Diagnostic yield of early repeat colonoscopy after suboptimal bowel preparation in a fecal immunochemical test-based screening program

Abstract

Background Current guidelines regarding surveillance after screening colonoscopy assume adequate bowel preparation. However, follow-up intervals after suboptimal cleansing are highly heterogeneous. We aimed to determine the diagnostic yield of early repeat colonoscopy in patients with suboptimal bowel preparation in fecal immunochemical test (FIT)-based screening colonoscopy.

Methods An observational study including patients who underwent colonoscopy with suboptimal bowel preparation after positive FIT screening and then repeat colonoscopy within 1 year. Suboptimal preparation was defined as a Boston Bowel Preparation Scale (BBPS) score of 1 in any segment. Patients with a BBPS score of 0 in any segment or incomplete examination were excluded. The adenoma detection rate (ADR), advanced ADR (AADR), and colorectal cancer rate were calculated for the index and repeat colonoscopies.

Results Of the 2474 patients with FIT-positive colonoscopy at our center during this period, 314 (12.7 %) had suboptimal preparation. Of the 259 (82.5 %) patients who underwent repeat colonoscopy, suboptimal cleansing persisted in 22 (9 %). On repeat colonoscopy, the ADR was 38.7 % (95 %CI 32.6 % to 44.8 %) and the AADR was 14.9 % (95 %CI 10.5 % to 19.4 %). The per-adenoma miss rate was 27.7 % (95 %CI 24.0 % to 31.6 %), and the per-advanced adenoma miss rate was 17.6 % (95 %CI 13.3 % to 22.7 %). After repeat colonoscopy, the post-polypectomy surveillance recommendation changed from 10 to 3 years in 14.7 % of the patients with previous 10-year surveillance recommendation.

Conclusions Patients with suboptimal bowel preparation on FIT-positive colonoscopy present a high rate of advanced adenomas in repeat colonoscopy, with major changes in post-polypectomy surveillance recommendations.

• References

• 1 Winawer SJ, Zauber AG, Ho MN. et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. NEJM 1993; 329: 1753-1759
• 2 Rutter MD, Beintaris I, Valori R. et al. World Endoscopy Organization consensus statements on post-colonoscopy and post-imaging colorectal cancer. Gastroenterology 2018; 155: 909-925
• 3 Imperiale TF, Glowinski EA, Lin-Cooper C. et al. Five-year risk of colorectal neoplasia after negative colonoscopy. NEJM 2008; 359: 1218-1224
• 4 Kaminski MF, Regula J, Kraszewska E. et al. Quality indicators for colonoscopy and the risk of interval cancer. NEJM 2010; 8: 1795-2803
• 5 Kaminski MF, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378-397
• 6 Lebwohl B, Kastrinos F, Glick M. et al. The impact of suboptimal bowel preparation on adenoma miss rates and the factors associated with early repeat colonoscopy. Gastrointest Endosc 2011; 14: 1207-1214
• 7 Clark BT, Protiva P, Nagar A. et al. Quantification of adequate bowel preparation for screening or surveillance colonoscopy in men. Gastroenterology 2016; 150: 396-405
• 8 Rembacken B, Hassan C, Riemann JF. et al. Quality in screening colonoscopy: Position statement of the European Society of Gastrointestinal Endoscopy (ESGE). Endoscopy 2012; 44: 957-968
• 9 Hassan C, East J, Radaelli F. et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2019. Endoscopy 2019; 51: 775-794
• 10 Saltzman JR, Cash BD, Pasha SF. et al. Bowel preparation before colonoscopy. Gastrointest Endosc 2015; 81: 781-794
• 11 Clark BT, Rustagi T, Laine L. What level of bowel prep quality requires early repeat colonoscopy: systematic review and meta-analysis of the impact of preparation quality on adenoma detection. Am J Gastroenterol 2014; 11: 1714-1724
• 12 Calderwood AH, Jacobson BC. Comprehensive validation of the Boston Bowel Preparation Scale. Gastrointest Endosc 2010; 4: 686-692
• 13 Adams WJ, Meagher AP, Lubowski DZ. et al. Bisacodyl reduces the volume of polyethylene glycol solution required for bowel preparation. Dis Colon Rectum 1994; 37: 224-229
• 14 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: S3-S43
• 15 Hassan C, Quintero E, Dumonceau J-M. et al. Post-polypectomy colonoscopy surveillance: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2013; 45: 842-851
• 16 Mangas-Sanjuan C, Jover R, Cubiella J. et al. Endoscopic surveillance after colonic polyps and colorrectal cancer resection. 2018 update. Gastroenterol Hepatol 2019; 42: 188-201
• 17 Ben-Horin S, Bar-Meir S, Avidan B. The impact of colon cleanliness assessment on endoscopists’ recommendations for follow-up colonoscopy. Am J Gastroenterol 2007; 102: 2680-2685
• 18 Menees SB, Kim HM, Elliott EE. et al. The impact of fair colonoscopy preparation on colonoscopy use and adenoma miss rates in patients undergoing outpatient colonoscopy. Gastrointest Endosc 2013; 78: 1-12
• 19 Kim JS, Kang SH, Moon HS. et al. Impact of bowel preparation quality on adenoma identification during colonoscopy and optimal timing of surveillance. Dig Dis Sci 2015; 60: 3092-3099
• 20 Zorzi M, Senore C, Da Re F. et al. Quality of colonoscopy in an organised colorectal cancer screening programme with immunochemical faecal occult blood test: the EQuIPE study (Evaluating Quality Indicators of the Performance of Endoscopy). Gut 2015; 64: 1389-1396
• 21 Wong JCT, Chiu H, Kim H. et al. Adenoma detection rates in colonoscopies for positive fecal immunochemical tests versus direct screening colonoscopies. Gastrointest Endosc 2019; 89: 607-614
• 22 Jover R, Herraiz M, Alarcon O. et al. Clinical practice guidelines: quality of colonoscopy in colorectal cancer screening. Endoscopy 2012; 44: 444-451
• 23 Chokshi RV, Hovis CE, Hollander T. et al. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointest Endosc 2012; 75: 1197-1203
• 24 Chang JY, Moon CM, Lee HJ. et al. Predictive factors for missed adenoma on repeat colonoscopy in patients with suboptimal bowel preparation on initial colonoscopy: A KASID multicenter study. PLoS One 2018; 13: 1-14