Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps

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.

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.

Effects of visual and audiovisual distraction on pain and anxiety among patients undergoing colonoscopy

The aim of this study was to test the effects of visual and audiovisual distraction on pain, anxiety, and procedure tolerance among patients undergoing colonoscopy. A prospective, randomized, controlled design was used with 180 consecutive patients who underwent colonoscopy. Subjects were randomly allocated into 3 groups: Group A received visual distraction, Group B received audiovisual distraction, Group C with routine care. Outcome variables included pain, anxiety, and willingness to undergo colonoscopy again if the procedure was to be repeated. No significant difference was found on the pain scores of the 3 groups. However, when groups A and B were further divided into groups A1, A2, A3 (low-, middle-, high-involvement groups), and B1, B2, B3 (low-, middle-, high-involvement groups) according to the level of distraction involvement, significant differences in pain scores were found between 7 groups (A1 and A3, A2 and A3, A1 and B3, A2 and B3, A3 and C, B1 and B3, B3 and C). The pain score of Group A3 was significantly lower than those of groups A1, A2, and C, and the pain score of Group B3 was significantly lower than those of groups B1 and C. The reduction of anxiety levels after procedure was insignificant between the 2 intervention groups and control group. The rates of willingness to undergo colonoscopy again if the procedure was to be repeated of the 2 intervention groups were significantly higher than that of the control group. Visual and audiovisual distraction is effective in promoting pain control for patients undergoing colonoscopy and improving their tolerance of the procedure.

Do no harm: no psychological harm from colorectal cancer screening

BACKGROUND

Participation in cancer screening programmes might cause worries in the population outweighting the benefits of reduced mortality. The present study aimed to investigate possible psychological harm of participation in a colorectal cancer (CRC) screening pilot in Norway.

METHODS

In a prospective, randomised trial participants (aged 50-74 years) were invited to either flexible sigmoidoscopy (FS) screening, faecal immunochemical test (FIT), or no screening (the control group; 1 : 1: 1). Three thousand two hundred and thirteen screening participants (42% of screened individuals) completed the Hospital Anxiety and Depression Scale questionnaire as well as the SF-12-a health-related quality of life (HRQOL) questionnaire when invited to screening and when receiving the screening result. A control group was invited to complete the questionnaires only. Two thousand six hundred and eighteen control participants (35% of invited individuals) completed the questionnaire.

RESULTS

A positive screening result did not increase participants' level of anxiety or depression, or decrease participants' level of HRQOL. Participants who received a negative result reported decreased anxiety and improvement on some HRQOL dimensions. However, no change was considered to be of clinical relevance.

CONCLUSION

The current study showed no clinically relevant psychological harm of receiving a positive CRC screening result or of participating in FS or FIT screening, in a Norwegian population.

Risk of Colorectal Neoplasia According to Fatty Liver Severity and Presence of Gall Bladder Polyps

BACKGROUND

Fatty liver is the hepatic manifestation of metabolic syndrome (MetS) and is a known risk factor for colorectal neoplasia (CRN). Gallbladder (GB) polyps share many common risk factors with CRN. However, studies evaluating CRN risk according to fatty liver severity and the presence of GB polyps are rare.

AIM

To investigate CRN risk according to the fatty liver severity and the presence of GB polyps.

METHODS

A retrospective cross-sectional study was performed on 44,220 participants undergoing colonoscopy and abdominal ultrasonography (US) as part of a health-screening program.

RESULTS

Of the participants, fatty liver was diagnosed as mild in 27.7 %, moderate in 5.1 %, and severe in 0.4 % and 13.4 % were diagnosed with GB polyps. Mean age of participants was 42.7 years. In adjusted models, risk of overall CRN and non-advanced CRN increased with worsening fatty liver severity (P for trend = 0.007 and 0.020, respectively). Adjusted odd ratios for overall CRN and non-advanced CRN comparing participants with mild, moderate, and severe fatty liver to participants without fatty liver were 1.13 and 1.12 for mild, 1.12 and 1.10 for moderate, and 1.56 and 1.65 for severe. The presence of GB polyps did not correlate with CRN risk after adjusting for confounders.

CONCLUSIONS

CRN risk increased with worsening fatty liver severity. However the association between GB polyp and CRN was not significant in the presence of other variables. Considering that many people undergo noninvasive abdominal US as a health screen, our study will contribute to colonoscopy screening strategies in people undergoing abdominal US.

Sedated vs unsedated colonoscopy: A prospective study

AIM: To compare sedated to unsedated colonoscopy in terms of duration, pain and the patient’s willingness to repeat the procedure.

METHODS: Consecutive patients who underwent colonoscopies over a 2-year period were invited to participate. All patients who were to undergo our endoscopy unit were offered sedation with standard intravenous sedatives and analgesics, or an unsedated colonoscopy was attempted. Demographic details were recorded. The patient anxiety level prior to the procedure, time to reach the cecum, total discharge time, patient and endoscopist pain assessments, satisfaction after the examination and the patient’s willingness to return for the same procedure in the future were recorded.

RESULTS: Among the 403 observed patients, more males were observed in the unsedated group (66.2% vs 55.2%, P = 0.04). Additionally, the unsedated group patients were less anxious prior to the procedure (5.1 vs 6.0, P < 0.01). The colonoscopy completion rates were comparable between the 2 groups (85.9% vs 84.2%, P = 0.66). The time to reach the cecum was also comparable (12.2 min vs 11.8 min); however, the total discharge times were shorter in the unsedated group (20.7 min vs 83.0 min, P < 0.01). Moreover, the average patient pain score (3.4 vs 5.7, P < 0.01) was lower in the sedated group, while the satisfaction score (8.8 vs 7.8, P < 0.01) was significantly higher. There was no significant difference, however, between the groups in terms of willingness to repeat the procedure if another was required in the future (83.3% vs 77.3%, P = 0.17).

CONCLUSION: Unsedated colonoscopy is feasible in willing patients. The option saves the endoscopy units up to one hour per patient and does not affect the patient willingness to return to the same physician again for additional colonoscopies if a repeated procedure is needed.

Water-aided colonoscopy

Water-aided methods for colonoscopy include the established water immersion and the recent novel modification of water exchange. Water immersion entails the use of water as an adjunct to air insufflations to facilitate insertion. Water exchange evolved from water immersion to facilitate completion of colonoscopy without discomfort in unsedated patients. Infused water is removed predominantly during insertion rather than withdrawal. A higher adenoma detection rate has been reported with water exchange. Aggregate data of randomized controlled trials suggest that water exchange may be superior to water immersion in attenuating colonoscopy discomfort and optimizing adenoma detection, particularly in the proximal colon.

Gender differences in attitudes impeding colorectal cancer screening

Background

Colorectal cancer screening (CRCS) is the only type of cancer screening where both genders reduce risks by similar proportions with identical procedures. It is an important context for examining gender differences in disease-prevention, as CRCS significantly reduces mortality via early detection and prevention. In efforts to increase screening adherence, there is increasing acknowledgment that obstructive attitudes prevent CRCS uptake. Precise identification of the gender differences in obstructive attitudes is necessary to improve uptake promotion. This study randomly sampled unscreened, screening - eligible individuals in Ontario, employing semi-structured interviews to elicit key differences in attitudinal obstructions towards colorectal cancer screening with the aim of deriving informative differences useful in planning promotions of screening uptake.

