Bayesian network meta-analysis: Efficacy of air insufflation, CO2 insufflation, water exchange, and water immersion in colonoscopy

Adenoma detection rate in colonoscopy: how can it be improved?

INTRODUCTION

The introduction of widespread colonoscopy screening programs has helped in decreasing the incidence of Colorectal Cancer (CRC). However, 'back-to-back' colonoscopies revealed relevant percentage of missed adenomas. Quality indicators were created to further homogenize detection performances and decrease the incidence of post-colonoscopy CRC. Among them, the Adenoma Detection Rate (ADR), defined as the percentage obtained by dividing the number of endoscopic procedures in which at least one adenoma was resected, by the total number of procedures, was found to be inversely associated with the risks of interval colorectal cancer, advanced-stage interval cancer, and fatal interval cancer.

AREAS COVERED

In this paper, we performed a comprehensive review of the literature focusing on promising new devices and technologies, which are meant to positively affect the endoscopist performance in detecting adenomas, therefore increasing ADR.

EXPERT OPINION

Considering the current knowledge, although several devices and technologies have been proposed with this intent, the recent implementation of AI ranked over all of the other strategies and it is likely to become the new standard within few years. However, the combination of different device/technologies need to be investigated in the future aiming at even further increasing of endoscopist detection performances.

CO2 Is Beneficial to Gut Microbiota Homeostasis during Colonoscopy: Randomized Controlled Trial

Background: Many studies have reported minor complications and disturbance of the gut microbiota after colonoscopy. Compared with air, carbon dioxide (CO₂) insufflation could decrease minor complications, but its impact on gut microbiota remains unknown. Methods: Thirty-eight healthy subjects were assessed and twenty were randomized to receive either CO₂ or air insufflation during colonoscopy. Neither the participants nor the staff involved in the follow-up knew which gas was used. Minor complications were assessed using symptom scores. Fecal samples were collected at eight time-points for microbiome analysis by full-length 16S rRNA gene amplicon analysis. Results: Baseline characteristics were similar in both groups. The recovery of minor complications after colonoscopy was faster in the CO₂ group (the day of the colonoscopy) than in the air group (the day after the colonoscopy). There was no significant reduction in alpha diversity (species richness) of the first stool after colonoscopy in the CO₂ group (115.0 ± 32.81 vs. 97.4 ± 42.31, p = 0.28) compared with the air group (123.8 ± 37.25 vs. 84.8 ± 31.67, p = 0.04). However, there were no differences in beta diversity between the groups. Linear discriminant analysis effect size (LEfSe) analysis indicated that anaerobic probiotics such as Bacteroides caccae, Bacteroides finegoldii and Bacteroides thetaiotaomicron were more abundant in the CO₂ group than in the air group within 14 days after colonoscopy. On the contrary, the content of Escherichiacoli, Ruminococcus torques and Ruminococcus guavus was higher in the air group. Conclusions: CO₂ is beneficial to gut microbiota homeostasis during colonoscopy in healthy subjects. The effects in patients with different diseases need to be further studied.

Practical considerations for colorectal cancer screening in older adults

Recent guidelines recommend that colorectal cancer (CRC) screening after age 75 be considered on an individualized basis, and discourage screening for people over 85 due to competing causes of mortality. Given the heterogeneity in the health of older individuals, and lack of data within current guidelines for personalized CRC screening approaches, there remains a need for a clearer framework to inform clinical decision-making. A revision of the current approach to CRC screening in older adults is even more compelling given the improvements in CRC treatment, post-treatment survival, and increasing life expectancy in the population. In this review, we aim to examine the personalization of CRC screening cessation based on specific factors influencing life and health expectancy such as comorbidity, frailty, and cognitive status. We will also review screening modalities and endoscopic technique for minimizing risk, the risks of screening unique to older adults, and CRC treatment outcomes in older patients, in order to provide important information to aid CRC screening decisions for this age group. This review article offers a unique approach to this topic from both the gastroenterologist and geriatrician perspective by reviewing the use of specific clinical assessment tools, and addressing technical aspects of screening colonoscopy and periprocedural management to mitigate screening-related complications.

Clinical effects of left-colon water exchange colonoscopy vs conventional air-insufflation colonoscopy

BACKGROUND

The left colon is difficult to detect via conventional air-injection colonoscopy, and patients may have obvious discomfort during intubation. Studies have reported that water exchange technology can significantly reduce the pain and discomfort of patients during endoscopy. However, there are still few studies comparing the clinical effects of left-colon water exchange (WE) colonoscopy with conventional air-insufflation (AI) colonoscopy.

