Sigmoidoscopic examinations with rigid and flexible fiberoptic sigmoidoscopes in the surgeon's office: a comparative prospective study of effectiveness in 1,012 cases

General Practitioner Referral of Patients with Lower Gastrointestinal Symptoms

Of 500 consecutive patients with symptoms of colorectal disease referred to a specialist hospital for outpatient assessment, 305 were studied. There was a low incidence of examination by the general practitioner; less than half the patients had a rectal examination and 31% had no examination at all. In cases where GPs made a diagnosis, this was correct in half, which both demonstrates the potential for dangerous misdiagnosis and confirms the fact that many anorectal conditions can be identified by the history alone.

It is suggested that direct-access clinics in a colorectal unit would minimize delay in accurate diagnosis. The resource implications for such a system would be limited in terms of special investigations and additional clinic facilities.

Accuracy of Double Contrast Barium Enema and Sigmoideoscopy in the Detection of Polyps in Patients with Diverticulosis

The sensitivity between double contrast barium enema (DCBE) and sigmoideoscopy in diagnosing neoplastic lesions in the sigmoid colon was compared in patients with diverticulosis. In 52 patients with severe diverticulosis (≥15 diverticulas) the DCBE detected one out of 4 polyps found by sigmoideoscopy. In the remaining 54 patients with mild diverticulosis (<15 diverticulas) DCBE detected 7 out of 10 polyps found by sigmoideoscopy. Successful bowel preparation did not influence the outcome of the DCBE. Sigmoideoscopy was incomplete in 17 (16%) of the patients; females were more difficult to examine than males (p= 0.012), as were those with a previous pelvic operation (p= 0.032). We conclude that neither DCBE nor sigmoideoscopy alone is sufficient to detect all neoplastic lesions in the sigmoid colon in patients with sigmoid diverticulosis of the colon.

Rigid or flexible sigmoidoscopy in colorectal clinics? Appraisal through a systematic review and meta-analysis

AIM

Rigid sigmoidoscopy is sometimes performed at first presentation in colorectal clinics. We assessed the feasibility of flexible sigmoidoscopy in similar situations by comparing it with rigid sigmoidoscopy as a first investigative tool.

METHODS

The Medline, Embase, and Cochrane databases were searched for randomized and non-randomized clinical trials comparing the usefulness of rigid and flexible sigmoidoscopy. The risk difference (RD) and weighted mean difference (WMD) were calculated for the cancers/abnormalities detected and discomfort associated with the procedure, respectively. The standard mean difference (SMD) was calculated for the depth of examination and duration of the procedure.

RESULTS

Flexible sigmoidoscopy had a significantly higher rate of detection of cancers and total abnormalities (RD of 0.020 and 0.138 and 95% confidence interval [CI] of 0.006-0.034 and 0.077-0.200, respectively), and rigid sigmoidoscopy caused significantly more patient discomfort (WMD of 0.981 and 95% CI of 0.693-1.269). Flexible sigmoidoscopy provided significantly greater depth of examination (SMD of 3.175, 95% CI of 2.397-3.954), and rigid sigmoidoscopy required less time (SMD of -1.601, 95% CI of -2.728 to -0.474).

CONCLUSIONS

Flexible sigmoidoscopy is a better investigative tool in colorectal clinics than the rigid sigmoidoscopy. Implementation of this idea can help in early diagnosis at first presentation and can certainly expedite the management of colorectal malignancies.

Patient satisfaction with residents vs attending following fluoroscopy-guided pain injections

OBJECTIVE

Patient satisfaction has been the object of interest in health care for some time and is now increasingly used as the basis for quality management and improvement. This study compares patient satisfaction between residents and attending in a pain clinic setting following fluoroscopy-guided steroid injections.

DESIGN

This is a retrospective cohort design study.

SETTING

The study was performed at an academic university pain management center.

SUBJECTS

A total of 242 patients (119 female and 123 male) presenting with low back pain were evaluated and offered fluoroscopically guided steroid injections as part of a conservative care treatment plan.

INTERVENTIONS

All injections were performed consecutively over a 4-month period by one attending and three senior residents (two anesthesia and one psychiatry resident). A staff member specifically asked each participant about their satisfaction following the procedure. Answers were documented as "Expected,""Better," or "Worse" than expected.

OUTCOME MEASURES

Two main outcome measures were recorded: 1) table and fluoroscopy time for residents and attending, and 2) patient satisfaction through subjective reporting.

RESULTS

Overall, residents had longer mean table time and mean fluoroscopy time as compared with the attending physician (P < 0.05). Patients treated by residents were more often likely to rate their experience as "worse" compared with those treated by the attending (P < 0.05). Otherwise, the proportion of patients rating their experience "as expected" or "better" was not significantly different statistically between the two groups. In addition, as table time increased, satisfaction level decreased in both resident and attending groups.

CONCLUSION

Patients treated by residents are more likely to rate their experience as worse compared with the attending. However, majority of patients in both groups were satisfied in that they perceived their procedure as expected or better than expected.

Nurse led flexible sigmoidoscopy in primary care--the first thousand patients

OBJECTIVES

Secondary care Trusts have traditionally been providers of flexible sigmoidoscopy services in the United Kingdom. The aim of this study was to establish a Nurse-led flexible sigmoidoscopy clinic that would provide a patient orientated service in a primary care setting.

PATIENTS AND METHODS

A protocol driven flexible sigmoidoscopy clinic was established in a primary care setting. The first thousand patients who underwent flexible sigmoidoscopy at the community clinic were prospectively studied.