Methods

N = 81 participants (49 females, 32 males), 50 years and above, with no prior CRCS, were contacted via random-digit telephone dialing, and consented via phone-mail contact. Altogether, N = 4,459 calls were made to yield N = 85 participants (1.9% response rate) of which N = 4 participants did not complete interviews. All subjects were eligible for free-of-charge CRCS in Ontario, and each was classified, via standard interview by CRCS screening decision-stage. Telephone-based, semi-structured interviews (SSIs) were employed to investigate gender differences in CRCS attitudes, using questions focused on 5 attitudinal domains: 1) Screening experience at the time of interview; 2) Barriers to adherence; 3) Predictors of Adherence; 4) Pain-anxiety experiences related to CRCS; 5) Gender-specific experiences re: CRCS, addressing all three modalities accessible through Ontario’s program: a) fecal occult blood testing; b) flexible sigmoidoscopy; c) colonoscopy.

Results

Interview transcript analyses indicated divergent themes related to CRCS for each gender: 1) bodily intrusion, 2) perforation anxiety, and 3) embarrassment for females and; 1) avoidant procrastination with underlying fatalism, 2) unnecessary health care and 3) uncomfortable vulnerability for males. Respondents adopted similar attitudes towards fecal occult blood testing, flexible sigmoidoscopy and colonoscopy, and were comparable in decision stage across tests. Gender differences were neither closely tied to screening stage nor modality. Women had more consistent physician relationships, were more screening-knowledgeable and better able to articulate views on screening. Men reported less consistent physician relationships, were less knowledgeable and kept decision-making processes vague and emotionally distanced (i.e. at ‘arm’s length’).

Conclusions

Marked differences were observed in obstructive CRCS attitudes per gender. Females articulated reservations about CRCS-associated distress and males suppressed negative views while ambiguously procrastinating about the task of completing screening. Future interventions could seek to reduce CRCS-related stress (females) and address the need to overcome procrastination (males).

Water infusion versus air insufflation for colonoscopy: a meta-analysis of randomized controlled trials

BACKGROUND

The aim of this meta-analysis was to determine whether water infusion colonoscopy (WIC) is a more effective diagnostic tool than standard air insufflation colonoscopy (AIC).

METHODS

All articles pertinent to a comparison of water-related methods and air insufflation to facilitate insertion of the colonoscope were retrieved from PubMed, Web of Science, Embase, and Cochrane databases. Pooling results were derived by using the Review Manager Software. Outcomes were assessed using the weighted mean difference (MD) with 95 % confidence intervals (CI) for continuous variables and the odds ratios (OR) with 95 % CI for dichotomous variables.

RESULTS

Eighteen studies involving 2,797 patients were included. WIC was associated with a significantly higher cecal intubation rate than AIC (OR = 1.90; 95 % CI 1.21-2.99; p = 0.005). The intubation time was similar for the two types of colonoscopy, but in WIC there was a significantly lower visual analog scale score for abdominal pain than in AIC (MD = -1.30; 95 % CI -2.03 to -0.58; p < 0.001) without sacrificing the polyp detection rate (OR = 1.17; 95 % CI 0.78-1.77; p = 0.44). Statistically, the patient's willingness to repeat colonoscopy was significantly greater for WIC than for AIC (OR = 1.74; 95 % CI 1.14-2.67; p < 0.01). Furthermore, in the subgroup for trainees, the WIC group achieved a higher cecal intubation rate (OR = 1.83; 95 % CI 1.15-2.93; p = 0.01) and a shorter intubation time (MD = -1.72 min; 95 % CI -3.34 to -0.11; p = 0.04) than the AIC group.

CONCLUSIONS

In contrast to AIC, WIC improved cecal intubation, alleviated abdominal pain, and increased patients' willingness to repeat the procedure.

Patient comfort and quality in colonoscopy

AIM

To explore the relationship of patient comfort and experience to commonly used performance indicators for colonoscopy.

METHODS

All colonoscopies performed in our four endoscopy centres are recorded in two reporting systems that log key performance indicators. From 2008 to 2011, all procedures performed by qualified endoscopists were evaluated; procedures performed by trainees were excluded. The following variables were measured: Caecal intubation rate (CIR), nurse-reported comfort levels (NRCL) on a scale from 1 to 5, polyp detection rate (PDR), patient experience of the procedure (worse than expected, as expected, better than expected), and use of sedation and analgesia. Pearson's correlation coefficient was used to identify relationships between performance indicators.

RESULTS

A total of 17027 colonoscopies were performed by 23 independent endoscopists between 2008 and 2011. Caecal intubation rate varied from 79.0% to 97.8%, with 18 out of 23 endoscopists achieving a CIR of > 90%. The percentage of patients experiencing significant discomfort during their procedure (defined as NRCL of 4 or 5) ranged from 3.9% to 19.2% with an average of 7.7%. CIR was negatively correlated with NRCL-45 (r = -0.61, P < 0.005), and with poor patient experience (r = -0.54, P < 0.01). The average dose of midazolam (mean 1.9 mg, with a range of 1.1 to 3.5 mg) given by the endoscopist was negatively correlated with CIR (r = -0.59, P < 0.01). CIR was positively correlated with PDR (r = 0.44, P < 0.05), and with the numbers of procedures performed by the endoscopists (r = 0.64, P < 0.01).

CONCLUSION

The best colonoscopists have a higher CIR, use less sedation, cause less discomfort and find more polyps. Measuring patient comfort is valuable in monitoring performance.

Does a fitted abdominal corset makes colonoscopy more tolerable?

BACKGROUND AND AIM

  The present study evaluated the usefulness of a fitted abdominal corset for colonoscopy, enabling proper compression of the abdomen during the entire examination.

METHODS

  Patients undergoing colonoscopy were subjected to either traditional methods or to using a fitted abdominal corset. Two hundred and sixteen patients were divided into two groups: group 1 (conventional colonoscopy) and group 2 (colonoscopy with abdominal corset). Cecal intubation rate and time need for manual compression and change of position were recorded. At the end of each colonoscopic examination, the patient evaluated pain by an 11-point visual analog scale from 0 to 10 (0: no pain, 10: worst pain).

RESULTS

  Cecal intubation time was shorter, the need for extra manual compression and change of position decreased and patients felt less pain during the procedure as denoted by lower visual analog scale scores in the group using a fitted abdominal corset, when compared to the group without a corset, in a statistically proven manner.

CONCLUSION

  Our data confirm the usefulness of the abdominal corset in decreasing the degree of patient pain and it makes colonoscopy easier and quicker with less manipulation, so we propose using a fitted abdominal corset during routine colonoscopic procedures.

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.

Water infusion for cecal intubation increases patient tolerance, but does not improve intubation of unsedated colonoscopies

BACKGROUND & AIMS

Several studies have indicated that water infusion, instead of air insufflation, enhances cecal intubation in selected patients undergoing unsedated colonoscopy. We performed a prospective, randomized, controlled trial to investigate whether the water technique increases the proportion of patients that are able to complete unsedated colonoscopy.

