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An evaluation of flexible fibreoptic sigmoidoscopy.
Results of 350 flexible fibreoptic sigmoidoscopy examinations showed a diagnostic yield of 30% compared with 6.5% by rigid sigmoidoscopy of the same patients. The mean time for the examinations was eight minutes, a distance of over 50 cm being visualised in 65% of the patients. Preparation of the bowel with a single phosphate enema was adequate in 95% of the patients. As an outpatient investigation for clinicians fibreoptic sigmoidoscopy is a safe, quick, and useful addition to rigid sigmoidoscopy and should result in a decrease in the number of barium enema examinations required.
A UK training programme for nurse practitioner flexible sigmoidoscopy and a prospective evaluation of the practice of the first UK trained nurse flexible sigmoidoscopist.
BACKGROUND: Flexible sigmoidoscopy is a technical skill that has been successfully performed by suitably trained colorectal nurse practitioners in the USA. However, no recognised training course exists for nurse practitioners in the UK. AIMS: To design and evaluate a training programme for nurse endoscopists. METHODS: A multidisciplinary committee of nurses and clinicians developed a structured programme of study and practice. This involved a staged process of observations, withdrawals, and ultimately, full procedures. Once training had been completed the nurse practitioner was permitted to practice independently. Patients with colorectal symptoms referred for flexible sigmoidoscopy were examined for the final stages of training and independent practice. A prospective evaluation of the training and practice of the first trained nurse flexible sigmoidoscopist was performed. Barium enema, video, clinical follow up, and histology were used to validate the results of the flexible sigmoidoscopies. RESULTS: The training programme required that 35 observations, 35 withdrawals, and 35 supervised full procedures were performed prior to the development of independent practice. Subsequent to the completion of this programme 215 patients have been examined independently by the nurse practitioner. Ninety three per cent of the examinations were judged successful and pathology was identified in 51%. The nurse endoscopist successfully identified all "significant" pathology whereas barium enema failed to identify pathology in 12.5%. There were no complications. CONCLUSION: With suitable training nurse endoscopists are able to perform flexible sigmoidoscopy safely and effectively.
Evaluation of flexible sigmoidoscopy as an investigation for "left sided" colorectal symptoms.
BACKGROUND: Colonoscopy is the best way of imaging the colon with concurrent biopsy and treatment. However it is expensive, requires full bowel preparation, and carries a risk of complications. Flexible sigmoidoscopy is an alternative way to investigate symptoms that raise the suspicion of a lesion of the rectum or left colon. AIM OF THE STUDY: To evaluate flexible sigmoidoscopy as the main investigation for "left sided" colorectal symptoms. METHODS: The clinical records of 317 patients who were assessed at a colorectal specialist clinic and were thought to have a suspicion of a lesion of the rectum or left colon were retrospectively reviewed. All patients had flexible sigmoidoscopy as the primary investigation. Primary outcome was the diagnostic yield of flexible sigmoidoscopy and secondary outcomes were any additional colonic investigations required, failure rates, and complication rates. RESULTS: Three hundred and sixteen patients who had flexible sigmoidoscopy with the above criteria were retrospectively analysed. Twenty four procedures (7.6%) had to be abandoned because of poor bowel preparation. The examination was considered complete when it reached the splenic flexure, which was the case in 205 cases (65%). In 137 flexible sigmoidoscopies (43.3%) there were no abnormal findings. Of the remaining 179 a carcinoma of the rectum or colon was found in 28 cases (8.8%) and one or more polyps was found in 57 (18%) cases. On the basis of the findings it was calculated that 31% of the patients would require an additional investigation for further imaging of the right colon. DISCUSSION: Although flexible sigmoidoscopy has a high yield of pathologies when carried out by a specialist colorectal clinic, the presence of those pathologies makes the full imaging of the whole colon with an additional investigation necessary. Therefore the cost efficiency of flexible sigmoidoscopy is questionable. Although flexible sigmoidoscopy is indicated for certain patients, it cannot replace colonoscopy as the main investigation used by a specialist colorectal clinic.
Postendoscopy barium enema examinations.
A study was designed to evaluate whether sigmoidoscopy performed on the same day as barium enema examination interferes with quality or interpretation of the barium study. The study included 295 patients who had either single- or double-contrast barium enema examinations subsequent to sigmoidoscopy performed either on a prior day or the same day. Luminal air, spasm, colonic fluid, and mucosal coating were assessed, as was the resultant diagnostic quality of each barium examination. The results suggest that rigid or fiberoptic sigmoidoscopy can be performed the same day as single- or double-contrast barium enema examinations without adversely affecting the quality or interpretation of the barium study.
Glutaraldehyde colitis: radiologic findings.
PURPOSE: Two percent glutaraldehyde on colonic mucosa may result in a toxic colitis, and the clinical features may mimic those of colonic ischemia. The study was performed to determine the radiologic appearance of glutaraldehyde-induced toxic colitis. MATERIALS AND METHODS: A retrospective review was performed with the clinical and imaging findings in four patients with glutaraldehyde-induced colitis seen during a 6-year period. RESULTS: Patients developed a self-limited syndrome of cramps and abdominal pain, tenesmus, and rectal bleeding within 48 hours of uncomplicated sigmoidoscopy or colonoscopy. Sample cultures excluded enteric pathogens. Computed tomography (CT) demonstrated circumferential thickening of the colonic wall in a left-sided distribution in all patients. Heterogeneous mural enhancement (target-sign appearance) was noted in two patients. Follow-up CT studies confirmed resolution of mural wall thickening with conservative management. CONCLUSION: The clinical and radiologic features of glutaraldehyde-induced toxic colitis may mimic those of colonic ischemia. This complication should be suspected in patients who develop hemorrhagic colitis immediately after undergoing colonoscopy.