RESULTS

A nurse endoscopist performed 1002 procedures on 1000 patients. Median time from referral to flexible sigmoidoscopy was 35 days (Range 1-180 days). Two hundred and twenty-two (22%) patients were diagnosed with significant colonic pathology including 25 (2.5%) patients with colorectal cancer. Median time from referral to histological diagnosis of colorectal cancer was 26 days (range 7-87 days). No complications were encountered. Patients who required further follow-up were referred to a Consultant led (29%) or Nurse led clinic (5%) in secondary care. Patient satisfaction as assessed by postal questionnaire indicated that 447 (99%) patients were satisfied with the service.

CONCLUSIONS

A community endoscopy clinic can provide a safe and effective flexible sigmoidoscopy service with high levels of patient satisfaction. Nurse Endoscopists can extend their role in primary care with adequate training and support from secondary care hospitals.

Comparison of rigid vs flexible sigmoidoscopy in detection of significant anorectal lesions

OBJECTIVE

Sigmoidoscopy is an essential tool in colorectal clinics in the detection of anorectal lesions including rectosigmoid adenomas and carcinomas. However, rigid sigmoidoscope (RS) is still more widely used than flexible sigmoidoscope (FS) as the primary investigation, despite the fact that the latter is more comfortable to the patient and has greater diagnostic yield. Hence we wanted to compare the two modalities in terms of diagnostic use for picking up significant anorectal lesions.

METHODS

A retrospective review of all patients referred to the colorectal clinic who had undergone both rigid and flexible sigmoidoscopy for investigation of colorectal symptoms in 2001 was done. Findings recorded during rigid and flexible sigmoidoscopy including depth of insertion, site of lesion and complications were analysed.

RESULTS

152 patients underwent both rigid and flexible sigmoidoscopy as part of investigation of colorectal symptoms. Of the 115 (75.6%) declared normal by RS, 39 (33.9%) had significant lesions including 7 polyps and 4 malignant lesions within 20 cm of the anal verge during FS. Of the 31 patients (20.4%) in whom RS was not helpful due to faecal loading, 15 (48.4%) had significant lesions including 4 malignancies and 1 polyp --all within 20 cm of the anal verge during FS. Only 2 polyps and 1 malignant lesion were picked up by both flexible and rigid sigmoidoscopy. There were no complications in both procedures.

CONCLUSION

Since flexible sigmoidoscopy is superior to rigid sigmoidoscopy in terms of patient comfort, diagnostic value and ease of doing procedures like biopsy and polypectomy; it can be used as a front line investigation to exclude colorectal pathology in out patient clinics. The utility of rigid sigmoidoscope is in question and in view of obvious shortcomings, may be replaced by flexible sigmoidoscopy, though obvious resource constraints need to be considered.

The yield of colonoscopy in average-risk patients with non-specific colonic symptoms

OBJECTIVES

The need for full colonoscopies in average-risk patients with non-specific colonic symptoms is controversial. We aimed to evaluate: (1) the yield of full colonoscopy; (2) the prevalence of proximal neoplasia in these patients; (3) the yield if any of doing full colonoscopies to diagnose proximal lesions in patients in whom the distal colon was clear; (4) the significance of this yield with respect to age.

DESIGN

This is a retrospective analysis to assess the value of open access colonoscopy.

PATIENTS AND METHODS

All patients who underwent a colonoscopy in our Endoscopy Unit during January 1996 to December 1999 were assessed (n = 3357).

RESULTS

We analysed 945 patients with average risk and non-specific colonic symptoms (significant risk factors excluded). The overall yield of adenomas was 5.8%. The yield of distal adenomas in patients > or= 50 years of age was 8.2% (37 out of 450) versus 0.2% in the 50 years group (one out of 495; = 0.0001). The proximal adenoma yield in > or= 50 year olds was 3.8% (17 out of 495) versus 0.2% in < 50 year olds (one out of 495) (P = 0.0001).

CONCLUSIONS

In a cohort of average-risk patients with non-specific colonic symptoms attending an "open access" colonoscopy clinic, the yield for proximal adenomas is small in the < 50 years group. In patients aged < 50 years, distal colonic examination is all that is required, whereas a full colonoscopy may be justified in patients > or = 50 years old.

Flexible sigmoidoscopy in general practice

OBJECTIVE: Flexible sigmoidoscopy (FS) is increasingly being accepted as the method of choice for initial investigation of rectal bleeding and other lower gastrointestinal symptoms. The aim of this study was to assess the feasibility of FS in general practice and to compare the yield, cost and efficiency of a service provided by a consultant surgeon and a General Practitioner (GP). SUBJECTS AND METHODS: A prospective study of FS was undertaken on 430 unsedated patients with symptoms suggestive of lower bowel disease in two general practices. RESULTS: The yield was comparable to hospital based data. Fifteen (3.5%) cancers were detected, of which 40% were Dukes A, and 46 (10.7%) adenomatous polyps. Cost per patient examination by a GP including capital costs, depreciation of equipment, and training was calculated to be cheaper or at least equivalent to a hospital-based service but inefficient due to the low numbers examined per month. There were no complications and no missed cancers after a minimum follow up of 2 years. CONCLUSIONS: The results suggest that FS can be safely performed by a suitably trained GP in health centres, but better utilization of equipment and value for money would be obtained by providing the service for a group of practices rather than a single practice as in this study.

Rationale for colonoscopy screening and estimated effectiveness in clinical practice

Colonoscopy screening has the highest anticipated level of effectiveness of the available colorectal cancer screening techniques. Its long-term cost-effectiveness is also comparable with or superior to other modalities. Evidence for the expected reduction in colorectal cancer incidence and mortality varies with colonoscopy screening from 50% to 90%, for reasons that are not fully understood. Maintaining a high standard of performance is critical with regard to achieving the highest level of effectiveness possible.

