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Whitlock EP, Lin J, Liles E, et al. Screening for Colorectal Cancer: An Updated Systematic Review [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Oct. (Evidence Syntheses, No. 65.1.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Screening for Colorectal Cancer: An Updated Systematic Review [Internet].

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Appendix E. Study Details. KQ3a Harms of colonoscopy and flexible sigmoidoscopy

Colonoscopy. We found 16 fair-to-good quality studies that evaluated clinically significant adverse events from colonoscopy conducted in predominantly asymptomatic persons (see Appendix E Table 1). Study details for the four trials that included colonoscopy as followup procedures for flexible sigmoidoscopy are discussed in the following section. 6, 82, 173, 175

Kim and colleagues conducted a fair-quality prospective cohort study (n=3163) examining colonoscopies performed in a predominantly average-risk, asymptomatic population through a university medical center in the US. 182 The population mean age was 57 years old, and approximately 56 percent women. All procedures were conducted by one of ten experienced gastroenterologists. The authors reviewed all significant adverse events, defined as those requiring hospital admission and/or medical or surgical treatment. In the published manuscript, they reported only complications of perforations. The authors reported seven (0.2 percent) perforations, four of which required surgical repair.

Ko and colleagues reported their findings in a recent abstract from a fair-quality prospective cohort study (n=18,271) in the US evaluating the incidence of serious complications from screening and surveillance colonoscopy in persons enrolled through the Clinical Outcomes Research Initiative (CORI). 177 Additional information was obtained through personal communication with the study investigators. 183 This study was given a fair-quality rating, instead of good quality rating, because full details in manuscript form are not yet available, and the investigators are currently determining if any of those persons lost to follow-up died. Approximately 90 percent of the population was age 50 to 79 years, and 45 percent were women. All procedures were conducted by 89 gastroenterologists at 19 separate practice sites; trainees participated in approximately 10 percent of the procedures. They reported all serious adverse events for persons with followup at 30 days. Their cohort included an additional 3,104 persons at the 7-day followup, who were lost to followup at 30 days. In total, they found 45 (0.25 percent) serious complications, including 4 (0.02 percent) perforations, 25 (0.14 percent) episodes of bleeding requiring hospitalization, five (0.03 percent) cases of diverticulitis requiring hospitalization, and two (0.02 percent) post-polypectomy syndrome. The authors found no deaths in the persons with 30-day followup and are currently determining if any of those persons lost to followup died.

Rathgaber and colleagues conducted a fair-quality retrospective cohort study (n procedures =12,407) looking at all colonoscopies performed between 2002 and 2004 through a large multi-specialty community group practice in the US. 172 The population's mean age was approximately 60 years and 52 percent women. Eight gastroenterologists conducted all procedures. Their main outcome measures were any perforation or bleeding complications within 30 days of colonoscopy. In total, they found 14 (0.11 percent) serious complications, including two (0.02 percent) perforations, 11 (0.09 percent) episodes of bleeding requiring hospitalization, and one (0.008 percent) cerebral vascular accident (CVA).

Levin and colleagues conducted a fair-quality retrospective cohort study (n procedures =16,318) looking at all colonoscopies performed in an asymptomatic population between 1994 and 2002 in a large HMO in the US. 185 The indications for colonoscopy were positive screening test, surveillance, or primary screening. There were a total of 11,083 polypectomies. The population's mean age was approximately 62 years and 40 percent were women. Nearly all procedures were conducted by physician endoscopists. Ninety six percent of these physician endoscopists were gastroenterologists. The study's main outcome measures were serious complications requiring hospitalization and deaths within 30 days of colonoscopy. In total, they found 44 (0.27 percent) serious complications requiring hospitalization, including 15 (0.09 percent) perforations, 15 (0.09 percent) episodes of bleeding, six (0.04 percent) cases of diverticulitis, six (0.04 percent) post-polypectomy syndrome, and two (0.01 percent) other serious complications. They also found a total of 10 deaths. Only one (0.006 percent) death, however, appeared to be directly related to colonoscopy with polypectomy.

Ko and colleagues conducted a fair-quality prospective cohort study (n=502) evaluating colonoscopies performed in an asymptomatic population at a university medical center in the US. 176 The population was age 40 years and older, approximately 58 percent were aged 50 to 59 years and 51 percent were women. Eight gastroenterologists conducted all procedures. The study's outcome measures included both major and minor complications, as well as patient perceptions after colonoscopy. In total, they found eight (1.6 percent) serious complications that they defined as requiring unexpected medical attention, including hospitalization or an emergency department or clinic visit.

Lee and colleagues conducted a fair-quality prospective cohort study (n=1000) looking at colonoscopies performed in an asymptomatic population at a university hospital in Taiwan. 178 The population was age 19 years and older with a mean age of 51 years, and 43 percent women. All procedures were conducted by seven gastroenterologists. The study's main outcome measure was assessment of post procedural abdominal pain. While the authors found three (0.3 percent) persons with severe abdominal pain, it is unclear if these cases required additional medical attention. The authors state that no complications were noted during their study followup, therefore these three cases are not included in the meta-analysis for total serious complications from colonoscopy.

Cotterill and colleagues conducted a fair-quality prospective cohort study (n=324) looking at colonoscopies performed in an asymptomatic population through a rural practice in Canada. 174 The population was age 22 to 80 years and 44 percent were women. Two family practice physicians conducted all procedures. The study's outcome measures included perforation, bleeding requiring hospitalization, and problems related to sedation requiring hospitalization. The study found no serious complications.

Pickhardt and colleagues reported a fair-quality prospective study that was designed to evaluate CT colonography for colorectal cancer screening in an average-risk population in three US medical centers. 136 Colonoscopies (n= 1239) were performed as a reference standard. The population was age 40 to 79 years, with an average age of 58 years old, and 41 percent were women. All colonoscopies were conducted by physician endoscopists, 14 were gastroenterologists and three were colorectal surgeons. While the duration of followup for adverse events is unclear, they found one (0.08 percent) episode of delayed bleeding requiring hospitalization after polypectomy. The authors did not report any other significant adverse events from colonoscopy.

Korman and colleagues conducted a fair quality large retrospective cohort study (n procedures =116,000) looking at all colonoscopies performed in 1999 through 45 endoscopic ambulatory surgery centers in the US. 170 General population characteristics and indications for colonoscopy are not described. All procedures were conducted by 264 gastroenterologists. The study's outcome measure was perforation. The population with complications had a mean age of 70 years and was 73 percent women. In total, they found 37 (0.03 percent) perforations. They did not consider other types of adverse events.

Nelson and colleagues conducted a good quality prospective cohort study (n=3196) evaluating colonoscopies in asymptomatic screening population between 1994 and 1997 at 13 Veteran Administration (VA) medical centers in the US. 179 The population was age 50 to 75 years, with a mean age of 63 years, and only three percent were women. Gastroenterologists conducted all procedures. They reported all major adverse events (i.e. requiring transfusion, hospitalization, surgery, or resulting in death) within 30 days of the colonoscopy. In total, they found 18 (0.56 percent) serious complications, including seven (0.22 percent) episodes of major bleeding, one (0.03 percent) new arrhythmia, four (0.12 percent) myocardial infarction or cerebral vascular accident, four (0.12 percent) other major complication, and one (0.03 percent) death.

