Good is better than excellent: bowel preparation quality and adenoma detection rates

doi:10.1016/j.gie.2014.10.032

Gastrointestinal Endoscopy

Volume 81, Issue 3, March 2015, Pages 691-699.e1

Presented at Digestive Disease Week, May 3-6, 2014, Chicago, Illinois (Gastrointest Endosc 2014;79:AB565).

https://doi.org/10.1016/j.gie.2014.10.032 Get rights and content

Background

Inadequate bowel cleansing is associated with missed lesions, yet whether polyp and adenoma detection rates (PDR, ADR) increase at the highest levels of bowel cleanliness is unknown.

Objective

To evaluate the association between bowel preparation quality by using the Boston Bowel Preparation Scale (BBPS) and PDR and ADR among colonoscopies with adequate preparation.

Design

Cross-sectional analysis.

Setting

Boston Medical Center (BMC) and the Clinical Outcomes Research Initiative (CORI).

Patients

Average-risk ambulatory patients attending screening colonoscopy with adequate bowel preparation defined as BBPS score ≥6.

Interventions

Colonoscopy.

Main Outcome Measurements

PDR and ADR stratified by BBPS score.

Results

Among the 3713 colonoscopies at BMC performed by 19 endoscopists, the PDR, ADR, and advanced ADR were 49.8%, 37.7%, and 6.0%, respectively. Among the 5532 colonoscopies in CORI performed by 85 endoscopists at 41 different sites, the PDR was 44.5%, and the PDR for polyps >9 mm (surrogate for advanced ADR) was 6.2%. The PDR associated with total BBPS scores of 6, 7, and 8 were higher than those associated with a BBPS score of 9 at BMC (BBPS 6, 51%; BBPS 7, 53%; BBPS 8, 52% vs BBPS 9, 46%; P = .002) and CORI (BBPS 6, 51%; BBPS 7, 48%; BBPS 8, 45% vs BBPS 9, 40%; P < .0001). This trend persisted after we adjusted for age, sex, and race and/or ethnicity and was observed for ADR and advanced ADR. PDR was higher among good compared with excellent preparations at BMC (odds ratio [OR] 1.3; 95% confidence interval [CI], 1.0-1.5) and CORI (OR 4.7; 95% CI, 3.1-7.1).

Limitations

Retrospective study.

Conclusion

The PDR and ADR decreased at the highest levels of bowel cleanliness. Endoscopists finding a pristine bowel preparation should avoid a sense of overconfidence for polyp detection during the inspection phase of screening colonoscopy and still perform a careful evaluation for polyps. Furthermore, endoscopists expending additional effort to maximize cleansing of the bowel should never sacrifice on their inspection technique or inspection time.

Section snippets

Methods

This study was approved by the institutional review boards at Boston Medical Center (H-32416) in October 2013 and Oregon Health & Science University (7038) in February 2011, with waivers of informed consent. This study used a limited data set and was therefore exempted from further institutional review board review.

Results

There were 3713 colonoscopies at BMC performed by 19 endoscopists that met inclusion criteria. In this cohort, 53.9% were female, with a median age of 55 (interquartile range 51-62) years. Forty-nine percent of examinations contained a qualitative assessment of bowel cleanliness. Table 1 shows the distribution of BBPS scores and qualitative ratings, race/ethnicity data, prevalence of diabetes mellitus, and BMI within the cohorts. The overall PDR, ADR, advanced ADR, and serrated PDR were 49.8%,

Discussion

In this study, which used 2 large, independent cohorts of average-risk screening colonoscopy examinations with adequate bowel preparation, there was a slight decrease in PDR and ADR as the degree of bowel cleanliness improved from good to excellent. Although the absolute difference in detection rates is of uncertain clinical significance, it is important to note that we did not observe any marginal increase in PDR or ADR that might be expected as bowel cleanliness improved. This phenomenon

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Cited by (50)