Resident participation in flexible sigmoidoscopy does not affect patient satisfaction

OBJECTIVE

We sought to assess the effect of resident involvement in flexible sigmoidoscopy on patient satisfaction and comfort.

METHODS

Adults undergoing flexible sigmoidoscopy completed a previsit questionnaire on indication for procedure, GI-related history, and functional status. Immediately after the procedure, satisfaction and procedure comfort were assessed. Additional information collected included procedure duration, depth of sigmoidoscope penetration, and visualization of diverticuli or polyps.

RESULTS

Among 408 endoscopies, patient characteristics and procedure indications were similar between sigmoidoscopies done by residents (n = 111) or staff. There were no differences in patient satisfaction, procedure comfort, or willingness to undergo the procedure again in the future. Sigmoidoscopies involving residents averaged 5.6 min longer, even after adjusting for preparation quality, depth of insertion, specific endoscopist, and the presence of polyps or diverticuli.

CONCLUSIONS

Patient satisfaction and comfort with flexible sigmoidoscopy was not reduced by resident involvement, though the procedure duration was slightly longer.

Intravenous antispasmodic and patient-controlled analgesia are of benefit for screening flexible sigmoidoscopy

The possible benefits of premedication with the antispasmodic hyoscine n-butyl bromide (hyoscine) and analgesia with inhaled nitrous oxide/oxygen mixture (nitrous oxide) were assessed in a double-blinded, placebo-controlled trial. Consecutive patients at normal risk for cancer undergoing screening flexible sigmoidoscopy were randomly allocated to receive either (1) intravenous hyoscine 20 mg plus inhaled oxygen on demand (n = 40), (2) sterile water injection plus inhaled nitrous oxide on demand (n = 48), or (3) sterile water injection plus inhaled oxygen on demand (n = 43). One recently trained primary care physician performed all procedures. Duration of the procedure, endoscopic findings, and depth of insertion were recorded. After the examination, screenees rated their degree of pain during the procedure using a visual analogue scale. Depth of insertion did not differ between the three study groups, but the duration of the procedure was significantly less in the hyoscine group (median, 12.5 minutes) as compared with placebo (median, 18 minutes; p = .0008). Fifty-four percent of screenees chose to use the on-demand gas. Pain scores were significantly lower in those individuals who inhaled nitrous oxide as compared with placebo (p = .045). Premedication with antispasmodic shortens total procedure time for flexible sigmoidoscopy by a moderately experienced endoscopist as compared with placebo. In this study, a significant number of screenees experienced discomfort during flexible sigmoidoscopy, which appeared to be reduced by offering nitrous oxide inhalation.

The yield of a second screening flexible sigmoidoscopy in average-risk persons after one negative examination

BACKGROUND/AIMS

The American Cancer Society recommends that asymptomatic persons aged > or = 50 years undergo sigmoidoscopy every 3-5 years. However, the yield of a second examination 3 years later in persons who are initially negative is unknown. The aim of this study was to determine the yield of a second flexible sigmoidoscopy in average-risk persons aged > or = 50 years after an initial negative examination.

METHODS

Two hundred fifty-nine asymptomatic, average-risk persons who had undergone a negative screening flexible sigmoidoscopy examination at age > or = 50 years underwent a second examination at least 2 years later (mean, 3.4 years).

RESULTS

The second examination found adenomas in 15 (6%) screenees, but no cancers or large (> 1 cm) or severely dysplastic adenomas were detected. Persons aged > or = 60 years at the time of the second examination were more likely (10%) to have adenomas than those < 60 years (3%) (odds ratio, 3.76; 95% confidence interval, 1.17-12.2), but no advanced lesions were found in persons aged > or = 60 years.

CONCLUSIONS

These data suggest that the American Cancer Society should consider changing its recommendation for screening flexible sigmoidoscopy in asymptomatic, average-risk persons to 5-year intervals after a negative examination.

Screening for colorectal cancer by nurse endoscopists

BACKGROUND

Case-control studies have demonstrated that screening by sigmoidoscopy is effective in reducing mortality from colorectal cancer. If nurses performed screening examinations, more patients could be screened and, at current income levels, at a lower cost.

METHODS

Two registered nurses and two licensed practical nurses learned to perform examinations with the flexible fiberoptic sigmoidoscope in order to screen patients for colorectal tumors. They performed 1881 independent examinations of outpatients more than 45 years of age. During the same period, 730 examinations were performed by two gastroenterologists in similar patients.

RESULTS

The mean depth of insertion of the sigmoidoscope was slightly but significantly greater in the patients examined by the physicians than in those examined by the nurses (48 vs. 46 cm in men, P = 0.003; 41 vs. 38 cm in women, P = 0.002). Adenomas were found in 14 percent of the men and 8 percent of the women examined (P = 0.001). Nine cancers were found in men and four in women. There were no significant differences between the nurses and the physicians in the proportion of examinations that were positive for adenomas or cancer. No complications occurred during the initial examinations or during 894 follow-up sigmoidoscopic procedures. Among the patients whose initial examination results were normal, more of those examined by nurses returned for follow-up sigmoidoscopy after 12 months or more (45 percent, vs. 30 percent of those examined by physicians; P = 0.001).

CONCLUSIONS

Nurses can carry out screening by flexible sigmoidoscopy as accurately and safely as experienced gastroenterologists.