Robinson and colleagues reported a fair-quality study that was part of a large randomized controlled trial designed to evaluate FOBT screening on colorectal cancer mortality in an average-risk population in the UK. 181 Persons who were FOBT positive received subsequent colonoscopy or double-contrast barium enema. At recruitment the study population was age 50 to 74 years. Details about endoscopists are not reported. The authors reported the adverse events for colonoscopy (n procedures = 1474) including death within 30 days of the procedure. In total, they found seven (0.47 percent) major complications, including one (0.3 percent) perforation, one (0.07 percent) major bleeding, and one (0.07 percent) snare entrapment. They found no deaths.

Newcomer and colleagues conducted a fair-quality prospective cohort study (n=250) among consecutive employed persons undergoing elective outpatient colonoscopies through a multi-specialty clinic in the US. 180 The population was age 18 to 70 years, with a mean age of 52 years, and 43 percent were women. Details about endoscopists are not reported. The study's main outcome measure was unplanned work absence within 7 days of colonoscopy. While they found 10 (4 percent) persons with unplanned work absence, it is unclear if these cases required additional medical attention. The authors state that no complications were noted during the study's followup period. Therefore these cases are not included in the meta-analysis for total serious complications from colonoscopy.

Flexible sigmoidoscopy. We found eight fair-to-good quality studies that evaluated clinically significant adverse events from flexible sigmoidoscopy for colorectal cancer screening in a general-risk population (see Appendix E Table 1).

Levin and colleagues conducted a fair-quality retrospective cohort study (n procedures =109,534) looking at all flexible sigmoidoscopies performed in an average-risk screening population for colorectal cancer between 1994 and 1996 in a large HMO in the US. 185 The population was age 50 to 79 years, mean age 61 years, and 48 percent were women. All procedures were conducted by gastroenterologists, other physicians, nurses or physician assistants. The study's main outcome measures were complications requiring hospitalization within 4 weeks of the procedure. In total, they found five cardiovascular deaths that may have been attributed to the procedure (0.004 percent) and 24 total complications (0.02 percent). There were only seven were ‘serious’ adverse events (0.006 percent), which included two perforations, two lower GI bleeds requiring transfusion, two diverticulitis, and one unexplained colitis.

Segnan and colleagues reported a fair-quality study that used the baseline results from a large ongoing multi-center randomized controlled trial in Italy to evaluate once-only flexible sigmoidoscopy screening in an average-risk screening population for colorectal cancer. 82 The population was age 55 to 64 years, and 50 percent were women. Gastroenterologists in hospital endoscopy units conducted all procedures. The authors reported the adverse events for the flexible sigmoidoscopies (n procedures = 9911) and followup colonoscopies (n procedures = 775). In total, they found one (0.01 percent) perforation and one (0.01 percent) severe abdominal pain from flexible sigmoidoscopy, and one (0.1 percent) perforation and one (0.1 percent) significant bleed from colonoscopy. They also found 60 (0.6 percent) minor self-limited complications from flexible sigmoidoscopy and 30 (four percent) minor self-limited complications from colonoscopy. These complications included chemical colitis, allergic reaction, mild vagal symptoms, abdominal pain, self-limited bleeding, and two seizures in persons receiving anti-epileptic treatment.

Jain and colleagues conducted a fair-quality retrospective cohort study (n procedures =5017) evaluating all flexible sigmoidoscopies performed in an average-risk screening population for colorectal cancer between 1995 and 2001 at a large HMO in the US. 184 The population was age 50 to 75 years, or greater than 75 years without major medical conditions. Registered gastroenterology nurses conducted all procedures. The authors reported that they found no deaths or complications from perforation, bleeding, or infection. It is unclear if they looked for all serious adverse events, therefore this study is not included in the meta-analysis for total serious complications from flexible sigmoidoscopy.

Wallace and colleagues conducted a fair-quality prospective cohort study (n procedures =3701) looking at flexible sigmoidoscopies performed in an average risk screening population for colorectal cancer between 1995 and 1997 in a large HMO in the US. 186 The population included individuals age 50 years and older, mean age 59 years, and 50 percent were women. Most procedures were conducted by gastroenterologists, and some by trained nonphysician staff (e.g., nurse practitioner and physician assistants). The study's outcome measures included both major and minor complications. They found no major complications, including death, perforation, or bleeding requiring transfusions.

Thiis-Evensen and colleagues reported a fair-quality study that was part of a larger population-based randomized controlled trial in Norway evaluating colorectal cancer screening in an average-risk population. 6 At recruitment, the population was age 50 to 59 years, average age at followup was 67 years, and the population included 50 percent women at baseline and 48 percent were women at followup. The authors reported the adverse events for the baseline and follow-up flexible sigmoidoscopies, n procedures = 446, and follow-up colonoscopies, n procedures = 521. They found no major complications, including perforation or bleeding, except for one person who was briefly hospitalized for “water intoxication,” after bowel preparation.

Kewenter and colleagues reported a fair-quality study that is part of a larger population based randomized controlled trial in Sweden to evaluate colorectal cancer screening in an average-risk population. 175 Persons who were FOBT positive received subsequent endoscopy (either flexible sigmoidoscopy or colonoscopy) or double-contrast barium enema. The population was age 60 to 64 years at recruitment. Details about endoscopists were not reported. The authors reported the adverse events for the flexible sigmoidoscopies (n procedures = 2108) and colonoscopies (n procedures = 190). In 113 cases, colonoscopies were performed for possible adenomas above the sigmoid colon seen on barium enema. They found three (0.14 percent) perforations from flexible sigmoidoscopy, two (1.05 percent) perforations from colonoscopy, and one (0.5 percent) major bleeding from colonoscopy. All perforations and major bleeding episodes were from polypectomies.

Atkin and colleagues reported a fair-quality study that represents the pilot results from a large ongoing multi-center randomized controlled trial in the UK to evaluate once-only flexible sigmoidoscopy screening in an average-risk screening population for colorectal cancer. 173 The population included individuals age 55 to 64 years. Details about endoscopists were not reported. The authors reported the adverse events for flexible sigmoidoscopies (n procedures = 1285) and follow-up colonoscopies (n procedures = 76). While they found a total of 40 bleeding episodes, it is unclear the significance of these episodes (i.e. major versus minor), and if they were from flexible sigmoidoscopy or colonoscopy. They also found three (0.2 percent) other complications from flexible sigmoidoscopy, including myocardial infarction, syncope, and severe diarrhea.

Viiala and colleagues reported a fair-quality study that represents the initial cohort of persons in a prospective cohort study of a community based flexible sigmoidoscopy CRC screening program in Western Australia. 187 The population included individuals age 55 to 64 years. Endoscopists were gastroenterologist, surgeons, or supervised registrars and general practitioners. The authors reported the adverse events for flexible sigmoidoscopies (n procedures = 3402). They found no perforation or significant bleeding during the screening period. It is unclear if they looked for all serious adverse events, therefore this study is not included in the meta-analysis for total serious complications from flexible sigmoidoscopy.