METHODS

We analyzed data from 116 consecutive outpatients who were willing to start colonoscopy without sedation; 58 were each randomly assigned to groups given water infusion or air insufflation during the insertion phase. Sedation and analgesia were administered on demand.

RESULTS

Fewer patients requested sedation in the water group (8.6%) than in the air group (34.5%; P = .003) and their maximum pain scores were lower (2.8 ± 1.9 vs 4.2 ± 2.3 in the air group; P = .011). However, differences in percentages of patients who received complete, unsedated colonoscopy between the water group (74.1%) and air group (62.1%) did not reach statistical significance (P = .23); the percentage of successful cecal intubations was lower in the water group (82.8%) than in the air group (96.5%; P = .03) because of poor visibility. Failed procedures in the water group were completed successfully after air insufflation. The cecal intubation time was shorter in the air group (6.2 ± 3.4 min) than in the water group (8.1 ± 3.0 min; P = .01).

CONCLUSIONS

In patients willing to undergo unsedated colonoscopy, water infusion improves patient tolerance for cecal intubation, compared with air insufflation. However, it does not increase the overall percentage of successful cecal intubations because suboptimal bowel preparation interferes with visibility.

Colorectal cancer screening and prevention in women

Colorectal cancer (CRC) is the third most common cause of cancer in women. Screening for CRC increases early detection of cancer and premalignant polyps and decreases morbidity from this disease. However, adherence to the screening guidelines continues to remain inadequate both at the physician and patient levels. Several factors are of special importance to women. Presence of prior gynecological malignancies may increase the risk of CRC in women. Furthermore, new studies have shown other factors such as obesity and smoking to increase the risk of CRC in women. This article highlights issues unique to women with regards to CRC and outlines special considerations for determining screening intervals in women, identifies factors that make screening more difficult in women, and reviews studies that identify preventative strategies which, together with screening, may reduce the burden of CRC.

Nonalcoholic fatty liver disease: an independent risk factor for colorectal neoplasia

BACKGROUND AND AIMS

Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of insulin resistance (IR), and IR is associated with an increased risk of colorectal carcinoma (CRC). Increased echogenicity suggesting NAFLD is a frequent incidental finding on ultrasound examination. We aimed to systematically evaluate whether NAFLD is an independent risk factor for colonic neoplasia.

PATIENTS AND METHODS

One thousand two hundred and eleven patients (603 males, 60.6 ± 9.6 years; 608 females, 61.1 ± 10.3 years) who underwent screening colonoscopy according to national screening recommendations for CRC were evaluated in a cross-sectional study. Colorectal adenomas were classified as tubular adenoma, advanced adenoma (villous features, size ≥ 1 cm or high-grade dysplasia) or carcinoma. NAFLD was diagnosed by increased echogenicity on ultrasound examination after serological exclusion of infectious, immunological, hereditary or alcoholic aetiology.

RESULTS

Nonalcoholic fatty liver disease was diagnosed in 367 (60.8%) males and in 265 (43.5%) females. The total rate of adenomas was increased in subjects with NAFLD (243/367 vs. 107/236 in males, P = 0.010; 94/265 vs. 78/343 in females; P = 0.014). In particular, more tubular adenomas (127/367 vs. 56/236; P = 0.006), adenomas of the rectum (40/367 vs. 8/236; P = 0.004) and more cancers (6/367 vs. 1/236; P < 0.001) were observed in males with NAFLD. In females with NAFLD, more tubular adenomas (59/265 vs. 48/343; P = 0.011) and adenomas of the proximal colon (51/265 vs. 40/343; P = 0.041) were observed. Multivariate regression analyses demonstrated an independent association of colorectal adenomas with hepatic steatosis after adjustment for age, sex, body mass index and glucose intolerance (OR 1.47; 95% CI 1.079-2.003; P = 0.015).

CONCLUSION

Patients with NAFLD undergoing screening colonoscopy reveal significantly more CRC precursor lesions and early CRC compared with subjects without NAFLD. This elevated risk is independent from other manifestations of IR. These findings suggest that detecting fatty liver on ultrasound should heighten the awareness for referral to screening colonoscopy.

Sedation, analgesia, and cardiorespiratory function in colonoscopy using midazolam combined with fentanyl or propofol

BACKGROUND AND AIMS

The use of sedatives during colonoscopy remains controversial because of its safety concerns. We compared cardiorespiratory function and sedative and analgesic effects in sedative colonoscopy, using combinations of midazolam with either fentanyl or propofol.

METHODS

Eligible patients (n = 480) received 1.0-2.0 mg midazolam alone (n = 160), midazolam combined with either 50-100 mg fentanyl intramuscularly (n = 160), or 0.5-2.5 mg/kg propofol intravenously, as premedication for sedative colonoscopy. Pulse rate, blood pressure, and saturation of peripheral oxygen (SpO(2)) were monitored. Levels of sedation and analgesia were semi-quantitatively scored using visual analog scales, and amnesia profiles were qualitatively evaluated.

RESULTS

Combining midazolam with either fentanyl or propofol resulted in acceptable sedative and analgesic effects compared to treatment with midazolam alone (P < 0.001), with the combination with propofol giving more favorable results. More patients receiving the propofol combination became amnestic to the procedure than patients receiving the fentanyl combination. However, midazolam combined with propofol disturbed the pulse rate (P < 0.05) and blood pressure (P < 0.001) more significantly than a combination with fentanyl, or midazolam alone.

CONCLUSION

The combination of midazolam with either fentanyl or propofol allowed patients to undergo colonoscopy under comparable sedative and analgesic conditions. The combination with fentanyl had a significantly lower effect on pulse rate and blood pressure. The combination with propofol produced superior amnestic effects.

The water method significantly enhances proximal diminutive adenoma detection rate in unsedated patients

BACKGROUND: Colonoscopy has been reported to fail to prevent some post screening colonoscopy incident cancers or minimize cancer mortality in the proximal colon. These reports question the effectiveness of colonoscopy in detecting all proximal adenomas. Diminutive ones which can be obscured by residual feces are particularly at risk. The water method provides salvage cleansing of sub-optimal preparations. OBJECTIVE: To test the hypothesis that the water method enhances proximal diminutive adenoma detection rate (ADR). DESIGN: The data bases of two parallel RCT were combined and analyzed. SETTING: Two Veterans Affairs endoscopy units. PATIENT AND METHODS: The water and air methods were compared in these two parallel RCT examining unsedated patients. MAIN OUTCOME MEASUREMENTS: The combined data on diminutive and overall ADR in the proximal colon, overall ADR, cecal intubation rate, withdrawal time and global bowel cleanliness score. RESULTS: Data in the water (n=92) and the air (n=90) groups were assessed. The water method yielded a significantly higher proximal diminutive ADR, 28.3% vs. 14.4% (p=0.0298); cecal intubation rate, 99% vs. 90% (p=0.0091); mean withdrawal time 19 (10) vs. 15 (8) min (p=0.0065) and mean global bowel cleanliness score during withdrawal, 2.6 (0.7) vs. 2.3 (0.6) (p=0.0032). Increase in proximal overall ADR in the water group approached significance, 29.3% vs. 16.7% (p=0.0592). LIMITATION: Small number of predominantly male veterans. CONCLUSION: The significantly higher cecal intubation rate, longer mean withdrawal time and better mean global bowel cleanliness score favor the outcome of significantly enhanced proximal diminutive ADR in the water group.

