Sedation and the technical performance of colonoscopy

Risk factors and management of iatrogenic colorectal perforation in diagnostic colonoscopy: a single-center cohort study

BACKGROUND AND AIMS

Diagnostic colonoscopy plays a central role in colorectal cancer screening programs. We analyzed the risk factors for perforation during diagnostic colonoscopy and discussed the treatment outcomes.

METHODS

We performed a retrospective analysis of risk factors and treatment outcomes of perforation during 74,426 diagnostic colonoscopies between 2013 and 2018 in a tertiary hospital.

RESULTS

A total of 19 perforations were identified after 74,426 diagnostic colonoscopies or sigmoidoscopies, resulting in a standardized incidence rate of 0.025% or 2.5 per 10,000 colonoscopies. The majority (15 out of 19, 79%) were found at the sigmoid colon and recto-sigmoid junction. Perforation occurred mostly in less than 1000 cases of colonoscopy (16 out of 19, 84%). In particular, the incidence of perforation was higher in more than 200 cases undergoing slightly advanced colonoscopy rather than beginners who had just learned colonoscopy. Old age (≥ 70 years), inpatient setting, low body mass index (BMI), and sedation status were significantly associated with increased risk of perforation. Nine (47%) of the patients underwent operative treatment and ten (53%) were managed non-operatively. Patients who underwent surgery were often diagnosed with delayed or concomitant abdominal pain. Perforations of rectum tended to be successfully treated with endoscopic clipping.

CONCLUSIONS

Additional precautions are required to prevent perforation in elderly patients, hospital settings, low BMI, sedated patients, or by a doctor with slight familiarity with endoscopies (but still insufficient experience). Endoscopic treatment should be actively considered if diagnosis is prompt, abdominal pain absent, and especially the rectal perforation is present.

Propofol sedation does not improve measures of colonoscopy quality but increase cost - findings from a large population-based cohort study

Background

Propofol is often used for sedation during colonoscopy. We assessed the impact of propofol sedation on colonoscopy related quality metrics and cost in a population-based cohort study.

Methods

All colonoscopies performed at 21 hospitals in the province of Ontario, Canada, during an 18-month period, from April 1, 2017 to October 31, 2018, using either propofol or conscious sedation were evaluated. The primary outcome was adenoma detection rate (ADR) and secondary outcomes were sessile serrated polyp detection rate (ssPDR), polyp detection rate (PDR), cecal intubation rate (CIR), and perforation rate. Binary outcomes were assessed using a modified Poisson regression model adjusted for clustering and potential confounders based on patient, procedure, and physician characteristics.

Findings

A total of 46,634 colonoscopies were performed, of which 16,408 (35.2%) received propofol and 30,226 (64.8%) received conscious sedation. Compared to conscious sedation, the use of propofol was associated with a lower ADR (24.6% vs. 27.0%, p < 0.0001) but not ssPDR (5.0% vs. 4.7%, p = 0.26), PDR (40.5% vs 40.4%, p = 0.79), CIR (97.1% vs. 96.8%, p = 0.15) or perforation rate (0.04% vs. 0.06%, p = 0.45). On multi-variable analysis, propofol sedation was not associated with any differences in ADR (RR = 0.90, 95% CI 0.74-1.10, p = 0.30), ssPDR (RR = 1.20, 95% CI 0.90-1.60, p = 0.22), PDR (RR = 1.00, 95% CI 0.90-1.11, p = 0.99), or CIR (RR = 1.00, 95% CI 0.80-1.26, p = 0.99). The additional cost associated with propofol sedation was $12,730,496 for every 100,000 cases.

Interpretation

The use of propofol sedation was not associated with improved colonoscopy related quality metrics but increased costs. The routine use of propofol for colonoscopy should be reevaluated.

Funding

None.

Effect of remimazolam vs propofol in high-risk patients undergoing upper gastrointestinal endoscopy: a non-inferiority randomized controlled trial

BACKGROUND

Procedural sedation is essential for optimizing upper gastrointestinal endoscopy, particularly in high-risk patients with multiple underlying diseases. Respiratory and circulatory complications present significant challenges for procedural sedation in this population. This non-inferiority randomized controlled trial aims to investigate the safety and comfort of remimazolam compared to propofol for procedural sedation during upper gastrointestinal endoscopy in high-risk patients.

METHODS

A total of 576 high-risk patients scheduled to undergo upper gastrointestinal endoscopy are planned to be enrolled in this study and randomly allocated to either the remimazolam or propofol group. The primary outcome measure is a composite endpoint, which includes (1) achieving a Modified Observer's Alertness/Sedation scale (MOAA/S) score ≤ 3 before endoscope insertion, (2) successful completion of the endoscopic procedure, (3) the absence of significant respiratory instability during the endoscopy and treatment, and (4) the absence of significant circulatory instability during the examination. The noninferiority margin was 10%. Any adverse events (AEs) that occur will be reported.

DISCUSSION

This trial aims to determine whether remimazolam is non-inferior to propofol for procedural sedation during upper gastrointestinal endoscopy in high-risk patients, regarding success rate, complication incidence, patient comfort, and satisfaction. TRIAL REGISTRATION {2A AND 2B}: Chinese Clinical Trial Registry ClinicalTrials.gov ChiCTR2200066527. Registered on 7 December 2022.

Women require routine opioids to prevent painful colonoscopies: a randomised controlled trial

BACKGROUND

Women are at high risk for painful colonoscopy. Pain, but also sedation, are barriers to colorectal cancer (CRC) screening participation. In a randomised controlled trial, we compared on-demand with pre-colonoscopy opioid administration to control pain in women at CRC screening age.

METHODS

Women, aged 55-79 years, attending colonoscopy at two Norwegian endoscopy units were randomised 1:1:1 to (1) fentanyl on-demand, (2) fentanyl prior to colonoscopy, or (3) alfentanil on-demand. The primary endpoint was procedural pain reported by the patients on a validated four-point Likert scale and further dichotomized for the study into painful (moderate or severe pain) and non-painful (slight or no pain) colonoscopy. Secondary endpoints were: willingness to repeat colonoscopy, adverse events, cecal intubation time and rate, and post-procedure recovery time.

RESULTS

Between June 2017 and May 2020, 183 patients were included in intention-to-treat analyses in the fentanyl on-demand group, 177 in the fentanyl prior to colonoscopy group, and 179 in the alfentanil on-demand group. Fewer women receiving fentanyl prior to colonoscopy reported a painful colonoscopy compared to those who were given fentanyl on-demand (25.2% vs. 44.1%, p < .001). There was no difference in the proportion of painful colonoscopies between fentanyl on-demand and alfentanil on-demand (44.1% vs. 39.5%, p = .40). No differences were observed for adverse events or any of the other secondary endpoints between the three groups.

CONCLUSIONS

Fentanyl prior to colonoscopy provided better pain control than fentanyl or alfentanil on-demand. Fentanyl before colonoscopy should be recommended to all women at screening age. Trial registration: Clinicaltrials.gov (NCT01538550). Norwegian Medicines Agency (16/16266-13). EU Clinical Trials Register (EUDRACTNR. 2016-005090-13).

Anesthetic effect of different doses of butorphanol in patients undergoing gastroscopy and colonoscopy

Background

This study aimed to investigate the anesthetic effect of butorphanol with different doses in patients undergoing gastroscopy and colonoscopy.

Methods

480 patients undergoing gastroscopy and colonoscopy were recruited and randomly divided into four groups to receive different doses of butorphanol (Group A = 2.5 μg/kg, Group B = 5 μg/kg, Group C = 7.5 μg/kg and Group D = 10 μg/kg). Butorphanol was administered 5 min before propofol infusion. The primary outcome was the incidence of body movement. Secondary outcomes were postoperative recovery time, length of stay in the Post-Anesthesia Care Unit (PACU), the total dose of propofol, and the incidence of intraoperative hypoxemia, propofol injection pain, cough, postoperative nausea and vomiting, drowsiness, and dizziness.

Results

The incidence of body movement and the dose of propofol in Group C and D were lower than those in Group A and B (P < 0.05). The incidence and intensity of propofol injection pain and the incidence of cough in Group B, C, and D were lower than those in Group A (P < 0.05). The length of stay in PACU and the incidence of postoperative drowsiness and dizziness were higher in Group D than in Group A, B, and C (P < 0.05).

Conclusion

Intravenous pre-injection of 7.5 μg/kg butorphanol with propofol can be the optimal dosage for patients undergoing gastroscopy and colonoscopy.

Trial registration: Trial registration: Chinese Clinical Trial Registry, ChiCTR2000031506. Registered 3 April 2020—Retrospectively registered, http://www.medresman.org.cn.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01262-8.

The Effect of Music Listening on Pain in Adults Undergoing Colonoscopy: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the role of music listening in reducing pain in adults undergoing colonoscopy.

DESIGN

This is a systematic review and meta-analysis of randomized control trials (RCTs) that evaluated the effect of music in reducing pain in adults undergoing colonoscopy.

