A meta-analysis of carbon dioxide versus room air insufflation on patient comfort and key performance indicators at colonoscopy

Longer withdrawal time is not associated with increased patient discomfort in colonoscopy: a retrospective observational study

PURPOSE

Withdrawal time of sufficient length is a quality indicator for colonoscopies. Nonetheless, whether extending the withdrawal time contributes to patient discomfort remains unknown. This study aimed to clarify the relationship between colonoscopy withdrawal time and patient discomfort.

METHODS

A cohort of consecutive patients who underwent colonoscopy at a single institution from October 2018 to January 2020 was retrospectively analyzed. Initially, the relationship between the mean withdrawal time for each colonoscopist in no-finding examinations and polyp detection rate was investigated in 2,043 patients. Subsequently, the primary outcome of association between withdrawal time and patient discomfort, as determined by patient questionnaire, was assessed for each examination in 481 patients from the initial cohort.

RESULTS

The mean withdrawal time was strongly correlated with polyp detection rate (correlation coefficient, 0.72; P<0.001). In contrast, longer withdrawal time was not associated with increased discomfort; however, there was a weak inverse correlation between patient discomfort and longer withdrawal time (correlation coefficient, -0.25; P<0.001). Similarly, multiple regression analysis adjusted for confounding variables revealed that longer withdrawal time was not associated with increased patient discomfort (regression coefficient, -0.04 for each 1-minute increase in the length of withdrawal time; P=0.45).

CONCLUSION

This study showed for the first time that longer withdrawal times did not result in increased discomfort, indicating that withdrawal time can be extended to sufficient length for optimal patient examination and polyp detection.

Water immersion sigmoidoscopy versus standard insufflation for colorectal cancer screening: A cohort study

BACKGROUND

Although the efficacy of water-assisted colonoscopy is well established, the role of water immersion sigmoidoscopy (WIS) remains unclear. We compared WIS with carbon dioxide insufflation sigmoidoscopy (CO₂S) on patient outcomes.

METHODS

We conducted an analysis of prospectively collected data from a single-center quality improvement program about patients undergoing unsedated screening sigmoidoscopy (WIS and CO₂S) between May 2019 and January 2020. Outcomes studied included the following: Rates of severe pain <17% (score of ≥7 on a numeric rating scale of 0-10, and on a Likert scale), willingness to repeat the procedure without sedation, adequate bowel cleanliness >75% (proportion of Boston Bowel Preparation Scale score: 2-3) and adenoma detection rate (ADR).

RESULTS

In total, 234 patients (111 WIS; 123 CO₂S) were included. All patients were aged 58 years and 58.9% were female; baseline characteristics were comparable between groups. There were no significant differences in rates of severe pain (WIS: 16.5%, CO₂S: 13.8%; P = 0.586), willingness to repeat the unsedated procedure (WIS: 82.3%, CO₂S: 84.5%; P = 0.713), adequate bowel cleanliness (WIS: 78.4%, CO₂S: 78%, P = 0.999) or ADR (WIS: 25.2%, CO₂S: 16.3%; P = 0.106) between groups. However, average procedure times were longer with WIS (9.06 min) compared to CO₂S (6.45 min; P < 0.001). Overall, 29.6% of women reported that they would repeat sigmoidoscopy only if sedated.

CONCLUSIONS

WIS does not ameliorate tolerance to and quality of sigmoidoscopy screening measured by several scores. When offered a choice, the women's willingness to repeat WIS or CO₂S without sedation was poor and raises concern on the opportunity of screening sigmoidoscopy without sedation in these subjects.