Table 1Evidence table for KQ3A

Study
Quality
Setting/Study DesignScreening test operator characteristicsInclusion/ Exclusion CriteriaPatient CharacteristicsProcedure InformationFollowUpMortalityPerforation or bleedingOther major adverse effectsApplicability
Colonoscopy
Kim 2007 182 Prospective Cohort

Single institution, US

Recruitment through referrals for screening colonoscopy
Operator: 5 gastroenterologists Inclusion: Referral from PCP for CRC screening
Exclusions: Polyp surveillance, history of bowel disorder (e.g., inflammatory bowel disease, the polyposis syndrome, HNPCC)
Age: 57.0 (mean)
% female: 56.
% ethnic origin: NR
SES: NR
% symptomatic: 2
Colonoscopies: 3163
Completion Rate: Unknown
NR NR Perforation
Total: 7/3163 (0.2%)
Polypectomy: NR
4 of the 7 required surgical intervention

Bleeding
Total: NR
Polypectomy: NR
No other adverse effects reportedGood
Ko 2007 177

Fair
Multicenter, enrolled in Clinical Outcomes Research Initiative (CORI), US

Prospective Cohort
Operator: 89 gastroenterologists at 19 different practice sites
Experience: Trainees participated in 10% of procedures
# procedures performed: NR
Inclusion: Age 40+, undergoing colonoscopy at a participating CORI site, average risk screening, surveillance, or evaluation of another abnormal screening test
Exclusion: Recent visible gastrointestinal bleeding, personal history of inflammatory bowel disease, incomplete colonoscopy due to poor bowel preparation
Age:
40–49 years: 5.7%
50–59 years: 37.5%
60–69 years: 31.2%
70–79 years: 20.2%
>=80 years: 5.4%
% female: 45
% ethnic origin:
White: 90.3
AA: 7.6
Asian/PI: 1.4
Hispanic: 1.3
Native American: 0.5
Unknown: 0.3
% symptomatic: 0%
Colonoscopies: 18271

Completion Rate: 100%
30 days Total: NR
Polypectomy: NR
Perforation
Total: 4/18271 (0.02%)
Polypectomy: NR

Bleeding
Total: 25/18271 (0.14%) bleeding requiring hospitalization
Polypectomy: NR
Total:
All serious: 45/18271 (0.25%)
Diverticulitis requiring hospitalization:
5/18271 (0.03%)
Post-polypectomy syndrome: 2/18271 (0.02%)
Good
Levin 2006 171

Fair
Kaiser Permanente, Northern California Region (KPNC), US

Retrospective Cohort
Operator:
Gastroenterologists: 96%
Internists: 2%
Not identified: 2%
Experience: NR
# procedures performed:
80% <150 procedures
Inclusion:
1994 to 2002, age 40+, f/u for positive screening test, surveillance for previous polyp or CRC, primary screening
Exclusion: Symptomatic
Mean Age: 62
% female: 40.3
% ethnic origin: NR
% symptomatic: 0
Colonoscopies: 16318

Completion Rate: 464/16318 (2.8%)

25% missing data on depth of completion
30 days Total: 10/16,318 (0.06%)
Polypectomy: 1/16,318 (0.006%)
Perforation
Total: 15/16318 (0.09%)
Polypectomy: 12/11083 (0.11%)

Bleeding
Total:
Any bleeding: 53/16318 (0.32%)
Serious bleeding: 15/16318 (0.09%)
Polypectomy:
Any bleeding: 53/11083 (0.48%)
Serious bleeding: 15/11083 (0.13%)
Total:
All serious: 44/16,318 (0.2%)
Postpolypectomy syndrome: 6/16318 (0.04%)
Diverticulitis: 6/16,318 (0.04%)
Other serious illness: 2/16,318 (0.01%)
Polypectomy:
All serious: 78/11083 (0.70%)
Postpolypectomy syndrome: 6/11,083 (0.06%)
Diverticulitis: 5/11083 (0.05%)
Other serious illness: 2/11,083 (0.02%)
Good
Cotterill 2005 174

Fair
Rural Ontario, Canada

Prospective Cohort
Operator: 2 FP
Experience: NR
# procedures performed: NR
Inclusion: Age 50–75 average risk, or with a family history of CRC if younger than 50
Exclusion: Life expectancy <10 years, clinical indication for colonoscopy, previous colonoscopy in last 10 years, contraindications to colonoscopy
Age (range): 22–80
% female: 44.1
% ethnic origin: NR
% symptomatic: NR
Colonoscopies: 324 (152 screening)

Completion Rate: 94%
NR Total: NR
Polypectomy: NR
Perforation
Total: 0/152 (0%)

Bleeding
Total: 0/152 (0%)
No other adverse effects reportedGood
Rathgaber 2006 172

Fair
Western Wisconsin; Multi-specialty community group practice

Retrospective Cohort
Operator: 8 Gastroenterologists
Experience: NR
# procedures performed: NR
Inclusion: Included all colonoscopies done from 2002-2004
Exclusion: NR
Age: 59.7
% female: 52.2
% ethnic origin: NR
% symptomatic: NR
Colonoscopies: 12407
Completion Rate: 98.4%
30 days Total: NR
Polypectomy: NR
Perforation
Total: 2/12407 (0.016%)
(perforations in diagnostic colonoscopies)
Polypectomy: 0/5074 (0%)

Bleeding Total :
Any bleeding: 25/12407 (0.20%)
Requiring transfusions: 11/12,407 (0.09%) Polypectomy: 23/5074 (0.46%)
Total: 28/12,407 (0.22%)
Posterior circulation cerebral vascular event:1/12,407 (0.008%)
Polypectomy:
Posterior circulation cerebral vascular event:1/5074 (0.02%)
Fair
Newcomer 1999 180

Fair
Minneapolis, MN;
Large multispecialty clinic

Prospective Cohort
Operator: NR
Experience: NR
# procedures performend: NR
Inclusion: Age 18–70 years, full-time or part-time employed, scheduled to work the following day
Exclusion: Not specified
Age: 52.0
% female: 42.6%
% ethnic origin: NR
% symptomatic: NR
Colonoscopies: 270
(results for 250 reported)
Completion Rate: 98%
7 days Total: 0
Polypectomy: 0
Perforation
Total: 0

Bleeding
Total: 0
Total:
Unplanned work absence: 10/250 (4%)
Fair
Korman 2003 170

Fair
Multiple endoscopic ambulatory surgery centers in US

Retrospective Cohort
Operator: 264 Gastroenterologists
Experience: NR
# procedures performed: NR
Inclusion: All patients with perforation in 1999
Exclusion: Not specified
Only given those with perforation:
Age: 69.4
% female: 73
% ethnic origin: NR
% symptomatic: NR
Colonoscopies: 116000
Completion Rate: NR
NR Total: NR
Polypectomy: NR
Perforation
Total: 37/116000 (0.03%)
Polypectomy: 0

Bleeding
Total: NR
Polypectomy: NR
No other adverse effect reportedFair
Nelson 2002 179

Good
13 VA Medical Centers, US

Prospective Cohort
Operator: Gastro
Experience (range): 1–23
# procedures performed:
Avg p/y 100–750
Inclusion: Age 50–75, from 1994-1997, asymptomatic screening
Exclusion: Symptoms of lower GI disease, rectal bleeding past 6 mo, significant change in bowel habits, abdominal pain, prior colonic disease (including polyps), prior exam w/I 10 yrs, significant medical problems, limited life expectancy, need for special precaution, women of childbearing potential
Mean age: 63.0
% female: 3.2
% ethnic origin: NR
% symptomatic: 0
Colonoscopies: 3196

Completion Rate: 3107/3196 (97.2%)
30 days Total: 1/3196 (.03%)
Polypectomy: NR
Perforation
Total: 0

Bleeding
Total:
Major bleeding requiring hosp, transfusion or surgery: 7/3196 (0.22%)
Minor bleeding: 6/3196 (0.22%)
Polypectomy: 7/1672 (0.42%)
Total:
All serious: 18/3196 (0.56%)
New arrythmia: 1/3196 (0.03%)
MI/CVA: 4/3196 (0.12%)
Other major: 4/3196 (0.12%)
Vasovagal: 188/3196 (5.4%)
Oxygen desat: 141/3196 (4.4%)
Abdominal pain last >2 hr: 24/3196 (0.8%)
Abdominal pain resulting in colo termination: 29/3196 (3.9%)
Good/fair
Ko 2006 176

