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      Impact of Inadequate Bowel Cleansing on Colonoscopic Findings in Routine Screening Practice

      , MPH, PhD , 1 , , PhD 1 , , PhD 2 , , MPH, PhD 1 , 3 , , PhD 1 , , MPH, PhD, MD 1 , 2 , 3

      Clinical and Translational Gastroenterology

      Wolters Kluwer

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          Colonoscopy is an imperfect gold standard for detecting colorectal neoplasms because some proportion of adenomas may be missed, mainly small lesions. This proportion is expected to be higher in case of inadequate bowel cleansing, which is frequently seen in routine practice. We estimated the proportions of neoplasms that are in principle detectable by colonoscopy but might be missed in case of incomplete bowel preparation.


          For 8,193 participants of screening colonoscopy in South-Western Germany, recruited between 2005 and 2016, the prevalence and numbers of different findings were extracted from colonoscopy reports and compared according to the reported bowel preparation quality.


          Bowel preparation quality was reported as good, poor, or was unspecified in 30.3%, 11.1%, and 58.6% of colonoscopy records. Reported prevalences of nonadvanced adenomas (NAAs) were similar among participants with poor and unspecified bowel preparation quality but substantially lower than among participants with good bowel preparation (adjusted prevalence rate ratio [RR] 0.86, 95% confidence interval [CI]: 0.77–0.96). The differences were observed for proximal but not for distal NAAs (RRs 0.82, 95% CI: 0.71–0.95 and 0.95, 95% CI: 0.82–1.10).


          Our study suggests that a significant proportion of NAAs located in the proximal colon might be missed during colonoscopy if bowel cleansing is not adequate. Major efforts should be made to further facilitate and enhance high-quality bowel preparation in routine screening practice.

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          Most cited references 36

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          Easy SAS calculations for risk or prevalence ratios and differences.

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            Polyp miss rate determined by tandem colonoscopy: a systematic review.

            Colonoscopy is the best available method to detect and remove colonic polyps and therefore serves as the gold standard for less invasive tests such as virtual colonoscopy. Although gastroenterologists agree that colonoscopy is not infallible, there is no clarity on the numbers and rates of missed polyps. The purpose of this systematic review was to obtain summary estimates of the polyp miss rate as determined by tandem colonoscopy. An extensive search was performed within PUBMED, EMBASE, and the Cochrane Library databases to identify studies in which patients had undergone two same-day colonoscopies with polypectomy. Random effects models based on the binomial distribution were used to calculate pooled estimates of miss rates. Six studies with a total of 465 patients could be included. The pooled miss rate for polyps of any size was 22% (95% CI: 19-26%; 370/1,650 polyps). Adenoma miss rate by size was, respectively, 2.1% (95% CI: 0.3-7.3%; 2/96 adenomas > or =10 mm), 13% (95% CI: 8.0-18%; 16/124 adenomas 5-10 mm), and 26% (95% CI: 27-35%; 151/587 adenomas 1-5 mm). Three studies reported data on nonadenomatous polyps: zero of eight nonadenomatous polyps > or =10 mm were missed (0%; 95% CI: 0-36.9%) and 83 of 384 nonadenomatous polyps or =10 mm, but the miss rate increases significantly in smaller sized polyps. The available evidence is based on a small number of studies with heterogeneous study designs and inclusion criteria.
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              Colorectal cancer screening: a global overview of existing programmes.

              Colorectal cancer (CRC) ranks third among the most commonly diagnosed cancers worldwide, with wide geographical variation in incidence and mortality across the world. Despite proof that screening can decrease CRC incidence and mortality, CRC screening is only offered to a small proportion of the target population worldwide. Throughout the world there are widespread differences in CRC screening implementation status and strategy. Differences can be attributed to geographical variation in CRC incidence, economic resources, healthcare structure and infrastructure to support screening such as the ability to identify the target population at risk and cancer registry availability. This review highlights issues to consider when implementing a CRC screening programme and gives a worldwide overview of CRC burden and the current status of screening programmes, with focus on international differences.

                Author and article information

                Clin Transl Gastroenterol
                Clin Transl Gastroenterol
                Clinical and Translational Gastroenterology
                Wolters Kluwer (Philadelphia, PA )
                April 2020
                09 April 2020
                : 11
                : 4
                [1 ]Division of Clinical Epidemiology and Aging Research, German Cancer Research Center (DKFZ), Heidelberg, Germany;
                [2 ]Division of Preventive Oncology, German Cancer Research Center (DKFZ) and National Center for Tumor Diseases (NCT), Heidelberg, Germany;
                [3 ]German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany.
                Author notes
                Correspondence: Tobias Niedermaier, PhD, MPH. E-mail: t.niedermaier@ .
                CTG-19-0445 00006
                © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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                Gastroenterology & Hepatology


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