The effectiveness of walking exercise on the bowel preparation before colonoscopy: a single blind randomized clinical trial study

BACKGROUND AND AIM

Bowel preparation is a crucial factor affecting the diagnostic accuracy of colonoscopy, and few randomized control trials evaluated enhancement in bowel preparation. In this study, we aimed to evaluate the effectiveness of walking exercises on bowel preparation before a colonoscopy procedure.

METHODS

The present study is a single-blind randomized controlled trial involving 262 patients scheduled for colonoscopy procedures. These patients were randomly assigned to two groups: an intervention group (n = 131) and a control group (n = 131). In the intervention group, participants followed a predetermined plan that included the consumption of specific liquids and foods, bisacodyl pills, polyethylene glycol powder, and a regimen of walking exercises in preparation for their colonoscopy. Conversely, individuals in the control group followed the same regimen but were not instructed to engage in walking exercises. On the day of the colonoscopy, both groups were assessed for their level of physical activity using a foot counter. Additionally, an experienced gastroenterologist evaluated and compared the bowel preparation between the two groups using the Boston Bowel Preparation Scale (BBPS).

RESULTS

The number of footsteps recorded in the two groups exhibited a significant difference (P < 0.001). Although there was no statistically significant difference between the intervention and control groups in terms of mean BBPS scores (6.26 ± 1.9 vs. 6.29 ± 1.9, P = 0.416), individuals who took more than 6900 steps had significantly higher BBPS scores compared to those with fewer than 6900 footsteps (6.62 ± 1.8 vs. 5.92 ± 1.9, P = 0.003).In the univariate analysis, BBPS was found to be significantly associated with individuals under the age of 50 (OR: 2.45, 95% CI: 1.30-4.61, P = 0.006) and smoking status (OR: 0.41, 95% CI: 0.17-0.94, P = 0.043). In the multivariate analysis, the relationship between BBPS and age below 50 and smoking remained significant (OR: 2.50, 95% CI: 1.30-4.70, P = 0.005, and OR: 0.38, 95% CI: 0.16-0.93, P = 0.034, respectively).

CONCLUSION

A higher number of footsteps taken especially more than 6900 can significantly enhance bowel preparation; however, walking exercise as an intervention before colonoscopy is not significantly associated with BBPS. Also, older people and smokers seem to have fewer benefits from walking exercises for bowel preparation.

TRIAL REGISTRATION

ISRCTN32724024 (Registration date:22/08/2018).

The elderly population are more vulnerable for the management of colorectal cancer during the COVID-19 pandemic: a nationwide, population-based study

BACKGROUND/AIMS

The impact of coronavirus disease 2019 (COVID-19) on the management of colorectal cancer (CRC) may worse in elderly population, as almost all COVID-19 deaths occurred in the elderly patients. This study aimed to evaluate the impact of COVID-19 on CRC management in the elderly population.

METHODS

The numbers of patients who underwent colonoscopy, who visited hospitals or operated for CRC in 2020 and 2021 (COVID-19 era) were compared with those in 2019, according to 3 age groups (≥70 years, 50-69 years, and ≤49 years), based on the nationwide, population-based database (2019-2021) in South Korea.

RESULTS

The annual volumes of colonoscopy and hospital visits for CRC in 2020 were more significantly declined in the old age group than in the young age group (both P<0.001). In addition, the annual volume of patients operated for CRC numerically more declined in old age group than in young age group. During the first surge of COVID-19 (March and April 2020), old age patients showed statistically significant declines for the monthly number of colonoscopies (-46.5% vs. -39.3%, P<0.001), hospital visits (-15.4% vs. -7.9%, P<0.001), CRC operations (-33.8% vs. -0.7%, P<0.05), and colonoscopic polypectomies (-41.8% vs. -38.0%, P<0.001) than young age patients, compared with those of same months in 2019.

CONCLUSIONS

Elderly population are more vulnerable for the management of CRC during the COVID-19 pandemic. Therefore, the elderly population are more carefully cared for in the management of CRC during the next pandemic.

The imitation game: a review of the use of artificial intelligence in colonoscopy, and endoscopists' perceptions thereof

The development of deep learning systems in artificial intelligence (AI) has enabled advances in endoscopy, and AI-aided colonoscopy has recently been ushered into clinical practice as a clinical decision-support tool. This has enabled real-time AI-aided detection of polyps with a higher sensitivity than the average endoscopist, and evidence to support its use has been promising thus far. This review article provides a summary of currently published data relating to AI-aided colonoscopy, discusses current clinical applications, and introduces ongoing research directions. We also explore endoscopists' perceptions and attitudes toward the use of this technology, and discuss factors influencing its uptake in clinical practice.

Summary and comparison of recently updated post-polypectomy surveillance guidelines

Recently, updated guidelines for post-polypectomy surveillance have been published by the U.S. Multi-Society Task Force (USMSTF), the British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England (BSG/ACPGBI/PHE), the European Society of Gastrointestinal Endoscopy (ESGE), the Japan Gastroenterological Endoscopy Society (JGES), and the Korean Multi-Society Taskforce Committee. This review summarizes and compares the updated recommendations of these 5 guidelines. There are some differences between the guidelines for the recommended post-polypectomy surveillance intervals. In particular, there are prominent differences between the guidelines for 1-4 tubular adenomas < 10 mm with low-grade dysplasia (nonadvanced adenomas [NAAs]) and tubulovillous or villous adenomas. The USMSTF, JGES, and Korean guidelines recommend colonoscopic surveillance for patients with 1-4 NAAs and those with tubulovillous or villous adenomas, whereas the BSG/ACPGBI/PHE and ESGE guidelines do not recommend endoscopic surveillance for such patients. Surveillance recommendations for patients with serrated polyps (SPs) are limited. Although the USMSTF guidelines provide specific recommendations for patients who have undergone SPs removal, these are weak and based on very lowquality evidence. Future studies should examine this topic to better guide the surveillance recommendations for patients with SPs. For countries that do not have separate guidelines, we hope that this review article will help select the most appropriate guidelines as per each country's healthcare environment.

Surveillance after colorectal polyp resection

Post-polypectomy surveillance has proven to reduce colorectal cancer (CRC) incidence in patients with high-risk polyps, but it implies a major burden on colonoscopy units. Therefore, it should be targeted to individuals with a higher risk. Different societies have published guidelines on surveillance after resection of polyps, with notable discrepancies among them, and many recommendations come from low-quality evidence based on surrogate measures, such as risk of advanced adenoma, and not CRC risk. In this review, we aimed to summarize the evidence supporting post-polypectomy surveillance, compare the recently updated major guidelines, and discuss the existing discrepancies on this topic. Briefly, patients with adenomas ≥10 mm or high-grade dysplasia and patients with serrated polyps ≥10 mm or dysplasia are generally considered to have an increased risk of metachronous CRC and require surveillance, whereas the indication of surveillance is not clearly established in patients without these high-risk features.

Narrow Band Imaging versus White Light for the Detection of Sessile Serrated Colorectal Lesions: A Randomized Clinical Trial

Background

Colorectal cancer (CRC) is a leading cause of cancer. The detection of pre-malignant lesions by colonoscopy is associated with reduced CRC incidence and mortality. Narrow band imaging has shown promising but conflicting results for the detection of serrated lesions.

Methods

We performed a randomized clinical trial to compare the mean detection of serrated lesions and hyperplastic polyps ≥10 mm with NBI or high-definition white light (HD-WL) withdrawal. We also compared all sessile serrated lesions (SSLs), adenoma, and polyp prevalence and rates.

Results

Overall, 782 patients were randomized (WL group 392 patients; NBI group 390 patients). The average number of serrated lesions and hyperplastic polyps ≥10 mm detected per colonoscopy (primary endpoint) was similar between the HD-WL and NBI group (0.118 vs. 0.156, p = 0.44). Likewise, the adenoma detection rate (55.2% vs. 53.2%, p = 0.58) and SSL detection rate (6.8% vs. 7.5%, p = 0.502) were not different between the two study groups. Withdrawal time was higher in the NBI group (10.88 vs. 9.47 min, p = 0.004), with a statistically nonsignificant higher total procedure time (20.97 vs. 19.30 min, p = 0.052).

Conclusions

The routine utilization of narrow band imaging does not improve the detection of serrated class lesions or any pre-malignant lesion and increases the withdrawal time.

Role of colonoscopy in colorectal cancer screening: Available evidence

Colonoscopy is the cornerstone examination for colorectal cancer (CRC) screening and it is recommended as the first examination in the context of individuals with high risk of CRC development. Thereby, this examination is of choice in the setting of patients with hereditary CRC syndromes or in patients with long-standing inflammatory bowel disease with colon involvement. However, its role is less clear in the average risk-risk population and in patients with family history of CRC not linked to hereditary CRC syndromes. Despite this, current guidelines, include colonoscopy as alternative for CRC screening either in average risk population with the same evidence level that other screening strategies or in the familial risk population. The present manuscript reviews the clinical evidence on the role of colonoscopy in preventing CRC in different screening settings.

