Differences in colonoscopy technique impact quality

The Relationship Between Colonoscopy Practice Style, Operator Ergonomics and Procedure Quality

OBJECTIVE

We aimed to compare three endoscopy operators who performed colonoscopy in three different styles in terms of procedure results, colonoscopy quality, and operator comfort during the procedure.

PATIENTS AND METHODS

A total of 246 patients, who underwent routine screening colonoscopy for precancerous lesions between May and December 2022 in Istanbul Haydarpaşa Numune Education and Research Hospital, Istanbul, Turkey, were prospectively analyzed. The results of three different styles (single operator sitting, single operator standing, and two operators standing) were compared with each other. The following criteria were examined: polyp/adenoma detection rate, number of polyps detected per patient, cecal intubation rate, total procedure time, number of endoscope corrective maneuvers, number of patient position corrections during the procedure, and the endoscopist's subjective pain scale after the procedure.

RESULTS

 The number of corrections and changes in scope position, rates of changing the patient's position during the procedure, and the postprocedural fatigue degree of the endoscopist were the highest for the single-operator standing style (p<0.001). The total processing time and post-procedure fatigue degree of the endoscopist were the lowest for the single-operator sitting style (p<0.001). The adenoma detection rate was the highest for single-operator standing style (37.8% vs 22.0% and 29.3%). The strongest predictive factors for the total procedure time were the colonoscopy style and patient age. The strongest predictive factors for the change in the total number of detected polyps were colonoscopy style, patient gender, and patient age. Independent of all other factors, the total detected number of polyps was statistically significantly higher for the single-operator standing style compared to other styles (B=-0.217, 95% confidence interval: -0.369 - -0.066 and p=0.005) (B=-0.172, 95% confidence interval: -0.326 - -0.017 and p=0.029).

CONCLUSIONS

Two conclusions were drawn from this study. For routine screening colonoscopy, the single-operator sitting style seems to be superior to other styles in terms of the shortest procedure time and the least tiring. However, the widely used single-operator standing style should be preferred over other styles in terms of the highest adenoma detection rate although it is most tiring and time-consuming.

Sedative effect of remimazolam combined with alfentanil in colonoscopic polypectomy: a prospective, randomized, controlled clinical trial

Background

Remimazolam is a newer benzodiazepine with properties of rapid onset, short duration of action, and fast recovery. Our study was to evaluate the effects of different doses of remimazolam combined with alfentanil in colonoscopic polypectomy.

Methods

One hundred twenty patients were randomly divided into four groups: alfentanil and propofol (AP) group, alfentanil and remimazolam 0.1 mg/kg (AR1 group), 0.15 mg/kg (AR2 group), or 0.2 mg/kg (AR3 group). Patients in the four groups received alfentanil 10 μg/kg, followed by propofol 2 mg/kg and three dosages of remimazolam. Modified Observer's Assessment of Alertness and Sedation (MOAA/S) scale, heart rate (HR), oxygen saturation (SpO₂), respiratory rate (RR), bispectral index (BIS) values and mean arterial pressure (MAP) were collected at intervals of 5 min and analyzed at different time points: before anesthesia (T0), 5 min (T1), 10 min (T2), 15 min after anesthesia (T3) and at the end of surgery (T4). The average MAP was calculated utilizing the average of all MAP values. The primary outcome was the success rate of sedation. Secondary outcomes included time to full alert and adverse events.

Results

The success rate of sedation was 100% among the four groups. The incidence of hypotension was significantly decreased (all P < 0.05) and the average MAP was higher in AR1-AR3 groups than AP group (all P < 0.001). None of the patients developed bradycardia or hypertension during surgery in all study groups. BIS values were higher (all P < 0.001) and the time to full alert was statistically shorter in AR1-AR3 groups (all P < 0.05) compared with the AP group. The MOAA/S score in AR1 was higher than AR2 (P < 0.05) and the AR3 group (P < 0.05) at T1 and BIS values in the AR1 group were significantly higher than AR3 group (P < 0.05) at T4.

Conclusions

Remimazolam combined with alfentanil have a non-inferior sedative effect than propofol during the colonoscopic polypectomy. Moreover, this combination of two short-acting drugs might be a safer alternative.

Trial registration

The clinical trial was registered on (16/05/2021, ChiCTR2100046492).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01805-3.

