Effectiveness of digital feedback on patient experience and 30-day complications after screening colonoscopy: a randomized health services study

Background and study aims  European guidelines (ESGE) recommend measuring patient experience and 30-day complication rate after colonoscopy. We compared digital and paper-based feedback on patients' experience and 30-day complications after screening colonoscopy. Patients and methods  Screenees attending for primary screening colonoscopies in two centers from September 2015 to December 2016 were randomized (1:1) to an intervention arm (choice of feedback method) or control arm (routine paper-based feedback). Participants in the intervention arm could choose preferred feedback method (paper-based, automated telephone or online survey) and were contacted by automated telephone 30 days after colonoscopy to assess complications. Control group participants self-reported complications. Primary and secondary endpoints were response rates to feedback and complications questionnaire, respectively. Results  There were 1,281 and 1,260 participants in the intervention and control arms, respectively. There was no significant difference in response rate between study groups (64.8 % vs 61.5 %; P  = 0.08). Free choice of feedback improved response for participants identified as poor responders: younger than 60 years (60.8 % vs 54.7 %; P  = 0.031), male (64.0 % vs 58.6 %; P  = 0.045) and in small non-public center (56.2 % vs 42.5 %; P  = 0.043). In the intervention arm, 1,168 participants (91.2 %) answered the phone call concerning complications. A total of 79 participants (6.2 %) reported complications, of which two (0.2 %) were verified by telephone as clinically relevant. No complications were self-reported in the control group. Conclusion  The overall response rate was not significantly improved with digital feedback, yet the technology yielded significant improvement in participants defined as poor responders. Our study demonstrated feasibility and efficacy of digital patient feedback about complications after colonoscopy.

Polyp detection rates as quality indicator in clinical versus screening colonoscopy

Background Adenoma and Polyp Detection Rates (ADR and PDR) are advocated as general performance measures for screening and clinical colonoscopy, but their evidence is largely derived from screening data. This study compares PDRs in colonoscopy for screening versus clinical indications.

Methods Consecutive patients at two Norwegian centers were examined by eight endoscopists either for colonoscopy screening in a randomized colonoscopy screening trial (Nordic-European Initiative on Colorectal Cancer, NordICC) or for clinical indications during the same time period (January 2013 to December 2014). PDR-5 mm, defined as the proportion of colonoscopies with detection of at least one polyp with diameter ≥ 5 mm, was measured prospectively. We fitted multivariable logistic regression models and calculated the adjusted odds ratios (OR) to evaluate factors for differences in PDR-5 mm between screening and clinical colonoscopies.

Results The study included 2939 clinical and 771 screening colonoscopies. The PDR-5 mm was 26 % and 31 %, respectively (P = 0.005). Among sex, age, cecum intubation, bowel cleansing, and endoscopist, only the latter explained the higher PDR-5 mm in screening compared to routine colonoscopy. In the fully adjusted logistic regression model, the detection of polyps ≥ 5 mm was not associated with indication for colonoscopy. The OR for polyp detection in screening vs. routine colonoscopy was 1.04; 95 % confidence interval 0.85 – 1.27.

Conclusion In this study, the differences in PDR-5 mm between clinical and screening colonoscopies could be explained by the endoscopist. Accordingly, PDR-5 mm benchmarks may be similar for clinical and screening colonoscopy.

Systematic review with meta-analysis: the comparative effectiveness of aspirin vs. screening for colorectal cancer prevention

BACKGROUND

Both aspirin use and screening with flexible sigmoidoscopy or guaiac faecal occult blood testing (FOBT) may reduce mortality from colorectal cancer, but comparative effectiveness of these interventions is unknown.

AIM

To compare aspirin to guaiac FOBT screening with regard to incidence and mortality of colorectal cancer in a network meta-analysis.

METHODS

We searched Medline, EMBASE and the COCHRANE central register (CENTRAL) for relevant randomised trials identified until 31 October 2015. Randomised trials in average-risk populations that reported colorectal cancer mortality, colorectal cancer incidence, or both, with a minimum follow-up of 2 years, and more than 100 randomised individuals were included. Three investigators independently extracted data. We calculated relative risks [RR with 95% predictive intervals (PrIs)] for the comparison of the interventions by frequentist network meta-analyses.

RESULTS

The effect of aspirin on colorectal cancer mortality was similar to FOBT (RR 1.03; 95% PrI 0.76-1.39) and flexible sigmoidoscopy (RR 1.16; 95% PrI 0.84-1.60). Aspirin was more effective than FOBT (RR 0.36; 95% PrI 0.22-0.59) and flexible sigmoidoscopy (RR 0.37; 95% PrI 0.22-0.62) in preventing death from or cancer in the proximal colon. Aspirin was equally effective as screening in reducing colorectal cancer incidence, while flexible sigmoidoscopy was superior to FOBT (RR 0.84; 95% PrI 0.72-0.97).

CONCLUSIONS

Low-dose aspirin seems to be equally effective as flexible sigmoidoscopy or guaiac FOBT screening to reduce colorectal cancer incidence and mortality, and more effective for cancers in the proximal colon. A randomised comparative effectiveness trial of aspirin vs. screening is warranted.

Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis

OBJECTIVE

To assess the efficacy and safety of endoscopic resection of large colorectal polyps.

DESIGN

Relevant publications were identified in MEDLINE/EMBASE/Cochrane Central Register for the period 1966-2014. Studies in which ≥20 mm colorectal neoplastic lesions were treated with endoscopic resection were included. Rates of postendoscopic resection surgery due to non-curative resection or adverse events, as well as the rates of complete endoscopic removal, invasive cancer, adverse events, recurrence and mortality, were extracted. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was produced based on random effect models. I2 statistic was used to describe the variation across studies due to heterogeneity. Meta-regression analysis was also performed.

RESULTS

50 studies including 6442 patients and 6779 large polyps were included in the analyses. Overall, 503 out of 6442 patients (pooled rate: 8%, 95% CI 7% to 10%, I2=78.6%) underwent surgery due to non-curative endoscopic resection, and 31/6442 (pooled rate: 1%, 95% CI 0.7% to 1.4%, I2=0%) to adverse events. Invasive cancer at histology, non-curative endoscopic resection, synchronous lesions and recurrence accounted for 58%, 28%, 2.2% and 5.9% of all the surgeries, respectively. Endoscopic perforation occurred in 96/6595 (1.5%, 95% CI 1.2% to 1.7%) polyps, while bleeding in 423/6474 (6.5%, 95% CI 5.9% to 7.1%). Overall, 5334 patients entered in surveillance, 502/5836 (8.6%, 95% CI 7.9% to 9.3%) being lost at follow-up. Endoscopic recurrence was detected in 735/5334 patients (13.8%, 95% CI 12.9% to 14.7%), being an invasive cancer in 14/5334 (0.3%, 95% CI 0.1% to 0.4%). Endoscopic treatment was successful in 664/735 cases (90.3%, 95% CI 88.2% to 92.5%). Mortality related with management of large polyps was reported in 5/6278 cases (0.08%, 95% CI 0.01% to 0.15%).