Successful detection and removal of predictable juvenile polyp: a case report

Juvenile polyp makes up 70% to 80% of pediatric colon polyp, and the average age of diagnosis is 2 to 5 years. The treatment of juvenile polyp in children is polypectomy through colonoscopy. The fact that the lumen of intestine is much smaller than that of adults and the need to perform polypectomy is a heavy burden on the endoscopists. Recently, fecal calprotectin (FC) has been found to be related to juvenile polyp. A previously healthy 34-month-old female patient presented to the pediatric gastroenterology department with intermittent bloody stools that were progressively worsening. FC level was abnormally elevated at 2,719 µg/g (normal, < 50 µg/g). The polyp was successfully removed with a endoscopic polypectomy. This is the first case in Korea to show that FC can be used to screen juvenile polyp in children. Caution must be taken that FC levels can increase with inflammation, regardless of the number or size of the polyps.

pT1 colorectal cancer: A treatment dilemma

The implementation of population screening programs for colorectal cancer (CRC) has led to a considerable increase in the prevalence pT1-CRC originating on polyps amenable by local treatments. However, a high proportion of patients are referred for unnecessary oncological surgeries without a clear benefit in terms of survival. Selecting the appropriate endoscopic resection technique in the moment of diagnosis becomes crucial to provide the best treatment alternative to each individual polyp and patient. For this, it is imperative to increase the optical diagnostic skill for differentiating pT1-CRCs and decide the appropriate initial therapy. En bloc resection is crucial to obtain an adequate histological specimen that might allow organ preserving therapeutic management. In this review, we address key challenges in T1 CRC management, explore the efficacy and safety of the available diagnostic and therapeutic approaches, and shed light on upcoming advances in the field.

Changes in uptake of stool-based colorectal cancer screening during the Covid-19 pandemic

PURPOSE

Colorectal cancer (CRC) screening is underutilized and endoscopic colon screening includes a number of barriers that were exacerbated by the Covid-19 pandemic. At-home stool-based screening (SBS) increased during the pandemic and potentially reached eligible adults hesitant to be screened by endoscopy. The purpose of this analysis was to examine the change in uptake of SBS during the pandemic among adults not screened within guidelines by endoscopy.

METHODS

We used data from the 2019 and 2021 National Health Interview Surveys to estimate uptake of SBS among adults aged 50-75 years, without a previous diagnosis of CRC and without guideline-concordant endoscopic screening. We also examined provider recommendations for screening tests. To examine if changes in uptake differed during the pandemic by demographic and health characteristics, we combined survey years and ran logistic regression models with an interaction term for each factor and survey year.

RESULTS

In our study population, SBS increased 74% overall from 2019 to 2021 (8.7% to 15.1%; p < 0.001), with the largest percent increase among those aged 50-52 years (3.5% to 9.9%; p < 0.001). Among those aged 50-52 years, the ratio of endoscopy to SBS changed from 83%/17% in 2019 to 55%/45% in 2021. Cologuard was the only screening test where recommendations by healthcare providers significantly increased from 2019 (10.6% to 16.1%; p = 0.002).

CONCLUSIONS

Use and recommendations for SBS increased substantially during the pandemic. Increased awareness among patients could potentially improve future CRC screening rates if uptake of SBS occurs among those unable or unwilling to be screened by endoscopy.

Nasal continuous positive pressure versus simple face mask oxygenation for adult obese and obstructive sleep apnea patients undergoing colonoscopy under propofol-based general anesthesia without tracheal intubation: A randomized controlled trial

STUDY OBJECTIVE

To determine if a nasal positive airway pressure (nasal CPAP) mask would decrease the number of hypoxemic events in obese and obstructive sleep apnea patients undergoing colonoscopy.

DESIGN

Single-center prospective randomized controlled trial.

SETTING

Tertiary academic center.

PATIENTS

We enrolled 109 patients with diagnosis of obesity and/or obstructive sleep apnea scheduled to undergo colonoscopy under propofol general anesthesia without planned tracheal intubation.

INTERVENTION

Patients were randomly allocated (1:1 ratio) to receive supplementary oxygen at a flow of 10 L/min, either through a nasal CPAP or a simple facemask.

MEASUREMENTS

The primary endpoint was the difference in the mean percentage of time spent with oxygen saturation below 90% between the two groups. Secondary outcomes included the need for airway maneuvers/interventions, average SpO2 during the case, duration and severity of oxygen desaturation, incidence and duration of procedural interruptions, and satisfaction and tolerance scores.

MAIN RESULTS

54 were allocated to the simple face mask and 55 to the nasal CPAP mask arms, respectively. A total of 6 patients experienced a hypoxemic event. Among these patients, the difference in the percentage of time spent with oxygen saturation below 90% was not clinically relevant (p = 1.0). However, patients in the nasal CPAP group required less chin lift (20% vs. 42.6%; p = 0.01) and oral cannula insertion (12.7% vs.29.6%; p = 0.03). The percentage of patients with at least one airway maneuver was higher in the simple face mask arm (68.5% vs. 41.8%; p = 0.005). Patient tolerance to device score was lower in the nasal CPAP group (8.85 vs. 9.56; p = 0.003).

CONCLUSIONS

A nasal CPAP did not prevent hypoxemia and should not be used routinely for colonoscopy in obese or OSA patients if a simple face mask is an alternative therapy. However, potential advantages of its use include fewer airway maneuvers or interventions, which may be desirable in certain clinical settings.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier: NCT05175573.

Postcolonoscopy Colorectal Cancer in a Referral Center for Colorectal Cancer: Prevalence and Risk Factors

Background and Aims

Colonoscopy is effective to detect and remove colorectal lesions. However, after a negative colonoscopy, cancers could be detected during the interval follow-up. This study was designed to identify characteristics and risk factors for postcolonoscopy colorectal cancer - interval type.

Methods

Medical records of individuals who were newly diagnosed with colorectal cancer between January 2018 and December 2019 were reviewed. Clinical, demographic, and endoscopic variables were analyzed. Those with the diagnosis of colorectal cancer between two consecutive colonoscopies performed within the appropriated surveillance range were considered to have postcolonoscopy colorectal cancer - interval type. A comparison between the group of patients with non-postcolonoscopy colorectal cancer - interval type and the group of patients with postcolonoscopy colorectal cancer - interval type was then performed.

Results

During the study period, 491 patients were newly diagnosed with colorectal cancer. Among them, 61 (12.4%) had postcolonoscopy colorectal cancer - interval subtype. Postcolonoscopy colorectal cancer - interval type was three times more prevalent on the proximal colon (p = 0.014) and was associated with the presence of two or more cardiovascular risk factors (aOR = 4.25; p = 0.016), cholecystectomy in the past (aOR = 10.09; p = 0.019), and family history of colorectal cancer on a first-degree relative (aOR = 4.25; p = 0.006). Moreover, isolated cardiovascular risk factors revealed a protective effect for the absence of all cardiovascular risk factors (aOR = 20; p = 0.034). The ROC curve associated with the multivariate model revealed a predictive power of 77.8% (p < 0.001).

Conclusions

Postcolonoscopy colorectal cancer - interval type is more common in the proximal colon and in patients with a family history (first-degree relative) of colorectal cancer, two or more cardiovascular risk factors, and a history of cholecystectomy. All of these are easily detectable in clinical practice and may be of extreme importance in the control of postcolonoscopy colorectal cancer in the near future.

A case of fulminant amoebic colitis during systemic chemotherapy for gastric cancer

Amoebiasis is a parasitic infection caused by the protozoan, Entamoeba histolytica. At times, amoebiasis is activated under immunosuppressive conditions such as chemotherapy. We report a case of fulminant amoebic colitis resulting from an asymptomatic Entamoeba histolytica infection, which was activated by chemotherapy for gastric cancer. The patient developed diarrhea and fever after three courses of chemotherapy for gastric cancer and was diagnosed with acute enteritis. A colonoscopy and biopsy were performed because of the bloody stool. Histopathological findings revealed amoebic invasion of the rectum. Therefore, the patient was diagnosed with amoebic colitis and was treated with metronidazole. Emergency surgery was performed because intestinal perforation was suspected after which his general condition improved and was discharged. Subsequently, gastric cancer surgery was performed and the patient was discharged without postoperative complications. Hence, amoebic colitis should be listed as a differential diagnosis, and a colonoscopic biopsy should be performed when colitis occurs during chemotherapy for cancer.

Dynamics of colorectal cancer screening in low and middle-income countries: A modeling analysis from Thailand

BACKGROUND

Low and middle-income countries face constraints for early colorectal cancer (CRC) detection, including restricted access to care and low colonoscopy capacity. Considering these constraints, we studied strategies for increasing access to early CRC detection and reducing CRC progression and mortality rates in Thailand.

METHODS

We developed a system dynamics model to simulate CRC death and progression trends. We analyzed the impacts of increased access to screening via fecal immunochemical test and colonoscopy, improving access to CRC diagnosis among symptomatic individuals, and their combination.

RESULTS

Projecting the status quo (2023-2032), deaths per 100K people increase from 87.5 to 115.4, and CRC progressions per 100K people rise from 131.8 to 159.8. In 2032, improved screening access prevents 2.5 CRC deaths and 2.5 progressions per 100K people, with cumulative prevented 7K deaths and 9K progressions, respectively. Improved symptom evaluation access prevents 7.5 CRC deaths per 100K with no effect on progression, totaling 35K saved lives. A combined approach prevents 9.3 deaths and 1.8 progressions per 100K, or 41K and 7K cumulatively. The combined strategy prevents most deaths; however, there is a tradeoff: It prevents fewer CRC progressions than screening access improvement. Increasing the current annual colonoscopy capacity (200K) to sufficient capacity (681K), the combined strategy achieves the best results, preventing 15.0 CRC deaths and 10.3 CRC progressions per 100K people, or 54K and 30K cumulatively.

