Digestive Endoscopy 2014; 26: 707–708
Editorial
Bowel cleansing for colonoscopy: Is same-day preparation the way ahead?
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OWEL PREPARATION IS a critical part of colonoscopy and has the potential to reduce deaths from cancer with many countries introducing national screening programs. For colonoscopy to be successful, it is necessary for the endoscopist to detect and remove premalignant adenomatous polyps. Some adenomatous and sessile serrated polyps can be flat and subtle. Therefore, the effectiveness of colonoscopy is dependent on the identification of subtle early changes. Although there has been considerable discussion around colonoscope resolution and image enhancement techniques, none of these developments are of value if the colon is not completely clean, and it is established that poor bowel preparation leads to lesions being missed.1,2 Therefore, the importance of high-quality bowel preparation cannot be underestimated. In particular, although there are many preparations and regimens available, patient compliance with bowel cleansing can be a significant issue,3,4 with one in seven patients showing a lack of compliance with a standard split-dose regimen. Much of the controversy surrounding bowl cleansing has centered around how the dose should be given. Evidence has emerged from several well-conducted studies suggesting that split-dose preparation is superior to single-dose delivery in achieving adequate bowel cleansing.5,6 Such regimens have involved the patient taking some bowel preparation the day before the procedure with further medication given on the morning of colonoscopy. Furthermore, there are data emerging that suggest that the final dose needs to be given as close to the procedure as possible,7,8 ideally within 5 h of colonoscopy. In this issue of Digestive Endoscopy, Tellez-Avila et al. report a randomized study examining three different methods of delivery of polyethylene glycol (PEG), a commonly used bowel prepatory agent.9 The authors compared three different regimens: a single 4-L dose of PEG the day before colonoscopy (group 1), a 2-L split dose the day before and 2 L on the day of the procedure (group 2), and a unique low-volume 2-L regimen delivered on the day of the procedure only (group 3). Unsurprisingly, group 1 did not perform well. Of greater interest was the comparison between groups 2 and 3. Bowel cleansing was very similar, suggesting that, at best, there was limited benefit from the preparation given the night before colonoscopy. Patients in group 3 reported fewer
side-effects and discomfort, suggesting that a same-day preparation regimen is better tolerated. In particular, nausea, vomiting, and abdominal discomfort were less frequent, with patients experiencing fewer sleep disorders and fewer hours of lost sleep compared to the other groups. The study was large and well powered, addressing key issues that are important and relevant to clinical practice. It was limited to examining patients recruited from a single center only and, perhaps more importantly, only included patients receiving inpatient bowel preparation. However, it should be noted that this is traditionally a very challenging population in which to achieve adequate cleansing, but this does not detract from the significance of the findings achieved. The data reported in this study were very similar to results published in an earlier randomized trial of 121 patients receiving PEG based bowel cleansing.10 This study compared two timings of bowel preparation, delivered either on the day of colonoscopy or the night before the procedure. Same-day cleansing was shown to achieve superior results and also reported a higher diagnostic yield of pathology. Work conducted by the Portsmouth research group in the United Kingdom also showed similar findings.11 This study examined the use of sodium picosulfate + magnesium citrate (Picolax; Ferring Pharmaceuticals, Drayton, UK) for bowel preparation and reported two regimens for preparation for afternoon colonoscopy: a split-dose regimen and a same-day regimen. This study interviewed patients to investigate patient preference and found that same-day preparation led to better cleansing with increased patient tolerability. In particular, there was less nausea or vomiting, less interruption to sleep and fewer episodes of fecal incontinence. Patients reported a clear preference for same-day preparation and not for the split dose. This mirrors the findings of Tellez-Avila et al. and would suggest that the benefits of same-day preparation are not restricted to a single preparatory agent. Evidence is emerging to suggest that the key to achieving good bowel cleansing is simply in delivering the preparatory agent shortly before the procedure. It would appear that whereas split-dose regimens are better than a single dose the day before colonoscopy, we should probably go further and consider same-day delivery of cleansing as the optimum model. There are clearly logistical problems with this.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
