Clinical Characteristics and Main Findings of Colonoscopy in Tripoli Central Hospital: A Cross-Sectional Study of 1858 Patients

Introduction Colonoscopy is used to detect colorectal abnormalities, including inflammatory bowel disease, polyps, cancers, and other colorectal lesions. We aimed to analyze the demographic and clinical characteristics, main findings, and indications of patients who underwent colonoscopy in the Surgery department of Tripoli Central Hospital in Libya. Methods The study data were retrospectively extracted from the medical in and out-patient records of individuals who underwent colonoscopy procedures between December 2009 and December 2016 in the general surgery department of Tripoli General Hospital. Results A total of 1858 patients underwent colonoscopy during the study period with a mean age of 51.7 ± 18.5 years. Hematochezia was the most common patient complaint (530; 28.5%), followed by constipation (354; 19.1%), and weight loss (178; 9.6%), respectively. Seven-hundred sixty-five (765; 41.2%) participants completed the procedure, 420 (22.6%) did not, and 673 (36.2%) participants failed the colonoscopy. The most common reasons for procedure failure were failed preparation (609; 55.7%), followed by patient intolerance (251; 23.0%), and obstructive lesions (229; 21.0%). The most common finding was colonic masses, followed by polyps (29.0% and 20.8%, respectively). Conclusion This study describes the characteristics of colonoscopy patients in the largest surgical center in Libya over seven years. Hematochezia and chronic constipation were the most common complaints among the participants with reported complaints. Half of the colonoscopy procedures are incomplete or failed due to the lack of patient preparation. Colonic masses and polyps were the most common among the reported colonoscopic findings. Future research to increase the quality of colonoscopy service and patient preparations in Libya is required.


Introduction
Colonoscopy is the gold-standard examination of lower gastrointestinal symptoms such as abdominal pain, polyps, diarrhea, difficulty defecation, hematochezia, or mucoid stool. Colonoscopy is performed through a long flexible tube called a colonoscope with a fiber-optic camera at its tip and enters the body through the rectum [1]. It is helpful for the detection and/or removal of precancerous and cancerous colonic or rectal lesions [2]. Colonoscopy is essential for the final diagnosis of inflammatory bowel disease (IBD), colonic adenomas, colonic polyps, and colorectal cancer (CRC) [3]. The progress and development of the modern gastroenterology field depend significantly on the advances in colonoscopy technology [3]. The colonoscopy was completed if the endoscope reached the cecum and ileum or the anastomosis in subjects with surgical resection for the tumor [4].
Libya is a war-torn country despite having large, proven oil reserves: worldwide (3%) and in Africa (39%). Political instability and militia attacks have restricted the country's development due to low external and internal investments since 2011 [5]. A recent study showed that most colorectal cancer patients in Libya present in the late or metastatic stages, which requires further improvements in the screening methods and particularly necessitates more efficient colonoscopy protocols [6]. Another epidemiological study showed that Libya has the highest incidence of CRC in North African countries. In Libya, CRC was the most common cancer among men and the second most common cancer among women after breast cancer [7].
Tripoli, Libya's biggest city and official capital, has over one million citizens out of seven million Libyans [8].
Despite the high safety, acceptability, and efficacy of colonoscopy globally, the applicability, availability, and screening protocols might be limited in some poor-resource settings.
To better understand the demographic and clinical characteristics of colonoscopy patients and colonoscopy procedure characteristics, we conducted this retrospective chart review of all patients who underwent colonoscopy in Tripoli Central Hospital, Libya, within seven years, from 2009 to 2016.

Materials And Methods
We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement guidelines when reporting this manuscript. The ethics committee of Tripoli Central Hospital approved this study. The confidentiality and anonymity of the participants were maintained when exporting these data from the database.

Study setting and design
The study setting was the surgery department of Tripoli General Hospital, the only hospital conducting colonoscopy procedures in the whole of Tripoli. This cross-sectional study aimed to assess the demographic and clinical characteristics, main findings, and indications of patients who underwent the service of the colonoscopy procedure.

Study population
The study data were retrospectively extracted from the medical in and out-patient records of individuals who underwent colonoscopy procedures between December 2009 and October 2016 in the surgery department of Tripoli General Hospital.

Selection criteria
We did not apply strict selection criteria. All patients who underwent colonoscopy within the study period were included in this analysis if they met the following criteria: (1) Adult patients, age >18 years (2) Both sexes (males and female)

The procedure of case identification
We retrospectively identified patients from a prospectively collected database in the surgery department of Tripoli Central Hospital. At the time of initiating this study, a total of 1858 patients were eligible for inclusion in the final analysis.

Data collection
We retrieved this study data from the Surgery department of Tripoli Central Hospital, which hosts a prospective database of patient data. On a weekly basis, the surgical team, including surgical specialists, trainees, and registrars, submit the electronic records to Google Drive forms based on the paper copies of the patient tickets. The database was maintained by a computer engineer responsible for database maintenance, coding, and exporting, with no further involvement in the study.

