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PubMed2001

Training general practitioners in flexible sigmoidoscopy to screen for colorectal cancer.

BACKGROUND: A screening programme to detect polyps or early carcinoma would significantly reduce the mortality and morbidity of colorectal cancer (CRC). The aims of the present study were to evaluate: (i) the feasibility of training general practitioners in flexible sigmoidoscopy (FS) for CRC screening; (ii) the acceptability of screening by faecal occult blood testing (FOBT) and FS in asymptomatic standard risk Australians aged over 50 years; and (iii) the yield of such screening. METHODS: Subjects were recruited by general practitioner (GP) referral, newspaper advertisement or by a direct approach to retirement villages. Participants were mailed a FOBT kit and a prescreening questionnaire. Flexible sigmoidoscopy was performed by a GP supervised by an experienced endoscopist. Subjects then completed a second questionnaire. General practitioners were assessed after 50 unassisted procedures. RESULTS: A total of 264 individuals contacted the study coordinator; 169 were screened. Screening was accepted well by the participants. Fifteen per cent of subjects had polyps and 4% had a positive FOBT. Training in FS was adversely affected by the availability of resources. Three GPs completed 50 unassisted procedures over a 15-month period, but none were able to reliably assess the distal bowel. CONCLUSIONS: Although the three trainees and their supervisors did not consider that the GPs were adequately trained after 50 unassisted procedures, training was adversely affected by limited resources within the Victorian public hospital system. Screening by FOBT and FS was considered to be acceptable by the patients undergoing these procedures. Existing facilities are not adequate if GPs are to be trained in FS as part of a national CRC screening program.

Aged↗
PubMed2002

Is carbon dioxide as an insufflation agent for double contrast barium enema still worthwhile after a same-day flexible sigmoidoscopy?

PURPOSE: The aim of the study was to evaluate the efficacy of a double-contrast barium enema (DCBE) with CO(2) as a distending gas after a screening flexible sigmoidoscopy for reducing abdominal distension after an examination. PATIENTS AND METHODS: A total of 165 DCBEs for patients with positive faecal occult blood tests were randomly allocated to a CO(2) group (n = 83) and a control group (n = 82) using air. Abdominal radiograph were taken before the DCBE, immediately following it, and 30 minutes later to determine residual bowel gas. The degree of abdominal discomfort was recorded using a scoring system. RESULTS: The patients in the CO(2) group had significantly smaller amounts of residual gas 30 minutes after the DCBE than did the control group, both in the colon (P < 0.02) and in the small intestine (P < 0.001). There was significantly less abdominal distension after the DCBE in the CO(2) group compared to the control group (P < 0.001). The abdominal discomfort score at 30 minutes after CO(2) correlated with the residual gas in the small intestine (r = 0.390,P = 0.003) but not in the colon (r = 0.155, P = 0.15). The quality of the images and the number of polyps detected did not differ between two groups. CONCLUSIONS: We concluded that using CO(2) when administering a DCBE after a screening sigmoidoscopy was useful for relieving abdominal discomfort following the examination; furthermore, it did not impair the diagnostic ability of the DCBE.

Abdominal Pain↗
PubMed2002

[Colonoscopy and sigmoidoscopy in patients aged eighty years or older].

