Minor adverse events of colonoscopy on ambulatory patients: the impact of moderate sedation

How to implement adverse events as a quality indicator in gastrointestinal endoscopy

Quality improvement through the registration of endoscopy-related adverse events (AEs) has been recognized by major international endoscopy societies as an important quality indicator. The theory behind this is easier to approve than its implementation in daily practice. The results of many valuable attempts have been published in the literature, mainly highlighting the diverse hurdles trying to capture events related to endoscopy and the sedation used for endoscopic procedures. The current review discusses the difficulties encountered attempting to register AEs and incidents related to endoscopic procedures. Government-driven and financed health-care databases with automated coupling of specific data seem the only efficient way to implement endoscopy-related AEs and outcomes on a prospective and complete basis. This will not only allow continuous confidential feedback to endoscopists in relation to the pooled national benchmark data, but also follow-up in time through data-driven credentialing aiming to progressively optimize these benchmark data.

Robotic Colonoscopy and Beyond: Insights into Modern Lower Gastrointestinal Endoscopy

Lower gastrointestinal endoscopy is considered the gold standard for the diagnosis and removal of colonic polyps. Delays in colonoscopy following a positive fecal immunochemical test increase the likelihood of advanced adenomas and colorectal cancer (CRC) occurrence. However, patients may refuse to undergo conventional colonoscopy (CC) due to fear of possible risks and pain or discomfort. In this regard, patients undergoing CC frequently require sedation to better tolerate the procedure, increasing the risk of deep sedation or other complications related to sedation. Accordingly, the use of CC as a first-line screening strategy for CRC is hampered by patients' reluctance due to its invasiveness and anxiety about possible discomfort. To overcome the limitations of CC and improve patients' compliance, several studies have investigated the use of robotic colonoscopy (RC) both in experimental models and in vivo. Self-propelling robotic colonoscopes have proven to be promising thanks to their peculiar dexterity and adaptability to the shape of the lower gastrointestinal tract, allowing a virtually painless examination of the colon. In some instances, when alternatives to CC and RC are required, barium enema (BE), computed tomographic colonography (CTC), and colon capsule endoscopy (CCE) may be options. However, BE and CTC are limited by the need for subsequent investigations whenever suspicious lesions are found. In this narrative review, we discussed the current clinical applications of RC, CTC, and CCE, as well as the advantages and disadvantages of different endoscopic procedures, with a particular focus on RC.

Comparison of Procedural Sequences in Sedated Same-Day Bidirectional Endoscopy with Water-Exchange Colonoscopy: A Randomized Controlled Trial

Background: Previous studies have favored esophagogastroduodenoscopy (EGD) followed by colonoscopy as the optimal sequence in bidirectional endoscopy (BDE) with air insufflation. However, the optimal sequence in same-day BDE with WE colonoscopy is unclear. Methods: A total of 200 patients undergoing BDE with propofol sedation from May 2018 to January 2021 were randomized to either the EGD-first group (n = 100) or the colonoscopy-first group (n = 100). Results: The EGD-first group required a longer cecal-intubation time (median 16.0 min vs. 13.7 min, p < 0.001) and a lower Boston Bowel Preparation Scale score (8.5 vs. 9, p = 0.030) compared with the colonoscopy-first group. However, the EGD-first group needed a significantly lower dose of propofol (200 mg vs. 250 mg, p < 0.001) and a shorter recovery time (7 min vs. 13.5 min, p < 0.001), resulting in a shorter turnover time of the endoscopy room (39.5 min vs. 42.6 min, p = 0.004). There were no differences in the sedation-related adverse events, patients’ satisfaction scores, adenoma-detection rates, or the outcomes of EGD between the two groups. Conclusions: During propofol-sedated BDE, EGD followed by WE colonoscopy was more efficient with a shorter turnover time despite a longer cecal-intubation time (NCT03638713).

Characteristics of Patients with Post-Colonoscopy Unplanned Hospital Visit: A Retrospective Single-Center Observational Study

Background

Colonoscopy, although a low-risk procedure, is not without associated adverse events. The rates of major adverse events such as perforation and bleeding after a colonoscopy are well reported. The rates of minor incidents following a colonoscopy, however, are less well examined. Recently the Centers for Medicare and Medicaid Services (CMS) started public reporting on the quality of outpatient endoscopy facilities by using a measure of risk-standardized rates of unplanned hospital visits within 7 days of colonoscopy.

Aim

We intended to record and present the characteristics of our patient population who had an unplanned hospital visit within 7 days after undergoing colonoscopy in an outpatient setting.

Methods

This is a retrospective single-center observational study. During the study period of July 2018 to December 2019, we reviewed charts of all patients who returned to the emergency room within a week of undergoing an outpatient colonoscopy. Patient demographics, clinical data and details of colonoscopy were collected and analyzed.

Results

Of the 5344 outpatient colonoscopies performed, our post-colonoscopy emergency room visit rate was 1.05% (n=56). The mean age of the participants was 58 years and 55% were male; 32% of our patients reported gastrointestinal symptoms such as abdominal pain or gastrointestinal bleeding. Patients with gastrointestinal symptoms had a higher rate of polypectomies performed (36.4% vs 11.8%, P = 0.04) and reported higher illicit drug use (31.9% vs 5.9%, P = 0.02) compared with those with non-gastrointestinal complaints. After colonoscopy, 41% of the patients reported reasons for emergency room visits that were entirely unrelated to the procedure.

Conclusion

Our study highlights that unplanned visits within 7 days of colonoscopy are not necessarily related to the procedure, and those that are, tend to be due to unavoidable patient factors. Hence the CMS measure may not be an accurate determinant of the quality of procedure or facility care delivered.