CONCLUSIONS

Endoscopic resection of large polyps appeared to be an extremely effective and safe intervention. However, an adequate endoscopic surveillance is necessary for its long-term efficacy.

Comparative analysis of breast cancer mortality following mammography screening in Denmark and Norway

BACKGROUND

Denmark and Norway are the best countries to study effects of mammography screening, because they are the only countries with stepwise introduction of nationwide mammography screening, enabling comparative effectiveness studies of high quality. Although Denmark and Norway are countries with similar populations and health care systems, reported reductions in breast cancer mortality (incidence-based) caused by screening differed vastly; 25% in Denmark versus 10% in Norway. This study explores reasons for this difference.

PATIENTS AND METHODS

We compared two published studies from the Danish and Norwegian screening programs (Olsen et al., 2005; Kalager et al., 2010) investigating biennial mammography screening for women age 50-69 years. Four comparison groups of women were constructed ('current' and 'historical screening groups'; 'current' and 'historical nonscreening groups') based on county of residence. We calculated incidence-based breast cancer mortality in the current versus the historical period for screening and nonscreening groups, using mortality rate ratios (MRR) in the two countries, accounting for concomitant changes in breast cancer mortality.

RESULTS

In the screening groups, similar reductions in breast cancer mortality were found when periods preceding and following start of screening were compared, in Denmark [25%; MRR 0.75; 95% confidence interval (CI) 0.64% to 0.88%] and in Norway (28%; MRR 0.72; 95% CI 0.63% to 0.81%). However, mortality increased in Denmark in the current nonscreening group compared with the historical nonscreening group; for women >59 years, breast cancer mortality increased by 14% (MRR 1.14, 95% CI 1.07-1.22), whereas in Norway a 19% reduction was seen (MRR 0.81, 95% CI 0.72-0.92). This increase accounts for the different relative effect of screening in Denmark and Norway; 25% breast cancer mortality reduction in Denmark, 10% in Norway.

CONCLUSIONS

The seemingly larger effect of screening in Denmark may not be solely attributable to screening itself, but to increased breast cancer mortality in women older than 59 years not invited to screening.

Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline

BACKGROUND AND AIM

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the choice amongst regimens available for cleansing the colon in preparation for colonoscopy.

METHODS

This Guideline is based on a targeted literature search to evaluate the evidence supporting the use of bowel preparation for colonoscopy. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendation and the quality of evidence.

RESULTS

The main recommendations are as follows. (1) The ESGE recommends a low-fiber diet on the day preceding colonoscopy (weak recommendation, moderate quality evidence). (2) The ESGE recommends a split regimen of 4 L of polyethylene glycol (PEG) solution (or a same-day regimen in the case of afternoon colonoscopy) for routine bowel preparation. A split regimen (or same-day regimen in the case of afternoon colonoscopy) of 2 L PEG plus ascorbate or of sodium picosulphate plus magnesium citrate may be valid alternatives, in particular for elective outpatient colonoscopy (strong recommendation, high quality evidence). In patients with renal failure, PEG is the only recommended bowel preparation. The delay between the last dose of bowel preparation and colonoscopy should be minimized and no longer than 4 hours (strong recommendation, moderate quality evidence). (3) The ESGE advises against the routine use of sodium phosphate for bowel preparation because of safety concerns (strong recommendation, low quality evidence).

Current status of screening for colorectal cancer

BACKGROUND

Colorectal cancer (CRC) is a leading cause of cancer morbidity and mortality. A well-defined precursor lesion (adenoma) and a long preclinical course make CRC a candidate for screening. This paper reviews the current evidence for the most important tests that are widely used or under development for population-based screening.

MATERIAL AND METHODS

In this narrative review, we scrutinized all papers we have been aware of, and carried out searches in PubMed and Cochrane library for relevant literature.

RESULTS

Two screening methods have been shown to reduce CRC mortality in randomised trials: repetitive faecal occult blood testing (FOBT) reduces CRC mortality by 16%; once-only flexible sigmoidoscopy (FS) by 28%. FS screening also reduces CRC incidence (by 18%), FOBT does not. Colonoscopy screening has a potentially larger effect on CRC incidence and mortality, but randomised trials are lacking. New screening methods are on the horizon but need to be tested in large clinical trials before implementation in population screening.

CONCLUSIONS

FS screening reduces CRC incidence and CRC mortality by removal of adenomas; FOBT reduces CRC mortality by early detection of cancer. Several other tests are available, but none has been evaluated in randomised trials. Screening strategies differ considerably across countries.

Principles, effectiveness and caveats in screening for cancer

BACKGROUND

Cancer screening has the potential to prevent or reduce incidence and mortality of the target disease, but may also be harmful and have unwanted side-effects.

METHODS

This review explains the basic principles of cancer screening, common pitfalls in evaluation of effectiveness and harms of screening, and summarizes the evidence for effects and harms of the most commonly used cancer screening tools.

RESULTS

Cancer screening has either been established or is considered for breast, lung, prostate, cervical and colorectal cancer. In contrast, screening for gastrointestinal malignancies outside the large bowel is not generally accepted, available or implemented. Oesophageal and gastric carcinoma, and hepatocellular carcinoma, may be subject to screening in certain risk populations, but currently not for population screening based on available technology. Screening for colorectal cancer and cervical cancer by endoscopy and cytology respectively can decrease incidence of the target disease, whereas screening tools for lung, prostate and breast cancer detect early-stage invasive disease and thus do not decrease disease incidence. Overdiagnosis (detection of cancers that will not have become clinically apparent in the absence of screening) is a challenge in lung, prostate and breast cancer screening. The improvement of quality of clinical practice following the introduction of cancer screening programmes is an appreciated 'side-effect', but it is important to disentangle the effect of screening on cancer incidence and mortality from that of quality improvement of clinical services. As new, powerful screening tests emerge-particularly in molecular and genetic fields, but also in radiology and other clinical diagnostics-the basic requirements for screening evaluation and implementation must be borne in mind.

CONCLUSION

Cancer screening has been established for several cancer forms in Europe. The potential for incidence and mortality reduction is good, but harms do exist that need to be addressed, and communicated to the public.