BACKGROUND: The demographic development will lead to an increase in endoscopic examinations in elderly patients. Indications, feasibility and therapeutic consequences following detection of pathologic findings are important assessing the relevance of endoscopy in geriatric patients. METHODS: We analyzed all colonoscopies and sigmoidoscopies which were performed between January 1995 and December 2000 in patients older than 80 years. The parameters indication, sedation, colonoscopy completion rate, endoscopic findings, therapeutic consequences and complications were evaluated. RESULTS: A total of 951 endoscopies in patients older than 80 years (781 colonoscopies, 170 sigmoidoscopies; mean age 84.3 years) were performed. The most frequent indications were: abdominal pain (n = 144; 15 %), bleeding (n = 115; 12 %), constipation (n = 97; 10 %), anemia (n = 85; 9 %), and history of polyps (n = 78; 8 %). Sedation was used in 183 examinations (19 %), mostly with midazolam (n = 179). Colonoscopy was completed successfully to the coecum in 71 %. 214 examinations were unremarkable (23 %). Frequent pathologic findings were: diverticular disease (n = 396; 42 %), polyps (n = 256; 27 %), and colorectal carcinoma (n = 75; 8 %). Curative surgery was possible in 55 % and palliative surgery in 9 % of patients with colorectal carcinoma, respectively. A complication was observed in six patients (0.6 %), four bleedings following polypectomy, one perforation after dilatation of a stenotic tumor, and one transient neurologic deficit. CONCLUSIONS: Endoscopy of the lower gastrointestinal tract is feasible in geriatric patients with a low rate of complications. The low number of normal findings and the frequent diagnosis of colorectal carcinoma were remarkable. In spite of old age more than half of the patients with carcinoma could be operated curatively emphasizing the importance of endoscopic investigations in this age group.

Age Factors↗
PubMed2003

A prospective randomized trial comparing a virtual reality simulator to bedside teaching for training in sigmoidoscopy.

BACKGROUND AND STUDY AIMS: Clinical investigation using endoscopy simulators is now possible due to recent advances in virtual reality technology. A prospective randomized trial was conducted to compare the exclusive use of a virtual reality endoscopy simulator with bedside teaching for training in sigmoidoscopy. MATERIALS AND METHODS: Internal medicine residents were randomly assigned to training exclusively using a virtual reality simulator (group 1) or via bedside teaching (group 2). Residents were then observed performing five sigmoidoscopic procedures in asymptomatic patients referred for colorectal cancer screening. Endoscopic examinations were evaluated for procedure duration, completion, ability to perform retroflexion, and level of patient comfort/discomfort. Each examination was scored from 1 (inability to insert the endoscope beyond the rectum) to 5 (able to complete the entire examination independently in less than 20 min). RESULTS: Sixty-six sigmoidoscopic examinations were completed by nine residents in group 1 (simulator-trained group) and seven residents in group 2 (traditional teaching group). Participants in group 1 had more difficulty with initial endoscope insertion and negotiation of the rectosigmoid junction (mean score +/- SEM 2.9 +/- 0.2) than those in group 2 (3.8 +/- 0.2) ( P < 0.001). The splenic flexure was reached independently in 10 of 34 examinations (29 %) in group 1, compared with 23 of 32 examinations (72 %) in group 2 ( P = 0.001). Retroflexion was successfully performed by 19 of 34 (56 %) in group 1 compared to 27 of 32 (84 %) in group 2 ( P = 0.02). The average procedure time, patient satisfaction, and discomfort associated with the procedure did not differ statistically between the two groups. CONCLUSIONS: The use of a state-of-the-art virtual reality-based endoscopy simulator is inferior to traditional bedside teaching techniques when used exclusively for training medical residents to perform sigmoidoscopy.

Adult↗
PubMed2006

Flexible sigmoidoscopy performed by nurses.

Flexible sigmoidoscopy by nurses has rapidly become a widely accepted technique for distal colonic investigation. This review explores the issues of training and application of nurse performed flexible sigmoidoscopy, including the limitations, complications and cost issues.

Colorectal Neoplasms↗
PubMed1991

Use of computer graphics simulation for teaching of flexible sigmoidoscopy.

The concept of simulation training in endoscopy is now well-established. The systems currently under development employ either computer graphics simulation or interactive video technology; each has its strengths and weaknesses. A flexible sigmoidoscopy training device has been designed which uses graphic routines--such as object oriented programming and double buffering--in entirely new ways. These programming techniques compensate for the limitations of currently available desk-top microcomputers. By boosting existing computer 'horsepower' with next generation coprocessors and sophisticated graphics tools such as intensity interpolation (Gouraud shading), the realism of computer simulation of flexible sigmoidoscopy is being greatly enhanced. The computer program has teaching and scoring capabilities, making it a truly interactive system. Use has been made of this ability to record, grade and store each trainee encounter in computer memory as part of a multi-center, prospective trial of simulation training being conducted currently in the USA. A new input device, a dummy endoscope, has been designed that allows application of variable resistance to the insertion tube. This greatly enhances tactile feedback, such as resistance during looping. If carefully designed trials show that computer simulation is an attractive and effective training tool, it is expected that this technology will evolve rapidly and be made widely available to trainee endoscopists.

