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Background: Bowel preparation represents a significant issue to high-quality colonoscopy. Oral mannitol requires a single dose, is of low volume, and has a pleasant taste and rapid action., Aims: This SATISFACTION study compared single-dose (same day) oral mannitol 100 g/750 mL with standard split-dose PEG-ASC2 L (MoviPrep®)., Methods: The primary endpoint was the proportion of patients with adequate bowel cleansing. Secondary endpoints included efficacy (adenoma detection rate, caecal intubation rate, time of evacuation), safety (intestinal gases concentration, haemato-chemical parameters, adverse events), and patient satisfaction., Results: The study included 703 patients (352 treated with mannitol and 351 with PEG-ASC). Mannitol was not inferior to PEG-ASC for the primary endpoint (91.1 % and 95.5 %, respectively; p-value for the non-inferiority =0.0131). There was no significant difference for secondary efficacy endpoints. The acceptability profile was significantly better in the mannitol group for ease of use, taste, and willingness to reuse (p < 0.0001 for all). The concentration of intestinal gases (H 2 , CH 4 ) was similar between groups and well below those potentially critical., Conclusions: The SATISFACTION study indicated that low-volume, single-dose mannitol may satisfy an unmet clinical need since it was more acceptable to the patient and not inferior to the split-dose PEG-ASC for bowel cleansing efficacy., Competing Interests: Declaration of competing interest AO is an employee of NTC. MC and MM are consultants with NTC. MV and GET received a consultant fee after the study end. The remaining Authors declare that there is no conflict of interest. NTC is developing a bowel cleansing preparation based on mannitol., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The implementation of FIT programs reduces incidence and mortality from CRC in the screened subjects. The ultimate efficacy for CRC morbidity and mortality prevention in a FIT program depends on the colonoscopy in FIT+ subjects that has the task of detecting and removing these advanced lesions. Recently, there has been growing evidence on factors that influence the quality of colonoscopy specifically withing organized FIT programs, prompting to dedicated interventions in order to maximize the benefit/harm ratio of post-FIT colonoscopy. This document focuses on the diagnostic phase of colonoscopy, providing indications on how to standardise colonoscopy in FIT+ subjects, regarding timing of examination, management of antithrombotic therapy, bowel preparation, competence and sedation., Competing Interests: Conflict of Interest None., (Copyright © 2023 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Several scoring systems have been developed for both upper and lower GI bleeding to predict the bleeding severity and discriminate between low-risk patients, who may be suitable for outpatient management, and those who would likely need hospital-based interventions and are at high risk for adverse outcomes. Risk scores created to identify low-risk patients (namely the Glasgow Blatchford Score and the Oakland score) showed very good discriminative performances and their implementation has proven to be effective in reducing hospital admissions and healthcare burden. Conversely, the performances of risk scores in identifying specific adverse events to define high-risk patients are less accurate, and whether their integration into routine clinical practice has a tangible impact on patient management remains unproven. This review describes the existing risk score systems for GI bleeding, emphasizes key research findings, elucidates the circumstances in which their utilization can be beneficial, examines their constraints when considering routine clinical application, and discuss future development., Competing Interests: Declaration of competing interest All the Authors certify that they have NO affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript., (Copyright © 2023. Published by Elsevier Ltd.)

