Reply to Azmi et al.

We appreciate the interest of Azmi et al. in our recently published study [1], which allows us to underline several aspects and implications of the main findings of our study. Our study is the first randomized non-inferiority trial comparing low-volume versus high-volume preparations in the so-called “hard to prepare” patients. Indeed, it has been demonstrated that a history of colorectal resection represents an independent predictor for inadequate colon cleansing [2] [3]. Nowadays, splitting the dose of bowel preparation is the recommended standard of practice [4].

Our hypothesis was that the splitting of the dose, rather than the total amount of preparation, was the main factor determining the quality of bowel cleansing in patients with a history of colorectal resection too. Based on the results of our study, the split-dose low-volume mixed preparation was not inferior to the split-dose high-volume preparation, therefore suggesting that a split-dose low-volume preparation is a feasible option for bowel cleansing in “hard to prepare” patients too. In addition, the low-volume preparation was better tolerated and may also achieve better quality cleansing in patients with a history of left colectomy.

If the results of our study are confirmed by larger, prospective, equivalence, multicenter trials, the preparation regimens could be tailored according to the type of surgical resection, in order to guarantee an adequate quality of cleansing and high adenoma detection rates, especially in patients at higher risk of relapse (such as those with a history of left-sided colectomy) [5].

• References

• 1 Mussetto A, Frazzoni L, Paggi S et al. Split dosing with a low-volume preparation is not inferior to split dosing with a high-volume preparation for bowel cleansing in patients with a history of colorectal resection: a randomized trial. Endoscopy 2015; 47: 917-924
• 2 Hassan C, Fuccio L, Bruno M et al. A predictive model identifies patients most likely to have inadequate bowel preparation for colonoscopy. Clin Gastroenterol Hepatol 2012; 10: 501-506
• 3 Dik VK, Moons LM, Hüyük M et al. Predicting inadequate bowel preparation for colonoscopy in participants receiving split-dose bowel preparation: development and validation of a prediction score. Gastrointest Endosc 2015; 81: 665-672
• 4 Hassan C, Bretthauer M, Kaminski MF et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2013; 45: 142-150
• 5 Fuccio L, Spada C, Frazzoni L et al. Higher adenoma recurrence rate after left- versus right-sided colectomy for colon cancer. Gastrointest Endosc 2015; 82: 337-343