Introduction

Colonoscopy is the gold standard of an optimal exploration of the colon. Complete colonoscopy stands as the cornerstone for detecting precancerous lesions and colorectal screening.

Aims & Methods

The aim of our study was to identify factors limiting the completeness of the colonoscopy. We retrospectively colonoscopy reports performed between August 2023 and April 2024. Colonoscopies performed under general anesthesia were excluded from our analysis. Demographics, clinical and endoscopic data were collected. We investigated predictive factors of incomplete examinations.

Results

In total, 400 performed colonoscopies were included. The mean age of the patients was 56.5 years ± 14.22 (ranging from 16 to 91 years) and a male-to-female ratio of 2. History of diabetes was present in 24% of patients, hypertension in 38% of patients, and 7.8% of patients had chronic inflammatory bowel disease. The predominant indications for colonoscopy were constipation in 29% of cases, digestive bleeding in 16.1% of cases, diarrhea in 11% of cases, anemia in 9% of cases, screening in 4.8% of cases, and anal fistula in 3.8% of cases. The cecum was intubated in 381 colonoscopies (79.8% of cases). Interruption of the endoscopic examination were attributed to various causes, including inadequate preparation (45.5%), poor tolerance (32.5%) and irreducible loops (13%). In univariate analysis, anemia (p=0.033), history of benign prostatic hyperplasia, tolerance (p=0.05), and poor preparation (assessed by the Boston Bowel Preparation Scale) (p<0.0001) were identified as associated factors to incomplete colonoscopy. Demographic characteristics, comorbidities, irritable bowel syndrome, body mass index, abdominal hernia, history of anterior abdominal surgery were not associated with incomplete examination. On multivariate analysis, poor tolerance (p<0.0001, OR= 2.45 95%IC: 1.667-3.672), colonic preparation (p<0.0001, OR= 4.04 95%IC: 2.384-6.845) were predictive factors of incomplete colonoscopies.

Conclusion

This study confirms the importance of addressing limiting factors of a complete colonoscopy to avoid rescheduling the procedure and to prevent its psychological impact and delay in management and economic burden. Adequate analgesia and improved preparation are necessary for successful cecal intubation.

Introduction

A successful colonoscopy aims to thoroughly visualize the entire colon, including the terminal ileum, to maximize the detection of lesions and effectively screen for colorectal cancer. However, approximately 10% of colonoscopies are incomplete, often due to a combination of technical challenges and patient-related factors. The goal of our study is to identify and analyze the factors that contribute to incomplete colonoscopy procedures.

Aims & Methods

We conducted a retrospective descriptive and analytical study including all patients who underwent a colonoscopy between January 2019 and August 2024. Patients known to have chronic inflammatory bowel disease (IBD) were excluded from our study. An incomplete colonoscopy was defined as non-visualization of the caecum.

Results

Out of 1,518 colonoscopies performed, 105 (11.5%) were deemed incomplete. Factors associated with incomplete colonoscopy included older age (p=0.003), male sex (p=0.026), history of abdominal surgery (p<0.001), constipation (p=0.001), diarrhea (p=0.002), rectal bleeding (p=0.006), and poor bowel preparation (p=0.001). Multivariate analysis revealed that factors linked to incomplete colonoscopy included: a history of abdominal surgery (OR: 13.8, 95% CI: 4.2–45.1, p=0.001), poor preparation (OR: 224, 95% CI: 57–884, p=0.001), presence of diarrhea (OR: 0.2, 95% CI: 0.08–0.5, p=0.002), and constipation (OR: 0.33, 95% CI: 0.1–0.7, p=0.007).

Conclusion

In this study, 11.5% of colonoscopies were incomplete. The factors most strongly associated with incomplete procedures were a poor preparation, a history of abdominal surgery, and the presence of diarrhea or constipation.

Introduction

Colonoscopy is the gold standard for accurate exploration of the colon. Thus, it must be performed as efficiently as possible with the respect of pre-established quality standards to ensure optimal exploration. The patient's tolerance considerably affects the quality of sedation-free examinations and exposes to a high rate of interruption. Pharmacological sedation can solve this issue, however it can expose to significant adverse events and is not always available.