Cost-effectiveness analysis of strategies for colorectal cancer screening in Japan

To determine the cost-effectiveness of colorectal cancer screening strategies in Japan and to determine the influence of long-term compliance with screening programs on the selection of strategies, the natural history of a simulated cohort of 40-year-old Japanese of both genders was modeled with and without colorectal cancer screening until age 75 years. Survival, number of complications, and direct medical costs were compared among several combinations of screening examinations. In addition, the age of initiating screening was varied, as was the long-term compliance rate. Strategies using immunological fecal occult blood test were found to be the most cost-effective. Immunological fecal occult blood test followed by colonoscopy, if positive, would save 24.05 (5.88 discounted) days of life and cost 28,420 yen (US $210) per screened person, thus offering a cost-effectiveness ratio of 1.765 million yen (US $13,100) per year of life saved. If long-term compliance is 100%, initiating screening at age 40 years offers more years of life saved and a low incremental cost of screening. However, if more likely dropout rates are considered, initiation at age 40 years is dominated by later initiation of screening.

Prevention of colorectal cancer by once-only sigmoidoscopy

There is no national screening programme for colorectal cancer in the UK despite the fact that the annual death toll from this disease exceeds that of breast and cervical cancer. Faecal occult blood testing (FOBT) is under evaluation for screening, but screening by sigmoidoscopy is not considered viable. This situation contrasts with the USA where both annual FOBT and screening by flexible sigmoidoscopy every 3 to 5 years are recommended from 50 years old. We seek to demonstrate that most of the benefit from the US screening policy would accrue from a single flexible sigmoidoscopy examination at age 55 to 60 years with appropriate colonoscopic surveillance for the 3% to 5% found to have high-risk adenomas (> or = 1 cm or villous histology). If applied nationally, this screening regimen could prevent about 5500 colorectal cancer cases and 3500 deaths in the UK each year, thus saving 40,000 years of life. We estimate that there would be little net cost to the National Health Service because savings obtained from treating fewer patients would largely offset the cost of screening. We recommend that a randomised trial to evaluate screening by single flexible sigmoidoscopy should start without delay. Such a trial would involve about 120,000 participants, and 15 years of follow-up would be required to obtain a clear answer on mortality, although information on incidence reduction would be available sooner.

Screening flexible sigmoidoscopy: patient attitudes and compliance

OBJECTIVE

To measure patients' expectations and attitudes about screening flexible sigmoidoscopy and their discomfort during the procedure, and to identify factors affecting compliance among patients scheduled for sigmoidoscopy.

DESIGN

Patient survey at the time sigmoidoscopy was ordered and again one week after the procedure was performed.

SETTING

An academic general internal medicine practice.

PATIENTS

105 consecutive patients scheduled for screening flexible sigmoidoscopy.

MAIN RESULTS

Seventy-five percent of patients (79/105) scheduled for sigmoidoscopy complied with the procedure. Compliance was higher among men and among patients who had family histories of colon cancer. Although many patients experienced moderate to extreme embarrassment (27%), discomfort (42%), and pain (31%), patients experienced less embarrassment (p = 0.03) and pain (p = 0.02) than they had expected. Patients aged 65 years and older were twice as likely as younger ones (52% versus 25%) to experience moderate to extreme pain (p = 0.04). Only 1.4% of patients reported that they would probably not have the test again.

CONCLUSION

Although flexible sigmoidoscopy is an uncomfortable procedure for some patients, especially those aged 65 and older, in general it is not as bad as patients expect and most would have the test again. Therefore, rather than assuming sigmoidoscopy is too uncomfortable for all patients to tolerate as a screening test, clinicians should inform their patients about the potential benefits and risks of sigmoidoscopy and about what the patient can expect during the procedure, thus enabling the patient to make an informed decision about whether to undergo screening sigmoidoscopy.

Screening for large bowel neoplasms in individuals with a family history of colorectal cancer

Logistical problems associated with population screening for colorectal cancer are identified and the possibility of targeting screening to those with a familial predisposition to the disease is discussed. Evidence for a substantial genetic effect on the overall incidence of colorectal cancer is reviewed. The screening detection rate of colorectal neoplasms in relatives of patients with colorectal cancer has been shown to be higher than that expected in a non-selected population; the evidence that polypectomy will reduce future colorectal cancer risk in such individuals is explored. Recent advances in the molecular genetics of colorectal cancer susceptibility are reviewed; it is possible that a genetic test might be developed in the future which could identify at least a proportion of those at risk. Excluding financial considerations, the risk-benefit ratio of colonoscopy in a screened population is intimately related to the remaining risk of colorectal cancer in those who undergo the examination. At present, patients undergoing colonoscopy to investigate a positive faecal occult blood (FOB) test as part of a population-based screening programme include individuals with a familial predisposition as well as those without. About 20 per cent of all cases of colorectal cancer are associated with an obvious genetic predisposition, and the risk of cancer in their relatives is high. Because false positives occur with Haemoccult, the residual risk to the population who are FOB positive but do not have a familial trait may be sufficiently low that the dangers of colonoscopy could outweigh the potential benefits. Scotland has a high incidence of colorectal cancer, and analysis of recent Scottish incidence data shows an actuarial lifetime risk of developing this disease of one in 23 for men and one in 33 for women. As a family history of the disease increases that risk by two to four times and the neoplasms arise throughout the colon in such a group, there may be a case for offering colonoscopy to all first-degree relatives of those under 50 years of age at diagnosis, if not of all index cases of colorectal cancer.

