Same-day Versus Split-dose Bowel Preparation Before Colonoscopy: A Meta-analysis.

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BackgroundAdenoma detection rate (ADR) is one of the most important quality indicators of colonoscopy. Monitoring endoscopists and providing feedback has shown to improve ADR. We performed a systematic review of the literature and meta-analysis to determine the effect of any form of feedback on ADR.MethodsA literature search for comparative studies that employed any form of feedback to assess the impact on ADR before and after the feedback was done on MEDLINE, EMBASE, and Cochrane Database. The primary outcome of interest was ADR. Secondary outcomes included polyp detection rate, advanced adenoma detection rate, sessile serrated adenoma detection rate, withdrawal time, and cecal intubation rate. Cochrane Revman 5.3 software was used for statistical analysis.ResultsA total of 12 studies met the inclusion criteria for the analysis of primary outcomes. There were 78,355 subjects (45.42% male) with a mean age of 59.52 years. There was a significant improvement in ADR after any form of feedback compared to no feedback: 36.18% vs. 26.75%; pooled odds ratio 1.51, 95% confidence interval 1.37-1.66; P<0.001. There was a substantial heterogeneity (I2=82%). ADR improved in both active or passive feedback, irrespective of whether endoscopists knew about being monitored for their performance or not.ConclusionsMonitoring and providing feedback to endoscopists in any form leads to improvement in ADR. Feedback is an easy and effective way of improving the ADR of endoscopists, especially in those not achieving the recommended benchmarks.

Polyethylene glycol (PEG) is the standard agent for bowel preparation in colonoscopy. However, its combination with linaclotide may enhance bowel cleansing. This systematic review and meta-analysis compared the efficacy and safety of linaclotide combined with PEG versus PEG alone in patients undergoing colonoscopy. We searched PubMed, Embase, and Cochrane Library databases. We calculated pooled risk ratios (RRs) for dichotomous and mean differences (MDs) for continuous outcomes, with 95% confidence intervals (CIs). We included 8 RCTs (3591 patients). Linaclotide improved preparation quality (MD 0.31; 95% CI [0.08, 0.54]), willingness to repeat the preparation (RR 1.16; 95% CI [1.09, 1.23]), and reduced adverse events (AEs). Adenoma detection rate (ADR), polyp detection rate (PDR), cecal intubation rate, and withdrawal time were similar between the groups. Subgroup analyses showed consistent results, except for: (1) patients with constipation - linaclotide improved PDR and reduced withdrawal time; (2) studies using a lower volume of PEG in the intervention group - preparation quality was similar between groups; and (3) studies using the same volume of PEG in both groups- linaclotide improved PDR and ADR, but with similar willingness to repeat the preparation and risk of AEs. Linaclotide with PEG improved preparation quality, willingness to repeat the preparation, and reduced AEs compared to PEG alone. Subgroup analyses findings are particularly relevant for patients with a history of inadequate bowel preparation, especially those with low tolerance to high-volume PEG or difficulty achieving effective colonic cleansing. Future studies should further explore the cost-effectiveness and the applicability across diverse regimens and patient characteristics.

Association Between Endoscopist Specialty and Colonoscopy Quality: A Systematic Review and Meta-analysis

Impact of cap-assisted colonoscopy on detection of proximal colon adenomas: systematic review and meta-analysis

Factors Associated With Incomplete Colonoscopy: A Population-Based Study

High-quality colonoscopy is paramount for colorectal cancer prevention. Since 2009, endoscopists at our institution have received quarterly report cards summarizing individual colonoscopy quality indicators. We have previously shown that implementing this intervention was associated with short-term improvement in adenoma detection rate (ADR). However, the long-term effect of continued monitoring on colonoscopy quality is unclear. We conducted a retrospective study of prospectively administered quarterly colonoscopy quality report cards at the Roudebush Veteran's Affairs Medical Center between April 1, 2012, and August 31, 2019. The anonymized reports included individual endoscopists' ADRs, cecal intubation rates, and withdrawal times. Analyses were performed to determine slopes over time for each quality metric by physician and assess for differences based on whether ADRs were calculated quarterly or yearly. Data from the report cards of 17 endoscopists who had performed 24,361 colonoscopies were included. The mean quarterly ADR (±SD) was 51.7% (±11.7%) and mean yearly ADR was 47.2% (±13.8%). There was a small increase in overall ADR based on quarterly and yearly measurements (slope + 0.6%, P = 0.02; and slope +2.7%, P < 0.001, respectively), but no significant change in individual ADRs, cecal intubation rates, or withdrawal times. Analysis of SD of ADRs showed no significant difference between yearly and quarterly measurements ( P = 0.064). Individual endoscopists' ADR SD differences between yearly and quarterly measurements ranged from -4.7% to +6.8%. Long-term colonoscopy quality monitoring paralleled stable improvements in overall ADR. For endoscopists with baseline high ADR, frequent monitoring and reporting of colonoscopy quality metrics may not be necessary.

