Optimal sequences of same-visit bidirectional endoscopy: Systematic review and meta-analysis

Comparison of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy conducted by pediatric gastroenterologists

Objectives

The effectiveness and safety of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy were compared.

Methods

We retrospectively analyzed the cases of pediatric patients (≤15 years old) who had undergone bidirectional endoscopy, esophagogastroduodenoscopy, and colonoscopy by pediatric gastroenterologists. Demographic data, indications, sedatives/dosages, clinical outcomes, endoscopic findings, adverse events, and total patient time requirements (total time in which patients stay in our hospital) were compared in the two sedation groups.

Results

Ninety-one children (51 boys, 40 girls, mean age 13 years, range 9-15) treated at our hospital were enrolled. Propofol alone or in combination with midazolam and/or pentazocine was administered to 51 patients (propofol-based sedation group). Midazolam alone or in combination with pentazocine was administered to the other 40 patients (midazolam sedation group). In the propofol group, the following mean doses were used: propofol, 96 mg (range 40-145 mg); midazolam, 4.9 mg (range 3-5 mg); and pentazocine, 7.5 mg. In the midazolam group, the mean doses of midazolam and pentazocine were 6.2 mg (range 4-10 mg) and 15 mg, respectively. All procedures were successfully completed by pediatric gastroenterologists. The total procedure times and endoscopic findings were similar in the two groups, but the median patient time requirement in the propofol group was significantly shorter versus the midazolam group (7.3 h vs. 8.4 h, p < 0.001). No adverse events occurred in either group.

Conclusions

Propofol-based sedation in pediatric bidirectional endoscopy was safely and effectively performed by pediatric gastroenterologists, and its patient time requirement was shorter than that for midazolam sedation.

Optimal Sequencing in Same-Day Bidirectional Endoscopy: A Tertiary US Healthcare Center Experience

BACKGROUND

Same-day performance of esophagogastroduodenoscopy (EGD) and colonoscopy is called bidirectional endoscopy (BDE). BDE is commonly performed, but the optimal sequence for which procedure to do first is not well established. This is the first study in the US to investigate the optimal sequence for BDE.

METHODS

We performed a cohort study of patients with same-day BDE (2003-2018) at our institution. The two study groups were (1) EGD followed by colonoscopy (UL) and (2) Colonoscopy followed by EGD (LU). Endpoints included procedure duration, extent reached, sedation, and diagnostic yield.

RESULTS

22,905 patients underwent BDE, with complete data available for 16,538. 14,325 underwent UL, and 2213 underwent LU. For diagnostic indications, the LU group was more likely to require opiates (OR 2.8, CI 2.5-3.3, p < 0.001), benzodiazepines (OR 3.0, CI 2.6-3.4, p < 0.001), antihistamines (OR 1.5, CI 1.2-1.8, p < 0.001), while less likely to require anesthesia (OR 0.33, CI 0.28-0.39, p < 0.001). Similar results were found for surveillance indication of endoscopy and in screening colonoscopy, with no differences in EGD screening indications. Total Procedure duration: UL had shorter total procedure duration (23.2 vs. 28.8 min; p < 0.001), EGD duration (5.4 vs. 6.5 min; p < 0.001), and colonoscopy duration (17.9 vs. 22.3 min; p < 0.001). Diagnostic yield: UL and LU sequences had comparable polyp detection rates (37.6% vs. 38.1%, p = 0.65) with similar adenoma detection rates (ADR).

CONCLUSION

Performing EGD first resulted in shorter procedure times and a reduced likelihood of requiring opioids and benzodiazepines, with no differences regarding procedure-related adverse events or diagnostic yield.

Operation sequence of bidirectional endoscopy with topical anesthesia affected colonoscopy performance: a randomized controlled trial

BACKGROUND

The operation sequence of bidirectional endoscopy with topical anesthesia varies among endoscopists, which interferes with clinical procedure. The study aimed to investigate the influence of different operation sequences on the outcomes of quality indicators and improve bidirectional endoscopy performance.