European guidelines for quality assurance in colorectal cancer screening and diagnosis: overview and introduction to the full supplement publication

Population-based screening for early detection and treatment of colorectal cancer (CRC) and precursor lesions, using evidence-based methods, can be effective in populations with a significant burden of the disease provided the services are of high quality. Multidisciplinary, evidence-based guidelines for quality assurance in CRC screening and diagnosis have been developed by experts in a project co-financed by the European Union. The 450-page guidelines were published in book format by the European Commission in 2010.  They include 10 chapters and over 250 recommendations, individually graded according to the strength of the recommendation and the supporting evidence. Adoption of the recommendations can improve and maintain the quality and effectiveness of an entire screening process, including identification and invitation of the target population, diagnosis and management of the disease and appropriate surveillance in people with detected lesions. To make the principles, recommendations and standards in the guidelines known to a wider professional and scientific community and to facilitate their use in the scientific literature, the original content is presented in journal format in an open-access Supplement of Endoscopy. The editors have prepared the present overview to inform readers of the comprehensive scope and content of the guidelines.

European guidelines for quality assurance in colorectal cancer screening and diagnosis. First Edition--Quality assurance in endoscopy in colorectal cancer screening and diagnosis

Multidisciplinary, evidence-based guidelines for quality assurance in colorectal cancer screening and diagnosis have been developed by experts in a project coordinated by the International Agency for Research on Cancer. The full guideline document covers the entire process of population-based screening. It consists of 10 chapters and over 250 recommendations, graded according to the strength of the recommendation and the supporting evidence. The 450-page guidelines and the extensive evidence base have been published by the European Commission. The chapter on quality assurance in endoscopy includes 50 graded recommendations. The content of the chapter is presented here to promote international discussion and collaboration by making the principles and standards recommended in the new EU Guidelines known to a wider professional and scientific community. Following these recommendations has the potential to enhance the control of colorectal cancer through improvement in the quality and effectiveness of endoscopy and other elements in the screening process, including multidisciplinary diagnosis and management of the disease.

Reduced pain during screening colonoscopy with an ultrathin colonoscope: a randomized controlled trial

BACKGROUND AND STUDY AIMS

Screening colonoscopy for colorectal cancer (CRC) is recommended in several countries, but uptake rates are often low. Fear of pain and also time-consuming costly sedation are barriers for colonoscopy, and thus development of colonoscopy equipment that decreases patient discomfort is worthwhile. This randomized controlled trial investigated the performance of an ultrathin colonoscope in CRC screening.

PATIENTS AND METHODS

Consecutive participants in a colonoscopy screening trial were randomized to examination with an ultrathin prototype colonoscope or a standard colonoscope. The main outcome measure was pain during the examination. Participants rated pain (no, slight, moderate, severe) using a validated questionnaire.

RESULTS

From 187 enrolled participants (80 women [43 %]), 162 (87 %) responded to the questionnaire. The study groups were similar regarding baseline characteristics. Pain scores were significantly lower in the prototype instrument group compared with the standard group (78 % vs. 29 % of patients with no pain in prototype and standard groups, respectively; odds ratio [OR] 0.11; 95 % confidence interval [CI] 0.06 - 0.23; P < 0.001). Cecal intubation rate was 98 % in the prototype group and 92 % in the standard group (P = 0.085). Sedation was used in 2 % and 7 % in the prototype and standard groups respectively (P = 0.12). Adenoma detection rate was 13 % in the prototype group vs. 24 % in the standard group (P = 0.052).

CONCLUSION

The new ultrathin Olympus colonoscope decreases patient pain during screening colonoscopy. This feature may improve uptake and patient satisfaction in screening colonoscopy. Further study is needed to evaluate the lower adenoma detection rate.

Withdrawal time as a quality indicator for colonoscopy - a nationwide analysis

BACKGROUND AND STUDY AIMS

A withdrawal time of at least 6 min has been recommended as a quality indicator for colonoscopy. One drawback of many of the studies that have investigated withdrawal time and produced conflicting results has been their single-center design involving few endoscopists. Therefore, the validity of withdrawal time as a quality measure remains unclear. This study explores the value of individual withdrawal time in a nationwide analysis.

PATIENTS AND METHODS

This prospective cohort study comprised data from outpatient colonoscopies performed at 19 Norwegian centers from January to September 2009 and registered in the Norwegian Gastronet Quality Assurance (QA) program. The participating endoscopists were characterized by their median withdrawal time for visual colonoscopies (diagnostic colonoscopies without biopsy or therapy) and categorized into two visual withdrawal time (VWT) groups (< 6 min or ≥ 6 min) to analyze the predictive value of VWT for detection of one or more polyps ≥ 5 mm in diameter using multiple logistic regression models.

RESULTS

The study included 4429 consecutive colonoscopies performed by 67 endoscopists. The adjusted odds ratio for the detection of polyps ≥ 5 mm was 1.21 (95 %CI 0.94 - 1.56, P = 0.14) for endoscopists with a median VWT ≥ 6 min compared with endoscopists with a median VWT < 6 min.

CONCLUSION

Withdrawal time using 6 min as the threshold is not a strong predictor of the likelihood of finding a polyp during colonoscopy and should not be used as a quality indicator.

Incontinence after colonoscopy--an unrecognized and preventable problem. A cross-sectional study from the Gastronet quality assurance program

BACKGROUND

Colonoscopy requires insufflation of gas for visualization of the bowel wall. Worldwide, this is usually done using air. The aim of the present study was to assess the risk of postcolonoscopy incontinence, and to investigate whether insufflation of CO₂ instead of air may reduce this risk, since it is easily absorbed through the bowel mucosa.

METHODS

This is a prospective multicenter study of colonoscopy patients undergoing bowel insufflation using air or CO₂. A successive series of colonoscopies were reported to a national quality assurance program in Norway between January and December 2009 from 21 endoscopy centers with varying insufflation practices. The study comprised 7812 patients aged 18 years or older who were referred for outpatient colonoscopy. Of these, 5015 underwent colonoscopy performed using air and 2797 colonoscopy using CO₂ insufflation.

RESULTS

Patient-reported incontinence up to 24 h after colonoscopy was compared using binary logistic regression analysis for the type of gas used for insufflation. The air and CO₂ patient groups were comparable with regard to age, sex, indication for colonoscopy, and sedation practice. Incontinence was reported by 336 out of 7812 patients (4.3%). Incontinence was significantly less frequent in the CO₂ group than in the air group [2.1% versus 5.5%; adjusted odds ratio (OR) 0.38; 95%CI 0.28-0.50; P < 0.001]. Female patients had a higher risk of incontinence than men (adjusted OR 1.77; 95% CI 1.39-2.24; P < 0.001).

CONCLUSION

About every 20th patient undergoing colonoscopy using standard air insufflation experiences postexamination incontinence. This proportion can be reduced by 60% by converting from air insufflation to insufflation with the absorbable CO₂.