Is there a place for sedationless colonoscopy?

Usedated colonoscopy is routinely available in many parts of the world. In the US, only educated professionals appear to be knowledgeable enough to request the unsedated option. Colonoscopists have also been willing to perform unsedated colonoscopy when a patient presents without an escort after undergoing bowel purge preparation. While the actual side-effects of sedation are minimal, the escort requirement and time burden of sedation are barriers to the uptake of screening colonoscopy in the US. The recent trend of deep sedation with propofol for screening colonoscopy increases the efficiency of the colonoscopists at significant costs (e.g. anesthetist reimbursement). The options of as needed and on demand sedation permit patients to complete colonoscopy without sedation. The latter appears to be potentially less coercive. Nurses with experience in the unsedated options recognize the benefit of the quick turn-around of the examination room and shortened occupancy of the recovery area. Discharge planning can be optimized due to absence of amnesia. Patients completing unsedated colonoscopy have given their endorsement of the options. Pain and discomfort continue to limit the success rate of cecal intubation to about 80%. A recently described water method (warm water infusion in lieu of air insufflation combined with removal of all residual colonic air by suction and residual feces by water exchange) has the potential of decreasing procedural discomfort and enhancing cecal intubation in unsedated colonoscopy. The availability of the novel water method assures colonoscopists that high success rate of cecal intubation can be achieved in the unsedated patients.

A comparison of optical colonoscopy and CT colonography screening strategies in the detection and recovery of subcentimeter adenomas

OBJECTIVES

Evidence has shown that computerized tomographic colonography (CTC) and optical colonoscopy (OC) can detect advanced adenomas at an equal rate; however, a comparison of the subcentimeter adenoma detection has not been performed. The objective of this study is to compare CTC and OC screening programs, with a focus on the detection and recovery of subcentimeter adenomas.

METHODS

In all, 1,700 screening OC examinations in average-risk patients were compared with 1,307 CTC examinations in similar patients drawn from the same referral pool completed in 2006-2008. The detection rate for adenomas ≤ 5 mm, 6-9 mm, and <10 mm with advanced histology were compared.

RESULTS

In the OC group, 23.2% of patients had at least one adenoma removed; in the CTC screening group, 5.9% of patients had at least one adenoma detected and removed, P<0.001. There were significantly more ≤ 5 mm adenomas (detection rate 0.22, 378/1,700) detected by OC than by CTC (detection rate 0.04, 56/1,307), P<0.001. There were significantly more adenomas 6-9 mm (detection rate 0.12, 204/1,700) detected by OC than by CTC (detection rate 0.05, 67/1,307), with 70 patients with polyps of unknown histology in CTC surveillance, P<0.001. The number of advanced lesions <10 mm detected by OC (15/1,700) compared with CTC (4/1,307) were not significantly different, P=0.06. In the OC group, 27.1% of patients had non-adenomatous polyps removed; in the CTC group, 4.1% of patients had non-adenomatous polyps removed, P<0.001.

CONCLUSIONS

(i) An OC screening program detects and recovers a significant four and a half fold greater number of non-advanced adenomas compared with a CTC screening program. (ii) The primary difference between screening with OC and CTC is the recovery and management of the subcentimeter adenoma.

A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method

BACKGROUND

An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy.

OBJECTIVE

To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT).

DESIGN

Prospective RCT, intent-to-treat analysis.

SETTING

Veterans Affairs ambulatory care facility.

PATIENTS

Veterans undergoing scheduled unsedated colonoscopy.

INTERVENTIONS

During insertion, the water and traditional air methods were compared.

MAIN OUTCOME MEASUREMENTS

Discomfort and procedure-related outcomes.

RESULTS

Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method (P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort (t = -1.998, P = .049, R(2) = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield.

LIMITATIONS

Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability.

CONCLUSIONS

The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).

Targeting risk groups for screening

Currently colorectal cancer (CRC) screening guidelines are based on age and to some extent on family history of screenees only. Potentially CRC screening could be also customised according to gender, race, ethnicity, smoking habits, presence of obesity, diabetes and metabolic syndrome. The factors that could be individually modified are: choice of screening test, age of initiation of screening and screening intervals. Gender is probably the easiest factor to be included. One of the professional societies has already included the race into guidelines in order to lower the age of starting screening in African-Americans. Targeting persons at higher than average-risk aims at optimising the use of available resources. However, an important drawback of such approach exists; it is the risk of making guidelines too complex and incomprehensible for both eligible screenees and physicians.

Sedation-risk-free colonoscopy for minimizing the burden of colorectal cancer screening

Unsedated colonoscopy is available worldwide, but is not a routine option in the United States (US). We conducted a literature review supplemented by our experience and expert commentaries to provide data to support the use of unsedated colonoscopy for colorectal cancer screening. Medline data from 1966 to 2009 were searched to identify relevant articles on the subject. Data were summarized and co-authors provided critiques as well as accounts of unsedated colonoscopy for screening and surveillance. Diagnostic colonoscopy was initially developed as an unsedated procedure. Procedure-related discomfort led to wide adoption of sedation in the US, although unsedated colonoscopy remains the usual practice elsewhere. The increased use of colonoscopy for colorectal cancer screening in healthy, asymptomatic individuals suggests a reassessment of the burden of sedation in colonoscopy for screening is appropriate in the US for lowering costs and minimizing complications for patients. A water method developed to minimize discomfort has shown promise to enhance outcomes of unsedated colonoscopy. The use of scheduled, unsedated colonoscopy in the US appears to be feasible for colorectal cancer screening. Studies to assess its applicability in diverse practice settings deserve to be conducted and supported.

Family communication, genetic testing and colonoscopy screening in hereditary non-polyposis colon cancer: a qualitative study

OBJECTIVE

Genetic testing and colonoscopy is recommended for people with a strong history of colorectal cancer (CRC). However, families must communicate so that all members are aware of the risk. The study aimed to explore the factors influencing family communication about genetic risk and colonoscopy among people with a strong family history of CRC who attended a genetic clinic with a view to having a genetic test for hereditary non-polyposis colon cancer (HNPCC).

METHODS

Interviews were held with 30 people with a high familial risk of colon cancer. The transcripts were transcribed verbatim and analysed using Interpretative Phenomenological Analysis.

RESULTS

The family context, family history and perceptions about family duties and responsibilities were important motivators for communication about risk, genetic testing and colonoscopy and influenced participation in genetic testing and screening programmes. Participants reported usually communicating openly with their relatives about genetic risk and colonoscopy. Individuals felt a duty towards affected relatives and to their own children. The influence of the spouse and other relatives, particularly those affected by CRC, was also important. Colonoscopy was perceived to be embarrassing, unpleasant and sometimes painful. While there was sometimes anxiety about the result of the colonoscopy the results were usually reassuring.

CONCLUSIONS

The family context and the experience of the family history can have an impact on communication, genetic testing and screening in HNPCC and this should be explored during counselling. Some individuals might benefit from support in communicating with relatives about genetic risk. Ways of improving the individual's experience of colonoscopy should also be examined.

