Abdominal Pressure and Patient Position Changes During Colonoscopy: Potential Adjunct Variables in Assessment of Colonoscopy Competence

Abdominal Pressure and Patient Position Changes During Colonoscopy: Potential Adjunct Variables in Assessment of Colonoscopy Competence | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Abdominal Pressure and Patient Position Changes During Colonoscopy: Potential Adjunct Variables in Assessment of Colonoscopy Competence Alyssa Grossen, Bishr Swar, Bryce Yohannan, Nimrah Bader, Maham Khan, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6753446/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Colonoscopy competency is a critical milestone in progression through gastroenterology fellowship. Overcoming looping is essential for achieving proficiency – often overcome with abdominal pressure and patient position changes. Literature is limited on the systematic evaluation of these maneuvers in training centers. We aim to evaluate the frequency of abdominal pressure and/or patient position adjustments throughout fellowship. Methods: This was a cross-sectional study of 1029 individuals undergoing colonoscopy at the Oklahoma City VA Medical Center. Maneuvers used were assessed using a questionnaire completed by the endoscopist. Patient demographics were extracted retrospectively. Factors associated with need for abdominal pressure or position changes were determined through univariate and multivariate regression analyses. Adjusted odds ratios (aOR) were calculated using attending physicians as the reference and comparing them to junior (first year) and senior fellows (second/third year). Results: 999/1029 (97%) of colonoscopies had post-procedure questionnaires completed. Female sex (OR=1.6, 95% CI: 1.1, 2.4), moderate sedation (OR=1.5, 95% CI: 1.1, 2.1), and fellow involvement (OR=2.3, 95% CI: 1.7, 3.1) were significantly associated with abdominal pressure or patient position changes. Either or both maneuvers were required in 193 (51%) junior fellow cases (aOR=1.6, 95% CI: 1.3, 1.9); 128 (42%) senior fellow cases (aOR=2.0, 95% CI: 1.4, 2.9); and 82 (26%) attending-only cases (aOR=1.00). Conclusions: Abdominal pressure and patient repositioning were more common in fellow-led colonoscopies but decreased with training progression. This study emphasizes the potential utility of incorporating these maneuvers into colonoscopy competency assessment tools to help provide standardization of loop management across fellowship programs. colonoscopy looping fellowship training abdominal pressure position changes Background Investigation of the gastrointestinal tract for colorectal disease is most effectively achieved through a colonoscopy. Many factors can lead to an incomplete or “difficult” colonoscopy, including inadequate bowel preparation, obstructing lesions, colonic looping, and endoscopic technique. Looping of the colonoscope is one of the most common technical obstacles in achieving a successful colonoscopy. When encountered, loop formation impedes progression of the colonoscope with respective maneuvers resulting in ‘paradoxical motion;’ this causes inappropriate stretching of the bowels with predisposition to colonic perforation, contributes to significant patient discomfort, prolonged sedation, and increased procedure times [9]. Studies have demonstrated that looping is a prevalent occurrence, happening up to 73% during routine endoscopy ( 1 ). Looping has been found to occur more frequently in older, smaller women compared to other patient populations ( 1 ). Several strategies have been explored to decrease or improve looping during colonoscopies which include use of water techniques, manually intensive abdominal compression techniques, patient position changes, hands free abdominal compression devices, torque-based reduction maneuvers and use of stiff endoscopic devices and overtubes [2, 4, 6, 8]. Endoscopic skill is of unparalleled importance in managing challenging procedures [9]. Competency in colonoscopy is a critical milestone in the progression through gastroenterology fellowship. Currently, colonoscopy competence is assessed by using a variety of assessment tools, such as the direct observation of procedural skills (DOPS), Assessment of Competency in Endoscopy (ACE), and Mayo Colonoscopy Skills Assessment Tool (5, 7). These tools assess non-technical (consent, knowledge, indication, etc.) and technical skills. A recent study by Siau et al. suggests that proactive problem solving and loop management are the last steps trainees achieve prior to achieving competency