AIM

To compare the clinical effects of left-colon WE colonoscopy and conventional AI colonoscopy.

METHODS

Consecutive patients who underwent colonoscopy at our hospital from June 2020 to December 2020 were collected and randomly divided into either a left-colon WE colonoscopy group or a conventional AI colonoscopy group at a ratio of 1:1. The success rate of ileocecal insertion, time to cecal insertion, time to colonoscope withdrawal, adenoma detection rate (ADR), visual analogue scale (VAS) score of pain, and rate of complications were recorded in the two groups.

RESULTS

A total of 276 patients were included according to the inclusion and exclusion criteria, including 139 cases in the left-colon WE colonoscopy group and 137 cases in the conventional AI colonoscopy group. There were no statistical differences in the success rate of ileocecal insertion, time to colonoscope withdrawal, or adenoma detection rate between the two groups (P > 0.05). However, time to cecal insertion was significantly shorter (4.6 min vs 5.3 min, P < 0.05) and VAS score was significantly lower (2.7 vs 3.1, P < 0.05) in the left-colon WE colonoscopy group than in the conventional AI colonoscopy group. No examination-related complications such as perforation occurred in either group.

CONCLUSION

Compared with conventional AI colonoscopy, left-colon WE colonoscopy significantly shortens the time to ileocecal insertion and reduces the pain and discomfort of the patients.

Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations

BACKGROUND AND AIMS

Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR.

METHODS

Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements.

RESULTS

In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11).

CONCLUSIONS

The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.

Effect of carbon dioxide versus room air insufflation on post-colonoscopic pain: A prospective, randomized, controlled study

BACKGROUND/AIMS

Room air (RA) and carbon dioxide (CO2) are widely used to insufflate the colon to examine the mucosa in colonoscopy. Pain, discomfort, and bloating can be seen during and after colonoscopy secondary to bowel distention. This study aimed to investigate the effect of CO2 on post-procedure pain sensation (PPPS) in comparison with RA.

MATERIALS AND METHODS

Patients were randomly assigned to the RA and CO2 insufflation groups in a 1:1 ratio. The visual analog scale (VAS) was used to measure the pain before and after the colonoscopy. VAS score of 0 was accepted as the absence of pain and above 0 was accepted as the presence of pain. The primary outcome was to investigate the effect of CO2 insufflation on PPPS. Secondary outcomes were to investigate the other contributing factors affecting PPPS and the effect of CO2 on PPPS in patients with inflammatory bowel disease (IBD).

RESULTS

A total of 204 patients were enrolled in the study. No significant difference in PPPS was seen between the 2 groups at any point in time after the colonoscopy. Furthermore, there was no significant difference in pain sensation between the CO2 and RA groups in patients with IBD. When we investigated the other contributing factors to pain sensation, body-mass index (BMI) was found to be significant at 30 minutes and BMI and colonoscopy time were found to be significant at 6 hours afterwards.

CONCLUSION

We found no favorable effect of CO2 insufflation on PPPS in colonoscopy, including in patients with IBD.

Cecal intubation time between the use of one-channel and two-channel water exchange colonoscopy: A randomized controlled trial

BACKGROUND AND AIM

Water exchange (WE) colonoscopy is the least painful insertion technique with high adenoma detection rate but requires a longer intubation time. In the published literature, some investigators used the instrument channel for both infusing and suctioning of water (one channel), while others use colonoscopes with an integrated water-jet channel specifically designed for infusing water (two channel). The aim of this study was to compare cecal intubation time between one-channel and two-channel WE.

METHODS

A total 120 patients undergoing colonoscopy from May 2017 to April 2019 at a regional hospital in southern Taiwan were randomized to either a two-channel group (n = 60) or a one-channel group (n = 60). The primary outcome was cecal intubation time.

RESULTS

The mean cecal intubation time was significantly shorter in the two-channel group compared with the one-channel group (14.0 ± 4.0 vs 17.4 ± 6.7 min, P < 0.001). The two-channel group required less water infused during insertion (564.8 ± 232.4 vs 1213.3 ± 467.5 mL, P < 0.001) but achieved a significantly higher Boston Bowel Preparation Scale score (8.4 ± 0.8 vs 7.5 ± 1.1, P < 0.001) than did the one-channel group. The adenoma detection rate was comparable in the two groups (50.0% vs 48.3%, P = 0.855).

