Unsedated colonoscopy: A neverending story

Acceptance and Preference of Computed Tomographic Colonography and Colonoscopy: Results of a Nationwide Multicenter Comparative Questionnaire Survey in Japan

Objectives

To investigate patient acceptance and preference for computed tomographic colonography (CTC) over colonoscopy.

Methods

Participants were recruited from a nationwide multicenter trial in Japan to assess the accuracy of CTC detection. They were scheduled to undergo colonoscopy after CTC with common bowel preparation on the same day. Some were administered sedative drugs during colonoscopy, depending on the referring clinician and participant's preferences. The participants were requested to complete a questionnaire to evaluate the acceptability of bowel preparation, examinations, and preference for future examinations.

Results

Of the 1,257 enrolled participants, 1,180 (mean age: 60.6 years; women: 43.3%) completed the questionnaire. Sedative drugs were not administered in 687 participants (unsedated colonoscopy group) and were administered intravenously during colonoscopy in 493 participants (sedated colonoscopy group). Before propensity score matching, the mean participants' age, percentages of asymptomatic participants, insufflation of gas during colonoscopy, and number of participants with a history of abdominal/pelvic operation significantly differed between the groups. After propensity score matching, 912 participants from each group were included in the analysis. In the unsedated colonoscopy group, CTC was answered as significantly easier than colonoscopy (p<0.001). Conversely, CTC was significantly more difficult than colonoscopy in the sedated colonoscopy group (p<0.001). In the unsedated colonoscopy group, 48% preferred CTC and 22% preferred colonoscopy for future examinations, whereas in the sedated colonoscopy group, 26% preferred CTC and 38% preferred colonoscopy (p<0.001).

Conclusions

CTC has superior participant acceptability compared with unsedated colonoscopy. However, our study did not observe the advantages of CTC acceptance over sedative colonoscopy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality Control in the Slovenian National Colorectal Cancer Screening Program

OBJECTIVES

The objective of the study was to assess the impact of an internal quality indicator (QI) audit on the quality level of colonoscopies in the National Colorectal Cancer Screening Program (NCCSP).

DESIGN

Sixty-eight colonoscopists from 29 endoscopic centres participated in the NCCSP from April 2009 to January 2015. Controlled QIs were the percentage of total colonoscopies, adenoma detection rate (ADR), mean adenoma per procedure (MAP), mean adenoma per positive procedure (MAP+), right-sided ADR, sessile serrated lesion (SSL) detection rate, and patient responses to post-procedural questionnaires. A group of 3 expert endoscopists from the NCCSP Council performed 91 inspections and provided education.

RESULTS

A total of 891.364 (58.2%) Slovenian citizens participated in the first 3 screening rounds of the NCCSP. Among 46.552 (6%) positive individuals, 42.866 (92.1%) underwent first colonoscopies. Total colonoscopies were performed in 98% of endoscopies (p = 0.459 between cycles), mean ADR was 51.8% (p = 0.872 between cycles), mean percentage of adenoma in the right colon was 37.5% (p = 0.227 between cycles), mean MAP was 1.1 (p = 0.981 between cycles), mean MAP+ was 2.0 (p = 0.824 between cycles), and mean SSL detection rate was 3% (p < 0.001). We observed great difference in QIs between endoscopists and a significant increase in MAP, ADR in the right colon, and SSL per endoscopist during the 6-year period. Due to quality underperformance, 3 endoscopic centres (10.3%) and 13 endoscopists (19.1%) were excluded from the program.

CONCLUSIONS

The success of the NCCSP is related to the quality of colonoscopies performed. To ensure the proper quality level, regular audit and permanent education are needed.

Anesthesia for GI endoscopy in the era of COVID-19

As a result of COVID-19, the last few weeks have necessitated a reevaluation of the sedation paradigm for gastrointestinal (GI) endoscopic procedures. Routine screening and some surveillance procedures have taken a backseat and likely to remain so until a vaccine or effective treatment becomes available. Anesthesia providers and endoscopists are required to adapt to this new reality rapidly. The general aim of sedation remains the same-patient comfort, reduced hypoxia, prevention of aspiration along with rapid recovery, and discharge. The present review focuses on necessary modification to reduce the risk of virus contagion for both patients (from health-care providers) and vice versa. A preprocedure evaluation and consenting should be modified and provided remotely. Unsedated GI endoscopy, sedation with minimal respiratory depression, and modification of general anesthesia are explored. Challenges with supplemental oxygen administration and monitoring are addressed. Guidelines for appropriate use of personal protective equipment are discussed. Measures for limiting aerosolization are deliberated.