Variation in colonoscopic technique and adenoma detection rates at an academic gastroenterology unit

The purpose of this research is to evaluate the quality of colonoscopy at an academic institution with a focus on factors influencing withdrawal times and adenoma detection rates. Procedural data and pathologic results of 550 consecutive screening colonoscopies in average risks patients (mean [+/-SD] age, 57 +/- 7.6, 44% male) completed by ten academic gastroenterologists were reviewed. Per individual gastroenterologist, the adenoma detection rates ranged widely from 0.09 to 0.82 adenomas per patient with a mean of 0.46 for the group. The mean withdrawal time was 7.0 min for the group and ranged from 3.4 to 9.6 min. There was a significant positive relationship between the number of adenomas detected and the withdrawal time (P = 0.006). Endoscopists with cecal intubation time to withdrawal time ratios of less than 1 detected significantly more adenomas compared to endoscopists with ratios greater than 1 (P = 0.001). (1) Significant variation in academic gastroenterologists' abilities to detect adenomas during screening colonoscopies exists. (2) Colonoscopic withdrawal time and the cecal intubation to withdrawal time ratio are important factors associated with increased adenoma detection rates.

Medication-free colonoscopy--factors related to pain and its assessment

AIM

This paper is a report of a study conducted to determine the possibility of performing colonoscopy without medication, elucidate the factors related to a painful colonoscopy experience and compare colonoscopy patients' reported pain assessment to nurses' and endoscopists' observations.

BACKGROUND

Sedation and pain medication are routinely administered for colonoscopies in many countries. However, medication-free colonoscopies have attracted attention because the use of medication requires a time commitment from patients and increases complications. Earlier studies show that, for instance, gender, age and pelvic operations may increase the risk of painful colonoscopy and those healthcare professionals and patients appear to assess pain differently.

METHOD

A cross-sectional descriptive study was conducted in a Finnish university hospital using questionnaires developed for this study and analysed statistically. The sample of 138 colonoscopy patients, 11 nurses and 11 endoscopists was recruited in 2006.

RESULTS

Over three-quarters of patients reported mild pain or no pain at all. Patients' nervousness is a risk factor for experiencing pain during colonoscopy. Both nurses and endoscopists slightly underestimated the intensity of pain experienced by patients.

CONCLUSION

It is possible to perform colonoscopy without medication with most patients and focus sedation and pain medication on at-risk patients, especially those who are nervous. Before the procedure, nurses must devote time to discovering which patients are nervous and at risk of having a painful colonoscopy to present them for sedation. To improve pain management for patients having colonoscopy, endoscopists and nurses should participate systematically in pain education and use pain scales.

A prospective evaluation of the feasibility of primary screening with unsedated colonoscopy

BACKGROUND

Colonoscopy is the most effective screening tool for colorectal cancer. In Taiwan, colonoscopy is used much less than sigmoidoscopy for screening because sedation significantly increases the cost and is not readily available, and unsedated colonoscopy is considered to be poorly tolerated. However, unsedated colonoscopy has been shown to be well accepted and may improve the cost-effectiveness and access to colonoscopic screening.

OBJECTIVES

To compare the feasibility of unsedated colonoscopy and sigmoidoscopy for primary screening and to analyze factors associated with acceptance of the procedures and need for sedation.

DESIGN

Single center, prospective.

SETTING

National Taiwan University Medical Center. POPULATION AND INTERVENTIONS: A consecutive series of 261 subjects without history of colonoscopy or sigmoidoscopy who underwent unsedated colonoscopy (n = 176) or sigmoidoscopy (n = 85) for primary screening.

MAIN OUTCOME MEASUREMENTS

Pain scores, acceptance, and need for sedation.

RESULTS

No significant differences in pain, acceptance, and need for sedation were found between the colonoscopy and sigmoidoscopy groups. Only 9.6% in the colonoscopy group and 10.1% in the sigmoidoscopy group considered sedation necessary. Multivariate analyses revealed that the examinee's sex and the endoscopist, but not the type of endoscopic examination, were associated with the severity of pain and need for sedation.

LIMITATIONS

Nonrandomized study design.

CONCLUSIONS

Unsedated colonoscopy for primary screening is well accepted in nine tenths of examinees who accept this option and is similar to sigmoidoscopy in pain, acceptance, and need for sedation. Primary screening with unsedated colonoscopy is feasible, as with sigmoidoscopy.

Factors associated with abdominal discomfort during colonoscopy: a prospective analysis

OBJECTIVES

Colonoscopy can be uncomfortable. To increase safety, there is a trend, in the UK, towards reduced sedative use. We aimed to determine factors predictive of discomfort during colonoscopy.

METHODS

Prospectively recruited patients were asked to grade anticipated discomfort on a Numeric Rating Scale ranging from 0 to 10. Discomfort scores were recorded every 2 min during the procedure and during peaks of discomfort. An overall discomfort score was recorded.

RESULTS

One hundred and nine patients [44 male, 65 female; median 61.5 (21-80) years] were recruited. One hundred and three procedures were completed. Forty-five patients received midazolam [median 2 (1.5-5) mg]. Mean overall Numeric Rating Scale score was 4.7 (men 4.0; women 5.2; P<0.01) and median peak score 7. Discomfort was usually greatest at the beginning of the procedure, while in the sigmoid colon. Discomfort scores were higher in patients with irritable bowel syndrome (P = 0.03); diverticular disease (P<0.01); midazolam (P = 0.02), buscopan (P<0.001) or nitrous oxide (P<0.001) use; endoscope tracker use (P = 0.01); incomplete procedures (P<0.001) or a preceding gastroscopy (P = 0.02), but were not correlated with discomfort during venous cannulation or digital rectal examination. Multivariate analysis showed that female sex, high anxiety, anticipation of high discomfort, longer intubation time and higher endoscopist's grade of procedural difficulty were independent factors significantly related to overall discomfort scores. Recollected discomfort scores 2-3 months later were lower (P<0.01). Low-dose midazolam had no appreciable amnesic effect.

CONCLUSION

Factors indicative of difficult colonoscopy, and preceding gastroscopy, are associated with greater discomfort, as are the presence of female sex, irritable bowel, anxiety and anticipated discomfort. Low-dose midazolam neither relieves discomfort nor makes patients forget it. Selected patients may benefit from increased analgesia.

Remifentanil vs. meperidine for patient-controlled analgesia during colonoscopy: a randomized double-blind trial

OBJECTIVES

The aim was to compare patients' and endoscopists' satisfaction in terms of efficacy and safety of remifentanil patient-controlled analgesia (PCA) during colonoscopy with that of a combination of midazolam and meperidine.

METHODS

Sixty patients undergoing colonoscopy were randomly assigned to two groups. All of the patients received midazolam 0.03 mg/kg intravenously for premedication. In the remifentanil group, a bolus dose of remifentanil was given, and a patient-controlled sedation analgesia (PCSA) pump was set to inject further bolus doses with no "lockout" time. Patients in the meperidine group received a bolus of meperidine and sham PCSA. Non-invasive arterial blood pressure, electrocardiography, and pulse oximetry were monitored throughout the study. The Observer's Assessment of Alertness and Sedation Scale (OAA/S) was performed at baseline, every 5 min during, and after colonoscopy. Assessment of pain and satisfaction with sedoanalgesia was scheduled after colonoscopy and 24-72 h later by a 100 mm visual analog scale (VAS). The technical difficulty of the examination and the gastroenterologist's satisfaction were assessed similarly.