CONCLUSION

Until colonoscopy capacity increases, enhanced screening and symptom evaluation are needed simultaneously to curb CRC deaths, albeit not the best strategy for CRC progression prevention.

Qualitative Analysis of Colorectal Cancer Screening for African American and Hispanic Populations in Nebraska: an Application of the PRECEDE Framework

Nationally and in Nebraska, African Americans (AA) and Hispanics have lower colorectal cancer (CRC) screening rates compared to non-Hispanic Whites. We aimed to obtain perspectives from AA and Hispanic cancer survivors and caregivers in Nebraska about CRC screening to improve outreach efforts. Data from four virtual focus groups (AA female, AA male, Hispanic rural, and Hispanic urban) conducted between April-August 2021 were analyzed using a directed content approach based on the Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model. Most of the 19 participants were female (84%) and survivors (58%). Across groups, awareness of colonoscopy was high, but awareness of fecal testing needed to be higher, with confusion about different types of fecal tests. Predisposing factors were trust in the health system; awareness of CRC screening; machismo; fear of cancer; embarrassment with screening methods; and negative perceptions of CRC screening. Enabling factors included provider recommendations, healthcare access, and insurance. Reinforcing factors included prioritizing personal health and having a support system. Suggestions to improve screening included increasing healthcare access (free or low-cost care), increasing provider diversity, health education using various methods and media, and enhancing grassroots health promotion efforts. Lack of awareness, accessibility issues, attitudes and perceptions of CRC and CRC screening, trust, and cultural and linguistic concerns are major issues that need to be addressed to reduce CRC screening disparities among AA and Hispanic adults.

Knowledge, perceptions and behaviours of endoscopists towards the use of artificial intelligence-aided colonoscopy

BACKGROUND

Recent developments in artificial intelligence (AI) systems have enabled advancements in endoscopy. Deep learning systems, using convolutional neural networks, have allowed for real-time AI-aided detection of polyps with higher sensitivity than the average endoscopist. However, not all endoscopists welcome the advent of AI systems.

METHODS

We conducted a survey on the knowledge of AI, perceptions of AI in medicine, and behaviours regarding use of AI-aided colonoscopy, in a single centre 2 months after the implementation of Medtronic's GI Genius in colonoscopy. We obtained a response rate of 66.7% (16/24) amongst consultant-grade endoscopists. Fisher's exact test was used to calculate the significance of correlations.

RESULTS

Knowledge of AI varied widely amongst endoscopists. Most endoscopists were optimistic about AI's capabilities in performing objective administrative and clinical tasks, but reserved about AI providing personalised, empathetic care. 68.8% (n = 11) of endoscopists agreed or strongly agreed that GI Genius should be used as an adjunct in colonoscopy. In analysing the 31.3% (n = 5) of endoscopists who disagreed or were ambivalent about its use, there was no significant correlation with their knowledge or perceptions of AI, but a significant number did not enjoy using the programme (p-value = 0.0128) and did not think it improved the quality of colonoscopy (p-value = 0.033).

CONCLUSIONS

Acceptance of AI-aided colonoscopy systems is more related to the endoscopist's experience with using the programme, rather than general knowledge or perceptions towards AI. Uptake of such systems will rely greatly on how the device is delivered to the end user.

Faecal haemoglobin: Measurement, applications, and future potential

Faecal hemoglobin concentrations (f-Hb) can be quantitated using faecal immunochemical test for haemoglobin (FIT) analytical systems. FIT are of proven value and widely used in colorectal cancer (CRC) screening. Several factors affect f-Hb including sex, age, deprivation, geographical region, and FIT system. Thus, FIT data may not be transferable. Women are disadvantaged in programmes using a single f-Hb threshold for all participants, but risk scoring or sex stratified thresholds could be used to minimise this problem. In addition, low but detectable f-Hb, below the threshold, implies future risk of CRC. In several countries, where colonoscopy resources are constrained, FIT are now accepted as of added value in assessment of patients presenting in primary or secondary care with symptoms, although some serious colorectal disease is missed. Elevated f-Hb in the absence of any discernible colorectal lesions is common and has been found in several diseases with a systemic inflammatory component, including circulatory, respiratory, digestive, neuropsychological, blood and endocrine diseases, and others. There is growing evidence for the value of f-Hb in post-polypectomy surveillance, potentially saving costs and colonoscopy. There may be a role for FIT systems which have lower limits of detection than currently available methods. The faecal material remaining in FIT specimen collection devices could be used for further studies, including assessment of the microbiome. The estimation of f-Hb is now a mature investigative tool but further research will undoubtedly expand applications of value.

A water-soluble alternative to simethicone for gastrointestinal endoscopy: Results of a clinical trial

During endoscopy, simethicone defoaming agents are commonly used to improve visualization, but they leave residues and impact drying. This clinical trial involved patients undergoing colonoscopy procedures with substantial bubbles that impeded mucosal wall visibility. As an alternative to simethicone, investigators evaluated a water-soluble, ginger-based gastrointestinal supplement (GI-Ease) that did not contain sugars, thickeners, or binding agents. In 112/114 cases (98%), the bubbles were reduced sufficiently to allow visualization of the gastrointestinal tract, with no adverse events.

Colonoscopy surveillance in Lynch syndrome is burdensome and frequently delayed

Individuals with Lynch syndrome have an increased colorectal cancer risk, hence, biennial colonoscopy surveillance is recommended. We aimed to investigate patients' perception and preferences regarding surveillance, and to further explore compliance behaviour. Individuals with Lynch syndrome received a validated survey evaluating experiences of their three most recent colonoscopies. Individuals were non-compliant to surveillance if the interval between colonoscopies differed ≥ 6 months from the recommended interval. In total, 197 of 291 (68%) invited individuals returned the survey. They mostly underwent colonoscopy biennially (99%), under mild sedation (79%) and with bowel preparation performed by Moviprep® (99%). Surveillance was perceived as impacting quality of life in 21%, and as moderately to extremely burdensome in 57%, particularly in those below age 40. To lower the burden, patients prioritised improvements in volume and taste of bowel preparation, laxation-related bowel movements, waiting times, and a more personal and respectful approach of endoscopic staff. Additionally, many individuals (60%) would favour less-invasive surveillance modalities such as biomarkers. In total, 28% of individuals had delayed colonoscopy surveillance, predominantly for patient-related reasons. An additional 10% considered quitting/postponing surveillance. Upon multivariable analysis, patient-related delay was associated with low and medium education, history of ≤ 4 colonoscopies and having no hospital recall-system. Colonoscopy surveillance in Lynch syndrome is often experienced as burdensome, and frequently delayed. We identified determinants of surveillance behaviour in this population, and present potential interventions to reduce the burden and non-compliance rates.

Correlation between prescribing doctor attributes and intestinal cleanliness in colonoscopy: a study of 22522 patients

OBJECTIVE

This study aimed to analyze the correlation between different attributes of doctors who prescribe colonoscopies and the cleanliness of the intestine to guide the development of colonoscopy application protocols.

METHODS

Data on colonoscopy cases conducted in the gastroenterology department of Hangzhou First People's Hospital between April 2018 and March 2021 were collected. The gender, age, professional attributes of the prescribing doctors, and Boston Bowel Preparation Scale (BBPS) score were recorded. In addition, the correlation between the prescribing doctors' characteristics and the intestine's cleanliness was analyzed.

RESULTS

The study included 22,522 patients with a mean BBPS score of 6.83 ± 1.94. There were 16,459 male and 6,063 female doctors with similar BBPS scores (p = 0.212). The study found no significant difference in BBPS scores between 19,338 internist and 3,184 non-internist (p = 0.154). However, BBPS scores differed significantly between 18,168 gastroenterologists and 4,354 non-gastroenterologists (p = 0.016) and between 19,990 intestinal-related specialties(gastroenterology and gastrointestinal surgery) and 2,532 non-intestinal-related specialties (p = 0.000). In addition, BBPS scores were significantly different between 18,126 prescribing endoscopiests and 4,396 non-endoscopiests (p = 0.014). However, there was no significant difference in BBPS scores among doctors of different ages (p = 0.190). The study found significant differences in BBPS scores between male and female patients and those under or over 40 years (p = 0.000).

CONCLUSION

To improve colonoscopy preparation quality, priority should be given to doctors in gastroenterology, intestinal-related specialties, and endoscopiests. Their expertise may result in better education and improved bowel cleanliness.

A pediatric case series of catastrophic gastrointestinal complications of posttransplant lymphoproliferative disease with increasing incidence, high association with coronavirus disease 2019, higher mortality, and a plea for early endoscopy to prevent late fatal outcome

BACKGROUND

Posttransplant lymphoproliferative disorder is one of the most severe complications after transplantation, caused by uncontrolled proliferation of Epstein-Barr virus-positive B-cells in the setting of chronic immunosuppression. As one of the biggest transplant centers worldwide, we observed a potential increase in the number of patients with posttransplant lymphoproliferative disorder presenting with gastrointestinal symptoms in 1 year, during the coronavirus disease 2019 pandemic. There is limited information about dysregulation of the immune system following coronavirus disease 2019 infection, which may lead to Epstein-Barr virus reactivation in Epstein-Barr virus-positive B-cells and development of posttransplant lymphoproliferative disorder. Furthermore, there is no consensus in literature on a modality that can help in early diagnosis of posttransplant lymphoproliferative disorder with nonspecific gastrointestinal presentations before late and fatal complications occur.

