Impact of enhanced bowel preparation on complications and prognosis following colonoscopic polypectomy

Abstract

BACKGROUND

Colonoscopic polypectomy is a crucial procedure for the prevention and treatment of colorectal cancer, with its success and safety largely dependent on the quality of bowel preparation. Currently, polyethylene glycol electrolyte solution remains the standard method for bowel preparation, but its use may cause patient discomfort and incomplete cleansing.

AIM

To evaluate impact of enhanced and conventional bowel preparation protocols on the outcomes of colonoscopic polypectomy.

METHODS

This retrospective cohort study collected data from 130 patients who underwent colonoscopic polypectomy between March 2023 and June 2024. Patients were divided into the conventional bowel preparation group (n = 65) and enhanced bowel preparation group (n = 65). Primary outcome measures included Boston Bowel Preparation Scale (BBPS) scores, procedure-related parameters, complication rates, and prognosis. Statistical analysis was performed using SPSS version 25.0, with P < 0.05 indicating statistical significance.

RESULTS

The enhanced group demonstrated significant advantages over the conventional group, with higher BBPS total scores (4.2 ± 0.7 vs 3.1 ± 0.8, P < 0.001), higher one-time complete resection rates (95.4% vs 83.1%, P = 0.01), shorter operative times (23.1 ± 4.8 vs 25.4 ± 5.2 min, P = 0.03), and lesser intraoperative blood loss (18.2 ± 4.5 vs 20.3 ± 5.1 mL, P = 0.04). Total complication rates were significantly lower (5.9% vs 16.9%, P = 0.05), particularly for bleeding (1.5% vs 16.9%, P = 0.01) and infection (1.5% vs 7.7%, P = 0.04). The enhanced group also showed lower 6-month recurrence rates (3.1% vs 10.8%, P = 0.05) and higher patient satisfaction (87.7% vs 76.9%, P = 0.04) than did the conventional group.

CONCLUSION

The enhanced bowel preparation protocol demonstrates significant advantages, particularly in improving surgical outcomes, reducing complications, and increasing patient satisfaction, underscoring its importance of its application during colonoscopic polypectomy.

Key Words: Colonoscopic polypectomy; Bowel preparation; Complications; Patient satisfaction; Prognosis

Core Tip: This study evaluates the impact of enhanced vs conventional bowel preparation protocols on colonoscopic polypectomy outcomes, highlighting the superior efficacy of the enhanced approach. The findings reveal significant improvements in bowel preparation quality, one-time complete resection rates, operative efficiency, and patient satisfaction, alongside reduced complication rates and lower 6-month recurrence rates. These results underscore the clinical importance of adopting enhanced bowel preparation protocols to optimize surgical outcomes and enhance patient care in colonoscopic polypectomy.

INTRODUCTION

Colonoscopic polypectomy plays a crucial role in the prevention and treatment of colorectal cancer by identifying and removing precancerous polyps. The effectiveness and safety of this procedure are fundamentally dependent on the quality of bowel preparation, which significantly influences colonic mucosa visualization and subsequent polyp detection and removal[1-4].

Inadequate bowel preparation induces several critical challenges during colonoscopic polypectomy. Poor visualization due to inadequate cleansing can result in missed polyps and incomplete resection, potentially triggering the development of colorectal cancer. Furthermore, suboptimal preparation increases procedural complications, including bleeding, perforation, and infection, while also necessitating repeat procedures that exhaust healthcare resources and decrease patient well-being[5-7].

Currently, polyethylene glycol (PEG) electrolyte solutions has been the standard approach for bowel preparation. These non-absorbable, osmotically balanced solutions function by inducing hypotonic diarrhea to cleanse the bowel[8-11]. Despite its widespread use, however, PEG-based preparations have been associated with patient discomfort and occasionally incomplete cleansing. Recent attention has focused on enhancing traditional protocols by adding sodium phosphate (NaP), an osmotic laxative that promotes bowel evacuation by drawing water, into the intestinal lumen[12-15]. Studies have found that the combination of PEG and NaP could be a promising approach for improving bowel cleansing efficacy and reducing procedure-related complications[16,17]. However, there remains a significant gap in our understanding of the comparative effectiveness of combined PEG and NaP protocols vs. conventional PEG-only preparations in colonoscopic polypectomy.

The primary objective of this investigation was to evaluate the impact of these different preparation methods on procedure-related complications and outcomes. The secondary objectives included assessing polyp removal completeness, patient recovery parameters, and recurrence rates. We hypothesized that the enhanced preparation protocol would demonstrate superior bowel cleansing, improved polyp removal rates, reduced complications, and better postoperative outcomes compared to the conventional preparation.

