Routine ileal intubation in colonoscopy does not increase the polyp detection rate: a retrospective study

Abstract

Colonoscopy is effective in the prevention and screening of colorectal cancer. Whether terminal ileal (TI) intubation is required during conventional colonoscopy and whether it offers clinical benefits with respect to polyp detection rate (PDR) remain unclear. This retrospective study included patients who underwent colonoscopy at our hospital between July 1, 2018 and April 20, 2019. The positive findings and time for TI intubation were recorded. Univariate and multivariate analyses were performed to identify factors associated with PDR. There were 1675 patients with cecal intubation colonoscopy, including 994 (59 %) with TI intubation and 8 (1 %) with intestinal disease. The mean time for TI intubation was 40 seconds (3–338), and the mean time from cecal intubation to arrival at the deep part of TI mucosa was 24 seconds (2–118). The overall PDR was 27 %. On multivariable analysis, age > 50 years [95 % confidence interval (CI) 2.837–4.590], male sex (95 %CI, 0.406–0.649), presence of symptoms (abdominal symptoms vs. asymptomatic, 95 % CI, 1.146–2.468; stool changes vs. asymptomatic, 95 % CI, 1.070–1.834), and non-TI intubation (95 % CI, 1.040–1.648) were independent predictors of higher PDR. Trend analysis indicated decreasing trend of PDR among non-TI intubation group, 0–5 cm TI intubation group, and > 5 cm TI intubation group (30 % vs. 27 % vs. 24 %, respectively; p < 0.05). TI intubation is necessary to identify small bowel disease among a designated population, but it was not suggested to be routinely performed as part of colonoscopy, owing to limited positive intestinal findings, extra time requirement, and possible PDR worsening.

Zusammenfassung

Die Koloskopie ist eine effektive Untersuchungsmöglichkeit bei der Prävention und Früherkennung eines Kolorektalkarzinoms. Nicht bestätigt ist, ob bei der konventionellen Koloskopie eine Intubation des terminalen Ileums erforderlich ist und inwieweit diese klinisch vorteilhaft in Bezug auf die Polypenerkennungsrate ist. Diese retrospektive Studie schloss Patienten ein, die sich zwischen dem 1. Juli 2018 und dem 20. April 2019 in unserer Klinik einer Koloskopie unterzogen haben. Die positiven Befunde und die Zeit für die Intubation des terminalen Ileums wurden aufgezeichnet. Es wurden univariate und multivariate Analysen durchgeführt, um Faktoren im Zusammenhang mit der Polypenerkennungsrate zu identifizieren. Bei 1675 Patienten wurde eine Zökalkoloskopie durchgeführt, davon bei 994 (59 %) eine Intubation des terminalen Ileums; 8 der Patienten (1 %) litten unter einer Darmerkrankung. Die mittlere Zeit für die Intubation des terminalen Ileums betrug 40 s (3–338) und die mittlere Zeit von der Zökumintubation bis zum Erreichen des tiefen Bereichs der Ileum-Schleimhaut betrug 24 s (2–118). Die Gesamt- Polypenerkennungsrate betrug 27 %. Bei der multivariablen Analyse waren Alter > 50 Jahre [95 % Konfidenzintervall (KI) 2,837–4,590], männliches Geschlecht (95 % KI, 0,406–0,649), Vorliegen von Symptomen (abdominales Symptom vs. asymptomatisch, 95 % KI, 1,146–2,468; Stuhlveränderungen vs. asymptomatisch, 95 % KI, 1,070–1,834) und keine Intubation des terminalen Ileums (95 % KI, 1,040–1,648) unabhängige Prädiktoren für eine höhere Polypenerkennungsrate. Die Trendanalyse zeigte einen abnehmenden Trend der Polypenerkennungsrate in der Gruppe ohne Intubation des terminalen Ileums, der Gruppe mit 0–5 cm Intubation des terminalen Ileums und der Gruppe mit > 5 cm Intubation des terminalen Ileums (30 % vs. 27 % vs. 24 %; P < 0,05).

Eine Intubation des terminalen Ileums ist notwendig, um eine Dünndarmerkrankung bei einer bestimmten Patientengruppe zu erkennen; es wird jedoch nicht empfohlen, diese routinemäßig im Rahmen einer Koloskopie durchzuführen, da nur eine begrenzte Anzahl an positiven Befunden ermittelt wurde, mehr Zeit benötigt wird und sich die Polypenerkennungsrate möglicherweise verschlechtert.

