This randomized clinical trial compared the effectiveness and tolerability of split-dose vs same-day whole-dose administration of reduced-volume polyethylene glycol electrolyte lavage solution (PEG-ELS) for bowel preparation prior to morning colonoscopy. The study found that split-dose preparation was as effective as same-day whole-dose preparation for bowel cleanliness, but was better tolerated by patients with fewer experiencing nausea, vomiting, or inability to complete the preparation. Patients in the split-dose group also reported being less likely to refuse the same preparation in the future or want to try another option. The split-dose reduced-volume PEG-ELS preparation may provide an improved bowel cleansing regimen for morning colonoscopy.
Coffee Enema for Preparation for Small Bowel Video Capsule Endoscopv2zq
Coffee Enema for Preparation for Small Bowel Video Capsule Endoscop
`
For more information, Please see websites below:
`
Organic Edible Schoolyards & Gardening with Children
http://scribd.com/doc/239851214
`
Double Food Production from your School Garden with Organic Tech
http://scribd.com/doc/239851079
`
Free School Gardening Art Posters
http://scribd.com/doc/239851159`
`
Increase Food Production with Companion Planting in your School Garden
http://scribd.com/doc/239851159
`
Healthy Foods Dramatically Improves Student Academic Success
http://scribd.com/doc/239851348
`
City Chickens for your Organic School Garden
http://scribd.com/doc/239850440
`
Simple Square Foot Gardening for Schools - Teacher Guide
http://scribd.com/doc/239851110
This document provides information on bowel preparation for colonoscopy. It discusses the importance of adequate bowel preparation for a successful colonoscopy. Inadequate preparation can lead to missed diagnoses or suboptimal exams. The document outlines ideal characteristics for bowel preparations and compares various preparation regimens, including polyethylene glycol, sodium sulfate, magnesium citrate, and sodium phosphate solutions. It recommends split-dosing, starting the preparation within 5 hours of the procedure, and following enhanced written and verbal instructions to maximize preparation quality.
This study analyzed data from over 27,000 patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent elective colorectal resection from 2012 to 2015. The study found that while mechanical bowel preparation alone did not reduce postoperative infections, the combination of mechanical and antibiotic bowel preparation resulted in significantly fewer surgical site infections and Clostridium difficile infections compared to no preparation or antibiotic preparation alone. The authors conclude that combined mechanical and antibiotic bowel preparation should be used for elective colorectal resections when possible due to its effectiveness in reducing infectious complications.
The ERAS protocol was developed in 2001 to improve surgical recovery through evidence-based practices. It utilizes a multidisciplinary team and multimodal interventions including preoperative education and carbohydrate loading, intraoperative fluid management and opioid-sparing techniques, and postoperative early nutrition, ambulation and defined discharge criteria. Implementation of ERAS has been shown to reduce length of hospital stay by 35-40% and complications rates while lowering healthcare costs. While initially developed for colorectal surgery, ERAS has been applied to other specialties and demonstrated benefits but faces barriers to widespread adoption including resistance to changing traditional practices.
Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction...JohnJulie1
Gastric outlet obstruction is commonly considered as advanced malignancies of the stomach, duodenum, pancreas, hepatobiliary, and ampullary regions. Surgical bypass and chemotherapy are the common treatment modalities for gastric obstruction. This study was done to determine the outcomes of self-expandable metal stents in patients with gastric outlet obstruction.
Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction...JapaneseJournalofGas
Gastric outlet obstruction is commonly considered as advanced malignancies of the stomach, duodenum, pancreas, hepatobiliary, and ampullary regions. Surgical bypass and chemotherapy are the common treatment modalities for gastric obstruction. This study was done to determine the outcomes of self-expandable metal stents in patients with gastric outlet obstruction.
Coffee Enema for Preparation for Small Bowel Video Capsule Endoscopv2zq
Coffee Enema for Preparation for Small Bowel Video Capsule Endoscop
`
For more information, Please see websites below:
`
Organic Edible Schoolyards & Gardening with Children
http://scribd.com/doc/239851214
`
Double Food Production from your School Garden with Organic Tech
http://scribd.com/doc/239851079
`
Free School Gardening Art Posters
http://scribd.com/doc/239851159`
`
Increase Food Production with Companion Planting in your School Garden
http://scribd.com/doc/239851159
`
Healthy Foods Dramatically Improves Student Academic Success
http://scribd.com/doc/239851348
`
City Chickens for your Organic School Garden
http://scribd.com/doc/239850440
`
Simple Square Foot Gardening for Schools - Teacher Guide
http://scribd.com/doc/239851110
This document provides information on bowel preparation for colonoscopy. It discusses the importance of adequate bowel preparation for a successful colonoscopy. Inadequate preparation can lead to missed diagnoses or suboptimal exams. The document outlines ideal characteristics for bowel preparations and compares various preparation regimens, including polyethylene glycol, sodium sulfate, magnesium citrate, and sodium phosphate solutions. It recommends split-dosing, starting the preparation within 5 hours of the procedure, and following enhanced written and verbal instructions to maximize preparation quality.
This study analyzed data from over 27,000 patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent elective colorectal resection from 2012 to 2015. The study found that while mechanical bowel preparation alone did not reduce postoperative infections, the combination of mechanical and antibiotic bowel preparation resulted in significantly fewer surgical site infections and Clostridium difficile infections compared to no preparation or antibiotic preparation alone. The authors conclude that combined mechanical and antibiotic bowel preparation should be used for elective colorectal resections when possible due to its effectiveness in reducing infectious complications.
The ERAS protocol was developed in 2001 to improve surgical recovery through evidence-based practices. It utilizes a multidisciplinary team and multimodal interventions including preoperative education and carbohydrate loading, intraoperative fluid management and opioid-sparing techniques, and postoperative early nutrition, ambulation and defined discharge criteria. Implementation of ERAS has been shown to reduce length of hospital stay by 35-40% and complications rates while lowering healthcare costs. While initially developed for colorectal surgery, ERAS has been applied to other specialties and demonstrated benefits but faces barriers to widespread adoption including resistance to changing traditional practices.
Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction...JohnJulie1
Gastric outlet obstruction is commonly considered as advanced malignancies of the stomach, duodenum, pancreas, hepatobiliary, and ampullary regions. Surgical bypass and chemotherapy are the common treatment modalities for gastric obstruction. This study was done to determine the outcomes of self-expandable metal stents in patients with gastric outlet obstruction.
Self-Expandable Metal Stents for the Management of Gastric Outlet Obstruction...JapaneseJournalofGas
Gastric outlet obstruction is commonly considered as advanced malignancies of the stomach, duodenum, pancreas, hepatobiliary, and ampullary regions. Surgical bypass and chemotherapy are the common treatment modalities for gastric obstruction. This study was done to determine the outcomes of self-expandable metal stents in patients with gastric outlet obstruction.
How to improve enteral feeding tolerance in chronically critically ill patientsDr Jay Prakash
These interruptions to EN result in significant daily and cumulative calorie deficits, thus contributing to underfeeding and malnutrition. Underfed patients have an increased risk of all-cause mortality, bloodstream infections and longer ICU and hospital stays.