Fair
Academic medical center, Seattle, WA, US

Prospective Cohort
Operator: 8 endoscopists
Experience: NR
# procedures performed:
200–500 endoscopies in same year as study; trainee participated in 36% of procedures
Inclusion: Age 40+, undergoing colonoscopy for screening, surveillance of polyps, family history of CRC or polyps, evaluation of another abnormal screening test

Exclusion: Recent history of GI bleeding, anemic, IBD
Age: 57.8% aged 50–59
% female: 50.8
% ethnic origin:
white :92.0%
Afr-Amer: 2.6%
Asian/Pac Isl: 3.0%
Oth/mix: 2.4%
Hispanic: 2.2%
%symptomatic: 0
Colonoscopies: 502
470 with followup at both 7 and 30 days;
9 persons with no followup and excluded from analyses
Completion Rate:99%
7 and 30 days Total: NR Perforation
Total: 0

Bleeding
Total:
GI Bleed requiring medical attention:
0–6 days:2/479 (0.4%)
7–30 days:2/493 (0.4%)
Requiring blood transfusion:
0–6 days:1/479 (0.2%)
7–30 days:1/493 (0.2%)
Total:
Hospitalization:
0–6 days: 2/479 (0.4%)
7–30 days: 3/493 (0.6%)
ED:
0–6 days: 2/479 (0.4%)
7–30 days: 1/493 (0.2%)
Good/fair
Robinson 1999 181

Fair
UK

Participants identified through Family Health Service Authority lists and general practice registries, screen positive persons with endoscopic followup

RCT of FOBT
Operator: NR
Experience: NR
# procedures performed: NR
Inclusion: Age 50 to 75; FOBT screen positive

Exclusion: Identified by their doctor as having a serious illness, including CRC, within previous 5 years
Age (range): 50–75
% female: 51.9 invited to complete FOBT
Ethnic origin: NR
% symptomatic: NR
Colonoscopies: 1474
Completion Rate: NR
30 days Total: 0 Perforation
Total: 5/1474 (0.3%)
Polypectomy: NR

Bleeding
Total:
Major GI bleeding: 1/1474 (0.07%)
Polypectomy: NR
Snare Entrapment: 1/1474 (0.07%)Good
Lee 2006 178

Fair
Taiwan, university hospital

Prospective Cohort
Operator: 7 endoscopists
Experience: NR
# procedures performed: >500
Inclusion: Age 19 to 84, consecutive persons, “asymptomatic but susceptible”
Exclusion: advanced CRC, diverticulosis, non-IBS related abdominal pain
Age: 51
% female: 43.1
% ethnic origin:
Chinese: 100%
% symptomatic: NR
Colonoscopies: 1000

Completion Rate: 97.6%
24 hours Total: NR Perforation
Total: NR

Bleeding
Total: NR
Severe abdominal pain: 3/1000 (0.3%)Fair
Pickhardt 2003 136

Fair
Multicenter (3), US

Prospective cohort
(comparing CTC)
Operator:
Gastro: 14
Colo Surgeon: 3
Experience: NR
# procedures performed: NR
Inclusion: Age 50 to 79 with average risk of CRC, or 40+ with a family history of CRC, 2002-2003
Exclusion: FOBT positive; iron deficiency anemia; rectal bleeding; unintentional weight loss; previous CT colonography or barium enema; personal history of adenomatous polyps, CRC, IBD; history of FAP or HNPC; rejection for CT colonography; medical condition precluding NaP prep; pregnancy
Age: 57.8
% female: 41.0
% ethnic origin: NR
% symptomatic: 0
Colonoscopies: 1239

Completion Rate: 99.4%
NR Total: NR Perforation
Total: NR

Bleeding
Total: 1/1239 (0.08%)
Polypectomy: 1 with unknown denominator
No other adverse effect reportedGood
Flexible Sigmoidoscopy
Levin 2002 185

Fair
Kaiser Permanente, Northern CA, US

Retrospective Cohort
Operator: Gastroenterologist, non-Gastroenterologist MD or nurse; gastroenterologists supervise flex sig facilities
Experience: NR
# procedures performed: NR
Inclusion: age 50–79, ‘average’ risk for CRC, with screening flex sig at KP facility in Northern CA between 1994-1996
Exclusion: h/o colorectal polyps, h/o CRC, serious family history, pts with colonoscopy same day as flex sig
Age: 61.0
% female: 48.6
% ethnic origin: NR
% symptomatic: 0
Flex Sig: 109534

Completion Rate: NR
NR Total: 10/109,534 (0.009%)
Cardiovascular deaths 5/109,534 (0.004%)
(remaining 5 appear unrelated to flex sig)
Polypectomy: NR
Perforation
Total: 2/109534 (0.002%) requiring surgery
Polypectomy: NR

Bleeding
Total:
Any bleeding: 11/109534 (0.01%)
Serious bleeding: 2/109534 (0.002%)
Polypectomy: NR
Total:
All complications 24/109,534 (0.02%)
All ‘serious’ complications 7/109,534 (0.06%)
Fever 4/109,534 (0.003%)
Abdominal pain 4/109,534 (0.003%)
GI bleed, no transfusion 9/109,534 (0.008%)
Good
Atkin 1998 173
Fair
22 general practices in UK in two areas (Welwyn Garden City and Leicester)

RCT
Operator: NR
Experience: NR
# procedures performed: NR
Inclusion: Age 55–64 years, asymptomatic screening population
Exclusion: CRC, IBD, colorectal endoscopy within past 2 years, or severe illness
Age(Range): 55–64
% female: NR
% ethnic origin: NR
% symptomatic: NR
Flex Sig: 1285
Followup colonoscopies: 76

Completion Rates: NR
1 day Total: 0 Perforation
Total: NR

Bleeding
Total: 40/1285 (3.1%)
Polypectomy: 14/288 (4.9%)
Total:
MI: 1/1,285 (0.08%)
Vasovagal syncope: 1/1,285 (0.08%)
Diarrhea: 1/1,285 (0.08%)
Fair
Segnan 2002 82
Fair
General practices, Italy

RCT
Operator: Specialist gastroenterologists in hospital endoscopy units
Experience: NR
# procedures performed:
Inclusion: Age 55 to 64 years
Exclusion: history of CRC, history of colorectal polyps, IBD, colorectal endoscopy within 2 years, family history of CRC, or medical condition that would preclude benefit from screening
Age(Range): 55–64
% female: 50.0
% ethnic origin: NR
% symptomatic: NR
Flex Sig: 9911
Followup colonoscopies: 775

Completion Rate:
Flex sig: 119 incomplete
Colonoscopy: 188 incomplete
NR Total: NR
Polypectomy: NR
Perforation
Total:
Flexible Sig: 1/9911(0.01%)
Colonoscopy: 1/775 (0.13%)
Polypectomy: NR

Bleeding
Total:
Flexible Sig: 0/9911(0%)
Colonoscopy: 1/775 (0.13%)
Polypectomy:
Colonoscopy: 1, denominator not reported
Flex sig:
Severe abdominal pain: 1/9911 (0.01%)
Minor self-limited complications: 60/9911 (0.6%)

Colonoscopy:
Minor self-limited complications: 30/775 (4%)
Good/fair
Thiis-Evensen 1999 6

