Impact of an Incomplete Colonoscopy Referral Program on Recommendations After Incomplete Colonoscopy

Division of Gastroenterology and Hepatology, Department of Medicine, Feinberg School of Medicine, Northwestern University, 676 N. St. Clair, Suite 1400, Chicago, IL, 60611, USA.
Digestive Diseases and Sciences (Impact Factor: 2.61). 03/2013; 58(7). DOI: 10.1007/s10620-013-2605-1
Source: PubMed


BACKGROUND: There are limited data on recommendations and adherence to complete colon evaluation (CCE) after incomplete colonoscopy (IC). AIMS: Our objectives were to (1) identify recommendations and adherence to recommendations after IC, (2) determine the diagnostic yield of CCE after IC, and (3) determine the effect of an IC referral program on recommendations for CCE. METHODS: We conducted a retrospective review of IC procedures at a teaching hospital over two time periods (January 1 to May 1 2004 and July 1 to November 1 2010). A referral process for repeat colonoscopy after IC was instituted in April 2009. Outcomes included (1) recommendations (2) adherence, and (3) yield of CCE after IC. RESULTS: A total of 222 patients underwent at least one IC (overall rate of 2.5 %). In 120 patients (54.1 %), CCE was recommended within 1 year; the rate did not change from 2004 to 2010. Patients with IC due to poor preparation were more likely to have specific CCE recommendations (85.5 vs. 72.2 %, P = 0.03) and recommendations of endoscopic follow-up (76.3 vs. 10.4 %, P < 0.0001) than those with IC due to difficult anatomy. When IC was due to difficult colonoscopy, there was increase in endoscopic follow-up recommended (16.3 vs. 2.8 %, P = 0.01) in 2010 compared to 2004. Adherence to recommendations was similar regardless of modality recommended, inpatient/outpatient status, polyps on initial exam, or extent of initial exam. Polyp detection rate was greater utilizing colonoscopy than barium enema (34.3 vs. 3.6 %, P < 0.0001). CONCLUSIONS: There is a lack of consensus in management strategies for patients after IC. Implementation of a referral program has had minimal impact on provider recommendations.

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    • "However, modalities used in clinical practice vary based upon the individual patient and are often limited based on available institutional expertise. We have recently shown that an incomplete colonoscopy referral program had only a modest impact on provider recommendations at our institution [19]. "
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    ABSTRACT: In patients with incomplete colonoscopy, cecal intubation is sometimes unsuccessful due to a redundant or tortuous colon. Repeat colonoscopy may be successful with the use of alternate endoscopes or careful attention to technique but limited outcomes data is available. The aim of this study was to describe the technique, success rate and outcomes of consecutive patients referred for previous incomplete colonoscopy. We conducted a retrospective chart review of incomplete colonoscopy procedures in patients age 18-90 at an academic teaching hospital referred to an endoscopist specializing in difficult colonoscopy. Cecal intubation was successful in 96 of 100 repeat colonoscopies and 83 procedures were completed with a standard endoscope (adult, pediatric, or gastroscope). The adenoma detection rate was 28% for successful repeat colonoscopies; a majority of these patients had no adenomas identified on incomplete exam. In 69.4% of cases, an endoscope was used to successfully complete colonoscopy that was not used in the incomplete colonoscopy. The median insertion time was significantly less for the complete colonoscopy (10.6 min) compared to the incomplete colonoscopy (18.8 min, P = 0.004). Repeat colonoscopy has a high success rate and identified a significant number of new adenomas. Use of all available endoscopes should be considered prior to procedure termination in patients with a tortuous colon. Repeat colonoscopy can often be accomplished using a standard endoscope and is not attributed to increased endoscope insertion time.
    BMC Gastroenterology 03/2014; 14(1):56. DOI:10.1186/1471-230X-14-56 · 2.37 Impact Factor
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    ABSTRACT: This article presents inter- and intraobserver agreement for estimates of polyp diameter using CT colonography, including the effects of different visualization displays and prior experience. Four observers, three of whom had prior experience with CT colonography, estimated the maximum diameter of 48 polyps using three different visualization displays: 2D colonography window, 2D abdominal window, and 3D surface rendering. Each re-measured a subset of 10 polyps. Polyps measured 2 to 12 mm according to a colonoscopic reference. Inter- and intraobserver agreement and agreement with the reference measurement were determined using the Bland-Altman method, paired Student's t testing, analysis of variance, and analysis of covariance (ANCOVA), and by calculating the components of variance. CT measurements overestimated polyp diameter, a phenomenon found least using the 2D abdominal display. Generally, 95% limits of agreement encompassed different size categories for individual polyps: the widest spanned 14.6 mm (-4.6 mm to 10.0 mm) for an experienced observer using the 3D display. When using the 2D abdominal display, no significant difference was found between estimates and the reference value for the other two experienced observers (p = 0.83 and 0.23). All the observers' measurements were significantly different from the reference when using the 3D display (p < 0.001). The novice was significantly different from the experienced observers in some analyses. Inter- and intraobserver agreement were poorest for the 3D display. Measurement of polyp diameter from CT colonography is subject to variation contingent on the observer's experience and the viewing display used. Although 3D visualization display is commonly used for polyp detection, it should not be used for measurement.
    American Journal of Roentgenology 06/2006; 186(6):1597-604. DOI:10.2214/AJR.05.0171 · 2.73 Impact Factor
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    ABSTRACT: Objective In case of incomplete colonoscopy, several radiologic methods have traditionally been used, but more recently, capsule endoscopy was also shown to be accurate. Aim of this study was to compare colon capsule endoscopy (CCE) and CT colonography (CTC) in a prospective cohort of patients with incomplete colonoscopy. Design Consecutive patients with a previous incomplete colonoscopy underwent CCE and CTC followed by colonoscopy in case of positive findings on either test (polyps/mass lesions ≥6 mm). Clinical follow-up was performed in the other cases to rule out missed cancer. CTC was performed after colon capsule excretion or 10–12 h postingestion. Since the gold standard colonoscopy was performed only in positive cases, diagnostic yield and positive predictive values of CCE and CTC were used as study end-points. Results 100 patients were enrolled. CCE and CTC were able to achieve complete colonic evaluation in 98% of cases. In a per-patient analysis for polyps ≥6 mm, CCE detected 24 patients (24.5%) and CTC 12 patients (12.2%). The relative sensitivity of CCE compared to CTC was 2.0 (95% CI 1.34 to 2.98), indicating a significant increase in sensitivity for lesions ≥6 mm. Of larger polyps (≥10 mm), these values were 5.1% for CCE and 3.1% for CTC (relative sensitivity: 1.67 (95% CI 0.69 to 4.00)). Positive predictive values for polyps ≥6 mm and ≥10 mm were 96% and 85.7%, and 83.3% and 100% for CCE and CTC, respectively. No missed cancer occurred at clinical follow-up of a mean of 20 months. Conclusions CCE and CTC were of comparable efficacy in completing colon evaluation after incomplete colonoscopy; the overall diagnostic yield of colon capsule was superior to CTC. Trial registration number NCT01525940.
    Gut 06/2014; 64(2). DOI:10.1136/gutjnl-2013-306550 · 14.66 Impact Factor
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