in colonoscopy ( 5 ). However, loop management remains a subjective assessment and is not standardized across formal assessment tools. Currently, there is limited literature on the systematic evaluation of abdominal pressure and patient position changes within training centers, particularly in assessment of loop management. This study aimed to evaluate the prevalence of looping requiring the need for abdominal pressure and/or patient position changes during colonoscopy at various stages of gastroenterology fellowship training. Methods This was a cross-sectional study of 1029 individuals undergoing colonoscopies at the Oklahoma City Veterans’ Affairs Medical Center. Patients scheduled for outpatient screening and diagnostic colonoscopies at the Oklahoma City VA Gastroenterology Clinic were selected based on inclusion and exclusion criteria. Inclusion criteria included all patients who presented for a screening or diagnostic colonoscopy and had completed their prep prior to the procedure. Men and women 18 years or older of any race or ethnicity were included. Exclusion criteria included any patients who had surgical alteration to their colon. Patients completed a written questionnaire - which included questions about smoking history, alcohol use, previous abdominal surgeries, and other relevant data - during their wait time in the endoscopy lab prior to their scheduled colonoscopy. All endoscopies were completed in the same endoscopy unit at the Oklahoma City VA. On completion of the colonoscopy, endoscopists willing to participate completed a brief survey regarding their findings during the procedure. Need for abdominal pressure or change in patient position during colonoscopy for cecal intubation was assessed using this survey Retrospectively and via an anonymous numeric code, data including demographics, clinical and pathological data was extracted from the participants’ charts following the completion of their colonoscopy. The information gathered included cecal intubation time, sedation used, demographics, comorbidities, surgical history, and medications used by the patient. Junior fellows were defined as first year fellows, and senior fellows were defined as second- and third-year fellows. Statistical Methods SAS software (SAS Institute, Cary, NC, USA) was used for data analyses. All data was analyzed for descriptive analysis and any clinical factors associated with increased looping were evaluated for significance using T and chi-squared testing for univariate analysis for association. A multivariate regression analysis was performed to identify factors associated with the need for either abdominal pressure or patient position changes. Adjusted odds ratios (aOR) were calculated using attending physicians as the reference and comparing them to junior fellows (first year) and senior fellows (second or third year). Significance was determined at a P-value of < 0.05. Results 1029 patients were included in this study. 999/1029 (97%) of colonoscopies performed had post-procedure questionnaires completed. Patient demographics and procedural factors associated with looping during colonoscopy are outlined in Table 1 . There was a higher prevalence of looping in African American patients (19.9% vs. 13.3%, p = 0.01) and in those with hypothyroidism (14.6% vs. 10.1%, p = 0.03). Several procedural factors were also associated with increased risk of looping during colonoscopy. These factors include fellow involvement (79.9% vs. 59.9%, p < 0.0001), moderate sedation (76.9% vs. 62.5%, p < 0.0001), lower Boston Bowel Preparation Scale (BBPS) score (mean 7.9 vs. 8.3, p = 0.003), longer insertion time (mean 12.5 vs. 6.9 minutes, p < 0.0001), longer withdrawal time (mean 30.8 vs 23.6 minutes, p < 0.0001), and higher number of adenomas (mean 2.9 vs. 2.0, p = 0.01). A trainee was involved in 703/999 (70%) cases, abdominal pressure was necessary in 366/999 (37%) instances, patient position changes were required in 147/999 (15%) cases, and either maneuver or both were needed in 403/999 (40%) cases. Multivariate analyses revealed that female sex (OR = 1.6, 95% CI: 1.1, 2.4), moderate sedation (OR = 1.5, 95% CI: 1.1, 2.1), and fellow involvement (OR = 2.3, 95% CI: 1.7, 3.1) were significantly associated with the need for abdominal pressure or patient position changes during colonoscopy (Table 2). Abdominal pressure and/or patient position changes were required in 193/375 (51%) junior fellow cases (aOR = 1.6, p < 0.0001); 128/303 (42%) senior fellow cases (aOR = 2.0, p < 0.0001); and 82/320 (26%) attending-only cases (aOR = 1.00) (Table 