Hoff 2001 188

Fair
Population based, Norway

RCT
Operator: NR
Experience: NR
# procedures performed: NR
Inclusion: age 50 to 59, representing an average risk population, screening
Exclusion: NR
Age:
i: 50–59 (range)
fu: 67 (avg)
% female:
i: 50.0
fu: 47.9
% ethnic origin: NR
SES: NR
% symptomatic:
i: NR
fu: 17.6% IBD or abdominal complaints
Flex Sig: 446
Followup colonoscopies: 521

Completion Rate: NR
14 days Total: 0
Polypectomy: 0
Perforation
Total: 0

Bleeding
Total: 0
1/415 (0.24%) water intoxication due to “over-anxious bowel cleansing” resulting in 24 hour hospital stay.Good/fair
Wallace 1999 186

Fair
HMO, US

Prospective Cohort
Operator:
NP: 1
PA: 2
Gastro: 15
* all trained
Experience: NR
# procedures performed: NR
Inclusion: Age 50 or older, no new lower GI symptoms, no acute cardiopulmonary disease, negative FOBT, no first-degree relative with CRC at 55 or younger, 1995-1997
Exclusion: NR
Age: 59
% female: 50.5
% ethnic origin: NR
% symptomatic: 0
Flex Sig: 3701

Completion Rate: NR
NR Total: 0 Perforation
Total: 0

Bleeding
Total: 0
No other adverse effect reportedGood
Kewenter 1996 175

Fair
Population based, Sweden

RCT for FOBT
Operator: NR
Experience: NR
# of procedures performed: NR
Inclusion: Age 60–64 at the time of recruitment (recruitment was based on year of birth), FOBT positive on initial screen or positive on both initial and re-test FOBT
Exclusion: NR
Age (range): 60–64
% female: NR
% ethnic origin: NR
% symptomatic: NR
Flex Sig: 2108
Followup colonoscopies: 190 113 colonoscopies done for proximal lesions seen on DCBE

Completion Rate: NR
1, 3, and 12 days Total: NR Perforation
Total:
Flexible Sig: 3/2108 (0.14%)
Colonoscopy: 2/190 (1.05%)
Polypectomy:
Flexible Sig: 3/413 (0.7%)
Colonoscopy: 2/113 (1.8%)

Bleeding
Total:
Flexible Sig: 0/2108 (0%)
Colonoscopy: 1/190 (0.5%)
Polypectomy:
Flexible Sig: 0/413 (0%)
Colonoscopy: 1/113 (0.9%)
No other adverse effect reportedFair
Jain 2002 184

Fair
Kaiser Permanente, Hawaii, US

Retrospective Cohort
Operator: Registered GI nurses
Experience: NR
# procedures performed: >50
Inclusion: Age 50 to 75 (or above 75 if no major medical conditions), free of GI symptoms, no first degree relatives with CRC below age 60, not at high risk for CRC, negative FOBT, referral to colorectal screening clinic
Exclusion: NR
Age: >50
% female: NR
% ethnic origin: NR
% symptomatic: 0%
Flex Sig: 5017

Completion Rate: NR
NR Total: 0 Perforation
Total: 0/5017 (0%)

Bleeding
Total: 0/5017 (0%)
Reported no infections, no other adverse effects reportedGood
Viiala 2007 187

Fair
Hospital conducting community based screening program, Australia

Prospective Cohort
Operator: Gastroenterologists, surgeons, or supervised registrars and general practitioners
Experience: NR
# of procedures performed: NR
Inclusion: Age 55 to 64, asymptomatic and average-risk for CRC
Exclusion: NR
Age: 60
% female: 41
% ethnic origin: NR
% symptomatic: 0%
Flex Sig: 3402

Completion Rate: NR
NR Total: NR Perforation
Total:
Flexible Sig: 0/3402 (0%)

