Prophylactic Endoscopic Clipping Does Not Prevent Delayed Postpolypectomy Bleeding in Routine Clinical Practice: A Propensity Score-Matched Cohort Study.

INTRODUCTION: Delayed postpolypectomy bleeding (DPPB) is a relatively common adverse event. Evidence is conflicting on the efficacy of prophylactic clipping to prevent DPPB, and real-world effectiveness data are lacking. We aimed to determine the effectiveness of prophylactic clipping in preventing DPPB in a large screening-related cohort. METHODS: We manually reviewed records of patients who underwent polypectomy from 2008 to 2014 at a screening facility. Endoscopist-, patient- and polyp-related data were collected. The primary outcome was DPPB within 30 days. All unplanned healthcare visits were reviewed; DPPB cases were adjudicated by committee using a criterion-based lexicon. Multivariable logistic regression was performed, yielding adjusted odds ratios (AORs) for the association between clipping and DPPB. Secondary analyses were performed on procedures where one polyp was removed, in addition to propensity score-matched and subgroup analyses. RESULTS: In total, 8,366 colonoscopies involving polypectomy were analyzed, yielding 95 DPPB events. Prophylactic clipping was not associated with reduced DPPB (AOR 1.27; 0.83-1.96). These findings were similar in the single-polyp cohort (n = 3,369, AOR 1.07; 0.50-2.31). In patients with one proximal polyp ≥20 mm removed, there was a nonsignificant AOR with clipping of 0.55 (0.10-2.66). Clipping was not associated with a protective benefit in the propensity score-matched or other subgroup analyses. DISCUSSION: In this large cohort study, prophylactic clipping was not associated with lower DPPB rates. Endoscopists should not routinely use prophylactic clipping in most patients. Additional effectiveness and cost-effectiveness studies are required in patients with proximal lesions ≥20 mm, in whom there may be a role for prophylactic clipping.

Hair cannabinoid concentrations in emergency patients with cannabis hyperemesis syndrome.

OBJECTIVES: Cannabis hyperemesis syndrome is characterized by bouts of protracted vomiting in regular users of cannabis. We wondered whether this poorly understood condition is idiosyncratic, like motion sickness or hyperemesis gravidarum, or the predictable dose-response effect of prolonged heavy use. METHODS: Adults with an emergency department visit diagnosed as cannabis hyperemesis syndrome, near-daily use of cannabis for ≥6 months, and ≥2 episodes of severe vomiting in the previous year were age- and sex-matched to two control groups: RU controls (recreational users without vomiting), and ED controls (patients in the emergency department for an unrelated condition). Δ9-Tetrahydrocannabinol (THC), cannabinol (CBN), cannabidiol, and 11-nor-9-carboxy-THC concentrations in scalp hair were compared for subjects with positive urine THC. RESULTS: We obtained satisfactory hair samples from 46 subjects with positive urine THC: 16 cases (age 26.8 ± 9.2 years; 69% male), 16 RU controls and 14 ED controls. Hair cannabinoid concentrations were similar between all three groups (e.g. cases THC 220 [median; IQR 100,730] pg/mg hair, RU controls 150 [71,320] and ED controls 270 [120,560]). Only the THC:CBN ratio was different between groups, with a 2.6-fold (95%CI 1.3,5.7) lower age- and sex-adjusted ratio in cases than RU controls. Hair cannabidiol concentrations were often unquantifiably low in all subjects. CONCLUSIONS: Similar hair cannabinoid concentrations in recreational users with and without hyperemesis suggest that heavy use is necessary but not sufficient for hyperemesis cannabis. Our results underline the high prevalence of chronic heavy cannabis use in emergency department patients and our limited understanding of this plant's adverse effects.