METHODS

We searched CINAHL, Embase, MEDLINE, PsycINFO, and PubMed for RCTs that reported on the effects of music listening in reducing pain in adult patients undergoing colonoscopy from database inception to March 15, 2020, when the search was completed. Studies published in English with adult participants testing the efficacy of music during colonoscopy were eligible for inclusion. Studies reporting the results of combined nonpharmacological interventions were excluded. The methodological quality of each included RCT was assessed using the Cochrane Collaboration tool for assessing the risk of bias. Two authors independently abstracted data and assessed risks of bias.

FINDINGS

Seven RCTs with a total of 622 adult participants fulfilled our inclusion criteria and were, therefore, included. A random-effects model estimated the summary effect of the 7 included studies as -1.83 ± 0.98, P = 0.06.

CONCLUSIONS

Although our meta-analysis demonstrated a small treatment effect, this effect was clinically not statistically significant. Substantial heterogeneity among the included trials limits the certainty of our findings. Additional trials investigating the effects of listening to music on pain in adults undergoing colonoscopy are needed to generate further evidence to establish the analgesic effect of music in adults undergoing colonoscopy.

Smartphone-controlled patch electro-acupuncture versus conventional pain relief during colonoscopy: a randomized controlled trial

BACKGROUND

Smartphone-controlled patch electro-acupuncture (SCEA) is a novel device which gives the same analgesic effect as with conventional acupuncture. There are no published articles in the English literature on the use of this device as a primary mode of pain relief during colonoscopy. Primary aims of this study were to investigate the efficacy of SCEA as a substitute for pain relief during colonoscopy.

METHODS

Thirty-seven patients were randomized to receive SCEA (n = 19) or placebo (n = 18) during colonoscopy. Additional rescue sedation was administered to patients if they had pain or discomfort during the procedure. Visual analogue scale was used to quantify the intensity of pain from the beginning to end of the procedure. Other variables analysed were the amount of sedation used, duration from start to caecal intubation, length of time for completion of colonoscopy and recovery time to home discharge.

RESULTS

Patients who received SCEA had a lower median pain score of 4.6 (interquartile range 5.7) compared to the placebo group of 6.0 (interquartile range 3.2). Statistical analysis comparing the groups revealed a non-significant P-value of 0.12, although more than 90% of the patients indicated willingness for SCEA as the primary analgesia if they were to repeat the procedure. Throughout the study, there were no adverse complications that occurred during the use of SCEA.

CONCLUSIONS

Even though this study did not demonstrate, a significance in pain reduction, SCEA remains a safe modality which, more than 90% of patients favoured as a substitute for pain relief during colonoscopy.

The effect of pre-procedure anxiety on sedative requirements for sedation during upper gastrointestinal endoscopy

Objectives

Sedation for upper gastrointestinal endoscopy, commonly used for diagnosis and treatment of gastrointestinal diseases, has been increasing widespread. Sedative agent requirements during sedation or anesthesia can be affected by many factors such as age and sex. In the present study, we aimed to evaluate the effects of pre-procedural anxiety levels on sedative requirements during upper gastrointestinal endoscopy.

Material and Methods

300 patients between the ages of 18-70 years were studied. Baseline anxiety levels were measured before the procedure using Spielberger's State-Trait Anxiety Inventory (STAI) form X1. Propofol was administered to have BIS values between 65-85 during sedation. Doses of propofol, total procedure time, satisfaction of the patients and endoscopists and BIS values were recorded.

Results

Pre-procedural anxiety was 44 (40-48 [20-70]). We found significant correlations between pre-procedure anxiety and the usage of propofol (mg, mg/kg, mg/kg/dk) at BIS values between 65-85, [respectively, (p= 0.451, p <0.001), (p= 0.455, p <0.001), (p= 0.428, p <0.001)]. No correlation was found between pre-procedure anxiety and procedural or sedation complications (respectively p= 0.111, p= 0.424 and p= 0.408, p= 0.363). We found significant negative correlations between pre-procedure anxiety and the satisfaction of the patients/endoscopist [respectively, (p= -0.477, p <0.001), (p= -0.495, p <0.001)].

Conclusion

Based on the results of this study, we suggest that there is a significant association between the pre-procedural anxiety levels and use of sedative drugs in patients undergoing upper gastrointestinal endoscopy.

Unsedated Colonoscopy: Impact on Quality Indicators

BACKGROUND

In the USA, sedation is commonly used for colonoscopies; though colonoscopy can be successfully performed without sedation, outcomes data in this setting are scarce.

AIMS

To determine patient characteristics associated with undergoing unsedated colonoscopy and whether adenoma detection rate (ADR) and cecal intubation rate (CIR) differ between sedated and unsedated colonoscopy.

METHODS

Using a single-center electronic endoscopy database, we identified patients who underwent outpatient colonoscopy between 2011 and 2018 with or without sedation. We used multivariable logistic regression to determine factors associated with unsedated colonoscopy, CIR, and ADR.

RESULTS

We identified 24,795 patients who underwent colonoscopy during the study period. Of these, 179 patients (0.7%) underwent unsedated colonoscopy. ADR was 27.4% in sedated and 21.2% in unsedated colonoscopies (p = 0.06); CIR was 95.8% in sedated and 85.5% in unsedated patients (p < 0.01). On multivariable analysis, male sex (OR 2.06, CI 1.52-2.79) and suboptimal bowel preparation (OR 1.75, CI 1.24-2.45) were associated with undergoing unsedated colonoscopy, while higher BMI was inversely associated with unsedated colonoscopy (BMI 25-29.9: OR 0.44, CI 0.25-0.77). On multivariable analysis, colonoscopy with sedation was associated with CIR (OR 3.79, CI 2.39-6.00) and ADR (OR 1.45, OR 1.00-2.10).

CONCLUSION

We found that undergoing outpatient colonoscopy with sedation as opposed to no sedation was significantly associated with a higher CIR and ADR. Our findings suggest sedation is necessary to meet current CIR and ADR guidelines; however, given the potential cost and safety benefits of unsedated colonoscopy, further investigation into methods to improve patient selection and colonoscopy quality indicators is warranted.

Anesthesia Assistance in Screening Colonoscopy and Adenoma Detection Rate Among Trainees

BACKGROUND AND AIMS

The use of anesthesia assistance (AA) for screening colonoscopy has been increasing substantially over the past decade, raising concerns about procedure safety and cost without demonstrating a proven improvement in overall quality indicators such as adenoma detection rate (ADR). The effect of AA on ADR has not been extensively studied among trainees learning colonoscopy. We aimed to determine whether type of sedation used during screening colonoscopy affects trainee ADR.

METHODS

Using the electronic endoscopy databases of two hospitals in our medical center, we identified colonoscopies performed by 15 trainees from 2014 through 2018, including all screening examinations in which the cecum was reached. Multivariable logistic regression was used to determine factors associated with adenoma detection.

RESULTS

We identified 1420 unique patients who underwent screening colonoscopy by a trainee meeting the inclusion criteria. Of these, 459 (32.3%) were performed with AA. Overall trainee ADR was 39.6%, with ADR increasing from 35.0% in year one of training to 42.8% in year three (p = 0.047). ADR for cases with AA was 37.9%, while ADR for conscious sedation cases was 32.0% (p = 0.374). Despite this 5.9% absolute difference, the use of AA was not associated with finding an adenoma on multivariable analysis when controlling for patient age, sex, smoking status, body mass index, trainee year of training, mean withdrawal time, supervising attending ADR, and bowel preparation quality (OR 0.85; 95% CI 0.67-1.09).

CONCLUSIONS

Despite providing the ability to more consistently sedate patients, the use of AA did not affect trainee ADR. These results on trainee ADR and sedation type suggest that the overall lack of association between AA use and ADR is applicable to the trainee setting.

A Prospective Study of Factors Associated with Abdominal Pain in Patients during Unsedated Colonoscopy Using a Magnifying Endoscope

Objective With the advent of endoscopic treatment, the detailed diagnosis of colorectal neoplasms made using magnifying colonoscopy has become increasingly important. However, insertion difficulty causes pain in unsedated colonoscopy. The aim of this prospective observational study was to clarify the factors associated with a patient's pain in unsedated colonoscopy using a magnifying endoscope. Methods Patient pain was assessed using a numerical rating scale (0-10) immediately after the procedure. We defined 5 as mild enough pain that patients would not be reluctant to undergo another colonoscopy. Acceptable pain was defined as 5 or less and severe pain was defined as 8 to 10. Univariate and multivariate linear regression analyses were performed using the pain scale score as a dependent variable. Results A total of consecutive 600 patients undergoing unsedated colonoscopies were evaluated to assess their abdominal pain. The completion rate was 99.5% (597/600). The mean pain scale score was 3.88±2.38. The rate of acceptable pain was 80.5% (483/600). The rate of severe pain was 6.7% (40/600) including the incomplete cases. A comparison of polyp-positive and polyp-negative cases revealed no marked difference in patient pain (3.82±2.24 vs. 3.94±2.49, respectively; p=0.590) or insertion time (6.62±3.98 vs. 6.29±4.21, p=0.090), while more observation time was needed in polyp-positive cases than in polyp-negative ones (16.30±4.95 vs. 13.08±4.69, p<0.01). Univariate and multivariate linear regression analyses revealed that an older age, colectomy, antispasmodic agent use, and a small-diameter endoscope were significant factors associated with less patient pain. In particular, a small-diameter endoscope induces significantly more acceptable pain than a non-small diameter endoscope [85.63% (274/320) vs. 73.93% (207/280), p=0.00003]. Conclusion Unsedated colonoscopy using a magnifying endoscope by an expert may result in acceptable pain levels. The use of an antispasmodic agent, particularly hyoscine N-butyl bromide, and a small-diameter endoscope are recommended for reducing abdominal pain during unsedated colonoscopy.