3). Discussion Loop management during colonoscopy is a critical technical skill that a trainee acquires, often representing one of the final challenges to overcome ( 5 ). However, there is a lack of objective data on how frequently trainees encounter looping during procedures and the specific strategies they employ to address this challenge. In our study, either patient position changes, abdominal pressure, or both were required in 47.3% of cases involving a junior or senior fellow. However, when trainees were stratified, senior fellows utilized these maneuvers less consistently compared to junior fellows (42.2% vs. 51.5%, respectively). By contrast, in procedures performed solely by attending physicians, these maneuvers were necessarily in only 25.6% of cases. These findings imply that improved loop management is a natural progression of training and expertise. Progression through gastroenterology fellowship training requires the attainment of multiple milestones. These milestones include preprocedural, procedural, endoscopic nontechnical skills, postprocedural, and management aspects. Despite the consensus that these benchmarks must be met to practice successfully, there remains a noticeable lack of standardized, validated competency assessment tools in colonoscopy training. A recent study by Siau et al. demonstrated the utility of the direct observation of procedural skills (DOPS) tool as a valid and reliable method to support colonoscopy training. In this prospective, nationwide study performed in the United Kingdom, strong associations were observed between overall competence rating and procedural skills such as tip control (rho 0.719), proactive problem solving (rho 0.787), pace and progress (rho 0.734), and loop management (rho 0.780). Notably, “pre-procedural” aspects of endoscopy were less strongly associated with overall DOPS rating. In the skills assessment, procedural aspects of colonoscopy were the last milestones to be mastered. Several factors, both patient-related and endoscopist-related have been associated with the difficulty of performing a colonoscopy. Difficult colonoscopies often occur in cases of “redundant” colons characterized by significant looping, or in “fixed” colons, which are challenging to navigate and often require downsizing the scope. Certain patient characteristics such as female gender and older age, are often associated with redundant colons and significant looping ( 11 ). Conversely, conditions such as diverticular disease, prior abdominal surgeries, thin body habitus and inflammatory bowel disease linked to fixed sigmoid colon ( 11 ). Additionally, technical factors also play a crucial role in the quality and ease of endoscopy. These include the technical skill of the endoscopists and the provision of adequate sedation ( 9 ). Our study reinforces previously documented findings and provides new insights, notably that fellow involvement is significantly associated with looping during colonoscopy and its utilization decreases as fellows progress in training. Interestingly, while the use of these techniques decreased with advancing fellowship, the adjusted odds ratio for their utilization increased for senior fellows compared to junior fellows. The reason for this is unclear, but it could be that senior fellows are more likely to utilize abdominal pressure and patient position changes as tools in difficult colonoscopies – perhaps due to a deeper understanding of procedural problem-solving or could be related to other uncontrolled factors. There are several strengths of this study. The first is that this study includes a large patient population with a range of clinical comorbidities. The second is that this is a prospective study that specifically evaluates trainee involvement at both the junior and senior level, so a direct comparison can be drawn. The third is that, to the best of our knowledge, this is the first study to evaluate the prevalence of which abdominal pressure and patient position changes are being used amongst trainees, and a direct comparison can be drawn to attending physicians. Limitations of this study include inter-observer variability among physicians performing the colonoscopies, single hospital center data, and lack of objective confirmation of the presence of loops (as with scope guide). To further corroborate these findings, multi-center studies are needed to evaluate the frequency of these maneuvers across gastroenterology fellowship programs. Currently, loop management is a subjective assessment and is not standardized across formal assessment