OBJECTIF: Le syndrome d'hyperémèse cannabique se caractérise par des accès prolongés de vomissements chez les grands consommateurs de cannabis. La question était donc de savoir si ce trouble, peu compris encore, relève d'un état idiosyncrasique, comme le mal des transports ou l'hyperémèse gravidique, ou d'un effet de type dose-réponse prévisible chez les grands consommateurs de cannabis. MÉTHODE: Des adultes chez qui un diagnostic de syndrome d'hyperémèse cannabique a été posé au service des urgences (SU), qui faisaient un usage presque quotidien du cannabis depuis ≥ 6 mois et qui ont connu ≥ 2 épisodes de vomissements importants au cours de l'année précédente ont été appariés à deux groupes témoins selon l'âge et le sexe : des témoins faisant un usage récréatif du cannabis, sans vomissements (UR) et des témoins traités au SU (examinés pour des troubles non connexes). La teneur des cheveux en Δ9-tétrahydrocannabinol (THC), en cannabinol (CBN), en cannabidiol et en 11-nor-9-carboxy-THC a été comparée chez les sujets ayant obtenu des résultats positifs à l'égard du THC urinaire. RÉSULTATS: Des échantillons satisfaisants de cheveux ont été prélevés chez 46 sujets ayant obtenu des résultats positifs à l'égard du THC urinaire : 16 cas (âge : 26,8 ± 9,2 ans; sexe masculin : 69%), 16 témoins UR et 14 témoins SU. La teneur des cheveux en cannabinoïdes était comparable dans les trois groupes (cas : THC : 220 pg/mg de cheveux [médiane; écart interquartile : 100­730]; témoins UR : 150 [71­320] et témoins SU : 270 [120­560]). Seul le rapport THC/CBN différait entre les groupes : il était 2,6 fois (IC à 95% : 1,3­5,7) inférieur dans les cas (rapport rajusté selon l'âge et le sexe) que chez les témoins UR. La teneur des cheveux en cannabidiol était souvent non quantifiable, et ce, chez tous les sujets. CONCLUSION: Le fait que la teneur des cheveux en cannabinoïdes était comparable chez les utilisateurs faisant un usage récréatif du cannabis, tant chez ceux qui souffraient d'hyperémèse que chez ceux qui en étaient exempts, donne à penser qu'il y a un usage nécessairement abusif de la drogue mais non suffisant pour causer l'hyperémèse cannabique. Les résultats font ressortir la forte prévalence d'un usage excessif et prolongé du cannabis chez les patients traités au SU et le peu de connaissances que la communauté médicale a des effets indésirables de cette plante.

Two-year retrospective analysis of patients undergoing direct to procedure flexible sigmoidoscopy investigation with rectal bleeding as a primary complaint.

BACKGROUND AND AIMS: Rectal bleeding affects ~15 % of the general population and is a common reason for referral to gastroenterologists by primary care physicians. Direct to procedure flexible sigmoidoscopy is an appealing modality to investigate rectal bleeding due its diagnostic yield, safety profile, and accessibility. Patients referred on a routine basis for direct to procedure clinic by primary care physicians with the sole complaint of rectal bleeding have not previously been studied. Our study aims to explore the spectrum of diagnoses and evaluate for potential clinical predictors of underlying pathology in this specific patient population. METHODS: In total, 528 charts of patients referred to the Kingston General Hospital and Hotel Dieu Hospital endoscopy units (Kingston, Canada) with the sole complaint of rectal bleeding were reviewed. All of these patients were referred on a routine basis to direct to procedure clinic from primary care physicians. The performance of various clinical variables in predicting significant pathology was assessed by univariate analysis. RESULTS: The diagnostic spectrum of the cohort studied included hemorrhoids (75.5 %), anal fissures (4 %), ulcerative colitis (3.2 %), Crohn's disease (1.1 %), indeterminate proctitis/colitis (1.7 %), and colorectal malignancy (2.7 %). Of the various clinical variables assessed, only male sex predicted significant pathology (25.2 % of males vs 17.6 % of females, P  < 0.05). CONCLUSION: Our study highlights the need for a thorough investigation of rectal bleeding given the lack of clinical predictors. Future prospective studies with more patients are needed to fully assess the utility of various clinical variables in predicting pathology in this patient population. This would allow for more effective triaging of a routine rectal bleeding, a very common reason for patient referral to gastroenterologists by primary care physicians. Flexible sigmoidoscopy was not associated with complications or missed diagnosis in our study. As such, the technique appears to be a suitable initial investigative modality for patients with rectal bleeding.