Efficacy and safety of the starting position during colonoscopy: a systematic review and meta-analysis

Background and study aims  We aimed to assess the efficacy and safety of the starting position during colonoscopy. Patients and methods  We searched CENTRAL, MEDLINE, EMBASE, and the WHO International Clinical Trials Registry Platform through February 2019 to identify studies reporting the comparison between the right/supine/prone/tilt-down and left lateral starting position during colonoscopy. The primary outcomes were mean cecal insertion time and adverse events requiring medication. Two reviewers performed study selection and risk of bias assessment. We determined the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation method. This study was registered in PROSPERO (CRD42019124360). Results  We identified 10 randomized controlled trials (RCTs) (2083 participants), including three trials on right/tilt-down versus left, two trials on supine/prone versus left, respectively. Mean difference in mean cecal insertion time in supine versus left was -41.0 s (95 % confidence interval [CI] -57.3 to -24.7) in one study and in tilt-down versus left was - 37.3 s (95 % CI -72.1 to -2.4; I ²  = 58 %) in three studies; however, there were no statistically significant differences in prone/right versus left position (very low certainty of evidence). Four of eight studies noted adverse effects requiring medication (moderate certainty of evidence). One RCT applying the tilt-down position was terminated because of increased occurrence of oxygen desaturation. Conclusion  We could not conclusively determine the efficacy and safety of the starting position during colonoscopy because of low certainty of evidence. Further studies are needed to confirm the efficacy and safety of the starting potion during colonoscopy.

Factors for cecal intubation time during colonoscopy in women: Impact of surgical history

BACKGROUND/AIM

Cecal intubation during colonoscopy is prone to be prolonged in women, which may be related to frequent exposure to pelvic/abdominal surgery. We evaluated the association between Cecal Intubation Time (CIT) and prior episodes of pelvic/abdominal surgery in women.

PATIENTS AND METHODS

A cross-sectional study was conducted on screening participants who underwent colonoscopy. Multivariate regression with parameter estimates (β) was performed to determine the factors affecting CIT, including age, body mass index (BMI), bowel preparation, sedation, diverticulosis, experience of colonoscopists, and a surgical history. Also, subgroup analyses according to type of surgery were performed.

RESULTS

A total of 835 women were enrolled. The mean CIT was 5.82 ± 3.40 min. 323 females (38.7%) had episodes of surgery. The CIT was prolonged in cases performed by non-experienced trainees (β = 3.61, P< 0.001) and with a history of gynecological surgery (β = 0.97, P = 0.001). In the subgroup of non-experienced trainees, lower BMI, poor preparation, and a history of cesarean section significantly prolonged the CIT. Also, the risk for difficult colonoscopy (CIT ≥ 15 min) was increased with a history of cesarean section (odds ratio = 4.43, P= 0.024).

CONCLUSION

A prior episode of gynecological surgery prolonged CIT. Also, cesarean section history was associated with difficult colonoscopy in the examination by non-experienced trainees.

Impact of the supine position versus left horizontal position on colonoscopy insertion: a 2-center, randomized controlled trial

BACKGROUND AND AIMS

Colonoscopy insertion is painful for some patients and is one of the main barriers to screening colonoscopy. Few studies have assessed the impact of the supine position (SP) on colonoscopy insertion, especially for unsedated patients. The aim of this randomized controlled trial was to clarify this issue.

METHODS

Unsedated patients were randomized to SP or left horizontal position (LHP) as the starting position of colonoscopy insertion. The primary outcome measure was cecal intubation time (CIT), and the secondary outcome measures were descending colon intubation time (DIT), pain score of patients, difficulty score according to the endoscopist, and patients' acceptance of unsedated colonoscopy.

RESULTS

A total of 347 patients were randomized to the SP group (175) or the LHP group (172). The CIT in the SP group was significantly shorter than that in the LHP group (275.0 seconds [interquartile range (IQR), 234.0-328.5 seconds] versus 316.0 seconds [IQR, 261.0-370.0 seconds], P < .001). The DIT was also shorter in the SP group (64.5 seconds [IQR, 52.0-86.3 seconds] versus 74.0 seconds [IQR, 62.0-92.0 seconds], P = .001). Compared with the LHP, the SP had a lower pain score (3.3 versus 3.9, P = .002), a lower difficulty score (3.1 versus 3.7, P < .001), a lower frequency of position change (7.1% versus 38.0%, P < .001), and less need for abdominal compression (39.1% versus 45.5%, P = .02). SP was the only modifiable and independent factor identified to reduce CIT and pain score and improve patients' acceptance of unsedated colonoscopy.

CONCLUSIONS

As an economical and convenient method, SP can reduce CIT, ease pain, and improve patients' acceptance of unsedated colonoscopy. (Clinical trial registration number: NCT03289442.).

Effectiveness and safety of gastrointestinal endoscopy during a specific sedation training program for non-anesthesiologists

INTRODUCTION

sedation is a key component for the improvement of sedation quality. A correct administration requires appropriate training. We performed a study to compare sedation effectiveness, safety and patient satisfaction when administered by gastroenterologists, with and without specific training.