CONCLUSIONS

In comparison with the one-channel WE, two-channel WE showed a shorter cecal intubation time, required less amount of water during insertion, and provided a better salvage cleansing effect. (NCT03279705).

Propofol versus midazolam with or without short-acting opioids for sedation in colonoscopy: a systematic review and meta-analysis of safety, satisfaction, and efficiency outcomes

BACKGROUND AND AIMS

Propofol is increasingly being used for sedation in colonoscopy; however, its benefits over midazolam (± short-acting opioids) are not well quantified. The objective of this study was to compare safety, satisfaction, and efficiency outcomes of propofol versus midazolam (± short-acting opioids) in patients undergoing colonoscopy.

METHODS

We systematically searched Medline, Embase, and the Cochrane library (to July 30, 2018) for randomized controlled trials of colonoscopies performed with propofol versus midazolam (± short-acting opioids). We pooled odds ratios for cardiorespiratory outcomes using mixed-effects conditional logistic models. We pooled standardized mean differences (SMDs) for patient and endoscopist satisfaction and efficiency outcomes using random-effects models.

RESULTS

Nine studies of 1427 patients met the inclusion criteria. There were no significant differences in cardiorespiratory outcomes (hypotension, hypoxia, bradycardia) between sedative groups. Patient satisfaction was high in both groups, with most patients reporting willingness to undergo a future colonoscopy with the same sedative regimen. In the meta-analysis, patients sedated with propofol had greater satisfaction than those sedated with midazolam (± short-acting opioids) (SMD, .54; 95% confidence interval [CI], .30-.79); however, there was considerable heterogeneity. Procedure time was similar between groups (SMD, .15; 95% CI, .04-.27), but recovery time was shorter in the propofol group (SMD, .41; 95% CI, .08-.74). The median difference in recovery time was 3 minutes, 6 seconds shorter in patients sedated with propofol.

CONCLUSIONS

Both propofol and midazolam (± short-acting opioids) result in high patient satisfaction and appear to be safe for use in colonoscopy. The marginal benefits to propofol are small improvements in satisfaction and recovery time.

Impact of new techniques on adenoma detection rate based on meta-analysis data

The high incidence of colorectal cancer and the occurrence of interval cancers after screening colonoscopy support the need to develop methods to increase adenoma detection rate (ADR). This review focuses on the importance of ADR and the impact of new techniques on ADR based on meta-analysis data. The low-cost interventions (such as water-aided colonoscopy, second observation, and dynamic position change) were effective in increasing ADR. So were enhanced imaging techniques and add-on devices. Increase with higher cost interventions such as newer scopes is uncertain. Water exchange (WE) has the highest ADR compared with water immersion, air insufflation, and carbon dioxide insufflation. Second observation with forward or retroflexed views improved the right colon ADR. Add-on devices result in only modest improvement in ADR, of particular help in low performing endoscopists. The second-generation narrow-band imaging (NBI) provided a two-fold brighter image than the previous system. The improvement in ADR with NBI required the “best” quality bowel preparation. New endoscopic techniques incur various additional costs, nil for WE, small for tip attachments but large for the newer scopes. In conclusion, one or more of the above methods to improve ADR may be applicable in Taiwan. A comparison of these approaches to determine which is the most cost-effective is warranted.

Efficacy and safety of water-exchange enteroscopy compared to carbon dioxide insufflation during enteroscopy

INTRODUCTION

carbon dioxide (CO2) insufflation during enteroscopy reduces procedure time and subsequent symptoms and increases the insertion depth compared with room air. In colonoscopy, the water-exchange (WE) technique is associated with less pain compared with CO2 insufflation. The WE technique is not well studied in enteroscopy. The aim of this study was to compare the efficacy and safety of enteroscopy with WE and CO2.

METHODS

a prospective, comparative and observational study was performed of double balloon enteroscopies (DBE) that were randomized in two groups. The first group used WE while the second group used CO2 insufflation. The data collected was evaluated via univariate analysis and multiple logistic regression (variables with p ≤ 0.10 according to the univariate analysis).