Individualized intervention based on a preparation-related prediction model improves adequacy of bowel preparation: A prospective, multi-center, randomized, controlled study
2024, Digestive and Liver Disease
An easy-to-use preparation-related model (PRM) predicting inadequate bowel preparation (BP) was developed and proved superior to traditional models in our previous study. Here we aimed to investigate whether PRM-based individualized intervention can improve BP adequacy.
Patients undergoing morning colonoscopy were prospectively enrolled in 5 endoscopic centers in China. After standard BP of split-dose polyethylene glycol (PEG) was completed, patients were randomized (1:1) to the individualized group or standard group. High-risk patients predicted by PRM score ≥3 were instructed to drink an additional 1.5 L PEG in the individualized group while not in standard group. The primary endpoint was the rate of adequate BP, defined by segmental Boston bowel preparation scale ≥2. Secondary outcomes included adenoma detection rate (ADR) and adverse events.
900 patients were randomly allocated to the individualized group (n = 449) and the control (n = 451). Baseline characteristics were similar between the two groups. The rates of high-risk patients were 19.6 % in individualized group and 19.7 % in standard group. In intention-to-treat analysis, adequate BP was 91.8 % in individualized group and 84.7 % in the standard group (p = 0.001). Among high-risk patients, adequate BP rate was 94.3 % in individualized group and 49.3 % in standard group (p < 0.001), and ADR were 40.9 % vs 16.9 %, respectively (p < 0.001). No significant differences were found regarding the adverse events and willingness to repeat BP (all p >0.05).
The individualized intervention using an additional dose of PEG to high-risk patients predicted by PRM, significantly improved BP quality. The intervention significantly improved ADR in high-risk patients. (ClinicalTrials.gov number: NCT04434625)
Polyps and Polyposis Syndromes in Children: Novel Endoscopic Considerations
2023, Gastrointestinal Endoscopy Clinics of North America
Multi-step validation of a deep learning-based system for the quantification of bowel preparation: a prospective, observational study
2021, The Lancet Digital Health
Citation Excerpt :
The strong correlation indicates that the e-BBPS score has potential to be a powerful index for evaluation of bowel cleanliness. Previous BBPS validation studies found no significant difference in ADR among patients with a BBPS score of 6 or greater, or 2 or greater in each colon segment.31,32 Similarly, in our study, a plateau also existed for an e-BBPS score of 1–3 (figure 2).
Inadequate bowel preparation is associated with a decrease in adenoma detection rate (ADR). A deep learning-based bowel preparation assessment system based on the Boston bowel preparation scale (BBPS) has been previously established to calculate the automatic BBPS (e-BBPS) score (ranging 0–20). The aims of this study were to investigate whether there was a statistically inverse relationship between the e-BBPS score and the ADR, and to determine the threshold of e-BBPS score for adequate bowel preparation in colonoscopy screening.
In this prospective, observational study, we trained and internally validated the e-BBPS system using retrospective colonoscopy images and videos from the Endoscopy Center of Wuhan University, annotated by endoscopists. We externally validated the system using colonoscopy images and videos from the First People's Hospital of Yichang and the Third Hospital of Wuhan. To prospectively validate the system, we recruited consecutive patients at Renmin Hospital of Wuhan University aged between 18 and 75 years undergoing colonoscopy. The exclusion criteria included: contraindication to colonoscopy, family polyposis syndrome, inflammatory bowel disease, history of surgery for colorectal or colorectal cancer, known or suspected bowel obstruction or perforation, patients who were pregnant or lactating, inability to receive caecal intubation, and lumen obstruction. We did colonoscopy procedures and collected withdrawal videos, which were reviewed and the e-BBPS system was applied to all colon segments. The primary outcome of this study was ADR, defined as the proportion of patients with one or more conventional adenomas detected during colonoscopy. We calculated the ADR of each e-BBPS score and did a correlation analysis using Spearman analysis.
From May 11 to Aug 10, 2020, 616 patients underwent screening colonoscopies, which evaluated. There was a significant inverse correlation between the e-BBPS score and ADR (Spearman's rank −0·976, p<0·010). The ADR for the e-BBPS scores 1–8 was 28·57%, 28·68%, 26·79%, 19·19%, 17·57%, 17·07%, 14·81%, and 0%, respectively. According to the 25% ADR standard for screening colonoscopy, an e-BBPS score of 3 was set as a threshold to guarantee an ADR of more than 25%, and so high-quality endoscopy. Patients with scores of more than 3 had a significantly lower ADR than those with a score of 3 or less (ADR 15·93% vs 28·03%, p<0·001, 95% CI 0·28–0·66, odds ratio 0·43).
The e-BBPS system has potential to provide a more objective and refined threshold for the quantification of adequate bowel preparation.
Project of Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision and Hubei Province Major Science and Technology Innovation Project.
Measuring bowel preparation adequacy in colonoscopy-based research: review of key considerations
2020, Gastrointestinal Endoscopy
Citation Excerpt :
For example, use of a water jet to augment colon cleaning may be deemed so effective that endoscopists use it to seek a perfect bowel preparation, such as “excellent” or BBPS 9, each and every time, even if they would otherwise be satisfied with “good” or a BBPS of 6 or 7. In fact, data suggest pristine bowel preparations may be associated with lower adenoma detection rates because of overconfidence, lack of careful inspection, and other factors.20,21 If devices or adjuncts are potentially available to endoscopists participating in a study of bowel preparation but are not the primary intervention being studied, it would be important to ensure they are used uniformly by all the endoscopists, or at least capture how and when they are used.
Quality assurance of colonoscopy within the Dutch national colorectal cancer screening program
2019, Gastrointestinal Endoscopy
Citation Excerpt :
Insufficient visualization of the mucosa can lead to missed neoplastic polyps, which therefore contributes to an increased risk of PCCRCs.42 An abundant body of evidence has shown that an adequately clean colon is associated with increased adenoma and serrated polyp detection.42,46-52 Different scoring systems for bowel preparation exist, however no direct comparisons of performance between the bowel preparation scales are available.35,41
Colorectal cancer (CRC) screening is capable of reducing CRC-related morbidity and mortality. Colonoscopy is the reference standard to detect CRC, also providing the opportunity to detect and resect its precursor lesions: colorectal polyps. Therefore, colonoscopy is either used as a primary screening tool or as a subsequent procedure after a positive triage test in screening programs based on non-invasive stool testing or sigmoidoscopy. However, in both settings, colonoscopy is not fully protective for the occurrence of post-colonoscopy CRCs (PCCRCs). Because most PCCRCs are the result of colonoscopy-related factors, a high-quality procedure is of paramount importance to assure optimal effectiveness of CRC screening programs. For this reason, at the start of the Dutch fecal immunochemical test (FIT)-based screening program, quality criteria for endoscopists performing colonoscopies in FIT-positive screenees, as well as for endoscopy centers, were defined. In conjunction, an accreditation and auditing system was designed and implemented. In this report, we describe the quality assurance process for endoscopists participating in the Dutch national CRC screening program, including a detailed description of the evidence-based quality criteria. We believe that our experience might serve as an example for colonoscopy quality assurance programs in other CRC screening programs.
Excellent Bowel Preparation Quality Is Not Superior to Good Bowel Preparation Quality for Improving Adenoma/Polyp Detection Rate
2024, Clinical Medicine Insights: Oncology

