Colonoscopy is the gold standard for colorectal cancer (CRC) screening and success depends on colonoscopy quality. Many factors influence on quality and outcomes in colonoscopy. The relationship between endoscopist specialty and different techniques with colonoscopy quality has not been examined.

AIM:To compare the efficacy of different doses of sodium phosphate (NaP) and polyethylenglicol (PEG) alone or with bisacodyl for colonic cleansing in constipated and non-constipated patients.METHODS:Three hundred and forty-nine patients, older than 18 years old, with low risk for renal damage and who were scheduled for outpatient colonoscopy were randomized to receive one of the following preparations (prep): 90 mL of NaP (prep 1); 45 mL of NaP + 20 mg of bisacodyl (prep 2); 4 L of PEG (prep 3) or 2 L of PEG + 20 mg of bisacodyl (prep 4). Randomization was stratified by constipation. Patients, endoscopists, endoscopists' assistants and data analysts were blinded. A blinding challenge was performed to endoscopist in order to reassure blinding. The primary outcome was the efficacy of colonic cleansing using a previous reported scale. Secondary outcomes were tolerability, compliance, side effects, endoscopist perception about the necessity to repeat the study due to an inadequate colonic preparation and patient overall perceptions.RESULTS:Information about the primary outcome was obtained from 324 patients (93%). There were no significant differences regarding the preparation quality among different groups in the overall analysis. Compliance was higher in the NaP preparations being even higher in half-dose with bisacodyl: 94% (prep 1), 100% (prep 2), 81% (prep 3) and 87% (prep 4) (2 vs 1, 3 and 4, P < 0.01; 1 vs 3, 4, P < 0.05). The combination of bisacodyl with NaP was associated with insomnia (P = 0.04). In non-constipated patients the preparation quality was also similar between different groups, but endoscopist appraisal about the need to repeat the study was more frequent in the half-dose PEG plus bisacodyl than in whole dose NaP preparation: 11% (prep 4) vs 2% (prep 1) (P < 0.05). Compliance in this group was also higher with the NaP preparations: 95% (prep 1), 100% (prep 2) vs 80% (prep 3) (P < 0.05). Bisacodyl was associated with abdominal pain: 13% (prep 1), 31% (prep 2), 21% (prep 3) and 29% (prep 4), (2, 4 vs 1, 2, P < 0.05). In constipated patients the combination of NaP plus bisacodyl presented higher rates of satisfactory colonic cleansing than whole those PEG: 95% (prep 2) vs 66% (prep 3) (P = 0.03). Preparations containing bisacodyl were not associated with adverse effects in constipated patients.CONCLUSION:In non-constipated patients, compliance is higher with NaP preparations, and bisacodyl is related to adverse effects. In constipated patients NaP plus bisacodyl is the most effective preparation.

OBJECTIVE: To determine de incidence of colonic polyps in colonoscopies performed before scheduled and to identifY the clinical and endoscopic features that predicted this finding. METHODS: All patients who underwent at least two complete colonoscopies less than three years apart were retrospectively identified in our computerized database. We excluded patients with high risk of colonic neoplasm requiring a new colonoscopy in less than three years. We analyzed the incidence of polyps before the first and third year after the first study, and the clinical and endoscopic features related to this finding by means of multivariate logistic regression. RESULTS: 378 paired colonoscopies fulfilled criteria, 129 were performed less than one year apart (group 1), and 249 less than three years apart (group 2). Regarding surveillance colonoscopies, 19% of patients presented adenomas and 1.5% high grade dysplasia (HGD) in group 1, and 21% presented adenomas and 2% HGD in group 2. In group 1 fair preparation (P = 0.03), and prolonged colonoscopy (P = 0.02) on the first study were independent predictors to find any polyp on the second study before scheduled. In group 2 fair cleansing (P = 0.04), history of sessile polyps (P = 0.01) and 3 or more polyps in the first study (P = 0.01) were independent predictors to find any polyp, while more than 5 polyps in the first study predicate adenomas. CONCLUSION: During the first year incident polyps related to difficult procedures (missed polyps?) while at 3 years the history of previous polyps was also important.

Klippel-Trénaunay syndrome is a rare congenital vascular disorder characterized by varicose veins, hypertrophy of the soft tissues and bones, and hemangiomas. Although colorectal angiomatosis is uncommon, this association can lead to life-threatening complications because of acute or chronic bleeding. We report a patient with Klippel-Trénaunay syndrome who presented with transfusion-dependent anemia secondary to chronic rectal bleeding. Endoscopy and image studies revealed venous angiomata involving the rectum and distal sigmoid colon. We performed a laparoscopic ultralow anterior resection with intersphincteric dissection, obtaining good results. After a follow-up of 20 months the patient did not present hematochezia and maintained fecal continence.