RESULTS

forty-six DBE were included; 23 in each arm. The median age of cases was 63.5 years and 37% were female. There were no statistical differences between the groups with regard to the access route, findings, therapy and complications. Four patients (20%) in the CO2 group had adverse events (abdominal distension and pain) and one in the WE group (nausea), which was not statistically significant. The median insertion depth was greater in the CO2 group; 260 cm vs 160 cm (p = 0.048). Multiple logistic regression showed a statistically significant difference in the insertion depth using CO2 insufflation (OR 1.009, 1.001-1.017; p = 0.034).

CONCLUSIONS

DBE with a CO2 insufflation technique and WE are safe with a greater insertion depth with CO2.

Postcolonoscopy Appendicitis: A Review of 57 Cases

The purpose of this study is to review the cases of postcolonoscopy appendicitis (PCA) reported in the literature. A comprehensive search using PubMed, EMBASE, Scopus, and Google Scholar identified 57 cases. The median age at presentations of PCA was 55 years. PCAs typically occurred during the first 24 hours after colonoscopy, and the majority developed after diagnostic colonoscopy. Clinical presentations were similar to those with common acute appendicitis, though with a high perforation rate. Most patients were correctly diagnosed using ultrasound or computed tomography scan. Treatment included open appendicectomy, laparoscopic appendicectomy or cecotomy, radiologic drainage of the abscess, nonoperative treatment with antibiotics. In addition to barotrauma, fecalith impaction into the appendiceal lumen, direct trauma to the appendiceal orifice, and underlying ulcerative colitis, a pre-existing subclinical disease of the appendix seems to play an important role in the pathogenesis. For PCA, timely diagnosis and management are crucial to attain a satisfactory outcome.

Water Exchange (WE) and Quality Improvement-Enhanced Advanced Adenoma Detection: A Pooled Data Analysis of 6 Randomized Controlled Trials

INTRODUCTION

Advanced adenomas (≥10 mm in diameter, >25% villous, or high-grade dysplasia), a marker of colorectal cancer risk, are used to stratify patients for closer surveillance. Modern accessories, endoscopes, and age-adjusted evaluation have variable impacts on the advanced adenoma detection rate (AADR). In 1 randomized controlled trial (RCT) comparing air insufflation (AI) with water exchange (WE), the right colon AADR was significantly increased by WE. Four network meta-analyses reported that WE significantly increased overall adenoma detection rate (ADR), but the impact on AADR was not addressed.

AIM

The aim of this study was to test the hypothesis that WE significantly increased AADR compared with AI.

METHOD

Six Clinicaltrial.gov-registered RCTs were reported by a group of WE investigators. Data including AADR (primary outcome) and overall ADR (secondary outcome) were pooled.

RESULTS

A total of 5407 patients were randomized to AI (2699) and WE (2708). Compared with AI, WE significantly increased AADR (5.7% vs. 8.3%, P=0.001) and overall ADR (20.9% vs. 27.4%, P=0.001).

CONCLUSIONS

In contrast to published reports, which showed variable impacts on AADR, WE was consistent in increasing AADR in 6 reported RCTs. The pooled data confirm that the impact of WE in increasing AADR was significant. The significantly enhanced overall ADR indicated that WE provided a higher quality outcome than AI. The significant improvement in AADR confirmed WE to be clinically relevant and has finally arrived as a timely addition to colorectal cancer prevention programs.

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

BACKGROUND

Carbon dioxide (CO₂) has been used as an alternative to air insufflation at endoscopy with good results; however, uptake of the technique has been poor, possibly due to perceived lack of outcome equivalency. This meta-analysis evaluates the effectiveness of CO₂ versus air in reducing pain post-colonoscopy and furthermore examines other key performance indicators (KPIs) such as sedative use, procedure times and polyp detection rates.

METHODS

This meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pubmed, Pubmed Central, Embase and Cochrane Library were searched for randomized studies from 2004 to 2019, reporting outcomes for patients undergoing colonoscopy with air or CO₂ insufflation, who reported pain on a numerical or visual analogue scale (VAS). Results were reported as mean differences (MD) or pooled odds ratios (OR) with 95% confidence intervals (95% CI).

RESULTS

Of 3586 citations, 23 studies comprising 3217 patients were analysed. Patients undergoing colonoscopy with air insufflation had 30% higher intraprocedural pain scores than those receiving CO₂ (VAS 3.4 versus 2.6, MD -0.7, 95% CI - 1.4-0.0, p = 0.05), with a sustained beneficial effect amongst those in the CO₂ group at 30 min, 1-2-h and 6-h post procedure (MD - 0.8, - 0.6 and - 0.2, respectively, p < 0.001 for all), as well as less distension, bloating and flatulence (p < 0.01 for all). There were no differences between the two groups in KPIs such as the sedation required, procedure time, caecal intubation or polyp detection rates.