Barium enema versus colonoscopy for patients with polyps found during flexible sigmoidoscopy

This prospective study compares the accuracy of barium enema examination performed by experienced radiologists to colonoscopy performed by experienced gastroenterologists blinded to the radiographic findings to detect proximal, synchronous lesions in patients with polyps detected during fiberoptic sigmoidoscopy. Three thousand six patients were examined, of whom 147 (5%) had polyps larger than 0.5 cm in diameter. Of 114 patients who completed the protocol, 46 patients (40%) had synchronous, proximal colonic lesions. There were no radiographic false positives, but the single-contrast barium enema missed polyps in 13 while detecting polyps in 2 patients (sensitivity = 13%). The double-contrast barium enema missed proximal polyps in 23 patients while detecting them in 8 (sensitivity = 26%). We conclude that patients with neoplastic polyps found during fiberoptic sigmoidoscopy should have colonoscopy without barium enema. If the entire colon cannot be examined at colonoscopy, we advise double-contrast barium enema.

Colon cancer and polyps in acromegaly: increased risk associated with family history of colon cancer

A cohort of 52 subjects diagnosed with acromegaly in southeastern Michigan and northern Ohio between 1935 and 1985 were followed to determine the incidence of colon cancer and polyps. Medical records were reviewed, subjects or their next-of-kin were interviewed, and screening examinations of the colon were offered to the living patients who were located. Data on demographics, personal histories of cancer and colon polyps, family history of colon cancer, and cure from acromegaly were obtained for both living and deceased subjects. The risk for colon cancer compared to the general population was estimated using standardized incidence ratios (SIRs). The expected number of cases was determined utilizing age, sex and race-specific rates provided by the cancer registry in southeastern Michigan. Among the 52 subjects, one could not be located and nine were deceased, none from colon cancer, with one known to have a history of colon polyps. Of 13 (31%) who declined the screening physical, one had a history of polyps and none reported a history of colon cancer. Two of 29 screened patients were found to have right-sided adenocarcinoma of the colon. Of the entire cohort, eight people (including one deceased) had a current or previous diagnosis of polyps, with five known to be histologically adenomatous. The SIR for colon cancer was 4.7 (95% confidence interval 0.6-17.1). Seven subjects, including the two with detected adenocarcinoma and four of the six living subjects with polyps only, reported a family history of colon cancer. The SIR for the subset of subjects with a family history of colon cancer was 29.1 (95% confidence interval of 3.5-104.6).(ABSTRACT TRUNCATED AT 250 WORDS)

Avoidance of sedation during total colonoscopy

A prospective study of the necessity of sedation, or analgesia, or both in total colonoscopy was performed. The procedures were performed in the office on 212 consecutive, nonselected patients. Intravenous sedation was not started initially, and all procedures were begun without medication. If the patient developed significant discomfort or sharp pain, intravenous diazepam (Valium, Roche, Nutley, NJ) or midazolam (Versed, Roche, Nutley, NJ) was given. Total colonoscopy was successful in 201 (95 percent) patients. Of these procedures, 173 (82 percent) patients required no analgesia or sedation. In the remaining 39 (18 percent) patients, only small doses of Valium or Versed were necessary. There were 2 (1 percent) complications, but they were directly related to polypectomy (stalk bleeding, serosal burn) and not to the colonoscopy. Patient acceptance was high because most of the patients were able to leave the office immediately after the procedure and many (at least 82 percent) were able to return to work or resume normal activities that same day. Intravenous sedation is routinely used during total colonoscopy by most practitioners and is considered the standard of care in most communities. However, the need for sedation during total colonoscopy has never been proven and is probably not necessary in most cases. Furthermore, when sedation is necessary, most patients are probably over-anesthetized. This is significant, as it may make total colonoscopy more accessible, less expensive, and safer.

Colonoscopic diagnosis and treatment of lower gastrointestinal bleeding

Methods of diagnosis and treatment of lower gastrointestinal bleeding depend on the rate of bleeding and the amount of blood lost. If bleeding is occult, colonoscopy is the single best way to determine the source, if bleeding is gross but mild, causing melena or small amounts of hematochezia, colonoscopy or a combination of flexible sigmoidoscopy and double-contrast barium enema should be used to evaluate the colon. In most patients with melena, the upper tract must be examined endoscopically. Acute lower gastrointestinal bleeding stops spontaneously in 75 to 90 per cent of patients, permitting preparation of the colon before colonoscopy. If bleeding is continuing, diagnostic options include colonoscopy with no preparation of the colon, relying on the cathartic effect of blood, or a red cell radionuclide scan followed by angiography if the scan is positive. A bleeding lesion seen on angiography is usually treated by infusion of vasopressin. Colonoscopic treatment of a bleeding site uses the BICAP probe, heater probe, or argon laser. Patients who bleed severely and those who do not respond to treatment or rebleed after treatment are candidates for operation. Segmental resection is preferred if the bleeding site is known. If not, total colectomy with ileorectal anastomosis may be necessary. A mortality rate of 10 to 15 per cent in patients with severe bleeding reflects the advanced age of many of these patients and the difficulty of managing gastrointestinal bleeding in the presence of associated medical conditions.

Flexible fiberoptic sigmoidoscopy training for primary care physicians: results of a 5-year experience

The first 5 years of a flexible fiberoptic sigmoidoscopy (FFS) training program for primary care physicians was analyzed in an attempt to assess clinical competence and develop a procedure learning curve. A total of 47 primary care physicians (26 third-year family practice residents, 15 family practitioners, and 6 internists) were successfully trained in 60-cm FFS by five gastroenterologists. Didactic teaching methods included 5 hours of videotapes, slides, endoscopic models, and the use of a photo atlas. Following a patient demonstration, each trainee completed 25 examinations supervised with a teaching attachment. Criteria used to assess trainee competence included unassisted length of scope insertion and examination duration. Mean depth of scope insertion was 35.9 cm for the first five examinations, increasing to a mean of 51.7 cm for the final five examinations. Average examination duration decreased from 19.1 min for examinations 1 through 5 to 17.0 min for examinations 21 through 25. Out of 1236 examinations, one or more polyps were found in 222 patients (18.0%). Carcinoma was found in 15 of 1236 examinations (1.4%). In summary, experienced endoscopists can teach primary care physicians to perform 60-cm FFS. Completion of 25 supervised cases appears to be adequate for achieving technical competence in flexible fiberoptic sigmoidoscopy.