Colorectal cancer screening

Colorectal cancer (CRC) is the third most common cause of cancer death worldwide and a major health problem. In this review, the different approaches for CRC screening will be outlined with emphasis on evidence-based medicine. Evidence from randomized trials on the effectiveness of CRC screening is summarized. Several screening tools for CRC are available. They can be categorized according to their mode of action: early detection tools such as the faecal occult blood test (FOBT) and cancer prevention tools such as flexible sigmoidoscopy and colonoscopy. Meta-analyses of randomized trials show that FOBT screening reduces CRC mortality by 16% (risk ratio 0.84; 95% confidence interval (CI) 0.78-0.9) compared with 30% (risk ratio 0.7; 95% CI 0.6-0.81) for flexible sigmoidoscopy screening. FOBT screening is cheap and noninvasive, but results in large numbers of false-positive tests and needs to be repeated frequently. Flexible sigmoidoscopy is more invasive, but is effective for once-only screening. Although colonoscopy screening is used in some countries, no randomized trials have been conducted to estimate its benefit, and therefore, it should not be recommended at the present time. Faecal occult blood test and flexible sigmoidoscopy are the two CRC screening tools that can be recommended as they have been proven to reduce CRC mortality. Colonoscopy has the potential to be superior to FOBT and flexible sigmoidoscopy, but needs to be evaluated in randomized trials before any recommendation can be provided.

Single- vs. double-balloon enteroscopy in small-bowel diagnostics: a randomized multicenter trial

BACKGROUND AND STUDY AIMS

Double-balloon enteroscopy (DBE) is the first choice endoscopic technique for small-bowel visualization. However, preparation and handling of the double-balloon enteroscope is complex. Recently, a single-balloon enteroscopy (SBE) system has been introduced as being a simplified, less-complex balloon-assisted enteroscopy system.

PATIENTS AND METHODS

This study was a randomized international multicenter trial comparing two balloon-assisted enteroscopy systems: DBE vs. SBE. Consecutive patients referred for balloon-assisted enteroscopy were randomized to either DBE or SBE. Patients were blinded with regard to the type of instrument used. The primary study outcome was oral insertion depth. Secondary outcomes included complete small-bowel visualization, anal insertion depth, patient discomfort, and adverse events. Patient discomfort during and after the procedure was scored using a visual analog scale.

RESULTS

A total of 130 patients were included over 12 months: 65 with DBE and 65 with the SBE technique. Patient and procedure characteristics were comparable between the two groups. Mean oral intubation depth was 253 cm with DBE and 258 cm with SBE, showing noninferiority of SBE vs. DBE. Complete visualization of the small bowel was achieved in 18 % and 11 % of procedures in the DBE and SBE groups, respectively. Mean anal intubation depth was 107 cm in the DBE group and 118 cm in the SBE group. Diagnostic yield and mean pain scores during and after the procedures were similar in the two groups. No adverse events were observed during or after the examinations.

CONCLUSIONS

This head-to-head comparison study shows that DBE and SBE have a comparable performance and diagnostic yield for evaluation of the small bowel.

Patient satisfaction with on-demand sedation for outpatient colonoscopy

BACKGROUND AND STUDY AIM

To reduce the costs of colonoscopy the feasibility of unsedated procedures has been explored. The aims of our study were to assess patient satisfaction with on-demand sedation and identify factors related to painful colonoscopy.

PATIENTS AND METHODS

The Norwegian Gastronet quality assurance documentation tools consist of endoscopy reports (completed on site) and a patient satisfaction questionnaire (completed by the patient on the day after colonoscopy). Data were collected from January 1 2004 to December 31 2006. Colonoscopies reported to be moderately or severely painful were defined as "painful colonoscopy."

RESULTS

Nine endoscopy centers representing 86 endoscopists reported 14 915 examinations and 12 354 patient reports were returned (83 % response rate). Patient satisfaction with service and information given was greater than 95 % for all centers. Mean rate of painful colonoscopy was 34 % and mean sedation rate 34 %. Odds ratio (OR) for painful colonoscopy was 2.2 ( P < 0.001) when sedation was given. The ORs for painful colonoscopy were similar for all but one center (no. 4) with OR 1.6 ( P = 0.04), while the OR for giving sedation was higher for all but one center (no. 1) compared with the reference center (ORs 2.2 to 7.5, all P-values < 0.001).

CONCLUSION

A surprisingly high rate of painful colonoscopy was found. High sedation rates were not associated with low rates of painful colonoscopy. Recommending increased sedation rates as the only intervention to improve suboptimal performance might not lead to lower rates of painful colonoscopy.

The First Transatlantic Symposium on Colorectal Cancer Screening

The First Transatlantic Symposium on Strategies to Increase Colorectal Cancer Screening was held on April 20th 2009 in New York City at the prestigious location of the Consulate General of the Federal Republic of Germany. About 100 invited individuals, including experts in CRC screening and public awareness, clinicians, and researchers, discussed various topics in CRC screening.

Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis

BACKGROUND AND STUDY AIMS

Double-balloon enteroscopy (DBE) has been proved to be effective for deep intubation of the small bowel. Patients with a Roux-en-Y enteroanastomosis and biliary problems have been a challenge in gastrointestinal practice because of the lack of endoscopic access to the biliary anastomosis. We report on the first case series of patients with Roux-en-Y anatomy who have been examined using DBE.

PATIENTS AND METHODS

Between September 2005 and May 2006, 18 endoscopic retrograde cholangiography procedures were performed in 13 patients (median age 53, range 2 - 81 years) using the DBE technique at our hospital. Most of the cases (10/13) had had a liver transplant for primary sclerosing cholangitis. The Fujinon T-series DBE system was used in all cases.

RESULTS

The entero-enteric anastomosis was reached easily in all 18 procedures, and the end of the Roux limb was reached in 17/18 procedures. The mean intubation time was 40 minutes (range 5 - 120 minutes). Adequate imaging was achieved in all but two cases, one of whom had a native papilla. Biliary stenting was performed in two patients, stent removal in three patients, and removal of a small stone in one patient.

CONCLUSIONS

Endoscopic access and biliary cannulation in the setting of Roux-en-Y anatomy is safe and feasible using the new DBE system for enteral intubation. Adaptation of accessories would further improve the utility of the procedure.

Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial

BACKGROUND AND STUDY AIMS

Double-balloon enteroscopy (DBE) has been proven effective for deep intubation of the small bowel. However, intubation depth is limited by distention of the small bowel due to air insufflation during the procedure. The present trial investigated whether carbon dioxide (CO (2)) instead of standard air insufflation would improve intubation depth during DBE, as well as reduce postprocedure pain.