707
708
Editorial
Whereas same-day preparation for afternoon colonoscopy is practical, it is harder to deliver two doses of any bowelcleansing agent before a morning colonoscopy appointment. Such regimens may therefore necessitate a conceptual shift to colonoscopy becoming an afternoon procedure. This could have a big impact on service delivery and recovery of patients. However, with the growing evidence that patients find same-day regimens easier to tolerate and achieve better cleansing, this change in practice may have to be considered very seriously. It is important to recognize that the current model of colonoscopy (based around split-dose preparation) makes colonoscopy a 3-day process; 1 day for bowel cleansing, 1 day for the procedure and a 3rd day for recovering postsedation when return to work would not be considered safe for many occupations. With the world economic downturn affecting income and pensions, it is not uncommon to find that patients called for screening are in paid or voluntary employment, although possibly older than traditional retirement age, and losing 3 days of work can be a barrier to uptake. Reducing this by a day will be important to many patients. There is a need for further research in this area. We should not underestimate the impact of bowel cleansing on the patient’s perception of colonoscopy. Sadly, there has been a paucity of research examining this aspect of patient care. It is our contention that further studies focusing on same-day regimens and patient quality of life should be conducted. It is unfortunate that whereas most clinicians recognize that bowel preparation is not pleasant, exactly how it impacts on patients’ lives is poorly understood. It is only through studies that examine such details that we can take evidence-based steps to improve the process. An emphasis on how we can make bowel cleansing more patient friendly will not only improve the quality of bowel cleansing, but may also help increase participation in screening programs. Bowel cleansing may always be a barrier to screening uptake, but by addressing such issues as far as possible we will be offering our patients a much better service. Gaius Longcroft-Wheaton and Pradeep Bhandari Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK doi: 10.1111/den.12347
Digestive Endoscopy 2014; 26: 707–708
REFERENCES 1 Harewood GC, Sharma VK, de Garmo P. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest. Endosc. 2003; 58: 76–9. 2 Froehlich F, Wietlisbach V, Gonvers JJ, Burnand B, Vader JP. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest. Endosc. 2005; 61: 378–84. 3 [No authors listed]. The prep is worse than the procedure. Split dosing and some new liquids may make bowel cleansing needed for colonoscopy a bit easier and perhaps more palatable. Harv. Health Lett. 2010; 35: 6–7. 4 Menees SB, Kim HM, Wren P et al. Patient compliance and suboptimal bowel preparation with split-dose bowel regimen in average-risk screening colonoscopy. Gastrointest. Endosc. 2014; 79: 811–20. 5 Kilgore TW, Abdinoor AA, Szary NM et al. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a metaanalysis of randomized controlled trials. Gastrointest. Endosc. 2011; 73: 1240–5. 6 Flemming JA, Vanner SJ, Hookey LC. Split-dose picosulfate, magnesium oxide, and citric acid solution markedly enhances colon cleansing before colonoscopy: a randomized, controlled trial. Gastrointest. Endosc. 2012; 75: 537–44. 7 Eun CS, Han DS, Hyun YS et al. The timing of bowel preparation is more important than the timing of colonoscopy in determining the quality of bowel cleansing. Dig. Dis. Sci. 2011; 56: 539–44. 8 Siddiqui AA, Yang K, Spechler SJ et al. Duration of the interval between the completion of bowel preparation and the start of colonoscopy predicts bowel-preparation quality. Gastrointest. Endosc. 2009; 69: 700–6. 9 Téllez-Ávila FI, Murcio-Pérez E, Saúl A et al. Efficacy and tolerability of low-volume (2 L) versus single- (4 L) versus split-dose (2 L + 2 L) polyethylene glycol bowel preparation for colonoscopy: Randomized clinical trial. Dig. Endosc. Published online: 20 Mar 2014. doi: 10.1111/den.12265. [Epub ahead of print]. 10 Chiu HM, Lin JT, Wang HP, Lee YC, Wu MS. The impact of colon preparation timing on colonoscopic detection of colorectal neoplasms – a prospective endoscopist-blinded randomized trial. Am. J. Gastroenterol. 2006; 101: 2719–25. 11 Longcroft-Wheaton G, Bhandari P. Same-day bowel cleansing regimen is superior to a split-dose regimen over 2 days for afternoon colonoscopy: results from a large prospective series. J. Clin. Gastroenterol. 2012; 46: 57–61.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
Editorial
Bowel cleansing for colonoscopy: Is same-day preparation the way ahead?