IAH and ACS are underrecognized in critically ill children despite being associated with high morbidity and mortality. Studies show that up to half of pediatric healthcare providers are unaware of or unable to correctly define ACS. Measurement of IAP is also not routinely performed. The normal IAP range in children is 4-10 mmHg. IAH is defined as IAP above 10 mmHg and ACS is IAP above 10 mmHg with new organ dysfunction. Risk factors for IAH/ACS in children include diminished abdominal wall compliance, increased intra-abdominal contents, and fluid resuscitation. Treatment involves medical management through optimization of fluids and improving abdominal wall compliance. Surgical decompression through decompressive laparotomy may
This document provides an overview and learning objectives for the 15th Annual Gastroenterology/Hepatology Update meeting. Key presentations will cover new clinical information and treatment updates in gastrointestinal and liver diseases. Recent breakthrough research will be discussed, including updates on colorectal cancer screening guidelines, management of gastroesophageal reflux disease, evaluation and treatment of abnormal liver tests and viral hepatitis, and implications for clinical practice in lower GI diseases and pancreatic disorders.
Positive Oral Contrast for Oncology Patients Naglaa Mahmoud
Routine use of positive oral contrast is not required for oncology patients undergoing follow-up CT scans according to a retrospective study. A survey found patients found oral contrast the least pleasant part of the scan. An audit of 447 patients found the bowel could be adequately identified in 90% without oral contrast and no cases required recall. On secondary review, the bowel could be identified in 95% without missed diseases, suggesting oral contrast is not necessary for accurate interpretation of follow-up oncology CT scans.
1) Gastric cancer surgery can lead to nutritional deficiencies due to loss of stomach and changes to small bowel anatomy. Timely nutritional intervention is important to prevent issues like weight loss and micronutrient deficiencies.
2) Screening patients preoperatively for malnutrition is crucial, as up to 65% of patients may be at nutritional risk. Various screening tools evaluate factors like albumin, weight loss, and muscle mass. Nutritional support for 7-14 days preoperatively can reduce complications.
3) Postoperative nutritional goals include early oral feeding, adequate protein intake, and preventing deficiencies like anemia. Monitoring for deficiencies is important long-term, as nutritional recovery may take up to a year after surgery.
Endoscopic ultrasonography (EUS) is an outpatient procedure
During an EUS procedure, an upper gastrointestinal (GI) scope is inserted into the esophagus through the mouth to obtain ultrasonographic as well as endoluminal images of various upper gastrointestinal pathologies.
Spanish Multi-Center Fast-Track Group - Protocol and Preliminary Resultsfast.track
The document describes a multi-center study protocol and preliminary results for introducing an enhanced recovery program in colorectal surgery. The protocol aims to optimize pre-operative, intra-operative, and post-operative patient care and treatment to reduce morbidity, accelerate recovery, shorten hospital stays, and reduce costs. Preliminary retrospective results from one hospital show average length of stay was 12.1 days with 34.8% of patients experiencing complications. A prospective multi-center study will evaluate outcomes including success of the program, patient satisfaction, complications, mortality, re-operations, and readmissions.
This study analyzed 318 stable trauma patients who underwent laparoscopy over 4 years to investigate indications for laparoscopy and conversion to laparotomy. The conversion rate was higher for blunt abdominal trauma (22.9%) than penetrating abdominal trauma (11.7%). The most common reason for conversion was uncontrolled intraabdominal bleeding, followed by multiple complex injuries, hemodynamic instability, and poor visualization. Only lower pH was associated with conversion. The management of stable trauma patients with laparoscopy appears to be safe, though continuous bleeding, complex injuries, deterioration, poor visibility, or equipment failure indicate need for conversion.
This document provides guidance on indications and limitations of bariatric interventions in severely obese children and adolescents with and without nonalcoholic steatohepatitis (NASH). It finds that bariatric surgery can decrease steatosis, inflammation, and fibrosis in NASH, but uncomplicated NAFLD is not an indication. Roux-en-Y gastric bypass is considered safe and effective for adolescents with extreme obesity if long-term follow-up is provided, while laparoscopic adjustable gastric banding is still investigational. More research is needed on other procedures and temporary devices in pediatrics. NASH with significant fibrosis, type 2 diabetes, moderate-to-severe sleep apnea, and pseudot
This multicenter observational study evaluated the impact of enteral feeding protocols on nutrition delivery in critically ill patients. The study found that sites using a feeding protocol had better enteral nutrition adequacy, started enteral nutrition earlier, and had higher overall nutritional adequacy compared to sites without a protocol. Specifically, sites with a protocol achieved 45.4% enteral nutrition adequacy compared to 34.7% for sites without. The presence of a protocol was associated with a 4.1% increase in enteral nutrition adequacy after adjusting for patient and site characteristics. However, overall nutritional adequacy remained below targets, indicating need for further refinement of feeding protocols.
Cutting-Edge Advances in Gastroenterology and Hepatology_ Latest Breakthrough...DoctorsFoundationMed
Cutting-Edge Advances in Gastroenterology and Hepatology_ Latest Breakthroughs in Diagnostics, Therapies, and Patient Care
"Explore the latest innovations in gastroenterology and hepatology, from groundbreaking diagnostic techniques to revolutionary therapies and enhanced patient care strategies. This article delves into cutting-edge advancements that are shaping the future of gastrointestinal health and liver disease management, offering insights into state-of-the-art diagnostic tools, novel treatment approaches, and patient-centered care models. Discover how these breakthroughs are revolutionizing healthcare in the fields of gastroenterology and hepatology."
This document describes a study that aimed to test the hypothesis that the non-protein calorie to nitrogen ratio (NPC/N ratio) is a determinant of clinical outcomes in critically ill patients. The study analyzed data from 69 patients with esophageal cancer who were admitted to the ICU after surgery. The patients were divided into groups based on their median energy, protein intake, and NPC/N ratio values. Outcomes like ICU length of stay, highest CRP levels, and insulin doses were compared between the groups. Logistic regression was also used to analyze relationships between variables and shorter ICU stays. The results found that patients with a protein intake below 0.48 g/kg/day had a significantly shorter ICU stay. Those with an NPC
This document summarizes a discussion on endoscopy and gastrointestinal surgery led by Professor Dr. Mohamed Alshekhani. It notes that inadequate bowel preparation can negatively impact the accuracy and effectiveness of colonoscopy procedures by lowering adenoma detection rates, increasing miss rates of polyps larger than 5mm, and contributing to failed cecal intubations and unsatisfactory patient experiences. Maintaining at least a 90% adequate bowel preparation level assessed by validated scales is recommended to ensure screening colonoscopies are cost-effective and deliver accurate results. Recent evidence on optimizing preparation through diet, laxative timing and type, patient education, and specific scenarios is also referenced.
A randomized, multicenter, placebo controlled trial of polyethylene glycol la...Duwan Arismendy
OBJECTIVES:
Polyethylene glycol (PEG) 3350 (MiraLAX) is currently approved for the short-term treatment of occasional constipation. This study was designed to compare the safety and efficacy of PEG laxative versus placebo over a 6-month treatment period in patients with chronic constipation.