Fiberoptic sigmoidoscopy as the first screening procedure for colorectal neoplasms in an asymptomatic population

As the first screening for colorectal neoplasms, a total of 2243 examinations by fiberoptic sigmoidoscopy (FS) were performed on 1573 asymptomatic patients. One hundred seventy neoplasms were found in 134 patients (6 percent of total examinations), including nine adenocarcinomas (0.4 percent). A flat, intramucosal cancer and a small, 5-mm cancer detected by FS could not be demonstrated by barium enema examination. On further investigation, additional adenomas were identified in the proximal colon in 22 percent of patients in whom neoplasms had first been detected by FS and in only 4.4 percent of those in whom FS findings were negative but other criteria were positive. It is concluded that FS is the procedure of choice for the first screening of asymptomatic patients, not only because it enables detection of flat and small lesions within its observation range, but also because it could lead to detection of proximal neoplasms.

Screening for colorectal cancer: a critical review

This article discusses the place of symptom detection, endoscopy, and fecal occult blood testing in population screening for colorectal cancer. There is now considerable evidence that screening the population over the age of 50 years for occult blood in the feces will result in an increased yield of tumors localized to the bowel at the time of surgical treatment. These tumors also have other favorable prognostic features and it is likely that the prognosis of this group will be better than the prognosis of patients presenting with symptoms in the usual way. Because of the biases that result from the selection and detection of tumors in screening studies, the mortality results of the control trials now underway must be awaited until it is known whether population screening is of real value. In chemical fecal occult blood screening tests, a compromise has to be made between sensitivity and specificity. The fecal occult blood test most widely used and the one that has been subjected to the most evaluation in screening studies is the guaiac-based slide test, Hemoccult. The predictive value of a positive test for invasive cancer is 11-17%, and for adenomas, 36-41%. This specificity is achieved at a loss of sensitivity, the interval cancer rate reported in screening studies being over 20%. Newly developed immunological techniques appear to be more sensitive and specific, but require further evaluation in population screening studies.

Strategies for screening for colorectal carcinoma

Four tests commonly used in screening strategies to detect colorectal cancer were examined from a cost-effectiveness perspective. Thirteen combinations of the tests were evaluated. Evaluating a positive fecal occult blood test with a double-contrast barium enema study, followed, if necessary, by colonoscopy, is the most cost-effective strategy for individuals at average risk. An alternative screening strategy for higher-risk individuals or for populations in which the frequency of adenomatous polyps is higher is to follow a positive fecal occult blood test directly with colonoscopy. Sensitivity analysis demonstrated that the superior cost-effectiveness of these two strategies compared with the other 11 modeled strategies is almost independent for reasonable alterations in test cost and for the sensitivities and specificities of the procedures. The major contributing factor to the diagnostic cost is the frequency of adenomatous polyps. The major contributing factor to the marginal cost per year of extended life is the frequency of cancer.

Colorectal cancer detection with the 60 cm flexible sigmoidoscope in a solo general internist's office

Emphasis is placed on the importance of early detection of colorectal cancer by the primary care physician using the 60 cm flexible sigmoidoscope. A training format for this procedure is proposed. The author, trained according to this format, found 49 polyps and three carcinomas among his first 365 randomly chosen patients. Of these 317 (87%) were asymptomatic, having no risk factors. The average distance of insertion was 53 cm and the average examination time was 20 minutes. The calculated cost for these 365 patients was approximately +60,000, and the estimated average cost for a potentially curable colorectal cancer detection was approximately +20,000. Although a relatively long examination time may be necessary for the beginner, the author concludes that the primary care physician can be readily trained to handle the 60 cm flexible sigmoidoscope safely and cost effectively.

Role of sigmoidoscopy in screening for colorectal cancer: a critical review

The use of sigmoidoscopy as a screening method for colorectal cancer is controversial. Evidence regarding its efficacy is reviewed critically, with special attention given to potential biases in screening studies. The vast majority of studies are uncontrolled and without follow-up information and thus shed little light on the actual benefits of sigmoidoscopy. Two uncontrolled studies with follow-up and one randomized trial suggest a colorectal cancer mortality reduction because of the use of sigmoidoscopy, but all three studies have major shortcomings. The authors conclude that the currently available data are insufficient to establish a national recommendation for screening with sigmoidoscopy. To establish such a recommendation, a properly conducted randomized trial with colorectal cancer mortality as an outcome is needed.

Rigid sigmoidoscopy: an evaluation of three parameters regarding diagnostic accuracy

Rigid sigmoidoscopy is the method employed for examining the rectum and sigmoid colon in most general surgical clinics. Commonly, this is performed without any prior preparation of the bowel and with the patient in the left lateral (Sims') position. This study was designed to assess three factors relating to this method: preparation of the bowel; position of the patient; and the experience of the operator. The study shows that diagnostic accuracy without preparation is adequate in only 50 per cent of cases but, by employing a preliminary disposable (Fletcher's) enema, this can be improved to 80 per cent. Employing the knee-elbow position gave only slight advantage over the usual Sims' position and operator experience did not improve diagnostic accuracy once familiarity with the use of the sigmoidoscope had been achieved. The study underlines the importance of preparation as an essential prelude to sigmoidoscopy.