The current research seeks to contribute meaningful evidence for optimizing bowel preparation protocols in colonoscopic polypectomy. Our findings provide valuable guidance for clinical practice, potentially improving procedure safety, effectiveness, and patient outcomes following gastrointestinal endoscopy. By identifying more effective preparation methods, this study aimed to advance the standard of care in the prevention and treatment of colorectal cancer.

MATERIALS AND METHODS

Study design and ethics

This retrospective cohort study collected clinical data from patients who underwent colonoscopic polypectomy at XXXX between March 2023 and June 2024. The study protocol was approved by the hospital ethics committee (approval number pending). Given the retrospective nature of the current study, informed consent was waived.

Study population

Based on the inclusion and exclusion criteria, clinical data from 130 patients were included. Patients were divided into two groups according to their preoperative bowel preparation methods: A conventional bowel preparation group (65 cases) and an enhanced bowel preparation group (65 cases). The inclusion criteria were as follows: Age 18-75 years; colonic polyps confirmed via colonoscopy or imaging; complete clinical data including preoperative examinations, surgical records, and follow-up data; and a follow-up period ≥ 6 months. The exclusion criteria were as follows: Severe cardiac, hepatic, or renal dysfunction; history of inflammatory bowel disease; contraindications to colonoscopy or bowel preparation; incomplete clinical data; and loss to follow-up.

Colonoscopic polypectomy

Two main techniques were used to perform colonoscopic polypectomy based on the polyp characteristics (Figure 1). For elevated (types Ip and Isp) and small (< 2 cm) is lesions, cold or hot snare polypectomy is preferred. During this procedure, maintaining an adequate stalk length or distance from the intestinal wall is crucial. The endoscopist must ensure complete lesion capture while carefully avoiding normal mucosal entrapment. Gentle shaking of the snare helps verify proper tissue capture before resection. For more complex cases, endoscopic mucosal resection is performed. This technique begins by thoroughly evaluating the extent and morphology of the lesions. The procedure involves submucosal injections at the lesion margins using a colonoscopic injection needle. The injection solution, comprising glycerol fructose, epinephrine, and methylene blue, creates a protective cushion. Multiple injections may be necessary to achieve complete mucosal elevation. After removing the injection needle, a snare is inserted to capture the elevated lesion along with a margin of the surrounding normal mucosa. The resection is completed using a high-frequency generator, followed by careful inspection of the resection site for bleeding[18].

Figure 1 The procedure for colonoscopic polypectomy. A: Electronic colonoscopy showing a colonic polyp around 1.8 cm × 1.5 cm in size located on the rectal wall; B: Multiple injections with the solution comprising glycerol fructose, epinephrine, and methylene blue to achieve complete mucosal elevation. C: Using a snare to encircle the base of the polyp, leading to its complete resection; D: Careful rechecking of the wound surface to ensure that no residual tissues remain and that the surface is smooth; E: Using three hemostatic clips to close the wound surface, preventing postoperative bleeding and infection.

Hemostasis management is an essential component of the procedure. Minor bleeding can be controlled by spraying epinephrine–saline solution at the resection site. When additional hemostasis is needed, titanium clips provide an effective alternative. All resected specimens are carefully processed and sent for pathological examination to ensure accurate diagnosis and staging. Postoperative care follows a structured protocol to minimize complications. Patients are closely monitored for potential complications, particularly bleeding and perforation. A strict dietary progression is implemented, beginning with nil by mouth for 6 h post-procedure. On the first postoperative day, patients are started on a warm liquid diet, such as rice soup and noodle soup. From days 2 through 7, patients progress to a liquid and semi-liquid diet, avoiding spicy, irritating, and high-fiber foods that could irritate the healing mucosa[19,20].

Follow-up care is tailored to the specific procedure and findings. For cases involving piecemeal resection, a follow-up colonoscopy is scheduled within 1 month to check for residual tumors. This is particularly important for large colorectal polyps, which carry a higher risk of malignant transformation. When the pathology results indicate malignant transformation, patients are referred for open surgery to ensure complete oncological resection.

Bowel preparation groups

The included patients were divided into two distinct bowel preparation groups: Conventional and enhanced. The conventional group received standard written materials and verbal instructions regarding bowel preparation, whereas the enhanced group participated in interactive education sessions with additional psychological support and guidance, including opportunities to ask questions and address concerns. On the examination day, both groups followed identical check-in procedures at the endoscopy center where initial assessment of bowel preparation adequacy was performed before scheduling the colonoscopy. The basic bowel preparation protocol, comprising a low-residue diet for 3 days before the procedure, followed by clear liquids the day before examination and nil by mouth after 18:00, remained consistent across both groups. All patients were instructed to take PEG electrolyte solution between 19:00 and 20:00 with 2000 mL water and had the option to use simethicone to reduce intestinal gas. The primary distinction between the groups was the educational approach and level of psychological support provided, with the enhanced group receiving more comprehensive guidance to potentially improve preparation compliance and quality.