PATIENTS AND METHODS

One hundred and twelve consecutive patients scheduled for DBE at two centers were randomly assigned to either CO (2) or air insufflation during DBE. Patients and endoscopists were blinded with regard to the type of gas used. Intubation depth was registered using a validated form. Patients scored pain and discomfort during and after the examination on a 100-mm visual analog scale.

RESULTS

One hundred patients were eligible for data analysis (48 in the CO (2) group and 52 in the air group). The mean small-bowel intubation depth was extended by 30 % in the CO (2) group compared to the air group (230 vs. 177 cm, P = 0.008). The superiority was most pronounced for oral DBE, with a 71-cm improvement in intubation depth when using CO (2) (295 cm in the CO (2) group vs. 224 cm in the air group, P < 0.001). Patient pain and discomfort were significantly reduced in the CO (2) group at 1 and 3 hours after the examination.

CONCLUSIONS

CO (2) insufflation significantly extended intubation depth in DBE. CO (2) insufflation also reduces patient discomfort. CO (2) insufflation may lead to a higher diagnostic and therapeutic yield of DBE, with reduced patient discomfort.

Carbon dioxide insufflation for more comfortable endoscopic retrograde cholangiopancreatography: a randomized, controlled, double-blind trial

BACKGROUND AND STUDY AIMS

The effect on abdominal pain of using carbon dioxide (CO2) for insufflation during endoscopic retrograde cholangiopancreatography (ERCP) has not been investigated. The present study aimed to compare CO2 insufflation with standard air insufflation with respect to the pain experienced during and after ERCP. In addition, we investigated the effect of CO2 insufflation on the partial pressure of CO2 (Pco2).

PATIENTS AND METHODS

A total of 118 consecutive patients who were undergoing ERCP were randomized to CO2 insufflation or to air insufflation during the procedure. Both the endoscopists and the patients were blinded with regard to the gas used. Patients rated the intensity of pain experienced on a 100-mm visual analogue scale (VAS) during ERCP and at 1 hour, 3 hours, 6 hours, and 24 hours after the procedure. Transdermal Pco2 was measured continuously in all patients during the procedure.

RESULTS

Altogether, 116 patients were eligible for analysis, 58 in each treatment group, and 91 patients responded to the questionnaire (78 %). The mean severity of postprocedure pain was significantly reduced in the CO2 group compared with the air group at 1 hour (5 mm vs. 19 mm on the VAS, P < 0.001), at 3 hours (7 mm vs. 21 mm, P < 0.001), at 6 hours (10 mm vs. 22 mm, P = 0.006), and at 24 hours (4 mm vs. 20 mm, P < 0.001) after the procedure. Radiographs taken 5 minutes after the procedure showed that abdominal distension was more pronounced in patients in the air insufflation group. There were no differences in Pco2values between the two treatment groups.

CONCLUSIONS

Carbon dioxide insufflation during ERCP significantly reduces postprocedural abdominal pain. No side effects were observed. Carbon dioxide should be the standard gas used for insufflation in ERCP.

Biopsy of colorectal polyps is not adequate for grading of neoplasia

BACKGROUND AND STUDY AIM

Valid tissue sampling of colorectal adenomas is crucial for their management in terms of treatment and follow-up. The aim of this study was to assess the validity of a cold biopsy sample as representative for the whole polypectomy specimen, with regard to histopathological features.

PATIENTS AND METHODS

As part of the Norwegian Colorectal Cancer Prevention trial, 442 participants (60% men) who fulfilled the criterion of colonoscopic recovery of adenoma that had been biopsied at flexible sigmoidoscopy, had their adenomas subsequently removed by polypectomy (snare resection) at colonoscopy. Logistic regression analysis was used to determine which variables contributed to the histopathological discrepancy between cold biopsy and polypectomy specimens.

RESULTS

Among the 532 colorectal adenomas biopsied at flexible sigmoidoscopy and removed by colonoscopy, the assessment of intraepithelial neoplasia (dysplasia) status was changed in 51 adenomas (10%), and 38 (7%) of them had been underestimated at biopsy compared with polypectomy. Likewise, the assessment of villousness was changed in 45 adenomas (9%), being upgraded in 26 (6%) at polypectomy compared with biopsy. In a multivariate model, the diameter of neoplasia at polypectomy was positively associated with increased risk of the underestimation of intraepithelial neoplasia and/or villousness influencing a diagnosis of advanced colorectal neoplasia, when cold biopsy and polypectomy specimens were compared ( Ptrend=0.01). Among 56 cases of advanced neoplasia, 35 (63%) showed only low-grade intraepithelial neoplasia on biopsy.

CONCLUSIONS

Biopsy-based diagnosis underestimated histopathological diagnosis in about 10% of colorectal adenomas detected by flexible sigmoidoscopy screening, but advanced neoplasia was underestimated in more than 60%. Efforts must be made to obtain polypectomy specimens to secure precise diagnosis.

Lifestyle-related risk factors and chemoprevention for colorectal neoplasia: experience from the large-scale NORCCAP screening trial

The objective of this study was to evaluate the potential beneficial effects of non-steroidal anti-inflammatory drugs (NSAIDs) and/or acetylsalicylic acid (ASA) and hormone replacement therapy (HRT) on colorectal neoplasia, and to compare their effects with those of lifestyle-related risk factors in 12 960 individuals who underwent flexible sigmoidoscopy screening examination. The association between these factors and colonic neoplasia was assessed by logistic regression analysis. NSAIDs and/or ASA intake were associated with decreased risk of distal low grade adenoma (DLGA) (adjusted odds ratio (OR) 0.80, P trend=0.02) in men. The duration of HRT was inversely related to the risk of DLGA (OR 0.89, P trend=0.08). Current smoking increased the risk of DLGA and distal advanced neoplasia (DAN) in both men (OR 2.50, P<0.01) and women (OR 2.30, P<0.01). There was a significant positive trend for increasing risk of DLGA (OR 1.16, P<0.01) and DAN (OR 1.20, P=0.02) with increasing use of alcohol among men, but not among women. Prescription of NSAIDs and/or ASA for chronic conditions may not be expected to have a substantial preventive effect on colorectal neoplasia in comparison with the adverse effect of smoking and alcohol. This may be explained by an increased risk of colorectal neoplasia for patients with conditions for which NSAIDs or ASA are being prescribed.

Evaluation of a novel colonoscope designed for easier passage through flexures: a randomized study

BACKGROUND AND STUDY AIMS

A new colonoscope (XCF-Q160AW prototype, Olympus, Tokyo, Japan) has been developed, designed with an additional passive bending function to ease intubation through the left colonic flexure. In this study we investigated whether this function could be included in a standard colonoscope without jeopardizing general performance, particularly passage through the sigmoid colon.