Substantial Increase in Anesthesia Assistance for Outpatient Colonoscopy and Associated Cost Nationwide

BACKGROUND AND AIMS

The use of anesthesia assistance (AA) for outpatient colonoscopy has been increasing over the past decade, raising concern over its effects on procedure safety, quality, and cost. We performed a nationwide claims-based study to determine regional, patient-related, and facility-related patterns of anesthesia use as well as cost implications of AA for payers.

METHODS

We analyzed the Premier Perspective database to identify patients undergoing outpatient colonoscopy at over 600 acute-care hospitals throughout the United States from 2006 through 2015, with or without AA. We used multivariable analysis to identify factors associated with AA and cost.

RESULTS

We identified 4,623,218 patients who underwent outpatient colonoscopy. Of these, 1,671,755 (36.2%) had AA; the proportion increased from 16.7% in 2006 to 58.1% in 2015 (P < .001). Factors associated with AA included younger age (odds ratios [ORs], compared to patients 18-39 years old: 0.94, 0.82, 0.77, 0.72, and 0.77 for age groups 40-49 years, 50-59 years, 60-69 years, 70-79 years, and ≥80 years, respectively); and female sex (OR, 0.96 for male patients compared to female patients; 95% CI, 0.95-0.96). Black patients were less likely to receive AA than white patients (OR, 0.81; 95% CI, 0.81-0.82), although this difference decreased with time. The median cost of outpatient colonoscopy with AA was higher among all payers, ranging from $182.43 (95% CI, $180.80-$184.06) higher for patients with commercial insurance to $232.62 (95% CI, $222.58-$242.67) higher for uninsured patients.

CONCLUSIONS

In an analysis of a database of patients undergoing outpatient colonoscopy throughout the United States, we found that the use of AA during outpatient colonoscopy increased significantly from 2006 through 2015, associated with increased cost for all payers. The increase in anesthesia use mandates evaluation of its safety and effectiveness in colorectal cancer screening programs.

Conscious sedation using propofol versus midazolam in cirrhotic patients during upper GI endoscopy: A comparative study

Aim

We aimed to assess the safety and efficacy of propofol versus midazolam in cirrhotic patients undergoing upper GI endoscopy.

Methods

Ninety compensated cirrhotic patients (all met class I–III criteria according to the American Society of Anesthesia) were enrolled in this comparative study. They were classified into three groups according to scheduled pre‐endoscopy sedation drugs; the midazolam group, which included 30 patients who received IV weight‐dependent midazolam (0.05 mg/kg with additional doses of 1 mg every 2 min when necessary, up to a maximum dose of 0.1 mg/kg or 10 mg); the propofol group, which included 30 patients who received a propofol bolus dose according to age and weight (0.25 mg/kg with additional doses of 20–30 mg every 30–60 s when necessary, up to a maximum dose of 400 mg); and the combined group, which included 30 patients who received half a dose of midazolam and of propofol.

Results

Prolonged postendoscopy recovery times were reported in the midazolam group, while shorter recovery times were reported in the propofol and combined groups. All patients in the propofol and combined groups gained consciousness shortly postendoscopy; however, only half of the midazolam group's patients gained consciousness after the standard recovery time (10–30 min). Highly significant differences were found among the three groups regarding consciousness level according to the Glasgow coma scale, as well as regarding the occurrence of hypoxia during endoscopy.

Conclusion

Considering safety and efficacy issues, propofol is better than midazolam in gastrointestinal endoscopy, especially in patients with liver cirrhosis.

Cecal intubation rates in different eras of endoscopic technological development

Introduction

Colonoscopy plays a critical role in colorectal cancer (CRC) screening and has been widely regarded as the gold standard. Cecal intubation rate (CIR) is one of the well-defined quality indicators used to assess colonoscopy.

Aim

To assess the impact of new technologies on the quality of colonoscopy by assessing completion rates.

Material and methods

This was a dual-center study at the 2^nd Department of Surgery at Jagiellonian University Medical College and at the Specialist Center “Medicina” in Krakow, Poland. The CIR and cecal intubation time (CIT) in three different eras of technological advancement were determined. The study enrolled 27 463 patients who underwent colonoscopy as part of a national CRC screening program. The patients were divided into three groups: group I – 3408 patients examined between 2000 and 2003 (optical endoscopes); group II – 10 405 patients examined between 2004 and 2008 (standard electronic endoscopes); and group III – 13 650 patients examined between 2009 and 2014 (modern endoscopes).

Results

There were statistically significant differences in the CIR between successive eras. The CIR in group I (2000–2003) was 69.75%, in group II (2004–2008) was 92.32%, and in group III (2009–2014) was 95.17%. The mean CIT was significantly reduced in group III.

Conclusions

Our study shows that the technological innovation of novel endoscopy devices has a great influence on the effectiveness of the CRC screening program. The new era of endoscopic technological development has the potential to reduce examination-related patient discomfort, obviate the need for sedation and increase diagnostic yields.

Anesthesia Assistance in Outpatient Colonoscopy and Risk of Aspiration Pneumonia, Bowel Perforation, and Splenic Injury

BACKGROUND & AIMS

The increase in use of anesthesia assistance (AA) to achieve deep sedation with propofol during colonoscopy has significantly increased colonoscopy costs without evidence for increased quality and with possible harm. We investigated the effects of AA on colonoscopy complications, specifically bowel perforation, aspiration pneumonia, and splenic injury.

METHODS

In a population-based cohort study using administrative databases, we studied adults in Ontario, Canada undergoing outpatient colonoscopy from 2005 through 2012. Patient, endoscopist, institution, and procedure factors were derived. The primary outcome was bowel perforation, defined using a validated algorithm. Secondary outcomes were splenic injury and aspiration pneumonia. Using a matched propensity score approach, we matched persons who had colonoscopy with AA (1:1) with those who did not. We used logistic regression models under a generalized estimating equations approach to explore the relationship between AA and outcomes.

RESULTS

Data from 3,059,045 outpatient colonoscopies were analyzed; 862,817 of these included AA. After propensity matching, a cohort of 793,073 patients who had AA and 793,073 without AA was retained for analysis (51% female; 78% were age 50 years or older). Use of AA did not significantly increase risk of perforation (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.84-1.16) or splenic injury (OR, 1.09; 95% CI, 0.62-1.90]. Use of AA was associated with an increased risk of aspiration pneumonia (OR, 1.63; 95% CI, 1.11-2.37).

CONCLUSIONS

In a population-based cohort study, AA for outpatient colonoscopy was associated with a significantly increased risk of aspiration pneumonia, but not bowel perforation or splenic injury. Endoscopists should warn patients, especially those with respiratory compromise, of this risk.

Comparison of nalbuphine and sufentanil for colonoscopy: A randomized controlled trial

OBJECTIVES

Nalbuphine is as effective as morphine as a perioperative analgesic but has not been compared directly with sufentanil in clinical trials. The aims of this study were to compare the efficacy and safety of nalbuphine with that of sufentanil in patients undergoing colonoscopy and to determine the optimal doses of nalbuphine in this indication.

METHODS

Two hundred and forty consecutive eligible patients aged 18-65 years with an American Society of Anesthesiologists classification of I-II and scheduled for colonoscopy were randomly allocated to receive sufentanil 0.1 μg/kg (group S), nalbuphine 0.1 mg/kg (group N1), nalbuphine 0.15 mg/kg (group N2), or nalbuphine 0.2 mg/kg (group N3). Baseline vital signs were recorded before the procedure. The four groups were monitored for propofol sedation using the bispectral index, and pain relief was assessed using the Visual Analog Scale and the modified Behavioral Pain Scale for non-intubated patients. The incidences of respiratory depression during endoscopy, nausea, vomiting, drowsiness, and abdominal distention were recorded in the post anesthesia care unit and in the first and second 24-hour periods after colonoscopy.

RESULTS

There was no significant difference in analgesia between the sufentanil group and the nalbuphine groups (p>0.05). Respiratory depression was significantly more common in group S than in groups N1 and N2 (p<0.05). The incidence of nausea was significantly higher in the nalbuphine groups than in the sufentanil group in the first 24 hours after colonoscopy (p<0.05).

CONCLUSIONS

Nalbuphine can be considered as a reasonable alternative to sufentanil in patients undergoing colonoscopy. Doses in the range of 0.1-0.2 mg/kg are recommended. The decreased risks of respiratory depression and apnea make nalbuphine suitable for patients with respiratory problems.