Observation indicators

This study employed comprehensive observation indicators to evaluate the effectiveness of different bowel preparation methods. The primary outcome measure included bowel cleansing quality assessed using the Boston Bowel Preparation Scale (BBPS), which scored the cleanliness of three colonic segments (the rectum-sigmoid, transverse-descending, and ascending-cecum segments) on a scale of 0-3, with total scores ranging from 0-9. Procedure-related parameters were carefully documented, including operative time, one-time complete resection rate, and intraoperative blood loss. Complications, encompassing both immediate and delayed bleeding, perforation, infection, and postoperative pain scores measured using the visual analog scale (VAS), were systematically recorded. This study also tracked several recovery indicators, including length of hospital stay, time to first liquid diet, and patient satisfaction scores. Long-term outcomes were assessed through pathological examination of resected specimens over a 6-month follow-up period, during which polyp recurrence rates and late complications were monitored. Additionally, patient compliance with the preparation protocol and any adverse reactions to the bowel preparation regimens were documented to provide a comprehensive assessment of the safety and efficacy of the two preparation methods.

Statistical analysis

Statistical analysis was performed using SPSS version 25.0 (IBM Corp., Armonk, NY, United States). All data were tested for normal distribution using the Kolmogorov-Smirnov test. Continuous variables, including BBPS scores, operative time, intraoperative blood loss, length of hospital stay, and VAS pain scores, were expressed as mean ± SD for normally distributed data or median (interquartile range) for non-normally distributed data. Comparisons between the conventional and enhanced bowel preparation groups were performed using the independent student’s t-test for normally distributed data or Mann-Whitney U test for non-normally distributed data. Categorical variables, including one-time complete resection rates, complication rates (bleeding, perforation, and infection), patient satisfaction levels, and polyp recurrence rates, were presented as frequencies and percentages (n, %). Comparisons between groups were conducted using the χ² test or Fisher’s exact test when appropriate. The correlation between bowel preparation quality and procedure-related outcomes was analyzed using Spearman’s rank correlation coefficient. Multiple logistic regression analysis was performed to identify independent risk factors for complications and incomplete resection. For the 6-month follow-up data, Kaplan-Meier curves were constructed to analyze recurrence-free survival, with the log-rank test being used to compare differences between groups. A P value of < 0.05 indicated statistical significance. All statistical tests were two-sided, and 95% confidence intervals were calculated where appropriate.

RESULTS

Baseline characteristics of the study participants

This study compared two groups (conventional and enhanced bowel preparation) with 65 patients each. Both groups had similar demographic and clinical characteristics (Table 1), with a comparable mean age (55.2 ± 10.3 vs 54.8 ± 10.5 years, P = 0.82), similar gender distribution (58.5% and 56.9% of those in the conventional and enhanced groups were males, respectively), and similar body mass index measurements (24.1 ± 3.2 vs 23.9 ± 3.1 kg/m², P = 0.78). Both groups also showed comparable comorbidity profiles, with hypertension being the most common (23.1% vs 21.5%, P = 0.89), followed by diabetes (12.3% vs 10.8%, P = 0.81) and cardiovascular disease (7.7% vs 6.2%, P = 0.76). Regarding polyp characteristics, the number (1.3 ± 0.6 vs 1.4 ± 0.5, P = 0.42) and mean size (8.2 ± 2.1 vs 8.0 ± 2.0 mm, P = 0.68) of the polyps were similar in both groups. The distribution of polyp types was also comparable, with adenomatous polyps being the most prevalent (61.5% vs 64.6%, P = 0.72), followed by hyperplastic and serrated types. No significant differences in other clinical factors, including previous colonoscopy history (15.4% vs 16.9%, P = 0.85), family history of colorectal cancer (12.3% vs 10.8%, P = 0.81), anticoagulant use (7.7% vs 6.2%, P = 0.76), and history of inflammatory bowel disease (3.1% vs 1.5%, P = 0.50), were observed between the groups.

Table 1 Baseline characteristics of the study participants.