METHODS

A randomized trial was conducted at the affiliated hospital of a medical university in China. Outpatients who initially underwent bidirectional endoscopy with topical anesthesia were enrolled. Eligible patients were randomized to either the colonoscopy-first group or the esophagogastroduodenoscopy-first group. Dyclonine hydrochloride mucilage and oxybuprocaine hydrochloride gel were administered for topical anesthesia. After finishing the previous process, the subsequent one was performed immediately. Quality indicators of esophagogastroduodenoscopy and colonoscopy were compared between the groups.

RESULTS

Analyzing 395 combined procedures, the cecal intubation rate, discomfort score during esophagogastroduodenoscopy, examination score of esophagogastroduodenoscopy, and colorectal polyp detection rate were similar between the two groups. The colonoscopy-first group had lower colonic spasm incidence (66.0% vs. 30.3%, p < 0.001), shorter median cecal intubation time (254 s vs. 211 s, p < 0.001), and higher colonoscopy comfort rate (72.5% vs. 85.6%, p < 0.001) compared with the esophagogastroduodenoscopy-first group. Operation sequence significantly affected the incidence of colonic spasm (OR 4.739, 95%CI 3.054-7.352, p = 0.000), which correlated with cecal intubation time (r = 0.196, p < 0.001) and patient discomfort score (r = 0.136, p = 0.007).

CONCLUSION

In bidirectional endoscopy with topical anesthesia, performing colonoscopy first may improve colonoscopy performance without affecting esophagogastroduodenoscopy examination. The study was registered prior to conducting the research in the Chinese Clinical Trial Registry ( https://www.chictr.org.cn ) on November 7, 2023 with the trial identification number ChiCTR2300077408.

Efficacy and safety of fospropofol disodium sedation for same-day bidirectional endoscopy in elderly patients: protocol for a prospective, single-center, randomized, double-blind, non-inferiority trial

Introduction

Fospropofol disodium is a novel prodrug that has improved pharmacokinetic and pharmacodynamic properties when compared with propofol. This trial aims to compare the efficacy and safety of fospropofol versus propofol sedation for same-day bidirectional endoscopy in elderly patients.

Methods and analysis

This is a prospective, single-center, double-blind, randomized, propofol-controlled, non-inferiority trial. A total of 256 patients aged 65 years or older, who are scheduled for same-day bidirectional endoscopy under sedation, will be randomly allocated, in a 1:1 ratio, to either fospropofol group or propofol group (n = 128 in each group). All patients will receive analgesic pre-treatment with sufentanil 5 μg. Two minutes later, an initial bolus dose of fospropofol 6.5 mg/kg or 1.5 mg/kg propofol and supplemental doses of fospropofol 1.6 mg/kg or 0.5 mg/kg propofol will be titrated as needed to achieve target sedation levels during the procedures. The primary outcome is the success rate of same-day bidirectional endoscopy. Secondary outcomes include the time to successful induction of sedation, duration, time to being fully alert, time to patient discharge, endoscopist satisfaction, patient satisfaction, and the top-up frequency and dosage of sedative medications. The safety endpoints consist of adverse events concerning cough reflex, gag reflexes, body movement, muscular tremor, and pain on injection. Sedation-related AEs, including episodes of desaturation, severe desaturation (SpO2 < 90%), hypotension, severe hypotension (decrease in MBP ≥30% of baseline), and bradycardia, will also be recorded. Data will be analyzed on an intention-to-treat basis.

Discussion

We hypothesize that the efficacy and safety of fospropofol sedation for elderly patients undergoing same-visit bidirectional endoscopy will not be inferior to that of propofol. Our findings will potentially provide a new sedation regimen for same-visit bidirectional endoscopy in elderly patients.

Clinical Trial Registration

clinicaltrials.gov, identifier NCT02875639.

Comparison of three sedation models for same-day painless bidirectional endoscopy: A multicenter randomized controlled trial

BACKGROUND AND AIM

We investigated the most beneficial propofol sedation model for same-day painless bidirectional endoscopy (BDE).