CASE PRESENTATION

Our case series includes five Iranian (Persian) patients, three female (2, 2.5, and 5 years old) and two male (2 and 2.5 years old), who developed gastrointestinal posttransplant lymphoproliferative disorder after liver transplantation. All of our patients were on a similar immunosuppressant regimen and had similar Epstein-Barr virus serologic status (seronegative at time of transplantation but seropositive at time of posttransplant lymphoproliferative disorder diagnosis). Four patients had either a positive coronavirus disease 2019 polymerase chain reaction test or exposure within the family. Although all of our patients presented with nonspecific gastrointestinal symptoms, four patients developed late posttransplant lymphoproliferative disorder complications such as bowel perforation and obstruction. All five patients with gastrointestinal posttransplant lymphoproliferative disorder received chemotherapy, but only two survived and currently are continuing the therapy. In one of the surviving patients, prompt endoscopic investigation resulted in early diagnosis of posttransplant lymphoproliferative disorder and a better outcome.

CONCLUSION

Since 80% of our patients had exposure to coronavirus, a potential relationship might be suggested between the two. Furthermore, as we witnessed in one case, urgent endoscopic investigation in immunocompromised patients presenting with gastrointestinal symptoms can improve the clinical outcomes and therefore should be considered for early diagnosis of posttransplant lymphoproliferative disorder.

Human immunodeficiency virus patients with low CD4 counts are more likely to have precancerous polyps identified during index colonoscopy

BACKGROUND

Antiretroviral treatment (ART) has improved the life expectancy of patients living with human immunodeficiency virus (HIV). As these patients age, they are at increased risk for developing non-acquired immunodeficiency syndrome defining malignancies (NADMs) such as colon cancers.

AIM

To determine which factors are associated with the development of precancerous polyps on screening colonoscopy in patients with HIV and to investigate whether HIV disease status, measured by viral load and CD4 count, might influence precancerous polyp development.

METHODS

A retrospective review of records at two urban academic medical centers was performed for HIV patients who had a screening colonoscopy between 2005-2015. Patients with a history of colorectal cancer or polyps, poor bowel preparation, or inflammatory bowel disease were excluded. Demographic data such as sex, age, race, and body mass index (BMI) as well as information regarding the HIV disease status such as CD4 count, viral load, and medication regimen were collected. Well-controlled patients were defined as those that had viral load < 50 copies, and poorly-controlled patients were those with viral load ≥ 50. Patients were also stratified based on their CD4 count, comparing those with a low CD4 count to those with a high CD4 count. Using colonoscopy reports in the medical record, the size, histology, and number of polyps were recorded for each patient. Precancerous polyps included adenomas and proximal serrated polyps. Data was analyzed using Fisher's exact tests and logistic regression through SAS 3.8 software.

RESULTS

Two hundred and seven patients met our inclusion criteria. The mean age was 56.13 years, and 58% were males. There were no significant differences in terms of age, race or ethnicity, insurance, and smoking status between patients with CD4 counts above or below 500. BMI was lower in patients with CD4 count < 500 as compared to those with count > 500 (P = 0.0276). In patients with CD4 > 500, 53.85% of patients were female, and 70.87% of patients with CD4 < 500 were male (P = 0.0004). Only 1.92% of patients with CD4 ≥ 500 had precancerous polyps vs 10.68% of patients with CD4 < 500 (P = 0.0102). When controlled for sex, BMI, and ART use, patients with CD4 < 500 were 9.01 times more likely to have precancerous polyps [95% confidence interval (CI): 1.69-47.97; P = 0.0100]. Patients taking non-nucleoside reverse transcriptase inhibitors were also found to be 10.23 times more likely to have precancerous polyps (95%CI: 1.08-97.15; P = 0.0428). There was not a significant difference noted in precancerous polyps between those that had viral loads greater or less than 50 copies.

CONCLUSION

Patients with low CD4 counts were more likely to have precancerous polyps on their screening colonoscopy although the etiology for this association is unclear. We also found an increased risk of precancerous polyps in patients taking non-nucleoside reverse transcriptase inhibitors, which is contradictory to prior literature showing ART has decreased the risk of development of NADMs. However, there have not been studies looking at colorectal cancer and ART by drug class, to our knowledge. Further prospective studies are needed to determine the effect of HIV control and therapies on polyp development.

The role of colonoscopy in young patients with rectal bleeding: a systematic review and meta-analysis

PURPOSE

Anal bleeding is a frequent complaint in the coloproctological practice. Although usually associated with common anorectal disorders, it may represent a sign of an occult colorectal carcinoma. Our purpose was to evaluate the accuracy of the colonoscopy for detection of neoplastic lesions in patients under 50 years of age with rectal bleeding.

METHODS

This systematic review and meta-analysis searched publications in PubMed, Web of Science, and Cochrane Library databases up to August, 2023. Cross-sectional and case-control studies including patients under 50 years with rectal bleeding evaluated by colonoscopy were included. Primary outcome was prevalence of neoplastic lesions (adenomas and adenocarcinomas). Secondary outcomes were prevalence of those lesions according to age and anatomic location. The study was registered on PROSPERO (CRD42021257859) on July 5, 2021.

RESULTS

Nine studies comprising 4162 patients were analyzed. A total of 398 patients with adenomas and 40 patients with adenocarcinoma were identified. Prevalence of neoplastic lesions (adenomas and carcinomas) was 10%. In patients under 40 years, the prevalence of neoplastic lesions was 7% (6% of adenomas, 1% of carcinomas). Among patients aged 40-50 years the prevalence was 15%, 14%, and 1%, respectively. Most lesions (71%) were located distally to splenic flexure.

CONCLUSION

About 10% of patients under 50 years with anal bleeding will have a neoplastic lesion detected through colonoscopy. The greatest benefit of the procedure is observed between 40 and 50 years. Almost 30% of the neoplastic lesions were found in the proximal colon and could not be detected without the performance of a complete colonoscopy.

Usefulness and Educational Benefit of a Virtual Scale Endoscope in Measuring Colorectal Polyp Size

INTRODUCTION

The virtual scale endoscope (VSE) is a newly introduced endoscope that helps endoscopists in measuring colorectal polyp size (CPS) during colonoscopy by displaying a virtual scale. This study aimed to determine the usefulness of the VSE for CPS measurement and the educational benefit of using VSE images to improve CPS estimation accuracy.

METHODS

This study included 42 colorectal polyps in 26 patients treated at Hiroshima University Hospital. In study 1, CPS measured using a VSE before endoscopic mucosal resection was compared with CPS measured on resected specimens, and the agreement between the two measurement methods was evaluated via Bland-Altman analysis. In study 2, 14 endoscopists (5 beginners, 5 intermediates, and 4 experts) took a pre-test to determine the size of 42 polyps. After the pre-test, a lecture on CPS measurement using VSE images was given. One month later, the endoscopists took a post-test to compare CPS accuracy before and after the lecture.

RESULTS

In study 1, Bland-Altman analysis revealed no fixed or proportional errors. The mean bias ±95% limits of agreement (±1.96 standard deviations) of the measurement error was -0.05 ± 0.21 mm, indicating that the agreement between two measurement methods was sufficient. In study 2, the accuracy of CPS measurement was significantly higher among beginners (59.5% vs. 26.7%, p < 0.01) and intermediates (65.2% vs. 44.3%, p < 0.05) in the post-test than in the pre-test.

CONCLUSION

The VSE accurately measures CPS before resection, and its images are useful teaching tools for beginner and intermediate endoscopists.

Computer-aided diagnosis in predicting the invasion depth of early colorectal cancer: a systematic review and meta-analysis of diagnostic test accuracy

BACKGROUND

Endoscopic resection (ER) is widely applied to treat early colorectal cancer (CRC). Predicting the invasion depth of early CRC is critical in determining treatment strategies. The use of computer-aided diagnosis (CAD) algorithms could theoretically make accurate and objective predictions regarding the suitability of lesions for ER indication based on invasion depth. This study aimed to assess diagnostic test accuracy of CAD algorithms in predicting the invasion depth of early CRC and to compare the performance between the CAD algorithms and endoscopists.

METHODS

Multiple databases were searched until June 30, 2022 for studies that evaluated the diagnostic performance of CAD algorithms for invasion depth of CRC. Meta-analysis of diagnostic test accuracy using a bivariate mixed-effects model was performed.

RESULTS

Ten studies consisting of 13 arms (13,918 images from 1472 lesions) were included. Due to significant heterogeneity, studies were stratified into Japan/Korea-based or China-based studies. For the former, the area under the curve (AUC), sensitivity, and specificity of the CAD algorithms were 0.89 (95% CI 0.86-0.91), 62% (95% CI 50-72%), and 96% (95% CI 93-98%), respectively. For the latter, AUC, sensitivity, and specificity were 0.94 (95% CI 0.92-0.96), 88% (95% CI 78-94%), and 88% (95% CI 80-93%), respectively. The performance of the CAD algorithms in Japan/Korea-based studies was not significantly different from that of all endoscopists (0.88 vs. 0.91, P = 0.10) but was inferior to that of expert endoscopists (0.88 vs. 0.92, P = 0.03). The performance of the CAD algorithms in China-based studies was better than that of all endoscopists (0.94 vs. 0.90, P = 0.01).