Characteristic	Conventional bowel preparation group (n = 65)	Enhanced bowel preparation group (n = 65)	P value
Age (years)	55.2 ± 10.3	54.8 ± 10.5	0.82
Gender, n (%)
Male	38 (58.5)	37 (56.9)	0.85
Female	27 (41.5)	28 (43.1)
BMI (kg/m2)	24.1 ± 3.2	23.9 ± 3.1	0.78
Comorbidities, n (%)
Hypertension	15 (23.1)	14 (21.5)	0.89
Diabetes	8 (12.3)	7 (10.8)	0.81
Cardiovascular disease	5 (7.7)	4 (6.2)	0.76
Polyp characteristics
Number of polyps	1.3 ± 0.6	1.4 ± 0.5	0.42
Mean polyp size (mm)	8.2 ± 2.1	8.0 ± 2.0	0.68
Polyp type, n (%)
Adenomatous	40 (61.5)	42 (64.6)	0.72
Hyperplastic	20 (30.8)	19 (29.2)
Serrated	5 (7.7)	4 (6.2)
Previous colonoscopy, n (%)	10 (15.4)	11 (16.9)	0.85
Family history of colorectal cancer, n (%)	8 (12.3)	7 (10.8)	0.81
Current use of anticoagulants, n (%)	5 (7.7)	4 (6.2)	0.76
History of inflammatory bowel disease, n (%)	2 (3.1)	1 (1.5)	0.50

Values are presented as mean ± SD. BMI: Body mass index.

Bowel preparation quality

The enhanced bowel preparation group demonstrated significantly superior outcomes compared to the conventional group across multiple indicators (Table 2). The total BBPS score was significantly higher in the enhanced group (4.2 ± 0.7) than in the conventional group (3.1 ± 0.8, P < 0.001). Segment-specific BBPS scores also showed significant improvements in the enhanced group: Rectum-sigmoid (1.6 ± 0.3 vs 1.2 ± 0.4, P < 0.001), transverse-descending (1.4 ± 0.4 vs 1.0 ± 0.3, P < 0.001), and ascending-cecum (1.2 ± 0.3 vs 0.9 ± 0.3, P < 0.001). The adequacy of bowel preparation rate was significantly higher in the enhanced group [92.3% (60/65)] compared to the conventional group [85.0% (55/65), P = 0.04].

Table 2 Bowel preparation quality.

Indicator	Conventional bowel preparation group (n = 65)	Enhanced bowel preparation group (n = 65)	P value
Boston bowel preparation scale score
Total score	3.1 ± 0.8	4.2 ± 0.7	< 0.001
Rectum-sigmoid	1.2 ± 0.4	1.6 ± 0.3	< 0.001
Transverse-descending	1.0 ± 0.3	1.4 ± 0.4	< 0.001
Ascending-cecum	0.9 ± 0.3	1.2 ± 0.3	< 0.001
Adequacy of the bowel preparation rate	85.0% (55/65)	92.3% (60/65)	0.04
Cecal intubation rate	90.8% (59/65)	95.4% (62/65)	0.21
Withdrawal time (min)	6.2 ± 1.2	8.1 ± 1.4	< 0.001
Adenoma detection rate	30.8% (20/65)	38.5% (25/65)	0.23
Sessile serrated lesion detection rate	5.0% (3/65)	7.7% (5/65)	0.42
Frequency of recommending an appropriate screening or surveillance interval	86.2% (56/65)	93.8% (61/65)	0.12

Although the cecal intubation rate was numerically higher in the enhanced group [95.4% (62/65) vs 90.8% (59/65)], this difference did not reach statistical significance (P = 0.21). Withdrawal time was significantly longer in the enhanced group (8.1 ± 1.4 minutes) compared to the conventional group (6.2 ± 1.2 min, P < 0.001). The adenoma detection rate (ADR) and sessile serrated lesion detection rate (SSLDR) were numerically higher in the enhanced group [ADR: 38.5% (25/65) vs 30.8% (20/65), P = 0.23; SSLDR: 7.7% (5/65) vs 5.0% (3/65), P = 0.42], but these differences were not statistically significant. Finally, the frequency of recommending an appropriate screening or surveillance interval was higher in the enhanced group [93.8% (61/65)] compared to the conventional group [86.2% (56/65)], though this difference was not statistically significant (P = 0.12).