Anesthesia Assistance in Outpatient Colonoscopy and Risk of Aspiration Pneumonia, Bowel Perforation, and Splenic Injury.

BACKGROUND & AIMS: The increase in use of anesthesia assistance (AA) to achieve deep sedation with propofol during colonoscopy has significantly increased colonoscopy costs without evidence for increased quality and with possible harm. We investigated the effects of AA on colonoscopy complications, specifically bowel perforation, aspiration pneumonia, and splenic injury. METHODS: In a population-based cohort study using administrative databases, we studied adults in Ontario, Canada undergoing outpatient colonoscopy from 2005 through 2012. Patient, endoscopist, institution, and procedure factors were derived. The primary outcome was bowel perforation, defined using a validated algorithm. Secondary outcomes were splenic injury and aspiration pneumonia. Using a matched propensity score approach, we matched persons who had colonoscopy with AA (1:1) with those who did not. We used logistic regression models under a generalized estimating equations approach to explore the relationship between AA and outcomes. RESULTS: Data from 3,059,045 outpatient colonoscopies were analyzed; 862,817 of these included AA. After propensity matching, a cohort of 793,073 patients who had AA and 793,073 without AA was retained for analysis (51% female; 78% were age 50 years or older). Use of AA did not significantly increase risk of perforation (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.84-1.16) or splenic injury (OR, 1.09; 95% CI, 0.62-1.90]. Use of AA was associated with an increased risk of aspiration pneumonia (OR, 1.63; 95% CI, 1.11-2.37). CONCLUSIONS: In a population-based cohort study, AA for outpatient colonoscopy was associated with a significantly increased risk of aspiration pneumonia, but not bowel perforation or splenic injury. Endoscopists should warn patients, especially those with respiratory compromise, of this risk.

Patient comfort scores do not affect endoscopist behavior during colonoscopy, while trainee involvement has negative effects on patient comfort.

INTRODUCTION: Patient comfort is an important part of endoscopy and reflects procedure quality and endoscopist technique. Using the validated, Nurse Assisted Patient Comfort Score (NAPCOMS), this study aimed to determine whether the introduction of NAPCOMS would affect sedation use by endoscopists. PATIENTS AND METHODS: The study was conducted over 3 phases. Phase One and Two consisted of 8 weeks of endoscopist blinded and aware data collection, respectively. Data in Phase Three was collected over a 5-month period and scores fed back to individual endoscopists on a monthly basis. RESULTS: NAPCOMS consists of 3 domains - pain, sedation, and global tolerability. Comparison of Phase One and Two, showed no significant differences in sedative use or NAPCOMS. Phase Three data showed a decline in fentanyl use between individual months ( P  = 0.035), but no change in overall NAPCOMS. Procedures involving trainees were found to use more midazolam ( P  = 0.01) and fentanyl ( P  = 0.01), have worse NAPCOMS scores, and resulted in longer procedure duration ( P  < 0.001). Data comparing gastroenterologists and general surgeons showed increased fentanyl use ( P  = 0.037), decreased midazolam use ( P  = 0.001), and more position changes ( P  = 0.002) among gastroenterologists. CONCLUSIONS: The introduction of a patient comfort scoring system resulted in a decrease in fentanyl use, although with minimal clinical significance. Additional studies are required to determine the role of patient comfort scores in quality control in endoscopy. Procedures completed with trainees used more sedation, were longer, and had worse NAPCOMS scores, the implications of which, for teaching hospitals and training programs, will need to be further considered.

Comorbid Illness, Bowel Preparation, and Logistical Constraints Are Key Reasons for Outpatient Colonoscopy Nonattendance.