CONCLUSIONS

CO₂ insufflation improves patient comfort without compromising colonoscopic performance.

Gastrointestinal Endoscopy Editorial Board top 10 topics: advances in GI endoscopy in 2018

The American Society for Gastrointestinal Endoscopy's Gastrointestinal Endoscopy Editorial Board reviewed original endoscopy-related articles published during 2018 in Gastrointestinal Endoscopy and 10 other leading medical and gastroenterology journals. Votes from each individual member were tallied to identify a consensus list of 10 topic areas of major advances in GI endoscopy. Individual board members summarized important findings published in these 10 areas of adenoma detection, bariatric endoscopy, EMR/submucosal dissection/full-thickness resection, artificial intelligence, expandable metal stents for palliation of biliary obstruction, pancreatic therapy with lumen-apposing metal stents, endoscope reprocessing, Barrett's esophagus, interventional EUS, and GI bleeding. This document summarizes these "Top 10" endoscopic advances of 2018.

Diagnostic application of water exchange colonoscopy: A meta-analysis of randomized controlled trials

Background

Few well-designed studies have investigated water exchange colonoscopy (WE). We performed a meta-analysis to comprehensively evaluate the clinical utility of WE based on high-quality randomized controlled trials (RCTs) and to compare the impacts of WE, water immersion colonoscopy (WI), and gas-insufflation colonoscopy.

Methods

We searched the Cochrane Library, MEDLINE, Embase, PubMed, Elsevier, CNKI, VIP, and Wan Fang Data for RCTs on WE. We analyzed the results using fixed- or random-effect models according to the presence of heterogeneity. Publication bias was assessed by funnel plots.

Results

Thirteen studies were eligible for this meta-analysis. The colonoscopic techniques included WE as the study group, and WI and air- or CO₂-insufflation colonoscopy as control groups. WE was significantly superior to the control procedures in terms of adenoma detection rate, proportion of painless unsedated colonoscopy procedures, and cecal intubation rate according to odds ratios. WE was also significantly better in terms of maximal pain score and patient satisfaction score according to mean difference.

Conclusions

WE can remarkably improve the adenoma detection rate, proportion of painless unsedated colonoscopy procedures, patient satisfaction, and cecal intubation rate, as well as reducing the maximal pain score in patients undergoing colonoscopy.

Impact of water exchange colonoscopy on endoscopy room efficiency: a systematic review and meta-analysis

BACKGROUND AND AIMS

Separate randomized controlled trials (RCTs) showed water exchange (WE) colonoscopy outperformed other techniques in minimizing insertion pain and optimizing adenoma detection rate. Longer insertion time required for removal of infused water, residual air, and feces might have hampered its wider adoption. We evaluate the impact of WE compared with air or carbon dioxide insufflation (GAS) on room turnaround efficiency measured by cecal intubation, withdrawal, and total procedure times.

METHODS

With a systematic search in PubMed, Embase, and Cochrane Library, we identified RCTs (published before March 18, 2018) that compared WE with GAS. We focused on parameters of turnaround efficiency and patient-centered outcomes.

RESULTS

We analyzed 8371 subjects from 17 studies. Demographics and indications were comparable. Mean cecal intubation time (± standard deviation) was WE 12.5 ± 6.1 minutes versus GAS 11.1 ± 7.0 minutes, with a mean difference of 1.4 ± 3.4 minutes. Six studies showed significant differences in insertion time, with mean cecal intubation times of 11.6 ± 5.1 minutes for WE versus 7.7 ± 5.2 minutes for GAS, with a mean difference of 3.9 ± 1.1 minutes. Mean withdrawal time was similar. Mean total procedure time was WE 26.0 ± 9.7 versus GAS 24.2 ± 9.6, with a mean difference of 1.8 ± 6.2 minutes. All mean procedure times were significantly different. Patient-centered outcomes revealed that patients examined with WE had significantly lower real-time insertion pain score, less need for sedation, and higher willingness to repeat the procedure.

CONCLUSIONS

Based on parameters of procedural time, the impact of WE colonoscopy on endoscopy room turnaround yields an increase in total procedure time of about 2 minutes and is associated with significant improvement in specific patient-centered outcomes.