Several add-on devices have been developed to increase rates of colon adenoma detection. We aimed to compare the endocuff-assisted colonoscopy with cap-assisted colonoscopy through a pairwise meta-analysis of randomized trials. We searched the PubMed/Medline and Embase database through March 2020 and identified 6 randomized controlled trials (comprising 2,027 patients). The primary outcome was adenoma detection rate; secondary outcomes included sessile serrated adenoma detection rate, mean adenoma per colonoscopy, cecal intubation rate and time to reach cecum. Safety data were also analyzed. We performed pairwise meta-analysis through a random effects model and expressed data as risk ratio and 95% confidence interval. Overall, pooled adenoma detection rate was 48.1% (39.3-56.8%) with endocuff and 40.5% (30.4- 50.6%; risk ratio 1.14, 0.96-1.35) with cap. Proximal adenoma detection rate was 45.7% (36.8-54.7%) and 24% (17-45.1%) with endocuff and cap, respectively (risk ratio 2.04, 0.93-4.49), whereas endocuff outperformed cap-assisted colonoscopy in detecting diminutive (≤ 5 mm) adenomas (risk ratio 2.74, 1.53-4.90) and in terms of mean adenoma per colonoscopy (mean difference 0.31, 0.05 -0.57; p=0.02). Sessile serrated adenoma detection rate (risk ratio 1.36, 0.72-2.59), cecal intubation rate (risk ratio 0.99, 0.98-1.00), and time to reach cecum (6.87 min versus 6.87 min) were similar between the two groups. No serious adverse event was observed. Endocuff-assisted colonoscopy seems to provide a higher adenoma detection rate as compared to cap-assisted colonoscopy, in particular concerning smaller diminutive polyps.

High Resolution Colonoscopy With Chromoscopy Versus Standard Colonoscopy for the Detection of Colonic Neoplasia: A Randomized Study

A Prospective System for Tracking Colonoscopy Performance Among Trainees Using Key Colonoscopy Quality Indicators

Protective association of colonoscopy against proximal and distal colon cancer and patterns in interval cancer

Purpose: There is an increased interest in endoscopic performance indicators. Currently cecal intubation rates along with adenoma detection rates and colonoscope withdrawal time are being viewed as such performance indictors. A number of studies have been done to assess factors that could potentially affect these indicators. Factors such as inpatient status, female sex, and immobility, among others, have been associated with decreased cecal intubation rates. Trainee involvement could be another factor affecting quality indicators. There are very few studies that evaluated performance indicators in relation to trainee involvement. AIM: To determine whether trainee involvement affect cecal intubationand polyp detection rates. Methods: We retrospectively reviewed 6,027 consecutive colonoscopies that were performed on adults by six full-time gastroenterologists between mid-2003 and 2007 at a high-volume endoscopy unit in a large urban hospital. All colonoscopies by trainees were supervised by teaching attendings. For each colonoscopic procedure, trainee involvement, polyp findings, extent of the exam, type of anesthesia, patients age, sex, inpatient or outpatient status, were summarized and analyzed using Student t-test and Fischer's exact tests as indicated. P < 0.05 was considered to be significant. Results: Overallcecal intubation rate was 93%. Trainees participated in 28% of all colonoscopies. Colonoscopies with trainees' involvement had 94% cecal intubation rate compared with colonoscopies performed by attending gastroenterologists alone, 93%. The difference was statistically insignificant, P= 0.4. Trainees had 42% polyp detection rate compared with attending gastroenterologists, who had 41% detection rate, P= 0.5. Mean age of the patients undergoing colonoscopy with trainee involvement was older as compared to colonoscopies done by attending gastroenterologists alone, 60 (SD 13) and 58 (SD 14) respectively, P= 0.0005. Female patients constituted 63% of both groups. The percentage of outpatient colonoscopies was the same for trainees and attendings (88%). Conclusion: Results of this study do not suggest a significant effect of trainees' participation on cecal intubation andpolyp detection rates.