PATIENTS AND METHODS

280 outpatients referred for routine colonoscopy at Telemark Hospital were randomly allocated to colonoscopy with a standard colonoscope (Olympus 140 series) or the XCF-Q160AW prototype. Sedation was given on demand. End points were cecal intubation and the patients' grading of pain in a questionnaire.

RESULTS

Cecal intubation rates were 85% and 87% for standard and prototype endoscopes, respectively (P = 0.57). On-demand sedation was given to nine (7%) and 15 (11%) of the patients, respectively (P = 0.17). Of the patients, 256 (85%) returned their questionnaire, with 87 (63%) in the standard group and 109 (77%) in the prototype group reporting that they had experienced 'no pain/slight pain' (P < 0.001). In a multiple logistic regression analysis, this difference in experienced pain remained statistically significant after adjustment for interendoscopist variation and the use of the endoscope-stiffening function. Two patients in the study, in whom there had previously been several unsuccessful attempts at negotiating the splenic flexure, were successfully examined with the prototype colonoscope.

CONCLUSION

Examination with the Olympus XCF-Q160AW prototype with a passive bending function caused less pain than use of a standard Olympus 140 series colonoscope, without compromising other endoscope functions for colonic intubation.

Carbon dioxide insufflation in colonoscopy: safe and effective in sedated patients

BACKGROUND AND STUDY AIMS

Several studies have shown that insufflation of carbon dioxide (CO2) instead of air during colonoscopy can reduce postprocedural pain. However, CO2 insufflation might also lead to CO2 retention in the human body. It was recently shown that this side effect does not occur in unsedated patients, but that sedation leads to impaired respiration. Sedated patients may therefore be more prone to CO2 retention. This randomized, double-blinded study was designed to investigate whether CO2 insufflation leads to CO2 retention in sedated patients.

PATIENTS AND METHODS

A total of 103 consecutive patients undergoing colonoscopy were randomly assigned to the use of either CO2 or air insufflation. End-tidal carbon dioxide (ETCO2), a noninvasive parameter for arterial P CO2, was recorded before the examination, twice during it, and 10 min after it. Midazolam or pethidine, or both, were used for sedation. The patient's pain during the examination and 1, 3, 6, and 24 h afterwards was registered using a questionnaire.

RESULTS

CO2 was used in 52 patients and air insufflation in 51. A total of 52 patients (51 %) received sedation. There were no differences in ETCO2 between the CO2 and air group. A slight increase in ETCO2 was observed in sedated patients, while there was no increase in unsedated patients. CO2 insufflation significantly reduced pain after the procedure at all time points.

CONCLUSIONS

This study indicates that CO2 insufflation reduces pain and is safe to use in colonoscopy for sedated patients.

Polyethylene glycol versus sodium phosphate in bowel cleansing for colonoscopy: a randomized trial

BACKGROUND AND STUDY AIMS

There have been conflicting results regarding the adverse effects of established bowel cleansing regimens. The aim of the present study was to compare the effects of three bowel cleansing regimens on subjective well-being, electrolyte balance, cardiac arrhythmia, and the microscopic post-cleansing appearance of the colonic mucosa.

PATIENTS AND METHODS

A total of 231 consecutive outpatients were randomly assigned to receive bowel preparation for colonoscopy with either 4 l polyethylene glycol (PEG; group I, n = 76); 2 l PEG plus 10 mg Bisacodyl (group II, n = 71); or 90 ml sodium phosphate (group III, n = 84). After bowel preparation, the participants completed a questionnaire on symptoms. Endoscopists blinded to the regimen used gave scores for the quality of cleansing at endoscopy, ranging from poor (0) to very good (5). Blood samples were taken before and after bowel cleansing, electrocardiographic monitoring was used during colonoscopy, and mucosal biopsy samples were taken in the sigmoid colon.

RESULTS

Bowel preparation in group II was poorer (mean score 3.26) than in groups I (3.88) and III (4.01); P < 0.001 (II vs. III), P < 0.001 (I vs. II). The frequency of arrhythmias and post-cleansing mucosal inflammation was similar in all three groups. Lower serum potassium and higher serum phosphate concentrations were found in group III in comparison with the other groups ( P < 0.001).

CONCLUSIONS

No differences were detected regarding the effectiveness and safety of bowel preparation with PEG alone and sodium phosphate in individuals without cardiac, renal, or hepatic failure, despite a significantly stronger alteration of the electrolyte balance with sodium phosphate.

Testing for faecal calprotectin (PhiCal) in the Norwegian Colorectal Cancer Prevention trial on flexible sigmoidoscopy screening: comparison with an immunochemical test for occult blood (FlexSure OBT)

BACKGROUND

Screening for colorectal cancer (CRC) using guaiac based faecal occult blood tests (FOBT) has an estimated programme sensitivity of >60% but <30% for strictly asymptomatic CRC in a single screening round. In search for improved non-invasive tests for screening, we compared a test for faecal calprotectin (PhiCal) with a human haemoglobin immunochemical FOBT (FlexSure OBT).

METHODS

In the Norwegian Colorectal Cancer Prevention (NORCCAP) trial, screenees in one screening arm were offered screening with combined flexible sigmoidoscopy (FS) and FlexSure OBT. They were also requested to bring a fresh frozen sample of stool for the PhiCal test which was performed on samples from screenees with CRC (n = 16), high risk adenoma (n = 195), low risk adenoma (n = 592), and no adenoma (n = 1518) (2321 screenees in total). A positive PhiCal test was defined by a calprotectin level > or =50 microg/g.

RESULTS

The PhiCal test was positive in 24-27% of screenees whether they had no adenoma, low risk adenoma, or high risk adenoma. Ten (63%) of 16 CRCs gave a positive PhiCal test. The total positivity rate in this population was 25% for the PhiCal test compared with 12% for FlexSure OBT, with a sensitivity for advanced neoplasia of 27% and 35%, respectively. Specificity for "any neoplasia" was 76% for the PhiCal test and 90% for FlexSure OBT.

CONCLUSIONS

In colorectal screening, the performance of the PhiCal test on a single spot from one stool sample was poorer than a single screening round with FlexSure OBT and cannot be recommended for population screening purposes. The findings indicate a place for FlexSure OBT in FOBT screening.

Inter-endoscopist variation in polyp and neoplasia pick-up rates in flexible sigmoidoscopy screening for colorectal cancer

BACKGROUND

The Norwegian Colorectal Cancer Prevention study is an ongoing flexible sigmoidoscopy (FS) screening trial for colorectal cancer. Twenty-one thousand average-risk individuals, aged 50-64 years, living in two separate areas in Norway were randomly drawn from the Population Registry and invited to once-only screening flexible sigmoidoscopy. Examinations were performed over 3 years, at 2 centres, by 8 different endoscopists, using the same type of equipment. The aim of the present study was to investigate possible differences between endoscopists in detecting individuals with polyps, adenomas and advanced lesions (adenomas with severe dysplasia and/or villous components and/or size larger than 9 mm and carcinoma) in flexible sigmoidoscopy screening.

