An intraprocedural bowel cleansing system for difficult-to-prepare patients-A multicenter prospective feasibility study

Abstract

Background: Adequate bowel preparation is a prerequisite for colonoscopy. However, up to 20% of colonoscopies remain inadequately prepared. Risk factors for inadequate bowel preparation often overlap with those of failed cecal intubation. This study aimed to assess the feasibility of an intraprocedural bowel cleansing system (BCS) in patients with a history of inadequate bowel preparation.

Methods: Patients (n = 44) with a history of inadequate bowel preparation in the past 2 years were included. After a limited preparation with 300 mL split-dose sodium picosulfate magnesium citrate, additional cleansing during colonoscopy was performed with the BCS. The primary outcome was adequate bowel preparation using the Boston Bowel Preparation Scale (BBPS). Secondary outcomes included cecal intubation rate, procedure times, usability, and safety.

Results: Median BBPS increased from 1-2-2 (IQR 1-2) to 3-3-3 (IQR) (p < 0.0001), with 31.8% and 88.6% of patients adequately prepared before and after using the BCS, respectively (p < 0.0001). Cecal intubation rate was 88.6%. Reasons for incomplete colonoscopy were looping (n = 2), technical failure (n = 1), relative stricture (n = 1), and residual feces (n = 1). In patients with complete colonoscopy, the adequate cleansing rate was 97.5%. Median total procedure time was 26 min, of which 5.3 min were spent on cleaning. General ease of use was scored with a median of 4 out of 5, representing "as good as conventional colonoscopy". No serious adverse events occurred.

Conclusions: Adequate bowel cleaning can be achieved with an intraprocedural BCS in patients with a history of inadequate bowel preparation, which may reduce repeat colonoscopies and clinical admissions for bowel preparation. However, since these patients more frequently have complicated anatomy (surgical scarring, diverticulosis, etc.), adequate patient selection is advised to avoid incomplete procedures.

Keywords: Boston Bowel Preparation Scale; bowel preparation; cecal intubation rate; clinical trial; colonoscopy; colorectal cancer; inadequate bowel preparation; intraprocedural bowel cleansing; screening; surveillance.

FIGURE 1

(a) System set‐up. A 0.9% saline solution or sterile water was used for cleaning and connected to the oversleeve via the workstation. Suction tubes are also connected to the workstation to evacuate debris. The loading fixture is located on the workstation to load the oversleeve onto the colonoscope. (b) Details of the oversleeve with a standard size colonoscope.

FIGURE 2

Violin plot of Boston Bowel Preparation Scale (BBPS) scores before and after cleaning with the bowel cleansing system (BCS). The width of the plots indicates the prevalence of that particular score; median scores before BCS‐use were 1‐2‐2, after BCS‐use 3‐3‐3 (p < 0.0001).

FIGURE 3

Boxplot of procedure times, median and interquartile range (IQR). Dots indicate times that are >1.5 × IQR.

FIGURE 4

The proportional distribution of usability scores per category (n = 44). *Categories “Ease of polyp resection” (n = 9) and “ease of retroflex” (n = 11) were performed only on a subset of patients, when applicable. A score of “good” represents “as good as conventional colonoscopy”.