Etomidate versus propofol sedation for complex upper endoscopic procedures: a prospective double-blinded randomized controlled trial

BACKGROUND AND AIMS

Although a growing body of evidence demonstrates that propofol-induced deep sedation can be effective and performed safely, cardiopulmonary adverse events have been observed frequently. Etomidate is a new emerging drug that provides hemodynamic and respiratory stability, even in high-risk patient groups. The objective of this study was to compare safety and efficacy profiles of etomidate and propofol for endoscopic sedation.

METHODS

A total of 128 patients undergoing EUS were randomized to receive either etomidate or propofol blinded administered by a registered nurse. The primary outcome was the proportion of patients with any cardiopulmonary adverse events.

RESULTS

Overall cardiopulmonary adverse events were identified in 22 patients (34.38%) of the etomidate group and 33 patients (51.56%) of the propofol group, without significant difference (P = .074). However, the incidence of oxygen desaturation (4/64 [6.25%] vs 20/64 [31.25%]; P =.001) and respiratory depression (5/64 [7.81%] vs 21/64 [32.81%]; P =.001) was significantly lower in the etomidate group than in the propofol group. The frequency of myoclonus was significantly higher in the etomidate group (22/64 [34.37%]) compared with the propofol group (8/64 [12.50%]) (P =.012). Repeated measure analysis of variance revealed significant effects of sedation group and time on systolic blood pressure (etomidate group greater than propofol group). Physician satisfaction was greater in the etomidate group than in the propofol group.

CONCLUSIONS

Etomidate administration resulted in fewer respiratory depression events and had a better sedative efficacy than propofol; however, it was more frequently associated with myoclonus and increased blood pressure during endoscopic procedures. (Clinical trial registration number: KCT0001701.).

Impact of responsive insertion technology (RIT) on reducing discomfort during colonoscopy: randomized clinical trial

Background

In many countries, colonoscopies for colorectal cancer screening are performed without sedation due to the cost. Changes in the structure of the endoscopes are designed to facilitate the colonoscopic examination, reduce the duration of the procedure, and improve the imaging of the intestinal lumen. The variable stiffness of the endoscope and the recently introduced responsive insertion technology (RIT) are features aimed at easing colonoscope insertion and reducing the discomfort and pain during the examination. The aim of the study is to analyze whether the new RIT system can improve the practice of colonoscopy under no anesthesia with respect to the widely available variable stiffness colonoscopes.

Materials and methods

This analysis included 647 patients who underwent complete colonoscopy in the screening program. All colonoscopies were performed without sedation. Olympus series 180 and 190 endoscopes equipped with a magnetic positioning system were used. Group I included patients who were examined using endoscopes equipped with responsive insertion technology (RIT), and group II included patients who were examined using conventional variable stiffness colonoscopies. The main objective was to evaluate the cecal intubation time, the number of loops, the requirement to apply manual pressure to different areas of the abdomen and the degree of discomfort and pain expressed on a visual analogue scale (VAS). ClinicalTrials.gov number, NCT01688557.

Results

Group I consisted of 329 patients, and group II included 318 patients. The mean age of the patients was 58.4 years (SD ± 4.21). Both groups were compared in terms of age, sex, and BMI. The mean cecal intubation time was 209 s in group I and 224 s in group II (p < 0.05). Increased loop formation was observed upon endoscope insertion in group II (1.7 vs. 1.35) (p < 0.05) and required more manual pressure to the abdomen (2.2 vs. 1.7) (p = 0.001). In group I, less discomfort and pain, as graded on a VAS (2.3 vs. 2.6), were noted.

Conclusions

The implementation of RIT reduced of the cecal intubation time. The modified structure of the endoscope rendered the colonoscopic examination easier by reducing loop formation upon insertion with a subsequently reduced rate of auxiliary maneuvers.

Safety of Propofol Used as a Rescue Agent During Colonoscopy

GOAL

The goal of this study was to evaluate the safety of propofol when used by gastroenterologists in patients who have an inadequate response to standard sedation (narcotics and benzodiazepines).

BACKGROUND

Many patients fail to achieve adequate sedation from narcotics and benzodiazepines during colonoscopy. The administration of propofol for colonoscopy is increasing, although its use by gastroenterologists is controversial.

STUDY

We performed a retrospective review of our hospital's colonoscopy records from January 2006 to December 2009 to identify 403 subjects undergoing screening colonoscopies who required propofol (20 to 30 mg every 3 min as needed) because of inadequate response to standard sedation. We also randomly selected 403 controls undergoing screening colonoscopies from the same time period that only required standard sedation. The incidence of adverse effects was then compared.

RESULTS

There were no major adverse events in either group. The rates of minor adverse events in the propofol and control group were 0.02 and 0.01, respectively (P=0.56). Adverse effects in the propofol group included: transient hypotension (n=1), nausea/vomiting (n=3), agitation (n=2), and rash (n=1). Adverse effects seen with standard sedation included: transient hypotension (n=2), nausea/vomiting (n=1), and oversedation (n=2). Patients who received propofol were more likely to be younger, had a history of illicit drug use, and a longer procedure time (P<0.05).

CONCLUSIONS

Adjunctive propofol administered by gastroenterologist for conscious sedation was not associated with increased incidence of adverse events. It may be of value in patients who do not respond to conventional sedation.

Population-Based Colonoscopy Screening for Colorectal Cancer: A Randomized Clinical Trial

IMPORTANCE

Although some countries have implemented widespread colonoscopy screening, most European countries have not introduced it because of uncertainty regarding participation rates, procedure-related pain and discomfort, endoscopist performance, and effectiveness. To our knowledge, no randomized trials on colonoscopy screening currently exist.

OBJECTIVE

To investigate participation rate, adenoma yield, performance, and adverse events of population-based colonoscopy screening in several European countries.

DESIGN, SETTING, AND POPULATION

A population-based randomized clinical trial was conducted among 94 959 men and women aged 55 to 64 years of average risk for colon cancer in Poland, Norway, the Netherlands, and Sweden from June 8, 2009, to June 23, 2014.

INTERVENTIONS

Colonoscopy screening or no screening.

MAIN OUTCOMES AND MEASURES

Participation in colonoscopy screening, cancer and adenoma yield, and participant experience. Study outcomes were compared by country and endoscopist.

RESULTS

Of 31 420 eligible participants randomized to the colonoscopy group, 12 574 (40.0%) underwent screening. Participation rates were 60.7% in Norway (5354 of 8816), 39.8% in Sweden (486 of 1222), 33.0% in Poland (6004 of 18 188), and 22.9% in the Netherlands (730 of 3194) (P < .001). The cecum intubation rate was 97.2% (12 217 of 12 574), with 9726 participants (77.4%) not receiving sedation. Of the 12 574 participants undergoing colonoscopy screening, we observed 1 perforation (0.01%), 2 postpolypectomy serosal burns (0.02%), and 18 cases of bleeding owing to polypectomy (0.14%). Sixty-two individuals (0.5%) were diagnosed with colorectal cancer and 3861 (30.7%) had adenomas, of which 1304 (10.4%) were high-risk adenomas. Detection rates were similar in the proximal and distal colon. Performance differed significantly between endoscopists; recommended benchmarks for cecal intubation (95%) and adenoma detection (25%) were not met by 6 (17.1%) and 10 of 35 endoscopists (28.6%), respectively. Moderate or severe abdominal pain after colonoscopy was reported by 601 of 3611 participants (16.7%) examined with standard air insufflation vs 214 of 5144 participants (4.2%) examined with carbon dioxide (CO2) insufflation (P < .001).

CONCLUSIONS AND RELEVANCE

Colonoscopy screening entails high detection rates in the proximal and distal colon. Participation rates and endoscopist performance vary significantly. Postprocedure abdominal pain is common with standard air insufflation and can be significantly reduced by using CO2.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00883792.

Pre- and post-procedural quality indicators for colonoscopy: A nationwide survey

BACKGROUND

The provision of high-quality colonoscopy can be assessed by evaluating technical aspects of the procedure and, at individual center level, by comparing structural indicators and institutional policies for managing peri-procedural issues with guideline recommendations.

AIM

To assess the colonoscopy quality (CQ) in Italy at center level.

METHODS

Gastroenterologists participating in a nationwide colonoscopy education initiative provided information on structural indicators of their centers and on institutional policies by answering 10 multiple-choice clinical scenarios. Practice variation across centers and compliance with guidelines were analyzed.

RESULTS

Data from 282 Italian centers were evaluated. Overall, a significant proportion of centers did not meet CQ standards as concerns endoscopy facilities and equipments (e.g., dedicated recovery room, dirty-to-clean path, reporting software). CQ assurance programs were implemented in only 25% of centers. Concerning peri-procedural issues, main discrepancies with guidelines were recorded in the underuse of split-dose preparation (routinely adopted by 18% of centers), the routine request of coagulation tests prior to colonoscopy (30%), the routine interruption of aspirin for polypectomy (18%), and the adoption of 3-year surveillance for low-risk adenoma (49%).

CONCLUSIONS

Present survey shows a significant variation in the CQ of endoscopy centers in Italy on many items of colonoscopy practice that should be targeted for future interventions.