Enhanced bowel preparation improves procedural and clinical outcomes

A comparison of procedural and clinical outcomes between the two groups revealed several significant advantages in the enhanced bowel preparation group (Table 3). In particular, the enhanced group demonstrated shorter operative times (23.1 ± 4.8 vs 25.4 ± 5.2 minutes, P = 0.03), higher one-time complete resection rates (95.4% vs 83.1%, P = 0.01), and lesser intraoperative blood loss (18.2 ± 4.5 vs 20.3 ± 5.1 mL, P = 0.04). Notably, postoperative recovery parameters also favored the enhanced group, who showed significantly shorter hospital stays (2.1 ± 0.5 vs 3.4 ± 0.8 days, P < 0.001), shorter time to first liquid diet (10.2 ± 1.8 vs 12.3 ± 2.1 hours, P = 0.02), and lower postoperative pain scores (2.3 ± 0.7 vs 3.8 ± 0.9, P < 0.001). Although polyp detection parameters remained similar between the groups (number of polyps: 1.4 ± 0.5 vs 1.3 ± 0.6, P = 0.42; mean polyp size: 8.0 ± 2.0 vs 8.2 ± 2.1 mm, P = 0.68), the enhanced group showed a lower need for repeat colonoscopy due to inadequate preparation (3.1% vs 10.8%, P = 0.05) and higher patient satisfaction rates (87.7% vs 76.9%, P = 0.04). The enhanced group also tended to have less frequent use of additional sedation (10.8% vs 20.0%, P = 0.12), although this difference did not reach statistical significance.

Table 3 Procedure-related parameters.

Parameter	Conventional bowel preparation group (n = 65)	Enhanced bowel preparation group (n = 65)	P value
Operative time (min)	25.4 ± 5.2	23.1 ± 4.8	0.03
One-time complete resection rate	83.1% (54/65)	95.4% (62/65)	0.01
Intraoperative blood loss (mL)	20.3 ± 5.1	18.2 ± 4.5	0.04
Number of polyps detected	1.3 ± 0.6	1.4 ± 0.5	0.42
Mean polyp size (mm)	8.2 ± 2.1	8.0 ± 2.0	0.68
Adenoma detection rate	30.8% (20/65)	38.5% (25/65)	0.23
Sessile serrated lesion detection rate	5.0% (3/65)	7.7% (5/65)	0.42
Frequency of recommending an appropriate screening or surveillance interval	86.2% (56/65)	93.8% (61/65)	0.12
Postoperative hospital stay (days)	3.4 ± 0.8	2.1 ± 0.5	< 0.001
Time to first liquid diet (hours)	12.3 ± 2.1	10.2 ± 1.8	0.02
Postoperative pain score	3.8 ± 0.9	2.3 ± 0.7	< 0.001
Frequency of use of additional sedation during the procedure	20.0% (13/65)	10.8% (7/65)	0.12
Frequency of need for repeat colonoscopy due to inadequate preparation	10.8% (7/65)	3.1% (2/65)	0.05
Frequency of patient satisfaction with procedure	76.9% (50/65)	87.7% (57/65)	0.04

Enhanced bowel preparation reduces complications and improves patient experience

Analysis of complications revealed significantly lower adverse events in the enhanced bowel preparation group than in the conventional group (Table 4). In particular, the enhanced group showed a notably lower total complication rate (5.9% vs 16.9%, P = 0.05) and significantly lower rates of bleeding (1.5% vs 16.9%, P = 0.01), infection (1.5% vs 7.7%, P = 0.04), and abdominal pain (6.2% vs 15.4%, P = 0.04) than did the conventional group. Albeit not statistically significant, the enhanced group also demonstrated favorable trends in other complications, including lower rates of perforation (0.0% vs 3.1%, P = 0.10), nausea and vomiting (4.6% vs 12.3%, P = 0.12), and abdominal distension (3.1% vs 10.8%, P = 0.07). Additionally, the enhanced group showed reduced need for additional sedation (3.1% vs 7.7%, P = 0.21) and significantly decreased patient dissatisfaction with the preparation process (4.6% vs 13.8%, P = 0.05) compared to the conventional group, suggesting that the enhanced bowel preparation protocol had better overall tolerability and safety profiles.

Table 4 Enhanced bowel preparation reduces complications and improves patient experience, n (%).

Complication	Conventional bowel preparation group (n = 65)	Enhanced bowel preparation group (n = 65)	P value
Total complication rate	16.9% (11/65)	5.9% (4/65)	0.05
Bleeding	11 (16.9)	1 (1.5)	0.01
Perforation	2 (3.1)	0 (0.0)	0.10
Infection	5 (7.7)	1 (1.5)	0.04
Nausea and vomiting	8 (12.3)	3 (4.6)	0.12
Abdominal pain	10 (15.4)	4 (6.2)	0.04
Abdominal distension	7 (10.8)	2 (3.1)	0.07
Need for additional sedation	5 (7.7)	2 (3.1)	0.21
Patient dissatisfaction with the preparation	9 (13.8)	3 (4.6)	0.05