Patients over Age 75 Are at Increased Risk of Emergency Department Visit and Hospitalization Following Colonoscopy

BACKGROUND

The age to stop screening or surveillance colonoscopy is not well established, and unplanned hospital use after colonoscopy in the elderly is not well understood.

AIMS

To evaluate unplanned emergency department (ED) visits and hospitalization in patients over 75 within 7 days of outpatient colonoscopy.

METHODS

In this retrospective, single-center, cohort study, we reviewed outpatient screening or surveillance colonoscopies in patients ≥ 50 in a tertiary care academic medical center or affiliated facility between January 2008 and September 2013. Colonoscopies were divided by age based on USPSTF recommendations. The rate of ED visits and hospitalizations per colonoscopy for each age-group was determined. Predictors of ED visit and hospitalization were assessed through univariate and multivariate logistic regressions, and mortality following colonoscopy was evaluated using Kaplan-Meier analysis.

RESULTS

A total of 30,409 colonoscopies were performed in 27,173 patients (51% male) by 40 endoscopists. ED visits occurred after 188 colonoscopies (0.62%). Age over 75 years was independently associated with ED visit (OR 1.58, 95% CI 1.05-2.37, p = 0.027) and hospitalization (OR 3.7, 95% CI 2.03-6.73, p < 0.001) within 7 days of colonoscopy. Higher number of medication classes, recent ED visit, polypectomy, and endoscopic mucosal resection were also independent variables associated with ED utilization after procedure. The mortality rate at the end of the follow-up (median 4.4; IQR 2.7-6 years) was 1.9, 8.6, and 15.8% for the age-groups 50-75, 76-85, and > 85 years, respectively.

CONCLUSION

Patients over age 75 are 1.6 times as likely to use the ED and 3.7 times as likely to be hospitalized after colonoscopy. Further prospective studies are needed to assess the risk/benefit of nondiagnostic colonoscopy in geriatric patients.

Effect of conscious sedation with midazolam and fentanyl on the overall quality of colonoscopy: a prospective and randomized study

INTRODUCTION

a prospective, randomized study was performed to assess the influence of conscious sedation on the overall quality of colonoscopy, simultaneously quantifying its effect on the scientific quality, perceived quality and patient safety.

METHODS

patients referred for a colonoscopy were included in the study and were randomized to receive or not receive sedation. Demographic data, indication for colonoscopy, cecal intubation, introduction and withdrawal time, resected adenomas and complications during the exploration were collected. Thirty days later, a satisfaction questionnaire was performed (GHAA 9-me) and patients were asked about complications after the examination.

RESULTS

a total of 5,328 patients were included, the average age was 62 ± 15.22 years, 47% were male, 3,734 were sedated and 1,594 were not sedated. The sedated patients had a shorter endoscope insertion time (7'20 ± 2'15 min vs 6'15 ± 3'12 min, p < 0.019), a higher rate of cecal intubations (96% vs 88%, p < 0.05), longer withdrawal time (7'20 ± 2'15 min vs 6'15 ± 3'12 min, p < 0.01) and higher adenoma detection rates (22% vs 17%, p < 0.05). The use of sedation reduced discomfort during and after the exploration, without increasing the complications. The satisfaction questionnaire score was higher (23.6 ± 1.5 vs 16.6 ± 4.8, p < 0.001) in the sedated patients.

CONCLUSIONS

superficial sedation not only reduces patient discomfort but also improves the overall quality of the colonoscopy. Therefore, we must consider the use of sedation as an essential part of colonoscopy.

Patient-reported minor adverse events after colonoscopy: a systematic review

OBJECTIVE

The purpose of this systematic review was to investigate the incidence and nature of minor adverse events (MAEs) after colonoscopy, and response rates to questionnaires concerning MAEs in patients undergoing colonoscopy.

MATERIALS AND METHODS

A systematic literature search was conducted in the databases PubMed and Embase. Predictor variables were patient-reported MAEs after colonoscopy. The outcome was frequency and types of MAEs and the patients' response rate to questionnaires after colonoscopy. Quality assessment for potential risk of bias and level of evidence was evaluated using the National Health and Medical Research Council guidelines.

RESULTS

Seven prospective cohorts were included with a pooled total of 6172 participants. Patients undergoing colonoscopy had a response rate to questionnaires ranging from 64% to 100%, with a mean of 81%. One-third of the patients experienced MAEs, most prominently in the first 1-2 weeks after colonoscopy, and less common at 30 days post colonoscopy. The most frequently reported MAEs were abdominal pain, bloating and abdominal discomfort.

CONCLUSIONS

In general, patients undergoing colonoscopy have a high response rate to questionnaires about MAEs. MAEs after colonoscopy are commonly seen. High age and score of American Society of Anesthesiologists (ASA) classification, female gender and duration of procedure seem to be associated with a higher risk of MAEs, whereas adequate sedation seems to decreases the risk. MAEs after colonoscopy seems to be underreported in the current literature and the existing evidence is based on inhomogeneous reports. In the current study, it was not possible to conduct a meta-analysis. There is a need for larger scale studies addressing the MAEs patients experience in conjunction with a colonoscopy. Furthermore, the assessment of the MAEs should rely on questionnaires tested for validity, comprehensibility and reliability, to reflect the patient-reported experience of a colonoscopy as precise as possible.

