Difficult or Incomplete Flexible Sigmoidoscopy: Implications for a Screening Programme

Stewart, Bruce T.; Keck, James; Duncan, Anne; Santamaria, Nicholas M.; Allen, Philip J.

doi:10.1046/j.1440-1622.1999.01499.x

Cited by 28 publications

(18 citation statements)

References 16 publications

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“…None the less, this study is, to our knowledge, the first to attempt to quantify the risk of subsequent cancer according to depth of endoscopic insertion. Our results are largely consistent with those of prior studies examining age [5][6][7] and sex [5][6][7][8][9] as risk factors for incomplete sigmoidoscopy. In another recent analysis from the Clinical Outcomes Research Initiative (CORI), Walter et al used data from over 15 000 examinations in asymptomatic persons performed in multiple sites throughout the USA to assess the risk of inadequate sigmoidoscopy (less than 50 cm) by age and sex.…”

Section: Discussionsupporting

confidence: 92%

“…As certain potentially relevant variables were unavailable to us, it remains possible that at least part of the observed association with age and sex is due to uncontrolled confounding. However, other studies that have controlled for the variables above still found associations with age and sex, [5][6][7][8] although admittedly no study has controlled for all of the above variables. Additionally, it is possible that underreporting of examination limitations by clinicians (as discussed above) could lead to residual confounding when this variable is included in the multivariate models, resulting in risk estimates that are too high.…”

Section: Discussionmentioning

confidence: 97%

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Incomplete screening flexible sigmoidoscopy associated with female sex, age, and increased risk of colorectal cancer

Doria-Rose

2005

Gut

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Background: Several previous studies have found that females and older individuals are at greater risk of having incomplete flexible sigmoidoscopy. However, no prior study has reported the subsequent risk of colorectal cancer (CRC) following incomplete sigmoidoscopy. Methods: Using data from 55 791 individuals screened as part of the Colon Cancer Prevention (CoCaP) programme of Kaiser Permanente of Northern California, we evaluated the likelihood of having an inadequate (,40 cm) examination by age and sex, and estimated the risk of distal CRC according to depth of sigmoidoscope insertion at the baseline screening examination. Multivariate estimation of risks was performed using Poisson regression. Results: Older individuals were at a much greater risk of having an inadequate examination (relative risk (RR) for age 80+ years compared with 50-59 years 2.6 (95% confidence interval (CI) 2.3-3.0)), as were females (RR 2.3 (95% CI 2.2-2.5)); these associations were attenuated but remained strong if Poisson models were further adjusted for examination limitations (pain, stool, and angulation). There was an approximate threefold increase in the risk of distal CRC if the baseline sigmoidoscopy did not reach a depth of at least 40 cm; a smaller increase in risk was observed for examinations that reached 40-59 cm. Conclusions: Older individuals and women are at an increased risk of having inadequate sigmoidoscopy. Because inadequate sigmoidoscopy results in an increased risk of subsequent CRC, physicians should consider steps to maximise the depth of insertion of the sigmoidoscope or, failing this, should consider an alternative screening test.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 97%

Incomplete screening flexible sigmoidoscopy associated with female sex, age, and increased risk of colorectal cancer

Doria-Rose

2005

Gut

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“…A retrospective study by Brill and Baumgardner,15 which analyzed the factors affecting the depth of insertion of the sigmoidoscope on 223 asymptomatic and symptomatic patients performed by residents at various levels of training, did show a correlation of depth of insertion with female gender, prior abdominal surgery and quality of the preparation. In their prospective study on 206 asymptomatic volunteers, Stewart et al 6 found incomplete depth of insertion in up to a third of the patients and correlated this with female sex, previous abdominal surgery in women, high expectation of pain in women, and poor bowel preparation.…”

Section: Discussionmentioning

confidence: 99%

“…Olynyk et al 5 noted that 30% of patients had a depth of insertion of less than 50 cm. Stewart et al 6 suggest a 25% incomplete examination rate and technical difficulty in up to one third of the cases. Painter et al 7 found that in up to a quarter of the patients, the descending colon was not intubated.…”

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confidence: 96%

Predictors of Incomplete Flexible Sigmoidoscopy

Ramakrishnan¹,

Scheid²

2003

The Journal of the American Board of Family Medicine

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Objectives: Flexible sigmoidoscopy (flex sig) is an easily administered method of screening for colorectal polyps and cancer. In some patients, the depth of insertion is incomplete, which may result in missed polyps and cancers. To address the question of prospective patient selection for this procedure, we analyzed the factors affecting depth of insertion of sigmoidoscopies performed in outpatients over a 3-year period.Study Design: The study involved retrospective chart review of procedures performed by one endoscopist over a 3-year period.Outcomes Conclusions: Our study showed a relationship between incomplete examination and increasing age, female sex (more than 75% of the incomplete examinations were in women), poor bowel preparation (in women), hysterectomy, abdominal surgery (in men) and weight loss (in men). Further research is necessary to determine whether a predictive model can be developed that would be useful to select patients most appropriate for flex sig. In those patients in whom difficulty is anticipated, the choice can be made in to perform flex sig under sedation, analgesia, with the help of distraction techniques, or offer primary colonoscopy. Most colorectal cancers arise from adenomatous polyps.1 Their long asymptomatic phase allows for timely screening and adequate treatment of these premalignant lesions. Although screening colonoscopy is regarded as the ideal mechanism of detecting polyps because of its completeness and therapeutic potential, significant logistic barriers prevent its widespread implementation. Studies evaluating colonoscopy have suggested that screening flexible sigmoidoscopy (flex sig) using the 60-cm instrument has the capability of detecting 65% to 75% of polyps and 40% to 65% of colorectal cancers. 2-4The procedure can be performed by many physicians and physician extenders with relatively less investment in training and equipment. Hence, flex sig remains an important means of screening a major segment of the population at risk for colorectal cancer.Incomplete examination is an unfortunate drawback of flex sig, because the procedure is routinely offered without sedation or analgesia for simplicity and ease of administration. Olynyk et al 5 noted that 30% of patients had a depth of insertion of less than 50 cm. Stewart et al 6 suggest a 25% incomplete examination rate and technical difficulty in up to one third of the cases. Painter et al 7 found that in up to a quarter of the patients, the descending colon was not intubated. Using radiopaque clips, Lehman et al 8 noted that a 60-cm examination reached the splenic flexure in only 33% of patients, a 50-to 55-cm examination reached the sigmoid/ descending colon junction in most instances, a 40-

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“…The Joint Advisory Group in Endoscopy has defined completion of flexible sigmoidoscopy as insertion of the endoscope to descending colon, and this should be achieved in 90% of examinations. Another study has shown that examination of the entire sigmoid colon was not achieved in 25% of cases, and descending colon was intubated in a minority of cases [6].…”

mentioning

confidence: 99%

Quality assurance in flexible sigmoidoscopy: medical and nonmedical endoscopists

et al. 2009

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Difficult or Incomplete Flexible Sigmoidoscopy: Implications for a Screening Programme

Abstract: Estimates of the efficacy of flexible sigmoidoscopy as a colorectal cancer screening modality should take into account the relatively high rate of incomplete studies, particularly in women.

Cited by 28 publications

References 16 publications

Incomplete screening flexible sigmoidoscopy associated with female sex, age, and increased risk of colorectal cancer

Incomplete screening flexible sigmoidoscopy associated with female sex, age, and increased risk of colorectal cancer

Predictors of Incomplete Flexible Sigmoidoscopy

Quality assurance in flexible sigmoidoscopy: medical and nonmedical endoscopists

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