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      Factors affecting bowel preparation adequacy and procedural time

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          Abstract

          Background and Aim

          Poor bowel preparation results in difficult colonoscopies, missed lesions, and repeat procedures. Identifying patient risk factors for poor bowel preparation, such as prolonged runway time and prolonged cecal intubation, will aid in interventions prior to a procedure.

          Methods

          This was a retrospective, single‐center analysis of 3 295 colonoscopies performed between May 2012 and November 2014. Indications for colonoscopy included gastrointestinal bleed and anemia, change in bowel habits, for screening, and others (including planning re‐anastomoses, abdominal distension, family history and angioectasias). Data were collected from medical charts and endoscopy reports. Comparisons between patient factors and runway time were made with adequacy of bowel preparation as the primary outcomes.

          Results

          Male and diabetic patients had statistically higher rates of inadequate bowel preparation and prolonged cecal intubation times. A previous history of abdominal surgery also demonstrated prolonged cecal intubation. A runway time of ≤7.63 h was associated with higher rates of adequate bowel preparation by multivariate analysis. The optimal time frame is 3–6 h for the highest success rates.

          Conclusion

          Patient risk factors for inadequate bowel preparation or prolonged cecal intubation should signal clinicians to intervene prior to colonoscopy. A runway time between 3 and 6 h is optimal for adequate bowel preparation. This may involve further patient education, along with work flow optimization, to facilitate ideal runway times. Future studies should explore how to avoid repeat endoscopies using protocols enforcing this timeframe.

          Abstract

          Optimizing runway time plays a critical role in adequate bowel preparation for colonoscopy. Identifying methods of good bowel preparation in patients is ideal to prevent repeat procedures.

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          Most cited references 41

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          Global cancer statistics, 2012.

          Cancer constitutes an enormous burden on society in more and less economically developed countries alike. The occurrence of cancer is increasing because of the growth and aging of the population, as well as an increasing prevalence of established risk factors such as smoking, overweight, physical inactivity, and changing reproductive patterns associated with urbanization and economic development. Based on GLOBOCAN estimates, about 14.1 million new cancer cases and 8.2 million deaths occurred in 2012 worldwide. Over the years, the burden has shifted to less developed countries, which currently account for about 57% of cases and 65% of cancer deaths worldwide. Lung cancer is the leading cause of cancer death among males in both more and less developed countries, and has surpassed breast cancer as the leading cause of cancer death among females in more developed countries; breast cancer remains the leading cause of cancer death among females in less developed countries. Other leading causes of cancer death in more developed countries include colorectal cancer among males and females and prostate cancer among males. In less developed countries, liver and stomach cancer among males and cervical cancer among females are also leading causes of cancer death. Although incidence rates for all cancers combined are nearly twice as high in more developed than in less developed countries in both males and females, mortality rates are only 8% to 15% higher in more developed countries. This disparity reflects regional differences in the mix of cancers, which is affected by risk factors and detection practices, and/or the availability of treatment. Risk factors associated with the leading causes of cancer death include tobacco use (lung, colorectal, stomach, and liver cancer), overweight/obesity and physical inactivity (breast and colorectal cancer), and infection (liver, stomach, and cervical cancer). A substantial portion of cancer cases and deaths could be prevented by broadly applying effective prevention measures, such as tobacco control, vaccination, and the use of early detection tests. © 2015 American Cancer Society.
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            Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study.

