|ORIGINAL RESEARCH REPORT
|Year : 2016 | Volume
| Issue : 1 | Page : 29-33
Audit of colonoscopy practice in Lagos University Teaching Hospital
Adedapo Osinowo1, Oluwagbemiga Lawal1, Olufumilayo A Lesi2, Thomas Olajide1, Adedoyin Adesanya1
1 Department of Surgery, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria
2 Department of Medicine, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria
|Date of Web Publication||2-Feb-2016|
Department of Surgery, Lagos University Teaching Hospital, Surulere, Lagos
Source of Support: None, Conflict of Interest: None
Introduction: Recent procurement of new endoscopies and accessories led to the reactivation of diagnostic and therapeutic colonoscopy services at our center. A preliminary audit is deemed necessary after a 2-year period of open access colonoscopy. Objective: To assess the pattern of indications, diagnostic yield, and selected key performance indicators in the practice of colonoscopy at our tertiary hospital. Patients and Methods: The endoscopy reports of all patients that underwent colonoscopy from January 2012 to April 2014 were reviewed. The demographic data, indications, and endoscopic findings were recorded. Information on cecal intubation, colonoscopy withdrawal time, polyp detection, adverse events, and bowel preparation quality were also extracted and analyzed. Results: Colonoscopy was performed in 149 patients. They were 81 males and 68 females, aged between 18 and 101 years with a mean of 46.9 ± 22.7 years. 126 (84.5%) patients had a colonoscopy for symptomatic conditions while 5 (4%) were for screening. Bowel preparation was assessed to be excellent in 81 (54.4%), adequate in 42 (28.2%), and inadequate in 26 (17.4%) patients, respectively. The cecal intubation rate (CIR) was 80.2%, polyp detection rate 7.4%, average colonoscopy withdrawal time was 6 min 53 s, overall diagnostic yield 55.9% and there were no adverse events. Tumors were seen in 19 patients (10.1%); 13 were located in the rectum, three in the sigmoid and three in the descending colon. Conclusion: The audit revealed that our CIR could be improved by a more effective bowel preparation, increased expertise, and procedure volume of endoscopists. Tumors of the colorectum were detected in 10.1% of patients.
Keywords: Adenoma detection rate, cecal intubation rate, colonoscopy practice, colonoscopy withdrawal time, key performance indicators, polyp detection rate
|How to cite this article:|
Osinowo A, Lawal O, Lesi OA, Olajide T, Adesanya A. Audit of colonoscopy practice in Lagos University Teaching Hospital. J Clin Sci 2016;13:29-33
| Introduction|| |
High-quality colonoscopy is now recognized as the gold standard diagnostic tool for colorectal diseases and large bowel symptoms. It has been shown in recent studies to be more sensitive and specific for colorectal disease than barium enema., It is the gold standard screening tool for colorectal cancer. Colonoscopy should be safe, complete, and comfortable. It should also provide the opportunity to safely and completely remove precancerous lesions. The performance of colonoscopy varies widely among endoscopists, as it is technically more difficult than upper gastrointestinal endoscopy. To maintain standards as an effective screening and diagnostic tool, a number of validated quality indicators have been developed to assess practice.
This report is a preliminary audit of all colonoscopies undertaken in a 28-month period to assess the pattern of indications, diagnostic yield, and our compliance with selected key performance indicators (KPIs). Colonoscopy quality indicators , such as cecal intubation rate (CIR), colonoscopy withdrawal time, polyp detection rate, adverse event incidence, and bowel preparation quality were evaluated. The audit will invariably support quality improvement in our endoscopy practice.
| Patients and Methods|| |
This was a retrospective study of all patients who underwent colonoscopy at the Endoscopy Unit between January 2012 and April 2014. The endoscopy reports of all patients that underwent colonoscopy were reviewed. The demographic data, indications, and endoscopic findings were recorded. Colonoscopy reports with information on cecal intubation, colonoscopy withdrawal time, adverse events, and bowel preparation quality were critically analyzed. All data were analyzed using IBM SPSS Statistics for windows version 20 statistical package.
Cecal intubation was defined as the passage of the colonoscopy tip to a point proximal to the ileocecal valve and identification of cecal landmarks, intubation of the terminal ileum or passage of the scope to anastomosis with the small bowel. The CIR was defined as the proportion of complete examinations, adjusted for incomplete examinations owing to very poor bowel preparation or a stricture caused by a tumor., Polyp detection rate was the proportion of patients in which polyps were identified. Colonoscopy withdrawal time was the time in minutes and seconds that it took to withdraw the colonoscopy following cecal intubation. Adverse event was defined as one that prevented completion of the planned procedure (excluding technical failure or poor preparation) and/or resulted in admission to hospital or prolongation of existing hospital admission, another interventional procedure (endoscopic, radiologic or surgery) or subsequent medical consultation.
