|Year : 2018 | Volume
| Issue : 1 | Page : 6-9
Cecal intubation time during colonoscopy: Do waist circumference and waist-to-hip ratio play better roles than body mass index?
Adegboyega Akere, Morenike A Osundina
Department of Medicine, College of Medicine, University of Ibadan/University College Hospital, Ibadan, Nigeria
|Date of Web Publication||20-Jun-2018|
Dr. Adegboyega Akere
Department of Medicine, College of Medicine, University of Ibadan/University College Hospital, Ibadan, PMB 5116, Ibadan
Backgroundand Aim: Among the factors that influence cecal intubation time (CIT) are gender, the quality of bowel preparation, age, prior abdominal surgery, constipation, the experience of the endoscopist, body mass index (BMI), the amount of visceral fat, and waist circumference (WC). This study aimed to compare the effects of WC and waist-to-hip ratio (WHR) to that of BMI on CIT.
Patients and Methods: One hundred patients had colonoscopy during the study period. The height and weight of each patient were taken using a stadiometer. BMI was calculated by dividing the weight in kilogram by the square of the height in meter. WC (cm) was measured at a point midway between the subcostal margin and the upper border of the iliac crest. Hip circumference (HC in cm) was measured at the greatest point between the iliac crest and the thighs. WHR was calculated by dividing the WC by the HC.
Results: There were 60 (60%) males and 40 (40%) females. Mean age was 60.0 ± 13.1 years (range 27.0–87.0 years). Mean CIT was 1009.5 ± 410.7 s (range 329.0–2110.0 s). Mean BMI, WC, HC, and WHR were 25.5 ± 5.6, 92.2 ± 13.7 cm, 97.5 ± 11.7 cm, and 0.9 ± 0.1, respectively. Age ≥60 years and BMI ≤24.9 kg/m2 were significantly associated with a prolonged CIT in males. In both genders, WC and WHR were not significantly associated with CIT.
Conclusion: Higher BMI, WC, and WHR were associated with shorter CIT. However, among these parameters, only BMI was found to be significantly associated with CIT in males.
Keywords: Cecal intubation time, colonoscopy, waist circumference, waist-to-hip ratio
|How to cite this article:|
Akere A, Osundina MA. Cecal intubation time during colonoscopy: Do waist circumference and waist-to-hip ratio play better roles than body mass index?. Sub-Saharan Afr J Med 2018;5:6-9
|How to cite this URL:|
Akere A, Osundina MA. Cecal intubation time during colonoscopy: Do waist circumference and waist-to-hip ratio play better roles than body mass index?. Sub-Saharan Afr J Med [serial online] 2018 [cited 2018 Sep 25];5:6-9. Available from: http://www.ssajm.org/text.asp?2018/5/1/6/234757
| Introduction|| |
Colonoscopy is regarded as the gold standard for the diagnosis and treatment of colorectal disorders, as well as one of the recommended modalities for colorectal cancer screening.,,,,, It is said to be complete only when the cecum or ileum is intubated. The quality of colonoscopy determines how effective the procedure is.
Although cecal intubation rate and adenoma detection rate have been considered as quality indicators for colonoscopy,, cecal intubation time (CIT) is considered a measure of difficult colonoscopy.,, CIT varies from one procedure to the other, but experienced colonoscopists have intubated the cecum in 10–20 min.,
Among the factors that influence CIT are gender, the quality of bowel preparation, age, prior abdominal surgery, constipation, the experience of the endoscopist, body mass index (BMI), the amount of visceral fat, and waist circumference (WC).,,,,
Some studies have found that the higher the BMI, the shorter the CIT. This was attributed to the much visceral fat found in participants with high BMI, which tends to support the colon and prevents looping compared to participants with low BMI.,, However, it has been argued that WC is a better measurement of visceral fat than BMI.