Plasma concentration based response surface model predict better than effect-site concentration based model for wake-up time during gastrointestinal endoscopy sedation

BACKGROUND

Sedation for esophagogastroduodenoscopy (EGD) and colonoscopy is characterized by rapid patient induction and emergence. The drugs midazolam and alfentanil have long been used for procedural sedation; however, the relationship between plasma or effect-site concentrations (Cp or Ce, respectively) and emergence remains unclear. The aim of this study is to develop patient wake-up prediction models for both Cp and Ce using response surface modeling, a pharmacodynamics tool for assessing patients' responses.

METHODS

The Observer's Alertness/Sedation (OAA/S) score was used to monitor sedation depth during the examinations. Concentration pairs of midazolam and alfentanil were calculated for each of Cp and Ce using pharmacokinetic simulation software. Response surface models were developed using the Greco construct. Temporal analysis was done by comparing model-predicted wake-up time with true patient wake-up time.

RESULTS

Thirty-three patients with an average body mass index of 21.85 ± 2.3 kg/m² were pooled for analysis. The average duration of examination were 2.9 ± 1.4 min for EGD and 6.6 ± 2.7 min for colonoscopy. Seventy-five concentration pairs of midazolam and alfentanil were obtained for each Cp and Ce. The Cp-based Greco response surface model showed significant synergy between midazolam and alfentanil and was a better predictor of patient wake-up time, with an average deviation of 1.0 ± 3.9 min, while the Ce model show time deviation greater than 20 min.

CONCLUSION

The early phases of drug distribution are unique and complicated by nonsteady-state concentrations, and our study revealed that Ce-based wake-up time prediction is more difficult under these circumstances.

Predictors of post-colonoscopy emergency department use

BACKGROUND AND AIMS

Unplanned hospital visits within 7 days of colonoscopy were recently proposed as a quality measure. It is unknown whether patient, procedure, or endoscopist characteristics predict post-colonoscopy emergency department (ED) visits. Our aim was to determine the incidence and relatedness of ED visits within 7 days of colonoscopy and to identify predictors of post-colonoscopy ED use.

METHODS

In this retrospective, single-center, cohort study, we evaluated outpatient colonoscopies performed at a tertiary academic medical center or affiliated facility between January 2008 and September 2013. We determined the incidence of ED visits within 7 days of colonoscopy and the relatedness of the ED visit to the procedure. We assessed for independent factors associated with ED use within 7 days using logistic regression analysis.

RESULTS

We reviewed 50,319 colonoscopies performed on 44,082 individuals (47% male, median age 59 years) by 40 endoscopists. There were 382 (0.76%) ED visits after colonoscopy, of which 68% were related to the procedure. On multivariate analysis, recent ED visit (odds ratio [OR], 16.60; 95% confidence interval [CI], 12.83-21.48; P < .001), EMR (OR, 4.69; 95% CI, 2.82-7.79; P < .001), number of medication classes (OR, 1.18; 95% CI, 1.11-1.26; P < .001), endoscopist adenoma detection rate (ADR) (OR, 1.14; 95% CI, 1.01-1.29; P = .029), and white race (OR, 0.77; 95% CI, 0.62-0.97; P = .028) were identified as independent variables associated with ED visits after colonoscopy.

CONCLUSIONS

Increased patient complexity, higher endoscopist ADR, and EMR were associated with increased ED use after colonoscopy. Patients at high risk for an unplanned hospital visit within 7 days should be targeted for quality improvement efforts to reduce adverse events and cost.

Screening Indication Associated With Lower Likelihood of Minor Adverse Events in Patients Undergoing Outpatient Colonoscopy

We sought to determine, among outpatients at one university hospital endoscopy center, rates of self-reported minor adverse events (MAEs) at 2, 14, and 30 days postcolonoscopy and to identify predictors of MAEs at Day 2 postcolonoscopy. A single-center longitudinal cohort study with follow-ups at Days 2, 14, and 30 postcolonoscopy was conducted in Montreal, Canada. Baseline self-report data included patient age, gender, gastrointestinal discomforts and other discomforts in the preceding month, and comorbidity. Intracolonoscopy procedures and the method of insufflation were obtained from endoscopy reports. Minor adverse event data were obtained by either phone or Internet survey. Multivariate logistic regression was used to identify predictors of MAEs at Day 2. Of 705 individuals approached, 420 (mean age = 58.7 years; SD = 8.4, 45.7% female) were eligible and consented to study participation, and 378 (90%) participated in at least one follow-up. At Days 2, 14, and 30, 86 (25.1%), 46 (13.7%), and 13 (3.1%) patients, respectively, experienced at least one MAE. At the Day 30 follow-up, 2 (0.53%) patients reported having experienced a serious adverse event. The multivariable analysis results showed that screening compared with nonscreening colonoscopy was protective for MAEs at 2 days (OR = 0.5, 95% CI [0.3, 0.9]). We found that 25% of patients experienced at least one MAE at 2 days postcolonoscopy, and screening compared with nonscreening colonoscopy patients were half as likely to experience these early MAEs. Nurses may use these findings to educate and reassure patients about colonoscopy risks. Large, longitudinal multicenter studies are needed to corroborate our findings.

Prospective Analysis of Minor Adverse Events After Colon Polypectomy

BACKGROUND

The risks of minor adverse events (MAEs) such as abdominal pain and bloating after colon polypectomy (CP) are less clearly documented than major adverse events. However, these complications may cause significant discomfort during the performance of normal activities. We aimed to estimate the incidence of MAE, associated risk factors, and healthcare resource utilization after CP.

METHODS

Patients who underwent CP were prospectively enrolled in this study. Trained nurses contacted patients by telephone at 7 and 30 days after the CP and administered a standardized questionnaire to obtain information regarding the development of complications. MAEs were defined as any discomfort the patient experienced after CP excluding major bleeding, perforation, and post-polypectomy coagulation syndrome.