tools used for gastroenterology fellows. The data presented in this study emphasizes the potential utility of incorporating abdominal pressure and patient position changes as components of colonoscopy competence assessment tools to help provide standardization of evaluation of loop management – a core endoscopic milestone that is often reached after other non-endoscopic landmarks are met. Statements and Declarations No financial or non-financial disclosures exist for any author Funding Declaration: no funding disclosures to provide Author Contribution A.G wrote the main manuscript text and collected dataB.S., B.Y., N.B., M.K., M.N., T.C. collected dataI.A. reviewed manuscriptM.M. prepared figures and reviewed manuscript Ethics Declaration: This study was approved by the OU Health Sciences Institutional Review Board, which works to protect the rights, safety, and well-being of people involved in the research. This study was approved as it met the ethical principles and complied with federal regulations, state laws, and OU policies. References Eickhoff A, et al. Colon anatomy based on CT colonography and fluoroscopy: Impact on looping, straightening and ancillary manoeuvres in colonoscopy. Dig Liver Dis. 2010 Apr; 42(4): 291-6. Franco DL, Leighton JA, Gurudu SR. Approach to Incomplete Colonoscopy: New Techniques and Technologies. Gastroenterol Hepatol (N Y). 2017;13:476-483. Gupta M, Holub JL, Eisen G. Do indication and demographics for colonoscopy affect completion? A large national database evaluation. Eur J Gastroenterol Hepatol. 2010 May; 22(5). Haycock A, et al. Cotton and Williams' practical gastrointestinal endoscopy - the fundamentals. 7th ed. John Wiley & Sons; 2014. Saiu K, et al. Colonoscopy Direct Observation of Procedural Skills Assessment Tool for Evaluating Competency Development During Training. Gastroenterology. Feb 2020; 115: 234-243. Schulman AR, Ryou M, Chan WW. A Novel Hands-Free Abdominal Compression Device for Colonoscopy Significantly Decreases Cecal Intubation Time: A Prospective Single-Blinded Pilot Study. J Laparoendosc Adv Surg Tech A. 2017;27(6):564-570. Walsh C. In-training gastrointestinal endoscopy competency assessment tools: Types of tools, validation and impact. Best Practice & Research Clinical Gastroenterology. 2016; 30: 357-374. Wayne JD, Yessayan SA, Lewis BS, Fabry TL. The technique of abdominal pressure in total colonoscopy. Gastrointest Endosc. 1991;37:147-151. Wayne JD. Difficult Colonoscopy. Gastroenterol Hepatol. 2013 Oct; 9(10): 676-678. Witte TN, Enns R. The difficult colonoscopy. Can J Gastroenterol. 2007;21(8):487-490. Cuda T, et al. The correlation between diverticulosis and redundant colon. Int J Colorectal Dis. 2017; 32(11): 1603-1607. Tables Tables 1 to 3 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6753446","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466480748,"identity":"326f3181-fc2e-4e91-98b1-c88d2910e20a","order_by":0,"name":"Alyssa 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01:46:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":338465,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6753446/v1/7aaed6bf-6767-4d7e-95ef-67f17296a6f6.pdf"},{"id":83969130,"identity":"57c877d0-d6d1-4f5a-b23e-02582b200334","added_by":"auto","created_at":"2025-06-05 07:35:39","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30970,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6753446/v1/b0836fc38247e07eb14f5837.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Abdominal Pressure and Patient Position Changes During Colonoscopy: Potential Adjunct Variables in Assessment of Colonoscopy Competence","fulltext":[{"header":"Background","content":"\u003cp\u003eInvestigation of the gastrointestinal tract for colorectal disease is most effectively achieved through a colonoscopy. Many factors can lead to an incomplete or \u0026ldquo;difficult\u0026rdquo; colonoscopy, including inadequate bowel preparation, obstructing lesions, colonic looping, and endoscopic technique. Looping of the colonoscope is one of the most common technical obstacles in achieving a successful colonoscopy. When encountered, loop formation impedes progression of the colonoscope with respective maneuvers resulting in \u0026lsquo;paradoxical motion;\u0026rsquo; this causes inappropriate stretching of the bowels with predisposition to colonic perforation, contributes to significant patient discomfort, prolonged sedation, and increased procedure times [9].