Tolerability of Bowel Preparation and Colonoscopy in IBD Patients: Results From a Prospective, Single-Center, Case-Control Study

Background

Endoscopy plays a fundamental role in the management of patients with inflammatory bowel disease (IBD). The aim of this study was to prospectively evaluate the tolerability and efficacy of bowel preparation and colonoscopy in ulcerative colitis (UC) and Crohn's disease (CD) patients compared to subjects participating in a colorectal cancer population screening program.

Methods

Consecutive enrolment of CD and UC patients and screening subjects (SS) undergoing colonoscopy. Bowel preparation was done by split dose of 2 L PEG-ELS + simethicone. We recorded endoscopic, clinical, and demographic features; cleanliness rating using the Boston Bowel Preparation Scale (BBPS); and sedation doses. Bowel-preparation tolerability, discomfort, and pain during colonoscopy were assessed using a Visual Analogue Scale from 0 to 100 mm.

Results

Sixty-three UC (mean age 49.9 ± 14.9 years), 63 CD (mean age 44.0 ± 14.0 years), and 63 SS (mean age 59.9 ± 6.3 years) patients were enrolled. Bowel preparation was similarly tolerated in UC, CD, and SS (P = 0.397). A complete colonoscopy was similarly performed in UC (59/63, 93.7%), CD (58/63, 92.1%), and SS (60/63, 95.2%) (P = 0.364). The BBPS did not show significant differences between UC (6.2 ± 1.6), CD (6.1 ± 1.3), and SS (6.2 ± 1.4) (P = 0.824). The need to increase sedation doses was significantly higher in CD (24/63, 38.1%) and UC (16/63, 25.4%) than in SS (4/63, 6.3%) (P < 0.0001).

Conclusions

Bowel preparation is equally tolerated and efficacious in IBD patients and in healthy SS. In IBD, higher sedation doses are needed to guarantee an equally tolerated colonoscopy.

Virtual reality distraction for patients to relieve pain and discomfort during colonoscopy

Background and study aims  Colonoscopy is an invasive procedure that may cause patients pain and discomfort. Routine use of sedation, while effective, is expensive and requires logistical planning. Virtual reality (VR) offers immersive, three-dimensional experiences that distract the attention and might comfort patients. We performed a pilot study to investigate the feasibility of VR distraction during colonoscopy. Patients and methods  Adults referred for colonoscopy were considered for inclusion and divided over two groups: with and without VR glasses. The main outcome was patient acceptance of wearing VR glasses during colonoscopy without compromising the technical success of the procedure. Secondary outcomes were patient comfort, pain, and anxiety before, during and after the procedure, using validated patient questionnaires. Patient comments were collected through a qualitative interview. Results  We included 19 patients, 10 of whom were offered VR glasses. All patients accepted VR glasses without prolonging procedural time. No disadvantages of the VR glasses were reported in terms of communication or change of position of the patient. We found that patient comfort, pain, anxiety, and satisfaction in relation to the procedure were similar in both groups. Patients described a pleasant distracting effect using VR glasses. Conclusion  VR glasses during colonoscopy are accepted by patients and do not compromise endoscopic technical success. Patients reported that the VR experience was pleasant and distracting.

Medical, Political, and Economic Considerations for the Use of MAC for Endoscopic Sedation: Big Price, Little Justification?

The last few decades of gastrointestinal (GI) endoscopy have seen phenomenal growth. In many aspects, GI endoscopy has led the field of nonsurgical interventional medicine. In many aspects, this growth is facilitated by advancements in sedation-both drugs and techniques. Unfortunately, the topic of GI endoscopy sedation is also mired in many controversies, mainly emanating from the cost of anesthesia providers. While no one debates their role in the majority of advanced endoscopic procedures, the practice of universal propofol sedation in the USA, delivered by anesthesia providers, needs a closer look. In this review, medical, political, and economic considerations of this important topic are discussed in a very frank and honest way. While such ubiquitous propofol use has increased satisfaction of both patients and gastroenterologists, there is little justification. More importantly, going by the evidence, there is even less justification for the mandated anesthesia providers use for such delivery. Unfortunately, the FDA could not be convinced otherwise. The new drug fospropofol met the same fate. Approval of SEDASYS^®, the first computer-assisted personalized sedation system, was a step in the right direction, nevertheless an insufficient step that failed to takeoff. As a result, in spite of years of research and efforts of many august societies, the logjam of balancing cost and justification of propofol sedation has continued. We hope that recent approval of remimazolam, a novel benzodiazepine, and potential approval of oliceridine, a novel short-acting opioid, might be able to contain the cost without compromising the quality of sedation.

Short article: Willingness to undergo colonoscopy with virtual reality instead of procedural sedation and analgesia

OBJECTIVE

This study explored the willingness of patients to start colonoscopy with virtual reality (VR) instead of procedural sedation and analgesia (PSA), as well as their motives and characteristics. There is a growing interest in colonoscopy without PSA. Offering VR as a distraction technique instead of PSA may increase the percentage of colonoscopies without PSA.

