Rates of repeated colonoscopies to clean the colon from low-risk and high-risk adenomas: results from the EPoS trials.

OBJECTIVE: High-quality colonoscopy (adequate bowel preparation, whole-colon visualisation and removal of all neoplastic polyps) is a prerequisite to start polyp surveillance, and is ideally achieved in one colonoscopy. In a large multinational polyp surveillance trial, we aimed to investigate clinical practice variation in number of colonoscopies needed to enrol patients with low-risk and high-risk adenomas in polyp surveillance. DESIGN: We retrieved data of all patients with low-risk adenomas (one or two tubular adenomas <10 mm with low-grade dysplasia) and high-risk adenomas (3-10 adenomas, ≥1 adenoma ≥10 mm, high-grade dysplasia or villous components) in the European Polyp Surveillance trials fulfilling certain logistic and methodologic criteria. We analysed variations in number of colonoscopies needed to achieve high-quality colonoscopy and enter polyp surveillance by endoscopy centre, and by endoscopists who enrolled ≥30 patients. RESULTS: The study comprised 15 581 patients from 38 endoscopy centres in five European countries; 6794 patients had low-risk and 8787 had high-risk adenomas. 961 patients (6.2%, 95% CI 5.8% to 6.6%) underwent two or more colonoscopies before surveillance began; 101 (1.5%, 95% CI 1.2% to 1.8%) in the low-risk group and 860 (9.8%, 95% CI 9.2% to 10.4%) in the high-risk group. Main reasons were poor bowel preparation (21.3%) or incomplete colonoscopy/polypectomy (14.4%) or planned second procedure (27.8%). Need of repeat colonoscopy varied between study centres ranging from 0% to 11.8% in low-risk adenoma patients and from 0% to 63.9% in high-risk adenoma patients. On the second colonoscopy, the two most common reasons for a repeat (third) colonoscopy were piecemeal resection (26.5%) and unspecified reason (23.9%). CONCLUSION: There is considerable practice variation in the number of colonoscopies performed to achieve complete polyp removal, indicating need for targeted quality improvement to reduce patient burden. TRIAL REGISTRATION NUMBER: NCT02319928.

Endoscopy assistants influence the quality of colonoscopy.

BACKGROUND: Colonoscopy performance varies between endoscopists, but little is known about the impact of endoscopy assistants on key performance indicators. We used a large prospective colonoscopy quality database to perform an exploratory study to evaluate differences in selected quality indicators between endoscopy assistants. METHODS: All colonoscopies reported to the Norwegian colonoscopy quality assurance register Gastronet can be used to trace individual endoscopy assistants. We analyzed key quality indicators (cecum intubation rate, polyp detection rate, colonoscopies rated as severely painful, colonoscopies with sedation or analgesia, and satisfaction with information) for colonoscopies performed between 1 January 2013 and 31 December 2014. Differences between individual assistants were analyzed by fitting multivariable logistic regression models, with the best performing assistant at each participating hospital as reference. All models were adjusted for the endoscopist. RESULTS: 63 endoscopy assistants from 12 hospitals assisted in 15 365 colonoscopies. Compared with their top performing peers from the same hospital, one assistant was associated with cecum intubation failure, four with poor polyp detection, nine with painful colonoscopy, 16 with administration of sedation or analgesics during colonoscopy, and three with patient dissatisfaction about information given relating to the colonoscopy. The number of procedures during the study period or lifetime experience as an endoscopy assistant were not associated with any quality indicator. CONCLUSION: In this exploratory study, there was little variation on important colonoscopy quality indicators between endoscopy assistants. However, there were differences among assistants that may be clinically important. Endoscopy assistants should be subject to quality surveillance similarly to endoscopists.

Nitrous oxide for analgesia in colonoscopy without sedation.

BACKGROUND: Colonoscopy is associated with pain and discomfort, and intravenous analgesics and sedatives are widely used. There are several disadvantages regarding this practice, including risk of complications, resources demanded, and amnesia after sedation. In spite of promising results in previous studies, nitrous oxide is rarely used at endoscopy centers around the world. OBJECTIVE: To investigate the efficiency of nitrous oxide versus placebo as an analgesic during colonoscopy without sedation. DESIGN: A double-blind, randomized, placebo-controlled trial. SETTING: The endoscopy unit at Oslo University Hospital Rikshospitalet, Oslo, Norway, between June 2006 and May 2008. PATIENTS: This study involved patients undergoing elective colonoscopy. INTERVENTION: Patients inhaled nitrous oxide or placebo on demand. MAIN OUTCOME MEASUREMENTS: The participants filled in a questionnaire regarding their experiences with the examination. Pain was graded from 1 (no pain) to 4 (severe pain). RESULTS: We recruited 199 patients. We randomized 97 patients to the nitrous oxide group and 102 to the control group. The groups were comparable regarding demographic factors. Median patient-reported pain was 2 in both the nitrous oxide group and the control group (interquartile range 2-3 in both groups). Additional sedatives and analgesics were given equally often and in similar doses in both groups. No side effects related to administration of nitrous oxide were reported. LIMITATIONS: The questionnaire was returned by 76% of the patients. The study gas was given on demand, not continuously. CONCLUSION: Nitrous oxide given intermittently is not an effective substitution for intravenous on-demand sedation and analgesics in the setting of colonoscopy without sedation.