To increase colorectal cancer screening among urban minorities, New York Presbyterian Hospital/Columbia University, with support from the New York City Department of Health and the Citywide Colon Cancer Control Coalition (C5), instituted a patient navigation and direct endoscopic referral system. We assessed the effect of this program on the volume of colonoscopy in this institution, which caters to a socioeconomically diverse patient population. We compared colonoscopy volume during the first year of the navigator program with the volume during the year before this program. We stratified on Medicaid status to assess the secular trend of screening rates. To assess quality during this period, we measured cecal intubation rates, preparation quality, and adenoma detection rates. Of the 749 patients assessed by the patient navigators, 678 (91%) underwent colonoscopy. Colonoscopy volume among the Medicaid outpatients increased by 56% (957 to 1489). Adenoma detection was 27% and the cecal intubation rate was 97%. Comparing navigated patients with the nonnavigated Medicaid outpatients, preparation quality was superior (34% vs. 40% suboptimal, P=0.0282), although preparation quality remained inferior to that of private patients (20% suboptimal, P<0.0001). Volume of the colonoscopy increased, coinciding with the onset of the patient navigation program. This increase was nearly entirely owing to a rise in the colonoscopies among Medicaid outpatients, the principal focus of the navigator program. This increase in quantity was accomplished while maintaining an overall high level of quality as measured by cecal intubation rates and adenoma detection, although preparation quality requires further efforts at improvement.

Background:In an effort to improve visualization during colonoscopy, a transparent plastic cap or hood may be placed on the end of the colonoscope. Cap-assisted colonoscopy (CAC) has been studied and is thought to improve polyp detection. Numerous studies have been conducted comparing pertinent clinical outcomes between CAC and standard colonoscopy (SC) with inconsistent results.Methods:Numerous databases were searched in November 2016. Only randomized controlled trials (RCTs) involving adult subjects that compared CAC to SC were included. Outcomes of total colonoscopy time, time to cecum, cecal intubation rate, terminal ileum intubation rate, polyp detection rate (PDR), and adenoma detection rate (ADR) were analyzed in terms of odds ratio (OR) or mean difference (MD) with fixed effect and random effects models.Results:Five hundred eighty-nine articles and abstracts were discovered. Of these, 23 RCTs (n=12,947) were included in the analysis. CAC showed statistically significant superiority in total colonoscopy time (MD -1.51 min; 95% confidence interval [CI] -2.67 to -0.34; P<0.01) and time to cecum (MD -0.82 min; 95%CI -1.20 to -0.44; P<0.01) compared to SC. CAC also showed better PDR (OR 1.17; 95%CI 1.06-1.29; P<0.01) but not ADR (OR 1.11; 95%CI 0.95-1.30; P=0.20). In contrast, on sensitivity analysis, ADR was better with CAC. Terminal ileum intubation and cecal intubation rates demonstrated no significant difference between the two groups (P=0.11 and P=0.73, respectively).Conclusions:The use of a transparent cap during colonoscopy improves PDR while reducing procedure times. ADR may improve in cap-assisted colonoscopy but further studies are required to confirm this.

Membranous nephropathy (MN) is an organ-specific autoimmune disease, and its prevalence is increasing. B lymphocytes activated by T cells produce antibodies. CD19+/CD20+ plasma cells may contribute to autoantibody and alloantibody production. Rituximab has been effective in treating MN in many clinical trials. Thus, we conducted a meta-analysis to explore the clinical efficacy and safety of rituximab with MN. We searched Embase, PubMed, Cochrane Library and ClinicalTrials.gov without language or publication date limitations. Studies were classified in high-risk, medium-risk and low-risk groups based on baseline proteinuria. Follow-up periods and different administrations of rituximab were also compared. Complete remission (CR) and partial remission (PR) were assessed to measure the efficacy of rituximab, and adverse effects were also extracted. Dichotomous data were expressed by the odds ratio (OR), and the 95% confidence intervals (95% CI) were used for the recruited studies. Fourteen articles, including 17 studies, were included in this meta-analysis. The pooled OR of overall PR and CR remission rate was 0.58 (95% CI: 0.53-0.63; p = 0.003). No studies belonged to the low-risk group. The overall PR and CR remission rate in the medium-risk group was 0.56 (95% CI: 0.36-0.73; p = 0.57). The pooled OR of overall PR and CR remission rate in the high-risk group was 0.59 (95% CI: 0.53-0.65; p = 0.03). At the 12-month follow-up, the pooled OR of overall PR and CR remission rate was 0.51 (95% CI: 0.43-0.59; p = 0.72). At the 24-month follow-up, the pooled OR of overall PR and CR remission rate was 0.71 (95% CI: 0.48-0.86; p = 0.07). The pooled OR of efficacy of rituximab at 375 mg/m2 × 4 was 0.63 (95% CI: 0.55-0.70; p = 0.001). Rituximab was tolerated in MN, and most adverse effects were mild. The pooled OR of infusion reaction rate of rituximab was 0.25 (95% CI: 0.13-0.44; p = 0.01) in MN. The pooled OR of cardiovascular-related event rate of rituximab in MN was 0.04 (95% CI: 0.02-0.11). The pooled OR of infection rate of rituximab in MN was 0.06 (95% CI: 0.03-0.12; p < 0.00001). Rituximab is safe and effective in MN and a promising alternative treatment. More randomized control trials and studies on the role of MN are expected.