PATIENTS AND METHODS

A survey with demographic, colonoscopy-related and psychology-related questions was completed by 326 adults referred for colonoscopy with PSA.

RESULTS

Overall, 25.7% reported to be willing to start with VR instead of PSA. Main reasons for this choice were receiving as little medication as possible, resuming daily life activities faster and participating in traffic independently afterwards. Logistic regression analysis showed that significant predictors of the willingness to use VR were male sex, higher educational level and absence of worries about the outcome of the colonoscopy.

CONCLUSION

If VR turns out to be effective in the future, present results may be useful to customize patient information to help patients choosing VR.

Endoscopy for patients affected by inflammatory bowel disease: bowel preparation and sedation

Endoscopy has a key role in the management of inflammatory bowel disease (IBD). It is helpful in the diagnosis, in case of relapse, refractoriness, before therapeutic changes, after surgery as well as in the assessment of mucosal healing and in the surveillance of colo-rectal cancer. IBD patients are intended to undergo several times the examination during their lifespan. Bowel preparation and sedation highly contribute to high-quality colonoscopy. Areas covered: Few studies addressed preparation and sedation in the field of IBD. In this review, we focused our attention on the available evidences about bowel preparation and sedation in patients with IBD. Expert commentary: In recent years, the goal of medical treatment in IBD is shifting from clinical improvement in symptoms towards mucosal healing. High-quality endoscopy will gain even more importance in the management of IBD. It is important to locate the most effective preparation and the best sedation in patient with IBD to perform a high-quality endoscopy.

Can Water Exchange Improve Patient Tolerance in Unsedated Colonoscopy A Prospective Comparative Study

Background & Aims

Unsedated colonoscopy can be painful, poorly tolerated by patients, and associated with unsatisfactory technical performance. Previous studies report an advantage of water exchange over conventional air insufflation in reducing pain during unsedated colonoscopy. Our goal was to analyze the impact of water exchange colonoscopy on the level of maximum pain reported by patients submitted to unsedated colonoscopy, compared to conventional air insufflation.

Methods

We performed a single-center, patient-blinded, prospective randomized comparative study, where patients were either allocated to the water group, in which the method of colonoscopy used was water exchange, or the standard air group, in which the examination was accomplished with air insufflation.

Results

A total of 141 patients were randomized, 70 to the water and 71 to the air group. The maximum level of pain reported by patients during unsedated colonoscopy, measured by a numeric scale of pain (0-10), was significantly lower in the water group (3.39 ± 2.32), compared to the air group (4.94 ± 2.10), p < 0.001. The rate of painless colonoscopy was significantly higher in the water group (12.9 vs. 1.4%, p = 0.009). There were no significant differences between the two groups regarding indications for the procedure, quality of bowel preparation, cecal intubation time, withdrawal time, number of position changes, adenoma detection rate, and postprocedural complications. Only the number of abdominal compressions was significantly different, showing that water exchange decreases the number of compressions needed during colonoscopy.

Conclusions

Water exchange was a safe and equally effective alternative to conventional unsedated colonoscopy, associated with less intraprocedural pain without impairing key performance measures.

Colonoscopy without sedation: Patient factors alone are less likely to influence its uptake

BACKGROUND AND STUDY AIMS

Conscious sedation during colonoscopy minimizes discomfort, improves polyp detection rates, and reduces technical failure, but carries medication-related risks and requires dedicated and costly recovery services. Sedation-free procedures may offer a safer alternative. We aimed to compare this group with those receiving sedation to determine differences in patient characteristics, cecal intubation rates, polyp detection rates, discomfort levels and safety in patients for whom anesthesia is high risk.

PATIENTS AND METHODS

Prospectively collected data from all colonoscopies performed over a 1-year period at three district general hospitals were analyzed. Conscious sedation was offered to all patients and outcomes in those who refused were compared with outcomes in those who received sedation.

RESULTS

One hundred ninety-four of 1694 (11 %) colonoscopies were performed without sedation (61 % male, P < 0.001) but rates varied between hospitals. Of these, 55 % were American Society of Anesthesiologists (ASA) grade 3 or more and 5 % experienced moderate discomfort, compared to 40 % (P < 0.0001) and 10 % (P = 0.023) respectively of those receiving sedation. They were more likely to have indications of rectal bleeding or frequency of stool and less likely to have anaemia or macroscopic inflammation at colonoscopy. Complications, completion. and polyp detection rates were similar in both groups.

CONCLUSIONS

Colonoscopy without sedation can be completed successfully in select patients without compromising comfort or polyp detection rates and is safe in those for whom anesthesia is high risk. It is therefore a safe alternative for clinicians concerned about sedation, but the findings suggest that hospital, rather than patient factors, may prevent its uptake.