Aims & Methods

The aim of this study was to evaluate the impact of intraprocedural immersive virtual reality (VR) combining visual and auditory distraction in the improvement of the tolerance and the progress during unsedated colonoscopy. We conducted a prospective controlled study from February to April 2023 including outpatients presenting to the endoscopy unit for unsedated colonoscopy after consent. Patients were randomized into two groups: Group 1: colonoscopy with virtual reality headset. Group 2: control group without intervention.The material used was a virtual reality headset provided with a fully adjustable headband. The video content displayed on the hardware is made of several clips showing nature scenes. The audio content was adapted to allow optimal communication with the patient. We have excluded patients with severe visual and/or auditory impairment, dementia, cognitive impairment and epilepsy. All participants initially completed a form covering health issues and a validated anxiety questionnaire (STAI). After colonoscopy, all patients completed a form with questionnaires assessing per-procedural patient comfort (Gloucester), anxiety (STAI) and pain (EVS). In addition, patients in the intervention group completed a satisfaction questionnaire (NPS: net promoter score) assessing their experiences with the VR headset.

Results

In total, 63 patients were included in the final analysis: intervention group G1 (n=33) and control group G2 (n=30). The mean age was of 57 years. No patient encountered a technical problem with the equipment used and no adverse events occurred during the immersive experience. The two groups were comparable in terms of age, gender, comorbidities, body mass index (BMI) and colonic preparation assessed by the Boston score. A slightly lower time to caecal intubation was noted in the intervention group without significant difference (G1: 19 min vs G2: 26 min, p=0.07). Patients with VR mask expressed lower levels of post-procedural anxiety than those in the control group (Mean STAI G1: 47 vs G2: 53, p<0.01) and a significant decrease in the STAI score compared to pre-endoscopy values (8 points vs 4 points, p<0.01). The per-procedural pain assessed by EVS was significantly lower in the patients using VR (Mean G1: 0.44 vs G2 :1,32, p<0.01). Moreover, endoscopic examination was found to be more comfortable with virtual reality based on the Gloucester scale p <0.01. No patient reported any impediment to communication with medical staff due to the VR mask. Four patients were not satisfied with the resolution of the videos and 8 patients have expressed their preference to choose the content themselves. Patients of the intervention group were greatly satisfied with the VR experience with a mean NPS at 30.

Conclusion

Immersive VR technology is a promising, non-invasive and well-accepted simple tool for improving tolerance by reducing colonoscopy induced pain and anxiety allowing an optimized examination. It can be a useful alternative to conventional sedation if undesired or contraindicated or in health care institutions with a lack of adequate anesthesia facilities.

Introduction

Screening colonoscopy is effective in preventing colorectal cancer by removing precancerous lesions. Incomplete examinations are associated with a higher risk of post-colonoscopy colorectal cancer. Therefore, the minimum standard for cecal intubation rate is >90%, and the target standard >95%. However, little is known about the distribution of reasons for incomplete colonoscopy in colorectal cancer screening programs.

Aims & Methods

Based on data from the Austrian quality assurance program for screening colonoscopy, we analyzed the reasons for incomplete colonoscopies. We further investigated whether the use of sedation and the adenoma detection rate (ADR) are associated with lower rates of complete examination.

Results

489,800 screening colonoscopies were analyzed within the Austrian quality assurance program. Of these, 2.9% (n=14,325) were incomplete. 59,7% of those patients were female and 40.3% male. 85.4% of patients with an incomplete vs. 91.2% with a complete examination were sedated (p<0.001). The reasons for not reaching the cecum were insufficient bowel preparation in 23.3% (n=3335), pain in 23% (n=3291), stenosis in 11.7% (n=1674), complications in 1.6% (n=227), and other factors in 40.5% (n=5798). 69% of incomplete colonoscopies were performed by endoscopists with an ADR lower than 25% and 31% with an ADR over 25%. 54.6% of complete examinations were done by endoscopists with an ADR lower than 25% and 45.4% with an ADR over 25% (p<0.001).

Conclusion

The target standard of the cecal intubation rate has been achieved (97.1%). Incomplete colonoscopies were more often in female (84.4%) compared to male (40.3%), performed in unsedated patients and by endoscopists with an ADR <25%. The most common reason for not reaching the cecum was categorized as other factors (40.5%), this category is not well defined and requires further investigation.

Introduction

Water exchange, replacing air insufflation during colonoscopy's insertion phase, has become popular for its effectiveness in enhancing endoscopic quality. Its adoption by novices, who show improved performance, raises questions about its benefits for experienced colonoscopists. This study examines the adaptation process of three seasoned colonoscopists to water exchange, evaluating if they achieve similar improvements, to understand its broader utility.