METHODS

The present trial comprises data from 8822 individuals, aged 55-64 years, who have undergone a flexible sigmoidoscopy. In the study period, all lesions detected by the different endoscopists were registered. Tissue samples were taken from all lesions detected.

RESULTS

Detection rates varied significantly between endoscopists, ranging from 36.4% to 65.5% for individuals with any polyp, from 12.7% to 21.2% for any adenoma and from 2.9% to 5.0% for advanced lesions. In a multiple logistic regression model, the performing endoscopist was a strong independent predictor for detection of individuals with polyps (P < 0.001 ), adenomas (P < 0.001) and advanced lesions (P = 0.01).

CONCLUSION

Detection rates for colorectal lesions vary significantly between endoscopists in colorectal cancer screening. Establishing systems for monitoring performance in screening programmes is important. Supervised training and re-certification for endoscopists with poor performance should be considered.

The Norwegian Colorectal Cancer Prevention (NORCCAP) screening study: baseline findings and implementations for clinical work-up in age groups 50-64 years

BACKGROUND

Randomized controlled trials of sufficient power testing the long-term effect of screening for colorectal neoplasia only exist for faecal occult blood testing (FOBT). There is indirect evidence that flexible sigmoidoscopy (FS) may have a greater yield. The aim of this study was to determine the diagnostic yield of screening with FS or a combination of FS and FOBT in an average-risk population in an urban and combined urban and rural population in Norway.

METHODS

20,780 men and women (1:1), aged 50-64 years, were invited for once-only screening (FS only or a combination of FS and FOBT (1:1)) by randomization from the population registry. A positive FS was defined as a finding of any neoplasia or any polyp > or = 10 mm. A positive FS or FOBT qualified for colonoscopy.

RESULTS

Overall attendance was 65%. Forty-one (0.3%) cases of CRC were detected. Any adenoma was found in 2208 (17%) participants and 545 (4.2%) had high-risk adenomas. There was no difference in diagnostic yield between the FS and the FS and FOBT group regarding CRC or high-risk adenoma. Work-up load comprised 2821 colonoscopies in 2524 (20%) screenees and 10% of screenees were recommended later colonoscopy surveillance. There were no severe complications at FS, but six perforations after therapeutic colonoscopy (1:336).

CONCLUSIONS

The present study bodes well for future management of a national screening programme, provided that follow-up results reflect adequate proof of a net benefit. It is highly questionable whether the addition of once-only FOBT to FS will contribute to this effect.

Grading of distal colorectal adenomas as predictors for proximal colonic neoplasia and choice of endoscope in population screening: experience from the Norwegian Colorectal Cancer Prevention study (NORCCAP)

BACKGROUND AND AIMS

The purpose of this study was to evaluate the utility of easily measured clinical variables at flexible sigmoidoscopy (FS) screening that might predict a proximal advanced neoplasm (PAN).

METHODS

We studied 1833 subjects with biopsy verified adenomas at FS who subsequently underwent full colonoscopy.

RESULTS

A total of 387 (21%) subjects had proximal colonic neoplasms (PCN) and 85 (5%) had PAN. In univariate comparison, the risk of PAN increased more than threefold in the presence of a distal adenoma measuring either > or =10 mm in diameter or containing villous components. Multiplicity of distal adenomas, severe dysplasia, or age > or =60 years increased the risk of PAN more than twofold. In the multivariate model, the presence of a distal adenoma > or =10 mm, villousness, and multiplicity maintained their significance as predictive variables for increased risk of proximal neoplasms, whereas sex and severe dysplasia lost their significance. By recommending colonoscopy only to individuals with multiple (>1) adenomas or any high risk adenoma at FS, we would have reduced the number of colonoscopies by 1209 (66%) but would have missed 32 (38%) participants with PAN and 217 (56%) with PCN. By using a 60 cm endoscope instead of an ordinary colonoscope at FS, nine (2%) participants with advanced neoplasms, including three patients with cancer, would have been missed.

CONCLUSION

The present study supports the concept of defining "any adenoma" as a positive FS, qualifying for colonoscopy. We recommend the use of an ordinary colonoscope instead of a 60 cm sigmoidoscope for FS screening examinations.

Use of a disposable sheath system for flexible sigmoidoscopy in decentralized colorectal cancer screening

BACKGROUND AND STUDY AIMS

To prevent transmission of infectious agents and to reduce instrument reprocessing time, the use of disposable sheath systems instead of conventionally reprocessed endoscopes has been promoted for flexible sigmoidoscopy. This trial primarily investigated the feasibility of a disposable sheath system for flexible sigmoidoscopy in decentralized colorectal cancer screening.

PATIENTS AND METHODS

In an ongoing colorectal cancer screening trial, 226 consecutive participants were randomly allocated to have their flexible sigmoidoscopy performed with either a fiberoptic sigmoidoscope covered with a disposable sheath ("EndoSheath group") or a conventional video colonoscope ("standard colonoscope group"). All examinations were performed at a temporary screening center. The patients' experience was documented using a questionnaire. The feasibility of running temporary screening units was evaluated.

RESULTS

Examinations beyond the 60-cm level were excluded. Thus, 113 patients (examined with the disposable instrument) and 87 (standard instrument) were eligible for analysis. When the sheathed system was used, all the devices needed could be satisfactorily transported. A screening center could be set up within a few hours. No differences were observed in patient discomfort. Fewer patients with polyps were observed in the EndoSheath group (48 [42%]), compared with 55 (63%) in the standard colonoscope group; P = 0.005). No significant differences were observed for polyps larger than 5 mm (14 [12%] in the EndoSheath group, 13 [15%] in the standard colonoscope group; P = 0.6).

CONCLUSIONS

Using the disposable system, decentralized colorectal cancer screening was easily established. However, fewer polyps were found, possibly due to the fiberoptic nature of the instrument. Sheathed video instruments are desirable and may increase the diagnostic yield.

Carbon dioxide insufflation reduces discomfort due to flexible sigmoidoscopy in colorectal cancer screening

BACKGROUND

Flexible sigmoidoscopy is currently recommended as a screening modality for colorectal cancer. However, a substantial number of patients experience discomfort because of the procedure. possibly limiting compliance and thus screening success. During endoscopy, air is commonly used to insufflate the bowel. Carbon dioxide rather than air insufflation has been shown to reduce procedure-related pain and discomfort in colonoscopy. The aim of the present study was to evaluate whether carbon dioxide insufflation reduces discomfort during and after flexible sigmoidoscopy for colorectal cancer screening.