This study aimed to compare the effects of WC and waist-to-hip ratio (WHR) to that of BMI on CIT.
| Patients and methods|| |
This study was conducted at the Endoscopy Unit of the University College Hospital, Ibadan, Nigeria. A total of 100 patients had colonoscopy during the study period. Written informed consents were obtained from all the patients prior to the procedure. Patients’ demographic data as well as a history of prior abdominal or pelvic surgery were recorded using a questionnaire. The height and weight of each patient were taken using a stadiometer. The BMI was calculated by dividing the weight in kilogram by the square of the height in meter, and the patients were divided into the following four categories: <18.5, 18.5–24.9, 25–29.9, and ≥30.0 kg/m2 The WC was measured in centimeter (cm) at a point midway between the subcostal margin and the upper border of the iliac crest. The normal values were ≤102 cm for men and ≤88 cm for women.
The hip circumference (HC) was also measured in cm at the greatest point between the iliac crest and the thighs. The WHR was calculated by dividing the WC by the HC. The normal values were ≤0.9 for men and ≤0.8 for women. All the patients had bowel preparation, which consisted of 3 days of liquid diet, bisacodyl tablets, and suppository, as well as oral normal saline 2 L in the morning and evening a day before the procedure, and another 2 L early in the morning on the day of the procedure. Conscious sedation was achieved with intravenous midazolam 2.5–5 mg and pentazocine 15–30 mg.
All the patients gave written informed consent before the procedure. Colonoscopy was performed using an Olympus Exera III Videocolonoscope (CF HQ190L, Olympus, UK and Ireland Essex, UK) by one examiner, whose yearly volume is about 500 procedures. The patients had their vital signs monitored pre-, intra-, and postprocedure with a Multiparameter Monitor (Marathon Z, Health-Care Equipment and Supplies Co. Ltd., UK). CIT was measured from the time of the insertion of the colonoscope into the anal canal to the time when the base of the cecum was intubated (when the appendiceal opening and the ileocecal valve were identified) using the digital clock with seconds on the screen of the videoscope monitor. Bowel preparation was adjudged as poor if there was a significant amount of semisolid/solid feces and good if only a small amount of clear liquid was seen in the colonic lumen. The procedures followed in this study were in accordance with the Helsinki Declaration of 1975, as revised in 2000.
The data were analyzed using the Statistical Product and Service Solutions version 17.0 software (SPSS Inc., Chicago, Illinois, USA). Means were used to express continuous variables, and the means were compared when appropriate. Univariate and gender subgroup analyses were also performed at a significant level of P < 0.05.
| Results|| |
The study comprised 60 (60%) males and 40 (40%) females, giving a male-to-female ratio of 1.5. The mean age of the patients was 60.0 ± 13.1 years (range 27.0–87.0 years). Forty-seven (47%) of the patients were less than 60 years of age, whereas 53 (53%) patients were 60 years and above.
The mean CIT was 1009.5 ± 410.7 s (range 329.0–2110.0 s). The mean BMI, WC, HC, and WHR were 25.5 ± 5.6 (range 13.6–45.9), 92.2 ± 13.7 cm (range 61.0–127.0 cm), 97.5 ± 11.7 cm (range 69.0–131.0 cm), and 0.9 ± 0.1 (range 0.7–1.2), respectively.
The mean CIT in females (1037.1 ± 436.7 s) was higher than in males (991.7 ± 395.9 s), but there was no significant difference between the two groups (P = 0.59). The mean WC in females (95.3 ± 12.9 cm) was higher than that of males (90.1 ± 13.9 cm); however, this difference was not significant as well (P = 0.06). The difference between the mean WHR in males (1.0 ± 0.1) and in females (0.9 ± 0.1) was also not statistically significant (P = 0.09) [Table 1]. An analysis of the categories of BMI showed that 46 (46.0%) of the patients had normal BMI [Figure 1].
With respect to the quality of bowel preparation, 85 (85%) patients had good bowel preparation, while poor bowel preparation was observed in 15 (15%) patients. The mean CIT (992.3 ± 410.0 s) in those with good bowel preparation was shorter compared to those with poor bowel preparation (1103.8 ± 415.6 s). However, there was no significant difference between the two groups (P = 0.34).