METHODS:
Study subjects who met defined criteria for chronic constipation were randomized in this double-blind, placebo-controlled, parallel, multicenter study to receive PEG laxative as a single daily dose of 17 g or placebo for 6 months. Baseline constipation status was confirmed during a 14-day observation period. As a primary efficacy variable, treatment success was defined as relief of modified ROME criteria for constipation for 50% or more of their treatment weeks. Various secondary measures were assessed. An Interactive Voice Response System (IVRS) recorded daily bowel movement experience and study efficacy and safety information. Laboratory testing at baseline and monthly for the study duration was analyzed for hematology, blood chemistry including amylase, GGT, uric acid, lipids, and urinalysis.
RESULTS:
A total of 304 patients were enrolled and received treatment at one of 50 centers. Successful treatment according to the primary efficacy variable was seen in 52.0% of PEG and 11% of placebo subjects (P < 0.001). Similar efficacy was seen in a subgroup of 75 elderly subjects. According to the primary efficacy definition (based on individual treatment weeks), 61% of PEG treatment weeks versus 22% of the placebo weeks were successful (P < 0.001). There were no significant differences in laboratory findings or adverse events except for the gastrointestinal category where diarrhea, flatulence, and nausea were the most frequent with PEG although they were not individually statistically significant compared with placebo. Similar results were observed when analyzed for differences due to gender, race, or age.
This meta-analysis compared the efficacy and tolerability of same-day (SaD) versus split-dose (SpD) bowel preparation regimens for colonoscopy. Fourteen randomized controlled trials with over 4,000 participants were included. The analysis found that the proportion of adequate bowel preparation was comparable between SaD and SpD regimens. SaD with bisacodyl was found to have higher odds of adequate preparation than SpD without bisacodyl. SaD also resulted in better sleep quality than SpD. However, overall rates of optimal preparation remained low for both regimens due to heterogeneous protocols. Further research is still needed to determine optimal purgative agents and dosing.
This meta-analysis compared the efficacy and tolerability of same-day (SaD) versus split-dose (SpD) bowel preparation regimens for colonoscopy. Fourteen randomized controlled trials with over 4,000 participants were included. The analysis found that the proportion of adequate bowel preparation was comparable between SaD and SpD regimens. SaD with bisacodyl was found to have higher odds of adequate preparation than SpD without bisacodyl. SaD also resulted in better sleep quality than SpD. However, overall rates of optimal preparation remained low for both regimens due to heterogeneous protocols. Further research is still needed to determine optimal purgative agents and dosing.
Fast-track or enhanced recovery after surgery (ERAS) protocols aim to reduce the stress response to surgery and speed recovery. This document outlines ERAS protocols for several types of surgeries including colorectal, bariatric, liver, breast and gallbladder surgeries. The protocols emphasize preoperative counseling and nutrition, minimal invasive surgery when possible, multimodal pain control, early feeding and mobilization to reduce hospital length of stay and complications compared to traditional care.
Endoscopic and surgical treatment of obesityDrShivaraj SA
The document discusses several endoscopic and surgical treatments for obesity, including space occupying devices, gastric restrictive measures, malabsorptive procedures, and measures regulating gastric emptying. It provides details on several intragastric balloons (e.g. ORBERA, ReShape, Obalon, Spatz), transoral endoscopic procedures (e.g. gastroplasty, DJBL), and describes results from studies on weight loss and safety outcomes. Endoscopic sleeve gastroplasty is highlighted as a minimally invasive procedure for weight loss that can reduce comorbidities like diabetes up to 24 months after the procedure.
Colorectal cancer screening and computerized tomographic colonographySpringer
This document discusses quality considerations for colorectal cancer screening programs that utilize both optical colonoscopy and CT colonography. It notes that adenoma detection rates, colonoscopy withdrawal times, and bowel preparation quality impact the effectiveness of optical colonoscopy screening. Maintaining high quality in these areas is important for any integrated CRC screening program that uses both modalities. Fatigue in endoscopists can negatively impact adenoma detection rates, so scheduling approaches need to account for this. Effective patient education on bowel preparation is also key to ensuring screening program success and adherence.
This document provides information on direct and indirect inguinal hernias, including their anatomy and symptoms. It also describes the laparoscopic procedure for treating inguinal hernias, including positioning the patient, dissecting the hernia sac, placing and securing mesh to cover the defect laparoscopically, and post-operative care considerations. The advantages of the laparoscopic approach are less tissue disruption, smaller incisions, less pain, and earlier return to normal activities compared to open surgery.
How to improve enteral feeding tolerance in chronically critically ill patientsDr Jay Prakash
These interruptions to EN result in significant daily and cumulative calorie deficits, thus contributing to underfeeding and malnutrition. Underfed patients have an increased risk of all-cause mortality, bloodstream infections and longer ICU and hospital stays.
IAH and ACS are underrecognized in critically ill children despite being associated with high morbidity and mortality. Studies show that up to half of pediatric healthcare providers are unaware of or unable to correctly define ACS. Measurement of IAP is also not routinely performed. The normal IAP range in children is 4-10 mmHg. IAH is defined as IAP above 10 mmHg and ACS is IAP above 10 mmHg with new organ dysfunction. Risk factors for IAH/ACS in children include diminished abdominal wall compliance, increased intra-abdominal contents, and fluid resuscitation. Treatment involves medical management through optimization of fluids and improving abdominal wall compliance. Surgical decompression through decompressive laparotomy may
This document provides an overview and learning objectives for the 15th Annual Gastroenterology/Hepatology Update meeting. Key presentations will cover new clinical information and treatment updates in gastrointestinal and liver diseases. Recent breakthrough research will be discussed, including updates on colorectal cancer screening guidelines, management of gastroesophageal reflux disease, evaluation and treatment of abnormal liver tests and viral hepatitis, and implications for clinical practice in lower GI diseases and pancreatic disorders.
Positive Oral Contrast for Oncology Patients Naglaa Mahmoud
Routine use of positive oral contrast is not required for oncology patients undergoing follow-up CT scans according to a retrospective study. A survey found patients found oral contrast the least pleasant part of the scan. An audit of 447 patients found the bowel could be adequately identified in 90% without oral contrast and no cases required recall. On secondary review, the bowel could be identified in 95% without missed diseases, suggesting oral contrast is not necessary for accurate interpretation of follow-up oncology CT scans.
1) Gastric cancer surgery can lead to nutritional deficiencies due to loss of stomach and changes to small bowel anatomy. Timely nutritional intervention is important to prevent issues like weight loss and micronutrient deficiencies.
2) Screening patients preoperatively for malnutrition is crucial, as up to 65% of patients may be at nutritional risk. Various screening tools evaluate factors like albumin, weight loss, and muscle mass. Nutritional support for 7-14 days preoperatively can reduce complications.
3) Postoperative nutritional goals include early oral feeding, adequate protein intake, and preventing deficiencies like anemia. Monitoring for deficiencies is important long-term, as nutritional recovery may take up to a year after surgery.
Endoscopic ultrasonography (EUS) is an outpatient procedure
During an EUS procedure, an upper gastrointestinal (GI) scope is inserted into the esophagus through the mouth to obtain ultrasonographic as well as endoluminal images of various upper gastrointestinal pathologies.