Computer Graphics↗
PubMed1985

Flexible sigmoidoscopy for screening in primary practice. A key to improved survival in colon cancer.

Numerous recommendations have been made in recent years regarding periodic screening for colon disease, specifically cancer. Early detection and treatment are essential for improved survival rates, and patient education is the key to success. Important factors in a screening test are reasonable cost and ease of performance. Testing for fecal occult blood fulfills these requisites but lacks specificity. Digital rectal examination should be done regularly but has limitations. Because flexible fiberoptic sigmoidoscopy has a high acceptance rate, low complication rate, and high yield and is relatively easy to perform, this procedure should be in the diagnostic armamentarium of all primary care physicians. Results of 129 flexible sigmoidoscopies performed by primary care physicians at Scripps Clinic indicate the usefulness of this procedure as a screening test for colon cancer.

Adult↗
PubMed1989

Flexible fiberoptic sigmoidoscopy. Important screening tool for colorectal disorders.

Because of the frequency of colorectal disease and the effectiveness of early intervention in the polyp-cancer sequence, surveillance for this problem should be a routine part of health-maintenance examinations. The general use of flexible sigmoidoscopy in conjunction with fecal occult blood screening is an extremely important part of healthcare delivery. Flexible sigmoidoscopy can easily be learned by most physicians. If use of the procedure becomes widespread, the effects of colorectal disease, in terms of both patient suffering and healthcare costs, can be reduced.

Colonic Diseases↗
PubMedDate not supplied

Performance of flexible sigmoidoscopy by a clinical nurse specialist.

According to the National Cancer Institute, 138,200 new cases and more than 55,000 deaths from colorectal cancer occurred in the U.S. in 1995. A high percentage of early cancers can be detected by screening asymptomatic persons older than age 50 with a digital rectal exam, fecal occult blood testing, and sigmoidoscopy. Evidence suggests that a decrease in mortality from colorectal cancer is associated with regular screening by sigmoidoscopy in an average risk population. As the population ages, more persons are eligible for colorectal cancer screening. Physician endoscopists are not available in all areas, and changes in reimbursement rates have caused some to discontinue this service. For these reasons, the Veterans Administration Medical Center in Buffalo, NY, developed a Colorectal Cancer Screening Program managed by a gastroenterology Clinical Nurse Specialist (CNS). Through study and supervision, the CNS has become proficient in the performance of 60-cm flexible sigmoidoscopic techniques and the diagnosis of multiple colon disorders, including sessile and pedunculated polyps, diverticulosis, tumors, hemorrhoids, and other conditions.

Colorectal Neoplasms↗
PubMed1988

Cancellation rates and gas scores for air contrast barium enema immediately after 65-CM flexible sigmoidoscopy. A randomized clinical trial.

A randomized prospective study examined the impact of bowel gas introduced by 65-cm flexible sigmoidoscopy (FS) on the ability to perform air-contrast barium enema (ACBE) on the same day. Seventy-five patients at risk for colorectal cancer were randomly assigned to two groups. Of these, 28 patients in each group completed the protocol. The study group received flexible sigmoidoscopy and air-contrast barium enema on the same day, whereas the control group had their air-contrast barium enema on a different day. Bowel gas observed on an abdominal scout film prior to air-contrast barium enema was quantified on a scale of 1 (excessive gas) to 5 (no gas). The cancellation rate for the air-contrast barium enema was measured in each of the groups. The study group had significantly more bowel gas compared with the control group (p = 0.000003). The air-contrast barium enema cancellation rate was also higher in the study group (36%) than in the control group (14%) (p = 0.06). Greater than 60% of the study group patients were successfully examined. Same-day scheduling would reduce the number of bowel preparations required in the evaluation of patients at risk for colorectal cancer. Although retrospective studies have suggested no impact of same-day FS on ACBE quality, radiologists in this study canceled approximately one-third of scheduled patients due to perceived excessive bowel gas.