RESULTS

Among a total of 2716 patients, 2253 patients completed the interview at 7 and 30 days. MAEs occurred in 263 patients (11.7%) before day 7, among which the most common were abdominal pain (4.5%), rectal bleeding (2.8%), and bloating (2.6%). Cumulative incidence of MAEs was in 267 patients (11.9%) at 30 days. On multivariate analysis, female sex (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.58-3.18) and use of meperidine (OR 1.54, 95% CI 1.04-2.27) were risk factors for the occurrence of MAEs. Two patients (0.7%) required hospital admission, 117 patients (43.8%) were treated medically in the outpatient clinic, and the majority at 148 patients (55.4%) experienced resolution of symptoms after observation.

CONCLUSIONS

The post-CP MAE rate was as low as 11.8%. The MAEs occurred mainly in the first seven postoperative days and resulted in little use of healthcare resources.

Complications of diagnostic colonoscopy, upper endoscopy, and enteroscopy

Endoscopy is an inherent and an invaluable tool in every gastroenterologist's armamentarium. The prerequisite for quality and safety remains foremost. Adverse events should be minimized and proactive steps should taken before, during and after the endoscopic procedure. Upper endoscopy and colonoscopy are part of basic endoscopy and their major complications will be reviewed here, together with those of enteroscopy. The most common of all endoscopy related complications are cardiopulmonary and thus they will be addressed in detail first. Colonoscopy's major complications are bleeding and perforation. Their epidemiology, mechanisms/risk factors, diagnosis, treatment and prevention will be addressed. The incidence of both of these complications increases significantly with polypectomy. Thus clinical judgment and experience in both polypectomy techniques and the ways to treat these complications, especially with the advanced endoscopic options advanced in the last decade, are of paramount importance. Post-polypectomy syndrome, infection and gas explosion are less frequent and will be reviewed briefly. Bleeding and perforation are upper endoscopy's major complications as well. Advances in endoscopic techniques in recent years offer endoscopic treatment instead of directly resorting to surgery, as was used to be the case and still is if the first fails. Enteroscopy is generally a more advanced procedure and overall complication rate is often quoted as 1%, most of them have been attributed to the passage of the overtube. Perforation and bleeding are the major complications, and a unique upper enteroscopy-associated complication is pancreatitis.

Post-Colonoscopy Complications: A Systematic Review, Time Trends, and Meta-Analysis of Population-Based Studies

OBJECTIVES

Many studies around the world addressed the post-colonoscopy complications, but their pooled prevalence and time trends are unknown. We performed a systematic review and meta-analysis of population-based studies to examine the pooled prevalence of post-colonoscopy complications ("perforation", "bleeding", and "mortality"), stratified by colonoscopy indication. Temporal variability in the complication rate was assessed.

METHODS

We queried Pubmed, Embase, and the Cochrane library for population-based studies examining post-colonoscopy complications (within 30 days), performed from 2001 to 2015 and published by 1 December 2015. We determined pooled prevalence of perforations, post-colonoscopy bleeding, post-polypectomy bleeding, and mortality.

RESULTS

We retrieved 1,074 studies, of which 21 met the inclusion criteria. Overall, pooled prevalences for perforation, post-colonoscopy bleeding, and mortality were 0.5/1,000 (95% confidence interval (CI) 0.4-0.7), 2.6/1,000 (95% CI 1.7-3.7), and 2.9/100,000 (95% CI 1.1-5.5) colonoscopies. Colonoscopy with polypectomy was associated with a perforation rate of 0.8/1,000 (95% CI 0.6-1.0) and a post-polypectomy bleeding rate of 9.8/1,000 (95% CI 7.7-12.1). Complication rate was lower for screening/surveillance than for diagnostic examinations. Time-trend analysis showed that post-colonoscopy bleeding declined from 6.4 to 1.0/1,000 colonoscopies, whereas the perforation and mortality rates remained stable from 2001 to 2015. Overall, considerable heterogeneity was observed in most of the analyses.

CONCLUSIONS

Worldwide, the post-colonoscopy complication rate remained stable or even declined over the past 15 years. The findings of this meta-analysis encourage continued efforts to achieve and maintain safety targets in colonoscopy practice.

Differences in Colonoscopy Quality Among Facilities: Development of a Post-Colonoscopy Risk-Standardized Rate of Unplanned Hospital Visits

BACKGROUND & AIMS

Colonoscopy is a common procedure, yet little is known about variations in colonoscopy quality among outpatient facilities. We developed an outcome measure to profile outpatient facilities by estimating risk-standardized rates of unplanned hospital visits within 7 days of colonoscopy.

METHODS

We used a 20% sample of 2010 Medicare outpatient colonoscopy claims (331,880 colonoscopies performed at 8140 facilities) from patients ≥65 years or older, and developed a patient-level logistic regression model to estimate the risk of unplanned hospital visits (ie, emergency department visits, observation stays, and inpatient admissions) within 7 days of colonoscopy. We then used the patient-level risk model variables and hierarchical logistic regression to estimate facility rates of risk-standardized unplanned hospital visits using data from the Healthcare Cost and Utilization Project (325,811 colonoscopies at 992 facilities), from 4 states containing 100% of colonoscopies per facility.