Spanish Multi-Center Fast-Track Group - Protocol and Preliminary Resultsfast.track
The document describes a multi-center study protocol and preliminary results for introducing an enhanced recovery program in colorectal surgery. The protocol aims to optimize pre-operative, intra-operative, and post-operative patient care and treatment to reduce morbidity, accelerate recovery, shorten hospital stays, and reduce costs. Preliminary retrospective results from one hospital show average length of stay was 12.1 days with 34.8% of patients experiencing complications. A prospective multi-center study will evaluate outcomes including success of the program, patient satisfaction, complications, mortality, re-operations, and readmissions.
This study analyzed 318 stable trauma patients who underwent laparoscopy over 4 years to investigate indications for laparoscopy and conversion to laparotomy. The conversion rate was higher for blunt abdominal trauma (22.9%) than penetrating abdominal trauma (11.7%). The most common reason for conversion was uncontrolled intraabdominal bleeding, followed by multiple complex injuries, hemodynamic instability, and poor visualization. Only lower pH was associated with conversion. The management of stable trauma patients with laparoscopy appears to be safe, though continuous bleeding, complex injuries, deterioration, poor visibility, or equipment failure indicate need for conversion.
This document provides guidance on indications and limitations of bariatric interventions in severely obese children and adolescents with and without nonalcoholic steatohepatitis (NASH). It finds that bariatric surgery can decrease steatosis, inflammation, and fibrosis in NASH, but uncomplicated NAFLD is not an indication. Roux-en-Y gastric bypass is considered safe and effective for adolescents with extreme obesity if long-term follow-up is provided, while laparoscopic adjustable gastric banding is still investigational. More research is needed on other procedures and temporary devices in pediatrics. NASH with significant fibrosis, type 2 diabetes, moderate-to-severe sleep apnea, and pseudot
This multicenter observational study evaluated the impact of enteral feeding protocols on nutrition delivery in critically ill patients. The study found that sites using a feeding protocol had better enteral nutrition adequacy, started enteral nutrition earlier, and had higher overall nutritional adequacy compared to sites without a protocol. Specifically, sites with a protocol achieved 45.4% enteral nutrition adequacy compared to 34.7% for sites without. The presence of a protocol was associated with a 4.1% increase in enteral nutrition adequacy after adjusting for patient and site characteristics. However, overall nutritional adequacy remained below targets, indicating need for further refinement of feeding protocols.
Cutting-Edge Advances in Gastroenterology and Hepatology_ Latest Breakthrough...DoctorsFoundationMed
Cutting-Edge Advances in Gastroenterology and Hepatology_ Latest Breakthroughs in Diagnostics, Therapies, and Patient Care
"Explore the latest innovations in gastroenterology and hepatology, from groundbreaking diagnostic techniques to revolutionary therapies and enhanced patient care strategies. This article delves into cutting-edge advancements that are shaping the future of gastrointestinal health and liver disease management, offering insights into state-of-the-art diagnostic tools, novel treatment approaches, and patient-centered care models. Discover how these breakthroughs are revolutionizing healthcare in the fields of gastroenterology and hepatology."
This document describes a study that aimed to test the hypothesis that the non-protein calorie to nitrogen ratio (NPC/N ratio) is a determinant of clinical outcomes in critically ill patients. The study analyzed data from 69 patients with esophageal cancer who were admitted to the ICU after surgery. The patients were divided into groups based on their median energy, protein intake, and NPC/N ratio values. Outcomes like ICU length of stay, highest CRP levels, and insulin doses were compared between the groups. Logistic regression was also used to analyze relationships between variables and shorter ICU stays. The results found that patients with a protein intake below 0.48 g/kg/day had a significantly shorter ICU stay. Those with an NPC
This document summarizes a discussion on endoscopy and gastrointestinal surgery led by Professor Dr. Mohamed Alshekhani. It notes that inadequate bowel preparation can negatively impact the accuracy and effectiveness of colonoscopy procedures by lowering adenoma detection rates, increasing miss rates of polyps larger than 5mm, and contributing to failed cecal intubations and unsatisfactory patient experiences. Maintaining at least a 90% adequate bowel preparation level assessed by validated scales is recommended to ensure screening colonoscopies are cost-effective and deliver accurate results. Recent evidence on optimizing preparation through diet, laxative timing and type, patient education, and specific scenarios is also referenced.
A randomized, multicenter, placebo controlled trial of polyethylene glycol la...Duwan Arismendy
OBJECTIVES:
Polyethylene glycol (PEG) 3350 (MiraLAX) is currently approved for the short-term treatment of occasional constipation. This study was designed to compare the safety and efficacy of PEG laxative versus placebo over a 6-month treatment period in patients with chronic constipation.
METHODS:
Study subjects who met defined criteria for chronic constipation were randomized in this double-blind, placebo-controlled, parallel, multicenter study to receive PEG laxative as a single daily dose of 17 g or placebo for 6 months. Baseline constipation status was confirmed during a 14-day observation period. As a primary efficacy variable, treatment success was defined as relief of modified ROME criteria for constipation for 50% or more of their treatment weeks. Various secondary measures were assessed. An Interactive Voice Response System (IVRS) recorded daily bowel movement experience and study efficacy and safety information. Laboratory testing at baseline and monthly for the study duration was analyzed for hematology, blood chemistry including amylase, GGT, uric acid, lipids, and urinalysis.
RESULTS:
A total of 304 patients were enrolled and received treatment at one of 50 centers. Successful treatment according to the primary efficacy variable was seen in 52.0% of PEG and 11% of placebo subjects (P < 0.001). Similar efficacy was seen in a subgroup of 75 elderly subjects. According to the primary efficacy definition (based on individual treatment weeks), 61% of PEG treatment weeks versus 22% of the placebo weeks were successful (P < 0.001). There were no significant differences in laboratory findings or adverse events except for the gastrointestinal category where diarrhea, flatulence, and nausea were the most frequent with PEG although they were not individually statistically significant compared with placebo. Similar results were observed when analyzed for differences due to gender, race, or age.
This meta-analysis compared the efficacy and tolerability of same-day (SaD) versus split-dose (SpD) bowel preparation regimens for colonoscopy. Fourteen randomized controlled trials with over 4,000 participants were included. The analysis found that the proportion of adequate bowel preparation was comparable between SaD and SpD regimens. SaD with bisacodyl was found to have higher odds of adequate preparation than SpD without bisacodyl. SaD also resulted in better sleep quality than SpD. However, overall rates of optimal preparation remained low for both regimens due to heterogeneous protocols. Further research is still needed to determine optimal purgative agents and dosing.
This meta-analysis compared the efficacy and tolerability of same-day (SaD) versus split-dose (SpD) bowel preparation regimens for colonoscopy. Fourteen randomized controlled trials with over 4,000 participants were included. The analysis found that the proportion of adequate bowel preparation was comparable between SaD and SpD regimens. SaD with bisacodyl was found to have higher odds of adequate preparation than SpD without bisacodyl. SaD also resulted in better sleep quality than SpD. However, overall rates of optimal preparation remained low for both regimens due to heterogeneous protocols. Further research is still needed to determine optimal purgative agents and dosing.
Fast-track or enhanced recovery after surgery (ERAS) protocols aim to reduce the stress response to surgery and speed recovery. This document outlines ERAS protocols for several types of surgeries including colorectal, bariatric, liver, breast and gallbladder surgeries. The protocols emphasize preoperative counseling and nutrition, minimal invasive surgery when possible, multimodal pain control, early feeding and mobilization to reduce hospital length of stay and complications compared to traditional care.