METHODS

a training program enrolled a group of gastroenterologists (trained group, n = 4) and their results were compared to those from a non-trained group (n = 3). ASA 1-3 patients who had undergone sedation by a gastroenterologist using midazolam and fentanyl were included over a period of 30 months. Safety was assessed in terms of the complication rate, effectiveness was assessed via the rate of completed endoscopic procedures and patient satisfaction was evaluated via a phone interview the day after the procedure.

RESULTS

a total of 3,475 patients were sedated by gastroenterologists during the study period. Significant differences were found that favored the trained group for completed procedures (5.6% vs 8.9%). A lower rate of excessive sedation (1.3% vs 8.61%), hypoxemia (0.72% vs 2.49%) and post-procedural pain (1.8% vs 4.3%) were also achieved. Patient satisfaction surpassed 99.5% and there were no significant differences between groups.

CONCLUSIONS

our sedation training program improved the effectiveness and safety outcomes when compared to sedation administered by gastroenterologists without this specific training.

A descriptive monitoring study of a non-anesthetist sedation quality program

INTRODUCTION

sedation substantially improves the quality of digestive endoscopy procedures but may result in severe complications.

METHODS

a joint commission-based multidisciplinary protocol was used to define a protocol for sedation by non-anesthesiologists. ASA 4 patients were excluded, as well as patients with a difficult airway, complex procedures and deep sedation. Quality based on the analysis of 9 indicators were monitored. Incomplete procedures were also monitored in order to assess efficacy.

RESULTS

patient safety was established based on a very low incidence of complications and a rate of respiratory events of 1.07. Furthermore, a low rate of hypotension and bradycardia was found, as well as a low rate of pain, either during or after endoscopy and an incidence of unexpected admissions lower than 0.5%. The quality indicators measured reflect the evolution of the results of the program.

CONCLUSIONS

ongoing sedation program monitoring in endoscopy allows the control of different quality dimensions and the implementation of steps for process improvement.

Colonoscopy procedure simulation: virtual reality training based on a real time computational approach

BACKGROUND

Colonoscopy plays an important role in the clinical screening and management of colorectal cancer. The traditional 'see one, do one, teach one' training style for such invasive procedure is resource intensive and ineffective. Given that colonoscopy is difficult, and time-consuming to master, the use of virtual reality simulators to train gastroenterologists in colonoscopy operations offers a promising alternative.

METHODS

In this paper, a realistic and real-time interactive simulator for training colonoscopy procedure is presented, which can even include polypectomy simulation. Our approach models the colonoscopy as thick flexible elastic rods with different resolutions which are dynamically adaptive to the curvature of the colon. More material characteristics of this deformable material are integrated into our discrete model to realistically simulate the behavior of the colonoscope.

CONCLUSION

We present a simulator for training colonoscopy procedure. In addition, we propose a set of key aspects of our simulator that give fast, high fidelity feedback to trainees. We also conducted an initial validation of this colonoscopic simulator to determine its clinical utility and efficacy.

The use of ancillary techniques to aid colonoscope insertion

BACKGROUND

There is more to a high-quality colonoscopy than reaching the cecum or finding adenomas. Gentle insertion involves ancillary techniques, some of which are impossible in patients receiving deep sedation. The aim of this study was to assess the importance of ancillary techniques in achieving a comfortable, complete colonoscopy.

METHODS

This was a prospective study of 500 consecutive outpatient colonoscopies performed by a single endoscopist. During the procedure, note was taken of various ancillary techniques used to facilitate insertion: turning the patient, patient holding their breath, abdominal pressure. The success of these techniques in helping scope advancement was also noted. After the procedure the patient was asked to rate the severity of their pain and their degree of satisfaction with the examination.

RESULTS

A total of 238 women and 262 men participated in the study, and colonoscopy was complete in 96.2 and 98.5%, respectively. Overall, 97% of patients received versed alone (average dose 2 mg), and 3% received a narcotic (average dose 46 U). Average pain score was 3.9 on a scale of 1 (least pain) to 10 (worst pain), and average satisfaction with the procedure as a whole was 9.5 on a similar scale. Ancillary techniques of holding breath, directed abdominal pressure, and turning to the left, right, and prone were used in 46, 56, 17, 23, and 4% of examinations, respectively. Each technique was effective in helping insertion in over 70% of cases. Turning the patient was also used to clear stool, open the colon, or facilitate polypectomy in another 33 cases. Multiple techniques were used in 49% of patients.

CONCLUSION

The use of ancillary techniques to facilitate colonoscope insertion helps avoid the expense and potential side effects of deep sedation.