Background: A relevant number of adenomas can be missed during colonoscopy., Aims: Assess the current status of colonoscopy procedures in Italian centers., Methods: A prospective observational study involving 17 hospitals (34 endoscopists) included consecutive patients undergoing standard colonoscopy. In the first phase, endoscopists performed consecutive colonoscopies. In the second phase, retraining via an online learning platform was planned, while in the third phase data were collected analogously to phase 1., Results: A total of 3,504 patients were enrolled. Overall, a BBPS score ≥6 was obtained in 95.6% of cases (94.8% and 96.9% in the pre- and post-training phases, respectively). 88.4% of colonoscopies had a withdrawal time ≥6 min (88.2% and 88.7% in the pre- and post-training phases). Median adenoma detection rate (ADR) was 39.1%, with no significant differences between the pre- and post-training phases (40.1% vs 36.9%; P = 0.83). In total, 81% of endoscopists had a ADR performance above the 25% threshold., Conclusion: High colonoscopy quality standards are achieved by the Italian hospitals involved. Quality improvement initiatives and repeated module-based colonoscopy-training have been promoted in Italy during the last decade, which appear to have had a significant impact on quality colonoscopy metrics together with the activation of colorectal cancer screening programs., Competing Interests: Declaration of Competing Interest None to declare., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Few studies focused on minor adverse events which may develop after colonoscopy., Aims: To investigate the incidence and factors associated to post-colonoscopy symptoms., Methods: This is a prospective study conducted in 10 Italian hospitals. The main outcome was a cumulative score combining 10 gastrointestinal (GI) symptoms occurring the week following colonoscopy. The analyses were conducted via multivariate logistic regression., Results: Of 793 subjects included in the analysis, 361 (45.5%) complained the new onset of at least one GI symptom after the exam; one symptom was reported by 202 (25.5%), two or more symptoms by 159 (20.1%). Newly developed symptoms more frequently reported were epigastric/abdominal bloating (32.2%), pain (17.3%), and dyspeptic symptoms (17.9%). Symptoms were associated with female sex (odds ratio [OR]=2.54), increasing number of symptoms developed during bowel preparation intake (OR=1.35) and somatic symptoms (OR=1.27). An inverse association was observed with better mood (OR=0.74). A high-risk profile was identified, represented by women with bad mood and somatic symptoms (OR=8.81)., Conclusion: About half of the patients develop de novo GI symptoms following colonoscopy. Improving bowel preparation tolerability may reduce the incidence of post-colonoscopy symptoms, especially in more vulnerable patients., Competing Interests: Declaration of Competing Interest AR received consulting fees from ERBE, Fujifilm, Boston Scientific, Norgine, Olympus, Medtronic, Cosmo, EndoStart; payment or honoraria for lectures, presentations, speaker's bureau, manuscript writing or educational events from: Norgine, Boston Scientific, Fujifilm, Medtronic, ERBE, 3D-Matrix. LFu received consulting fees and honoraria for lectures from Norgine and AlfaSigma. All other authors declared no competing interest., (Copyright © 2022 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Symptoms developing during bowel preparation are major concerns among subjects who refuse the procedure., Aims: We aimed to explore the determinants of symptoms occurring during preparation among patients undergoing elective colonoscopy., Methods: This is a prospective multicenter study conducted in 10 Italian hospitals. A multidimensional approach collecting socio-demographic, clinical, psychological and occupational information before colonoscopy through validated instruments was used. Outcome was a four-category cumulative score based on symptoms occurring during preparation, according to the Mayo Clinic Bowel Prep Tolerability Questionnaire, weighted by intensity. Missing values were addressed through multiple imputation. Odds ratios (OR) and 95% confidence intervals (CI) were estimated through multivariate logistic regression models., Results: 1137 subjects were enrolled. Severe symptoms were associated with female sex (OR=3.64, 95%CI 1.94-6.83), heavier working hours (OR=1.13, 95% CI=1.01-1.25), previous gastrointestinal symptoms (OR=7.81, 95% CI 2.36-25.8 for high score), somatic symptoms (OR=2.19, 95% CI=1.06-4.49 for multiple symptoms), day-before regimen (OR=2.71, 95%CI 1.28-5.73). On the other hand, age ≥60 years (OR=0.10, 95% CI 0.02-0.44) and good mood (p=0.042) were protective factors. A high-risk profile was identified, including women with low mood and somatic symptoms (OR=15.5, 95%CI 4.56-52.7)., Conclusions: We identified previously unreported determinants of symptoms burdening bowel preparation and identified a particularly vulnerable phenotype. Symptoms during preparation especially impact heavier working activity., Competing Interests: Conflict of interest AR received consulting fees from ERBE, Fujifilm, Boston Scientific, Norgine, Olympus, Medtronic, Cosmo, EndoStart; payment or honoraria for lectures, presentations, speaker's bureau, manuscript writing or educational events from: Norgine, Boston Scientific, Fujifilm, Medtronic, ERBE, 3D- Matrix. LFu received consulting fees and honoraria for lectures from Norgine and AlfaSigma. All other authors declared no competing interest., (Copyright © 2022 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Failed biliary cannulation still poses a major challenge in patients undergoing Endoscopic Retrograde Cholangiopancreatography (ERCP). To date, there is a lack of data on rates of Difficult Biliary Cannulation (DBC) in patients with distal malignant biliary obstruction (DMBO)., Materials: This was a retrospective study (09/2015 to 02/2019) of consecutive patients with DMBO that underwent ERCP in four Italian centers. The primary outcome was to evaluate the rate of DBC. Secondary outcomes were: cannulation failure, rate of adverse events (AEs), the predictive factors for DBC as well as for AEs., Results: A total of 622 patients with DMBO, were included in the study, with 351(56,4%) matching the definition of DBC. One-hundred and two ERCP-related AEs occurred in 97 of 622 patients (15,6%). Subjects with DBC showed a higher risk for AEs (p = 0.02). The lack of pancreatitis prophylaxis (p = 0.03), diagnosis of cholangiocarcinoma (p = 0.02), the use of papillotomy (OR=1.98; 95%CI = 1.14-3.45) and the combination of two or more techniques for cannulation (OR = 2.88; 95%CI = 1.04-7.97) were associated with the occurrence of AEs., Conclusions: According to the results of this study, patients with DMBO carries a higher rate of DBC thus requiring alternative techniques for biliary drainage. Furthermore, DBC carries a high risk for AEs. Further prospective multicentric studies are needed to confirm these data in this specific subgroup of patients., (Copyright © 2021. Published by Elsevier Ltd.)