CONCLUSION

The CAD algorithms showed comparable accuracy for prediction of invasion depth of early CRC compared to all endoscopists, which was still lower than expert endoscopists in diagnostic accuracy; more improvements should be achieved before it can be extensively applied to clinical practice.

Detecting colorectal lesions with image-enhanced endoscopy: an updated review from clinical trials

Colonoscopy plays an important role in reducing the incidence and mortality of colorectal cancer by detecting adenomas and other precancerous lesions. Image-enhanced endoscopy (IEE) increases lesion visibility by enhancing the microstructure, blood vessels, and mucosal surface color, resulting in the detection of colorectal lesions. In recent years, various IEE techniques have been used in clinical practice, each with its unique characteristics. Numerous studies have reported the effectiveness of IEE in the detection of colorectal lesions. IEEs can be divided into two broad categories according to the nature of the image: images constructed using narrowband wavelength light, such as narrowband imaging and blue laser imaging/blue light imaging, or color images based on white light, such as linked color imaging, texture and color enhancement imaging, and i-scan. Conversely, artificial intelligence (AI) systems, such as computer-aided diagnosis systems, have recently been developed to assist endoscopists in detecting colorectal lesions during colonoscopy. To better understand the features of each IEE, this review presents the effectiveness of each type of IEE and their combination with AI for colorectal lesion detection by referencing the latest research data.

Screening for colorectal cancer : A recommendation statement of the Austrian National Committee for Cancer Screening

BACKGROUND

Colorectal cancer is the fourth most common cancer in Austria. To date, colorectal cancer screening in Austria remains opportunistic and includes colonoscopy or stool-based blood tests. The Austrian National Committee for Cancer Screening developed evidence-based recommendations for a nationwide organized colorectal cancer screening program.

METHODS

The methodological framework followed the approach of the United States Preventive Services Task Force. The evidence base underlying the newly developed recommendations comprised a review of the existing published evidence and a decision analytic model tailored to the Austrian context. Using a structured process, committee members considered 1) the magnitude of the net benefit of each screening strategy, 2) the certainty of evidence, and 3) the level of acceptance of the interventions among the target population.

RECOMMENDATIONS

The Austrian National Committee for Cancer Screening recommends the implementation of a nationwide organized colorectal cancer screening program for all adults aged 45-75 years. For persons 65 years or older, screening decisions should occur on an individual basis in accordance with a person's overall health, prior screening history, and preferences. Specifically, the committee recommends either a 10-year screening colonoscopy or biennial fecal immunochemical tests with colonoscopy following a positive result, with both screening strategies considered equivalent. Each citizen should be able to make an informed decision about their preferred screening method. Switching between the two screening strategies should be possible. Following an unremarkable colonoscopy, screening by fecal immunochemical test (FIT) is only required after 10 years. Screening recommendations apply only to asymptomatic persons at average risk for colorectal cancer. The screening program must be pilot tested, and accompanied by a public information campaign, formative evaluation, quality assurance, and data collection.

Prediction of advanced colorectal neoplasia based on metabolic parameters among symptomatic patients

BACKGROUND AND AIM

Worldwide, colorectal cancer (CRC) is the third most common cancer and ranks second among the leading causes of cancer death. This study aims to devise and validate a scoring system based on metabolic parameters to predict the risk of advanced colorectal neoplasia (ACN) in a large Chinese population.

METHODS

This was a cohort study of 495 584 symptomatic subjects aged 40 years or older who have received colonoscopy in Hong Kong from 1997 to 2017. The algorithm's discriminatory ability was evaluated as the area under the curve (AUC) of the mathematically constructed receiver operating characteristic curve.

RESULTS

Age, male gender, inpatient setting, abnormal aspartate transaminase/alanine transaminase, white blood cell, plasma gamma-glutamyl transferase, high-density lipoprotein cholesterol, triglycerides, and hemoglobin A1c were significantly associated with ACN. A scoring of < 2.65 was designated as "low risk (LR)." Scores at 2.65 or above had prevalence higher than the overall prevalence and hence were assigned as "high risk (HR)." The prevalence of ACN was 32% and 11%, respectively, for HR and LR groups. The AUC for the risk score in the derivation and validation cohort was 70.12%.

CONCLUSIONS

This study has validated a simple, accurate, and easy-to-use scoring algorithm, which has a high discriminatory capability to predict ACN in symptomatic patients. Future studies should examine its predictive performance in other population groups.

The impact of abdominal compression devices on colonoscopy outcomes: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Colonoscopy is the gold standard method for colorectal cancer screening. Looping occurs in 91% of cases undergoing colonoscopy and can cause patient discomfort, prolonged cecal intubation time (CIT), and colon perforation. This meta-analysis investigates the impact of abdominal compression devices (ACD) on colonoscopy outcomes.

METHODS

A systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), retrieved by systematically searching: PubMed, EMBASE, WOS, SCOPUS, and Cochrane through February 2nd, 2023. Continuous and dichotomous outcomes were pooled using mean difference (MD) and risk ratio (RR) along with confidence interval (CI) using Revman. Our review protocol was prospectively published on PROSPERO with ID: CRD42023397344.

RESULTS

We included eight RCTs with a total of 1,889 patients. ACD was effective to decrease CIT (MD: -2.15 with a 95% CI [-3.49, -0.80], p = .002), postural change (RR: 0.57 with 95% CI [0.49, 0.66], p = .00001), and VAS pain score (MD: -1.49 with 95% CI [-1.81, -1.17], p = .0001). However, there was no difference between ACD and control groups regarding manual compression (RR: 0.65 with 95% CI [0.42, 1.00], p = .05), complete colonoscopy rate (CCR) (RR: 1.01 with 95% CI [0.99, 1.04], p = .31), and cecal intubation length (CIL) (MD: -2.25 with 95% CI [-7.64, 3.14], p = .41).

CONCLUSION

ACD during colonoscopy may enhance patient comfort by reducing CIT, pain, and postural changes. Nevertheless, additional RCTs are necessary to validate these results and determine the most suitable approach to utilize ACD for colonoscopy.

Efficacy and safety of 1 L polyethylene glycol plus ascorbic acid for bowel preparation in elderly: comparison with oral sulfate solution

BACKGROUND/AIMS

Recently, 1 L of polyethylene glycol (PEG) plus ascorbic acid (Asc) has been introduced in Korea as a colonoscopy preparation agent. Data on its efficacy and safety in older adults have been limited. We aimed to evaluate the safety and efficacy of 1 L PEG/Asc in older adults by comparing it with oral sulfate solution (OSS).

METHODS

A prospective multicenter randomized study was conducted with subjects aged ≥ 65 years who underwent colonoscopy. The participants were randomized to receive 1 L PEG/Asc or OSS. The primary endpoint was successful bowel preparation, defined as total Boston Bowel Preparation Scale ≥ 6, and ≥ 2 at each segment. Patient satisfaction, adverse events, and renal function changes were compared between the groups.

RESULTS

Among the 106 patients, 104 were finally included in the analysis. Overall, successful bowel preparation was achieved in 96.2% of both 1 L PEG/Asc and OSS groups. The satisfaction scores for taste, total amount ingested, overall feeling, and willingness to repeat the same regimen were not significantly different between the groups. Adverse events of moderate or higher severity occurred in 16 and 10 cases in the 1 L PEG/Asc and OSS group, respectively. There were no significant changes in electrolyte levels or renal function from baseline.

CONCLUSION

The successful bowel preparation rate was > 90% in both groups without severe adverse effects and significant changes in renal function. As a new low-dose preparation regimen for colonoscopy in older adults, 1 L PEG/Asc, is as effective and safe as OSS.

Neoplasia Diagnosis After Multi-target Stool DNA Is Enhanced Among Lowest Baseline Detectors

BACKGROUND AND AIMS

Variation in colorectal neoplasia detection limits the effectiveness of screening colonoscopy. By evaluating neoplasia detection rates of individual colonoscopists, we aimed to quantify the effects of pre-procedural knowledge of a positive (+) multi-target stool DNA (mt-sDNA) on colonoscopy quality metrics.

METHODS

We retrospectively identified physicians who performed a high volume of + mt-sDNA colonoscopies; colorectal neoplasia at post-mt-sDNA colonoscopy was recorded. These colonoscopists were stratified into quartiles based on baseline adenoma detection rates. Baseline colonoscopy adenoma detection rates and sessile serrated lesion detection rates were compared to post-mt-sDNA colonoscopy neoplasia diagnosis rates among each quartile. Withdrawal times were measured from negative exams.

RESULTS

During the study period (2014-17) the highest quartile of physicians by volume of post-mt-sDNA colonoscopies were evaluated. Among thirty-five gastroenterologists, their median screening colonoscopy adenoma detection rate was 32% (IQR, 28-39%) and serrated lesion detection rate was 13% (8-15%). After + mt-sDNA, adenoma diagnosis increased to 47% (36-56%) and serrated lesion diagnosis increased to 31% (17-42%) (both p < 0.0001). Median withdrawal time increased from 10 (7-13) to 12 (10-17) minutes (p < 0.0001) and was proportionate across quartiles. After + mt-sDNA, lower baseline detectors had disproportionately higher rates of adenoma diagnosis in female versus male patients (p = 0.048) and higher serrated neoplasia diagnosis rates among all patients (p = 0.0092).