Enhanced bowel preparation reduces complications and improves patient experience

The enhanced group exhibited a shorter postoperative hospital stay (2.1 ± 0.5 vs 3.4 ± 0.8 days, P < 0.001), reduced time to the first liquid diet (10.2 ± 1.8 vs 12.3 ± 2.1 hours, P = 0.02), and lower postoperative pain scores (2.3 ± 0.7 vs 3.8 ± 0.9, P < 0.001) (Table 5). Additionally, the time to the first bowel movement was shorter (18.3 ± 3.1 vs 24.5 ± 4.2 hours, P < 0.001), and postoperative fatigue scores were lower (2.8 ± 0.6 vs 4.2 ± 0.8, P < 0.001). Patient satisfaction with recovery was higher in the enhanced group (89.2% vs 70.8%, P = 0.01), and rates of postoperative nausea and vomiting were significantly reduced (4.6% vs 15.4%, P = 0.04). Although not statistically significant, favorable trends were observed for postoperative dizziness (3.1% vs 10.8%, P = 0.07) and urinary retention (1.5% vs 7.7%, P = 0.05), suggesting that the enhanced protocol's potential to optimize recovery and improve patient outcomes.

Table 5 Postoperative recovery.

Indicator	Conventional bowel preparation group (n = 65)	Enhanced bowel preparation group (n = 65)	P value
Postoperative hospital stay (days)	3.4 ± 0.8	2.1 ± 0.5	< 0.001
Time to first liquid diet (h)	12.3 ± 2.1	10.2 ± 1.8	0.02
Postoperative pain score	3.8 ± 0.9	2.3 ± 0.7	< 0.001
Time to the first bowel movement (h)	24.5 ± 4.2	18.3 ± 3.1	< 0.001
Postoperative fatigue score	4.2 ± 0.8	2.8 ± 0.6	< 0.001
Patient satisfaction with recovery	70.8% (46/65)	89.2% (58/65)	0.01
Postoperative nausea and vomiting	15.4% (10/65)	4.6% (3/65)	0.04
Postoperative dizziness	10.8% (7/65)	3.1% (2/65)	0.07
Postoperative urinary retention	7.7% (5/65)	1.5% (1/65)	0.05

Enhanced bowel preparation protocol: Reduced complications and improved patient tolerability

The enhanced bowel preparation group showed favorable trends in long-term outcomes compared to the conventional group (Table 6). The 6-month recurrence rate was significantly lower in the enhanced group [3.1% (2/65)] than in the conventional group [10.8% (7/65), P = 0.05]. Tumor marker levels were also reduced in the enhanced group, with significantly lower CA19-9 (28.1 ± 8.5 vs 35.2 ± 10.3, P = 0.02) and CEA levels (3.9 ± 0.9 vs 4.8 ± 1.2, P = 0.04). Although not statistically significant, the enhanced group demonstrated numerically lower rates of pathological confirmation of malignancy [6.2% (4/65) vs 7.7% (5/65), P = 0.76], lymph node metastasis [7.7% (5/65) vs 12.3% (8/65), P = 0.32], and late complications [0.0% (0/65) vs 3.1% (2/65), P = 0.10]. Postoperative infection rates were also lower in the enhanced group [3.1% (2/65) vs 7.7% (5/65), P = 0.10]. Patient satisfaction with pathological results was higher in the enhanced group [87.7% (57/65) vs 80.0% (52/65)], though this difference was not statistically significant (P = 0.12).

Table 6 Pathological examination and follow-up, n (%).

Indicator	Conventional bowel preparation group (n = 65)	Enhanced bowel preparation group (n = 65)	P value
Pathological confirmation of malignancy	5 (7.7)	4 (6.2)	0.76
6-month recurrence rate	10.8% (7/65)	3.1% (2/65)	0.05
Late complications	2 (3.1)	0 (0.0)	0.10
Tumor marker levels (CA19-9)	35.2 ± 10.3	28.1 ± 8.5	0.02
Tumor marker levels (CEA)	4.8 ± 1.2	3.9 ± 0.9	0.04
Lymph node metastasis rate	12.3% (8/65)	7.7% (5/65)	0.32
Postoperative infection rate	7.7% (5/65)	3.1% (2/65)	0.10
Patient satisfaction with the pathological results	80.0% (52/65)	87.7% (57/65)	0.12