\u003c/p\u003e \u003cp\u003eStudies have demonstrated that looping is a prevalent occurrence, happening up to 73% during routine endoscopy (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Looping has been found to occur more frequently in older, smaller women compared to other patient populations (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Several strategies have been explored to decrease or improve looping during colonoscopies which include use of water techniques, manually intensive abdominal compression techniques, patient position changes, hands free abdominal compression devices, torque-based reduction maneuvers and use of stiff endoscopic devices and overtubes [2, 4, 6, 8]. Endoscopic skill is of unparalleled importance in managing challenging procedures [9].\u003c/p\u003e \u003cp\u003eCompetency in colonoscopy is a critical milestone in the progression through gastroenterology fellowship. Currently, colonoscopy competence is assessed by using a variety of assessment tools, such as the direct observation of procedural skills (DOPS), Assessment of Competency in Endoscopy (ACE), and Mayo Colonoscopy Skills Assessment Tool (5, 7). These tools assess non-technical (consent, knowledge, indication, etc.) and technical skills. A recent study by Siau et al. suggests that proactive problem solving and loop management are the last steps trainees achieve prior to achieving competency in colonoscopy (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, loop management remains a subjective assessment and is not standardized across formal assessment tools. Currently, there is limited literature on the systematic evaluation of abdominal pressure and patient position changes within training centers, particularly in assessment of loop management.\u003c/p\u003e \u003cp\u003eThis study aimed to evaluate the prevalence of looping requiring the need for abdominal pressure and/or patient position changes during colonoscopy at various stages of gastroenterology fellowship training.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis was a cross-sectional study of 1029 individuals undergoing colonoscopies at the Oklahoma City Veterans\u0026rsquo; Affairs Medical Center. Patients scheduled for outpatient screening and diagnostic colonoscopies at the Oklahoma City VA Gastroenterology Clinic were selected based on inclusion and exclusion criteria. Inclusion criteria included all patients who presented for a screening or diagnostic colonoscopy and had completed their prep prior to the procedure. Men and women 18 years or older of any race or ethnicity were included. Exclusion criteria included any patients who had surgical alteration to their colon.\u003c/p\u003e \u003cp\u003ePatients completed a written questionnaire - which included questions about smoking history, alcohol use, previous abdominal surgeries, and other relevant data - during their wait time in the endoscopy lab prior to their scheduled colonoscopy. All endoscopies were completed in the same endoscopy unit at the Oklahoma City VA. On completion of the colonoscopy, endoscopists willing to participate completed a brief survey regarding their findings during the procedure. Need for abdominal pressure or change in patient position during colonoscopy for cecal intubation was assessed using this survey\u003c/p\u003e \u003cp\u003eRetrospectively and via an anonymous numeric code, data including demographics, clinical and pathological data was extracted from the participants\u0026rsquo; charts following the completion of their colonoscopy. The information gathered included cecal intubation time, sedation used, demographics, comorbidities, surgical history, and medications used by the patient. Junior fellows were defined as first year fellows, and senior fellows were defined as second- and third-year fellows.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Methods\u003c/h2\u003e \u003cp\u003eSAS software (SAS Institute, Cary, NC, USA) was used for data analyses. All data was analyzed for descriptive analysis and any clinical factors associated with increased looping were evaluated for significance using T and chi-squared testing for univariate analysis for association. A multivariate regression analysis was performed to identify factors associated with the need for either abdominal pressure or patient position changes. Adjusted odds ratios (aOR) were calculated using attending physicians as the reference and comparing them to junior fellows (first year) and senior fellows (second or third year). Significance was determined at a P-value of \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e1029 patients were included in this study. 