Endoscopic and surgical treatment of obesityDrShivaraj SA
The document discusses several endoscopic and surgical treatments for obesity, including space occupying devices, gastric restrictive measures, malabsorptive procedures, and measures regulating gastric emptying. It provides details on several intragastric balloons (e.g. ORBERA, ReShape, Obalon, Spatz), transoral endoscopic procedures (e.g. gastroplasty, DJBL), and describes results from studies on weight loss and safety outcomes. Endoscopic sleeve gastroplasty is highlighted as a minimally invasive procedure for weight loss that can reduce comorbidities like diabetes up to 24 months after the procedure.
Colorectal cancer screening and computerized tomographic colonographySpringer
This document discusses quality considerations for colorectal cancer screening programs that utilize both optical colonoscopy and CT colonography. It notes that adenoma detection rates, colonoscopy withdrawal times, and bowel preparation quality impact the effectiveness of optical colonoscopy screening. Maintaining high quality in these areas is important for any integrated CRC screening program that uses both modalities. Fatigue in endoscopists can negatively impact adenoma detection rates, so scheduling approaches need to account for this. Effective patient education on bowel preparation is also key to ensuring screening program success and adherence.
This document provides information on direct and indirect inguinal hernias, including their anatomy and symptoms. It also describes the laparoscopic procedure for treating inguinal hernias, including positioning the patient, dissecting the hernia sac, placing and securing mesh to cover the defect laparoscopically, and post-operative care considerations. The advantages of the laparoscopic approach are less tissue disruption, smaller incisions, less pain, and earlier return to normal activities compared to open surgery.
The document summarizes updated guidelines for the treatment of colon cancer from the National Comprehensive Cancer Network. Key updates include splitting treatment algorithms between patients with proficient mismatch repair/microsatellite stable tumors and those with deficient mismatch repair/microsatellite high tumors. New pages were added to cover treatment for dMMR/MSI-H patients. Terminology was also modified to be more inclusive. Additional changes were made to footnotes and recommendations for workup, staging, and treatment of localized and metastatic colon cancer.
The document outlines the recommended pre-operative workup for bariatric surgery patients. It includes: 1) completing a medical history and physical exam; 2) conducting routine lab tests, nutritional screening, and women's health evaluations; 3) assessing patients psychosocially and for any endocrine, pulmonary, cardiovascular, or gastrointestinal conditions that could impact surgery. The goal is to optimize patient health and identify any risks prior to their bariatric procedure.
This tumor conference case discusses a 75-year-old female patient who presented with abdominal pain and fever. Imaging found a pancreatic tail mass, as well as lesions in both kidneys suspected to be metastases. She underwent a distal pancreatectomy with splenectomy. Pathology revealed a 6.1cm neuroendocrine tumor of the pancreas, grade 2. Staging was stage II. Surveillance with follow up CT was recommended for curative intent.
Bariatric surgery guidelines have been updated based on long-term studies demonstrating its effectiveness in treating severe obesity and related conditions. The guidelines now recommend considering bariatric surgery for patients with a BMI ≥30 who have obesity-related medical issues, especially if other treatments have failed. Bariatric procedures lead to greater weight loss than other options and higher remission rates of diabetes and other metabolic conditions. Risks of bariatric surgery are low with mortality rates below 1% for most patients.
NCCN Guidelines Version 3.2022 Colon Cancer.pdfChanyutTuranon1
- The document presents the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines for Colon Cancer. It lists the panel members and provides a summary of recent updates made in Version 3.2022.
- Key updates include adding tucatinib in combination with trastuzumab as a treatment option for HER2-amplified metastatic colon cancer, and revising dosing information for HER2-targeted therapies.
- The document presents updated guidelines from the National Comprehensive Cancer Network (NCCN) for the treatment of anal carcinoma.
- Key updates include revising treatment recommendations for metastatic disease and surveillance, capping the mitomycin dose for concurrent chemoradiation regimens, and revising target volume definitions and quality assurance procedures for radiation therapy.
- The guidelines are intended to help clinicians determine the best evidence-based approaches for treating patients with this cancer.
Heritage Conservation.Strategies and Options for Preserving India HeritageJIT KUMAR GUPTA
Presentation looks at the role , relevance and importance of built and natural heritage, issues faced by heritage in the Indian context and options which can be leveraged to preserve and conserve the heritage.It also lists the challenges faced by the heritage due to rapid urbanisation, land speculation and commercialisation in the urban areas. In addition, ppt lays down the roadmap for the preservation, conservation and making value addition to the available heritage by making it integral part of the planning , designing and management of the human settlements.
1. See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/267731822
Split-dose vs same-day reduced-volume polyethylene glycol electrolyte
lavage solution for morning colonoscopy
Article in World Journal of Gastroenterology · October 2014
DOI: 10.3748/wjg.v20.i39.14488 · Source: PubMed
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3. Chan WK et al. Reduced-volume PEG-ELS for morning colonoscopy
volume polyethylene glycol electrolyte lavage solution
(PEG-ELS) plus bisacodyl was found to be as effective
but better tolerated than whole-dose taken on the
same morning. To the best of our knowledge, this
is the first time these regimes have been compared.
Moreover, bowel preparation using split-dose reduced-
volume PEG-ELS has not been reported before al-
though there have been many studies comparing split-
dose and previous-evening whole-dose regimes using
larger volumes of PEG-ELS. We believe the findings of
this study will be of interest to those in related fields.
Chan WK, Azmi N, Mahadeva S, Goh KL. Split-dose vs same-
day reduced-volume polyethylene glycol electrolyte lavage
solution for morning colonoscopy. World J Gastroenterol 2014;
20(39): 14488-14494 Available from: URL: http://www.wjgnet.
com/1007-9327/full/v20/i39/14488.htm DOI: http://dx.doi.
org/10.3748/wjg.v20.i39.14488
INTRODUCTION
The incidence of colorectal cancer has rapidly increased
in the Asia-Pacific region[1]
. Colonoscopy remains the
most accurate tool in diagnosing colorectal cancer and is
advocated in many regions to be the modality of choice
for screening and surveillance[2]
. However, the sensitiv-
ity depends largely on the quality of bowel preparation.
Detection of neoplastic lesions is significantly reduced
when bowel preparation is poor[3,4]
. Poor bowel prepara-
tion increases technical difficulty, prolongs procedure
duration, decreases cecal intubation rate, and leads to
greater costs associated with colonoscopy[3,5,6]
.
A good bowel preparation regime is one that is not
only effective in cleansing the colon but should be rela-
tively small in volume and well-tolerated by patients with
minimal adverse gastrointestinal symptoms[7]
. At our
centre, reduced-volume 2-litre polyethylene glycol elec-
trolyte lavage solution (PEG-ELS) plus bisacodyl and
low fibre diet is used for bowel preparation for patients
undergoing colonoscopy. Patients undergoing morn-
ing outpatient colonoscopy would normally ingest the
PEG-ELS the day before. This regime is better tolerated
by patients without compromising the quality of bowel
preparation when compared with conventional 4-litre
PEG-ELS[8,9]
.