A univariate analysis of the factors that predict CIT showed that only age was statistically significant [Table 2]. It showed that age 60 years and above was significantly associated with a prolonged CIT (P = 0.01).
In the subgroup analysis by gender, age and BMI were significantly associated with CIT only in males. It showed that age ≥60 years and BMI ≤ 24.9 kg/m2 were significantly associated with a prolonged CIT in males (P = 0.03 and 0.01, respectively) but not in females (P = 0.27 and 0.56, respectively). In both genders, WC and WHR were not significantly associated with CIT [Table 3].
| Discussion|| |
In this study, the effects of BMI, WC, and WHR on CIT were evaluated. It was found that the lower the BMI, the higher the CIT. This inverse relationship was observed up to a BMI of 29.9 kg/m2. The CIT was observed to increase in those with BMI ≥ 30 kg/m2, but this was still lower than that observed in underweight and those with normal BMI. These observations were, however, not significant in both genders. Nevertheless, a gender subgroup analysis showed a significant inverse relationship between BMI and CIT among male participants.
Studies have found that lower BMI was associated with a prolonged CIT in both genders.,, This has been explained by the fact that participants with lower BMI have a less amount of visceral fat, which may predispose to loop formation during colonoscopy. In a study by Jain et al., an inverse relationship between BMI and CIT was also reported in males, but not among females, as was observed in this study. However, this association was not statistically significant in their study in contrast to this study. The difference in the categories of recruited patients in both studies might account for this.
This gender difference in the relationship between BMI and CIT could be explained by the gender difference in the site of fat accumulation. Women are said to accumulate fat more in the gluteal and femoral regions compared to men, who tend to accumulate fat more in the visceral and abdominal regions. The fact that CIT has been reported to be prolonged in females in some studies,,, including this study, could also explain this observation. Some of the reasons for prolonged CIT in females are longer colon, deeper and rounder pelvis, and less abdominal wall musculature in women compared to men, all of which predispose to looping during colonoscopy.
In this study, both WC and WHR were inversely related to CIT, that is, participants with higher WC and WHR were found to have shorter CIT, but this relationship was not statistically significant. This is in contrast to the finding of Hsieh et al., wherein WC was observed to be significantly associated with CIT and was even found to be a better predictor of cecal intubation compared to BMI.
It has been argued that BMI measures overall obesity index, whereas WC measures abdominal obesity index. Therefore, the latter measures the amount of visceral fat more accurately than the former., Support for the colon is said to be provided by the visceral fat, thereby minimizing loop formation during colonoscopy. However, Chung et al. and Moon et al. did not find any direct correlation between WC and CIT. It was believed that WC seemed not to measure the real volume of the peritoneal cavity. However, Hsieh et al. argued that participants who have less WC tend to have reduced abdominal cavity, giving rise to more acute colonic bends, for which more time will eventually be required to overcome these bends.
| Conclusion|| |
In this study, higher BMI, WC, and WHR were associated with shorter CIT. However, among these parameters, only BMI was found to be significantly associated with CIT in males.
We thank all the nurses and other members of the staff of the endoscopy unit of the University College Hospital, Ibadan for their support and cooperation during the conduct of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Atia MA, Ramirez FC, Gurudu SR. Quality monitoring in colonoscopy: Time to act. World J Gastrointest Endosc 2015;7:328-35.
Allen JI. Quality measures for colonoscopy: Where should we be in2015. Curr Gastroenterol Rep 2015;17:10.
Davila RE, Rajan E, Baron TH, Adler DG, Egan JV, Faigel DO et al.
ASGE guideline: Colorectal cancer screening and surveillance. Gastrointest Endosc 2006;63:546-57.
Anderson JC, Butterly LF. Colonoscopy: Quality indicators. Clin Transl Gastroenterol 2015;6:e77.
Lee TJ, Rees CJ, Blanks RG, Moss SM, Nickerson C, Wright KC et al.
Colonoscopic factors associated with adenoma detection in a national colorectal cancer screening program. Endoscopy 2014;46:203-11.