Enhanced bowel preparation protocol: Improved compliance and tolerability

The enhanced bowel preparation group demonstrated significantly better compliance and tolerability outcomes compared to the conventional group. The overall compliance rate was notably higher in the enhanced group than in the conventional group (89.2% vs 70.8%, P = 0.01), with improved adherence to the medication schedule (84.6% vs 68.0%, P = 0.02) and higher completion rates of the full bowel preparation course (86.2% vs 65.0%, P = 0.003). The enhanced group also experienced fewer adverse effects than did the conventional group, with decreased rates of adverse drug reactions (4.6% vs 12.3%, P = 0.04), reduced frequency of nausea and vomiting (4.6% vs 15.4%, P = 0.04), and a tendency toward less abdominal distension (3.1% vs 10.8%, P = 0.07). Patient satisfaction was significantly higher in the enhanced group than in the conventional group (87.7% vs 72.3%, P = 0.02), with lower rates of dissatisfaction with the preparation process (4.6% vs 13.8%, P = 0.05). Although not significant, the enhanced group showed a trend toward reduced need for additional sedation (3.1% vs 7.7%, P = 0.21), suggesting better overall tolerability of the enhanced preparation protocol (Table 7).

Table 7 Patient compliance and adverse reactions.

Indicator	Conventional bowel preparation group (n = 65)	Enhanced bowel preparation group (n = 65)	P value
Overall compliance rate	70.8% (46/65)	89.2% (58/65)	0.01
Adherence to the medication schedule	68.0% (44/65)	84.6% (55/65)	0.02
Completion of the full bowel preparation course	65.0% (42/65)	86.2% (56/65)	0.003
Frequency of adverse drug reactions	12.3% (8/65)	4.6% (3/65)	0.04
Patient satisfaction with medication	72.3% (47/65)	87.7% (57/65)	0.02
Frequency of additional sedation required	7.7% (5/65)	3.1% (2/65)	0.21
Patient dissatisfaction with the preparation process	13.8% (9/65)	4.6% (3/65)	0.05
Frequency of nausea and vomiting	15.4% (10/65)	4.6% (3/65)	0.04
Frequency of abdominal distension	10.8% (7/65)	3.1% (2/65)	0.07

DISCUSSION

The current study provides compelling evidence for the superiority of an enhanced bowel preparation protocol over conventional methods in colonoscopic polypectomy. The identification and removal of precancerous polyps through colonoscopic polypectomy have been a cornerstone in the prevention and treatment of colorectal cancer. A fundamental determinant to the success of this approach lies in the quality of bowel preparation, which directly impacts the endoscopist’s ability to clearly visualize the colonic mucosa and effectively detect and remove polyps[21-23].

Suboptimal bowel preparation creates significant obstacles to successful colonoscopic polypectomy. Limited visibility from inadequate cleansing not only hampers the detection of polyps but also increases the risk of incomplete resection, which may promote the development of colorectal cancer. The consequences of poor preparation extend beyond missed lesions to encompass elevated risk for procedural complications, such as bleeding, perforation, and infection[24-26]. Moreover, inadequate preparation often necessitates repeat procedures, creating unnecessary strain on healthcare systems and causing increased patient discomfort and inconvenience.

The significance of adequate bowel preparation in colonoscopic polypectomy extends far beyond immediate procedural success, particularly considering its crucial role in the prevention of colorectal cancer. The enhanced bowel preparation protocol demonstrated promising results with tendencies toward higher ADR (38.5% vs 30.8%, P = 0.23) and significantly improved one-time complete resection rates (95.4% vs 83.1%, P = 0.01). This improvement is particularly crucial given that adenomas represent the primary precursor lesions for colorectal cancer; hence, missing these lesions during colonoscopy can lead to interval colorectal cancer. The distribution of polyp types (adenomatous: 64.6% vs 61.5%, hyperplastic: 29.2% vs 30.8%, serrated: 6.2% vs 7.7%) provides further evidence regarding the effectiveness of the protocol, suggesting enhanced visualization across all polyp subtypes, which is particularly beneficial for traditionally challenging-to-detect flat or sessile adenomas. Moreover, the enhanced bowel preparation protocol promoted long-term cancer prevention benefits as evidenced by the lower 6-month recurrence rates (3.1% vs 10.8%, P = 0.05) and better tumor marker profiles (CA19-9: 28.1 ± 8.5 vs 35.2 ± 10.3, P = 0.02; CEA: 3.9 ± 0.9 vs 4.8 ± 1.2, P = 0.04) than with the conventional bowel preparation protocol. The enhanced protocol also induced significant improvements in quality metrics, including higher BBPPS scores and longer withdrawal times (8.1 ± 1.4 vs 6.2 ± 1.2 min, P < 0.001) than with the conventional protocol. These findings have broader implications for screening programs, suggesting potential improvements in program adherence and more appropriate surveillance intervals. The technical aspects of the procedure were also enhanced, with decreased bleeding rates (1.5% vs 16.9%, P = 0.01) and improved complete resection rates. Moving forward, further research is needed to assess the long-term impact of the enhance protocol on colorectal cancer incidence, cost-effectiveness, and effectiveness in high-risk populations. Based on these findings, our practical recommendations include implementing enhanced bowel preparation protocols for all screening colonoscopies, developing comprehensive patient education programs, and standardizing preparation protocols across practice settings.