RESULTS

The degree of pain, the level of satisfaction with sedoanalgesia by patients and gastroenterologists, and the degree of difficulty experienced by the endoscopist were not different in the two groups. The time to reach an Aldrete score > or = 9 was significantly shorter in the remifentanil group (P < 0.0001); discharge times did not differ between the groups (P = 0.36). There was no difference between the groups regarding the duration of colonoscopy (P = 0.82) and the stability of vital signs. At the end of the procedure, OAA/S was significantly higher in the remifentanil group (P = 0.03).

CONCLUSIONS

Remifentanil PCA is safe and effective to induce sedoanalgesia during colonoscopy. Further studies should address the optimization of dosing and lock out setting.

Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans

BACKGROUND

Intermittent warm-water infusion in lieu of air insufflation permitted 52% of patients who accepted sedation on demand to complete colonoscopy without sedation.

OBJECTIVE

To test the hypothesis that the water method enhances cecal intubation and increases the proportion of patients who report willingness to repeat a scheduled unsedated colonoscopy.

DESIGN

Observational study.

PATIENTS

Two consecutive groups of veterans.

INTERVENTIONS

From June 2005 to May 2006, the usual air insufflation method was used to aid colonoscope insertion. From June 2006 to October 2007, the water method was used.

MAIN OUTCOME MEASUREMENTS

Cecal intubation; report of willingness to repeat unsedated colonoscopy.

RESULTS

Sixty-two and 63 veterans were examined by the air method and the water method, respectively. Intention-to-treat analysis revealed that the cecal intubation rate with the water method (97% [61/63]) was significantly higher than that with the air method (76% [47/62]). The proportion of patients who reported willingness to repeat unsedated colonoscopy was significantly higher with the water method (90% [57/63]) compared with the air method (69% [43/62]).

LIMITATIONS

Single site, nonrandomized, unblinded, small number of elderly male veterans.

CONCLUSION

The effects of the water method in the group for scheduled unsedated colonoscopy were sufficiently provocative to warrant calling for their confirmation by a randomized controlled trial.

Methods of reducing discomfort during colonoscopy

In the United States sedation for colonoscopy is usual practice. Unsedated colonoscopy is limited to a small proportion of unescorted patients and those with a personal preference for no sedation. Over 80% of patients who accept the option of as-needed sedation can complete colonoscopy without sedation. Colonoscopy in these unsedated patients is performed with techniques similar to those used in the sedated patients. Uncontrolled observations indicate willingness to repeat colonoscopy amongst these patients was correlated significantly with low discomfort score during the examination. Methods reported to minimize patient discomfort or enhance cecal intubation during sedated or unsedated colonoscopy included use of pediatric colonoscope, variable stiffness colonoscope, gastroscope, and inhalation of nitrous oxide or insufflation of carbon dioxide, hypnosis, music, audio distraction, or simply allowing the patients to participate in administration of the medication. Research focusing on confirming the efficacy of a simple inexpensive nonmedication dependent method for minimizing discomfort will likely improve the outcome of care and more importantly will ensure compliance with future surveillance in patients accepting the unsedated option.

Involvement of trainees in routine unsedated colonoscopy: review of a pilot experience

BACKGROUND

Unsedated colonoscopy is not required by the Accreditation Council of Graduate Medical Education in the curriculum of GI trainees.

OBJECTIVE

We describe our pilot experience with trainee participation in unsedated colonoscopy.

DESIGN

A retrospective review of a performance improvement program to provide access to colonoscopy.

SETTING

A Veteran's Affair ambulatory care facility that discontinued sedated colonoscopy because of a nursing shortage.

PATIENTS

A total of 145 of 483 patients who chose unsedated colonoscopy after both sedated and unsedated options were discussed.

INTERVENTIONS

GI fellows performed unsedated colonoscopy under the supervision of the attending physician.

MAIN OUTCOME MEASUREMENTS

Cecal intubation rate, patient assessment of the reasons for the choice, the unsedated experience, willingness to have another colonoscopy, and the rate of return for unsedated colonoscopy among eligible patients.

RESULTS

Cecal intubation was achieved in 112 of 145 patients. The adjusted success rate (excluding inadequate bowel preparation and an obstructing lesion) was 81%. The most frequently acknowledged reason for the choice was the ability to communicate with the colonoscopist. Eighty-six patients reported a good experience and were likely to accept another unsedated colonoscopy. To date, all 8 patients eligible for 3-year follow-up successfully completed another unsedated examination.

LIMITATION

An uncontrolled, nonrandomized review in predominantly male older veterans.

CONCLUSIONS

An unsedated colonoscopy might be acceptable to some populations, particularly when communication with clinicians and procedural convenience are highly valued. Involvement of trainees is feasible. Randomized controlled comparisons of sedated and unsedated options in terms of safety (eg, sedation and procedure-related complications) and cost in settings with and without a nursing shortage deserve to be considered.

Endoscopic follow-up of positive fecal occult blood testing in the Ontario FOBT Project

BACKGROUND

The Ontario FOBT Project is a pilot study of fecal occult blood testing (FOBT) for colorectal cancer screening conducted among age-eligible volunteers (50 to 75 years) in 12 of 37 public health regions in Ontario.

METHODS

Volunteers responded to invitations from primary care practitioners (PCPs) in six regions, and from public health programs in the remaining regions. FOBT collection kits were distributed from routine laboratory specimen collection sites, to which completed kits were returned. Results were sent to PCPs in all 12 regions, with copies sent to the study office at Cancer Care Ontario (Toronto, Ontario). Follow-up of positive results was at the discretion of the PCPs. The study files contained the unique Ontario Health Insurance Numbers, the date of the analyses, the number of satisfactory slides and the results for each slide. The Ontario Health Insurance Numbers were encrypted for each participant, and along with the study file, were linked to medical billing claims, hospital records and aggregate demographic data.

RESULTS

Among participants with positive results (men 3.5% and women 2.2%), the median time from date of FOBT analysis to date of colonoscopy was 121 days among men and 202 days among women. At the end of follow-up, after positive FOBT (six to 17 months), 73% of men and 56% of women had proceeded to colonoscopy.

CONCLUSION

Although colonoscopy appeared to be acceptable to the majority of participants with positive FOBT, accessibility problems was the likely explanation for lengthy intervals between the date of positive FOBT and its performance. Differences between the experiences of men and women require further investigation.

Single use of fentanyl in colonoscopy is safe and effective and significantly shortens recovery time

BACKGROUND

Colonoscopy remains an uncomfortable examination and many patients prefer to be sedated. The aim of this study was to evaluate the efficacy and safety of intravenous administration of fentanyl in titrated doses compared with intravenous administration of the well-known midazolam in titrated doses.