BACKGROUND:Laparoscopic colectomy can be performed using 2 approaches: lateral or medial. However, it is unknown if one of these techniques provides better results. Thus, the object of the present study is to assess whether one of the approaches has any potential benefits over the other. METHODS:A comparative, retrospective study was performed that included all patients scheduled for left and right laparoscopic colon resection for both neoplastic and benign diseases between June 2000 and June 2006. The following factors were assessed: operation time, recovery variables (bowel sounds, passage of gases, intake of liquids and solids), length of hospital stay, and morbidity and mortality rates. The population was divided into 4 groups: right colectomy using a lateral approach (RL); right colectomy using a medial approach (RM); left colectomy using a lateral approach (LL); and left colectomy using a medial approach (LM). RESULTS:A total of 202 patients were evaluated: RL: 16 (8%); RM: 37 (18.3%); LL: 110 (54.4%); LM: 39(19.3%). No differences in recovery parameters were observed between the right colectomies. However, the presence of bowel sounds and solid intake was significantly earlier in the patients subjected to left colectomies using a medial approach. A tendency toward a higher conversion rate was observed in left colectomies with lateral approach (LL: 18 vs. LM: 1, P=0.052). The operation time was significantly shorter when a medial approach was used for both right and left colectomies (RL: 185.6 min vs. RM: 148.6 min, P=0.009; LL: 205.5 min vs. LM: 139.9 min, P<0.0001). No differences in the morbidity and mortality rates were found between lateral and medial approach in both types of colectomy. CONCLUSIONS:The use of a medial approach in a laparoscopic colectomy provides short-term benefits compared with a lateral approach.

Introduction: An optimal colonic cleansing prior to a videocolonoscopy (VCC) reduces the possible failures in the detection of mucosa lesions and the need to repeat the study. Although a number of papers have been published that assess the safety and efficacy of Polyethilenglicol (PEG) and Sodium Phosphate (NaP), they don't allow us to draw definitive conclusions on which is the best agent. Aim: To compare the tolerance and efficacy of NaP and PEG alone and associated with Bisacodyl for colonic cleansing. Method. 353 patients, older than 18 years old, were randomized to receive one of the following preparations: 90 ml of NaP (group A); 45 ml of NaP + 20 mg of Bisacodyl (group B); 4 liters of PEG (group C) or 2 liters of PEG + 20 mg of Bisacodyl (group D). The allocation of the randomization was councealed. The patients, the doctors who carried out the VCC, the nurses who conducted surveys on tolerance, the secretary who handed out the boxes to the patients and the ones in charge of the statistical analysis were blinded to the allocated preparation. The primary outcome was the necessity to repeat the VCC due to an inadequate preparation. The secondary outcomes were: quality of preparation (measured with a validated scale), tolerance to the preparation and adverse effects. Results. From the 353 patients, 3 were excluded post randomization for not complying with the inclusion criteria, 7 were unable to finish the study due to a sigmoid colon stenosis or fixed angulation, and 19 did not undergo the VCC. Information about the primary outcome was obtained from 323 patients (92%). The primary outcome (necessity to repeat the study due to an inadequate preparation) was similar in all the groups: A 3.5%, B 4.9%, C 7.1%, D 8.1% (p>0.05). There were no significant differences regarding the quality of the preparation either. The compliance was significantly higher in the NaP preparations (A vs C+D p 0.05, B vs C+D p <0.01) being even higher in the association with Bisacodyl (B vs A+C+D p< 0.01). Patients who received preparations with Bisacodyl presented abdominal pain with more frequency, although this was not a significative observation (p>0.05). The combination of NaP and Bisacodyl was associated with insomnia (p 0.039). Conclusion. 90 ml of NaP is more easily completed and equally effective as the rest of the preparations. The combination with Bisacodyl was associated with a higher number of adverse effects.

OBJECTIVE:To determine de incidence of colonic polyps in colonoscopies performed before scheduled and to identifY the clinical and endoscopic features that predicted this finding.METHODS:All patients who underwent at least two complete colonoscopies less than three years apart were retrospectively identified in our computerized database. We excluded patients with high risk of colonic neoplasm requiring a new colonoscopy in less than three years. We analyzed the incidence of polyps before the first and third year after the first study, and the clinical and endoscopic features related to this finding by means of multivariate logistic regression.RESULTS:378 paired colonoscopies fulfilled criteria, 129 were performed less than one year apart (group 1), and 249 less than three years apart (group 2). Regarding surveillance colonoscopies, 19% of patients presented adenomas and 1.5% high grade dysplasia (HGD) in group 1, and 21% presented adenomas and 2% HGD in group 2. In group 1 fair preparation (P = 0.03), and prolonged colonoscopy (P = 0.02) on the first study were independent predictors to find any polyp on the second study before scheduled. In group 2 fair cleansing (P = 0.04), history of sessile polyps (P = 0.01) and 3 or more polyps in the first study (P = 0.01) were independent predictors to find any polyp, while more than 5 polyps in the first study predicate adenomas.CONCLUSION:During the first year incident polyps related to difficult procedures (missed polyps?) while at 3 years the history of previous polyps was also important.

Background: colonic diverticular fistulas are infrequent, and because of this reason, surgeons are not able to gain a great experience with their management objective: to find the best diagnostic and treatment method for the management of the different diverticular fistulas. Setting: Surgical and Coloproctological Departments of the German Hospital from Buenos Aires. Design: retrospective study. Population: 906 patients were operated on for diverticular disease in the last 50 years, and 33 of them had diverticular fistulas and were diagnosed and treated 3.6%. Method: evaluation of the diagnostic and surgical procedures used during the last 50 years. Results: the whole group was successfully treated surgically with low morbidity and without mortality. 19 patients were intended to be treated in 3 stages but 5 of them 26% (3 after transverse colostomy and 2 after sigmoidectomies) refused to continue the surgical treatment and remained with the stoma. Conclusions: it is very important to determine the clinical features in order to suspect such a possibility. After exclusion of a colorectal carcinoma by colonoscopy or barium enema, the following diagnostic methods are advised: CT scan for colovesical fistulas, vaginal examinations and vaginography for colovaginal fistulas, barium enema for coloenteric fistulas and fistulography for colocutaneous fistulas. For their treatment, one stage open or laparoscopic surgery are indicated.