Background & Aim: Although acute lower GI bleeding (LGIB) represents a significant healthcare burden, prospective real-life data on management and outcomes are scanty. Present multicentre, prospective cohort study was aimed at evaluating mortality and associated risk factors and at describing patient management., Methods: Adult outpatients acutely admitted for or developing LGIB during hospitalization were consecutively enrolled in 15 high-volume referral centers. Demographics, comorbidities, medications, interventions and outcomes were recorded., Results: Overall 1,198 patients (1060 new admissions;138 inpatients) were included. Most patients were elderly (mean-age 74±15 years), 31% had a Charlson-Comorbidity-Index ≥3, 58% were on antithrombotic therapy. In-hospital mortality (primary outcome) was 3.4% (95%CI 2.5-4.6). At logistic regression analysis, independent predictors of mortality were increasing age, comorbidity, inpatient status, hemodynamic instability at presentation, and ICU-admission. Colonoscopy had a 78.8% diagnostic yield, with significantly higher hemostasis rate when performed within 24-hours than later (21.3% vs.10.8%, p = 0.027). Endoscopic hemostasis was associated with neither in-hospital mortality nor rebleeding. A definite or presumptive source of bleeding was disclosed in 90.4% of investigated patients., Conclusion: Mortality in LGIB patients is mainly related to age and comorbidities. Although early colonoscopy has a relevant diagnostic yield and is associated with higher therapeutic intervention rate, endoscopic hemostasis is not associated with improved clinical outcomes [ClinicalTrial.gov number: NCT04364412]., Competing Interests: Conflict of Interest None declared., (Copyright © 2021 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Colonoscopy demands a considerable amount of resources, and little is known about its diagnostic yield among inpatients., Aims: To assess indications, diagnostic yield and findings of colonoscopy for inpatients, and to identify risk factors for relevant findings and cancer., Methods: Multicentre, prospective, observational study including 12 hospitals. Consecutive adult inpatients undergoing colonoscopy were evaluated from February through November 2019., Results: 1,302 inpatients underwent colonoscopy. Diagnostic yield for relevant findings and cancer was 586 (45%) and 112 (8.6%), respectively. Adequate colon cleansing was achieved in 896 (68.8%) patients. Split-dose/same-day regimen was adopted in 847 (65%) patients. Factors associated to relevant findings were age ≥70 years (RR 1.32), male gender (RR 1.11), blood loss (RR 1.22) and adequate cleansing (RR 1.63). Age ≥70 years (RR 2.08), no previous colonoscopy (RR 2.69) and split-dose/same-day regimen (RR 1.59) significantly increased cancer detection. Implementing adequate cleansing and split-dose/same-day regimen in all patients would increase the diagnostic yield for any relevant findings and cancer from 43% to 70% and from 6% to 10%, respectively., Conclusion: Relevant colorectal diseases and cancer were frequent among inpatients. Factors associated with detection of relevant findings were identified. Adequate colon cleansing and split-dose/same-day regimen significantly increased colonoscopy diagnostic yield., Competing Interests: Declaration of Conflicting Interest The Authors declare that there is no conflict of interest, neither personal nor financial., (Copyright © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Inpatients are at risk for inadequate colon cleansing. Experts recommend 4L-polyethylene-glycol (PEG) solution. A higher colon cleansing adequacy rate for a hyperosmolar 1L-PEG plus ascorbate prep has been recently reported., Aims: We aimed to determine whether 1L-PEG outperforms 4L-PEG among inpatients., Methods: post-hoc analysis of a large Italian multicenter prospective observational study among inpatients (QIPS study). We performed a propensity score matching between 1L-PEG and 4L-PEG group. The primary outcome was the rate of adequate colon cleansing as assessed by unblinded endoscopists through Boston scale. Secondary outcome was the safety profile., Results: Among 1,004 patients undergoing colonoscopy, 724 (72%) were prescribed 4L-PEG and 280 (28%) 1L-PEG. The overall adequate colon cleansing rate was 69.2% (n = 695). We matched 274 pairs of patients with similar distribution of confounders. The rate of patients with adequate colon cleansing was higher in 1L-PEG than in 4L-PEG group (84.3% vs. 77.4%, p = 0.039). No different shift in serum concentration of electrolytes (namely Na + , K + , Ca 2+ ), creatinine and hematocrit were observed for both preparations., Conclusion: We found a higher rate of adequate colon cleansing for colonoscopy with the 1L-PEG bowel prep vs. 4L-PEG, with apparent similar safety profile, among inpatients. A confirmatory randomized trial is needed. (ClinicalTrials.gov no: NCT04310332)., (Copyright © 2020. Published by Elsevier Ltd.)