RESULTS

Outpatient colonoscopies were followed by 5412 unplanned hospital visits within 7 days (16.3/1000 colonoscopies). Hemorrhage, abdominal pain, and perforation were the most common causes of unplanned hospital visits. Fifteen variables were independently associated with unplanned hospital visits (c = 0.67). A history of fluid and electrolyte imbalance (odds ratio [OR] = 1.43; 95% confidence interval [CI]: 1.29-1.58), psychiatric disorders (OR = 1.34; 95% CI: 1.22-1.46), and, in the absence of prior arrhythmia, increasing age past 65 years (aged >85 years vs 65-69 years: OR = 1.87; 95% CI: 1.54-2.28) were most strongly associated. The facility risk-standardized unplanned hospital visits calculated using Healthcare Cost and Utilization Project data showed significant variation (median 12.3/1000; 5th-95th percentile, 10.5-14.6/1000). Median risk-standardized unplanned hospital visits were comparable between ambulatory surgery centers and hospital outpatient departments (each was 10.2/1000), and ranged from 16.1/1000 in the Northeast to 17.2/1000 in the Midwest.

CONCLUSIONS

We calculated a risk-adjusted measure of outpatient colonoscopy quality, which shows important variation in quality among outpatient facilities. This measure can make transparent the extent to which patients require follow-up hospital care, help inform patient choices, and assist in quality-improvement efforts.

Prospective long-term assessment of sedation-related adverse events and patient satisfaction for upper endoscopy and colonoscopy

BACKGROUND

Fear of pain and sedation-related adverse events are impediments for patients to attend endoscopic screening or surveillance programs.

OBJECTIVE

To investigate the long-term effect of different sedation protocols in patients undergoing screening or surveillance endoscopy. Moreover, motivation of patients to decline endoscopic procedures was evaluated by focusing on the patient's satisfaction, fear and pain in relation to type of sedation used.

DESIGN

A prospective, double-blind controlled trial data collection was performed by using a standardized clinical questionnaire followed by a telephone interview 3-4 weeks after the initial endoscopic procedure.

SETTING

The study was conducted at the Department of Medicine I at the University Hospital of Erlangen-Nuremberg. Data collection was performed during June 2012 till April 2013.

PATIENTS

Overall, 307 patients were prospectively evaluated (44.3% female, mean age 51 ± 17.4 years; mean BMI 25.5 ± 5.7). 247 patients (80.5%) were outpatients, 60 inpatients (19.5%).

INTERVENTIONS

Endoscopic procedures were divided into five groups: (i) procedures in the upper gastrointestinal tract, (ii) complete colonoscopies, (iii) ileocolonoscopies, (iv) incomplete colonoscopies, and (v) other procedures.

MAIN OUTCOME MEASUREMENTS

Patient satisfaction, fear and pain were measured in a structured and standardized clinical interview using a 6-point numerical rating scale, where 1 was 'very satisfied/no pain' and 6 was 'very unsatisfied/unsupportable pain'.

RESULTS

Different types of sedation were assessed: propofol in monosedation (6.5%), combination of propofol + meperidine (41.0%), combination of midazolam + meperidine (48.5%) and other combinations (3.9%). Patient satisfaction was significantly reduced regarding fear and pain during the endoscopic procedure (p = 0.001 and p = 0.0001, respectively). All patients receiving propofol monosedation indicated significantly less pain in comparison to other sedation groups (p < 0.0001). Moreover, sedation with midazolam + meperidine increased the fear during the procedure significantly in comparison to monosedation with propofol (p = 0.082). Propofol/meperidine in combination and midazolam/meperidine increased the probability for cardiovascular events in comparison to monosedation with propofol (p = 0.005; p = 0.039). Finally, we observed significantly lower doses of propofol when used in monosedation than propofol in combination with meperidine (p = 0.066).

LIMITATION

Single-center study at a tertiary referral center.

CONCLUSIONS

Propofol in monosedation should preferably be used for patient sedation in screening and surveillance endoscopies. Whether this approach could also improve participation rates in screening and surveillance endoscopies requires further investigations.

Rates of minor adverse events and health resource utilization postcolonoscopy

BACKGROUND

Little is known about minor adverse events (MAEs) following outpatient colonoscopies and associated health care resource utilization.

OBJECTIVE

To estimate the rates of incident MAE at two, 14 and 30 days postcolonoscopy, and associated health care resource utilization. A secondary aim was to identify factors associated with cumulative 30-day MAE incidence.

METHODS

A longitudinal cohort study was conducted among individuals undergoing an outpatient colonoscopy at the Montreal General Hospital (Montreal, Quebec). Before colonoscopy, consecutive individuals were enrolled and interviewed to obtain data regarding age, sex, comorbidities, use of antiplatelets/anticoagulants and previous symptoms. Endoscopy reports were reviewed for intracolonoscopy procedures (biopsy, polypectomy). Telephone or Internet follow-up was used to obtain data regarding MAEs (abdominal pain, bloating, diarrhea, constipation, nausea, vomiting, blood in the stools, rectal or anal pain, headaches, other) and health resource use (visits to emergency department, primary care doctor, gastroenterologist; consults with nurse, pharmacist or telephone hotline). Rates of incident MAEs and health resources utilization were estimated using Bayesian hierarchical modelling to account for patient clustering within physician practices.

RESULTS

Of the 705 individuals approached, 420 (59.6%) were enrolled. Incident MAE rates at the two-, 14- and 30-day follow-ups were 17.3% (95% credible interval [CrI] 8.1% to 30%), 10.5% (95% CrI 2.9% to 23.7%) and 3.2% (95% CrI 0.01% to 19.8%), respectively. The 30-day rate of health resources utilization was 1.7%, with 0.95% of participants seeking the services of a physician. No predictors of the cumulative 30-day incidence of MAEs were identified.