METHODS

One hundred twenty-six patients scheduled for ambulatory colonoscopy were randomly assigned to receive either 25 mcg fentanyl (Fentanyl group, n = 66, 35 females, mean age = 61.5 years) and titrated up to 50 mcg or 2 mg midazolam (Midazolam group, n = 60, 33 females, mean age = 63.2 years) and titrated up to 5 mg. Patients graded discomfort on a scale from 0 to 4 and pain on a scale from 0 to 10. Success of the procedure, time to cecum, complications, and recovery time for each patient were independently recorded.

RESULTS

Mean discomfort scores were 0.4 in the Fentanyl group and 1.0 in the Midazolam group (p = 0.002). Similarly, mean scores for pain and anus to cecum time were lower in the Fentanyl group than in the Midazolam group [2.59 vs. 4.43 (p = 0.002) and 8.7 vs. 12.9 min (p = 0.012), respectively]. No adverse events were reported in the Fentanyl group, while in the Midazolam group a decrease in oxygen saturation was noted in 23/60 (35%) patients. Mean recovery time was 5.6 min in the Fentanyl group and 16 min in the Midazolam group (p = 0.014). Mean dosage was 36 mcg for fentanyl and 4.6 mg for midazolam.

CONCLUSION

Administration of fentanyl in low incremental doses is sufficient to achieve a satisfactory level of comfort during colonoscopy.

Colorectal cancer screening: results of a 5-year program in asymptomatic subjects at increased risk

BACKGROUND AND AIMS

The province of Ferrara has one of the highest incidences of colorectal cancer (CRC) in Italy. In January 2000, we set up a colonoscopy screening program focussing on first-degree relatives of CRC patients. We now report the results 5 years after the beginning of the project. SCREENEES AND METHODS: In October 1999, we started a campaign stressing the usefulness of colonoscopy for the first-degree relatives of CRC patients. Subjects included in the screening program were aged between 45 and 75 years with at least one first-degree relative affected by CRC. They were invited to an interview where a physician suggested colonoscopy as a screening option.

RESULTS

In 5 years, 776 subjects were interviewed and 733 (94.4%) agreed to an endoscopic examination (M/F:375/401; mean age 55 years): 562 colonoscopies were performed. Adenomas and cancers were found in 122 (21.7%) and 12 (2.1%) subjects, respectively. Histological examination in 181 persons with lesions (32.8%) showed (most serious lesion quoted) 47 hyperplastic polyps (26% of all lesions), 2 serrated adenomas (1.1%), 68 tubular adenomas (48%), 24 tubulovillous adenomas (13.3%), 9 adenomas with high grade dysplasia (5%) and 12 adenocarcinomas (6.6%). The majority of the cancers were at an early stage (8 Dukes A and 3 Dukes B). Sedation was used in only 42 colonoscopies (7.5%).

CONCLUSIONS

A colonoscopy-based screening in this selected high-risk population is feasible. Even without sedation subjects readily agreed to the endoscopic procedure. We identified a significant number of advanced neoplasms and cancers at an early stage suggesting that this could be a useful tool in early identification of CRC.

Uniquely women's issues in colorectal cancer screening

Colorectal cancer (CRC) is the third most common cause of cancer in women. Screening has been shown to increase detection and decrease morbidity from this disease, but compliance is poor. This paper reviews special considerations for determining screening intervals in women, factors making screening more difficult in women, and studies reviewing preventative strategies in addition to screening that may reduce CRC.

Anaesthesia and sedation for gastrointestinal endoscopy

PURPOSE OF REVIEW

Wide variations exist around the world in the practice of sedation for endoscopy, in terms of the depth of sedation, drug choices, delivery methods and the practitioners involved. These variations are driven by historical, cultural and economic factors. Professional bodies have promulgated guidelines in an attempt to unify and raise standards for sedation and monitoring. Nevertheless, preventable morbidity associated with sedation still occurs. A review of the recent literature is therefore justified.

RECENT FINDINGS

The main themes in this literature are the advent of the widespread use of propofol by non-anaesthesiologists, and particularly non-medical staff; novel methods for administering propofol; the acceptability of endoscopy without sedation; and emerging technologies that obviate the need for endoscopy.

SUMMARY

There is still much scope to research and refine sedation techniques for endoscopy. We believe that the involvement of anaesthesiologists in this research is vital.

Extended flexible sigmoidoscopy performed by colonoscopists for colorectal cancer screening: a pilot study

BACKGROUND

Caecal intubation can be achieved by extended flexible sigmoidoscopy in 32% of patients.

AIM

To assess the feasibility of extended flexible sigmoidoscopy performed by colonoscopists for colorectal cancer screening.

METHODS

We enrolled 41 patients referred for screening flexible sigmoidoscopy. After purging, examination was performed with a colonoscope. All patients completed sigmoidoscopy (success in meeting referral goal); 93% and 71% had examination to the transverse or ascending colon, and caecum, respectively. Overall yield and right-sided polyps was 56% and 27%, respectively. Caecal intubation and complete examination with polypectomy took 6.0 +/- 2.5 and 18.3 +/- 5.1 min, respectively; with no complications. Twelve patients requested colonoscope withdrawal because of discomfort. Although 46% reported moderate to severe discomfort, 39% and 36%, respectively, were definitely or probably willing to repeat flexible sigmoidoscopy.

RESULTS

Unsedated colonoscopy introduced as extended flexible sigmoidoscopy emphasizes the benefits of added yield rather than the negative image of withholding of discomfort relief. The patient can choose to accept the equivalent of an unsedated colonoscopy or reject the option based on perceived discomfort during extended flexible sigmoidoscopy performed by the colonoscopist.

CONCLUSION

Extended flexible sigmoidoscopy is a feasible option in carefully selected patients, fully prepared and by an experienced colonoscopist.

Significance of patient-controlled sedation during colonoscopy. Results from a prospective randomized controlled study

BACKGROUND

In France, general anesthesia is given to more than 90% of patients undergoing colonoscopy although in several countries sedation is limited to intolerant patients. This study was carried out to determine whether Patient-Controlled Sedation (PCS) could provide a lighter sedation than general anesthesia adapted to the patient's individual requirement.

METHODS

Patients aged from 18 to 80 scheduled for elective colonoscopy were prospectively randomized to receive either standard sedation (control group) or patient-controlled-sedation (PCS). In the control group, patients received a continuous infusion of propofol. Patients in the PCS group were connected to an infusion pump containing propofol and self-administered 20-mg boluses as often as they required. An anesthetist was present throughout the procedure. Patient satisfaction measured on a visual analog scale four hours after colonoscopy was the main outcome criterion.

RESULTS

From December 2002 to September 2003, 402 patients underwent elective colonoscopy, 173 of them were eligible and were asked to participate in the study. Seventy-two gave their informed consent and were prospectively randomized. The patients' mean satisfaction scores were not statistically different between the two groups: 84.7 mm (PCS group) vs. 91.5 mm (control group); P = 0.24. Mean doses of propofol (60 mg vs. 248 mg; P <0.001), depth of sedation and time before discharge (1.75 hours vs. 4.45 hours) were significantly lower for patients in the PCS group; nine of them (25.7%) did not use the pump and had total colonoscopy without sedation. There were no statistically significant differences between the two groups regarding total duration of colonoscopy (19.4 min (PCS) vs. 18 min (control)) difficulty and therapeutic procedures (biopsy or polypectomy). Two weeks after the procedure, 96.5% of patients in the PCS group were willing to repeat the examination under the same conditions vs. 72.5% of patients in the control group (P = 0.03).