999/1029 (97%) of colonoscopies performed had post-procedure questionnaires completed.\u003c/p\u003e\n\u003cp\u003ePatient demographics and procedural factors associated with looping during colonoscopy are outlined in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. There was a higher prevalence of looping in African American patients (19.9% vs. 13.3%, p\u0026thinsp;=\u0026thinsp;0.01) and in those with hypothyroidism (14.6% vs. 10.1%, p\u0026thinsp;=\u0026thinsp;0.03). Several procedural factors were also associated with increased risk of looping during colonoscopy. These factors include fellow involvement (79.9% vs. 59.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), moderate sedation (76.9% vs. 62.5%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), lower Boston Bowel Preparation Scale (BBPS) score (mean 7.9 vs. 8.3, p\u0026thinsp;=\u0026thinsp;0.003), longer insertion time (mean 12.5 vs. 6.9 minutes, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), longer withdrawal time (mean 30.8 vs 23.6 minutes, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and higher number of adenomas (mean 2.9 vs. 2.0, p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003eA trainee was involved in 703/999 (70%) cases, abdominal pressure was necessary in 366/999 (37%) instances, patient position changes were required in 147/999 (15%) cases, and either maneuver or both were needed in 403/999 (40%) cases.\u003c/div\u003e\n\u003c/div\u003e\n\u003cp\u003eMultivariate analyses revealed that female sex (OR\u0026thinsp;=\u0026thinsp;1.6, 95% CI: 1.1, 2.4), moderate sedation (OR\u0026thinsp;=\u0026thinsp;1.5, 95% CI: 1.1, 2.1), and fellow involvement (OR\u0026thinsp;=\u0026thinsp;2.3, 95% CI: 1.7, 3.1) were significantly associated with the need for abdominal pressure or patient position changes during colonoscopy (Table\u0026nbsp;2).\u003c/p\u003e\n\u003cp\u003eAbdominal pressure and/or patient position changes were required in 193/375 (51%) junior fellow cases (aOR\u0026thinsp;=\u0026thinsp;1.6, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001); 128/303 (42%) senior fellow cases (aOR\u0026thinsp;=\u0026thinsp;2.0, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001); and 82/320 (26%) attending-only cases (aOR\u0026thinsp;=\u0026thinsp;1.00) (Table\u0026nbsp;3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eLoop management during colonoscopy is a critical technical skill that a trainee acquires, often representing one of the final challenges to overcome (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e5\u003c/span\u003e). However, there is a lack of objective data on how frequently trainees encounter looping during procedures and the specific strategies they employ to address this challenge. In our study, either patient position changes, abdominal pressure, or both were required in 47.3% of cases involving a junior or senior fellow. However, when trainees were stratified, senior fellows utilized these maneuvers less consistently compared to junior fellows (42.2% vs. 51.5%, respectively). By contrast, in procedures performed solely by attending physicians, these maneuvers were necessarily in only 25.6% of cases. These findings imply that improved loop management is a natural progression of training and expertise.\u003c/p\u003e \u003cp\u003eProgression through gastroenterology fellowship training requires the attainment of multiple milestones. These milestones include preprocedural, procedural, endoscopic nontechnical skills, postprocedural, and management aspects. Despite the consensus that these benchmarks must be met to practice successfully, there remains a noticeable lack of standardized, validated competency assessment tools in colonoscopy training. A recent study by Siau et al. demonstrated the utility of the direct observation of procedural skills (DOPS) tool as a valid and reliable method to support colonoscopy training. In this prospective, nationwide study performed in the United Kingdom, strong associations were observed between overall competence rating and procedural skills such as tip control (rho 0.719), proactive problem solving (rho 0.787), pace and progress (rho 0.734), and loop management (rho 0.780). Notably, \u0026ldquo;pre-procedural\u0026rdquo; aspects of endoscopy were less strongly associated with overall DOPS rating. In the skills assessment, procedural aspects of colonoscopy were the last milestones to be mastered.