Study variables
The main variables of this study were as follows: sex, age, training level of the medical personnel conducting the colonoscopy, patient complaints, endoscope entry point, endoscopy type, presence, number, and type of pathologies in every patient.

Statistical analysis
Data were summarized and described as frequencies and percentages for categorical variables or mean and standard deviation for continuous variables. The Shapiro-Wilk test was conducted to ensure the normality distribution of the continuous variables. Data were analyzed using Jamovi version 2.0 for macOS (https://www.jamovi.org/).  Hematochezia was the most common patient complaint among the reported complaints, followed by constipation and weight loss, representing 530 (28.5%), 354 (19.1%), and 178 (9.6%), respectively. Additionally, ulcerative colitis was the least common complaint, reported as the reason for endoscopy in six (0.3%) of the patients ( Table 1).

n (%)
The outcome of the procedure  Repeat endoscopy was advised for 25% of the patients, 18.2% were admitted to receive surgical or medical treatment, 17.7% were advised fiber diets, and the remaining patients received variable recommendations ( Table 3).

Discussion
Colonoscopy is used for the diagnosis and removal of precancerous and cancerous colonic or rectal lesions, including the diagnosis of inflammatory bowel disease, colonic adenomas, colonic polyps, and colorectal cancer, recently. Moreover, the clinical characteristics, main findings, and indications of colonoscopy have been assessed in different regions of the world, especially in developed countries [9][10][11].
To the best of our knowledge, this is the first cross-sectional study to assess colonoscopy's clinical characteristics and main findings in Tripoli, Libya. Our results expand the literature by providing new information about the demographic, clinical characteristics, and main findings of colonoscopy procedures in the Surgery department of Tripoli Central Hospital. The mean age of the study participants was 51.7 ± 18.5, and females were slightly higher than males. This study showed that bleeding per rectum and chronic constipation were the most common reasons for colonoscopy. The most common findings were masses and polyps. A significant proportion of patients have an incomplete or failed colonoscopy, mostly because of the failed preparation or the patient's intolerance to the procedure.
As mentioned earlier, the colonoscopy was completed if the endoscope reached the cecum and ileum or the anastomosis in subjects with surgical resection for the tumor. Our results showed a completed colonoscopy in 765 participants (41.2%). Bowles et al. reported colonoscopy completion rates ranging from 56.9 to 76.9% according to the exact definition [10]. Similarly, Qu et al. reported the procedure's completion in 315/448 participants (70.31%) using the precise completion definition [4]. These differences could be explained by the difference in the type of patients who undergo colonoscopy, different settings, and different medical facilities and personnel.
In this study, colonic polyps were found in 20.8% of the participants. In African countries, such as Kenya, Nigeria, and Zimbabwe, colonic polyps have been reported at lower rates, from 5% to 10.3% in several studies [12][13][14]. A recent retrospective observational study conducted in Tanzania found that colonic polyps occur in 25% of colonoscopy patients [4]. Since some types of colonic polyps are genetically inherited, this difference may be explained by the variations in patient race and origins (e.g., Arabs, Africans, … etc.).
The indications and system of colonoscopy are recently debated topics in Libyan healthcare systems. On the one hand, studies report a high incidence of CRC in Libya compared to other North African countries and a more late presentation with advanced or metastatic CRC [6,7]. On the other hand, there are no national guidelines for colonoscopy procedures in Libya. Each center operates based on physician judgment, expert opinion, and local regulations. A recent study showed that a modified open-access referral system increases the appropriateness of colonoscopy procedures even if no definitive guidelines were followed [15].

Strengths and limitations
To the best of our knowledge, this is the first study to assess the clinical characteristics and main findings of colonoscopy in Tripoli using data from the largest surgical center in Libya. The results of this study reflect the real-life characteristics of colonoscopy patients in Tripoli, Libya, as well as the indications of colonoscopy according to the local guidelines. Also, the political instability in Libya during the study period may play a role in the shortage of medical facilities, especially endoscopic devices, and trained medical personnel, resulting in a decreased proportion of patients receiving a colonoscopy.

Conclusions
This study describes the characteristics of colonoscopy patients in the largest surgical center in Libya over seven years. Hematochezia and chronic constipation were the most common complaints among participants with reported complaints. Half of the colonoscopy procedures are either incomplete or failed due to the lack of patient preparation for the procedure. Colonic masses and polyps were the most common among the reported colonoscopic findings. Future research to increase the quality of colonoscopy service and patient preparations in Libya is required.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Tripoli Central Hospital, Tripoli, Libya issued approval NA. We followed the STROBE statement guidelines when reporting this manuscript. This study was approved by the ethics committee of Tripoli central hospital. The confidentiality and anonymity of the participants were maintained when exporting these data from the database. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.