Anxiety Levels in Patients Undergoing Sedation for Elective Upper Gastrointestinal Endoscopy and Colonoscopy

BACKGROUND

Anxiety is a common preprocedural problem and during processing especially in interventional medical processes.

AIM

Aim of this study was to assess the level of anxiety in patients who will undergo upper gastrointestinal endoscopy and coloscopy.

METHODS

Five hundred patients scheduled to undergo sedation for elective upper gastrointestinal endoscopy and colonoscopy were studied. Beck Anxiety Inventory (BAI) was administered to each patient before brought to the endoscopy room. Demographic data of patients were collected.

RESULTS

BAI scores and anxiety levels were significantly lower in; males compared to females, patients with no comorbidity compared to patients with comorbidity (both P values < 0.001). BAI scores were significantly lower in patients educational status university and upper compared to patients educational status primary-high school (p=0.026). There were no significant difference between BAI and anxiety levels compared to procedures (Respectively, P=0.144 P=0.054). There were no significant difference between BAI scores and anxiety levels compared to age groups (Respectively, P=0.301 P=0.214).

CONCLUSIONS

We think that level of anxiety in patients who will undergo upper gastrointestinal endoscopy and colonoscopy was effected by presence of comorbidities and gender but was not effected by features such as age, procedure type and educational status.

Retrospective comparison of sedated and non-sedated colonoscopy in an outpatient practice

Although sedation and analgesia for patients undergoing colonoscopy are the standard practice in western countries, non-sedated colonoscopy is still in practice in Europe and the Far East. This variation in sedation practice relies on the different cultural attitudes of both patients and endoscopists across these countries. Data from the literature consistently report that, in non-sedated patients, the use of alternative techniques, such as water irrigation or carbon dioxide insufflation, can allow a high-quality and well-tolerated examination. We retrospectively reviewed prospectively collected performance improvement in endoscopy unit at King Khalid Hospital, Najran, Saudi Arabia. The tolerance of colonoscopy without sedation in terms of patient's ability to return to routine work and drive if necessary on the same day of procedure was evaluated. A total of 538 patients who underwent a colonoscopy at King Khalid Hospital endoscopy unit (Najran, Kingdom of Saudi Arabia) were reviewed from September 2011 to November 2013. All of the procedures were performed by two expert endoscopists, assisted by well-trained nursing staff. Insertion of the colonoscope was aided by insufflations of air, and in a few instances, by water through the colonoscope to minimize air insufflations. IV sedatives were administered upon the judgment of the physician when patient was unable to tolerate the procedure. Of 538 patients who underwent a colonoscopy, 79 patients required sedation. Forty-seven during the procedure and 32 requested pre-procedure sedation, most of them below 20 years of age. Thirty-two who requested pre-procedure sedation were excluded from our statistics. Of the remaining 506 cases, 47 (9.3 %) required sedation during procedure while 459 (90.7 %) tolerated the procedure without sedation. This shortened the hospital stay time, improved the ability to return to work much earlier, and undertake daily activities such as driving. It is also cost effective. The approach of non-sedative colonoscopy and use of sedation on-demand with minimal air insufflation or water infusion when needed during the procedure were well tolerated by approximately 91 % of patients at a single center in Saudi Arabia.

Diagnostic and therapeutic applications of water-immersion colonoscopy

Colonoscopy techniques combining or replacing air insufflation with water infusion are becoming increasingly popular. They were originally designed to reduce colonic spasms, facilitate cecal intubation, and lower patient discomfort and the need for sedation. These maneuvers straighten the rectosigmoid colon and enable the colonoscope to be inserted deeply without causing looping of the colon. Water-immersion colonoscopy minimizes colonic distension and improves visibility by introducing a small amount of water. In addition, since pain during colonoscopy indicates risk of bowel perforation and sedation masks this important warning, this method has the potential to be the favored insertion technique because it promotes patient safety without sedation. Recently, this water-immersion method has not only been used for colonoscope insertion, but has also been applied to therapy for sigmoid volvulus, removal of lesions, lower gastrointestinal bleeding, and therapeutic diagnosis of abnormal bowel morphology and irritable bowel syndrome. Although a larger sample size and prospective head-to-head-designed studies will be needed, this review focuses on the usefulness of water-immersion colonoscopy for diagnostic and therapeutic applications.

Water immersion colonoscopy facilitates straight passage of the colonoscope through the sigmoid colon without loop formation: randomized controlled trial

BACKGROUND AND AIM

One of the major causes of pain during colonoscopy is looping of the instrument during insertion through the sigmoid colon, which causes discomfort by stretching the mesentery. There are many studies in colonoscope techniques, but they have not been assessed objectively with respect to colonoscope passage through the sigmoid colon without loop formation. The aim of the present study was to determine whether cap-fitted colonoscopy and water immersion increase the success rate of insertion through the sigmoid without loop formation.

METHODS

A total of 1005 patients were randomized to standard colonoscopy, cap-fitted colonoscopy or water immersion technique. All examinations were carried out under a magnetic endoscope imaging device. Main outcome was the success rate of insertion without loop formation.

RESULTS

Success rate of insertion without loop formation was 37.5%, 40.0%, and 53.8% in the standard, cap, and water groups, respectively (standard vs water P = 0.00014, cap vs water P = 0.00186). There were no significant differences among the groups regarding cecal intubation rate, cecal intubation time and number of polyps ≥5 mm per patient.

CONCLUSIONS

Water immersion increases the success rate of insertion through the sigmoid colon without loop formation. This practical technique, requiring only preparation of a cap and water, is useful without compromising cecal intubation rate, cecal intubation time, or polyp detection rate.

The hemodynamic effect of an intravenous antispasmodic on propofol requirements during colonoscopy: A randomized clinical trial

PURPOSE

Hemodynamic status during induction of anesthesia may modify the amount of propofol needed to induce loss of consciousness (LOC). This study was aimed to evaluate the effect of antispasmodic-induced tachycardia on the concentration of propofol at the effect-site for inducing LOC when deep sedation was executed for colonoscopy.

METHODS

One hundred and sixteen adult patients were randomly assigned to receive either 20 mg of the antispasmodic Buscopan intravenously (Buscopan group; n = 58) or normal saline (control group; n = 58) for colonoscopy. After administration of Buscopan, the antispasmodic or normal saline, propofol was given by means of target-controlled infusion to induce LOC. We recorded patient characteristics, hemodynamic profiles, effect-site propofol concentration upon LOC, total propofol dosage for colonoscopy, and colonoscopy outcomes.

RESULTS

There were no significant differences in the characteristics between the two groups. Although the patients receiving Buscopan had a higher heart rate than those of the control group (101 ± 15 beats/minute vs. 77 ± 13 beats/minute; p < 0.001), we found no significant difference between two groups in the effect-site propofol concentration for inducing LOC (3.9 ± 0.6 μg/mL vs. 3.8 ± 0.6 μg/mL; p = 0.261) nor total propofol dosage required for colonoscopy (3.2 ± 1.4 mg/kg vs. 3.1 ± 1.1 mg/kg; p = 0.698). Both groups had comparable colonoscopy outcomes, including percentage of patients completing the procedure and total procedure time.

CONCLUSION

The hemodynamic responses to intravenous Buscopan neither affected the effect-site propofol concentration needed to induce LOC, nor the total propofol dosage required for colonoscopy in this study. There is no need to modify the dosage of propofol in patients subject to Buscopan premedication in colonoscopy.

Factors associated with incomplete colonoscopy at a Japanese academic hospital

AIM: To evaluate significant risk factors for incomplete colonoscopy at a Japanese academic hospital.

METHODS: A total of 11812 consecutive Japanese people were identified who underwent a colonoscopy at an academic hospital. A multiple logistic regression model was used to evaluate retrospectively the significant risk factors for incomplete colonoscopy.

RESULTS: The cecal intubation rate was 95.0%. By univariate analysis, age, female sex, poor bowel cleansing, and a history of abdominal or pelvic surgery were significant risk factors for incomplete colonoscopy (P < 0.001). Moreover, age- and sex-adjusted analysis showed that significant risk factors for incomplete colonoscopy were female sex (OR = 1.38, 95%CI: 1.17-1.64, P = 0.0002), age ≥ 60 years old (OR = 1.44, 95%CI: 1.22-1.71, P < 0.0001), a history of prior abdominal or pelvic surgery (OR = 1.55, 95%CI: 1.28-1.86, P < 0.0001), poor bowel cleansing (OR = 4.64, 95%CI: 3.69-5.84, P < 0.0001), and inflammatory bowel disease (IBD) (OR = 1.48, 95%CI: 1.13-1.95, P = 0.0048). In Japanese men, by age-adjusted analysis, IBD (OR = 1.69, 95%CI: 1.18-2.43, P = 0.005) was an independent risk factor for incomplete colonoscopy.

CONCLUSION: Several characteristics in the Japanese population were identified that could predict technical difficulty with colonoscopy.

Effect of propofol anesthesia on force application during colonoscopy

BACKGROUND

Sedation is frequently used during colonoscopy to control patient discomfort and pain. Propofol is associated with a deeper level of sedation than is a combination of a narcotic and sedative hypnotic and, therefore, may be associated with an increase in force applied to the colonoscope to advance and withdraw the instrument.