METHODS

Asymptomatic participants scheduled for same-day painless BDE examination from October 2020 to September 2021 were randomized to three groups: sedated esophagogastroduodenoscopy followed by unsedated colonoscopy (Group A); sedated esophagogastroduodenoscopy followed by sedated colonoscopy (Group B); and sedated esophagogastroduodenoscopy followed by sedated insertion colonoscopy (Group C). Patient discomfort, colonoscopy performance, doses of propofol, cardiovascular stress, anesthesia resuscitation, and sedation-related adverse events were evaluated.

RESULTS

A total of 3200 participants were analyzed. Baseline demographics, patient discomfort, cecal intubation rate, adenoma detection rate and sedation-related adverse events were similar in the three groups. Propofol dose was the lowest in Group A (137.65 ± 36.865 mg) compared with Group B (177.71 ± 40.112 mg, P < 0.05) and Group C (161.63 ± 31.789 mg, P < 0.05). Decline in vital signs was most obvious in Group B during the procedure (P < 0.05). Recovery time was the shortest in Group A (5.01 ± 1.404 min) compared with Group B (9.51 ± 2.870 min, P < 0.05) and Group C (5.83 ± 2.594 min, P < 0.05); discharge time was the shortest in Group A (3.53 ± 1.685 min) compared with Group B (11.29 ± 5.172 min, P < 0.05) and Group C (6.47 ± 2.338 min, P < 0.05). Adenomas per positive patient of Group A (2.29 ± 1.055) and Group C (2.28 ± 0.931) were more than that in Group B (2.11 ± 0.946, P < 0.05).

CONCLUSIONS

Sedated esophagogastroduodenoscopy followed by unsedated colonoscopy is the superior model for same-day painless BDE with the benefits of satisfactory patient comfort, reduced sedation dose, less cardiovascular stress, faster recovery, shorter discharge time and high colonoscopy quality.

Low-Dose Esketamine as an Adjuvant to Propofol Sedation for Same-Visit Bidirectional Endoscopy: Protocol for a Multicenter Randomized Controlled Trial

Background

Same-visit bidirectional endoscopy (esophagogastroduodenoscopy and colonoscopy) is widely performed under sedation. At present, the optimal sedation regimen remains unclear. This study aims to test the hypothesis that a low-dose esketamine added to propofol sedation reduces hemodynamic and respiratory adverse events in these procedures.

Methods

In this multicenter, randomized, double-blind, placebo-controlled trial, 660 adult patients scheduled for same-visit bidirectional endoscopy under sedation from 3 teaching hospitals in China will be recruited. Patients will be randomly allocated, in a 1:1 ratio, to an esketamine group or a normal saline group (n = 330 in each group), stratified by study center. All patients will receive intravenous propofol 0.5 mg/kg and sufentanil 0.1 μg/mL for induction of sedation, followed by intravenous esketamine 0.15 mg/kg or the same volume of normal saline. Propofol will be titrated to the target sedation levels during the procedures. The primary endpoint is a composite of desaturation (peripheral oxygen saturation < 90%) and hypotension (systolic blood pressure <80 mmHg or decrease >30% of baseline). Secondary endpoints include desaturation, hypotension, total dose of propofol, pain scores and fatigue scores on the 0-10 numerical rating scale, dizziness or headache, hallucination or nightmare, nausea or vomiting, endoscopist satisfaction, and patient satisfaction. All analyses will be intention-to-treat.

Discussion

We expect that a low-dose esketamine adjunct to propofol-based sedation will improve cardiorespiratory stability in patients undergoing same-visit bidirectional endoscopy, providing reference for clinical sedation practice during these procedures.

Trial Registration

Chinese Clinical Trial Registry (Identifier: ChiCTR-ChiCTR2200055938).

Esketamine as an Adjuvant to Ciprofol or Propofol Sedation for Same-Day Bidirectional Endoscopy: Protocol for a Randomized, Double-Blind, Controlled Trial With Factorial Design

Background: Same-day esophagogastroduodenoscopy and colonoscopy procedures under sedation have been increasingly performed. This study aims to assess the effects of esketamine combined with ciprofol (a novel anesthetic/sedative agent) or propofol on respiratory and hemodynamic adverse events in patients undergoing same-day bidirectional endoscopy.

