Reply to Grimminger & Hölscher

We would like to thank Grimminger & Hölscher for their comments. It is true that the indications for colonoscopy were not reviewed in our study; however we would contend that that the surgical and gastroenterology patient cohorts were not notably dissimilar. In Ireland a significant proportion of gastrointestinal endoscopies are performed by surgeons; in some institutions all such procedures are done by surgeons. In 2006 – 2007, 40 % of colonoscopies at our institution were performed by the surgical service. Our endoscopy service is structured in such a way that much of the outpatient cohort is shared non-selectively between surgeons and gastroenterologists. Furthermore, patients with a prior history of surgery are not followed up exclusively by the surgical service, and the surgical clinics incorporate screening and surveillance colonoscopies.

We feel that the performance of colonoscopy, as opposed to flexible sigmoidoscopy or proctoscopy, should meet the quality parameters proposed by the American Society for Gastrointestinal Endoscopy/American College of Gastroenterology (ASGE/ACG) regardless of the clinical indication. Obviously, because of the retrospective nature of this study, the intention to reach the cecum was inferred. However, we did exclude any incomplete procedures where there had clearly been no intention to perform a complete colonoscopy.

In our study the surgical trainees reported diverticulosis as the reason for failing to complete the colonoscopy more frequently did than the gastroenterology trainees, but this is not the same as the prevalence of diverticulosis in the surgical and gastroenterological patient cohorts. Poor bowel preparation was reported as the reason for failure to complete the procedure more frequently by the gastroenterology trainees; the majority of the procedures involved were inpatient procedures. Although the standard bowel preparation varied between the cohorts, we feel that with regard to bowel preparation the patient designation (inpatient or outpatient) was the more significant factor. The surgical trainees performed significantly fewer inpatient procedures; therefore one would expect better bowel preparation in this group.