OBJECTIVE

To compare force application to the colonoscope insertion tube during propofol anesthesia and moderate sedation.

DESIGN

An observational cohort study of 13 expert and 12 trainee endoscopists performing colonoscopy in 114 patients. Forces were measured by using the colonoscopy force monitor, which is a wireless, handheld device that attaches to the insertion tube of the colonoscope.

SETTING

Community ambulatory surgery center and academic gastroenterology training programs.

PATIENTS

Patients undergoing routine screening or diagnostic colonoscopy with complete segment force recordings.

MAIN OUTCOME MEASUREMENTS

Axial and radial forces and examination time.

RESULTS

Axial and radial forces increase and examination time decreases significantly when propofol is used as the method of anesthesia.

LIMITATIONS

Small study, observational design, nonrandomized distribution of sedation type and experience level, different instrument type and effect of prototype device on insertion tube manipulation.

CONCLUSIONS

Propofol sedation is associated with a decrease in examination time and an increase in axial and radial forces used to advance the colonoscope.

Differences in colonoscopy technique impact quality

BACKGROUND

Colonoscopists differ in skill, technique, and attitude in relation to the examination. These differences have a potential impact on the quality of the examination and the risk of complications. This study aimed to document differences in technique between individual colonoscopists and to explore some possible consequences to the patient and the examination.

METHODS

This prospective, comparative study analyzed 10 individual endoscopists practicing in outpatient endoscopy clinics at a major medical center. Consecutive patients presenting for elective outpatient colonoscopy were included in the study. Examinations were observed, and techniques used during scope insertion and withdrawal were recorded. The type and dose of medication, the pain score recorded by the endoscopy nurses (scale of 1-10), and the incidence of hypotension and hypoxia were noted.

RESULTS

The study involved 245 patients (129 men and 116 women) with a mean age of 59.5 years. The number of colonoscopies per examiner ranged from 12 to 31, with nine tenths of the examiners performing more than 20 colonoscopies. Completion rates ranged from 82.6 to 100 %; the withdrawal time averages ranged from 3.5 to 21.7 min; and the average number of techniques used ranged from one per four exams to three per exam. The average pain score per endoscopist ranged from 2.1 to 4.3, and the percentage of patients with either hypoxia or hypotension ranged from 11.5 to 85.0 %. A sedation/analgesia product (SAP) was derived by multiplying the mean dose of versed by the mean dose of meperidine. Regression analysis showed significant relationships between the number of techniques used and the levels of pain (R (2) = 0.395) and hypoxia/hypotension (R (2) = 0.513). The findings showed that SAP was significantly associated with hypoxia/hypotension (R (2) = 0.826) but not pain (R (2) = 0.01).

CONCLUSIONS

Use of ancillary techniques for colonoscope insertion minimizes pain, narcotic use, and hypoxia/hypotension. The product of benzodiazepine dose and narcotic dose is a good way of assessing sedative effect.

Risk factors for early colonoscopic perforation include non-gastroenterologist endoscopists: a multivariable analysis

BACKGROUND & AIMS

Bowel perforation is a rare but serious complication of colonoscopy. Its prevalence is increasing with the rapidly growing volume of procedures performed. Although colonoscopies have been performed for decades, the risk factors for perforation are not completely understood. We investigated risk factors for perforation during colonoscopy by assessing variables that included sedation type and endoscopist specialty and level of training.

METHODS

We performed a retrospective multivariate analysis of risk factors for early perforation (occurring at any point during the colonoscopy but recognized during or immediately after the procedure) in adult patients by using the Clinical Outcomes Research Initiative National Endoscopic Database. Risk factors were determined from published articles. Additional variables assessed included endoscopist specialty and years of experience, trainee involvement, and sedation with propofol.

RESULTS

We identified 192 perforation events during 1,144,900 colonoscopies from 85 centers entered into the database from January 2000-March 2011. On multivariate analysis, increasing age, American Society of Anesthesia class, female sex, hospital setting, any therapy, and polyps >10 mm were significantly associated with increased risk of early perforation. Colonoscopies performed by surgeons and endoscopists of unknown specialty had higher rates of perforation than those performed by gastroenterologists (odds ratio, 2.00; 95% confidence interval, 1.30-3.08). Propofol sedation did not significantly affect risk for perforation.

CONCLUSIONS

In addition to previously established risk factors, non-gastroenterologist specialty was found to affect risk for perforations detected during or immediately after colonoscopy. This finding could result from differences in volume and style of endoscopy training. Further investigation into these observed associations is warranted.

No increased risk of perforation during colonoscopy in patients undergoing Nurse Administered Propofol Sedation

OBJECTIVE

Nurse Administered Propofol Sedation (NAPS) contributes to a deeper sedation of the patients, making them unable to respond to pain and an increased incidence of perforations has been speculated. The objective of this study was to evaluate the risk of perforations during colonoscopies performed with either NAPS or conventional sedation regimes.

MATERIAL AND METHODS

Data were retrospectively retracted from medical journals from 1 January 2007 to 31 December 2011. All journals were examined and cross-referenced to reveal any perforations. We analyzed all colonoscopies in regard to nature of the procedure (diagnostic vs therapeutic), experience of the endoscopist and ASA-classification of the patients.

RESULTS

A total of 6371 colonoscopies were performed, of which 3155 were performed under propofol sedation. There were 16 perforations (0.25%); 10 of these performed during NAPS and 6 during conventional colonoscopy (p = 0.454, OR: 1.7 (95% CI: 0.6-5.7)). There were 4874 diagnostic and 1497 therapeutic colonoscopies, with a majority of the perforations (94%) occurring during a diagnostic procedure (p = 0.389). No statistically difference was found in the incidence of perforations caused by an experienced or less experienced endoscopist (p = 0.589).

CONCLUSION

The risk of colonic perforations during colonoscopy was not found to be significantly higher in patients undergoing NAPS compared to patients undergoing conventional sedation, although a tendency may exist. Furthermore, we found no correlation to neither experience of the endoscopist, nature of the procedure nor sex of the patients. Larger and prospective studies are needed to further evaluate on this subject.

Conscious Sedation and Analgesia in Colonoscopy: Ketamine/Propofol Combination has Superior Patient Satisfaction Versus Fentanyl/Propofol

Background

Colonoscopy is performed without preparing sedation in many countries. However, according to the current literature patients are more satisfied when appropriate sedation is prepared for them.

Objectives

We hypothesize that propofol-ketamine may prepare more patient satisfaction compared to propofol-fentanyl combination.

Patients and Methods

Sixty adult patients older than 18 with ASA physical status of I, II or III were enrolled in the present study after providing the informed consent. They were prospectively randomized into two equal groups: 1- Group PF: was scheduled to receive IV bolus dose of fentanyl 1µg/kg and propofol 0.5mg/kg. 2- Group PK: was scheduled to receive IV bolus dose of ketamine 0.5mg/kg and propofol 0.5mg/kg. As a primary goal, patient’s satisfaction was assessed by the use a Likert five-item scoring system in the recovery. Comparisons of hemodynamic parameters (mean heart rate, mean systolic blood pressure, mean diastolic blood pressure), mean Spo2 values during the procedure and side effects such as nausea, vomiting, and psychological reactions during the recovery period were our secondary goals. Level of sedation during the colonoscopy was assessed with the Observer’s Assessment of Alertness/Sedation score (OAA/S).

Results

Mean satisfaction scores in the group PK were significantly higher than the group PF (P = 0.005) while the level of sedation during the procedure was similar (P = 0.17). Hemodynamic parameters and SpO2 values were not significantly different (P > 0.05). Incidence of nausea and vomiting was the same in both groups.

Conclusions

IV bolus injection of propofol-ketamine can lead to more patients’ satisfaction than the other protocols during colonoscopy.

Carbon dioxide insufflation or warm-water infusion versus standard air insufflation for unsedated colonoscopy: a randomized controlled trial

BACKGROUND

The increasing demand for colonoscopy has renewed the interest for unsedated procedures. Alternative techniques, such as carbon dioxide insufflation and warm-water infusion, have been advocated to improve patient tolerance for colonoscopy in comparison with air insufflation.

OBJECTIVE

The aim of this study was to evaluate the benefits of carbon dioxide insufflation and warm-water irrigation over air insufflation in unsedated patients.

DESIGN

This study was a randomized, controlled trial.

SETTING

This study was conducted at a nonacademic single center.

PATIENTS

Consecutive outpatients agreeing to start colonoscopy without premedication were included.

INTERVENTIONS

Patients were assigned to either carbon dioxide insufflation, warm-water irrigation, or air insufflation colonoscopy insertion phase. Sedation/analgesia were administered on patient request if significant pain or discomfort occurred.

MAIN OUTCOME MEASURES

The primary outcome measured was the percentage of patients requiring sedation/analgesia. Pain and tolerance scores were assessed at discharge by using a 100-mm visual analog scale.