Key words

adenoma detection rate - colorectal cancer - polyp detection rate - screening colonoscopy - terminal ileal intubation

Schlüsselwörter

Adenom-Erkennungsrate - Kolorektalkarzinom - Polypen­erkennungsrate - Screening-Koloskopie - Intubation des terminalen Ileums

Publication History

Received: 23 March 2020

Accepted: 06 July 2020

Article published online:
09 October 2020

• References

• 1 Peery AF, Dellon ES, Lund J. et al. Burden of gastrointestinal disease in the United States: 2012 update. Gastroenterology 2012; 143: 1179-1187 e3
• 2 Lieberman DA, Rex DK, Winawer SJ. et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2012; 143: 844-857
• 3 Meral M, Bengi G, Kayahan H. et al. Is ileocecal valve intubation essential for routine colonoscopic examination?. Eur J Gastroenterol Hepatol 2018; 30: 432-437
• 4 Jeong SH, Lee KJ, Kim YB. et al. Diagnostic value of terminal ileum intubation during colonoscopy. J Gastroenterol Hepatol 2008; 23: 51-55
• 5 Harewood GC, Mattek NC, Holub JL. et al. Variation in practice of ileal intubation among diverse endoscopy settings: results from a national endoscopic database. Aliment Pharmacol Ther 2005; 22: 571-578
• 6 Xu Y, Chen K, Xu L. et al. Diagnostic yield is not influenced by the timing of screening endoscopy: morning versus afternoon. Scand J Gastroenterol 2018; 53: 365-369
• 7 Lai EJ, Calderwood AH, Doros G. et al. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc 2009; 69: 620-625
• 8 Calderwood AH, Schroy 3rd PC. et al. Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness. Gastrointest Endosc 2014; 80: 269-276
• 9 Gavin DR, Valori RM, Anderson JT. et al. The national colonoscopy audit: a nationwide assessment of the quality and safety of colonoscopy in the UK. Gut 2013; 62: 242-249
• 10 Powell N, Knight H, Dunn J. et al. Images of the terminal ileum are more convincing than cecal images for verifying the extent of colonoscopy. Endoscopy 2011; 43: 196-201
• 11 Rex DK, Petrini JL, Baron TH. et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006; 101: 873-885
• 12 Armstrong D, Barkun A, Bridges R. et al. Canadian Association of Gastroenterology consensus guidelines on safety and quality indicators in endoscopy. Can J Gastroenterol Hepatol 2012; 26: 17-31
• 13 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
• 14 Kennedy G, Larson D, Wolff B. et al. Routine ileal intubation during screening colonoscopy: a useful maneuver?. Surg Endosc 2008; 22: 2606-2608
• 15 Kundrotas LW, Clement DJ, Kubik CM. et al. A prospective evaluation of successful terminal ileum intubation during routine colonoscopy. Gastrointest Endosc 1994; 40: 544-546
• 16 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
• 17 Cohen J, Pike IM. Defining and measuring quality in endoscopy. Gastrointest Endosc 2015; 8: 1-2
• 18 Kaminski MF, Anderson J, Valori R. et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomised trial. Gut 2016; 65: 616-624
• 19 Gurudu SR, Ramirez FC, Harrison ME. et al. Increased adenoma detection rate with system-wide implementation of a split-dose preparation for colonoscopy. Gastrointest Endosc 2012; 76: 603-608
• 20 Ngu WS, Bevan R, Tsiamoulos ZP. et al. Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial. Gut 2019; 68: 280-288
• 21 Sola-Vera J, Catala L, Uceda F. et al. Cuff-assisted versus cap-assisted colonoscopy for adenoma detection: results of a randomized study. Endoscopy 2019; 51: 742-749
• 22 Francis DL, Rodriguez-Correa DT, Buchner A. et al. Application of a conversion factor to estimate the adenoma detection rate from the polyp detection rate. Gastrointest Endosc 2011; 73: 493-497
• 23 Oines M, Helsingen LM, Bretthauer M. et al. Epidemiology and risk factors of colorectal polyps. Best Pract Res Clin Gastroenterol 2017; 31: 419-424