Division of Gastroenterology, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
Division of Gastroenterology, Department of Medicine, White River Junction VAMC, White River Junction, Vermont, USA.
Am J Gastroenterol. 2023 Oct 1;118(10):1779-1786. doi: 10.14309/ajg.0000000000002407. Epub 2023 Jul 18.
Based on published evidence and our expert experience, we provide recommendations to maximize the efficacy, safety, efficiency, and cost-effectiveness of routine colonoscopy. High-quality colonoscopy begins with colon preparation using a split or same-day dose and preferably a low-volume regimen for optimal patient tolerance and compliance. Successful cecal intubation can be achieved by choosing the correct colonoscope and using techniques to facilitate navigation through challenges such as severe angulations and redundant colons. Safety is a primary goal, and complications such as perforation and splenic rupture can be prevented by avoiding pushing through fixed resistance and avoiding loops in proximal colon. Furthermore, barotrauma can be avoided by converting to water filling only (no gas insufflation) in every patient with a narrowed, angulated sigmoid. Optimal polyp detection relies primarily on compulsive attention to inspection as manifested by adequate inspection time, vigorous probing of the spaces between haustral folds, washing and removing residual debris, and achieving full distention. Achieving minimum recommended adenoma detection rate thresholds (30% in men and 20% in women) is mandatory, and colonoscopists should aspire to adenoma detection rate approaching 50% in screening patients. Distal attachments can improve mucosal exposure and increase detection while shortening withdrawal times. Complete resection of polyps complements polyp detection in preventing colorectal cancer. Cold resection is the preferred method for all polyps < 10 mm. For effective cold resection, an adequate rim of normal tissue should be captured in the snare. Finally, cost-effective high-quality colonoscopy requires the procedure not be overused, as demonstrated by following updated United States Multi Society Task Force on Colorectal Cancer postpolypectomy surveillance recommendations.
基于已发表的证据和我们的专业经验，我们提供了一些建议，以最大限度地提高常规结肠镜检查的疗效、安全性、效率和成本效益。高质量的结肠镜检查始于使用分剂量或同天剂量的结肠准备，最好采用低容量方案，以实现最佳的患者耐受性和依从性。通过选择正确的结肠镜和使用技术来解决严重的角度和冗余结肠等挑战，可以实现盲肠插管的成功。安全性是首要目标，可以通过避免推过固定阻力和避免近端结肠的环来预防穿孔和脾破裂等并发症。此外，通过在每个狭窄、角度的乙状结肠患者中仅转换为水填充（不充气），可以避免气压伤。最佳的息肉检测主要依赖于强制性的检查注意力，表现为足够的检查时间、充分探查皱襞之间的空间、清洗和清除残留的碎片，并实现完全扩张。达到最低推荐的腺瘤检出率阈值（男性 30%，女性 20%）是强制性的，结肠镜医师应努力使筛查患者的腺瘤检出率接近 50%。远端附件可以改善黏膜暴露并增加检测，同时缩短撤回时间。息肉的完全切除补充了息肉检测在预防结直肠癌中的作用。冷切除是所有<10mm 息肉的首选方法。为了有效地进行冷切除，圈套器应捕获足够的正常组织边缘。最后，成本效益高的高质量结肠镜检查需要避免过度使用，这可以通过遵循最新的美国多学会工作组关于结直肠息肉切除术后监测的建议来证明。