Intraluminal measurement of distance in the colorectal region employing rigid and flexible endoscopes

Intraluminal measurements of distance cephalad to the anal verge in the colorectal region of 40 consecutive adult patients were performed employing rigid and flexible proctosigmoidoscopic techniques. In 2/40 (5%) patients, the measurements were identical. In 32/40 (80%) patients, measurements employing a flexible proctosigmoidoscope exceeded measurements employing a rigid instrument by at least 3 cm. The observations have relevance in the context of assessments of adequate distal margins and preservation of anal continence in patients requiring colorectal surgery via transabdominal, transsacral, transperineal, and/or transanal routes.

Patient response to sigmoidoscopy. A randomized, controlled trial of rigid and flexible sigmoidoscopy

Sigmoidoscopy could aid in the control of large bowel cancer by early detection of the 55% of colorectal cancers that develop in the rectosigmoid and by the identification and eradication of significant rectosigmoid adenomas. Rigid sigmoidoscopy has had poor patient acceptance and therefore has not been successful. The present study is a prospective randomized trial to evaluate patient response to flexible as compared with rigid sigmoidoscopy. Patients reported significantly less discomfort (10.1% versus 29.7%), anxiety (9.8% versus 27.6%) and embarrassment (5.2% versus 12.8%) during flexible as compared with rigid sigmoidoscopy. Flexible sigmoidoscopy appears to have better patient acceptance than rigid sigmoidoscopy (P less than 0.01). This could enhance its value as a cancer-control instrument. This article addresses the feasibility of sigmoidoscopy. Its validity also needs to be addressed within the framework of a long-term trial, evaluating mortality for rectosigmoid cancer.

Major ambulatory surgery of the general surgical patient. Management of anorectal conditions, peripheral vascular problems, and gastrointestinal endoscopy

The growing experience with controlling postoperative pain and with using Foley catheters postoperatively has made surgeons less hesitant to perform some anorectal procedures in an ambulatory setting. Procedures for the treatment of varicose veins of lesser severity can often be done in an ambulatory surgical center. Because of the risk for respiratory complications and perforations, some endoscopic procedures are appropriate for the major ambulatory surgical unit.

Effect of workup strategy on the cost-effectiveness of fecal occult blood screening for colorectal cancer

Physicians respond to a positive fecal occult blood test with a variety of workup strategies. To study the effect of the choice of strategy on the net costs and health benefits of colorectal cancer screening using this test, we used a decision analysis model to compare seven strategies that physicians might choose to examine a positive "screenee." Strategies using rigid or flexible sigmoidoscopy alone are not only insensitive, but also have high cost-effectiveness ratios. The strategy of air contrast barium enema alone had the lowest cost-effectiveness ratio. Rigid sigmoidoscopy combined with barium enema had a lower cost-effectiveness ratio than primary colonoscopy, but the strategy of primary colonoscopy could have an equal or better ratio depending on assumptions about test costs and the benefit of removing benign polyps. The primary colonoscopy strategy is both more effective and less costly than the combination of flexible sigmoidoscopy and barium enema. The optimal strategy will vary with local factors, and with the perspective of the decision-maker.

Screening for colorectal cancer in a high-risk population. Results of a mathematical model

A mathematical model was used to estimate the cost-effectiveness of colorectal cancer screening strategies for people who are at high risk because of a first-degree relative with colorectal cancer. The model uses indirect evidence about such factors as cancer incidence, sensitivity and specificity of different tests, and treatment effectiveness. The analysis indicates that for screening people over 40 yr old an annual fecal occult blood test may reduce colorectal cancer mortality by about one-third, either colonoscopy or barium enema may reduce mortality by approximately 85%, a 3-5-yr frequency for endoscopies or barium enemas preserves 70%-90% of the effectiveness of an annual frequency, and beginning screening at age 50 reduces effectiveness by 5%-10%. Although both barium enemas and colonoscopies appear to be effective in reducing mortality, the lower cost of the barium enema makes it a more cost-effective strategy. All of these estimates depend on the baseline estimates of each of the factors incorporated in the model; the conclusions are most sensitive to assumptions about the natural history of adenomatous polyps, the bleeding of adenomas and presymptomatic cancers, and the sensitivity of the fecal occult blood test. Recommendations about colorectal cancer screening must also consider factors such as discomfort, inconvenience, and the availability of various technologies.

Complications of flexible fiberoptic sigmoidoscopy. A conceptual approach

This paper presents an overview of the potential risks associated with the use of the flexible fiberoptic sigmoidoscope. A reasonable review of the literature on endoscopy reveals few instances of admitted complications. We draw upon a decade of personal observations and experience with over 10,000 examinations to substantiate the actual and potential hazards of flexible fiberoptic sigmoidoscopy. A conceptual approach to recognizing and avoiding the consequences of complications is presented.

The workup of the asymptomatic patient with a positive fecal occult blood test

Twenty-two protocols for working up an asymptomatic patient who has a positive fecal occult blood test were evaluated using existing information on the prevalences of cancers, adenomas and other conditions in such patients; the natural history of colorectal cancer; the effectiveness of screening tests; risks; and costs. The authors estimate the impacts of the 22 workup strategies on outcomes such as the chance of finding an existing cancer or adenoma, risks (bleeding and perforation), and financial costs of different strategies involving rigid sigmoidoscopy, flexible sigmoidoscopy, barium enema, and colonoscopy. Two protocols were particularly effective. The first involves performing a barium enema study and following it with colonoscopy; if colonoscopy is negative, the barium enema study should be repeated. The second is to perform colonoscopy and if it is negative, follow it with a barium enema study.

