Bowel Preparation Quality for Optimal Sessile Serrated Lesions Detection: Is Excellent the Enemy of Good?

Bowel preparation quality is a critical indicator of colonoscopy performance. This study investigated the relationship between different adequate preparation levels and the detection rates of SSLs.

We retrospectively analyzed 9,854 individuals with adequate bowel preparation (Aronchick scale) undergoing index colonoscopy. The primary outcome was SSL detection rate (SSLDR), and secondary outcomes include adenoma detection rate (ADR). Multivariable logistic regression and sensitivity analyses were performed to identify independent predictors.

SSLDR was significantly higher in the "good" preparation group compared to the "excellent" group (8.4% vs. 4.7%, P < 0.001). In the multivariable analysis including fecal occult blood test results, symptomatic presentation (OR 10.22; 95% CI, 5.49-19.02), high-performing endoscopist expertise (OR 3.78; 95% CI, 2.34-6.11), and longer withdrawal time (OR 1.15 per minute; 95% CI, 1.12-1.19) were identified as strong independent predictors of SSL detection. Conversely, positive FOBT results (OR 0.46; 95% CI, 0.30-0.68) and synchronous adenoma detection (OR 0.39; 95% CI, 0.28-0.52) were inversely associated with SSL detection. Sensitivity analysis of the full cohort confirmed these procedural predictors and the robust inverse relationship with synchronous adenomas (OR 0.42; P < 0.001). ADR was also independently higher in the good preparation group (OR 1.38; 95% CI, 1.12-1.69, P < 0.001).

Excellent bowel preparation did not translate into a higher SSLDR compared to good preparation. Instead, SSL detection may be primarily driven by endoscopist expertise, inspection time, and the clinical context of the patient.