Relief Effect of Carbon Dioxide Insufflation in Transnasal Endoscopy for Health Checks-A Prospective, Double-Blind, Case-Control Trial

CO2 insufflation has proven effective in reducing patients’ pain after colonoscopies but has not been examined in esophagogastroduodenoscopies. Therefore, we examined the effect of CO2 insufflation in examinees who underwent transnasal endoscopies without sedation. This study is a single-center, prospective, double-blind, case-control trial conducted between March 2017 and August 2018. Subjects were assigned weekly to receive insufflation with either CO2 or air. The primary outcome was improvement of abdominal pain and distension at 2 h and 1-day postprocedure. In total, 336 and 338 examinees were assigned to the CO2 and air groups, respectively. Visual analog scale (VAS) scores for abdominal distension (15.4 vs. 25.5; p < 0.001) and distress from flatus (16.0 vs. 28.8; p < 0.001) at 2 h postprocedure were significantly reduced in the CO2 group. VAS scores for pain during the procedure (33.5 vs. 37.1; p = 0.059) and abdominal pain after the procedure (3.9 vs. 5.7; p = 0.052) also tended to be lower at 2 h postprocedure, but all parameters showed no significant difference at 1-day postprocedure. All procedures were safely completed through the planned program, and no apparent adverse events requiring treatment or follow-up occurred. In conclusion, CO2 insufflation may reduce postprocedural abdominal discomfort from transnasal esophagogastroduodenoscopies. (UMIN000028543).

Comparing Colon Capsule Endoscopy to colonoscopy; a symptomatic patient’s perspective

Background

Colon Capsule Endoscopy (CCE) has proven efficacy in a variety of gastrointestinal diseases. Few studies have assessed patient-reported outcomes and preference between colonoscopy and CCE.

Methods

Patients from our centre who had both a CCE and colonoscopy within a 12-month period were identified. We performed over-the-phone interviews focused on satisfaction, comfort, and overall preference with a 10-point Likert scale. Electronic records were reviewed; reported Modified-Gloucester-Comfort-Scale (GCS) score, sedation, bowel preparation and endoscopist grade were documented. Data was compared between procedures. A Fishers exact test was used to compare proportions and a Student t-test was used to compare means, a p < 0.05 was considered significant.

Results

In all, 40 patients were identified, 57.5% (23/40) were female and the mean age was 48 years (24–78). All patients were referred for investigation of lower gastrointestinal symptoms as part of an ongoing study [Endosc Int Open. 2021;09(06):E965–70]. There was a significance difference in mean comfort (9.2 vs 6.7, p < 0.0001, 95% CI − 3.51 to − 1.44) but not satisfaction (8.3 vs 7.7, p = 0.2, 95% CI − 1.48 to 0.33) between CCE and colonoscopy. Main cause of dissatisfaction with CCE was bowel preparation and for colonoscopy was discomfort. Age and gender were not found to be variables. The correlation between GCS and patient reported values was weak (R = − 0.28). Overall, 77.5% (31/40) of patients would prefer a CCE if they required further bowel investigation. Of these, 77.4% (24/31) preferred a CCE despite the potential need for follow-up colonoscopy.

Conclusions

CCE has a high satisfaction rating (8.3 vs 7.7) and has a higher patient reported comfort rating (9.2 vs 6.7) than colonoscopy. Studies have confirmed CCE and colonoscopy have equivalent diagnostic yields. The majority of patients in our cohort prefer CCE to colonoscopy. CCE should be considered as an alternative to colonoscopy in selected individuals.

Colonoscopy-related colonic ischemia

Colonoscopy is a risk factor for colon ischemia. The colon is susceptible to ischemia due to its minor blood flow compared to other abdominal organs; the etiology of colon ischemia after colonoscopy is multifactorial. The causative mechanisms include splanchnic circulation impairment, bowel preparation, drugs used for sedation, bowel wall ischemia due to insufflation/barotrauma, and introduction of the endoscope. Gastroenterologists must be aware of this condition and its risk factors for risk minimization, early diagnosis, and proper treatment.

Insufflation of Carbon Dioxide versus Air During Colonoscopy Among Pediatric Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims:

Carbon dioxide is increasingly used in insufflation during colonoscopy in adult patients; however, air insufflation remains the primary practice among pediatric gastroenterologists. This systematic review and meta-analysis aims to evaluate insufflation using CO₂ versus air in colonoscopies in pediatric patients.