However, a previous study on patient satisfaction
found that nearly half of the patients attending the
outpatient colonoscopy service at our centre were dis-
satisfied with the bowel preparation regime used. Of
the seven items considered in the evaluation of patient
satisfaction, comfort level during bowel preparation was
the main cause of unfavorable responses[10]
. Moreover, a
separate study using the same bowel preparation regime
at our centre found a high percentage of poor quality
bowel preparation, which was associated with greater
technical difficulty and patient discomfort during colo-
noscopy[11]
. There was clearly a need for a better bowel
preparation regime.
Current literature suggests that either taking reduced-
volume PEG-ELS on the same morning instead of
the previous evening[12]
, or splitting the bowel prepara-
tion[7]
, would enhance the quality of bowel preparation.
However, it is uncertain which of these two regimes are
better. The aim of our study was to compare the use of
same-day whole-dose and split-dose reduced-volume
PEG-ELS for colon cleansing in patients undergoing
morning colonoscopy.
MATERIALS AND METHODS
The study included consecutive adult patients attending
morning outpatient colonoscopy at the Endoscopy Suite
of the University of Malaya Medical Centre from August
2012 to March 2013. The colonoscopy service is open-
access, whereby patients are referred directly for colo-
noscopy from primary as well as secondary care clinics.
The following subjects were excluded from the study:
in-patients, patients scheduled for colonoscopy in the
afternoon, patients who used other methods of bowel
preparation than that assigned and patients who had an
incomplete examination that was unrelated to quality of
colon cleansing e.g., obstructing tumour. The study was
approved by the ethics committee of the institution. The
study was registered with ClinicalTrials.gov. The protocol
may be accessed at http://clinicaltrials.gov/ct2/show/
study/ NCT01916564?term = chan+wah+kheong&rank
= 1. All co-authors had access to the study data and had
reviewed and approved the final manuscript.
Allocation and bowel preparation regime
Patients were assigned into two groups i.e., split-dose or
same-day whole-dose in a deterministic manner. Patients
scheduled for colonoscopy on a particular day were
listed by alphabetical order. Patients who were numbered
odd were assigned to the same-day whole-dose group
while patients who were numbered even were assigned
to the split-dose group. The list did not reflect the se-
quence that patients would undergo colonoscopy. All
patients were given instructions for bowel preparation
through phone call 3-5 d prior to scheduled colonos-
copy. In the whole-dose group, patients had to complete
2 L of PEG-ELS between 5 am and 6 am on the day
of procedure. In the split-dose group, patients had to
complete 1 L of PEG-ELS between 8 pm and 8.30 pm
on the day before followed by another 1 L of PEG-ELS
between 5.30 am and 6 am on the day of the procedure.
All patients received 2 tablets of bisacodyl 5 mg on the
two evenings prior to the procedure and were told to be
on low residue diet on the day before the procedure. Pa-
tients were advised to drink clear liquids only after din-
ner at 6 pm and to keep nil orally once at the Endoscopy
Unit. Adherence to instructions for bowel preparation
was checked when patients arrived at the Endoscopy
Unit. Allocation, providing instructions for bowel prepa-
ration and checking for adherence were carried out by a
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4. trained research assistant who was not involved in other
parts of the study.
Assessment of patient tolerability
All patients completed a questionnaire on tolerability of
the bowel preparation regime used which was designed
by Aronchick and colleagues[13]
. In addition, patients
answered a question on comfort level during bowel
preparation. This question was the same as that used in
the earlier study on patient satisfaction of our colonos-
copy service[10]
. This question has an ordinal five-value
Likert scale (excellent, very good, good, fair, and poor).
Patient response to this question was dichotomized to
favourable (excellent, very good, good) and unfavour-
able (fair, poor) during analysis. An investigator who was
blinded to the colon cleansing regime gathered other
relevant information using a standard protocol. Comple-
tion of questionnaire and gathering of information were
performed prior to patient undergoing the colonoscopy
procedure. Patients were given Midazolam 2.5-5 mg and
Fentanyl 50-100 mcg as sedation for the colonoscopy
procedure.
Assessment of quality of bowel preparation
Standard video-endoscopes (CF 160AL, Olympus, To-
kyo, Japan) were used for the colonoscopy procedures.
The endoscopists were considered as trainee if they had
performed < 200 colonoscopies and as senior if they
had performed ≥ 200 colonoscopies. The endoscopists
were unaware of the regime used for bowel preparation.
They graded the quality of bowel preparation using the
Boston bowel preparation scale (BBPS)[14]
. According to
the BPPS, three broad regions of the colon i.e., the right
colon (including the cecum and ascending colon), the
transverse colon (including the hepatic and splenic flex-
ures), and the left colon (including the descending colon,
sigmoid colon, and rectum) are given a score of 0-3 as
follows: 0 = unprepared colon segment with mucosa not
seen due to solid stool that cannot be cleared; 1 = por-
tion of mucosa of the colon segment seen, but other
areas of the colon segment not well seen due to staining,
residual stool and/or opaque liquid; 2 = minor amount
of residual staining, small fragments of stool and/or
opaque liquid, but mucosa of colon segment seen well;
and 3 = entire mucosa of colon segment seen well with
no residual staining, small fragments of stool or opaque
liquid.
In addition, endoscopists gave an overall grading of
the quality of bowel preparation as follows: excellent
= adequate visualization without flushing and suction;
good = adequate visualization requiring minimal flushing
and suction; fair = unsatisfactory visualization of all or
part of the colon with coloured fluid requiring flushing
and suction; poor = unsatisfactory visualization of all or
part of the colon with coloured fluid and faeces requir-
ing flushing and suction and repeat colonoscopy had to
be considered. The overall quality of bowel preparation
was then re-categorized as good (i.e., excellent), inter-
mediate (i.e., good and fair) and poor as this has been
shown to have better inter-observer variability during the
previous study on quality of bowel preparation at our
centre[11]
. Good and intermediate quality bowel prepa-
ration were considered satisfactory while poor quality
bowel preparation was considered non-satisfactory.
Other colonoscopy procedure details
The following information was obtained: cecal intu-
bation time i.e., time taken after the colonoscope was
inserted through the anus until the cecum was reached,
withdrawal time i.e., time taken to pull back colonoscope
from cecum till complete withdrawal from the anus, and
total colonoscopy time i.e., time from colonoscope inser-
tion until complete removal from the anus. Times were
recorded from the display screen during colonoscopy
and adjustment was made for the time spent to carry out
therapeutic work. Adenoma detection rate and number
of adenomas detected for each patient (if detected) were
also recorded. All adenomas were at least 0.5 cm in size
and were followed by histological confirmation.
Statistical analysis
Sample size was calculated using an online calculator
for binary outcome non-inferiority trial[15]
. The rate of
satisfactory bowel preparation using same-day whole-
dose reduced-volume PEG-ELS has been reported to
be 93%[12]
. The rate of satisfactory bowel preparation
using split-dose 4-L PEG-ELS has been reported to be
95.6%[16]
. As reduced-volume PEG-ELS plus bisacodyl
has been shown to be as good as 4-L PEG-ELS, and as
the rate of satisfactory bowel preparation using split-
dose reduced-volume PEG-ELS plus bisacodyl has
never been reported before, we assumed that the rate of
satisfactory bowel preparation using split-dose reduced-
volume PEG-ELS plus bisacodyl to be 93%. A sample
size of 112 patients per group will have 90% power to
detect a treatment difference of 10% at a significance
level of 0.05.