Background. Colonoscopy nonattendance is a challenge for outpatient clinics globally. Absenteeism results in a potential delay in disease diagnosis and loss of hospital resources. This study aims to determine reasons for colonoscopy nonattendance from a Canadian perspective. Design. Demographic data, reasons for nonattendance, and patient suggestions for improving compliance were elicited from 49 out of 144 eligible study participants via telephone questionnaire. The 49 nonattenders were compared to age and sex matched controls for several potential contributing factors. Results. Nonattendance rates were significantly higher in winter months; the OR of nonattendance was 5.2 (95% CI, 1.6 to 17.0, p < 0.001) in winter versus other months. Being married was positively associated with attendance. There was no significant association between nonattendance and any of the other variables examined. The top 3 reasons for nonattendance were being too unwell to attend the procedure, being unable to complete bowel preparation, or experiencing logistical challenges. Conclusions. Colonoscopy attendance rates appear to vary significantly by season and it may be beneficial to book more colonoscopies in the summer or overbook in the winter. Targets for intervention include more tailored teaching sessions, reminders, taxi chits, and developing a hospital specific colonoscopy video regarding procedure and bowel preparation requirements.

Risk factors for early colonoscopic perforation include non-gastroenterologist endoscopists: a multivariable analysis.

BACKGROUND & AIMS: Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training. METHODS: We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol. RESULTS: We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000-March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30-3.08). Propofol sedation did not significantly affect risk for perforation. CONCLUSIONS: In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.

Split-dose administration of a dual-action, low-volume bowel cleanser for colonoscopy: the SEE CLEAR I study.

BACKGROUND: New bowel cleansers for colonoscopy that lead to improved efficacy, safety, and tolerability are needed. OBJECTIVE: This study evaluated a nonphosphate, dual-action, low-volume, orange-flavored preparation containing sodium picosulfate and magnesium citrate (P/MC). DESIGN: Multicenter, assessor-blinded, randomized, noninferiority study. SETTING: University hospitals, academic medical centers, and private clinics across the United States. PATIENTS: Adults preparing for colonoscopy. INTERVENTIONS: P/MC versus 2 L of polyethylene glycol solution (2L PEG-3350) and two 5-mg bisacodyl tablets. MAIN OUTCOME MEASUREMENTS: This phase 3 study investigated the efficacy, safety, and tolerability of split-dose administration of P/MC versus day-before dosing of 2L PEG-3350 and two 5-mg bisacodyl tablets (SEE CLEAR I study). Efficacy was evaluated by using the Aronchick and Ottawa scales; noninferiority and superiority analyses were performed. Safety was assessed by monitoring adverse events (AEs). Tolerability was measured via a patient questionnaire. RESULTS: The intent-to-treat population consisted of 601 patients who self-administered P/MC (n = 304) or 2L PEG-3350 and bisacodyl tablets (n = 297). P/MC was superior to 2L PEG-3350 and bisacodyl tablets in overall colon cleansing (84.2% vs 74.4%; 1-sided 97.5% confidence interval [CI], 3.4) (Aronchick scores of excellent or good) and in cleansing of the ascending (89.5% vs 78.8%; 1-sided 97.5% CI, 4.9), mid (transverse and descending) (92.4% vs 85.9%; 1-sided 97.5% CI, 1.6), and rectosigmoid (92.4% vs 87.2%; 1-sided 97.5% CI, 0.4) segments of the colon (Ottawa scores of excellent, good, or fair). Commonly reported AEs related to the bowel preparations were nausea, vomiting, headache, and chills. Patient-reported tolerability, including ease of consumption and taste, was significantly higher for P/MC than 2L PEG-3350 and bisacodyl tablets (P < .0001). LIMITATIONS: Because of differences in administration and volume of the bowel preparations, the study was designed to be a single-assessor, blinded study. CONCLUSIONS: The bowel-cleansing effects and patient acceptability of split-dose P/MC were superior to day-before dosing with 2L PEG-3350 and bisacodyl tablets.

