation or bowel purgative, incomplete studies due to colon redundancy or tortuosity may be more challenging to manage. We and others have shown that repeat colonoscopy is successful in a large majority of patients referred for prior incomplete procedures utilizing specialty endoscopes [ 11 — 15 , 18 ].
A limitation of these studies is that they often rely exclusively on studying specialty endoscopes whereas in daily practice there are a full range of other standard endoscopes which may facilitate cecal intubation with careful attention to technique. Our results suggest that many incomplete colonoscopies can be completed with standard endoscopes, especially in patients with tortuous colons. Two large retrospective studies, both from the same endoscopist, have been published with similar findings [ 10 , 20 ].
In these studies, a wide variety of endoscopes and techniques were used to facilitate cecal intubation after prior incomplete colonoscopy. However, our study is different in that complete colonoscopy was achieved mostly using standard endoscopes, which are more readily available than specialty scopes.
Also, prior studies provided minimal data on the initial incomplete colonoscopy and, thus, an understanding of what differences facilitated cecal intubation was not possible. Our data should encourage endoscopists that many difficult colonoscopies can likely be completed with standard endoscopes before subjecting patients to a referral for a second procedure which carries added cost and additional risk.
We have demonstrated that repeat colonoscopy does not require significantly greater endoscope insertion time. However, the majority of patients did require use of an endoscope not used during prior incomplete colonoscopy suggesting that failure to switch to another available endoscope may be an important contributing factor to incomplete colonoscopy. In addition, procedures with a tortuous colon may be completed more often by switching to a different smaller caliber standard endoscope.
There are several limitations to our study that merit attention. Our study represents the experience of a referral based program at a high volume tertiary academic enter and further work is needed to determine if the results are generalizable to other practice settings and individual endoscopists.
This study was not a randomized controlled study; as this was a retrospective study using clinical data, complete information was not available on certain procedures including the use of ancillary techniques water immersion, patient positioning, or external pressure. Furthermore, the choice of endoscope used was determined by endoscopist preference and not by a predetermined protocol. This study also represents the efforts of a single endoscopist which may not be generalizable to all endoscopists.
Finally, all procedures in this study were performed with monitored anesthesia care.
0コメント