B
bs_bs_banner
OWEL PREPARATION IS a critical part of colonoscopy and has the potential to reduce deaths from cancer with many countries introducing national screening programs. For colonoscopy to be successful, it is necessary for the endoscopist to detect and remove premalignant adenomatous polyps. Some adenomatous and sessile serrated polyps can be flat and subtle. Therefore, the effectiveness of colonoscopy is dependent on the identification of subtle early changes. Although there has been considerable discussion around colonoscope resolution and image enhancement techniques, none of these developments are of value if the colon is not completely clean, and it is established that poor bowel preparation leads to lesions being missed.1,2 Therefore, the importance of high-quality bowel preparation cannot be underestimated. In particular, although there are many preparations and regimens available, patient compliance with bowel cleansing can be a significant issue,3,4 with one in seven patients showing a lack of compliance with a standard split-dose regimen. Much of the controversy surrounding bowl cleansing has centered around how the dose should be given. Evidence has emerged from several well-conducted studies suggesting that split-dose preparation is superior to single-dose delivery in achieving adequate bowel cleansing.5,6 Such regimens have involved the patient taking some bowel preparation the day before the procedure with further medication given on the morning of colonoscopy. Furthermore, there are data emerging that suggest that the final dose needs to be given as close to the procedure as possible,7,8 ideally within 5 h of colonoscopy. In this issue of Digestive Endoscopy, Tellez-Avila et al. report a randomized study examining three different methods of delivery of polyethylene glycol (PEG), a commonly used bowel prepatory agent.9 The authors compared three different regimens: a single 4-L dose of PEG the day before colonoscopy (group 1), a 2-L split dose the day before and 2 L on the day of the procedure (group 2), and a unique low-volume 2-L regimen delivered on the day of the procedure only (group 3). Unsurprisingly, group 1 did not perform well. Of greater interest was the comparison between groups 2 and 3. Bowel cleansing was very similar, suggesting that, at best, there was limited benefit from the preparation given the night before colonoscopy. Patients in group 3 reported fewer
side-effects and discomfort, suggesting that a same-day preparation regimen is better tolerated. In particular, nausea, vomiting, and abdominal discomfort were less frequent, with patients experiencing fewer sleep disorders and fewer hours of lost sleep compared to the other groups. The study was large and well powered, addressing key issues that are important and relevant to clinical practice. It was limited to examining patients recruited from a single center only and, perhaps more importantly, only included patients receiving inpatient bowel preparation. However, it should be noted that this is traditionally a very challenging population in which to achieve adequate cleansing, but this does not detract from the significance of the findings achieved. The data reported in this study were very similar to results published in an earlier randomized trial of 121 patients receiving PEG based bowel cleansing.10 This study compared two timings of bowel preparation, delivered either on the day of colonoscopy or the night before the procedure. Same-day cleansing was shown to achieve superior results and also reported a higher diagnostic yield of pathology. Work conducted by the Portsmouth research group in the United Kingdom also showed similar findings.11 This study examined the use of sodium picosulfate + magnesium citrate (Picolax; Ferring Pharmaceuticals, Drayton, UK) for bowel preparation and reported two regimens for preparation for afternoon colonoscopy: a split-dose regimen and a same-day regimen. This study interviewed patients to investigate patient preference and found that same-day preparation led to better cleansing with increased patient tolerability. In particular, there was less nausea or vomiting, less interruption to sleep and fewer episodes of fecal incontinence. Patients reported a clear preference for same-day preparation and not for the split dose. This mirrors the findings of Tellez-Avila et al. and would suggest that the benefits of same-day preparation are not restricted to a single preparatory agent. Evidence is emerging to suggest that the key to achieving good bowel cleansing is simply in delivering the preparatory agent shortly before the procedure. It would appear that whereas split-dose regimens are better than a single dose the day before colonoscopy, we should probably go further and consider same-day delivery of cleansing as the optimum model. There are clearly logistical problems with this.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