Following standard bowel preparation, each patient filled a questionnaire and signed a consent form. The consent included a clear and realistic explanation of the procedure, the risks, and benefits. Patients had colonoscopy under conscious sedation induced by intravenous midazolam 2 mg and intravenous pentazocine 30 mg.
The assessment of the endoscopists of the quality of bowel preparation were categorized as excellent if no or minimal solid stool and only clear fluid requiring suction, adequate if collections of semi-solid debris that are cleared with washing/suction and inadequate if solid or semisolid debris that cannot be cleared effectively.
| Results|| |
Colonoscopy was performed in 149 patients. They were 81 males and 68 females giving a male: female ratio of 1.2:1.0. They were aged between 18 and 101 years with a mean of 46.9 ± 22.7 years. One hundred and twenty-six (84.5%) patients had a colonoscopy for symptomatic conditions while 5 (4%) were for screening for colorectal cancer. The indications for colonoscopy were not specified in the report of 18 patients [Table 1].
The findings are as shown in [Table 2]. Internal hemorrhoids were the most common abnormalities occurring alone or with other findings in 36 patients (20.1%), tumors were seen in 19 patients (10.1%); 13 were located in the rectum, three in the sigmoid and three in the descending colon. Diverticula alone or with other findings were seen in 16 patients (7.4%). The diverticuli were detected in the sigmoid and descending colon in 14 patients, and two patients had diverticuli detected in the descending colon and transverse colon. Polyps were detected in 11 patients (7.4%); one patient had diffuse polyposis, and the polyp was seen in the sigmoid in four patients, rectum in two patients, descending colon in two patients, and location of the polyp was not reported in two patients. Polyps were however detected in seven patients with complete colonoscopy. The polyp detection rate is 7.4%.
A cross-tabulation of clinical indications and endoscopic findings was done for clinical indications that had seven patients or more [Table 3]. This revealed that internal hemorrhoid is the most common cause of rectal bleeding, and hitherto rare entity diverticulosis was seen in 16 patients. The diverticuli were detected in the sigmoid and descending colon in 14 patients, and two patients had diverticuli detected in the descending colon and transverse colon.
|Table 3: Cross tabulation of clinical indications with endoscopic findings|
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The review had an overall diagnostic yield of 55.9%. A calculation of diagnostic yield was also done for clinical indications that had seven or more patients [Table 4]. This revealed that chronic diarrhea and rectal bleeding had the highest diagnostic yields, 70% and 65.5%, respectively.
Cecal intubation rate
Cecal intubation evidenced by identification of standard cecal landmarks was achieved in 93 patients (62.4%). With the exclusion of 13 patients with obstructing rectal tumors and four patients with stenosing sigmoid/descending colon tumors that precluded further intubation and 16 patients (10.7%) with inadequate bowel preparation, the overall adjusted CIR was 80.2%. Cecal intubation was not achieved in remaining 23 patients (15.4%) on account of inability to navigate an acute angulation.
Colonoscopy withdrawal time
The colonoscopy withdrawal time was only calculated for patients with cecal intubation and excellent or adequate bowel preparation. The average colonoscopy withdrawal time in 93 patients with complete colonoscopy and excellent or adequate bowel preparation was 6 min 53 s.
Polyp detection rate
Polyps were seen in 11 patients, one of whom had diffuse polyposis. Following exclusion of polyps seen in patients with incomplete colonoscopy, the polyp detection rate was 7.5% (7/93). Snare polypectomies were not undertaken during the audited period; hence the polyps could not be classified as hyperplastic or adenomatous.
There were no significant adverse events recorded during the performance of colonoscopy for the 93 patients with complete colonoscopy and the remaining 56 patients with incomplete colonoscopy.
Bowel preparation was assessed as excellent in 81 (54.4%), adequate in 42 (28.2%), and inadequate in 26 (17.4%) patients, respectively. Of the initial, 26 patients with inadequate bowel preparation, 10 patients had excellent preparation following repeat with the same protocol. The remaining 16 patients did not attend the second colonoscopy that was offered either because of inadequate bowel preparation or inability cecal intubation to achieve.
| Discussion|| |
The Endoscopy Unit undertook an open access endoscopy for 12 varied indications and had a high diagnostic yield of clinically relevant conditions. The clinical indications were appropriate according to the American Society for Gastrointestinal Endoscopy guidelines  which are essential to the rational utilization of resources. This is particularly pertinent in a resource poor setting. The overall diagnostic yield during the audited period was 55.9%. The diagnostic yield of colonoscopy was high in patients with rectal bleeding (65.7%) and chronic diarrhea (70%). This reinforces the notion that open access colonoscopy is ideal for patients with symptomatic lower gastrointestinal diseases in our region.