RESULTS

Three hundred forty-one subjects (115 in the carbon dioxide, 113 in the warm-water, and 113 in the air group) were enrolled. Intention-to-treat analysis showed that the proportion of patients requesting sedation/analgesia during colonoscopy was 15.5% in the carbon dioxide group, 13.2% in the warm-water group, and 25.6% in the air group (p = 0.04 carbon dioxide vs air; p = 0.03 warm water vs air). Median (interquartile range) scores for pain were 30 (10-50), 28 (15-50), and 46 (22-62) in the carbon dioxide, warm-water, and air groups (carbon dioxide vs air, p < 0.01; warm water vs air, p < 0.01); corresponding figures for tolerance were 20 (5-30), 19 (5-36), and 28 (10-50) (carbon dioxide vs air, p < 0.01; warm water vs air, p < 0.01).

LIMITATIONS

This investigation was limited because it was a single-center study and the endoscopists were not blinded to randomization.

CONCLUSIONS

Carbon dioxide insufflation was associated with a decrease in the proportion of patients requesting on-demand sedation, improved patient tolerance, and decreased colonoscopy-related pain in comparison with air insufflation. The findings regarding warm-water irrigation confirmed the previously reported advantages, so that warm-water irrigation and carbon dioxide insufflation could represent competitive strategies for colonoscopy in unsedated patients.

The effect of pre-procedure anxiety on sedative requirements for sedation during colonoscopy

This study investigated the effects of pre-procedural anxiety (assessed using the Beck Anxiety Inventory) on sedative requirements in 135 patients undergoing sedation for colonoscopy. Deep sedation was defined as loss of consciousness and no response to colonoscopy, and was achieved by target-controlled infusion of propofol. Patients' characteristics, baseline haemodynamic profiles, Beck Anxiety Inventory scores, effect-site propofol concentration at loss of consciousness and characteristics of recovery were recorded. No correlations were found between Beck Anxiety Inventory scores and effect-site propofol concentration at loss of consciousness or baseline haemodynamic profiles. There was no statistical difference in the characteristics of recovery among patients with different levels of anxiety. In conclusion, in patients receiving deep sedation for colonoscopies, the level of pre-procedural anxiety did not relate to the sedative requirement or post-procedural recovery characteristics.

Body mass index predicts cecal insertion time: the higher, the better

BACKGROUND

It is essential to determine the factors that predict prolonged procedural time during colonoscopy. The aim of this study was to determine the effect of body mass index (BMI) on cecal insertion time (CIT) during colonsocopy.

METHODS

Consecutive outpatients who received colonoscopies over a 10 month period (April-October 2007) were enrolled. Exclusion criteria included colonic resection, strictures or exophytic masses precluding colonic evaluation. Data were collected for age, sex, race, height, weight, BMI, waist circumference, prior history of abdominal or pelvic surgery, history of diverticulosis, participation of fellow, CIT, quality of colon cleansing and the amount of sedation used during the procedure.

RESULTS

A total of 1430 patients (586 men and 844 women; mean age 60.3 years) were included in the final analysis. The mean CIT was 648.5 seconds (SE = 11.47). Older age, female gender, fellow involvement, poor bowel preparation and lower BMI were associated with prolonged mean CIT on linear regression analysis ((R2) = 0.116; P < 0.001). Mean CIT declined linearly with increasing BMI.

CONCLUSION

A higher BMI is strongly associated with progressively shorter CIT.

Interim report of a randomized cross-over study comparing clinical performance of novice trainee endoscopists using conventional air insufflation versus warm water infusion colonoscopy

BACKGROUND

The applicability of water method colonoscopy in trainee education is not known.

AIM

To compare the water method vs. usual air method in teaching novice trainee colonoscopy.

METHOD

An IRB approved prospective randomized cross-over study (NCT01482546) in a university setting with diverse patient population.

DESIGN

Three first year GI fellows consented to participate in the study. Trainees were randomized to learn with either usual air method or the water method in performing colonoscopy with a dedicated endoscopy attending during their weekly outpatient endoscopy clinics for the initial six months of training and then cross-over to the other method for the remaining six months.

PATIENTS

Patients undergoing screening, surveillance or diagnostic colonoscopy.

RESULTS

The interim data revealed no significant difference in age, gender, and body mass index (BMI). Trainees rated the water method colonoscopy as significantly easier to learn compared to the air method (p=0.007).

CONCLUSIONS

The interim data demonstrate positive effects of using the water method in training novice endoscopists who reported a significant ease of learning colonoscopy using this method. Training programs could consider joining us in evaluating the use of warm water infusion in colonoscopy education.

Randomized trial of standard versus magnetic endoscope imaging colonoscopes for unsedated colonoscopy

BACKGROUND

Unsedated colonoscopy has potential benefits, including decreased costs and decreased risks.

OBJECTIVE

To determine whether patient comfort during unsedated colonoscopy can be improved through the use of a magnetic endoscopic imaging (MEI) colonoscope compared with a standard colonoscope.

DESIGN

Prospective, patient-blinded, randomized, controlled trial.

SETTING

San Francisco Veterans Affairs Medical Center.

PATIENTS

Veterans undergoing outpatient screening or surveillance colonoscopy.

INTERVENTIONS

Use of a standard or MEI colonoscope during unsedated colonoscopy.

MAIN OUTCOME MEASUREMENT

The primary outcome variable was patient perception of pain using a 7-point scale. The secondary endpoint was patient willingness to undergo a future unsedated colonoscopy.

RESULTS

Of the 160 patients enrolled, 140 completed an unsedated colonoscopy in the study protocol. In a per-protocol analysis, the mean and median pain score was 3.12 (standard deviation 1.22) and 4 (interquartile range 2-4) for the standard colonoscope group and 3.06 (standard deviation 1.13) and 3 (interquartile range 2-4) for the MEI group, where 3 was mild pain (P = not significant). Overall, 80% of subjects were willing to undergo a future unsedated colonoscopy for screening or surveillance. In an intention-to-treat analysis, 80% of subjects (64/80) in the standard colonoscope arm and 79% in the MEI arm (63/80) were willing to undergo a future unsedated colonoscopy (P = not significant).

LIMITATIONS

Single-center study of mostly male veterans.

CONCLUSIONS

This patient-blinded, randomized, controlled trial did not demonstrate any difference in patient perception of pain or willingness to undergo unsedated examinations when using the MEI versus the conventional colonoscope. Unsedated colonoscopy is generally feasible and well tolerated and is associated with high patient satisfaction rates.

Unsedated colonoscopy: A neverending story

Although sedation and analgesia for patients undergoing colonoscopy is the standard practice in Western countries, unsedated colonoscopy is still routinely provided in Europe and the Far East. This variation in sedation practice relies on the different cultural attitudes of both patients and endoscopists across these countries. Data from the literature consistently report that, in unsedated patients, the use of alternative techniques, such as warm water irrigation or carbon dioxide insufflation, can allow a high quality and well tolerated examination.

Unsedated colonoscopy: an option for some but not for all

BACKGROUND

The increasing request for colonoscopy in clinical practice, coupled with the lack of time, has led to a renewed interest in unsedated procedures.

OBJECTIVE

To evaluate the acceptability of unsedated colonoscopy and to characterize the subset of patients more likely to undergo and complete the procedure without sedation and/or analgesia.

DESIGN

Prospective, population study.

SETTING

Nonacademic community hospital, 6-month observation period.

PATIENTS

Adult outpatients referred for colonoscopy were offered unsedated procedure, with the possibility of on-demand sedation.

INTERVENTIONS

Demographics, clinical features, and endoscopy outcomes were recorded. Data were analyzed by stepwise logistic regression analysis, and odds ratio (OR) and 95% confidence interval (CI) are given for significant variables.

MAIN OUTCOME MEASUREMENTS

Unsedated colonoscopy acceptance rate. Factors significantly associated with acceptance and completion of unsedated procedures.

RESULTS

The acceptance rate for unsedated colonoscopy was 56.2% of 964 consecutive evaluated patients. The cecal intubation rate in unsedated patients was 81.6% and increased to 97.3% with the option of on-demand sedation. At multivariate analysis, factors significantly associated with the acceptance were no previous colonoscopy (OR 1.52; 95% CI, 1.10-2.11), absent/low level of anxiety (OR 3.82; 95% CI, 2.71-5.38), and no concern about the examination (OR 1.80; 95% CI, 1.17-2.77). Fear of procedure-related pain was inversely associated with acceptance (OR 0.28; 95% CI, 0.17-0.35). Factors associated to drug-free colonoscopy completion were absence of preprocedure anxiety (OR 1.87; 95% CI, 1.08-3.21) and male sex (OR 3.59; 95% CI, 2.13-6.05).

LIMITATIONS

Single-center study.

CONCLUSION

The acceptance rate of unsedated colonoscopy is clinically relevant, and the procedure can be completed without sedation in the majority of patients. Subject-related factors may help to identify patients willing to undergo and potentially complete unsedated procedures.

Factors that influence cecal intubation rate during colonoscopy in deeply sedated patients

BACKGROUND AND AIM

The technical performance of colonoscopy performed in deeply sedated patients differs from that performed without sedation or under minimal to moderate sedation. The aim of this study is to evaluate the factors affecting cecal intubation during colonoscopy performed under deep sedation.