707
708
Editorial
Whereas same-day preparation for afternoon colonoscopy is practical, it is harder to deliver two doses of any bowelcleansing agent before a morning colonoscopy appointment. Such regimens may therefore necessitate a conceptual shift to colonoscopy becoming an afternoon procedure. This could have a big impact on service delivery and recovery of patients. However, with the growing evidence that patients find same-day regimens easier to tolerate and achieve better cleansing, this change in practice may have to be considered very seriously. It is important to recognize that the current model of colonoscopy (based around split-dose preparation) makes colonoscopy a 3-day process; 1 day for bowel cleansing, 1 day for the procedure and a 3rd day for recovering postsedation when return to work would not be considered safe for many occupations. With the world economic downturn affecting income and pensions, it is not uncommon to find that patients called for screening are in paid or voluntary employment, although possibly older than traditional retirement age, and losing 3 days of work can be a barrier to uptake. Reducing this by a day will be important to many patients. There is a need for further research in this area. We should not underestimate the impact of bowel cleansing on the patient’s perception of colonoscopy. Sadly, there has been a paucity of research examining this aspect of patient care. It is our contention that further studies focusing on same-day regimens and patient quality of life should be conducted. It is unfortunate that whereas most clinicians recognize that bowel preparation is not pleasant, exactly how it impacts on patients’ lives is poorly understood. It is only through studies that examine such details that we can take evidence-based steps to improve the process. An emphasis on how we can make bowel cleansing more patient friendly will not only improve the quality of bowel cleansing, but may also help increase participation in screening programs. Bowel cleansing may always be a barrier to screening uptake, but by addressing such issues as far as possible we will be offering our patients a much better service. Gaius Longcroft-Wheaton and Pradeep Bhandari Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK doi: 10.1111/den.12347
Digestive Endoscopy 2014; 26: 707–708
REFERENCES 1 Harewood GC, Sharma VK, de Garmo P. Impact of colonoscopy preparation quality on detection of suspected colonic neoplasia. Gastrointest. Endosc. 2003; 58: 76–9. 2 Froehlich F, Wietlisbach V, Gonvers JJ, Burnand B, Vader JP. Impact of colonic cleansing on quality and diagnostic yield of colonoscopy: the European Panel of Appropriateness of Gastrointestinal Endoscopy European multicenter study. Gastrointest. Endosc. 2005; 61: 378–84. 3 [No authors listed]. The prep is worse than the procedure. Split dosing and some new liquids may make bowel cleansing needed for colonoscopy a bit easier and perhaps more palatable. Harv. Health Lett. 2010; 35: 6–7. 4 Menees SB, Kim HM, Wren P et al. Patient compliance and suboptimal bowel preparation with split-dose bowel regimen in average-risk screening colonoscopy. Gastrointest. Endosc. 2014; 79: 811–20. 5 Kilgore TW, Abdinoor AA, Szary NM et al. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a metaanalysis of randomized controlled trials. Gastrointest. Endosc. 2011; 73: 1240–5. 6 Flemming JA, Vanner SJ, Hookey LC. Split-dose picosulfate, magnesium oxide, and citric acid solution markedly enhances colon cleansing before colonoscopy: a randomized, controlled trial. Gastrointest. Endosc. 2012; 75: 537–44. 7 Eun CS, Han DS, Hyun YS et al. The timing of bowel preparation is more important than the timing of colonoscopy in determining the quality of bowel cleansing. Dig. Dis. Sci. 2011; 56: 539–44. 8 Siddiqui AA, Yang K, Spechler SJ et al. Duration of the interval between the completion of bowel preparation and the start of colonoscopy predicts bowel-preparation quality. Gastrointest. Endosc. 2009; 69: 700–6. 9 Téllez-Ávila FI, Murcio-Pérez E, Saúl A et al. Efficacy and tolerability of low-volume (2 L) versus single- (4 L) versus split-dose (2 L + 2 L) polyethylene glycol bowel preparation for colonoscopy: Randomized clinical trial. Dig. Endosc. Published online: 20 Mar 2014. doi: 10.1111/den.12265. [Epub ahead of print]. 10 Chiu HM, Lin JT, Wang HP, Lee YC, Wu MS. The impact of colon preparation timing on colonoscopic detection of colorectal neoplasms – a prospective endoscopist-blinded randomized trial. Am. J. Gastroenterol. 2006; 101: 2719–25. 11 Longcroft-Wheaton G, Bhandari P. Same-day bowel cleansing regimen is superior to a split-dose regimen over 2 days for afternoon colonoscopy: results from a large prospective series. J. Clin. Gastroenterol. 2012; 46: 57–61.
© 2014 The Authors Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society