Data were analysed using SPSS 16 (SPSS Inc., Chi-
cago, Illinois, United States). Analyses was based upon
intent-to-treat. Categorical variables were expressed as
percentages and analysed using χ
2
test or Fisher exact
test where appropriate. Continuous variables were ex-
pressed as means ± standard deviations or median with
inter-quartile range and analysed with student’s t-test or
Mann-Whitney test where appropriate. Significance was
assumed at P-value < 0.05.
RESULTS
Three hundred and three patients attended outpatient
colonoscopy in the morning during the study period.
Eight patients were excluded for the following reasons:
obstructing tumour n = 3, acute colonic angulation n =
2, patient used a different bowel preparation regime than
that assigned n = 3. Data for 295 patients were analysed.
Mean age of the study population was 62.0 ± 14.4 years
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Chan WK et al. Reduced-volume PEG-ELS for morning colonoscopy
5. Table 1 Patient characteristics
old and consisted of 50.2% male. There were 152 pa-
tients in the whole-dose group and 143 patients in the
split-dose group. Patient characteristics were comparable
between the two groups (Table 1). A higher proportion
of patients in the whole-dose group had previous co-
lonic resection but this was not statistically significant.
Data on technical performance of colonoscopy, qual-
ity of bowel preparation and patient tolerability of the
bowel preparation regimes are presented in Table 2. Cecal
intubation rate (98.6% vs 98.7%), cecal intubation time
[657 (480-980) s vs 600 (432-900) s], withdrawal time [244
(180-348) s vs 298 (180-418) s] and total colonoscopy
time [960 (720-1304) s vs 960 (660-1320) s] were similar
between the two groups. Although adenoma detection
rates were similar between the two groups (30.1% vs
31.6%), the number of adenoma that were detected was
marginally higher in the split-dose group [2 (1-3) vs 1 (1-2),
P = 0.010].
Using the BPSS, there was a trend towards a better
score for the right colon in the split-dose group [2 (2-3)
vs 2 (2-2), P = 0.060]. Scores for the transverse and left
colon were similar between the groups. The total BBPS
score was as good in the split-dose group compared
to the whole-dose group [6 (6-8) vs 6 (6-7), P = 0.038].
Similarly, there was a trend towards a higher proportion
of patients graded as having good or intermediate qual-
ity bowel preparation in the split-dose group (97.2% vs
92.1%, P = 0.071).
A greater proportion of patients in the split-dose
group were able to complete the prescribed bowel prepara-
tion regime (99.3% vs 94.1%, P = 0.020). When enquired
about willingness to repeat the type of bowel prepara-
tion regime, patients in the split-dose group were less
likely to refuse the same bowel preparation regime (6.3%
vs 13.8%, P = 0.033) and less likely to want to try an-
other bowel preparation regime (53.8% vs 78.9%, P <
0.001). With regard to adverse symptoms, more patients
in the whole-dose group had nausea (37.5% vs 25.2%, P
= 0.023) and vomiting (16.4% vs 8.4%, P = 0.037). Oth-
er adverse effects were similar between the two groups.
There was a trend towards higher proportion of unfa-
vourable responses for level of comfort during bowel
preparation in the whole-dose group (28.3% vs 18.9%, P
= 0.058).
DISCUSSION
Several factors are recognized to influence the quality of
colon cleansing in adults undergoing colonoscopy, and
the timing of colon cleansing is one such determinant[17]
.
In this study, we have found that split-dose reduced-vol-
ume PEG-ELS is as effective as, but better tolerated and
preferred by patients, compared to whole-dose reduced-
volume PEG-ELS taken on the same day. To the best
of our knowledge, this is the first time these regimes
have been compared. Moreover, bowel preparation us-
ing split-dose reduced-volume PEG-ELS has not been
reported before, although there have been many studies
comparing split-dose and previous-evening whole-dose
regimes using larger volumes of PEG-ELS[7]
. In contrast
to recent studies at our centre that used previous-evening
whole-dose reduced-volume PEG-ELS[10,11]
, both bowel
preparation regimes in the current study were superior.
Chiu et al[12]
have already reported that a significantly
greater proportion of patients had satisfactory bowel
preparation when reduced-volume PEG-ELS was taken
in the morning of colonoscopy instead of the previous
evening (93% vs 72%, P = 0.003). Similarly, we found that
92.1% of our patients had satisfactory bowel prepara-
tion with same-morning reduced-volume PEG-ELS in
this study. In contrast, only 69.9% had satisfactory bowel
preparation with previous-evening reduced-volume PEG-
ELS in an earlier study[11]
. Same-morning as opposed to a
previous-evening PEG-ELS is superior due to a shorter
interval between completion of bowel preparation and
the colonoscopy procedure. The quality of bowel prepa-
ration has been shown to decline with an increasing in-
terval between completion of bowel preparation and the
colonoscopy procedure[18]
. Church et al[19]
hypothesized
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Characteristics Whole-dose
same-morning
Split-dose P
n = 152 n = 143
Age, yr 61.3 ± 14.9 62.8 ± 13.9 0.378
Male 51.3% 49.0% 0.685
Race
Chinese 56.6% 60.1% 0.434
Malay 21.7% 18.9%
Indian 21.7% 19.6%
Others 0% 1.4%
Education level
None or primary 28.9% 23.8% 0.314
Secondary or higher 71.1% 76.2%
Appointment waiting time
Less than 16 wk 52.6% 48.3% 0.452
16 wk or longer 47.4% 51.7%
Medical condition
Diabetes mellitus 23.7% 19.6% 0.393
Chronic constipation 7.9% 8.4% 0.876
Neurological condition 2.0% 2.8% 0.716
Others 52.6% 55.2% 0.514
Previous abdominal surgery 39.5% 38.5% 0.859
Previous colonic resection 21.1% 13.3% 0.078
Indication
Surveillance 30.3% 32.9% 0.263
Screening 16.4% 27.3%
Altered bowel habit 13.8% 14.0%
Per rectal bleeding 12.5% 9.8%
Abdominal pain 11.2% 6.3%
Anemia 5.3% 3.5%
Chronic diarrhoea 3.9% 1.4%
Chronic constipation 3.3% 3.5%
Others 3.3% 1.4%
Diagnosis
Normal colonoscopy 53.0% 46.5% 0.233
Colonic polyp 23.2% 26.8%
Diverticular disease 9.3% 11.3%
Colorectal carcinoma 4.0% 0.7%
Others 10.6% 14.8%
Seniority of endoscopist
Senior 34.2% 39.9% 0.315
Trainee 65.8% 60.1%
Chan WK et al. Reduced-volume PEG-ELS for morning colonoscopy
6. Table 2 Comparison of technical performance of colonoscopy, quality of bowel preparation and patient tolerability between groups
that there is a window period following bowel prepara-
tion, after which the quality of bowel preparation begins
to decline due to increasing entry of small bowel content
into the colon.