CONCLUSIONS

Our results demonstrate that need of sedation is widely overestimated in France. A subset of our patients is willing to consider colonoscopy without general anesthesia. For them, PCS with propofol is an effective and very well accepted form of sedation.

Sensitivity of pain rating scales in an endoscopy trial

OBJECTIVE

The purpose of this study was to compare the sensitivity of two commonly used pain-rating scales, the Visual Analog Scale and the 4-point verbal rating scale. Both are considered reliable and valid, but previous studies regarding sensitivity of rating scales have lead to different conclusions, and there is no firm agreement as to the best scale to choose.

METHODS

The sensitivity of the Visual Analog Scale and the 4-point verbal rating scale was compared by stochastic simulation. In the simulation model, we used 168 pairs of pain ratings on the Visual Analog Scale and the 4-point verbal rating scale from individuals undergoing a lower gastrointestinal endoscopy, maintaining the true relation between ratings from the same individual. We created empirical distributions mimicking 2 independent groups of pain ratings. Random samples from the 2 groups were compared by the Wilcoxon-Mann-Whitney U test in 10,000 repetitions of a computer algorithm. By increasing the proportion of individuals with a high level of pain in one group, we increased the true difference between pain ratings and estimated a statistical power function.

RESULTS

In the present pain model with pain ratings from healthy individuals undergoing endoscopy, the Visual Analog Scale is consistently more sensitive than the four-point verbal rating scale.

DISCUSSION

Because each individual provided one Visual Analog Scale and one 4-point verbal rating scale rating for the same pain experience, the ability of the two scales to detect differences between groups of pain ratings could be compared. The use of a simulation model enabled estimation of a power function and reduced the probability of basing the conclusion on a chance finding.

Sedation-free colonoscopy

PURPOSE

The administration of sedative drugs at colonoscopy has its drawbacks, such as increasing the rate of complications and the cost. There are a number of potential advantages to performing colonoscopy without sedation. The aim of this study is to evaluate patient tolerance and acceptance during sedation-free colonoscopy.

METHODS

Pain during sedation-free colonoscopy was evaluated in consecutive series of 675 patients in a prospective manner from January 1, 2003, to February 18, 2004. We recorded the degree of patient pain during colonoscopy, willingness to undergo sedation-free colonoscopy in the future, the complication rate, and the intubation time. The assisting endoscopy nurses and patients independently assessed the pain level immediately after the procedure using a four-point pain scale (nil, mild, moderate, severe).

RESULTS

Almost all colonoscopies (99.6 percent: 672/675) were successful. There were four complications related to colonoscopy (bleeding after polypectomy). Patients and nurses rated pain by a four-point pain scale as follows. For the patients: nil, 69.6 percent (470/675); mild, 28.0 percent (189/675); moderate, 2.2 percent (15/675); severe, 0.1 percent (1/675). For the nurses: nil, 76.1 percent (514/675); mild, 22.7 percent (153/675); moderate, 0.9 percent (6/ 675); severe, 0.3 percent (2/675). Patients rarely suffered from severe pain during carefully performed colonoscopies. The pain level of almost all colonoscopies was acceptable by patients, with only six patients (1.0 percent) stating that they would never undergo a colonoscopy without sedation in the future because of unbearable pain.

CONCLUSIONS

This study suggests that carefully performed sedation-free colonoscopy rarely causes complications and is well accepted by most patients. Sedation-free colonoscopy is more cost-effective, may be safer, and should be offered as an alternative to colonoscopy with sedation.

Anxiety during the performance of colonoscopies: modification using music therapy

BACKGROUND AND STUDY AIMS

Colonoscopies are usually performed using pharmacological sedation. This process entails certain risks. In the search for alternative methods, some studies have analysed the effect music can have on patients during the procedure when used as a complement to sedation. We present a prospective, randomized study in which we assess the anxiolytic action music has when it is administered during a single colonoscopy.

PATIENTS AND METHODS

We included 118 patients who were scheduled for ambulatory colonoscopies. They were randomly assigned to the control group (n = 55) and the experimental group (n = 63). We determined their levels of anxiety using the State-Trait Anxiety Inventory Test (STAI) form, which they filled in before and after the examination. Patients listened to music through personal headphones.

RESULTS

The score on the STAI form before the examination was 25.25 +/- 10.49 and 28.16 +/- 11.43 in the control and experimental groups, respectively (P > 0.05). The decrease of the score on the STAI scale after the colonoscopy in the control and experimental groups was 6.27 (95% confidence interval, 3.26-9.28) and 11.35 (95% confidence interval, 8.64-14.05), respectively (P < 0.01).

CONCLUSIONS

Listening to music during ambulatory colonoscopies decreases the level of anxiety that is inherent to the process without other anxiolytic methods.

Who is willing to undergo endoscopy without sedation: patients, nurses, or the physicians?

OBJECTIVES

Some studies suggest that the majority of the United States population is now willing to undergo unsedated endoscopy. We studied the willingness of patients, nurses, and physicians to undergo endoscopy without sedation.

METHODS

Adult patients presenting to us for outpatient endoscopy at two large tertiary care level 1 trauma hospitals were asked to fill out a survey questionnaire recording their demographic information, prior experience with endoscopy and sedation, and whether they were willing to undergo unsedated endoscopy. Their anxiety level was assessed using the Beck Anxiety Inventory. After the endoscopic procedure, patients were asked whether they had any change in their decision regarding unsedated endoscopy. A random convenience sample of physicians and nurses were also given a questionnaire asking about their experience with endoscopy and whether they were willing to undergo such procedures without sedation.

RESULTS

A total of 127 patients, 117 nurses, and 51 physicians participated in the study. Only 19.5% of patients were willing to undergo upper endoscopy without sedation. Among patients, the willingness dropped to 6.75% postprocedurally. Results were similar for colonoscopy. Physicians were least likely to agree to an unsedated procedure (2.2%). Gastroenterology (GI) nurses were more likely to undergo unsedated esophagogastroduodenoscopy (39.3%) as opposed to non-GI nurses (7.1%, P < 0.001). 19.6% of GI nurses agreed to unsedated colonoscopy versus 0% in the non-GI group (P = 0.001). Preprocedure anxiety level was not found to be a predictor for willingness to undergo unsedated endoscopy. Female patients were more likely to forego sedation preprocedurally (OR = 5.75; 95% CI = 2.05-16.2). However, postprocedurally, gender was no longer a significant predictor. Similarly, among the nurses and physicians, neither age nor gender was a significant predictor of willingness to undergo unsedated endoscopy. Patients with a high school (OR = 0.01; 95% CI = 0.01-0.06) or associates degree (OR = 0.02; 95% CI = 0.01-0.35) were less likely to forego sedation.

CONCLUSION

In contrast to reports from some major medical centers, the current study found that most patients as well as medical professionals were unwilling to undergo endoscopy without sedation.