Direct oral anticoagulants are being increasingly used in patients with non-valvular atrial fibrillation and venous thromboembolism, due to their improved efficacy/ safety ratio, a predictable anticoagulant effect without need for routine coagulation monitoring, and fewer food and drug interactions compared with vitamin K antagonists. Gastrointestinal bleeding remains a serious complication, whose management is challenging for gastroenterologists due to the lack of a standardized clinical approach. Clinical experience on periendoscopic management of these drugs is still limited and there is a paucity of clinical data supporting guidelines recommendations', and this ultimately turns out in different, unsubstantiated and potentially harmful practices of patient management. Present study will provide a thorough revision on the risk of GI bleeding for DOAC therapy and the identification of patient risk factors to individualize treatment. Moreover, the approach to management of DOACs in case of bleeding complications is discussed, and an algorithm of different strategies in presence or not of plasma level measurement is proposed. Finally the periendoscopic management for elective procedures will be reviewed, at the light of the guideline recommendations and new evidences from observational studies., (Copyright © 2020 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

We conducted a survey to investigate to what extent the fear of COVID-19 has influenced the patients decision to undergo or to cancel endoscopic procedures. We collected data from 847 patients from 13 centres. The main indication for endoscopy was anemia, followed by pain and unexplained weight loss. The percentage of not presenters progressively increased throughout the three weeks of study, from 15.1% at the beginning to 48.2% at the end. 37 (34.2%) upper GI endoscopies and 112 (56.3 %) colonoscopies showed an organic cause explaining the symptoms presented by the patients, respectively; 5 cases of gastric cancer (4.6%) and 16 cases of colorectal cancer (CRC) (6.0%), respectively, were detected; during the second week the percentage of organic diseases found at upper endoscopy was 19 (33.3%) with 5 cancer (8.7%), and 61 (49.1% ) at colonoscopy, with 2 CRC (1.6%); finally, during the third week the corresponding figures were 19 (48.7%) for upper GI examinations, with 3 gastric cancers (7.7%), and 43 (60.5%) with 4 (6.5%) CRC cases found.We conclude that patients weighted the fear of having a clinically relevant disease with the fear of becoming infected by coronavirus, and a relevant percentage of them (29.4%) decided not to attend the endoscopy suites at the scheduled date., Competing Interests: Conflict of interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Despite several guidelines on bowel preparation being available, their applicability in Italy is poorly investigated., Aims: (1) To create expert-based recommendations for the Italian setting based on available international guidelines on bowel preparation for colonoscopy; (2) to assess consensus across the Italian endoscopy community., Methods: The study was conducted in 2 phases: (a) statements formulation, (b) assessment of consensus. For the first phase, 6 topics related to bowel preparation were identified: (1) efficacy/tolerability; (2) timing; (3) assessment of quality of bowel preparation; (4) factors associated with inadequate preparation; (5) patient education and (6) impact of organisational factors. For each topic, statements were produced and voted by a panel of experts. For consensus assessment, the invited participants were asked to rate the statements. The statement achieved a good level of agreement when at least 70% of voters agreed with it., Results: 25 statements were agreed in the first phase. Agreement was not achieved by the endoscopy community for 7 statements, mainly concerning practical aspects (i.e. strategies for management of patients with inadequate preparation, organisational factors)., Conclusion: A clinically relevant consensus was achieved on the main topics of bowel preparation, such as the choice of laxative and the time of administration, and it may help to homogenize the colonoscopy practice in Italy. Nevertheless, there are a few country-specific preparation-related issues that need to be addressed., (Copyright © 2018 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: The provision of high-quality colonoscopy can be assessed by evaluating technical aspects of the procedure and, at individual center level, by comparing structural indicators and institutional policies for managing peri-procedural issues with guideline recommendations., Aim: To assess the colonoscopy quality (CQ) in Italy at center level., Methods: Gastroenterologists participating in a nationwide colonoscopy education initiative provided information on structural indicators of their centers and on institutional policies by answering 10 multiple-choice clinical scenarios. Practice variation across centers and compliance with guidelines were analyzed., Results: Data from 282 Italian centers were evaluated. Overall, a significant proportion of centers did not meet CQ standards as concerns endoscopy facilities and equipments (e.g., dedicated recovery room, dirty-to-clean path, reporting software). CQ assurance programs were implemented in only 25% of centers. Concerning peri-procedural issues, main discrepancies with guidelines were recorded in the underuse of split-dose preparation (routinely adopted by 18% of centers), the routine request of coagulation tests prior to colonoscopy (30%), the routine interruption of aspirin for polypectomy (18%), and the adoption of 3-year surveillance for low-risk adenoma (49%)., Conclusions: Present survey shows a significant variation in the CQ of endoscopy centers in Italy on many items of colonoscopy practice that should be targeted for future interventions., (Copyright © 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Colonoscopic polypectomy is effective in reducing the incidence of and mortality from colorectal cancer, but is not complication-free., Aims: To evaluate the incidence of early and delayed polypectomy complications and factors associated with their occurrence in a community setting., Methods: Web-database collection of patients' and polyp's features in consecutive colonic polypectomies during a 3-month period in 18 endoscopy centres., Results: Data on 5178 polypectomies in 2692 patients (54.3% males, mean age 59 years) were collected. The majority of the polyps were <10mm (83.5%). Antithrombotic agents were taken by 22.7% of patients, 57.3% of which withheld them before the procedure. Overall, 5 patients experienced perforations (0.2%) and 114 had bleeding (4.2%); the overall complication rate was 4.4%. Early complications were observed in 87 (3.2%); delayed complications (all major bleedings) occurred in 32 (1.2%). At multivariate analysis polyp size (size >10mm: OR 4.35, 95% CI 5.53-7.48) and, inversely, right-sided location (OR 0.58, 95% CI 0.36-0.94) were correlated with bleeding events. The use of antithrombotics was associated with 5-fold increased risk of delayed bleeding., Conclusions: In the community setting, polypectomy was associated with a 1.4% risk of major complications. Polyp size and, inversely, right-sided location were associated with early bleeding; the use of antithrombotics increased the risk of delayed events., (Copyright © 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Acute gastrointestinal bleeding represents the most common adverse event associated with the use of oral anticoagulant therapy. Due to increasing prescription of anticoagulants worldwide, gastroenterologists are more and more called to deal with bleeding patients taking these medications. Their management is challenging because several issues have to be taken into account, such as the severity of bleeding, the intensity of anticoagulation, the patient's thrombotic risk and endoscopy findings. The recent introduction into the marketplace of new direct oral anticoagulants, for whom specific reversal agents are still lacking, further contributes to make the decision-making process even more demanding. Available evidence on this topic is limited and practice guidelines by gastroenterology societies only marginally address key issues for clinicians, including when and how to reverse coagulopathy, the optimal timing of endoscopy and when and how to resume anticoagulation thereafter. The present paper reviews the evidence in the literature and provides practical algorithms to support clinicians in the management of patients on anticoagulants who present with acute gastrointestinal bleeding., (Copyright © 2015 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: The two-operator technique for colonoscopy, with the endoscopy assistant actively advancing and withdrawing the scope, is still commonly practiced in Europe. As uncontrolled data has suggested that the one-operator technique is associated with a higher adenoma detection rate, we tested the hypothesis that the two-operator-technique can achieve comparable performances in terms of adenoma detection., Methods: Non-inferiority trial in which consecutive adult outpatients were randomised to undergo colonoscopy by one (one-operator) or by four endoscopists. Each performed half the procedures by one-operator and half by two-operator technique independently of routine clinical practice. Main outcome measure was adenoma detection rate., Results: 352 subjects (49% males, mean age 60 ± 