Sub‐10‐minute High‐quality Diagnostic Colonoscopy With Terminal Ileum Intubation in Children Is Feasible and Safe

Abstract

Objectives: To critically appraise ileocolonoscopy practice in a large tertiary center, where ileocolonoscopy is exclusively performed by experienced pediatric colonoscopists, particularly focusing on: indications for the procedure; bowel preparation efficacy; IC completion rates and timings; diagnostic yield; and complications. Patients and methods:We prospectively evaluated all patients referred to our clinic between July 2015 and June 2016. Data on age, height and weight, gender, surgical history, indications for colonoscopy, bowel preparation given, bowel cleansing efficacy were collected. The following were calculated: percentage of terminal ileal intubation; time to terminal ileum; total duration of each procedure. Additionally, we evaluated the number and the type of complications encountered and the number of patients readmitted within 30 days from the elective procedure. Endoscopic diagnostic yield, stratified for indication, was calculated.Results: A total of 1392 patients were referred; 181 required an endoscopic evaluation of the lower GI tract (Outpatient Department conversion rate: 13%). Main indications for IC were: recurrent abdominal pain 38.1%; unexplained chronic diarrhea 16%; suspected IBD 24.9%; isolated rectal bleeding 13.2%; occult GI bleeding 1.6%; unexplained faltering growth 1.6%; IBD restaging 2.6%; miscellaneous 1.6%. Terminal ileum was reached in all the patients (TI intubation rate = 100%). Median time to TI was 9.8 minutes (1 to 50 minutes). Time to TI was lower in younger patients compared to older ones (p = 0.005). Bowel-cleansing was judged as: Grade 1 in 49.2%; Grade 2 in 33.7%; Grade 3 in 13.3%; and Grade 4 in 3.9%. A significant statistical correlation was recorded between bowel-cleansing and time to TI. The positive diagnostic yield was: 11.6% in patients with abdominal pain; 37.9% in patients with chronic diarrhea; 51.1% in patients with suspected IBD; 29.2% in patients with isolated rectal bleeding; 33.3% in patients with occult GI bleeding; 0% in patients with faltering growth; and 33% in the miscellaneous group. Conclusions:In conclusion, appropriately targeted IC in the management of children with GI symptoms, is a safe, fast and useful investigation. TI intubation rates of 100% are achievable and desirable and can be conducted quickly. Poor bowel preparation impacts negatively on this and IC duration may be faster in younger children. High diagnostic yields have been recorded in patients with a clinical suspicion of IBD. Diagnostic yield in isolated recurrent abdominal pain is low. Training to excellence in pediatric IC should be a persistent goal.

Diagnostic Yield Variation with Colonoscopy among Pediatric Endoscopists

“…To our knowledge, variability by individual physicians in diagnostic yield and ileal intubation rate has not been reported in a large pediatric population previously. It is notable that our overall diagnostic yield of 48% is similar with other studies [7][8][9][10][11][12][13]. Manfredi et al [8] examined 390 colonoscopies performed by 26 different clinicians.…”

“…Our group's average ileal intubation rate of 90% compares favorably with other studies which have ranged from 52 to 100% [7,9,10,13,[16][17][18]. The pediatric study reporting a 100% ileal intubation rate involved 6 endoscopists who had > 10 years of experience (mean 19 years) and more than a thousand prior colonoscopies each [13]. The NASGPHAN clinical report on quality improvement in pediatric endoscopy suggests an ileal intubation goal of 90% as a general quality metric [3], though noting that this is often not achieved.…”

“…Abnormal gross findings were present in 218 (56%), whereas 50% had abnormal pathology. In other pediatric studies, the diagnostic yields for colonoscopy ranged from 33 to 64% [9,10,[13][14][15].…”

Colonoscopy Quality Assurance and Maintenance of Competency Among Pediatric Gastroenterology Staff Members: A Canadian Center Experience

“…In addition, there is often a lack of regular nursing and supporting staff after-hours which is likely to contribute to longer procedure times after-hours. It is quite interesting to notice the increase in TI intubation rates in pediatric colonoscopies in the recently published data, suggesting increasing awareness among pediatric gastroenterologists about the need for it (Table 4) [20][21][22][23].…”

Colonoscope “Looping” During Ileo‐Colonoscopy in Children is Significantly Different to that Observed in Adult Practice

“…Several factors have been hypothesized to be associated with a longer procedural time in children, such as less adipose tissue with diminished potential stabilisation of the colon, the increased colonic elasticity in children, and their less developed abdominal musculature, that all might potentially lead to more frequent looping during IC (24,27). Indeed, most difficulties during IC in either age group arise as a result of recurrent, often unpredictable looping of the instrument shaft within the variable colonic anatomy (24,28,29). Available in vivo studies reported a mean colon length at birth of about 50-57 cm, which doubles in length at around two years of life and reaches adult length at around 5 years of life (30)(31)(32)(33)(34)(35)(36)(37).…”