A prospective analysis of 13,580 colonoscopies - Reevaluation of credentialing guidelines

Background: The aims of this study were to assess the safety and efficacy o f surgeons performing colonoscopy, and to use the results to reevaluate cur rently available credentialing guidelines. Methods: A prospective outcomes study was designed to include all members o f the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). End points were related to the efficacy and safety of colonoscopy. Credentiali ng guidelines were reviewed. Results: Between April 1998 and September 1999 13,580 colonoscopies were pr ospectively entered into a database. The most common indications were recta l bleeding, colonic polyps, and change in bowel habits. The colonoscopy was normal or revealed only diverticulosis or nonspecific inflammation in 8,47 3 (62.4%), lower gastrointestinal bleeding in 4 (0.03%), polyps in 4,645 (3 4.2%), and tumors in 458 (3.4%) patients. The most common biopsy methods fo r polyps or tumors were the snare (n = 1,728; 34%), the hot (n = 1,600; 31% ), and the cold (n = 1,340; 22%) procedures. The colonoscopy was complete i n 12,495 cases (92%), requiring a mean procedure time of 22.7 min (range, 1 -170 min). Intraprocedural complications included ar rhythmia (n = 14; 0.1% ), bradycardia (n = 115; 0.8%), hypotension (n = 171; 1.2%), and hypoxia (n = 806; 5.6%). Postprocedural complications were seen in 27 patients (0.2%) . Bleeding (n = 10; 0.07%) was managed by observation alone (II = 9; 0.06%) and repeat colonoscopy with transfusion (n = 1; 0.01%). Perforation (n = 1 0; 0.07%) was treated successfully by observation with conservative managem ent(n = 5; 0.05%) and surgery (n = 5; 0.05%); severe abdominal pain (n = 4; 0.03%) was managed by observation and conservative therapy; and bronchospa sm (n = 2; 0.015%) was managed by observation and supportive care. One sing le mortality (0.007%) was that of a 70-year-old man with a massive lower ga strointestinal hemorrhage who had a cardiac arrest in the recovery room fol lowing colonoscopy. The complication rate was not significantly associated statistically with either the level of experience or the number of prior or annual colonoscopies. However, prior colonoscopic experience did have an i mpact on the completion rate (p < 0.001) and was inversely proportional to the time to completion (p < 0.001). Similarly, the number of annual colonos copies affected the completion rate and was inversely correlated with the t ime to completion (p < 0.001). Conclusions: This large prospective outcomes study showed that colonoscopy performed by surgeons can be rapidly and successfully done with acceptably low morbidity and mortality. There was no association between experience an d complications. However, a minimum of 50 prior colonoscopies and 100 annua l colonoscopies were associated with a significant improvement in the rate of completion. There was also a significant correlation between both prior and ongoing annual experience and the time required for the examination. No minimum number of cases can be mandated for credentialing to perform "safe " colonoscopies.