A study of optimal length of flexible fiberoptic sigmoidoscopes for initial endoscopic training

Eighteen trainees with no prior fiberoptic endoscopic experience performed a total of 305 fiberoptic sigmoidoscopies using a colonoscope. Basic training, consisting of reading materials, lecture instructions, practice on a colon model, and observation of procedures, was completed prior to beginning patient examinations. Additional instruction was given between examinations. The performance of these examinations was an individual effort on the part of the trainee without verbal or mechanical assistance from the instructor after the initial ten examinations. All were performed with an instructor viewing through a teaching attachment. Total insertion distance was greater than or equal to 30, greater than or equal to 40, greater than or equal to 50, greater than or equal to 60 cm in 65, 60, 46, and 20 percent of examinations, respectively. Overall performance was better in those with prior rigid sigmoidoscopic experience (20 examinations). The mean examination time was 11.8 minutes. These data help to define the appropriate length of fiberoptic sigmoidoscope recommended for use by inexperienced endoscopists.

A comparison of the 25-cm rigid proctosigmoidoscope with the 65-cm flexible endoscope in the screening of patients for colorectal carcinoma

A comparison of the rigid with the flexible sigmoidoscope was evaluated in 293 patients as part of a screening project for colorectal cancer at Roswell Park Memorial Institute. Patients with either a positive family history for colorectal cancer, a positive stool guaiac test result, a history of hematochezia, or a change in bowel habits were randomly assigned to either rigid or flexible sigmoidoscopy. The median distance of colon examined with the flexible instrument was significantly greater than with the rigid scope (55 versus 17 cm, respectively). A significantly greater number of malignant and premalignant lesions were found with the flexible instrument than with the rigid scope. It was concluded that the flexible sigmoidoscope is superior to the rigid scope in the process of screening for colorectal lesions.

Training for flexible sigmoidoscopy

Three hundred twenty-six participants of five 1-day continuing medical education courses on flexible sigmoidoscopy were surveyed to determine their use of lower intestinal endoscopes and to identify how well the education trained them to use the flexible sigmoidoscope. The number of participants using a flexible sigmoidoscope and/or colonoscope increased after the course. About one half of the respondents went from no use of the flexible sigmoidoscope to using it. About one fifth of the respondents were not using a flexible sigmoidoscope after the course for various reasons. Most respondents used more than one instrument after the course, with the combination of the 60-cm flexible sigmoidoscope and the rigid sigmoidoscope being most popular. The overwhelming majority found the flexible sigmoidoscope to be either very easy to use or reasonably easy to use. Only one complication was reported. Most of the respondents had attended only this 1-day course, but one third had taken either other courses or had been supervised for several procedures.

Short (35-cm) versus long (60-cm) flexible sigmoidoscopy: a comparison of findings and tolerance in asymptomatic patients screened for colorectal neoplasia

The purpose of this study was to compare the utility of the 35-cm versus the 60-cm flexible sigmoidoscope in screening asymptomatic patients for colorectal neoplasia. Two hundred fifty-eight patients 45 years of age or older were examined in a randomized fashion with both the 35-cm and 60-cm instruments. Fifteen percent (39/258) of patients had a total of 50 polypoid lesions 3 mm or greater in diameter (including one carcinoma). Of all polypoid lesions, 76% were detected with the 35-cm instrument compared to 98% with the 60-cm sigmoidoscope. Eighty-four percent of all polyps occurred within the distal 35 cm of colon. The mean time required to complete the examination was significantly less with the 35-cm sigmoidoscope than with the 60-cm sigmoidoscope (2.5 vs. 5.7 min). Moderate to severe discomfort was experienced by 69% of patients with the 60-cm instrument compared to only 29% with the 35-cm sigmoidoscope. Seventy-two percent of patients preferred examination with the shorter instrument compared with 7% for the longer sigmoidoscope, while 21% of patients expressed no preference. The 35-cm flexible sigmoidoscope fulfills many criteria of an effective screening test for colorectal neoplasia including rapidity of examination, safety, good sensitivity, and excellent patient acceptance.

Sigmoidoscopy/proctoscopy service with open access to general practitioners

Many hospitals now offer barium enema examinations to general practitioners on an open access basis, so bypassing the traditional sequence of first carrying out a sigmoidoscopy. An open access sigmoidoscopy/proctoscopy service was therefore opened with requests for a barium enema being denied unless preceded by sigmoidoscopy. During the first three and a half years 1458 patients referred direct from their general practitioners were examined using a rigid sigmoidoscope. Patients were also examined with a proctoscope if thought appropriate. After the first year of the service a subsequent examination with a fibreoptic sigmoidoscope was also carried out if the presenting symptom was bleeding for which no cause could be found with the rigid instruments. A total of 516 abnormalities were found to account for symptoms in 506 patients giving a diagnostic rate of 35%. The most common lesion was piles (307 cases). Other relatively common disorders included inflammatory bowel disease (107 cases), benign tumours (44), and malignant tumours (38). Of 41 patients subsequently undergoing fibreoptic sigmoidoscopy a cause for the bleeding was found in 32, the most common being a malignant tumour (16). Most general practitioners in the district used the service and a questionnaire survey indicated that most found it very helpful. Requests from general practitioners for a barium enema fell substantially over the period.

Subcutaneous emphysema: a rare complication of fibreoptic sigmoidoscopy

Fibreoptic sigmoidoscopy is a commonly used technique. However, it is not without complications. We report the rare occurrence of subcutaneous emphysema, mediastinal emphysema, and pneumoperitoneum following routine sigmoidoscopy.