A dual-action, low-volume bowel cleanser administered the day before colonoscopy: results from the SEE CLEAR II study.

OBJECTIVES: Optimal bowel preparation is vital for the efficacy and safety of colonoscopy. The inconvenience, discomfort, required consumption of large volumes of product, and potential adverse effects associated with some bowel preparations deter patients from colonoscopy and may provide inadequate cleansing. A dual-action, non-phosphate, natural orange-flavored, low-volume preparation containing sodium picosulfate and magnesium citrate (P/MC) is currently being reviewed for bowel cleansing. METHODS: This was a phase 3, randomized, multicenter, assessor-blinded, prespecified non-inferiority, head-to-head study to investigate the efficacy, safety, and tolerability of day-before administration of P/MC vs. 2L polyethylene glycol solution and two 5-mg bisacodyl tablets (2L PEG-3350 and bisacodyl tablets (HalfLytely and Bisacodyl Tablets Bowel Prep Kit)) in adult patients preparing for colonoscopy (SEE CLEAR II Study). The primary objective of the study was to demonstrate the non-inferiority of P/MC to 2L PEG-3350 and bisacodyl tablets in overall colon cleansing using a modified Aronchick scale. In addition, efficacy in the ascending, mid (transverse and descending), and recto-sigmoid segments of colon was evaluated using a modified Ottawa scale. Patient acceptability and tolerability of the bowel preparations were assessed via a standard questionnaire. Safety was assessed based on the monitoring of adverse events (AEs) and meaningful findings on clinical evaluations including physical examinations, vital sign measurements, and electrocardiograms (ECGs). RESULTS: A total of 603 patients were randomized to receive either P/MC (n = 300) or 2L PEG-3350 and bisacodyl tablets (n = 303). Based on the Aronchick scale, successful overall cleansing was similar in patients receiving P/MC (83.0%) and patients receiving 2L PEG-3350 and bisacodyl tablets (79.7%). P/MC demonstrated non-inferiority to 2L PEG-3350 and bisacodyl tablets in overall cleansing of the colon, as measured by the Aronchick scale. Similarly, the efficacy of P/MC, as measured by the Ottawa scale, was non-inferior to 2L PEG-3350 and bisacodyl tablets in cleansing the ascending, mid, and recto-sigmoid segments of the colon. Patient-reported acceptability and tolerability for each item examined on the questionnaire was significantly greater for P/MC compared with 2L PEG-3350 and bisacodyl tablets (P<0.0001).Treatment-emergent AEs related to the bowel preparation reported by 1% of patients receiving P/MC or 2L PEG-3350 and bisacodyl tablets were nausea (3.0% vs. 4.3%), vomiting (1.4% vs. 2.0%), and headache (2.7% vs. 1.7%). No clinically meaningful changes were noted in either treatment arm in data collected from physical examinations, vital sign measurements, and ECGs. CONCLUSIONS: When administered as a day-before dose, the bowel cleansing effects of P/MC were non-inferior compared with 2L PEG-3350 and bisacodyl tablets using the clinician-rated Aronchick and Ottawa scales. Treatment acceptability was significantly more favorable in patients receiving P/MC than in patients receiving 2L PEG-3350 and bisacodyl tablets.

Serial monitoring of the physiological effects of the standard Pico-Salax® regimen for colon cleansing in healthy volunteers.