DISCUSSION

The incidence of MAEs was highest in the 48 h following colonoscopy and uncommon after two weeks, supporting the Canadian Association of Gastroenterology's recommendation for assessment of late complications at 14 days. Predictors of new onset of MAEs were not identified, but wide CrIs did not rule out possible associations. Although <1% of participants reported consulting a physician for MAEs, this figure may represent a substantial number of visits given the increasing number of colonoscopies performed annually.

CONCLUSION

Postcolonoscopy MAEs are common, occur mainly in the first two weeks postcolonoscopy and result in little use of health resources.

[Characteristics of deep sedation in gastrointestinal endoscopic procedures performed by intensivists]

OBJECTIVE

To determine tolerance, pain intensity, percentage of tests completed successfully and complications of deep sedation controlled by intensivists during gastrointestinal endoscopic procedures.

DESIGN

A one-year, prospective observational study was carried out.

SETTING

Department of Intensive Care intervention in the Endoscopy Unit of Hospital Universitario del Tajo (Spain).

PATIENTS

Subjects over 15 years of age subjected to endoscopic procedures under deep sedation.

RESULTS

A total of 868 patients were sedated during the study period, with the conduction of 1010 endoscopic procedures. The degree of tolerance was considered adequate («Very good»/«Good») in 96.9% of the patients (95%CI: 95.7-98.1%), with a median score of 0 on the pain visual analog scale. A total of 988 endoscopic procedures were successfully completed (97.8%; 95%CI: 96.9-98.8%): 675 colonoscopies (97.1%) and 305 endoscopies (99.7%). Complications were recorded in 106 patients (12.2%; 95%CI: 10.0-14.5%). The most frequent being desaturation (6.1%), rhythm disturbances (5.1%) and hypotension (2.4%).

CONCLUSION

Gastrointestinal endoscopic procedures under sedation controlled by intensivists are well tolerated and satisfactory for the patient, and are successfully completed in a very large percentage of cases. The procedures are associated with frequent minor complications that are resolved successfully.

Colonoscopy quality assurance in Ontario: Systematic review and clinical practice guideline

Colonoscopy is fundamental to the diagnosis and management of digestive diseases and plays a key role in colorectal cancer (CRC) screening and diagnosis. Therefore, it is important to ensure that colonoscopy is of high quality. The present guidance document updates the evidence and recommendations in Cancer Care Ontario's 2007 Colonoscopy Standards, and was conducted under the aegis of the Program in Evidence-Based Care. It is intended to support quality improvement for colonoscopies for all indications, including follow-up to a positive fecal occult blood test, screening for individuals who have a family history of CRC and those at average risk, investigation for symptomatic patients, and surveillance of those with a history of adenomatous polyps or CRC. A systematic review was performed to evaluate the existing evidence concerning the following three key aspects of colonoscopy: physician endoscopist training and maintenance of competency; institutional quality assurance parameters; and colonoscopy quality indicators and auditable outcomes. Where appropriate, indicators were designated quality indicators (where there was sufficient evidence to recommend a specific target) and auditable outcomes (insufficient evidence to recommend a specific target, but which should be monitored for quality assurance purposes). The guidance document may be used to support colonoscopy quality assurance programs to improve the quality of colonoscopy regardless of indication. Improvements in colonoscopy quality are anticipated to improve important outcomes in digestive diseases, such as reduction of the incidence of and mortality from CRC.

Prospective description of coughing, hemodynamic changes, and oxygen desaturation during endoscopic sedation

BACKGROUND

Deep sedation is increasingly used for endoscopy. The impact of sedation level on hemodynamic status, oxygenation, and aspiration risk is incompletely described.

AIMS

To describe the incidence of intraprocedural cough, hemodynamic changes, oxygen desaturation, and their relationship to clinical factors and sedation level.

METHODS

Detailed prospective recordings of hemodynamic changes, oxygen desaturation, and cough during 757 nonemergent endoscopic procedures done under sedation using propofol, midazolam, and/or fentanyl.

RESULTS

Thirteen percent of patients had at least one cough and 3% had prolonged cough. Cough was more common in nonsmokers (P = 0.05), upper endoscopy (P < 0.0001), with propofol (P = 0.0008), longer procedures (P = 0.0001), and hiccups (P = 0.01). The association between supine positioning during colonoscopy and cough approached significance (P = 0.06). Oxygen desaturation was rare (4%) and associated only with deep sedation (P = 0.02). Mean systolic and diastolic blood pressure (BP) dropped by 7.3 and 5.6% respectively. Decreases in systolic BP were more common in whites (P = 0.03), males (P = 0.004), nonsmokers (P = 0.04), during colonoscopy (P < 0.0001), and in patients receiving midazolam and fentanyl (P = 0.01). Heart rate (HR) dropped >20% from baseline in 15% of patients and was more common during colonoscopy (P = 0.002). HR increased >20% in 20% of patients and was more common with coughing (P < 0.0001) and in younger patients (P = 0.0002). No patient required pharmacologic treatment of BP or HR.

CONCLUSIONS

We have described procedural predictors of cough that may help clinicians reduce the risk of aspiration during endoscopy. Hemodynamic changes during endoscopy are common but largely clinically insignificant.

The sedation increases the acceptance of repeat colonoscopies

AIM

The aim of this research was to assess how the use of sedation during colonoscopy influences patient anxiety, fear, satisfaction, and acceptance of repeat examinations.

MATERIALS AND METHODS

A prospective case-control study quantifying the anxiety and fears of patients appointed for colonoscopy, comparing patients who had undergone previous colonoscopies with sedation (cases) with patients who had undergone previous colonoscopies without sedation and patients who had never had a colonoscopy before (controls). Following the examination, patients answered a satisfaction survey and were asked whether they would be willing to undergo future colonoscopies.