Aims & Methods

In this study, three expert colonoscopists, each with over 10,000 air insufflation colonoscopies, first conducted 100 standard procedures. They then switched to the water exchange technique for 100 more procedures across four groups. Key outcomes—cecal intubation rates, learning curves, pain scores, polyp detection, complications, abdominal compression, position changes, and bowel preparation quality—were compared between methods to evaluate the water exchange's effectiveness and patient experience.

Results

Cecal intubation success rates and median times for water exchange groups were over 90% and below 6 minutes, matching results from traditional air insufflation methods. No notable differences were found in intubation times between endoscopists A and B, but endoscopist C showed significant time variations, especially in the third quartile, indicating a performance shift (P<0.001). A slight, non-significant decrease in abdominal compression was observed for endoscopist A, while endoscopist B's transition to water exchange significantly reduced compression needs (37% vs. 21%; P<0.05), showcasing its advantages. No changes were evident for endoscopist C. Position change demands differed significantly between methods for endoscopists B and C, hinting at endoscopist C's preference for air insufflation (P=0.001). In this study, the pain scores in the water exchange group were significantly lower than those in the air insufflation group (P=0.008) for only one expert. For the other experts, although the number of patients with a pain score of 10 decreased and the number of patients with a pain score of 0 increased in the water exchange group, no significant difference was observed. This suggests that for seasoned professionals, the water method primarily played a significant role in reducing severe abdominal pain. For patients with mild pain, the effect was unclear. An analysis of the learning curve, considering cecal intubation success and time, found no correlation with the number of water exchange procedures performed, indicating all endoscopists quickly adapted to the method without a marked learning curve, maintaining success rates above 90%.

Conclusion

The study found the water method effectively reduced severe abdominal pain, with its impact on mild pain less clear. Experts showed proficiency with this technique from the start, achieving 95% success rates in cecal intubation, indicating quick adaptation. Despite this, traditional colonoscopy's known drawbacks weren't significantly highlighted. However, experts familiar with conventional techniques found the water method more challenging and saw no major advantages for colorectal screening.

References

1. Leung FW. Water Exchange to Facilitate Unsedated Colonoscopy-Reply. Jama, 2017,318:754-755.
2. de Groen PC. Water Exchange Insertion Colonoscopy-How You Can Do It Too. Am J Gastroenterol, 2019,114:703-704.
3. Cadoni S, Hassan C, Frazzoni L, et al. Impact of water exchange colonoscopy on endoscopy room efficiency: a systematic review and meta-analysis. Gastrointest Endosc, 2019,89:159-167.e113.

Introduction

Post-colonoscopy colorectal cancer (PCCRC) is that diagnosed after a colonoscopy in which no cancer is found. PCCRC has become an important quality indicator. We aimed to determine its rates, characteristics, and index colonoscopy-related predictive factors.

Aims & Methods

Multicenter, observational, retrospective study between 2015 and 2018. We considered as PCCRC those developing up to 10 years after colonoscopy. PCCRC rates were calculated and PCCRC were categorized according to their most plausible explanation using the World Endoscopy Organization (WEO) methodology. Our PCCRC population was compared to a control cohort without CRC matched 1:4 by sex, age, index colonoscopy date and indication, endoscopist, and hospital.

Results

107 PCCRC were detected, of 101,524 colonoscopies (0.1%) and 2,508 CRC (4.3%), leading to rates of 0.4% (1-year), 2.2% (3-year), 3.1% (5-year), 4.1% (10-year). PCCRCs were in right (42.4%), left (41.4%), transverse (16.4%) colon with 31.5% at stage I, 24.7% stage II, 32.6% stage III, 11.2% stage IV. 20.3% of PCCRCs were classified as incomplete resection, 5.4% as unresected detected lesions, 48.6% as missed lesions with adequate colonoscopy, and 25.7% as missed lesions with inadequate colonoscopy. Mean time from previous colonoscopy to PCCRC was 42 months. Previous inadequate preparation (OR 3.05, 95%CI 1.73-5.36) and piecemeal polypectomy (OR 19.89, 95%CI 8.67-45.61) were independently associated with PCCRC.

Conclusion

In our population, 4.3% of CRCs were PCCRC. Most of these lesions were in the right colon and almost half attributable to lesions not visualized despite adequate bowel cleansing. Previous inadequate cleansing and piecemeal polypectomy were associated with PCCRC.

Disclosure

RJ has received research grants from MSD, and has participated as an advisor to MSD, Norgine, Alpha-Sigma, and GISupply. The rest of authors have nothing to disclose.