The spectrum of lesions identified was similar to that observed in other tertiary hospitals in Nigeria., Polyps were detected in 11 (7.4%) patients. Tumors were seen in 19 patients (10.1%); 13 were located in the rectum, three in the sigmoid and three in the descending colon. Internal hemorrhoids were the most common colonoscopic abnormality. In addition, all the five patients that had screening colonoscopy had no significant abnormality (colonic neoplasia) detected.
Colonoscopy has the most validated set of quality indicators of all endoscopic procedures, and specific KPIs have been developed for assessing practice. Selected KPIs: CIR, polyp detection rate, colonoscopy withdrawal time, adverse events, and bowel preparation were assessed in the audit. The CIR in the review was 80.5% after adjusting for poor bowel preparation and structural lesions. This value is below the performance standard adopted by the USA Multi-Society Task Force on Colorectal Cancer and Cancer Care Ontario Colonoscopy standards, which is 95% completion rate, after adjusting for poor bowel preparation and structural lesions., Similarly, it was also below the 90% benchmark established by the Joint Advisory Group on Gastrointestinal endoscopy (JAG) on an intention-to-colonoscopy basis. Our CIR of 80.5% was similar to that of a previous audit of colonoscopy practice in Lagos.
CIR is an important performance indicator and is globally recognized as the main measure of competency in colonoscopy in a nonscreening setting. The main factor adduced for the low CIR was the inability to navigate an acute angulation, which is a reflection of the expertise of the endoscopists. Of the 23 patients with acute angulation that were not navigated by the endoscopists, three patients had prior abdominal surgeries but it could not be ascertained whether the failed cecal intubation was a combination of acute angulation and prior abdominal surgery. However, it has been demonstrated in literature that colonoscopies are more technically difficult in patients that have had abdominal surgeries. Altered anatomy and adhesions from prior surgery not uncommonly complicated colonoscopy. Other factors such as body mass index, advanced age, female sex, and diverticular disease that may impact negatively on cecal intubation were not explored in this audit. Colonoscopy procedures were done under conscious sedation. The low CIR below 90% in the audit may also be related to this as it was reported in an international study that deeply sedated patients were more likely to have a complete colonoscopy than moderately sedated or unsedated patients.
More importantly, however, the total number of colonoscopy done over 28 months (149) brought into consideration the impact of endoscopist-specific parameters (experience level, annual procedure volume) on CIRs. It is widely known that an annual volume of at least 200 procedures per endoscopist is necessary to maintain competence. Logically, the more colonoscopy an endoscopist does in a year, the higher would be the CIR. The overall technical skill of endoscopist is the foremost determinant of cecal intubation. Polyps were identified in 11 patients (7.4%) which is similar to that reported in a previous audit of colonoscopy practice in Lagos  but is lower than that documented elsewhere. The polyp detection rate of 7.4% may be the true incidence of polyps among our patients or an underestimation because of low CIR. Colonoscopy polypectomy was not undertaken during the audited period hence it was difficult to calculate the adenoma detection rate, which is a KPI. Colonoscopy withdrawal time, which is a surrogate marker of detailed examination around folds, was >6 min in all patients with cecal intubation and excellent or adequate bowel preparation.
There were no adverse events recorded in this series. The two most feared complications of colonoscopy which are perforation and bleeding (usually postpolypectomy) were not seen in any of the patients. The zero complication rates could be misleading as none of the patients had polypectomy or other therapeutic procedures. Since this is a useful indicator of colonoscopy safety, it may be modestly stated here that our limited but growing endoscopy practice has maintained acceptable safe standards. It is, however, possible that silent risks such as missed cancer or advanced polyp occurred in our study. This factor was however minimized by our routine use of computed tomography scan or double contrast barium enema in patients with incomplete colonoscopy.
Bowel preparation is an essential part of a high-quality colonoscopy. It has a crucial impact on diagnostic yield, completeness, difficulty, and duration of the procedure., In this review, 82.4% (123) of patients had excellent or adequate bowel preparation with the protocol administered. The standard set by JAG is ≥90% of bowel preparation being described as excellent or adequate. A study in our region showed sodium phosphate to have a better cleansing score for a colonoscopy than water enema. It is feasible that the use of split-dose osmotic laxatives may cleanse the bowel better and increase compliance rate.
| Conclusion|| |
The audit revealed that our CIR could be improved by a more effective bowel preparation, increased expertise, and procedure volume of endoscopists. All these will undoubtedly reduce the gap in performance against key benchmarks.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]