12.1 years) were randomised to one (n=176) or to two-operator technique (n=176) colonoscopy. No significant differences were found in adenoma detection (33% vs. 30.7%, p=0.65), or cecal intubation rate, procedure times, and patient tolerability. No differences were found in the subgroup analysis according to routinely adopted colonoscopy technique., Conclusions: This study does not confirm a higher adenoma detection rate for one-operator technique colonoscopy. Changing current practice to improve adenoma detection rate for endoscopists routinely using two-operator technique is not warranted., (Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Hyoscine N-butylbromide (HBB), commonly used during colonoscopy to facilitate cecal intubation, has been proposed to increase the adenoma detection rate (ADR)., Aims: To evaluate whether HBB administration increases the adenoma detection rate and influences patients' tolerance., Methods: Consecutive colonoscopy outpatients were randomized after cecal intubation to receive either 20mg HBB or placebo i.v. The number, size, histology and location of polyps were recorded. The air retained in the abdomen was either indirectly estimated by ΔAC (difference in the abdominal circumference measured before and after colonoscopy) or directly evaluated by patients' perception (visual analogic scale, range 0-100)., Results: 402 patients (44% male; mean age 57.7±12.5years) received either HBB or placebo. No differences in ADR (31.7% vs. 28%, p=0.48), advanced-ADR (7.4% vs. 10.5%, p=0.35) were observed between HBB and placebo group, respectively. A significantly lower detection rate of flat/depressed lesions was observed in the HBB group (0.5% vs. 5.5%, p=0.003). The ΔAC and the bloating perception were comparable between the two groups (p=0.22 and p=0.48, respectively)., Conclusions: HBB administered before colonoscope withdrawal does not increase adenoma detection rate and seems to hamper the visualization of flat/depressed lesions. This finding raises concerns on the indiscriminate use of HBB during colonoscopy., (Copyright © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background/aim: A nation-wide survey of colonoscopy practice carried out in 2004 showed disappointing data on colonoscopy quality in Italy. Present study was aimed prospectively at re-evaluating quality indicators of colonoscopy and their changes over a five-year-period., Methods: The main features of each Endoscopy Unit and performance indicators on consecutive colonoscopies performed in a 2-week period were recorded. Variation of colonoscopy quality was assessed by comparing caecal-intubation and polyp-detection rates in present survey with those collected five-years before; statistical analysis was restricted to centres participating in both data collections., Results: 6158 colonoscopies from 116 centres were evaluated; unadjusted caecal-intubation rate was 83.0%, with 21.6% centres reporting a value >90%; mean polyp-detection rate was 32.0% (range 9.6-71.2% across centres). To assess variation of performance indicators, 4452 procedures from 77 centres were compared to 3589 procedures performed five-years before, in the same centres. A significant difference between the two rounds of data collections was observed for both caecal-intubation (82.6% versus 80.9%, p=0.043) and polyp-detection (31.3% versus 28.1%, p=0.002). However, 52 centres maintained a caecal-intubation rate constantly <90%., Conclusions: Present data show that colonoscopy in Italy is still far below quality standards and that a significant improvement of practice did not occur over the last five years. Strategies to enhance colonoscopy quality should be pursued by professional societies., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Although the adherence to post-polipectomy recommendations is advocated as a quality indicator of colonoscopy programmes, prospective data on actual use of surveillance are lacking., Aim: To evaluate the appropriateness of post-polypectomy surveillance colonoscopy on a community-wide basis and to identify factors associated with it., Methods: Data on consecutive post-polypectomy surveillance examinations performed over a 4-week period in 29 Italian endoscopy units were collected. The time interval between index and surveillance colonoscopy was calculated and compared to guidelines recommendations. Determinants of surveillance timing appropriateness were assessed by logistic step-wise regression., Results: Of 7081 consecutive outpatients, 1218 (17.2%) were referred for post-polypectomy surveillance and 902 were included into the analysis. Surveillance colonoscopy was prescribed correctly in 330 subjects (36.6%) and earlier than recommended by guidelines in 490 (54.3%). Low-risk subjects had an anticipated surveillance colonoscopy more frequently than global cohort (67.4% vs. 54.3%, p<0.001). At multivariate analysis, determinants of correct surveillance timing were high-volume workload centres (OR 1.92; 1.41-2.63 95%CI), centres providing written recommendation on surveillance interval (OR 1.70; 1.18-2.58 95%CI) and surveillance examinations performed within the national screening programme (OR 2.62; 1.92-3.59 95%CI)., Conclusions: In community practice, post-polipectomy surveillance colonoscopy is often performed earlier than recommended, especially in low-risk subjects. Interventions to improve adherence to guidelines and to reduce unnecessary examinations are needed., (Copyright © 2012 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Best strategy of sedation/analgesia in gastrointestinal (GI) endoscopy is still debated., Aims of the Study: To evaluate sedation and monitoring practice among Italian gastroenterologists and to assess their opinion about non-anaesthesiologist propofol administration., Methods: A 19-item survey was mailed to all 1192 members of the Italian Society of Digestive Endoscopy (SIED). For each respondent were recorded demographic data, medical specialty, years of practise and practise setting., Results: A total of 494 SIED members returned questionnaires, representing a response rate of 41.4%. The most employed sedation pattern was benzodiazepines for oesophagogastroduodenoscopies (EGDS) in 50.8% of procedures, benzodiazepines plus opioids for colonoscopy and enteroscopy in 39.5% and 35.3% of procedures, respectively, propofol for endoscopic retrograde colangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in 42.3% and 35.6% of procedures, respectively. With regard to propofol use, 66% respondents stated that propofol was exclusively administered by anaesthesiologists. However, 76.9% respondents would consider non-anaesthesiologist propofol administration after appropriate training. Pulse oximetry is the most employed system for procedural monitoring. Supplemental O(2) is routinely administered by 39.3% respondents., Conclusions: Use of sedation has become a standard practise during GI endoscopy in Italy. Pattern varies for each type of procedure. Pulse oximetry is the most employed system of monitoring. Administration of propofol is still directed by anaesthesiologists., (Copyright © 2011 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: The management of vitamin K antagonists (VKAs) associated coagulopathy is a cornerstone of pre-endoscopic assessment of anticoagulated patients presenting with acute gastrointestinal bleeding., Aims: To evaluate physician attitudes in the management of VKAs-associated coagulopathy in patients presenting with gastrointestinal bleeding and to assess their compliance to current practice guidelines., Design: Cross sectional physician web-based survey amongst regional members of three Italian Gastroenterological Societies (AIGO, SIED, SIGE) practicing in academic medical centres or community hospitals. Physicians were asked to provide management preferences in four hypothetical case-scenarios describing patients with warfarin-associated coagulopathy presenting with gastrointestinal bleeding of varying severity., Results: A total of 105 out of 238 (48%) members responded; mean age±SD: 46.3±9.8 years, 68% male. The adherence to practice guidelines for the reversal of warfarin-induced anticoagulation ranged from 24% to 86% and it was not dependent on age, years and type of specialisation, hospital setting and active performance of "on call" emergency endoscopy or not., Conclusions: There is a considerable variability amongst physicians in the management of gastrointestinal bleeding patients with VKAs-associated coagulopathy and a poor compliance to practice guidelines. These data indicate that better education is needed in this area., (Copyright © 2010 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Background: Examining the current practice is important for the benchmarking of quality of colonoscopy and the comparison with the standards and recommendations expected by professional societies., Aim: To describe colonoscopy practice in Italy, on the basis of prospective analysis of a large number of examinations performed by operators with different levels of expertise in a wide range of unselected centres., Design and Setting: Cross-sectional, prospective and multicentre study., Methods: The main features of each endoscopy centre (structure indicators) were collected through the use of a standardised questionnaire. A second questionnaire was used to prospectively record details of all the consecutive colonoscopies performed in a 2-week study period., Results: Data from 278 centres and 12,835 consecutive colonoscopies were evaluated. Centres were uniformly distributed throughout Italy - north, centre and south - as was their organizational complexity and