In this study, the percentage of patients with an unfa-
vourable response to a question on comfort level during
bowel preparation with same-morning reduced-volume
PEG-ELS was 23.7%. This is much lower than that found
in an earlier study using previous-evening reduced-volume
PEG-ELS (48.6%)[10]
. The reason for this is unclear. We
hypothesize that the better response for same-morning
PEG-ELS could be related to the shorter interval between
completing bowel preparation and the colonoscopy pro-
cedure itself.
Although reduced-volume PEG-ELS plus bisacodyl
has been shown to be as good as conventional 4-liter
PEG-ELS[8]
, it was uncertain if splitting an already lower
volume of PEG-ELS would compromise its efficacy. We
have demonstrated in this study that split-dose reduced-
volume PEG-ELS was as effective as whole-dose same-
morning reduced-volume PEG-ELS in terms of quality
of bowel preparation. Importantly, splitting the dose re-
sulted in significantly less side effects (nausea and vomit-
ing), was more tolerable and resulted in more patients
being able to complete the bowel preparation. This may
have compensated for any negative effect of splitting the
dose and would explain the quality of bowel preparation
seen in the split-dose group.
There are some concerns with taking part of or the
whole dose of a bowel preparation solution in the same
morning for a morning colonoscopy procedure. For ex-
ample, bowel movements during transit to the Endosco-
py Unit may inconvenience patients. A randomized study
comparing a split-dose and a whole-dose bowel prepara-
tion regime found slightly more toilet stops on the way
to the hospital for patients in the split-dose group. How-
ever, patients in the split-dose group found it easier to
complete their bowel preparation, were more satisfied,
and had better quality of bowel preparation compared to
the whole-dose group[20]
. Another concern is aspiration
of bowel preparation solution from the stomach into the
lung following administration of sedation for the proce-
dure. However, a randomized study found no difference
in residual gastric volume between patients who fasted
for 2 h and patients who fasted for 6-23 h[21]
.
Approximately 40% of colonoscopy patients in our
centre are direct referrals from primary care clinics[22]
.
Hence, data from this study may be generalized to popu-
lations scheduled for colonoscopy at large. However,
the study was specifically on patients attending morning
outpatient colonoscopy. The findings may be different
for patients attending afternoon outpatient colonoscopy
and for in-patients. Recently, Longcroft-Wheaton and
colleagues reported that same-day bowel preparation
produced better quality bowel preparation compared to
split-dose bowel preparation for afternoon colonoscopy
and was preferred by patients[23]
. However, the same-
day group had to take less amount of bowel preparation
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Technical performance Whole-dose same-morning Split-dose P
n = 152 n = 143
Completed colonoscopy 98.7% 98.6% 1.000
Cecal intubation time, s 600 (432-900) 657 (480-980) 0.510
Withdrawal time, s 298 (180-418) 244 (180-348) 0.235
Total colonoscopy time, s 960 (660-1320) 960 (720-1304) 0.888
Adenoma detection rate 31.6% 30.1% 0.779
Number of adenoma detected 1 (1-2) 2 (1-3) 0.010
Boston bowel preparation scale
Right 2 (2-2) 2 (2-3) 0.060
Transverse 2 (2-3) 2 (2-3) 0.119
Left 2 (2-3) 2 (2-3) 0.176
Total 6 (6-7) 6 (6-8) 0.038
Overall grading of quality of bowel preparation
Good or intermediate 92.1% 97.2% 0.071
Poor 7.9% 2.8%
Completed bowel preparation 94.1% 99.3% 0.020
Difficult to complete bowel preparation 61.2% 29.4% < 0.001
Will try another preparation 78.9% 53.8% < 0.001
Refuse the same preparation 13.8% 6.3% 0.033
Barely tolerable or unacceptable taste 7.9% 5.6% 0.432
Nausea 37.5% 25.2% 0.023
Vomiting 16.4% 8.4% 0.037
Abdominal pain 19.7% 13.3% 0.137
Bloating 32.2% 30.1% 0.688
Chest pain 3.9% 5.6% 0.506
Dizziness 10.5% 9.8% 0.834
Level of comfort during bowel preparation
Unfavourable response 28.3% 18.9% 0.058
Favourable response 71.7% 81.1%
Chan WK et al. Reduced-volume PEG-ELS for morning colonoscopy
7. and completed bowel preparation closer to the colo-
noscopy procedure, both factors which were in favour
of the same-day group. Moreover, the colonoscopy was
performed by the same endoscopist and there was no in-
formation regarding randomization and blinding. Hence,
further studies are needed to elucidate which bowel
preparation regime is better for afternoon colonoscopy.
In summary, patients scheduled for morning colo-
noscopy preferred a split-dose to the whole-dose same-
morning of reduced-volume PEG-ELS for colon cleans-
ing. Patients given split-dose experienced significantly
less nausea and vomiting, and were more likely to com-
plete the regime. The quality of bowel preparation using
split-dose was as good as using whole-dose same-morn-
ing reduced-volume PEG-ELS. For endoscopy units
using a PEG-ELS-based bowel preparation regime, we
recommend a split-dose reduced-volume PEG-ELS plus
bisacodyl as the regime of choice for patients undergo-
ing morning colonoscopy (ClinicalTrials.gov Identifier:
NCT01916564).
ACKNOWLEDGMENTS
The authors would like to acknowledge the help from
Madam Talvant Kaur, Mr. Choo Pee Terh and Ms. Tan
Wen Nian in carrying out the study.
COMMENTS
Background
A good bowel preparation regime is one that is not only effective in cleansing
the colon but should be relatively small in volume and well-tolerated by patients
with minimal adverse gastrointestinal symptoms.
Research frontiers
Current literature suggests that either taking reduced-volume polyethylene
glycol electrolyte lavage solution (PEG-ELS) on the same day instead of the
previous evening, or splitting the bowel preparation, would be better for patients
undergoing morning colonoscopy. However, whether the former or the latter is
better, is unknown.
Innovations and breakthroughs
In this study of 295 patients undergoing morning colonoscopy, the authors
found split-dose reduced-volume PEG-ELS plus bisacodyl to be as effective as,
but better tolerated and preferred by patients than, a same-morning whole-dose
regime. To the best of our knowledge, this is the first time these regimes have
been compared. Moreover, bowel preparation using split-dose reduced-volume
PEG-ELS has not been reported before although there have been many studies
comparing split-dose and previous-evening whole-dose regimes using larger
volumes of PEG-ELS.
Applications
Split-dose should be considered when reduced-volume PEG-ELS is used for
colon cleansing for patients undergoing colonoscopy in the morning.
Peer review
This is an interesting, generally well-written study. The authors presented an
interesting method of providing bowel preparation prior to endoscopy. They
have split the dose of PEG-ELS, and demonstrated no discernable deteriora-
tion in quality of bowel preparation, with an improvement in patient-reported
symptoms compared to standard single-dose bowel preparation. The findings
may be different for patients attending afternoon outpatient colonoscopy and for
in-patients and further studies are needed to elucidate which bowel preparation
regime is better for afternoon colonoscopy.
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P- Reviewer: Lassandro F, Tudor E
S- Editor: Gou SX L- Editor: A E- Editor: Liu XM
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Chan WK et al. Reduced-volume PEG-ELS for morning colonoscopy