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

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

Sedation practice and comfort during colonoscopy: lessons learnt from a national screening programme

AIM

Medication may be used to manage discomfort during colonoscopy but practice varies. The relationship between medication use and comfort during colonoscopy was examined in the English Bowel Cancer Screening Programme.

METHODS

Data related to patient comfort and medication use from all 113,316 examinations performed within the English Bowel Cancer Screening Programme between 1 January 2010 and 31 December 2012 were analysed. Comfort was rated on the five-point Modified Gloucester Comfort Scale: 1, no discomfort; 5, severe discomfort. Scores of 4 and 5 were considered to indicate significant discomfort. Correlations between the proportion of examinations associated with significant discomfort and the amounts of medication used by colonoscopists were assessed using Spearman's ρ. Logistic regression modelling examined the independent predictors of significant discomfort.

RESULTS

Patients had a mean age of 65.7 years, and 58% were male. Examinations were performed by 290 endoscopists. In 91% of examinations, there was no significant discomfort reported during examination; however, there was considerable variation between individual colonoscopists (range 76.1-99.2%).Intravenous sedation and opiate analgesia were used during most examinations, but there was wide variation between colonoscopists, with a median (range) usage of 95.1% (4.1-100%) and 97.3% (5.6-100%), respectively. There was no association between the amount of sedation and analgesia used and significant discomfort (ρ<0.2). On multivariate analysis, significant discomfort was found to be more common among female individuals [odds ratio (OR)=2.0], on incomplete examinations (OR=6.7), and among patients with diverticulosis (OR=1.4).

CONCLUSION

There was wide variation in medication practice among English screening colonoscopists, but this was unrelated to the occurrence of significant discomfort.

Time trends in quality indicators of colonoscopy

BACKGROUND

There is considerable variation in the quality of colonoscopy performance. The Norwegian quality assurance programme Gastronet registers outpatient colonoscopies performed in Norwegian endoscopy centres. The aim of Gastronet is long-term improvement of endoscopist and centre performance by annual feedback of performance data.

OBJECTIVE

The objective of this article is to perform an analysis of trends of quality indicators for colonoscopy in Gastronet.

METHODS

This prospective cohort study included 73,522 outpatient colonoscopies from 73 endoscopists at 25 endoscopy centres from 2003 to 2012. We used multivariate logistic regression with adjustment for relevant variables to determine annual trends of three performance indicators: caecum intubation rate, pain during the procedure, and detection rate of polyps ≥5 mm.

RESULTS

The proportion of severely painful colonoscopies decreased from 14.8% to 9.2% (relative risk reduction of 38%; OR = 0.92 per year in Gastronet; 95% CI 0.86-1.00; p = 0.045). Caecal intubation (OR = 0.99; 95% CI 0.94-1.04; p = 0.6) and polyp detection (OR = 1.03; 95% CI 0.99-1.07; p = 0.15) remained unchanged during the study period.

CONCLUSIONS

Pain at colonoscopy showed a significant decrease during years of Gastronet participation while caecal intubation and polyp detection remained unchanged - independent of the use of sedation and/or analgesics and level of endoscopist experience. This may be due to the Gastronet audit, but effects of improved endoscopy technology cannot be excluded.

Water intubation method can reduce patients' pain and sedation rate in colonoscopy: a meta-analysis

Several randomized controlled trials (RCT) have shown that water infusion in lieu of air insufflation reduces sedation rate and pain score and increases cecal intubation rate in colonoscopy. The aim of the present study was to confirm the beneficial effects of the water intubation method over the air method. Electronic databases were searched to identify RCT reporting colonoscopy detection using the water method. The pooled data of sedation rate, pain score and other procedure-related outcomes were analyzed. Then, 15 full-text articles were selected and assessed. Nine trials with high-quality scores were enrolled into this meta-analysis including a total of 1414 participants. Pooled odds ratio (OR) of sedation rate was 0.392 (95% confidence interval (CI): 0.288-0.533, P = 0.000). Pooled weighted mean difference (WMD) of pain score was -1.543 (95% CI: -2.107--1.069,P = 0.000). Pooled OR of cecal intubation rate was 1.90 (95% CI: 1.29-2.82, P = 0.001). Pooled OR of polyp detection rate and adenoma detection rate were 0.805 (95% CI: 0.606-1.069, P = 0.134) and 0.913 (95% CI: 0.681-1.223, P = 0.168), respectively. Pooled WMD of cecal intubation time was 0.701 (95% CI: -0.486-1.889, P = 0.247). This meta-analysis confirmed that the water method significantly reduced sedation rate and degree of pain without decreasing cecal intubation rate and disease detection rate and without requiring more cecal intubation time, suggesting that the novel water method is better than the conventional air method in colonoscopy detection.