The enhanced protocol promoted significantly better postoperative outcomes than did the conventional, including shorter hospital stays (2.1 ± 0.5 vs 3.4 ± 0.8 days, P < 0.001) and lower postoperative pain scores (2.3 ± 0.7 vs 3.8 ± 0.9, P < 0.001). Patient satisfaction was also notably higher with the enhanced protocol than with the conventional protocol (87.7% vs 76.9%, P = 0.04), with less need for repeat procedures due to inadequate preparation (3.1% vs 10.8%, P = 0.05). These findings suggest that the benefits of enhanced bowel preparation extend beyond the immediate procedural setting.

The study revealed better long-term outcomes in the enhanced group than in the conventional group, with lower 6-month recurrence rates (3.1% vs 10.8%, P = 0.05) and better tumor marker profiles (CA19-9: 28.1 ± 8.5 vs 35.2 ± 10.3, P = 0.02; CEA: 3.9 ± 0.9 vs 4.8 ± 1.2, P = 0.04). These findings suggest that better initial bowel preparation may have implications for long-term disease control and surveillance.

A key finding of the current study was the significantly higher compliance rate in the enhanced group than in the conventional group (89.2% vs 70.8%, P = 0.01), with better adherence to medication schedules and completion rates of the preparation course. This improved compliance likely contributed to the better outcomes observed across multiple parameters.

These findings have important implications for clinical practice. The enhanced bowel preparation protocol not only improves immediate procedural outcomes but also appears to benefit long-term patient outcomes and healthcare resource utilization. The reduction in complications and the need for repeat procedures could translate into significant cost savings and improved healthcare efficiency.

However, several questions remain for future research, including the cost-effectiveness of the enhanced protocol, its applicability in different patient populations, and the potential for further optimization of the preparation regimen. Additionally, longer term follow-up studies would be valuable to assess the durability of the observed benefits.

Based on the results of our study, we recommend the implementation of the enhanced bowel preparation protocol in clinical practice using the following strategies. First, healthcare institutions can establish standardized multimedia educational platforms, including short videos, illustrated manuals, and interactive applications, allowing the patients to visually understand the importance and the specific steps of bowel preparation. These educational resources can be integrated into outpatient appointment processes, where they are provided by nurses during colonoscopy scheduling. Second, dedicated bowel preparation coordinators, who are responsible for patient education, follow-up, and psychological support, can be added to the existing nursing workflows. This can be achieved by reallocating existing nursing resources or training specialist nurses, without significantly increasing personnel costs. Third, a tiered psychologic support system can be established, wherein standard psychologic guidance materials are provided for routine patients whereas one-on-one psychologic counseling or telephone guidance are arranged for highly anxious patients or those with a history of poor bowel preparation. Fourth, existing hospital information systems or mobile healthcare platforms can be utilized to implement automatic reminders that send personalized guidance and encouragement 24-48 hours prior to the examination. Finally, healthcare institutions can establish quality improvement teams to regularly evaluate the efficacy of protocol implementation and to continuously optimize processes based on patient feedback. These measures can be gradually implemented within existing medical frameworks to improve patient compliance and examination quality while avoiding excessive pressure on medical resources.

Limitations

The present study has several limitations. First, we acknowledge the potential selection bias and confounding factors due in this retrospective cohort study, although we aimed to control for these through statistical approaches. Second, the single-center study design might limit the generalizability of our finding, because the patient characteristics and practice patterns might vary across healthcare institutions. Third, the sample size was relatively small, which might have impacted the statistical power of the analyses including certain secondary outcomes, particularly for the detection of low-frequency events. Furthermore, the 6-month follow-up period might have been insufficient for the comprehensive evaluation of the long-term outcomes, such as distant recurrence and survival.

CONCLUSION

The enhanced bowel preparation protocol exhibited significant clinical advantages across multiple metrics, including the polyp detection rate, procedural outcomes, patient satisfaction, and resource utilization. Based on these findings, we strongly recommend the adoption of this protocol in routine clinical practice for colonoscopic polypectomy. Implementation strategies should include standardized patient education, dedicated coordination personnel, psychologic support systems, and regular quality assessment. These evidence-based improvements should offer substantial benefits to both patients and healthcare systems in efforts on colorectal cancer prevention.