BACKGROUND: Sodium picosulfate/magnesium oxide/citric acid (Pico-Salax, Ferring Inc, Canada) is used widely in Canada and other countries for colon cleansing before colonoscopy. It is a low-volume osmotic/stimulant agent with the potential to deplete intravascular volume and alter electrolyte balance, yet there are little data regarding its effects on these clinically important end points. OBJECTIVE: To serially measure parameters of intravascular volume and electrolyte status in healthy volunteers over a 24 h period using the standard two-sachet dosing. METHODS: Twenty volunteers were given one sachet of Pico-Salax at time 0 h and another sachet 5 h later, as per usual bowel cleansing protocol. Subjects were continually monitored during the first 12 h of the study with postural vital signs, serum electrolytes and electrocardiograms obtained at intervals throughout this initial period and again at 24 h postingestion. RESULTS: No adverse events were reported nor were there any signs of intravascular volume depletion observed. There were decreases in potassium and calcium levels from baseline to 12 h, but these appeared minor and were corrected by 24 h. The proportions of patients with hypermagnesmia at 0 h, 5 h, 12 h and 24 h were 5%, 35%, 35% and 20%, respectively (P<0.05). However, the maximal values were only minimally elevated. Mean serum sodium, phosphate and creatinine levels remained within their respective reference ranges. There was a trend toward an increase in maximum corrected QT intervals from time 0 h (418 ms) to 5 h (430 ms) (P=0.06), but no significant change was seen subsequently at 12 h (419 ms). The subjects tolerated the medication well. The mean number of bowel movements per subject was 8.15 (range four to 15). Subjects consumed a mean (± SD) of 3.49±1.53 L of fluids during the observation period. CONCLUSIONS: The proportion of individuals with hypokalemia, hypocalcemia and hypermagnesemia following two sachets of Pico-Salax is significant, but the magnitude of the changes was not clinically relevant in this relatively small group, and both calcium and potassium levels normalized at 24 h. Nonetheless, this could have implications in patients with pre-existing electrolyte abnormalities and the safety of dosing with more than two sachets.

Split-dose picosulfate, magnesium oxide, and citric acid solution markedly enhances colon cleansing before colonoscopy: a randomized, controlled trial.

BACKGROUND: Picosulfate, magnesium oxide, and citric acid solution is a small-volume agent for colon cleansing before colonoscopy that is extremely well tolerated by patients, safe, and efficacious. Studies of other cleansing agents have suggested that split-dose regimens may further enhance efficacy. OBJECTIVE: To examine whether split-dosing of picosulfate, magnesium oxide, and citric acid solution increases bowel cleansing efficacy while maintaining tolerability and safety. DESIGN: Prospective, randomized, single-blinded, controlled trial. SETTING: Outpatient tertiary care center. PATIENTS: A total of 236 patients underwent colonoscopy (mean age 56 years, 53.8% female). INTERVENTIONS: Patients in the traditional arm (n = 123) consumed 1 sachet of solution at 5:00 pm and 10:00 pm the night before the colonoscopy. Patients in the split-dose arm (n = 127) consumed 1 sachet at 7:00 pm the night before and another sachet 4 hours before their colonoscopy appointment. MAIN OUTCOME MEASUREMENTS: Ottawa Bowel Preparation Scale (OBPS) score, Aronchick score, safety, tolerability. RESULTS: The 113 and 109 patients in the split-dose and traditional arms, respectively, had OBPS scores for analysis. Overall, the OBPS scores in the split-dose group were significantly improved compared with the traditional dose group (4.05 vs 5.51, P < .001). This was mostly attributed to improvements in right-sided colon cleansing (1.22 in split-dose vs 2.14 in traditional arm, P < .001). Both regimens were well tolerated by patients, and no safety issues were identified. LIMITATIONS: This was a single-center study. Disturbances in sleep related to the preparation were not assessed. CONCLUSIONS: The split-dose regimen of picosulfate, magnesium oxide, and citric acid solution is superior to the traditional dosing regimen for colon cleansing before colonoscopy. ( CLINICAL TRIAL REGISTRATION NUMBER: NCT00885274.).

Timing and frequency of bowel activity in patients ingesting sodium picosulphate/magnesium citrate and adjuvant bisacodyl for colon cleansing before colonoscopy.