CONCLUSIONS

Knowledge of + mt-sDNA enriches neoplasia diagnosis compared to average risk screening exams. Adenomatous and serrated lesion diagnosis was magnified among those with lower adenoma detection rates. Awareness of the mt-sDNA result may increase physician attention during colonoscopy. Pre-procedure knowledge of a positive mt-sDNA test improves neoplasia diagnosis rates among colonoscopists with lower baseline adenoma detection rates, independent of withdrawal time.

CTE-Based Radiomics Models Can Identify Mucosal Healing in Patients with Crohn's Disease

RATIONALE AND OBJECTIVES

To develop computed tomography enterography (CTE)-based radiomics models to assess mucosal healing (MH) in patients with Crohn's disease (CD).

MATERIALS AND METHODS

CTE images were retrospectively collected from 92 confirmed cases of CD at the post-treatment review. Patients were randomly divided into developing (n = 73) and testing (n = 19) groups. Radiomics features were extracted from the enteric phase images, and the least absolute shrinkage and selection operator (LASSO) logistic regression was applied for feature selection using 5-fold cross-validation on the developing group. The selected features were further identified from the top-ranked features and used to create improved radiomics models. Machine learning models were constructed to compare radiomics models with different radiomics features. The area under the ROC curve (AUC) was calculated to assess the predictive performance for identifying MH in CD.

RESULTS

Among the 92 CD patients included in our study, 36 patients achieved MH. The AUC of the radiomics model 1, which was based on the 26 selected radiomics features, was 0.976 for evaluating MH in the testing cohort. The AUCs of radiomics models 2 and 4, based on the top 10 and top 5 positive and negative radiomics features, were 0.974 and 0.952 in the testing cohort, respectively. The AUC of the radiomics model 3, built by removing features with r > 0.5, was 0.956 in the testing cohort. The clinical utility of the clinical radiomics nomogram was confirmed by the decision curve analysis (DCA).

CONCLUSION

The CTE-based radiomics models have demonstrated favorable performance in assessing MH in patients with CD. Radiomics features can be used as a promising imaging biomarker for MH.

The safety and effects of high- and low-volume polyethylene glycol bowel preparation methods before colonoscopy on bowel cleanliness: a systematic review and meta-analysis

Background

Although both high- and low-volume polyethylene glycol (PEG) are widely used in intestinal preparation before colonoscopy, there is still controversy over the superiority of their cleaning effects. This meta-analysis sought to explore the safety and effects of high-volume PEG solution and low-volume PEG mixed solution on intestinal cleanliness before colonoscopy.

Methods

The PubMed, EMBASE, and Cochrane Library databases were searched to retrieve relevant articles on the effects of high- and low-volume PEG mixture solutions on intestinal cleanliness from the inception of the databases to October 15, 2022. Two independent researchers screened the literature according to the predetermined inclusion and exclusion criteria, and extracted the required data separately. A bias risk assessment was conducted for each study using the relevant tools in the Cochrane Handbook. The included data were subjected to a meta-analysis using R 4.2.1 software.

Results

This article includes a total of 15 studies involving a total of 5,847 patients. There was no difference in the cleanliness score, qualified rate of intestinal cleanliness and patient compliance between the high- and low-volume group. The patients in the low-volume PEG mixed solution group had a higher repeat willingness bowel cleansing rate than those in the high-volume PEG group [risk ratio (RR) =0.71, 95% confidence interval (CI): 0.62-0.82, P<0.01]. Compared with the low-volume group, the incidence of adverse reactions such as nausea, vomiting, and abdominal pain increased in the high-volume group (RR =1.38, 95% CI: 1.22-1.56, P<0.01; RR =1.79, 95% CI: 1.41-2.27, P<0.01; RR =1.05, 95% CI: 1.01-1.08, P<0.01).

Conclusions

In the pre-colonoscopy preparation method for patients, although the high-volume PEG and low-volume PEG mixed regimen have similar effects on intestinal cleanliness, the low-volume mixed regimen has a higher willingness to repeat and a lower incidence of adverse reactions. In clinical practice, considering patient compliance and safety, a low-volume mixed regimen may be a more optimal option.

Colorectal cancer screening-what does the recent NordICC trial mean for the U.S. population?

The incidence of colorectal cancer (CRC) has declined over time, though it remains a significant cause of morbidity and mortality in the U.S. It has the third highest incidence in incidence among all cancers and is the second leading cause of cancer death in both men and women. Screening reduces the incidence and mortality from CRC. There are several modalities for CRC screening, but the most common ones are a choice between a non-invasive stool-based test, such as fecal immunochemical testing (FIT) or an invasive endoscopic modality, such as colonoscopy. In the U.S. colonoscopy is the predominant CRC screening modality, with observational studies reporting large reductions in CRC incidence and mortality. Recently, a large randomized controlled trial (RCT) on effectiveness of colonoscopy reported smaller than expected reduction in CRC incidence and no reduction in CRC mortality with colonoscopy screening. Explanations of the lower than expected benefit include low uptake of colonoscopy, short follow-up for mortality endpoints and quality indicators (QIs) for some of the endoscopists participating in the screening colonoscopies. The findings of the study need to be taken in context with other literature on effectiveness of colonoscopy, with the overall message of reassuring patients of the benefits of screening, and colonoscopy. Here, we discuss the latest evidence on colonoscopy screening and it in the context of other screening modalities and the landscape.

Implementation of an organized colorectal cancer screening program through quantitative fecal immunochemical test followed by colonoscopy in an urban low-income community: Guidance and strategies

Fecal Immunochemical Test (FIT) followed by a colonoscopy is an efficacious strategy to improve the adenoma detection rate and Colorectal Cancer (CRC). There is no organized national screening program for CRC in Brazil. The aim of this research was to describe the implementation of an organized screening program for CRC through FIT followed by colonoscopy, in an urban low-income community of São Paulo city. The endpoints of the study were: FIT participation rate, FIT positivity rate, colonoscopy compliance rate, Positive Predictive Values (PPV) for adenoma and CRC, and the rate of complications. From May 2016 to October 2019, asymptomatic individuals, 50-75 years old, received a free kit to perform the FIT. Positive FIT (≥ 50 ng/mL) individuals were referred to colonoscopy. 10,057 individuals returned the stool sample for analysis, of which (98.2%) 9,881 were valid. Women represented 64.8% of the participants. 55.3% of individuals did not complete elementary school. Positive FIT was 7.8% (776/9881). The colonoscopy compliance rate was 68.9% (535/776). There were no major colonoscopy complications. Adenoma were detected in 63.2% (332/525) of individuals. Advanced adenomatous lesions were found in 31.4% (165/525). CRC was diagnosed in 5.9% (31/525), characterized as adenocarcinoma: in situ in 3.2% (1/31), intramucosal in 29% (9/31), and invasive in 67.7% (21/31). Endoscopic treatment with curative intent for CRC was performed in 45.2% (14/31) of the cases. Therefore, in an urban low-income community, an organized CRC screening using FIT followed by colonoscopy ensued a high participation rate, and high predictive positive value for both, adenoma and CRC.

Development and validation of a simulation-based assessment tool in colonoscopy

BACKGROUND

Colonoscopy is difficult to learn. Virtual reality simulation training is helpful, but how and when novices should progress to patient-based training has yet to be established. To date, there is no assessment tool for credentialing novice endoscopists prior to clinical practice. The aim of this study was to develop such an assessment tool based on metrics provided by the simulator. The metrics used for the assessment tool should be able to discriminate between novices, intermediates, and experts and include essential checklist items for patient safety.

METHODS

The validation process was conducted based on the Standards for Educational and Psychological Testing. An expert panel decided upon three essential checklist items for patient safety based on Lawshe's method: perforation, hazardous tension to the bowel wall, and cecal intubation. A power calculation was performed. In this study, the Simbionix GI Mentor II simulator was used. Metrics with discriminatory ability were identified with variance analysis and combined to form an aggregate score. Based on this score and the essential items, pass/fail standards were set and reliability was tested.

RESULTS

Twenty-four participants (eight novices, eight intermediates, and eight expert endoscopists) performed two simulated colonoscopies. Four metrics with discriminatory ability were identified. The aggregate score ranged from 4.2 to 51.2 points. Novices had a mean score of 10.00 (SD 5.13), intermediates 24.63 (SD 7.91), and experts 30.72 (SD 11.98). The difference in score between novices and the other two groups was statistically significant (p<0.01). Although expert endoscopists had a higher score, the difference was not statistically significant (p=0.40). Reliability was good (Cronbach's alpha=0.86). A pass/fail score was defined at 17.1 points with correct completion of three essential checklist items, resulting in three experts and three intermediates failing and one novice passing the assessment.

CONCLUSION

We established a valid and reliable assessment tool with a pass/fail standard on the simulator. We suggest using the assessment after simulation-based training before commencing work-based learning.

Development and validation of a risk prediction model for post-polypectomy colorectal cancer in the USA: a prospective cohort study

Background

Effective risk stratification tools for post-polypectomy colorectal cancer (PPCRC) are lacking. We aimed to develop an effective risk stratification tool for the prediction of PPCRC in three large population-based cohorts and to validate the tool in a clinical cohort.