Bleeding
Total:
Flexible Sig: 0/3402 (0%)
No other adverse effect reportedFair

Table 2. Key question 3A excluded studies

Reference Reason for exclusion

  1. Abaskharoun R, Depew W, Vanner S. Changes in renal function following administration of oral sodium phosphate or polyethylene glycol for colon cleansing before colonoscopy. Can J Gastroenterol. 2007;21:227–231. Excluded for study relevance. [PMC free article: PMC2657697] [PubMed: 17431511]
  2. Ainley E. Hyperphosphataemia after bowel preparation with oral sodium phosphate. Endoscopy. 2006;38(7):759. Excluded for study design. [PubMed: 16810605]
  3. Anderson JC, Pollack BJ, Shaw RD. Virtual colonoscopy. N Engl J Med. 2000;342:738–739. Excluded for study design. [PubMed: 10712123]
  4. Anderson ML, Pasha TM, Leighton JA. Endoscopic perforation of the colon: lessons from a 10-year study. American Journal of Gastroenterology. 2000;95(12):3418–22. Excluded for setting. [PubMed: 11151871]
  5. Araghizadeh FY, Timmcke AE, Opelka FG, Hicks TC, Beck DE. Colonoscopic perforations. Diseases of the Colon & Rectum. 2001;44:713–716. Excluded for setting. [PubMed: 11357034]
  6. Arora A, Singh P. Colonoscopy in patients 80 years of age and older is safe, with high success rate and diagnostic yield. Gastrointestinal Endoscopy. 2004;60(3):408–13. Excluded for population. [PubMed: 15332032]
  7. Aydogan T, Kanbay M, Uz B. et al. Fatal hyperphosphatemia secondary to a phosphosoda bowel preparation in a geriatric patient with normal renal function. Journal of Clinical Gastroenterology. 2006;40(2):177. Excluded for study design. [PubMed: 16394883]
  8. Aziz F, Milman P, McNelis J. Abdominal pain after colonoscopy: can it be acute cholecystitis? Digestive Diseases & Sciences. 2007;52:2660–2661. Excluded for population. [PubMed: 17431770]
  9. Baillie J. Postpolypectomy bleeding. American Journal of Gastroenterology. 2007;102(6):1151–3. Excluded for study design. [PubMed: 17531008]
  10. Barkun A, Chiba N, Enns R et al. Commonly used preparations for colonoscopy: efficacy, tolerability, and safety—a Canadian Association of Gastroenterology position paper. Canadian Journal of Gastroenterology. 2006;699–710. Excluded for study design. [PMC free article: PMC2660825] [PubMed: 17111052]
  11. Basson MD, Etter L, Panzini LA. Rates of colonoscopic perforation in current practice. Gastroenterology. 1998;114:1115. Excluded for study design. [PubMed: 9606100]
  12. Belsey J, Epstein O, Heresbach D. Systematic review: oral bowel preparation for colonoscopy. Alimentary Pharmacology & Therapeutics. 2007;25(4):373–84. Excluded for study relevance. [PubMed: 17269992]
  13. Beyea A, Block C, Schned A. Acute phosphate nephropathy following oral sodium phosphate solution to cleanse the bowel for colonoscopy. American Journal of Kidney Diseases. 2007;50(1):151–4. Excluded for study design. [PubMed: 17591536]
  14. Blondon H, Compan F. Feasibility of colonoscopy without sedation. A retrospective study of 502 procedures. Gastroenterologie Clinique et Biologique. 2006;30(2):328–9. Did not report necessary outcomes. [PubMed: 16565675]
  15. Boenicke L, Maier M, Merger M. et al. Retroperitoneal gas gangrene after colonoscopic polypectomy without bowel perforation in an otherwise healthy individual: report of a case. Langenbecks Arch Surg. 2006;391:157–160. Excluded for study design. [PubMed: 16465554]
  16. Bowles CJ, Leicester R, Romaya C, Swarbrick E, Williams CB, Epstein O. A prospective study of colonoscopy practice in the UK today: are we adequately prepared for national colorectal cancer screening tomorrow? Gut. 2004;53:277–283. Excluded for population. [PMC free article: PMC1774946] [PubMed: 14724164]
  17. Bretthauer M, Thiis-Evensen E, Huppertz-Hauss G. et al. NORCCAP (Norwegian colorectal cancer prevention): a randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflation in colonoscopy. Gut. 2002;50(5):604–7. Excluded for setting. [PMC free article: PMC1773222] [PubMed: 11950803]
  18. Brooker JC, Saunders BP, Shah SG, Williams CB. Endoscopic resection of large sessile colonic polyps by specialist and non-specialist endoscopists. Br J Surg. 2002;89:1020–1024. Excluded for setting. [PubMed: 12153628]
  19. Brynitz S, Kjaergard H, Struckmann J. Perforations from colonoscopy during diagnosis and treatment of polyps. Ann Chir Gynaecol. 1986;75:142–145. Excluded for setting. [PubMed: 3740781]
  20. Cammarota G, Cesaro P, Cazzato A. et al. Hydrogen peroxide-related colitis (previously known as “pseudolipomatosis”): a series of cases occurring in an epidemic pattern. Endoscopy. 2007;39:916–919. Excluded for study relevance. [PubMed: 17674283]
  21. Carl DE, Sica DA. Acute phosphate nephropathy following colonoscopy preparation. Am J Med Sci. 2007;334:151–154. Excluded study design. [PubMed: 17873526]
  22. Church J, Delaney C. Randomized, controlled trial of carbon dioxide insufflation during colonoscopy. Diseases of the Colon & Rectum. 2003;46(3):322–6. Excluded for setting. [PubMed: 12626906]
  23. Clarke GA, Jacobson BC, Hammett RJ, Carr-Locke DL. The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort. Endoscopy. 2001;33:580–584. Excluded for population. [PubMed: 11473328]
  24. Cobb WS, Heniford BT, Sigmon LB. et al. Colonoscopic perforations: incidence, management, and outcomes. Am Surg. 2004;70:750–757. Excluded for setting. [PubMed: 15481289]
  25. Colonoscopes may spread HCV and HPV. AIDS Patient Care & Stds. 2003;17:257–258. Excluded for study design. [PubMed: 12825588]
  26. Conigliaro R, Rossi A. Implementation of sedation guidelines in clinical practice in Italy: results of a prospective longitudinal multicenter study. Endoscopy. 2006;38:1137–1143. Excluded for setting. [PubMed: 17111337]
  27. Dafnis G, Ekbom A, Pahlman L, Blomqvist P. Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden. Gastrointestinal Endoscopy. 2001;54(3):302–9. Excluded for population. [PubMed: 11522969]
  28. de GP, Slagt C, de Graaf JL, Loffeld RJ. Fatal aspiration of polyethylene glycol solution. Netherlands Journal of Medicine. 2006;64(6):196–8. Excluded for setting. [PubMed: 16788218]
  29. de Zwart IM, Griffioen G, Shaw MP, Lamers CB, de Roos A. Barium enema and endoscopy for the detection of colorectal neoplasia: sensitivity, specificity, complications and its determinants. Clin Radiol. 2001;56:401–409. Excluded for study quality. [PubMed: 11384140]
  30. Di LF, Vigano P, Pilati S, Mantovani N, Togliani T, Pulica C. Splenic rupture after colonoscopy. A case report and review of the literature. Chir Ital. 2007;59:755–757. Excluded for study design. [PubMed: 18019651]
  31. DiPrima RE, Barkin JS, Blinder M, Goldberg RI, Phillips RS. Age as a risk factor in colonoscopy: fact versus fiction. Am J Gastroenterol. 1988;83:123–125. Excluded for setting. [PubMed: 3341334]
  32. Dobrowolski S, Dobosz M, Babicki A, Glowacki J, Nalecz A. Blood supply of colorectal polyps correlates with risk of bleeding after colonoscopic polypectomy. Gastrointest Endosc. 2006;63:1004–1009. Excluded for setting. [PubMed: 16733117]
  33. Dominitz JA, Eisen GM, Baron TH. et al. Complications of colonoscopy. Gastrointest Endosc. 2003;57:441–445. Excluded for study design. [PubMed: 12665750]
  34. Doniec JM, Lohnert MS, Schniewind B, Bokelmann F, Kremer B, Grimm H. Endoscopic removal of large colorectal polyps: prevention of unnecessary surgery? Diseases of the Colon & Rectum. 2003;46(3):340–8. Excluded for setting. [PubMed: 12626909]
  35. Eckardt VF, Kanzler G, Schmitt T, Eckardt AJ, Bernhard G. Complications and adverse effects of colonoscopy with selective sedation. Gastrointest Endosc. 1999;49:560–565. Excluded for population. [PubMed: 10228252]
  36. Edwards JK, Norris TE. Colonoscopy in rural communities: can family physicians perform the procedure with safe and efficacious results? Journal of the American Board of Family Practice. 2004;17(5):353–8. Excluded for population. [PubMed: 15355949]