METHODS

A total of 5352 consecutive subjects who underwent a screening colonoscopy as part of a health check-up between January 2008 and December 2008 at an academic hospital were reviewed. All endoscopies were performed with deep sedation using combination propofol or propofol alone. Data collected included characteristics of the patients (age, gender, body mass index, bowel habits, history of abdominal or pelvic surgery, quality of bowel preparation, and presence/absence of colonic diverticula) and characteristics of the colonoscopists (experience level, colonoscopy procedure volume, and instrument handling method). These factors were analyzed to evaluate their impact on cecal intubation rates.

RESULTS

The crude cecal intubation rate was 98% and the adjusted cecal intubation rate was 98.3%. The mean cecal intubation time was 5.6 ± 3.2 min. Multivariate logistic regression analysis demonstrated that patient age greater than 60 years, constipation, poor colon preparation and a two-person colonoscopy procedure were independently associated with lower cecal intubation rates.

CONCLUSIONS

Colonoscopy performed under deep sedation by experienced colonoscopists results in high cecal intubation rates. Among the significant patient-related predictors influencing the cecal intubation, the quality of the bowel preparation was the only modifiable factor. When performed by experienced hands, the one-person method was associated with higher cecal intubation rates than the two-person method.

Randomised clinical trial: a 'nudge' strategy to modify endoscopic sedation practice

BACKGROUND

In behavioural economics, a 'nudge' describes configuration of a choice to encourage a certain action without taking away freedom of choice.

AIM

To determine the impact of a 'nudge' strategy - prefilling either 3mL or 5mL syringes with midazolam - on endoscopic sedation practice.

METHODS

Consecutive patients undergoing sedation for EGD or colonoscopy were enrolled. On alternate weeks, midazolam was prefilled in either 3mL or 5mL syringes. Preprocedure sedation was administered by the endoscopist to achieve moderate conscious sedation; dosages were at the discretion of the endoscopist. Meperidine was not prefilled.

RESULTS

Overall, 120 patients received sedation for EGD [59 (5mL), 61 (3mL)] and 86 patients were sedated for colonoscopy [38 (5mL), 48 (3mL)]. For EGDs, average midazolam dose was significantly higher in the 5-mL group (5.2mg) vs. 3-mL group (3.3mg), (P<0.0001); for colonoscopies, average midazolam dose was also significantly higher in the 5-mL group (5.1mg) vs. 3-mL group (3.3mg), (P<0.0001). There was no significant difference in mean meperidine dose (42.1mg vs. 42.8mg, P=0.9) administered to both colonoscopy groups. No adverse sedation-related events occurred; no patient required reversal of sedation.

CONCLUSIONS

These findings demonstrate that 'nudge' strategies may hold promise in modifying endoscopic sedation practice. Further research is required to explore the utility of 'nudges' in impacting other aspects of endoscopic practice.

Sedation issues in quality colonoscopy

The subject of endoscopic sedation for colonoscopy remains controversial because of unresolved questions concerning the relative benefits, risks, and cost of service. There is also disagreement about the most appropriate sedation drug(s), delegation of responsibility for drug administration, and patient monitoring. This article examines recent trends in endoscopic sedation; the impact of sedation on the quality, safety, and patient tolerability of colonoscopy; and reviews the economic implications of current sedation practices.

Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial

BACKGROUND

Uncontrolled data suggest that warm water infusion (WWI) instead of air insufflation (AI) during the insertion phase of unsedated colonoscopy improves patient tolerance and satisfaction.

OBJECTIVE

We tested the hypothesis that water could increase the proportion of patients able to complete unsedated colonoscopy and improve patient tolerance compared with the conventional procedure.

DESIGN

Randomized, controlled trial.

SETTING

Single center, community hospital.

PATIENTS

Consecutive outpatients agreeing to start colonoscopy without premedication.

METHODS

Patients were randomly assigned to either WWI or AI insertion phase of colonoscopy. Sedation and/or analgesia were administered on patient request if significant pain or discomfort occurred.

MAIN OUTCOME MEASUREMENTS

Percentage of patients requiring sedation/analgesia. Pain and tolerance scores were assessed at discharge by using a 100-mm visual analog scale.

RESULTS

A total of 230 subjects (116 in the WWI group and 114 in the AI group) were enrolled. Intention-to-treat analysis showed that the proportion of patients requesting sedation/analgesia during the procedure (main outcome measurement) was 12.9% in the WWI group and 21.9% in AI group (P = .07). Cecal intubation rates were 94% in the WWI group and 95.6% in the AI group (P = .57). Median (interquartile range) scores for pain were 28 (12-44) and 39 (14-54) in WWI and AI groups, respectively (P = .05); corresponding figures for tolerance were 10 (3-18) and 14 (5-42), respectively (P = .01). The adenoma detection rates were 25% and 40.1% for the WWI and AI groups, respectively (P = .013).

LIMITATIONS

Single-center study, endoscopists not blinded to randomization.

CONCLUSIONS

WWI instead of AI is not associated with a statistically significant decrease in the number of patients requiring on-demand sedation, although it significantly improves the overall patient tolerance of colonoscopy. The finding of a lower adenoma detection rate in the WWI group calls for further evaluations. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00905554).

Determining scope position during colonoscopy without use of ionizing radiation or magnetic imaging: the enhanced mapping ability of the NeoGuide Endoscopy System

BACKGROUND

Knowledge of the position and shape of the endoscope could overcome many challenges of performing colonoscopy, e.g., loop formation. A novel computer-assisted colonoscope (NeoGuide Endoscopy System) delivers a real-time, three-dimensional map of the tip position and insertion tube shape in addition to the video image of the colon lumen. The aim of this study is to evaluate the mapping capabilities of the NeoGuide Endoscopy System in terms of colonic looping, insertion depth, tip position, and tip angle formation.

METHODS

Ten endoscopists with various levels of experience were each shown 70 map images generated by the NeoGuide endoscopy system in a benchtop anatomical colon model. First endoscopists were asked to determine the tip angle based on the map image and the system's corresponding tip positioning aid (20 images). In the second part they had to identify the scope-tip position in the colon model (40 images). In the third part ten images were presented for identification of colonic loops.

RESULTS

The tip angle was correctly identified in 99% (198/200) of images. Using only the map images the scope position was accurately determined in 87.5% (350/400). Identification of colonic looping of the scope was appropriate in 99% (99/100). Overall accuracy was 92.4%, and overall positive predictive value was 94.9%.

CONCLUSION

Three-dimensional map images generated by the NeoGuide endoscopy system provide accurate information regarding tip position, insertion tube position, and colonic looping.

Patient self-administered abdominal pressure to reduce loop formation during minimally sedated colonoscopy

CONTEXT

Assistant-administered abdominal pressure is usually required to reduce loop formation during a colonoscopy. The effect of patient self-administered abdominal pressure has not been evaluated.

OBJECTIVE

To compare the effectiveness of patient self-administered abdominal pressure with assistant-administered abdominal pressure to reduce loop formation during colonoscopy performed with minimal sedation.

PATIENTS

Consecutive patients who underwent colonoscopy were randomized to receive either patient self-administered abdominal pressure (patient group, n = 51) or assistant-administered abdominal pressure (assistant group, n = 52) when looping occurred during colonoscopy minimally sedated with meperidine. When patient-administered abdominal pressure failed to reduce the loop formation, an assistant took over and delivered the abdominal pressure.

RESULTS

No difference was found regarding cecal intubation rate, intubation time, mean pain scores, and overall satisfaction of patients between groups. However, fewer patients required assistant-administered pressure in the patient group than in the assistant group (18/51 vs. 41/52, P < 0.001).

CONCLUSIONS

Patient self-administered pressure is effective in reducing looping during minimally sedated colonoscopy.

Superiority of split dose midazolam as conscious sedation for outpatient colonoscopy

AIM: To elucidate the efficacy and safety of a split dose of midazolam in combination with meperidine for colonoscopy.

METHODS: Eighty subjects undergoing outpatient colonoscopy were randomly assigned to group A or B. Group A (n = 40) received a split dose of midazolam in combination with meperidine. Group B (n = 40) received a single dose of midazolam in combination with meperidine. Outcome measurements were level of sedation, duration of sedation and recovery, degree of pain and satisfaction, procedure-related memory, controllability, and adverse events.

RESULTS: Group A had a lower frequency of significant hypoxemia (P = 0.043) and a higher sedation score on withdrawal of the endoscope from the descending colon than group B (P = 0.043). Group B recovered from sedation slightly sooner than group A (P < 0.002). Scores for pain and memory, except insertion-related memory, were lower in group A one week after colonoscopic examination (P = 0.018 and P < 0.030, respectively). Poor patient controllability was noted by the endoscopist and nurse in group B (P = 0.038 and P = 0.032, respectively).

CONCLUSION: Split dose midazolam in combination with meperidine resulted in a safer, more equable sedation status during colonoscopic examination and a reduction in procedure-related pain and memory, but resulted in longer recovery time.