Clark Brian T, Protiva Petr, Nagar Anil, Imaeda Avlin, Ciarleglio Maria M, Deng Yanhong, Laine Loren
Yale School of Medicine, New Haven, Connecticut.
Yale School of Medicine, New Haven, Connecticut; Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut.
Gastroenterology. 2016 Feb;150(2):396-405; quiz e14-5. doi: 10.1053/j.gastro.2015.09.041. Epub 2015 Oct 9.
BACKGROUND & AIMS: Bowel preparation is defined as adequate if it is sufficient for identification of polyps greater than 5 mm. However, adequate preparation has not been quantified. We performed a prospective observational study to provide an objective definition of adequate preparation, based on the Boston Bowel Prep Scale (BBPS, which consists of 0-3 points for each of 3 colon segments).
We collected data from 438 men who underwent screening or surveillance colonoscopies and then repeat colonoscopy examinations within 60 days by a different blinded endoscopist (1161 colon segments total) at the West Haven Veterans Affairs Medical Center from January 2014 to February 2015. Missed polyps were defined as those detected on the second examination of patients with the best possible bowel preparation (colon segment BBPS score of 3) on the second examination. The primary outcome was the proportion of colon segments with adenomas larger than 5 mm that were missed in the first examination. We postulated that the miss rate was noninferior for segments with BBPS scores of 2 vs those with BBPS scores of 3 (noninferiority margin, <5%). Our secondary hypotheses were that miss rates were higher in segments with BBPS scores of 1 vs those with scores of 3 or of 2.
The adjusted proportion with missed adenomas greater than 5 mm was noninferior for segments with BBPS scores of 2 (5.2%) vs those with BBPS scores of 3 (5.6%) (a difference of -0.4%; 95% confidence interval [CI], -2.9% to 2.2%). Of study subjects, 347 (79.2%) had BBPS scores of 2 or greater in all segments on the initial examination. A higher proportion of segments with BBPS scores of 1 had missed adenomas larger than 5 mm (15.9%) than segments with BBPS scores of 3 (5.6%) (a difference of 10.3%; 95% CI, 2.7%-17.9%) or 2 (5.2%) (a difference of 10.7%; 95% CI, 3.2%-18.1%). Screening and surveillance intervals based solely on the findings at the first examination would have been incorrect for 16.3% of patients with BBPS scores of 3 in all segments, for 15.3% with BBPS scores of 2 or 3 in all segments, and for 43.5% of patients with a BBPS score of 1 in 1 or more segments.
Patients with BBPS scores of 2 or 3 for all colon segments have adequate bowel preparation for the detection of adenomas larger than 5 mm and should return for screening or surveillance colonoscopy at standard guideline-recommended intervals. Colon segments with a BBPS score of 1 have a significantly higher rate of missed adenomas larger than 5 mm than segments with scores of 2 or 3. This finding supports a recommendation for early repeat colonoscopic evaluation in patients with a BBPS score of 0 or 1 in any colon segment.
如果肠道准备足以识别大于5毫米的息肉，则定义为充分。然而，充分准备尚未进行量化。我们进行了一项前瞻性观察性研究，以基于波士顿肠道准备量表（BBPS，由3个结肠段各0 - 3分组成）提供充分准备的客观定义。
我们收集了2014年1月至2015年2月在韦斯特黑文退伍军人事务医疗中心接受筛查或监测结肠镜检查，然后在60天内由另一位不知情的内镜医师进行重复结肠镜检查的438名男性的数据（共1161个结肠段）。漏诊息肉定义为在第二次检查中，肠道准备尽可能好（结肠段BBPS评分为3）的患者在首次检查中未检测到而在第二次检查中检测到的息肉。主要结局是首次检查中漏诊的大于5毫米腺瘤所在结肠段的比例。我们假设BBPS评分为2的结肠段与评分为3的结肠段的漏诊率非劣效（非劣效界值，<5%）。我们的次要假设是BBPS评分为1的结肠段的漏诊率高于评分为3或2的结肠段。
BBPS评分为2的结肠段（5.2%）与评分为3的结肠段（5.6%）相比，大于5毫米腺瘤漏诊的校正比例非劣效（差异为 -0.4%；95%置信区间[CI]，-2.9%至2.2%）。在研究对象中，347名（79.2%）在初次检查时所有结肠段的BBPS评分均为2或更高。BBPS评分为1的结肠段中大于5毫米腺瘤漏诊的比例（15.9%）高于BBPS评分为3的结肠段（5.6%）（差异为10.3%；95% CI，2.7% - 17.9%）或评分为2的结肠段（5.2%）（差异为10.7%；95% CI，3.2% - 18.1%）。仅基于首次检查结果的筛查和监测间隔对于所有结肠段BBPS评分为3的16.3%的患者、所有结肠段BBPS评分为2或3的15.3%的患者以及1个或更多结肠段BBPS评分为1的43.5%的患者而言会是不正确的。
所有结肠段BBPS评分为2或3的患者对于检测大于5毫米的腺瘤有充分的肠道准备，应按照标准指南推荐的间隔返回进行筛查或监测结肠镜检查。BBPS评分为1的结肠段大于5毫米腺瘤的漏诊率显著高于评分为2或3的结肠段。这一发现支持对任何结肠段BBPS评分为0或1的患者进行早期重复结肠镜评估的建议。