View all citing articles on Scopus

: DISCLOSURE: D. Lieberman is the executive director of the Clinical Outcomes Research Initiative (CORI), a nonprofit organization supporting this study. He also does consulting for Exact Science, Given Imaging, and Roche. This potential conflict of interest has been reviewed and managed by the Oregon Health & Science University and Veterans Affairs Conflict of Interest in Research Committee. B. Jacobson serves as a consultant to Olympus and Motus GI. This work was funded by National Institutes of Health (NIH) National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) grant K08-DK090150-03 (A. Calderwood). D. Lieberman and CORI are supported by NIH NIDDK grants U01 DK057132, R33-DK61778-01, and R21-CA131626. Funding from NIDDK supports the collection, management, analysis, and interpretation of this and all CORI research. In addition, the practice network (CORI) has received support for the infrastructure of the practice-based network from AstraZeneca, Bard International, Pentax USA, ProVation, Endosoft, Given Imaging, and Ethicon. The commercial entities had no involvement in this research. No other financial relationships relevant to this article were disclosed.

: If you would like to chat with an author of this article, you may contact Dr Calderwood at [email protected].

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Original articleClinical endoscopyGood is better than excellent: bowel preparation quality and adenoma detection rates

Background

Objective

Design

Setting

Patients

Interventions

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Methods

Results

Discussion

Gastrointest Endosc

Gastrointest Endosc

Am J Gastroenterol

Gastrointest Endosc

Gastrointest Endosc

Clin Gastroenterol Hepatol

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Am J Gastroenterol

Gastroenterol Clin North Am

Clin Gastroenterol Hepatol

Gastrointest Endosc

Original article
Clinical endoscopy
Good is better than excellent: bowel preparation quality and adenoma detection rates