Quality control in colorectal cancer screening: systematic microbiological investigation of endoscopes used in the NORCCAP (Norwegian Colorectal Cancer Prevention) trial.
BACKGROUND: Endoscopic colorectal cancer (CRC) screening is currently implemented in many countries. Since endoscopes cannot be sterilised, the transmission of infectious agents through endoscopes has been a matter of concern. We report on a continuous quality control programme in a large-scale randomised controlled trial on flexible sigmoidoscopy screening of an average-risk population. Continuously, throughout a two-year screening period, series of microbiological samples were taken from cleaned ready-to-use endoscopes and cultured for bacterial growth. RESULTS: 8573 endoscopies were performed during the trial period. Altogether, 178 microbiological samples (2%) were taken from the biopsy channels and surfaces from the endoscopes. One sample (0.5%) showed faecal contamination (Enterobacter cloacae), and 25 samples (14%) showed growth of environmental bacteria. CONCLUSIONS: Growth of bacteria occurs in a clinical significant number of samples from ready-to-use endoscopes. Pathogenic bacteria, however, were found only in one sample. Improvement of equipment design and cleaning procedures are desirable and continuous microbiological surveillance of endoscopes used in CRC screening is recommended.
Acceptance of flexible sigmoidoscopy and colonoscopy for screening and surveillance in colorectal cancer prevention.
OBJECTIVES: To study an individual's experience of either flexible sigmoidoscopy (FS) or colonoscopy in a colorectal cancer prevention programme. METHODS: Consecutive individuals in a Bowel Cancer Prevention Programme, who had either an unsedated FS or a colonoscopy with sedation, participated in a prospective cross-sectional questionnaire-based study. RESULTS: A total of 447 responses were obtained for 256 colonoscopies and 191 FSs (200 men [45%] and 247 women [55%]). The overall experience of colonoscopy was more comfortable than FS (75% versus 18%; P<0.001). Embarrassment was low for both procedures (8%). There was no pain associated with colonoscopy and most individuals had a pain score of less than 3 (11-point scale) for FS: 72% of men, 55% of women (P<0.001). Most individuals did not have a gender preference for the endoscopist. For colonoscopy, the worst part of the procedure was the preparation (78%) and for FS the preparation and the procedure ranked equally worst (30%). CONCLUSIONS: We have shown that colonoscopy with sedation is a very comfortable procedure. FS is more uncomfortable than colonoscopy; however, for the majority it is a tolerable experience. Women found FS only slightly more painful than men. The worst part of either procedure was the preparation. Embarrassment with either procedure was minimal. Both procedures are well tolerated and suitable for colorectal cancer screening.
Introduction to position papers from the Third International Symposium on Colorectal Cancer.
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The role of proctosigmoidoscopy in screening for colorectal neoplasia.
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Fibresigmoidoscopy: technique of choice?
A study was undertaken to determine the practicality of replacing rigid sigmoidoscopy with flexible fibresigmoidoscopy. A total of 388 examinations were performed and complete examination was possible in 79% of patients in less than 10 minutes. Abnormalities were found in 18% of patients; colorectal polyps and tumours were identified in 11% of patients. No complications occurred and the investigation was well tolerated. Fibresigmoidoscopy is a practical, safe procedure for routine use in the outpatient setting and has several advantages over rigid sigmoidoscopy.
Clinical competence in the use of flexible sigmoidoscopy for screening purposes. Health and Public Policy Committee.
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Barriers to office-based screening sigmoidoscopy: does reimbursement cover costs?
Screening with flexible sigmoidoscopy may reduce mortality rates from colorectal cancer. Primary care physicians are able to provide this screening procedure, but many have been reluctant to do so, partly because of the impression that reimbursement rates are inadequate to cover physician costs. This study examines the cost of performing flexible sigmoidoscopy in a primary care practice and compares this cost with the new Medicare reimbursement rate for flexible sigmoidoscopy. Fixed and variable costs associated with the performance of office-based flexible sigmoidoscopy were derived from the published literature. The principal assumption in the analyses is that the time required to perform flexible sigmoidoscopy represents an opportunity cost because the physician could use that time to see additional patients during routine office hours. Sensitivity analyses were done across a range of estimates for the cost variables. When Medicare reimbursement rates were used, the physician's total cost for flexible sigmoidoscopy without biopsy was $86.86, which is similar to the Medicare reimbursement rate for screening flexible sigmoidoscopy (code 45330, $87.84). The calculations were most sensitive to estimates of equipment cost, procedure time, number of procedures performed per year, additional malpractice coverage, and revenue generated per hour of outpatient care. The estimated cost per procedure in a screening program that includes the ability to perform biopsy is $152.93, which exceeds Medicare reimbursement rates across the range of all variables included in the sensitivity analyses. Thus, low reimbursement may limit the adoption of screening flexible sigmoidoscopy with or without biopsy in primary care practices.
Glutaraldehyde colitis: a complication of screening flexible sigmoidoscopy in the primary care setting.
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Cost analysis for procedure comparisons.
Using the methodology of activity-based costing as a conceptual framework, the authors present the potential cost reduction of a new office routine and a medical procedure. The costs of a new instrument for colorectal cancer screening and a new surveying and follow-up of at-risk patients show that time and relevant costs in the G.I Clinic and G.I Endoscopy Lab were significantly reduced.
Colorectal cancer--to screen or not to screen?
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Fiberoptic flexible sigmoidoscopy and pelvic masses.
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Is colonoscopy indicated for small adenomas found by screening flexible sigmoidoscopy?
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