  37. Farley DR, Bannon MP, Zietlow SP, Pemberton JH, Ilstrup DM, Larson DR. Management of colonoscopic perforations. Mayo Clin Proc. 1997;72:729–733. Excluded for setting. [PubMed: 9276600]
  38. Gatto NM, Frucht H, Sundararajan V, Jacobson JS, Grann VR, Neugut AI. Risk of perforation after colonoscopy and sigmoidoscopy: a population-based study. Journal of the National Cancer Institute. 2003;95(3):230–6. Excluded for population. [PubMed: 12569145]
  39. Gedebou TM, Wong RA, Rappaport WD, Jaffe P, Kahsai D, Hunter GC. Clinical presentation and management of iatrogenic colon perforations. Am J Surg. 1996;172:454–457. Excluded for population. [PubMed: 8942543]
  40. Gibbs DH, Opelka FG, Beck DE, Hicks TC, Timmcke AE, Gathright JB Jr. Postpolypectomy colonic hemorrhage. Dis Colon Rectum. 1996;39:806–810. Excluded for setting. [PubMed: 8674375]
  41. Gidwani AL, Makar R, Garrett D, Gilliland R. A prospective randomized single-blind comparison of three methods of bowel preparation for outpatient flexible sigmoidoscopy. Surgical Endoscopy. 2007;21(6):945–9. Excluded for study relevence. [PubMed: 17149552]
  42. Giusti de MM, Sgreccia A, Carmenini E, Morelli S. Infective endocarditis from Enterococcus faecalis complicating colonoscopy in Heyde's syndrome. Postgraduate Medical Journal. 2004;80(948):619–20. Excluded for population. [PMC free article: PMC1743112] [PubMed: 15467002]
  43. Gladman MA, Shami SK. Medical mystery: an unusual complication of colonoscopy—the answer.[comment] N Engl J Med. 2007;357:2309–2310. Excluded for study design. [PubMed: 18046038]
  44. Gonlusen G, Akgun H, Ertan A, Olivero J, Truong LD. Renal failure and nephrocalcinosis associated with oral sodium phosphate bowel cleansing: clinical patterns and renal biopsy findings. Archives of Pathology & Laboratory Medicine. 2006;130(1):101–6. Excluded for study design. [PubMed: 16390223]
  45. Gupta A. Splenic rupture following colonoscopy: rare in the U.K.? Surgeon Journal of the Royal Colleges of Surgeons of Edinburgh & Ireland. 2006;4(6):389. Excluded for study relevance. [PubMed: 17152206]
  46. Hanson JM, Plusa SM, Bennett MK, Browell DA, Cunliffe WJ. Glutaraldehyde as a possible cause of diarrhoea after sigmoidoscopy. British Journal of Surgery. 1998;85(10):1385–7. Excluded for study relevance. [PubMed: 9782020]
  47. Harnik IG. Pyogenic liver abscess presenting after malignant polypectomy. Digestive Diseases & Sciences. 2007;52:3524–3525. Excluded for study design. [PubMed: 17406839]
  48. Heldwein W, Dollhopf M, Rosch T. et al. The Munich Polypectomy Study (MUPS): Prospective Analysis of Complications and Risk Factors in 4000 Colonic Snare Polypectomies. Endoscopy. 2005;37:1116–1122. Excluded for setting. [PubMed: 16281142]
  49. Ho, C., Jacobs, P., Sandha, G., Noorani, H. Z., and Skidmore, B. Non-physicians performing screening flexible sigmoidoscopy: clinical efficacy and cost-effectiveness. 2006. Ottawa: Canadian Coordinating Office for Health Technology Assessment (CCOHTA). Excluded for study relevance.
  50. Hookey LC, Depew WT, Vanner S. The safety profile of oral sodium phosphate for colonic cleansing before colonoscopy in adults. Gastrointest Endosc. 2002;56:895–902. Did not report necessary outcomes. [PubMed: 12447305]
  51. Hookey LC, Depew WT, Vanner SJ. Combined low volume polyethylene glycol solution plus stimulant laxatives versus standard volume polyethylene glycol solution: a prospective, randomized study of colon cleansing before colonoscopy. Canadian Journal of Gastroenterology. 2006;2006:101–5. Excluded for setting. [PMC free article: PMC2538969] [PubMed: 16482236]
  52. Hookey LC, Vanner S. A review of current issues underlying colon cleansing before colonoscopy. Canadian Journal of Gastroenterology. 2007;21(2):105–11. Excluded for study relevence. [PMC free article: PMC2657670] [PubMed: 17299615]
  53. Iqbal CW, Chun YS, Farley DR. Colonoscopic perforations: a retrospective review. J Gastrointest Surg. 2005;9:1229–1235. Excluded for population. [PubMed: 16332478]
  54. Johanson JF, Popp JW Jr, Cohen LB. et al. A randomized, multicenter study comparing the safety and efficacy of sodium phosphate tablets with 2L polyethylene glycol solution plus bisacodyl tablets for colon cleansing. Am J Gastroenterol. 2007;102:2238–2246. Excluded for study design. [PubMed: 17573796]
  55. Johnson C, Mader M, Edwards DM, Vesy T. Splenic rupture following colonoscopy: two cases with CT findings. Emergency Radiology. 2006;13(1):47–9. Excluded for study design. [PubMed: 16915394]
  56. Josemanders DF, Spillenaar Bilgen EJ, van Sorge AA, Wahab PJ, de Vries RA. Colonic explosion during endoscopic polypectomy: avoidable complication or bad luck? Endoscopy. 2006;38:943–944. Excluded for setting. [PubMed: 17019761]
  57. Karajeh MA, Sanders DS, Hurlstone DP. Colonoscopy in elderly people is a safe procedure with a high diagnostic yield: a prospective comparative study of 2000 patients. Endoscopy. 2006;38(3):226–30. Excluded for setting. [PubMed: 16528647]
  58. Kastenberg D, Barish C, Burack H. et al. Tolerability and patient acceptance of sodium phosphate tablets compared with 4-L PEG solution in colon cleansing: combined results of 2 identically designed, randomized, controlled, parallel group, multicenter phase 3 trials. Journal of Clinical Gastroenterology. 2007;41(1):54–61. Excluded for study relevance. [PubMed: 17198066]
  59. Katsinelos P, Kountouras J, Paroutoglou G. et al. Endoloop-assisted polypectomy for large pedunculated colorectal polyps. Surgical Endoscopy. 2006;2006:1257–61. Excluded for setting. [PubMed: 16858525]
  60. Kavic SM, Basson MD. Complications of endoscopy. Am J Surg. 2001;181:319–332. Excluded for study quality. [PubMed: 11438266]
  61. Ker TS, Wasserberg N, Beart RW Jr. Colonoscopic perforation and bleeding of the colon can be treated safely without surgery. Am Surg. 2004;70:922–924. Excluded for setting. [PubMed: 15529852]
  62. Kim HS, Kim TI, Kim WH. et al. Risk factors for immediate postpolypectomy bleeding of the colon: a multicenter study. American Journal of Gastroenterology. 2006;101(6):1333–41. Excluded for setting. [PubMed: 16771958]
  63. Kirby E. Colonoscopy procedures at a small rural hospital. Canadian Journal of Rural Medicine. 2004;9(2):89–93. Excluded for population. [PubMed: 15603681]
  64. Ko CW, Sonnenberg A. Comparing risks and benefits of colorectal cancer screening in elderly patients. Gastroenterology. 2005;129:1163–1170. Excluded for study design. [PubMed: 16230070]
  65. Ladas SD, Karamanolis G, Ben-Soussan E. Colonic gas explosion during therapeutic colonoscopy with electrocautery. World Journal of Gastroenterology. 2007;13:5295–5298. Excluded for study design. [PMC free article: PMC4171316] [PubMed: 17879396]
  66. Lagares-Garcia JA, Kurek S, Collier B. et al. Colonoscopy in octogenarians and older patients. Surgical Endoscopy. 2001;15(3):262–5. Excluded for population. [PubMed: 11344425]
  67. Lambert A, Nguyen SQ, Byrn JC, Fishman EW, Shen HY. Small-bowel perforation after colonoscopy. Gastrointestinal Endoscopy. 2007;65(2):352–3. Excluded for study design. [PubMed: 17137862]
  68. Larsen IK, Grotmol T, Almendingen K, Hoff G. Impact of colorectal cancer screening on future lifestyle choices: a three-year randomized controlled trial. Clinical & Gastroenterology Hepatology. 2007;5(4):477–83. Did not report necessary outcomes. [PubMed: 17363335]
  69. Lee JG, Vigil H, Leung JW. A randomized controlled trial of total colonic decompression after colonoscopy to improve patient comfort. Am J Gastroenterol. 2001;96:95–100. Excluded for setting. [PubMed: 11197295]
  70. Leslie K, Tay T, Neo E. Intravenous fluid to prevent hypotension in patients undergoing elective colonoscopy. Anaesthesia & Intensive Care. 2006;34(3):316–21. Excluded for setting. [PubMed: 16802483]