BACKGROUND: Despite the wealth of research investigating bowel cleansing efficacy, there are very little data on the timing or frequency of bowel movements after each agent is ingested. OBJECTIVE: To examine the effect of each component of a three-day combined sodium picosulphate/magnesium citrate (PSLX) and bisacodyl regimen on the timing and frequency of bowel activity in patients undergoing colonoscopy. METHODS: Outpatients booked for colonoscopy were asked to complete a diary of their bowel preparation that tracked the timing of bowel movements. Bowel preparation quality was assessed using the Ottawa Bowel Preparation Scale. Bowel activity was compared with baseline and correlated with colon cleansing. Subgroup analysis was performed examining the effect of timing of the procedure and split-dose regimens. RESULTS: One hundred patients undergoing colon cleansing received bisacodyl 10 mg at 17:00 three days and two days before the day of colonoscopy. In one group, both sachets of PSLX were given the night before colonoscopy, while the second group, whose colonoscopies were scheduled after 11:00, ingested one sachet the night before and the second sachet at 06:00 on the day of colonoscopy. Patients had a mean of 1.7 bowel movements per day in the seven days before starting the cleansing regimen. Both doses of bisacodyl tablets resulted in a significant increase in the mean number of bowel movements compared with baseline (3.3/day first dose; 3.8/day second dose [P=0.03 and 0.001, respectively]). Each dose of PSLX also resulted in a significant increase in bowel movement frequency compared with baseline, with means of 4.4, 6.3 and 4.5 bowel movements after each dose. The mean time to the final bowel movement following the second sachet of PSLX was 8.9 h when taken the night before, and 3.9 h when taken the morning of the procedure. Bowel preparation quality significantly correlated with bowel frequency when total bowel movements were considered and when only the effects of bisacodyl were accounted for (P<0.01 for each). DISCUSSION: These data demonstrate that the addition of bisacodyl before PSLX ingestion has a significant additive effect on bowel frequency and correlates with bowel cleansing quality. The timing of the resulting bowel movements have practical implications for sleep and travel times to endoscopy suites.

A prospective, randomized assessment of a spatial orientation device in natural orifice transluminal endoscopic surgery.

BACKGROUND: One of the challenges in natural orifice transluminal endoscopic surgery (NOTES) is spatial orientation. The Queen's NOTES group has devised a novel method of orientation by using a magnetic device that passes within an endoscope channel allowing for 3-dimensional imaging of the shape and orientation of the endoscope. OBJECTIVE: To assess the feasibility and utility of a novel orientation device. DESIGN: Randomized, controlled trial. SETTING: Animal research laboratory study on four 25-kg pigs. INTERVENTION: The device was tested by 6 endoscopists and 6 laparoscopic surgeons. Starting at the gastrotomy, the time to identify 4 targets was recorded. Participants were required to identify and touch the gallbladder, the fallopian tube, a clip on the abdominal wall, and the liver edge. Use of the orientation device was randomized for each session. MAIN OUTCOME MEASUREMENTS: Time to identify targets with and without the device. Secondary analysis assessed differences between medical specialties and level of training. RESULTS: The mean time to identify all 4 targets with the device was 75.08 ± 42.68 seconds versus 100.20 ± 60.70 seconds without the device (P <.001). The mean time to identify all 4 targets on the first attempt was 102.29 ± 61.36 seconds versus 72.99 ± 40.19 seconds on the second attempt (P <.001). No differences based on specialty or level of training were identified. LIMITATIONS: Small sample size and simplicity of tasks. CONCLUSION: Regardless of randomization order, both groups were faster with the device. These encouraging results warrant further study using more complex scenarios.

Large-diameter self-expanding metal stents appear to be safe and effective for malignant colonic obstruction with and without concurrent use of chemotherapy.