Ennaifer R, Elleuch N, Sabbagh S, Romdhane H, Hefaiedh R, Ben Nejma H et al.
Quality indicators for colonoscopy in a Tunisian endoscopy unit. Tunis Med 2015;93:138-41.
Imperiale TF, Wagner DR, Lin CY, Larkin GN, Rogge JD, Ransohoff DF. Risk of advanced proximal neoplasms in asymptomatic adults according to the distal colorectal findings. N Engl J Med 2000;343:169-74.
Rex DK, Goodwine BW. Method of colonoscopy in 42 consecutive patients presenting after prior incomplete colonoscopy. Am J Gastroenterol 2002;97:1148-51.
Chung YW, Han DS, Yoo KS, Park CK. Patient factors predictive of pain and difficulty during sedation-free colonoscopy: A prospective study in Korea. Dig Liver Dis 2007;39:872-6.
Takahashi Y, Tanaka H, Kinjo M, Sakumoto K. Prospective evaluation of factors predicting difficulty and pain during sedation-free colonoscopy. Dis Colon Rectum 2005;48:1295-300.
Nelson DB, McQuaid KR, Bond JH, Lieberman DA, Weiss DG, Johnston TK. Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc 2002;55:307-14.
Hsieh YH, Kuo CS, Tseng KC, Lin HJ. Factors that predict cecal insertion time during sedated colonoscopy: The role of waist circumference. J Gastroenterol Hepatol 2008;23:215-7.
Krishnan P, Sofi AA, Dempsey R, Alaradi O, Nawras A. Body mass index predicts cecal insertion time: The higher, the better. Dig Endosc 2012;24:439-42.
Chung GE, Lim SH, Yang SY, Song JH, Kang HY, Kang SJ et al.
Factors that determine prolonged cecal intubation time during colonoscopy: Impact of visceral adipose tissue. Scand J Gastroenterol 2014;49:1261-7.
Nagata N, Sakamoto K, Arai T, Niikura R, Shimbo T, Shinozaki M et al.
Predictors for cecal insertion time: The impact of abdominal visceral fat measured by computed tomography. Dis Colon Rectum 2014;57:1213-9.
Jain D, Goyal A, Uribe J. Obesity and cecal intubation time. Clin Endosc 2016;49:187-90.
Akere A, Otegbayo JA. Complete colonoscopy: Impact of patients’ demographics and anthropometry on caecal intubation time. BMJ Open Gastro 2016;3:e000076. doi:10.1136/bmjgast- 2016-000076.
Anderson JC, Messina CR, Cohn W, Gottfried E, Inqber S, Bernstein G et al.
Factors predictive of difficult colonoscopy. Gastrointest Endosc 2001;54:558-62.
Anderson JC, Gonzalez JD, Messina CR, Pollack BJ. Factors that predict incomplete colonoscopy: Thinner is not always better. Am J Gastroenterol 2000;95:2784-7.
Lean ME, Han TS, Morrison CE. Waist circumference as a measure for indicating need for weight management. BMJ 1995;311:158-61.
Krotkiewski M, Bjorntorp P, Sjostrom L, Smith U. Impact of obesity on metabolism in men and women. Importance of regional adipose tissue distribution. J Clin Invest 1983;72:1150-62.
Cirocco WC, Rusin LC. Factors that predict incomplete colonoscopy. Dis Colon Rectum 1995;38:964-8.
Church JM. Complete colonoscopy: How often? And if not, why not? Am J Gastroenterol 1994;89:556-60.
Saunders BP, Fukumoto M, Halligan S, Jobling C, Moussa ME, Bartram CI et al.
Why is colonoscopy more difficult in women? Gastrointest Endosc 1996;43:124-6.
Waye JD, Bashkoff E. Total colonoscopy: Is it always possible? Gastrointest Endosc 1999;37:152-4.
Moon SY, Kim BC, Sohn DK, Han KS, Kim B, Hong CW et al.
Predictors for difficult cecal insertion in colonoscopy: The impact of obesity indices. World J Gastroenterol 2017;23:2346-54.
[Table 1], [Table 2], [Table 3]