RESULTS

The study included 2016 patients (average age 50.05 ± 14.44 years; 47% men). Of these, 1270 patients (63%) were undergoing colonoscopy for the first time and 746 (37%) had undergone the procedure before; in the latter group, 313 patients (42%) had been provided sedation, whereas 433 (58%) had not. Patients who had been sedated for prior colonoscopies assigned significantly lower scores than patients who had undergone previous colonoscopies without sedation and those undergoing the procedure for the first time both in the anxiety survey (3.3 ± 2.5 vs. 7.5 ± 2.8 vs. 10.3 ± 3.5; P<0.01) and in the fears survey (7.1 ± 3.0 vs. 14 ± 2.8 vs. 20.3 ± 4.5; P<0.01). Satisfaction survey scores were significantly higher among sedated patients than among nonsedated patients (22.8 ± 2.7 vs. 18.6 ± 2.3). The percentage of sedated patients who would be willing to undergo colonoscopy again was significantly higher than that of nonsedated patients (70 vs. 25%; P<0.001).

CONCLUSION

Sedation reduces the anxiety and fear of undergoing a repeat colonoscopy and improves both patient satisfaction and the acceptability of future procedures.

Analgesia without sedatives during colonoscopies: worth considering?

Colonoscopy is a proven method for bowel cancer screening and is often experienced as a painful procedure. Today, there are two main strategies to facilitate colonoscopy. First, deep sedation results in satisfied patients but increases sedation-associated risks and raises costs for healthcare providers. Second, there is the advocacy for colonoscopies without any form of sedation. This might be an option for a special group of patients, but does not hold true for everybody. Following Moerman’s hypothesis: “If pain is the crucial point, why do we need sedation?” this review shows the analgesic options for a painless procedure, increasing success rates without increasing risk of sedation. There are two agents, with the potential to be a nearly ideal analgesic agent for colonoscopy: alfentanil and nitrous oxide (N₂O). Administration of either substance causes the patient to be comfortable yet alert and facilitates a short turnover. Advantages of these drugs include rapid onset and offset of action, analgesic and anxiolytic effects, ease of titration to desired level, rapid recovery, and an excellent safety profile.

The incidence of 30-day adverse events after colonoscopy among outpatients in the Netherlands

OBJECTIVES

Colonoscopy is the gold standard for visualization of the colon. It is generally accepted as a safe procedure and major adverse events occur at a low rate. However, few data are available on structured assessment of (minor) post-procedural adverse events.

METHODS

Consecutive outpatients undergoing colonoscopy were asked for permission to be called 30 days after their procedure. A standard telephone interview was developed to assess the occurrence of (i) major adverse events (hospital visit required), (ii) minor adverse events, and (iii) days missed from work. Adverse events were further categorized in definite-, possible-, and unrelated adverse events. Patients were contacted between January 2010 and September 2010.

RESULTS

Out of a total of 1,528 patients who underwent colonoscopy and gave permission for a telephone call, 1,144 patients were contacted (response: 75%), 49% were male, the mean age was 59 years (s.d.: 14). Thirty-four patients (3%) reported major adverse events. These were definite-related in nine (1%) patients, possible-related in 6 (1%), and unrelated in 19 patients (2%). Minor adverse events were reported by 466 patients (41%). These were definite-related in 336 patients (29%), possible-related in 36 (3%), and unrelated in the remaining 94 patients (8%). Female gender (odds ratio (OR): 1.5), age <50 years (OR: 1.5), colonoscopy for colorectal cancer screening/surveillance (OR: 1.6), and fellow-endoscopy (OR: 1.7) were risk factors for the occurrence of any definite-related adverse event. Patients who reported definite-related adverse events were significantly less often willing to return for colonoscopy (81 vs. 88%, P<0.01) and were less often positive about the entire colonoscopy experience (84 vs. 89%, P=0.04).

CONCLUSIONS

Structured assessment of post-colonoscopy adverse events shows that these are more common than generally reported. Close to one-third of patients report definite-related adverse events, which are major in close to 1 in 100 patients. The occurrence of adverse events does have an impact on the willingness to return for colonoscopy.

Quality evaluation of colonoscopy reporting and colonoscopy performance in daily clinical practice

BACKGROUND

Comprehensive monitoring of colonoscopy quality requires complete and accurate colonoscopy reporting.

OBJECTIVE

This study aimed to assess the compliance with colonoscopy reporting and to assess the quality of colonoscopy performance.

DESIGN

Consecutive colonoscopy reports were reviewed by hand. Four hundred reports were included from each department.

SETTING

Daily clinical practice in 12 Dutch endoscopy departments.

PATIENTS

Consecutive patients undergoing scheduled colonoscopy procedures.

MAIN OUTCOME MEASUREMENTS

Quality of reporting was assessed by using the American Society for Gastrointestinal Endoscopy criteria for colonoscopy reporting. Quality of colonoscopy performance was evaluated by using the cecal intubation rate and adenoma detection rate (ADR).

RESULTS

A total of 4800 colonoscopies were performed by 116 endoscopists: 70% by gastroenterologists, 16% by gastroenterology fellows, 10% by internists, 3% by nurse-endoscopists, and 1% by surgeons. The mean age of the patients was 59 years (standard deviation 16), and 47% were male. Reports contained information on indication, sedation practice, and extent of the procedure in more than 90%. Only 62% of the reports mentioned the quality of bowel preparation (range between departments 7%-100%); photographic documentation of the cecal landmarks was present in 71% (range 22%-97%). The adjusted cecal intubation rate was 92% (range 84%-97%). The ADR was 24% (range 13%-32%).