            The quality of colon cleansing is a major determinant of quality of colonoscopy. To our knowledge, the impact of bowel preparation on the quality of colonoscopy has not been assessed prospectively in a large multicenter study. Therefore, this study assessed the factors that determine colon-cleansing quality and the impact of cleansing quality on the technical performance and diagnostic yield of colonoscopy. Twenty-one centers from 11 countries participated in this prospective observational study. Colon-cleansing quality was assessed on a 5-point scale and was categorized on 3 levels. The clinical indication for colonoscopy, diagnoses, and technical parameters related to colonoscopy were recorded. A total of 5832 patients were included in the study (48.7% men, mean age 57.6 [15.9] years). Cleansing quality was lower in elderly patients and in patients in the hospital. Procedures in poorly prepared patients were longer, more difficult, and more often incomplete. The detection of polyps of any size depended on cleansing quality: odds ratio (OR) 1.73: 95% confidence interval (CI)[1.28, 2.36] for intermediate-quality compared with low-quality preparation; and OR 1.46: 95% CI[1.11, 1.93] for high-quality compared with low-quality preparation. For polyps >10 mm in size, corresponding ORs were 1.0 for low-quality cleansing, OR 1.83: 95% CI[1.11, 3.05] for intermediate-quality cleansing, and OR 1.72: 95% CI[1.11, 2.67] for high-quality cleansing. Cancers were not detected less frequently in the case of poor preparation. Cleansing quality critically determines quality, difficulty, speed, and completeness of colonoscopy, and is lower in hospitalized patients and patients with higher levels of comorbid conditions. The proportion of patients who undergo polypectomy increases with higher cleansing quality, whereas colon cancer detection does not seem to critically depend on the quality of bowel preparation.
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              Impact of bowel preparation on efficiency and cost of colonoscopy.

              The impact of bowel preparation on the cost and efficiency of colonoscopy is uncertain. The aim of this study was to measure the impact of bowel preparation on total direct cost as well as procedure time and volume. For 200 consecutive outpatient colonoscopies in persons with intact colons both at a private university hospital and at a public university hospital, we recorded the time spent suctioning fluid and feces from the colon and the time spent washing the colon to clean the mucosa. We prospectively asked colonoscopists to designate examinations that should be repeated at an interval sooner than would otherwise be recommended because of imperfect preparation. The data were used to perform a cost analysis of the economic effect of bowel preparation on direct costs of colonoscopy. Suctioning fluid and washing occupied 6% and 1.5% of total examination time (including insertion and withdrawal) at the public hospital and 9% and 1.3% at the private hospital. Patients at the public hospital were more likely to have an aborted examination (6.5% vs 1%, p = 0.004) and to be brought back earlier than suggested or required by current practice standards because of imperfect bowel preparation (20% vs 12.5%, p = 0.04). Cost analysis indicated that to complete the initial examinations and the first round of surveillance, imperfect bowel preparation resulted in a 12% increase in costs at the university hospital and a 22% increase at the public hospital. The increase in colonoscopy costs associated with imperfect preparation is substantial, and seems likely to vary among practices. Aborted examinations and surveillance examinations performed earlier than recommended because of imperfect preparation are appropriate targets for continuous quality improvement programs. More reliable bowel preparations, or measures to improve patient compliance with bowel preparation, could significantly reduce the costs of colonoscopy in clinical practice.
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                Author and article information

                Contributors
                alexander.c.do@gmail.com
                Journal
                JGH Open
                JGH Open
                10.1002/(ISSN)2397-9070
                JGH3
                JGH Open: An Open Access Journal of Gastroenterology and Hepatology
                Wiley Publishing Asia Pty Ltd (Melbourne )
                2397-9070
                20 August 2019
                April 2020
                : 4
                : 2 ( doiID: 10.1002/jgh3.v4.2 )
                : 206-214
                Affiliations
                [ 1 ] Gastroenterology, Logan Hospital Brisbane Queensland Australia
                [ 2 ] General Medicine, Princess Alexandra Hospital Brisbane Queensland Australia
                [ 3 ] School of Medicine Griffith University Gold Coast Queensland Australia
                [ 4 ] Paediatrics, Monash Hospital Melbourne Victoria Australia
                [ 5 ] Gastroenterology, Ballarat Hospital Ballarat Victoria Australia
                Author notes
                [* ] Correspondence

                Cuong N Do, 54 Darra Station Rd, Darra, Brisbane, QLD 4076, Australia.

                Email: alexander.c.do@ 123456gmail.com

                Article
                JGH312241
                10.1002/jgh3.12241
                7144787
                © 2019 The Authors. JGH Open: An open access journal of gastroenterology and hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

                This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 6, Tables: 4, Pages: 9, Words: 6876
                Product
                Categories
                Original Article
                Original Articles
                Custom metadata
                2.0
                April 2020
                Converter:WILEY_ML3GV2_TO_JATSPMC version:5.7.9 mode:remove_FC converted:09.04.2020

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