A prospective study of factors that determine cecal intubation time at colonoscopy

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To the Editor:

We read with interest the study by Bernstein et al¹ about factors that determine cecal intubation time at colonoscopy. We appreciate the new insights of this study and want to add some interesting points that we obtained from our quality-management project that tested cecal and ileal valve intubation time.

To optimize our endoscopy organization and procedures, we started a prospective quality-management project testing cecal and ileal valve intubation time as well as factors prolonging the procedure. We included the following factors: age, gender, body mass index (BMI), bowel preparation, endoscopist's experience, quality of sedation, number of births in women, decompensated liver cirrhosis, and surgical history.

Thus far we enrolled 147 patients. No correlation was found between cecal and ileal valve intubation time and age, gender, BMI, bowel preparation, liver cirrhosis, and number of births in women.

Older age and poor bowel preparation were found, not only by Bernstein et al¹ but also by Kim,² to be prolonging factors. The most convincing explanation for the difference with our results is a difference between patient groups. Bowel preparation in our patients was usually satisfactory. It was rated on a scale from 0 (miserable) to 12 (excellent). The median of our patients' score was 8. Also, our population was younger than that of Bernstein et al¹ (median age of our population, 56 years [range, 17-85 years] vs. 69 years [range, 23-91 years]).

Surgical history was not identified as a prolonging or shortening factor for cecal valve intubation time by Bernstein et al.¹ The study by Kim² was divided into 3 groups: previous colorectal resection, previous hysterectomy, and previous abdominal surgery. In his patients, previous colorectal resection was a factor that shortened cecal intubation time. We can support this. In our patients, cecal intubation time was reduced (8 ± 6 minutes [33 patients] vs. 12 ± 10 minutes [132 patients], p = 0.062) in patients with previous colorectal resection. Other surgery did not influence cecal intubation time.

The main study end point was to analyze the factor “endoscopist's experience.” Our mean cecal intubation time was 11 ± 14 minutes. Three endoscopists of different experience were enrolled: one with more than 5 years of experience and more than 1000 colonoscopies (experienced endoscopist [EE]), one with more than 1 year of experience (endoscopist [E]), and one with less than 1 year of experience and approximately 100 colonoscopies (learner [L]). Mean cecal intubation time for EE was 8 ± 4 minutes, for E was 10 ± 5 minutes, and for L was 12 ± 11 minutes. There was a significant difference between EE and L (p = 0014).

A similar correlation was seen between endoscopist's experience and intubation time of the terminal ileum after having reached the cecum (EE, 3 ± 4 minutes; E, 4 ± 2 minutes; L, 12 ± 12 minutes). There was a significant difference between EE and L (p = 0.000) and between E and L (p = 0.003).

A further important point was the sedation of the patients. The quality of sedation was documented by the endoscopist and the nurse with a rating scale from 0 (miserable) to 12 (excellent). The median of our patient's score was 10. A higher quality of sedation was associated with a shorter cecal and ileal valve intubation time. There was a significant correlation between cecal intubation time (p = 0.0027), as well as ileal intubation time (p < 0.001), and the degree of sedation. We consider this important because many endoscopists tend to use minimal sedation, fearing complications in the period after an outpatient colonoscopy and overlooking the advantage of a short examination time, which also adds to patient's comfort.

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References 

1. Bernstein C, Thorn M, Monsees K, et al. A prospective study of factors that determine cecal intubation time at colonoscopy. Gastrointest Endosc. 2005;61:72–75
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2. Kim WH, Cho YJ, Park JY, Min PK, Kang JK, Park IS. Factors affecting insertion time and patient discomfort during colonoscopy. Gastrointest Endosc. 2000;52:600–605
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