  71. Levin B, Smith RA, Feldman GE. et al. Promoting early detection tests for colorectal carcinoma and adenomatous polyps: a framework for action: the strategic plan of the National Colorectal Cancer Roundtable. Cancer. 2002;95:1618–1628. Excluded for study relevance. [PubMed: 12365008]
  72. Lo AY, Beaton HL. Selective management of colonoscopic perforations. J Am Coll Surg. 1994;179:333–337. Excluded for setting. [PubMed: 8069431]
  73. Luchtefeld MA, Kim DG. Colonoscopy in the office setting is safe, and financially sound ... for now. Diseases of the Colon & Rectum. 2006;49(3):377–81. discussion 381 –2. Excluded for study quality. [PubMed: 16475034]
  74. Luebke T, Baldus SE, Holscher AH, Monig SP. Splenic rupture: an unusual complication of colonoscopy: case report and review of the literature. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2006;16(5):351–4. Excluded for study design. [PubMed: 17057581]
  75. Luning TH, Keemers-Gels ME, Barendregt WB, Tan AC, Rosman C. Colonoscopic perforations: a review of 30,366 patients. Surg Endosc. 2007;21(6):994–7. Excluded for setting. [PubMed: 17453289]
  76. Macrae FA, Tan KG, Williams CB. Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies. Gut. 1983;24:376–383. Excluded for setting. [PMC free article: PMC1419999] [PubMed: 6601604]
  77. Marin Gabriel JC, Rodriguez MS, de la Cruz BJ. et al. Electrolytic disturbances and colonoscopy: bowel lavage solutions, age and procedure. Revista Espanola de Enfermedades Digestivas. 2003;95(12):863–75. Excluded for setting. [PubMed: 14972007]
  78. Marriott D, Stark D, Harkness J. Veillonella parvula discitis and secondary bacteremia: a rare infection complicating endoscopy and colonoscopy?. [Review] [4 refs] Journal of Clinical Microbiology. 2007;45(2):672–4. Excluded for study design. [PMC free article: PMC1829049] [PubMed: 17108070]
  79. Marwan K, Farmer KC, Varley C, Chapple KS. Pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and subcutaneous emphysema following diagnostic colonoscopy. Annals of the Royal College of Surgeons of England. 2007;89(5):W20–1. Excluded for study design. [PMC free article: PMC2048627] [PubMed: 17688713]
  80. Mathus-Vliegen EM, Kemble UM. A prospective randomized blinded comparison of sodium phosphate and polyethylene glycol-electrolyte solution for safe bowel cleansing. Alimentary Pharmacology & Therapeutics. 2006;23:543–552. Excluded for population. [PubMed: 16441475]
  81. Maule WF. Screening for colorectal cancer by nurse endoscopists. N Engl J Med. 1994;330:183–187. Excluded for setting. [PubMed: 8264742]
  82. McCallion K, Mitchell RM, Wilson RH. et al. Flexible sigmoidoscopy and the changing distribution of colorectal cancer: implications for screening. Gut. 2001;48(4):522–5. Excluded for study design. [PMC free article: PMC1728246] [PubMed: 11247897]
  83. Miles A, Wardle J, Atkin W. Receiving a screen-detected diagnosis of cancer: the experience of participants in the UK flexible sigmoidoscopy trial. Psychooncology. 2003;12:784–802. Excluded for study relevance. [PubMed: 14681952]
  84. Miles A, Wardle J. Adverse psychological outcomes in colorectal cancer screening: does health anxiety play a role? Behav Res Ther. 2006;44:1117–1127. Excluded for setting. [PubMed: 16243291]
  85. Misra T, Lalor E, Fedorak RN. Endoscopic perforation rates at a Canadian university teaching hospital. Canadian Journal of Gastroenterology. 2004;18(4):221–6. Excluded for setting. [PubMed: 15054498]
  86. Mitchell RM, McCallion K, Gardiner K, Collins J, Watson P. Colonoscopy has a high diagnostic yield and low complication rate in older patients. Age & Ageing. 2002;31(4):323–5. Excluded for population. [PubMed: 12147577]
  87. Nagler J, Poppers D, Turetz M. Severe hyponatremia and seizure following a polyethylene glycol-based bowel preparation for colonoscopy. Journal of Clinical Gastroenterology. 2006;40(6):558–9. Excluded for study design. [PubMed: 16825941]
  88. Nelson D. Colonoscopy and polypectomy. Hematology - Oncology Clinics of North America. 2002;16(4):867–74. Excluded for study design. [PubMed: 12418052]
  89. Nelson RL, Abcarian H, Prasad ML. Iatrogenic perforation of the colon and rectum. Dis Colon Rectum. 1982;25:305–308. Excluded for setting. [PubMed: 7083975]
  90. Nivatvongs S. Complications in colonoscopic polypectomy: lessons to learn from an experience with 1576 polyps. Am Surg. 1988;54:61–63. Excluded for setting. [PubMed: 3341645]
  91. Palitz AM, Selby JV, Grossman S. et al. The Colon Cancer Prevention Program (CoCaP): rationale, implementation, and preliminary results. HMO Pract. 1997;11:5–12. Did not report necessary outcomes. [PubMed: 10165556]
  92. Parker MA, Robinson MH, Scholefield JH, Hardcastle JD. Noninvasive colorectal cancer screening. Journal of Medical Screening. 2002;9(1):7–10. Excluded for study relevance. [PubMed: 11943790]
  93. Parra-Blanco A, Kaminaga N, Kojima T, Endo Y, Tajiri A, Fujita R. Colonoscopic polypectomy with cutting current: is it safe? Gastrointest Endosc. 2000;51:676–681. Excluded for setting. [PubMed: 10840299]
  94. Pearl JP, McNally MP, Elster EA, DeNobile JW. Benign pneumoperitoneum after colonoscopy: a prospective pilot study. Mil Med. 2006;171:648–649. Excluded for study relevance. [PubMed: 16895133]
  95. Perez RF, Gonzalez CP, Legaz Huidobro ML. et al. Endoscopic resection of large colorectal polyps. Revista Espanola de Enfermedades Digestivas. 2004;96(1):36–47. Excluded for setting. [PubMed: 14971996]
  96. Pfefferkorn U, Hamel CT, Viehl CT, Marti WR, Oertli D. Haemorrhagic shock caused by splenic rupture following routine colonoscopy. International Journal of Colorectal Disease. 2007;22(5):559–60. Excluded for study design. [PubMed: 15830203]
  97. Qadeer MA, Vargo JJ, Khandwala F, Lopez R, Zuccaro G. Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis. Clin Gastroenterol Hepatol. 2005;3:1049–1056. Excluded for study relevance. [PubMed: 16271333]
  98. Rainis T, Keren D, Goldstein O, Stermer E, Lavy A. Diagnostic yield and safety of colonoscopy in Israeli patients in an open access referral system. Journal of Clinical Gastroenterology. 2007;41(4):394–9. Excluded for population. [PubMed: 17413609]
  99. Rasmussen M, Kronborg O. Upper gastrointestinal cancer in a population based screening program with fecal occult blood test for colorectal cancer summary for patients in. Scand J Gastroenterol. 2002;37:25. Did not report necessary outcomes. [PubMed: 11843044]
  100. Regula J, Rupinski M, Kraszewska E. et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia. New England Journal of Medicine. 2006;355(18):1863–72. Excluded for study quality. [PubMed: 17079760]
  101. Rerknimitr R. Sorbitol can be the cause of colonic explosion.[comment] Endoscopy. 2007;39(3):257. Excluded for study design. [PubMed: 17385112]
  102. Rex DK, Schwartz H, Goldstein M. et al. Safety and colon-cleansing efficacy of a new residue-free formulation of sodium phosphate tablets. American Journal of Gastroenterology. 2006;101(11):2594–604. Excluded for setting. [PubMed: 17029618]
  103. Ristikankare M, Hartikainen J, Heikkinen M, Janatuinen E, Julkunen R. The effects of gender and age on the colonoscopic examination. Journal of Clinical Gastroenterology. 2001;32(1):69–75. Excluded for population. [PubMed: 11154176]
  104. Ristikankare M, Julkunen R, Mattila M. et al. Conscious sedation and cardiorespiratory safety during colonoscopy. Gastrointest Endosc. 2000;52:48–54. Excluded for setting. [PubMed: 10882962]
  105. Rollino C, Tomasini C, Di PR. et al. Cholesterol embolism after colonoscopy: a case report. Gastrointest Endosc. 2006;63:730–732. Excluded for population. [PubMed: 16564892]
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