Methods

Leveraging the integrated endoscopic, histopathologic and epidemiologic data in three U.S population-based cohorts of health professional (the Nurses' Health Study (NHS) I, II and Health Professionals Follow-up Study (HPFS)), we developed a risk score to predict incident PPCRC among 26,741 patients with a polypectomy between 1986 and 2017. We validated the PPCRC score in the Mass General Brigham (MGB) Colonoscopy Cohort (Boston, Massachusetts, U.S) of 76,603 patients with a polypectomy between 2007 and 2018. In all four cohorts, we collected detailed data on patients' demographics, endoscopic history, polyp features, and lifestyle factors at polypectomy. The outcome, incidence of PPCRC, was assessed by biennial follow-up questionnaires in the NHS/HPFS cohorts, and through linkage to the Massachusetts Cancer Registry in the MGB cohort. In all four cohorts, individuals who were diagnosed with CRC or died before baseline or within six months after baseline were excluded. We used Cox regression to calculate the hazard ratio (HR), 95% confidence interval (CI) and assessed the discrimination using C-statistics and reclassification using the Net Reclassification Improvement (NRI).

Findings

During a median follow-up of 12.8 years (interquartile range (IQR): 9.3, 16.7) and 5.1 years (IQR: 2.7, 7.8) in the NHS/HPFS and MGB cohorts, we documented 220 and 241 PPCRC cases, respectively. We identified a PPCRC risk score based on 11 predictors. In the validation cohort, the PPCRC risk score showed a strong association with PPCRC risk (HR for high vs. low, 3.55, 95% CI, 2.59-4.88) and demonstrated a C-statistic (95% CI) of 0.75 (0.70-0.79), and was discriminatory even within the low- and high-risk polyp groups (C-statistic, 0.73 and 0.71, respectively) defined by the current colonoscopy surveillance recommendations, leading to a NRI of 45% (95% CI, 36-54%) for patients with PPCRC.

Interpretation

We developed and validated a risk stratification model for PPCRC that may be useful to guide tailored colonoscopy surveillance. Further work is needed to determine the optimal surveillance interval and test the added value of other predictors of PPCRC beyond those included in the current study, along with implementation studies.

Funding

US National Institutes of Health, the American Cancer Society, the South-Eastern Norway Regional Health Authority, the Deutsche Forschungsgemeinschaft.

Automated Detection of Anatomical Landmarks During Colonoscopy Using a Deep Learning Model

Background and aims

Identification and photo-documentation of the ileocecal valve (ICV) and appendiceal orifice (AO) confirm completeness of colonoscopy examinations. We aimed to develop and test a deep convolutional neural network (DCNN) model that can automatically identify ICV and AO, and differentiate these landmarks from normal mucosa and colorectal polyps.

Methods

We prospectively collected annotated full-length colonoscopy videos of 318 patients undergoing outpatient colonoscopies. We created three nonoverlapping training, validation, and test data sets with 25,444 unaltered frames extracted from the colonoscopy videos showing four landmarks/image classes (AO, ICV, normal mucosa, and polyps). A DCNN classification model was developed, validated, and tested in separate data sets of images containing the four different landmarks.

Results

After training and validation, the DCNN model could identify both AO and ICV in 18 out of 21 patients (85.7%). The accuracy of the model for differentiating AO from normal mucosa, and ICV from normal mucosa were 86.4% (95% CI 84.1% to 88.5%), and 86.4% (95% CI 84.1% to 88.6%), respectively. Furthermore, the accuracy of the model for differentiating polyps from normal mucosa was 88.6% (95% CI 86.6% to 90.3%).

Conclusion

This model offers a novel tool to assist endoscopists with automated identification of AO and ICV during colonoscopy. The model can reliably distinguish these anatomical landmarks from normal mucosa and colorectal polyps. It can be implemented into automated colonoscopy report generation, photo-documentation, and quality auditing solutions to improve colonoscopy reporting quality.

Bowel cleansing effectiveness and safety of 1L PEG + Asc in the real-world setting: Observational, retrospective, multicenter study of over 13000 patients

Background and study aims Effective bowel cleansing is critical for detecting lesions during colonoscopy, highlighting the importance of bowel preparations. 1L polyethylene glycol (PEG) + ascorbate (Asc) is the only recommended 1L PEG product in Europe and the United States. Its efficacy was demonstrated in large-scale controlled trials and confirmed in smaller-scale real-world studies. However, no large-scale real-world data exist. Patients and methods This observational, retrospective, multicenter study, used outpatient follow-up data from medical records from 10 centers in Spain and two in Portugal. Outpatients aged ≥18 years using 1L PEG + Asc as bowel preparation were included. The main outcome measures were overall adequate colon cleansing (Boston Bowel Preparation Scale [BBPS] score ≥6 with BBPS score ≥2 in each segment) and high-quality cleansing of the right colon (BBPS score=3). Results Data from 13169 eligible patients were included. Overall cleansing success was achieved in 89.3% (95%CI 88.7%-89.8%) and high-quality cleansing in the right colon in 49.3% (95%CI 48.4%-50.2%) of patients. For the overnight split-dose and same-day regimens, overall adequate quality cleansing success rate was 94.7% and 86.7% ( P <0.0001) and high-quality cleansing of the right colon rate was 65.4% and 41.4% ( P <0.0001), respectively. Colonoscopy was completed in 97.3% of patients, with non-completion due to poor preparation in only 0.8%; 2.3% of patients experienced at least one adverse event (AE). Conclusions This large-scale, real-world study demonstrates the effectiveness of 1L PEG + Asc in the total and right colon, with a low percentage of patients with AEs in routine clinical practice.

Effectiveness and safety of 1-L PEG-ASC versus other bowel preparations for colonoscopy: A meta-analysis of nine randomized clinical trials

BACKGROUND AND AIMS

A 1-L polyethylene glycol plus ascorbate (PEG-ASC) preparation has been recently developed to improve patients' experience in colonoscopy. This meta-analysis aimed to evaluate the effectiveness and safety of 1-L PEG-ASC compared with those of other bowel preparations for colonoscopy.

METHODS

MEDLINE, Embase, Scopus, and the Cochrane Library were systematically searched for randomized controlled trials comparing 1-L PEG-ASC with other bowel preparations published through July 2022. A random-effects model was applied for pooling the results; heterogeneity was expressed as I2.

RESULTS

Nine studies met the inclusion criteria and were included. The analysis showed significantly higher cleansing success (CS) (OR = 1.50; 95% CI = 1.25-1.81; p < 0.01, I2 = 0%) and right-colon high-quality cleansing (HQC) (OR = 1.67; 95% CI = 1.21-2.31; p < 0.01, I2 = 43%) with 1-L PEG-ASC compared to the other preparations. The pooled estimate of the adenoma detection rate (ADR) did not significantly differ between the two groups either in the overall (OR = 1.02; 95% CI = 0.87-1.20; p = 0.79, I2 = 0%) or split-dosing regimen subgroup analysis (OR = 0.99; 95% CI = 0.84-1.18; p = 0.94, I2 = 0%). A significantly higher pooled estimate of the number of patients with adverse events (AEs) (OR = 1.51; 95% CI = 1.23-1.84; p<0.01, I2 = 0%) and incidence of AEs (IRR=1.33; 95% CI = 1.11-1.58; p<0.01, I2 = 71%) was observed with 1-L PEG-ASC than with the other preparations. No serious AEs or deaths occurred.

CONCLUSIONS

Compared to other preparations, 1-L PEG-ASC yielded higher overall CS, higher right-colon HQC rates, and similar ADR. The number of patients with AEs and incidence of the total AEs were significantly higher with 1-L PEG-ASC in the absence of serious AEs.

Colorectal Cancer Screening Among Adults in Zuni Pueblo: Factors Associated with FOBT and Colonoscopy Utilization

Although strategies to mitigate barriers to colorectal cancer (CRC) screening have proven successful in some parts of the US, few of these strategies have been studied in rural, American Indian communities that may exhibit unique culturally driven attitudes toward and knowledge of colorectal cancer and experience increased barriers to healthcare access. In this study, we describe the results of a survey among CRC screen-eligible members of Zuni Pueblo (N = 218) on an array of questions regarding CRC screening behaviors, knowledge, satisfaction with and access to healthcare services, social support for CRC screening, perceptions toward FOBT, and preference for evidence-based interventions or strategies for improving CRC screening rates. Results from the multivariable model suggest age, having a regular healthcare provider, and harboring fewer negative perceptions toward FOBT are key drivers of ever completing CRC screening. Respondents reported strong support for Community Guide-recommended interventions and strategies for increasing CRC screening for nearly all proposed interventions. Results confirm the need for multilevel, multicomponent interventions, with a particular focus on improving Zuni Pueblo community members' access to a regular source of care, improving knowledge of CRC risk factor, and addressing negative perceptions toward CRC screening. These results provide critical, community-specific insight into better understanding the drivers of low guideline-adherent screening rates and inform local healthcare providers and community leaders of context-specific strategies to improve CRC screening in Zuni Pueblo.

A case report of a colouterine fistula treatment: when the patient chooses the steeplechase

Colouterine fistula is a rare disease that is primarily treated using surgical approaches. Although invasive surgery is controversial in terms of techniques and results, minimally invasive endoscopic treatments have not been widely described. However, because it is rare for these fistulas to close spontaneously, surgical treatment is often mandatory. Appropriate management of colouterine fistula is complicated, especially when the patient refuses surgery. In this case study, we provide the first description of a minimally invasive endoscopic treatment of an iatrogenic colouterine fistula using a self-expandable metallic stent after an over-the-scope clip malposition.