\u003c/p\u003e \u003cp\u003eSeveral factors, both patient-related and endoscopist-related have been associated with the difficulty of performing a colonoscopy. Difficult colonoscopies often occur in cases of \u0026ldquo;redundant\u0026rdquo; colons characterized by significant looping, or in \u0026ldquo;fixed\u0026rdquo; colons, which are challenging to navigate and often require downsizing the scope. Certain patient characteristics such as female gender and older age, are often associated with redundant colons and significant looping (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Conversely, conditions such as diverticular disease, prior abdominal surgeries, thin body habitus and inflammatory bowel disease linked to fixed sigmoid colon (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Additionally, technical factors also play a crucial role in the quality and ease of endoscopy. These include the technical skill of the endoscopists and the provision of adequate sedation (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study reinforces previously documented findings and provides new insights, notably that fellow involvement is significantly associated with looping during colonoscopy and its utilization decreases as fellows progress in training.\u003c/p\u003e \u003cp\u003eInterestingly, while the use of these techniques decreased with advancing fellowship, the adjusted odds ratio for their utilization increased for senior fellows compared to junior fellows. The reason for this is unclear, but it could be that senior fellows are more likely to utilize abdominal pressure and patient position changes as tools in difficult colonoscopies \u0026ndash; perhaps due to a deeper understanding of procedural problem-solving or could be related to other uncontrolled factors.\u003c/p\u003e \u003cp\u003eThere are several strengths of this study. The first is that this study includes a large patient population with a range of clinical comorbidities. The second is that this is a prospective study that specifically evaluates trainee involvement at both the junior and senior level, so a direct comparison can be drawn. The third is that, to the best of our knowledge, this is the first study to evaluate the prevalence of which abdominal pressure and patient position changes are being used amongst trainees, and a direct comparison can be drawn to attending physicians.\u003c/p\u003e \u003cp\u003eLimitations of this study include inter-observer variability among physicians performing the colonoscopies, single hospital center data, and lack of objective confirmation of the presence of loops (as with scope guide). To further corroborate these findings, multi-center studies are needed to evaluate the frequency of these maneuvers across gastroenterology fellowship programs.\u003c/p\u003e \u003cp\u003eCurrently, loop management is a subjective assessment and is not standardized across formal assessment tools used for gastroenterology fellows. The data presented in this study emphasizes the potential utility of incorporating abdominal pressure and patient position changes as components of colonoscopy competence assessment tools to help provide standardization of evaluation of loop management \u0026ndash; a core endoscopic milestone that is often reached after other non-endoscopic landmarks are met.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003eNo financial or non-financial disclosures exist for any author\u003c/p\u003e\n\u003cp\u003eFunding Declaration: no funding disclosures to provide\u003c/p\u003e\n\u003cp\u003eAuthor Contribution\u003c/p\u003e\n\u003cp\u003eA.G wrote the main manuscript text and collected dataB.S., B.Y., N.B., M.K., M.N., T.C. collected dataI.A. reviewed manuscriptM.M. prepared figures and reviewed manuscript\u003c/p\u003e\n\u003cp\u003eEthics Declaration:\u003c/p\u003e\n\u003cp\u003eThis study was approved by the OU Health Sciences Institutional Review Board, which works to protect the rights, safety, and well-being of people involved in the research. This study was approved as it met the ethical principles and complied with federal regulations, state laws, and OU policies. \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eEickhoff A, et al. Colon anatomy based on CT colonography and fluoroscopy: Impact on looping, straightening and ancillary manoeuvres in colonoscopy. Dig Liver Dis. 2010 Apr; 42(4): 291-6.\u003c/li\u003e\n \u003cli\u003eFranco DL, Leighton JA, Gurudu SR. Approach to Incomplete Colonoscopy: New Techniques and Technologies. Gastroenterol Hepatol (N Y). 2017;13:476-483.\u003c/li\u003e\n \u003cli\u003eGupta M, Holub JL, Eisen G. Do indication and demographics for colonoscopy affect completion? A large national database evaluation. Eur J Gastroenterol Hepatol. 