Methods:

Individualized search strategies were performed using MEDLINE, Cochrane Library, EMBASE, and LILACS databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane working methodology. Randomized control trials (RCTs) were selected for the present meta-analysis. Pooled proportions were calculated for outcomes including procedure time and abdominal pain immediately and 24 hours post-procedure.

Results:

The initial search yielded 644 records, of which five RCTs with a total of 358 patients (CO₂: n=178 versus air: n=180) were included in the final analysis. The procedure time was not different between the CO₂ and air insufflation groups (mean difference, 10.84; 95% confidence interval [CI], -2.55 to 24.22; p=0.11). Abdominal pain immediately post-procedure was significantly lower in the CO₂ group (risk difference [RD], -0.15; 95% CI; -0.26 to -0.03; p=0.01) while abdominal pain at 24 hours post-procedure was similar (RD, -0.05; 95% CI; -0.11 to 0.01; p=0.11).

Conclusions:

Based on this systematic review and meta-analysis of RCT data, CO₂ insufflation reduced abdominal pain immediately following the procedure, while pain was similar at 24 hours post-procedure. These results suggest that CO₂ is a preferred insufflation technique when performing colonoscopy in pediatric patients.

Carbon Dioxide vs. Air Insufflation for Pediatric Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Carbon dioxide (CO₂) insufflation during gastrointestinal (GI) endoscopic procedures has gained popularity in adults. However, its utility in pediatric patients is not known. The current review aimed to compare the efficacy of CO₂ vs. air insufflation for GI endoscopic procedures in pediatric patients. Methods: The electronic databases of PubMed, Embase, Scopus, and CENTRAL were searched from the inception of databases to 15th August 2020. Results: All randomized controlled trials (RCTs) comparing CO₂ vs. air insufflation for GI endoscopic procedures in pediatric patients were eligible for inclusion. Five RCTs were identified. Pooled analysis of data from 226 patients in the CO₂ group and 224 patients in the air group revealed that patients receiving CO₂ insufflation were at a lower odds of experiencing postoperative pain as compared to those undergoing the procedure with air (OR: 0.40; 95% CI: 0.19, 0.87; I ² = 62%; p = 0.02). Descriptive analysis indicated no difference in the two groups for abdominal distention after the procedure. Two trials reported elevated CO₂ in the study group but without any pulmonary complications. Bloating was reported by two studies and both reported significantly less bloating in the CO₂ group. Conclusion: Our study indicates that the incidence of pain may be reduced with the use of CO₂ insufflation in pediatric GI endoscopies without a significant risk of adverse events. However, current evidence is from a limited number of trials and not strong to recommend a routine of CO₂ in pediatric gastroenterology practice. Further high-quality RCTs are required to supplement current evidence.

Oral Antibiotics are Effective for Preventing Colonoscopy-associated Peritonitis as a Preemptive Therapy in Patients on Peritoneal Dialysis

Objective In patients on peritoneal dialysis (PD), it was reported that colonoscopy, but not upper gastrointestinal endoscopy, could cause peritonitis as a complication. A guideline of the International Society for Peritoneal Dialysis recommends preemptive intravenous antibiotics administration of ampicillin and aminoglycoside with or without metronidazole, to prevent colonoscopy-associated peritonitis. In this study, we retrospectively evaluated the effects of preemptive antibiotics therapy by oral administration instead of intravenous administration. Methods We investigated the incidence of colonoscopy-associated peritonitis in a single center. In 170 patients undergoing PD between January 2010 and December 2019, 50 colonoscopies were performed, including 49 with oral administration of amoxicillin and ciprofloxacin and/or metronidazole as preemptive therapy 1 hour before the colonoscopy procedure, and 1 without. Results We observed no incidence of colonoscopy-associated peritonitis. Conclusion Generally, oral administration of preemptive antibiotics is less painful and more convenient than intravenous administration, especially in outpatient procedures, such as a colonoscopy. Our results suggest that oral antibiotic administration might be effective for preventing colonoscopy-associated peritonitis in PD patients.