METHODS

In a randomized, double-blinded design, 230 consecutive participants in a population-based flexible sigmoidoscopy colorectal cancer screening trial were assigned to have their examination performed with either carbon dioxide or air insufflation. Patients were asked to grade discomfort experienced both during and in the hours after the procedure on a visual analogue scale.

RESULTS

Carbon dioxide insufflation significantly reduced the amount of discomfort at 1, 3 and 6 h after the sigmoidoscopy. One hour after the examination. 84% of patients in the CO2 group reported no discomfort, compared to 64% in the air group (P = 0.006). No differences between the groups were observed during the examination.

CONCLUSIONS

Carbon dioxide insufflation significantly reduced post-examination discomfort. The use of carbon dioxide rather than air insufflation may contribute to better public acceptance for flexible sigmoidoscopy screening.

Continuous evaluation of patient satisfaction in endoscopy centres

BACKGROUND

A randomized sample of 14,000 men and women, aged 55-64 years, resident in the City of Oslo and Telemark County, were drawn from the population registry to be offered a flexible sigmoidoscopy (FS) screening examination. A questionnaire was designed to modify routines and evaluate patient satisfaction.

METHODS

Consecutive participants (4956) were given a questionnaire immediately after the FS to be filled in and returned by mail on the following day. Participants were asked questions about service, practical issues, and the level of pain during the FS and post-examination discomfort. They were also encouraged to give their comments in free text.

RESULTS

Questionnaire replies were received from 4574 (92%) out of 4956 participants. The vast majority reported to have experienced no (70%) or slight (21%) pain during the examination. Women reported pain and post-examination discomfort more often than men. Pain was also associated with age of the patient and length of bowel examined, but not with total examination time. The proportion of painless examinations varied between endoscopists from 62% to 81%. For all endoscopists collectively, this improved during the study period, irrespective of past experience, but trainees seemed to adopt the score of their masters.

CONCLUSIONS

The study demonstrated that the use of feedback information in an endoscopy screening unit may be useful in improving standards, including the performance of endoscopists. It is possible that the introduction of similar feedback systems in routine endoscopy laboratories may in the long run improve the reputation of gastrointestinal endoscopy.

Design, organization and management of a controlled population screening study for detection of colorectal neoplasia: attendance rates in the NORCCAP study (Norwegian Colorectal Cancer Prevention)

BACKGROUND

In the past three decades, the incidence of colorectal cancer (CRC) in Norway has doubled, surpassing all other Nordic countries for both men and women to become the most frequently diagnosed cancer. A small-scale, randomized study on flexible sigmoidoscopy (FS) screening in Telemark, Norway, has shown a reduction in accumulated CRC incidence after 13 years. The aim of our study was to evaluate the effect on CRC mortality and morbidity by screen detection of CRC and removal of precursor lesions (polypectomy), and to test out the management and organization mimicking a countrywide screening service. A total of 13,823 men and women (1:1), age 55-64 years, were drawn randomly from the population registries in Oslo (urban) and the county of Telemark (mixed urban and rural) and invited to have a screening examination. The rest of the relevant age cohorts constituted the control groups. In the screening group, 535 individuals were excluded according to exclusion criteria, rendering 13,288 individuals eligible for screening examination.

METHODS

A once only screening model was used. In the screening group, individuals were randomized to have a once only FS or a combination of FS and faecal occult blood test (FOBT).

RESULTS

The overall attendance rate was 8,849 out of 13,288 (67%); 73% in Telemark and 60% in Oslo. Attendance for FS only was 68% and 65% for combined FS&FOBT.

CONCLUSIONS

The present FSIFS&FOBT screening study obtained a high acceptance rate for both screening modalities. The attendance rate was stable throughout the trial, suggesting an acceptable model for management of future countrywide screening.

NORCCAP (Norwegian colorectal cancer prevention): a randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflation in colonoscopy

BACKGROUND

To eliminate the risk of combustion during electrosurgical procedures and to reduce patient discomfort, carbon dioxide (CO2) insufflation has been recommended during colonoscopy. However, air insufflation is still the standard method, perhaps due to the lack of suitable equipment and shortage of randomised studies.

AIMS

This randomised controlled trial was conducted to assess patient tolerance and safety when using CO2 insufflation during colonoscopy.

PATIENTS

Over an eight month period a successive series of patients referred for a baseline colonoscopy due to findings in a flexible sigmoidoscopy screening trial were randomly assigned to the use of either air or CO2 insufflation during colonoscopy.

METHODS

End tidal CO2 (ETCO2), a non-invasive parameter of arterial pCO2, was registered before and repeatedly during and after the examination. The patient's experience of pain during and after the examination was registered using a visual analogue scale (VAS). Sedation was not used routinely.

RESULTS

CO2 insufflation was used in 121 patients (51%) and air in 119 patients (49%). The groups were similar in age, sex, and caecal intubation rate. No rise in ETCO2 was registered. There were statistically significant differences in VAS scores between the groups with less pain reported when using CO2.

CONCLUSIONS

This randomised study of unsedated patients shows that CO2 insufflation is safe during colonoscopy with no rise in ETCO2 level. CO2 was found to be superior to air in terms of pain experienced after the examination.

ACD versus standard CPR in a prehospital setting

BACKGROUND

Animal and human studies in cardiac arrest demonstrate significant improvements in systolic blood pressure, coronary perfusion pressure and total brain and myocardial blood flow with active compression-decompression (ACD) cardiopulmonary resuscitation (CPR). The results of recent studies in patients with out-of-hospital cardiac arrest and use of ACD-CPR are non-uniform and require supplementation.

METHODS

In a retrospective non-randomised design, 152 adult patients with prehospital cardiac arrest, not caused by trauma or hypothermia, were studied. Compressions were performed according to the recommendations of the American Heart Association. Three ACD devices were assigned to seven rescue units changing monthly. Study end-points were the rates of return of spontaneous circulation (ROSC), admission to hospital, survival at 24h, hospital discharge and neurologic outcome.

RESULTS

70 (46%) patients underwent standard (STD) CPR and 82 (54%) patients were treated with ACD-CPR. Both groups were comparable with regard to age, sex, witnessed cardiac arrests, bystander CPR, cause of arrest, time intervals, number of defibrillations, and total amount of epinephrine. No significant differences in outcome could be found: 20 patients (29%) who received STD-CPR, and 14 patients (17%) who underwent ACD-CPR survived to hospital discharge. Neither at other end-points nor in any subgroups could any significant differences be discovered. Patients regaining ROSC showed a significant difference in favour of STD-CPR for the end-points of hospital admission, 24-h survival and hospital discharge.

CONCLUSION

No significant differences in hospital discharge and neurological outcome were found between STD-CPR and ACD-CPR.