Methods: This is a prospective, randomized, double-blind, placebo-controlled, 2 × 2 factorial trial. A total of 180 adult patients scheduled for same-day bidirectional endoscopy under sedation will be randomized, in a 1:1:1:1 ratio, to receive 1 of 4 sedation regimens: 1) ciprofol and esketamine, 2) propofol and esketamine, 3) ciprofol and normal saline placebo, or 4) propofol and normal saline placebo. The primary outcome is a composite of desaturation [peripheral oxygen saturation (SpO₂) < 95%] and hypotension [mean blood pressure (MBP) < 65 mmHg or decrease in MBP ≥20% of baseline] during the sedation and in the recovery room. Secondary outcomes include episodes of desaturation, severe desaturation (SpO₂ < 90%), hypotension, severe hypotension (decrease in MBP ≥30% of baseline), bradycardia, postoperative nausea and vomiting, dizziness or headache, hallucination or nightmare, injection pain, pain scores and fatigue scores, endoscopist satisfaction, and patient satisfaction. Data will be analyzed on the modified intention-to-treat basis.

Discussion: We hypothesize that esketamine as an adjuvant to ciprofol or propofol sedation would improve cardiorespiratory stability. In addition, the potential interactions between interventions will be explored using the factorial design. The results of this trial will provide evidence for daily practice of sedation regimens for same-day bidirectional endoscopy.

Clinical Trial Registration: Chinese Clinical Trials Registry, Identifier ChiCTR2100052523.

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).

The Efficacy and Safety of Remimazolam Tosilate versus Etomidate-Propofol in Elderly Outpatients Undergoing Colonoscopy: A Prospective, Randomized, Single-Blind, Non-Inferiority Trial

Objective

The optimal sedation regime during endoscopy remains controversial, especially for elderly outpatients. In this study, we compared the efficacy and safety between remimazolam tosilate (RT) and etomidate-propofol (EP) in elderly outpatients undergoing colonoscopy.

Methods

A total of 260 elderly outpatients undergoing sedative colonoscopy were randomized into two groups. Patients in the RT group received a 0.075-mg/kg maintenance dose of remimazolam following an initial dose of 0.15 mg/kg, whereas patients in the EP group (10 mL:20 mg etomidate plus 10 mL:100 mg propofol) received a 0.05-mL/kg maintenance dose following an initial dose of 0.1 mL/kg to maintain a Modified Observer’s Assessment of Alertness/Sedation score of ≤3 during the procedure. The primary endpoint was the success of the procedure. Secondary endpoints included time metrics, hemodynamics, consumption of fentanyl, etomidate, propofol, and remimazolam, intraoperative body movement, patient and endoscopist satisfaction scores, supplemental dose of sedative and fentanyl, and incidence and severity of adverse events.

Results

The procedure success rate was 96.52% in the RT group and 100% in the EP group. The difference in procedure success rate between the RT and EP groups was −3.48% (95% confidence interval: −6.81%, −0.15%). Four patients in the RT group required rescue midazolam. Compared with patients in the RT group, the onset time of the EP group was significantly lower (p < 0.05), whereas time to fully alert (p = 0.001), ready for discharge (p = 0.001), and hospital discharge (p = 0.002) were all significantly higher in the EP group. However, there were no significant differences in procedure time (p = 0.846) or cecal intubation time (p = 0.320) between the two groups. Although the frequency of intraoperative body movement was higher in the RT group, the difference was not significant (p = 0.508). There were no significant differences in patients’ demographic and baseline characteristics, supplemental doses of sedative and fentanyl, or patient and endoscopist satisfaction scores (p > 0.05). Muscular tremor and pain on injection were recorded more frequently in the EP group (p < 0.05). However, there were no significant differences in hypoxia, respiratory depression, or incidence of postoperative nausea and vomiting. The severity of adverse events was all mild (grade 1) across both groups.

Conclusion

RT may have non-inferior efficacy and a higher safety profile than EP in elderly outpatients undergoing colonoscopy, which suggests that RT may be more suitable for elderly outpatients undergoing colonoscopy.