LIMITATIONS

Dependent on reports, no intervention in endoscopic practice. No analysis for performance per endoscopist.

CONCLUSION

Colonoscopy reporting varied significantly in clinical practice. Colonoscopy performance met the suggested standards; however, considerable variability between endoscopy departments was found. The results of this study underline the importance of the implementation of quality indicators and guidelines. Moreover, by continuous monitoring of quality parameters, the quality of both colonoscopy reporting and colonoscopy performance can easily be improved.

Impact of anesthesia on patient and endoscopist satisfaction after colonoscopy — A pilot study

Introduction

Colonoscopy is a standard diagnostic tool for the investigation and surveillance of diseases affecting the colon. The procedure can be uncomfortable and sometimes very painful, resulting in increased cecal intubation time and lower completion rate. However, it seems to be apparent that anesthesia for this procedure increases patient satisfaction; data are lacking about the impact of anesthesia on the technical performance of colonoscopic examination.

Aim

In our observational survey, we studied patients undergoing colonoscopy with or without anesthesia. We compared patient satisfaction, difficulties in endoscopy, and the impact of anesthesia on the examination room occupancy.

Methods

We enrolled 60 patients undergoing elective, outpatient colonoscopy because of various reasons. The patients were able to choose between anesthesia and sedation. Difficulties in colonoscopy were evaluated by the endoscopist's rating and by the time to cecal intubation. We assessed patient satisfaction by a numeric rating scale.

Results

We observed that neither the duration of colonoscopy nor the time spent in the examination room was different in the two groups (p 0.825, 0.998). There was a significant improvement in both patient and endoscopist satisfaction scores in patients undergoing anesthesia (p 0.0007).

Conclusion

We found that during colonoscopy, compared to sedation, anesthesia increases both endoscopist and patient satisfaction without prolonged occupation of the examination room.

Patient-controlled analgesia and sedation with alfentanyl versus fentanyl for colonoscopy: a randomized double blind study

STUDY OBJECTIVE

The aim of this study was to evaluate whether sedo-analgesia with alfentanyl/fentanyl, using a patient-controlled analgesia (PCA) pump, may have positive outcomes in terms of safety, postprocedural workload, and expectations of the colonoscopist, nurse, and patients in elective colonoscopy.

PATIENTS

One hundred American Society of Anesthesiology physical status I and II adult patients.

INTERVENTIONS

Patients were randomized in a double-blind trial to receive either alfentanyl (n=50) or fentanyl (n=50) by PCA, and incremental doses of midazolam.

MEASUREMENTS

Patient expectations were assessed using hemodynamic variables, willingness to have a repeat colonoscopy in the same way, adverse events, discomfort scores, and patient/operator/nurse satisfaction associated with sedo-analgesia.

RESULT

All patients in both groups had adequate sedo-analgesia with high satisfaction and willingness scores. There were no serious adverse effects and except for a few events, no required medication. The total sedation times were shorter in the alfentanyl group compared with the fentanyl group.

CONCLUSIONS

PCA and sedation with alfentanyl and fentanyl for colonoscopy are safe, feasible, and acceptable to most patients. However, shorter sedation times make alfentanyl more attractive for postprocedural workload.

Endotics system vs colonoscopy for the detection of polyps

AIM

To compare the endotics system (ES), a set of new medical equipment for diagnostic colonoscopy, with video-colonoscopy in the detection of polyps.

METHODS

Patients with clinical or familial risk of colonic polyps/carcinomas were eligible for this study. After a standard colonic cleaning, detection of polyps by the ES and by video-colonoscopy was performed in each patient on the same day. In each single patient, the assessment of the presence of polyps was performed by two independent endoscopists, who were randomly assigned to evaluate, in a blind fashion, the presence of polyps either by ES or by standard colonoscopy. The frequency of successful procedures (i.e. reaching to the cecum), the time for endoscopy, and the need for sedation were recorded. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the ES were also calculated.

RESULTS

A total of 71 patients (40 men, mean age 51.9 ± 12.0 years) were enrolled. The cecum was reached in 81.6% of ES examinations and in 94.3% of colonoscopies (P = 0.03). The average time of endoscopy was 45.1 ± 18.5 and 23.7 ± 7.2 min for the ES and traditional colonoscopy, respectively (P < 0.0001). No patient required sedation during ES examination, compared with 19.7% of patients undergoing colonoscopy (P < 0.0001). The sensitivity and specificity of ES for detecting polyps were 93.3% (95% CI: 68-98) and 100% (95% CI: 76.8-100), respectively. PPV was 100% (95% CI: 76.8-100) and NPV was 97.7% (95% CI: 88-99.9).

CONCLUSION

The ES allows the visualization of the entire colonic mucosa in most patients, with good sensitivity/specificity for the detection of lesions and without requiring sedation.

[Quality colonoscopy: assumptions and expectations]

Colonoscopy has become accepted as the most effective method of screening of the colon for neoplasia. Evidences prove that utilization of colonoscopy has increased dramatically in the past few years, largely because of increased rates of CRC screening. Effectiveness and safety of colonoscopy depend on the quality of examination, and growing body of evidence suggests that the quality of colonoscopy varies in clinical practice. Quality assurance of colonoscopy could be expected to contribute significantly to improved patient care. There is a clear need for evidence-based quality measures to ensure the quality of colonoscopy. In this review we present an overview of literature concerning criteria for best practice and important quality indicators for colonoscopy.