Adult↗
PubMed1992

Are tiny polyps important when found on sigmoidoscopy in asymptomatic people?

To determine the occurrence of synchronous large bowel polyps located proximal to the sigmoid, in persons undergoing screening flexible sigmoidoscopy, we examined those who had diminutive polyps (less than or equal to 0.5 cm) as the only finding in the distal colon by further colonoscopy. One hundred one asymptomatic persons (mean age 61 +/- 13 years) had 143 diminutive polyps; a single polyp was found in 76%, and 64% of all polyps were located in the rectum. Thirty (21%) were hyperplastic and 86 (60%) were neoplastic, including 14 with moderate and one with severe dysplasia. The others were inflammatory (five) or unclassified (hot biopsy changes or normal mucosa, 14 polyps), and eight were lost before processing. Colonoscopy revealed that 16 (16%) of the 101 patients had 21 additional polyps proximally, mostly less than 1 cm in diameter. These included one hyperplastic and 18 neoplastic polyps, and two specimens showed hot biopsy changes. Age, histological type, number or location of the index diminutive polyps, were not associated with proximal lesions. We question whether immediate colonoscopy is justified in asymptomatic patients with only diminutive polyps at flexible sigmoidoscopy.

Adult↗
PubMed1999

Flexible sigmoidoscopy by paramedical personnel.

Screening sigmoidoscopy is associated with a 45% to 80% reduction in colorectal cancer mortality. Although less than 50% of eligible Americans have been screened with flexible sigmoidoscopy (FS), the use of this procedure is rising rapidly. By the year 2000, as many as 10 million screening FS per year could be performed. To accommodate the increased demand, many medical centers have trained paramedical personnel (i.e. physician assistants, nurses, and gastroenterology technicians) to perform FS. However, as a result of the paucity of research about this practice, only physicians receive a professional fee for performing screening FS. Many state Boards of Nursing explicitly prohibit registered nurses (RNs) from performing this procedure. This review outlines research about the effectiveness of paramedical endoscopists, medico-legal and reimbursement issues, and outlines a training program in FS for paramedical personnel.

Allied Health Personnel↗
PubMed1991

Flexible sigmoidoscopy screening for asymptomatic colorectal disease in patients with and without inguinal hernia.

Several studies have evaluated the diagnostic value of flexible sigmoidoscopy for screening asymptomatic patients before hernia repair. All have shown a 16% to 28% incidence of neoplastic (malignant or premalignant) lesions. None of these studies compared a similar group of asymptomatic patients without hernia to determine whether the incidence is increased in patients with hernias. We reviewed 87 consecutive cases of male surgical patients without hernia or any anorectal disease who had flexible sigmoidoscopy between June 1986 and December 1989 (group 1) and compared them with a group of hernia patients that we previously reported (group 2). Patients with stool positive for occult blood were excluded from this study. Examinations in both groups were done under the direct supervision of an attending surgeon (W.W., C.S.C., or J.K.). No significant difference was noted between group 1 and group 2 in mean age (mean 65.6 vs 59.7 years), rate of normal findings (68% vs 63%), and incidence of neoplastic lesions (14% vs 22%). All patients tolerated the procedure well, and there were no complications.

Adenoma↗
PubMed2000

Defining the role of fiberoptic sigmoidoscopy in the investigation of patients presenting with bright red rectal bleeding.