Visualization analysis of research on pre-colonoscopy bowel preparation

BACKGROUND

Bowel preparation is an essential step before colonoscopy, and its research topics are relatively scattered. Understanding the research status and development trend of bowel preparation is of great value for disease research and actual clinical work. However, there is currently a lack of research in this field in the form of bibliometrics.

AIM

To understand the research hotspots and development trends of bowel preparation during colonoscopy around the world.

METHODS

The literature about the topics of bowel preparation was retrieved from the CNKI, Wanfang, VIP, China Biomedical Literature Database (CBM), and Web of Science core datasets from the inception of the database to September 10, 2022. CiteSpace 6.1. R3 was used to visually analyze the annual number of publications, countries, institutions, authors, keywords, clusters, and co-citation literature.

RESULTS

A total of 2340 Chinese and 2574 English publications were included, and the number of annual publications showed an increasing trend from year to year. The author with the largest number of publications worldwide was Hassan Cesare, and the most productive countries included USA, Korea, UK, Italy, and China. Meng Xiao-Fen, Zhang Yuan-Yuan, and Niu Mei-E were the China's most prolific authors. The First Affiliated Hospital of Suzhou University, the General Hospital of the Chinese People's Liberation Army, and the Second Affiliated Hospital of Xi'an University were the most prolific institutions. Research hotspots focused on the quality of bowel preparation, the design of bowel preparation programs, and special groups for bowel preparation.

CONCLUSION

Studies related to bowel preparation have certain foundations, and China's research can follow international hotspots, but cooperation among countries still needs to be strengthened. We should expand the research output related to bowel preparation based on a broader population and more suitable for the development of the era of big data, to provide higher quality research evidence for clinical practice.

Current Status of Diagnosis and Treatment of Colorectal Cancer in Asian Countries: A Questionnaire Survey

INTRODUCTION

Diagnostic and therapeutic methods for colorectal cancer (CRC) have advanced; however, they may be inaccessible worldwide, and their widespread use is challenging. This questionnaire survey investigates the current status of diagnosis and treatment of early-stage CRC in Asian countries.

METHODS

Responses to the questionnaire were obtained from 213 doctors at different institutions in 8 countries and regions. The questionnaire consisted of 39 questions on the following four topics: noninvasive diagnosis other than endoscopy (6 questions), diagnosis by magnification and image-enhanced endoscopy (IEE) including artificial intelligence (AI) (10 questions), endoscopic submucosal dissection (ESD), proper use among other therapeutic methods (11 questions), and pathologic diagnosis and surveillance (12 questions).

RESULTS

Although 101 of 213 respondents were affiliated with academic hospitals, there were disparities among countries and regions in the dissemination of advanced technologies, such as IEE, AI, and ESD. The NICE classification is widely used for the diagnosis of colorectal tumors using IEE, while the JNET classification with magnification was used in countries such as Japan (65/70, 92.9%) and China (16/22, 72.7%). Of the 211 respondents, 208 (98.6%) assumed that en bloc resection should be achieved for carcinomas, and 180 of 212 (84.9%) believed that ESD was the most suitable in cases with a diameter larger than 2 cm. However, colorectal ESD is not widespread in countries such as Thailand, the Philippines, and Indonesia.

CONCLUSION

The promotion of advanced technologies and education should be continual to enable more people to benefit from them.

A Case of Pneumoperitoneum after Colonoscopy without Frank Perforation

Benign pneumoperitoneum can happen after colonoscopy, which shows itself as free air in the abdomen without symptoms or pneumoperitoneum without peritonitis. In this case, we reported a rare case of an elderly man who had acute abdominal stiffness after colonoscopy and observation of free air under the diaphragm that no perforation was observed in the intestine during laparoscopy and only one tiny intestinal tumor was randomly reported. There is no consensus on the treatment of pneumoperitoneum after colonoscopy. Patients with peritonitis benefit from laparoscopy but patients with micro perforation and asymptomatic patients benefit from intravenous antibiotic treatment and bowel rest.

Differentiating gastrointestinal tuberculosis and Crohn's disease- a comprehensive review

Gastrointestinal Tuberculosis (GITB) and Crohn's disease (CD) are both chronic granulomatous diseases with a predilection to involve primarily the terminal ileum. GITB is often considered a disease of the developing world, while CD and inflammatory bowel disease are considered a disease of the developed world. But in recent times, the epidemiology of both diseases has changed. Differentiating GITB from CD is of immense clinical importance as the management of both diseases differs. While GITB needs anti-tubercular therapy (ATT), CD needs immunosuppressive therapy. Misdiagnosis or a delay in diagnosis can lead to catastrophic consequences. Most of the clinical features, endoscopic findings, and imaging features are not pathognomonic for either of these two conditions. The definitive diagnosis of GITB can be clinched only in a fraction of cases with microbiological positivity (acid-fast bacilli, mycobacterial culture, or PCR-based tests). In most cases, the diagnosis is often based on consistent clinical, endoscopic, imaging, and histological findings. Similarly, no single finding can conclusively diagnose CD. Multiparametric-based predictive models incorporating clinical, endoscopy findings, histology, radiology, and serology have been used to differentiate GITB from CD with varied results. However, it is limited by the lack of validation studies for most such models. Many patients, especially in TB endemic regions, are initiated on a trial of ATT to see for an objective response to therapy. Early mucosal response assessed at two months is an objective marker of response to ATT. Prolonged ATT in CD is recognized to have a fibrotic effect. Therefore, early discrimination may be vital in preventing the delay in the diagnosis of CD and avoiding a complicated course.

Strategies to manage the difficult colonoscopy

During endoscopy, an endoscopist is inevitably faced with the occasional “difficult colonoscopy,” in which the endoscopist finds it challenging to advance the endoscope to the cecum. Beyond optimization of technique, with minimized looping, minimal insufflation, sufficient sedation, and abdominal splinting when needed, sometimes additional tools may be needed. In this review, we cover available techniques and technologies to help navigate the difficult colonoscopy, including the ultrathin colonoscope, rigidizing overtube, balloon-assisted colonoscopy and the abdominal compression device.

Abdominal Ultrasonography After Transrectal Filling With Contrast Agents in Colorectal Cancer With Severely Stenotic Lesions

OBJECTIVE

Abdominal ultrasonography after transrectal filling with contrast agent (AU-TFCA) was retrospectively evaluated with respect to determination of T stage and lesion length in patients with colorectal cancer (CRC) who had previously failed colonoscopy because of severe intestinal stenosis.

METHODS

The population comprised 83 patients with CRC with intestinal stenosis and previously failed colonoscopy who underwent AU-TFCA, and in addition contrast-enhanced computed tomography (CECT) and/or magnetic resonance imaging (MRI), 2 wk before surgery. The diagnostic performance of AU-TFCA and CECT/MRI was evaluated relative to the post-operative pathological results (PPRs) by paired sample t-test, receiver operator characteristic (ROC) curve, Pearson's χ²-test and κ and intraclass correlation coefficients.

RESULTS

The T staging identified via AU-TFCA, but not CECT/MRI, was relatively consistent with that of the PPRs (linearly weighted κ coefficient: 0.558, p < 0.001, and linearly weighted κ coefficient: 0.237, p < 0.001, respectively). The overall diagnostic accuracy of T staging based on AU-TFCA (83.1%) was significantly higher than that based on CECT/MRI (50.6%). Regarding lesion length, the results of AU-TFCA and PPRs were comparable (t = 1.852, p = 0.068), but those of CECT/MRI and PPRs were significantly different (t = 8.450, p < 0.001).

CONCLUSION

AU-TFCA is effective in evaluation of lesion length and T stage in patients with severely stenotic CRC lesions who previously failed colonoscopy. The diagnostic accuracy of AU-TFCA is significantly better compared with that of CECT/MRI.

Yield and cost of government-organized colorectal cancer screening in young high-risk population in Northeast China

Guidelines for colorectal cancer (CRC) screening recommend screening at age 40 for high-risk population in China. However, the yield and cost of CRC screening in younger population are lacking. This analysis aimed to evaluate the yield and cost of CRC screening in high-risk 40- to 54-year-olds. Individuals aged 40-54 years who were determined to have a high risk of CRC were recruited from December 2012 to December 2019. We calculated odds ratios (OR) and 95% confidence intervals (CI) for the detection rate of colorectal lesions among the three age groups and further calculated number of colonoscopies needed to screen (NNS) to detect one advanced lesion and cost of each group. The detection rates of advanced colorectal neoplasm in men aged 45-49 years (OR = 2.00, 95% CI: 0.93-4.30) and 50-54 years (OR = 2.19, 95% CI: 1.04-4.62) were higher than that aged 40-44 years. The detection rates of colorectal adenoma in women aged 50-54 years was higher than that aged 40-44 years (OR = 1.64, 95% CI: 1.23-2.19). Among the male screening population, NNS and cost to detect one advanced lesion in participants aged 45-49 years were similar to that aged 50-54 years, saving approximately half endoscopic resources and financial expenses compared with screening that aged 40-44 years. From the perspective of screening results and costs, it might be beneficial to delay the starting age of screening by gender. This study may provide reference for optimizing CRC screening strategies.