Post written by Stefano Kayali, MD, from from the Department of Medicine and Surgery, University of Parma, and the Gastroenterology and Endoscopy Unit, University Hospital of Parma, and Stefano Fantasia, MD, from the Department of Medicine and Surgery, University of Parma, Parma, Italy.

Our study investigates the impact of bowel preparation quality, specifically comparing excellent (Boston Bowel Preparation Scale [BBPS] score 8-9) versus good (BBPS score 6-7) cleanliness, on the detection of serrated pathway lesions during fecal immunochemical test—positive screening colonoscopies. We evaluated key quality indicators, including the proximal serrated polyp detection rate and sessile serrated lesion detection rate, alongside traditional adenoma detection metrics.

The detection of serrated polyps, particularly in the proximal colon, is increasingly recognized as a crucial surrogate marker of colonoscopy quality and strongly linked to the risk of postcolonoscopy colorectal cancer. Although the influence of bowel cleanliness on adenoma detection is well-documented, its specific effect on serrated and sessile serrated lesions within a targeted screening cohort remained unclear. We wanted to determine if pushing for excellent rather than merely adequate preparation could offer an actionable strategy to improve identification of these subtle, often elusive precursor lesions.

We demonstrated that excellent bowel preparation (BBPS score 8-9) yielded a 5.8% absolute increase in proximal serrated polyp detection rate and a 3.6% absolute increase in sessile serrated lesion detection rate compared with good preparation (BBPS score 6-7). To our knowledge, this is the first study to investigate this dynamic within a fecal immunochemical test—based screening cohort using validated metrics.

Interestingly, this diagnostic benefit did not extend to the adenoma detection rate or adenomas per colonoscopy, which remained statistically unchanged once preparation was at least adequate (BBPS score 6-7). Furthermore, our stratified analysis revealed that the diagnostic advantage of excellent preparation was primarily realized by skilled endoscopists who were already proficient in serrated lesion detection. Future efforts should focus on a dual strategy: optimizing bowel cleansing protocols for all screening patients to achieve an excellent level of cleanliness and implementing targeted training to improve recognition of serrated polyps across endoscopists.

We appreciate the opportunity to share our findings and thank the GIE team for this platform.

Impact of bowel preparation quality on PSDR and SSLDR. BBPS, Boston Bowel Preparation Scale; PSDR, proximal serrated polyp detection rate; SSLDR, sessile serrated lesion detection rate.

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