OBJECTIVE: This study was done to determine whether sigmoidoscopy could theoretically constitute sufficient investigation for some patients with bright red rectal bleeding. METHODS: One hundred and forty-three patients undergoing investigative colonoscopy for bright red rectal bleeding and whose source of bleeding was identified were studied. The investigation took place in a large urban hospital over an 11-month period. Data obtained included changes in stool pattern, characteristics of the bleeding, lesions identified, and the distance of the lesion from the anus. RESULTS: In patients younger than 55 yr, all serious lesions except for one malignancy in a patient with massive bleeding lay within 60 cm of the anus and theoretically within reach of the fiberoptic sigmoidoscope. The mixing of red blood with stool was commonly due to distal lesions, especially hemorrhoids. CONCLUSIONS: In young persons with bright red rectal bleeding, fiberoptic sigmoidoscopy may prove to constitute appropriate initial investigation.

Adolescent↗
PubMed2000

Education improves colorectal cancer screening by flexible sigmoidoscopy in an inner city population.

OBJECTIVE: The District of Columbia General Hospital has a flexible sigmoidoscopy (FS) colorectal cancer screening program. We noted that this program was underused. The aim of this study was to determine whether education could improve use of a flexible sigmoidoscopy screening program in an inner city population. METHODS: Patients undergoing screening FS 5 months before our educational initiative were compared to patients undergoing screening FS 5 months after implementation. A 1-month period was allowed for implementation. Procedure logs and GI charts were reviewed. RESULTS: A total of 121 patients underwent FS screening during our study period. Of the patients, 97% were African-American; 58% were female; and the average age was 61 yr. A total of 50 patients underwent FS in the pre-education group, and 71 patients underwent FS after implementation of our educational initiative. CONCLUSIONS: Education resulted in a 42% increase in FS screening in this inner city, predominantly African-American population. Larger scale educational initiatives should be conducted to determine whether these benefits can persist and can be improved upon.

Age Factors↗
PubMed2004

A national survey of flexible sigmoidoscopy training in primary care graduate and postgraduate education programs.

OBJECTIVES: Expanding the pool of primary care endoscopists to perform flexible sigmoidoscopy (FS) has been advocated as a strategy for building colorectal cancer screening capacity. The principal aim of this study was to evaluate the availability and structure of FS training among internal medicine (IM), family practice (FP), physician assistant (PA), and nurse practitioner (NP) training programs. METHODS: A postal survey of all accredited IM (n = 445), FP (n = 471), PA (n = 118), and NP (n = 149) training programs nationwide was conducted. The primary outcome was the proportion of programs offering or mandating FS training; and secondary outcomes, if applicable, were the number of participating trainees, the number of required procedures, the availability of instruction in endoscopic biopsy technique, mentors, and barriers. RESULTS: The overall response rate was 63%. Most IM (89%) and FP (99%) programs offered FS training versus only 12% of PA and 0% of NP programs. Family practice programs were more likely to offer training (p < 0.0001), require training (p < 0.0001), and teach biopsy techniques (p < 0.0001); Internal medicine programs were more likely to have minimum requirements (p < 0.0001) and required >/= 25 procedures per trainee (p < 0.0001). Physician assistant programs were less structured and often lacked minimum requirements. CONCLUSIONS: Flexible sigmoidoscopy training is widely available among FP and IM programs but more restricted or nonexistent among PA and NP programs. The lack of minimum standards for ensuring competency highlights the need for a standardized credentialing process.

Clinical Competence↗
PubMed1981

Flexible sigmoidoscopy in outpatients with suspected colonic disease.

One hundred and fifteen patients attending a gastroenterology clinic were investigated by flexible sigmoidoscopy as outpatients. There were asked to fast before the examination and give a high-volume enema and sedated before the examination. A standard long colonoscope was used rather than the 60-cm sigmoidoscope, which limits the distance that can be examined and forces the operator to work very close to the patient. Preparation was considered good in 95 patients and 49 were examined as far as the hepatic flexure or beyond. Sixty-one patients were found to have lesions of the colon, 25 of them ulcerative colitis, 16 a poly, and nine carcinoma. Despite the fact that these patients were selected (some of them had already had ulcerative colitis diagnosed), flexible sigmoidoscopy proved to be a valuable initial outpatient investigation. The proximal colon was well visualised in 46 patients and a subsequent barium enema was considered unnecessary. There were no complications and the procedure seemed to be well tolerated.

Ambulatory Care↗