workload. Overall, adequate facilities (i.e. cleaning area for disinfection/reprocessing, equipped recovery room), and safety equipment (i.e. pulse oximetry, equipment for emergency cardiopulmonary resuscitation) were lacking in a considerable amount of centres, especially in those with a lower degree of organizational complexity. Written informed consent was routinely required in 87% of the centres, but a specific consent for colonoscopy, including detailed information on adverse events, was adopted by 66%. Regular programs for recording some quality indicators (i.e. cecal intubation, quality of bowel cleansing, patients' satisfaction and complications) were implemented in a minority of centres. About 93% of the colonoscopies were performed for diagnostic purpose; screening and surveillance accounted for 13.7% and 25.3% of the indications, respectively. Sedation and/or analgesia was administered in about half of the patients. Overall, colonoscopies were completed to the cecum in 80.7% of cases, and only 22.1% of the centres reported a cecal intubation rate >or=90%; this figure was reported in 33.1% of centres with high-organizational complexity and in 14.4% of outpatient units. The overall incidence of immediate complications was low (2 perforations, 26 bleedings and 32 serious cardiorespiratory complications)., Conclusions: This study documented a wide variation in colonoscopy practice between centres and highlighted problem areas where interventions are needed to improve performance and safety of the examinations.

Various clinical prognostic scoring systems (PSSs) have been suggested as means of selecting high-risk chronic idiopathic myelofibrosis (CIMF) patients at diagnosis. The WHO has recently proposed strict diagnostic criteria for CIMF, and the European consensus for bone marrow fibrosis (BMF) grading recommends 4 classes. It has been suggested that BMF grading may play a prognostic role in CIMF, but it has never been compared with the other PSSs in the same patients. We tested a prognostic model for overall survival (OS) based on the WHO criteria and BMF grading in 113 consecutive patients with chronic myeloproliferative disorders (98 with CIMF and 15 with postpolycythemic myelofibrosis), and compared the findings with those of PSSs. The results showed that our model is significantly associated with different OSs and, unlike the other PSSs, clearly discriminates the OS of intermediate- and high-risk patients.

Rofecoxib is a selective cyclooxygenase-2 inhibitor that has been approved for the treatment of osteoarthritis and management of acute pain. Recent debate has emerged regarding the prothrombotic potential and the cardiovascular safety of this new drug, especially at doses greater than 25mg. We describe two extensively investigated cases of self-limited ischemic colitis in patients who were briefly treated with 50mg rofecoxib daily for acute pain. In both cases, the onset of symptoms correlated temporally with rofecoxib use and symptoms abated with drug discontinuation. There was no evidence of other possible causes of colon ischemia. A causal relationship between the start of rofecoxib treatment and the colon ischemia cannot be definitely established on the basis of the evidence, but the temporal relationship is striking and the pathophysiological rationale could be founded.

Seventy-six consecutive untreated patients with B cell chronic lymphocytic leukemia (B-CLL) and classified according to Binet's staging system were studied at the clinical presentation. Several immunologic parameters (number of total and T circulating lymphocytes and their surface membrane immunoglobulin [Smlg] phenotypes and levels of serum Ig) were evaluated with the aim of identifying a biologic marker of prognostic relevance. In this series of persons, Binet staging confirmed its usefulness as a prognostic index (P less than .001). With regard to Smlg, they were mu-type in 41 cases (53.9%), mu-type plus delta-type in 29 cases (38.2%), alpha-type in one case, and not detectable in five cases. No correlations were found between clinical stage and immunoglobulin phenotype, although all but one patient in stage C showed mu-type Smlg alone. On analyzing the survival curves of our patients according to different Smlg phenotypes, we found that patients with only mu-type Smlg had a poorer prognosis (P less than .05) than those with mu-type plus delta-type; this difference was even more significant (P less than .01) in patients in stage A, whereas there were no statistical differences in those in stages B and C. Because the appearance of surface heavy chain of delta-type could be an expression of cell maturation, these results suggest that in B-CLL the presence of phenotypically more mature leukemic cells may correlate with better clinical prognosis, particularly in the early phase of the disease.