2010 May; 22(5).\u003c/li\u003e\n \u003cli\u003eHaycock A, et al. Cotton and Williams\u0026apos; practical gastrointestinal endoscopy - the fundamentals. 7th ed. John Wiley \u0026amp; Sons; 2014.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSaiu K, et al. Colonoscopy Direct Observation of Procedural Skills Assessment Tool for Evaluating Competency Development During Training. \u0026nbsp;Gastroenterology. Feb 2020; 115: 234-243.\u003c/li\u003e\n \u003cli\u003eSchulman AR, Ryou M, Chan WW. A Novel Hands-Free Abdominal Compression Device for Colonoscopy Significantly Decreases Cecal Intubation Time: A Prospective Single-Blinded Pilot Study. J Laparoendosc Adv Surg Tech A. 2017;27(6):564-570.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWalsh C. In-training gastrointestinal endoscopy competency assessment tools: Types of tools, validation and impact. \u0026nbsp;Best Practice \u0026amp; Research Clinical Gastroenterology. 2016; 30: 357-374.\u003c/li\u003e\n \u003cli\u003eWayne JD, Yessayan SA, Lewis BS, Fabry TL. The technique of abdominal pressure in total colonoscopy. Gastrointest Endosc. 1991;37:147-151.\u003c/li\u003e\n \u003cli\u003eWayne JD. Difficult Colonoscopy. Gastroenterol Hepatol. 2013 Oct; 9(10): 676-678.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWitte TN, Enns R. The difficult colonoscopy. Can J Gastroenterol. 2007;21(8):487-490.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eCuda T, et al. The correlation between diverticulosis and redundant colon. Int J Colorectal Dis. 2017; 32(11): 1603-1607. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"colonoscopy, looping, fellowship training, abdominal pressure, position changes","lastPublishedDoi":"10.21203/rs.3.rs-6753446/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6753446/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eColonoscopy competency is a critical milestone in progression through gastroenterology fellowship. Overcoming looping is essential for achieving proficiency – often overcome with abdominal pressure and patient position changes. Literature is limited on the systematic evaluation of these maneuvers in training centers. We aim to evaluate the frequency of abdominal pressure and/or patient position adjustments throughout fellowship.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a cross-sectional study of 1029 individuals undergoing colonoscopy at the Oklahoma City VA Medical Center. Maneuvers used were assessed using a questionnaire completed by the endoscopist. Patient demographics were extracted retrospectively. \u0026nbsp;Factors associated with need for abdominal pressure or position changes were determined through univariate and multivariate regression analyses. Adjusted odds ratios (aOR) were calculated using attending physicians as the reference and comparing them to junior (first year) and senior fellows (second/third year).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e999/1029 (97%) of colonoscopies had post-procedure questionnaires completed. Female sex (OR=1.6, 95% CI: 1.1, 2.4), moderate sedation (OR=1.5, 95% CI: 1.1, 2.1), and fellow involvement (OR=2.3, 95% CI: 1.7, 3.1) were significantly associated with abdominal pressure or patient position changes. Either or both maneuvers were required in 193 (51%) junior fellow cases (aOR=1.6, 95% CI: 1.3, 1.9); 128 (42%) senior fellow cases (aOR=2.0, 95% CI: 1.4, 2.9); and 82 (26%) attending-only cases (aOR=1.00).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAbdominal pressure and patient repositioning were more common in fellow-led colonoscopies but decreased with training progression. \u0026nbsp;This study emphasizes the potential utility of incorporating these maneuvers into colonoscopy competency assessment tools to help provide standardization of loop management across fellowship programs.\u003c/p\u003e","manuscriptTitle":"Abdominal Pressure and Patient Position Changes During Colonoscopy: Potential Adjunct Variables in Assessment of Colonoscopy Competence","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-05 07:27:35","doi":"10.21203/rs.3.rs-6753446/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"be2b0a4a-ff74-4df2-8c56-e633b78c82f8","owner":[],"postedDate":"June 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-07T01:38:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-05 07:27:35","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6753446","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6753446","identity":"rs-6753446","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}