BACKGROUND: Colonic stents are used chiefly for malignant large-bowel obstruction as a palliative measure or bridge to surgery that facilitates one-step resections. Literature on colorectal stenting demonstrates good safety and efficacy; however, a recent trial has raised concerns regarding the safety of a new large-diameter stent, especially in the setting of concurrent chemotherapy. This study evaluated our experience with colorectal stenting using mainly this stent. METHODS: The study was a retrospective chart review with a minimum 6-month telephone follow-up of patients who underwent colorectal stenting for malignant obstruction at Queen's University between December 2005 and March 2008. The primary outcome was clinical success, defined as full or partial relief of obstructive symptoms or successful bridge to surgery. Clinical failure was defined as persistence or recurrence of obstructive symptoms, death from obstruction, or the need for unplanned surgical intervention. RESULTS: Thirty patients underwent stenting for malignant obstruction during the study period. The technical success rate was 96.7%. Clinical success was 83% at 30 days and 69% at 6 months. The complication rate was 20%, with four early and two late complications. There were no perforations or stent migrations. Thirty-three percent of patients received chemotherapy with a stent in situ; this was not associated with an increased complication rate. Ninety-one percent of patients and families reported satisfaction with the procedure. CONCLUSIONS: Large-diameter stents appear to be safe for malignant colonic obstruction with and without concurrent chemotherapy and they have similar complication rates as older-generation stents with perhaps lower migration potential.

Pico-salax plus two-day bisacodyl is superior to pico-salax alone or oral sodium phosphate for colon cleansing before colonoscopy.

OBJECTIVES: This study examined whether Pico-Salax alone or Pico-Salax plus bisacodyl tablets for two nights before colonoscopy afford superior efficacy, patient tolerance, and safety compared with oral sodium phosphate. METHODS: Patients undergoing outpatient colonoscopy were randomized to receive either Pico-Salax at 5 and 10 PM the night before colonoscopy plus bisacodyl 10 mg at 5 PM in the two earlier evenings (n=105), Pico-Salax alone at 5 and 10 PM the night before colonoscopy (n=109), or oral sodium phosphate at 5 and 10 PM the night (n=101) before colonoscopy. All groups were encouraged to drink 3-4 l of Gatorade or other clear fluids the night before the colonoscopy. RESULTS: Global scoring of cleansing efficacy using the Ottawa scale did not reveal differences among groups, but Pico-Salax plus bisacodyl was superior in cleansing the right colon compared with the other regimens (P=0.003), providing almost 50% improvement over oral sodium phosphate. Patient tolerance of Pico-Salax plus bisacodyl did not differ from Pico-Salax alone but was much better than oral sodium phosphate (P<0.0001). Hemodynamic and biochemical monitoring of patients on Pico-Salax plus bisacodyl suggests this regimen has a very strong safety profile. It does not differ from Pico-Salax alone, which lacks the hyperphosphatemia and hypocalcemia associated with oral sodium phosphate. CONCLUSIONS: Together, these data suggest that Pico-Salax plus bisacodyl provides enhanced colon cleansing in the right colon compared with Pico-Salax alone or oral sodium phosphate, but this finding does not compromise the much greater tolerability or the safety profile of Pico-Salax alone.

Do patients undergo prostate examination while having a colonoscopy?

OBJECTIVES: To determine the rate at which physicians report performing a digital rectal examination and comment on the prostate gland before performing colonoscopy in men 50 to 70 years of age. METHODS: A retrospective chart review of all men 50 to 70 years of age who had a colonoscopy in Kingston, Ontario, in 2005 was completed. It was noted whether each physician described performing a digital rectal examination before the colonoscopy, and if so, whether he or she commented on the prostate. RESULTS: In 2005, 846 eligible colonoscopies were performed by 17 physicians in Kingston, Ontario. In 29.2% of cases, the physician made no comment about having performed a digital rectal examination; in 55.8% of cases, the physician commented on having completed a digital rectal examination but said nothing about the prostate; and in 15.0% of cases, the physician made a comment regarding the prostate. No physician consistently commented on the prostate for all patients, and in no circumstances was direct referral to another physician or follow-up suggested. DISCUSSION: A colonoscopy presents an ideal opportunity for physicians to use a digital rectal examination to assess for prostate cancer. Physicians performing colonoscopies in men 50 to 70 years of age should pay special attention to the prostate while performing a digital rectal examination before colonoscopy. This novel concept may help maximize resources for cancer screening and could potentially increase the detection rate of clinically palpable prostate cancer.