Send letter to journal:
Re: Poor bowel preparation: a poor excuse?

Dear Editor

In the article by Bowles et al,[1] poor bowel preparation is cited as the cause of 19.6% of failures to achieve complete colonoscopy. Similarly high figures of upto 35% have been quoted elsewhere.

In a personal series of 1195 procedures, only 19 of 197 (9.6%) failures were attributed to this cause. This difference is highly significant (p < 0.001).

As choice of laxative agent and population demographics are similar, one could conclude that either Guernsey patients are more compliant with or responsive to bowel preparation or that minimal faecal residue present in a difficult colon is used as a non-operator dependent reason (excuse?) for what is basically a technique failure.

I suspect the same applies to "patient discomfort", which, at 34.7%, is also significantly higher (p < 0.001) than my own figures of 31/197 (15.7%). My typical sedation is 5 mg. midazolam and 10 mg. nalbuphine.

I confess that my usage of these excuses has declined over the years as my success-rate has climbed! It is time to get training and be honest.

Reference

Send letter to journal:
Re: Patients' understanding of colonoscopy risk is sub-optimal

Dear Editor

We read with interest the British Society of Gastroenterology (BSG) lead audit by Bowles et al.[1] into colonoscopy practice within the UK. As part of the audit the authors questioned 1200 patients as to their experience of the procedure. Of the respondents, only 81.5% received written information with only 54.9% recalling information on possible adverse events such as bleeding and perforation. The poor recollection of potential problems is perhaps to be expected if the audit questionnaire was sent to patients sometime after the procedure.

In common with many endoscopy units, we send out an information leaflet with the patients’ appointment details. This explains the preparation required, what to expect on the day and any potential complications; with advice as to what to do, should these complications arise. As there are concerns regarding patients’ understanding of potential complications related to endoscopy, we designed a short questionnaire to determine how much information patients were able to recall from the information leaflet sent to them prior to colonoscopy. This consisted of 4 multi-choice questions with 5 possible answers, of which only one was correct. The correct answers were all in the information leaflet. Patients were requested to complete the questionnaire just prior to discharge, at least one hour after procedure completion; thus minimising the effects of sedation. The questions related to; the risk of perforation; the degree of rectal bleeding that required medical assistance; what to do should a problem arise out of office hours and; the correct means of getting home after receiving sedation.

Thirty three patients completed the colonoscopy questionnaire and of these only 37% answered all four questions correctly. Only 52% of patients remembered correctly the perforation rate from diagnostic colonoscopy, which was stated as 1 in a 1000 in our information leaflet. Worryingly, twelve patients (36%) thought that perforation rates were 10 – 100-fold lower than stated in the information leaflet.

Our study demonstrates that patients fail to fully appreciate the risks of colonoscopy despite the distribution of detailed written information prior to the procedure. This could have medico-legal implications should complications arise and reinforces the need for improved methods of informing patients.

RJ Makins
Barts and The London Hospital NHS Trust
London

AB Ballinger
Homerton University Hospital NHS Trust
Homerton Row
London

DS Rampton
Barts and The London Hospital NHS Trust
London

Reference

1. Bowles CJA, Leicester R, Romaya C, et al. A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut; 53:277-283.