Effects of carbon dioxide insufflation in balloon-assisted enteroscopy: A systematic review and meta-analysis

British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy

Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.

[Use of Device-Assisted Enteroscopy in Small Bowel Disease: An Expert Consensus Statement by the Korean Association for the Study of Intestinal Diseases]

The introduction of device-assisted enteroscopy (DAE) in the beginning of the 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of small bowel diseases, DAE has the unique advantages of allowing the observation of the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how it is to be performed and what technical factors should be taken into consideration. In response to these needs, the Korean Association for the Study of Intestinal Diseases has developed an expert consensus statement on the performance of DAE by reviewing current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases

The introduction of device-assisted enteroscopy (DAE) in the beginning of 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of the small bowel diseases, DAE has the unique advantages of observing the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how to perform it and what technical factors should be considered. In response to these needs, the Korean Association for the Study of Intestinal Diseases developed an expert consensus statement on the performance of DAE by reviewing the current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

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.

Additional Mosapride to Proton Pump Inhibitor for Gastroesophageal Reflux Disease: A Meta-Analysis

BACKGROUND AND AIM

In gastroesophageal reflux disease (GERD), the additive effect of mosapride to a proton pump inhibitor (PPI) is still controversial. This meta-analysis integrated randomized controlled trials (RCTs) in which mosapride combined with a PPI was compared with a PPI alone in GERD treatment.

METHODS

RCTs were systematically searched with the PubMed, Cochrane library, Web of Science, and the Igaku-Chuo-Zasshi database. We combined the data from the RCTs with a random effects model, calculated the standardized mean difference (SMD) and pooled the risk difference (RD) with 95% confidence intervals (CIs).

RESULTS

We included nine RCTs in the present meta-analysis. In the mosapride combined with PPI group, the improvement of the symptom score was significantly greater than that in the PPI alone group without significant heterogeneity (SMD: -0.28, 95% CI: -0.45 to -0.12, p = 0.0007). In the mosapride combined with PPI group, the symptom score after treatment was significantly lower than that in the PPI alone group (SMD: -0.24, 95% CI: -0.42 to -0.06, p = 0.007).

CONCLUSIONS

Mosapride combined with a PPI significantly improved the reflux symptom score compared with that of PPI alone.

The Safety and Feasibility of a New Through-the-scope Balloon-assisted Enteroscopy in Children

OBJECTIVES

Small bowel involvement in Crohn disease (CD) is clinically important for diagnosis and treatment. Single and double-balloon enteroscopy have already become important diagnostic tools in such cases. The on-demand NaviAid AB device enables deep advancement into the small bowel, using an anterograde or retrograde approach. In adults, this procedure is feasible, safe, and rapid. This work aimed to assess the safety and feasibility of NaviAid AB enteroscopy in pediatric patients.

METHODS

Single-center, prospective study using the through-the-scope balloon-assisted-enteroscopy (TTS-BAE) NaviAid AB device for the evaluation of the small bowel in children with suspected or known inflammatory bowel disease (IBD). The system consists of a single-use balloon catheter inserted through the instrument channel of a standard colonoscope. It consists of an inflation/deflation system (NaviAid SPARK), which is inflated to anchoring pressure. The repetitive push-pull technique enables the advancement of the colonoscope along the small intestine.

RESULTS

Fifty analyzed endoscopic procedures (30 retrograde, 20 anterograde) were performed in 34 children (52.9% boys, mean age 13.7 years). Average maximal depth of insertion (MDI), advancement depth using the NaviAid AB and average total procedure time were 138 cm (range 100-190 cm), 81 cm (range 40-120 cm), and 12.8 minutes (range 7.3-19.0 minutes), respectively, for the anterograde approach and 143 cm (range 100-170 cm), 64 cm (range 20-95 cm), and 21.9 minutes (range 13.9-32.0 minutes), respectively, for the retrograde approach. No serious or device-related adverse events were reported.

CONCLUSIONS

NaviAid AB enteroscopy in children is safe, feasible, and enables assessment of the small intestine in a short period of time.

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.

Effects of Encircled Abdominal Compression Device in Colonoscopy: A Meta-Analysis

: Background and Aim: The efficacy of encircling abdominal compression devices in colonoscopies is inconsistent. We performed a meta-analysis of randomized controlled trials (RCTs) in which encircling abdominal compression devices were compared with control in colonoscopies.

METHODS

We systematically searched RCTs published in the Cochrane Library, PubMed, and the Igaku-Chuo-Zasshi database. The data from the eligible RCTs were combined using the random-effects model. The weighted mean differences (WMDs), pooled odds ratios (ORs), and 95% confidence intervals (CIs) were calculated.

RESULTS

Five RCTs were included in this meta-analysis. Compared to the control group, encircling abdominal compression devices significantly reduced the caecal intubation time (WMD: -1.31, 95% CI: -2.40 to -0.23, p = 0.02). Compared to the control group, encircling abdominal compression devices significantly decreased the frequency of postural change (OR 0.30, 95% CI: 0.22 to 0.41, p < 0.00001). Compared to the control group, the use of encircling abdominal compression devices significantly reduced the need for abdominal compression (OR: 0.35, 95% CI: 0.17 to 0.70, p = 0.003).

CONCLUSIONS

Encircling abdominal compression devices in colonoscopies was found to reduce the caecal intubation time and the frequency of abdominal compression.

Device-assisted enteroscopy: An update on techniques, clinical indications and safety

After more than 15 years since its introduction into clinical practice, indications for device-assisted enteroscopy have greatly expanded. Alongside the consolidated indications such as the diagnosis and treatment of small bowel bleeding, Crohn's disease, hereditary polyposis, small-bowel tumors and complicated celiac disease, device-assisted enteroscopy is nowadays largely used to perform endoscopic retrograde cholangiopancreatography in patients with altered anatomy, stent placement, retrieval of foreign bodies, direct insertion of jejunal feeding tubes, and in selected cases of incomplete colonoscopy. This has been made possible by the technical improvements of the enteroscopes and accessories and by the widespread use of the method. Device-assisted enteroscopy endotherapy currently offers a safe and effective alternative to major surgery and often represents the preferred option for treatment of small-bowel pathology. Its safety profile is favourable even in the elderly patient, provided that it is performed in high-volume and experienced centers. The evolution of the enteroscopy technique is a challenge for the future and could be facilitated by the new enteroscopes models. These prototypes need a thorough clinical and safety assessment especially for the complex therapeutic procedures. Large prospective, multicenter studies should be performed to assess whether the use of device-assisted enteroscopy leads to improved patients' long-term outcomes.

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

Pethidine dose and female sex as risk factors for nausea after esophagogastroduodenoscopy

Nausea and vomiting after esophagogastroduodenoscopy have not been studied in detail. The aim of this study was to evaluate the risk factors for post-endoscopic nausea. We performed a case-control study at the Toyoshima Endoscopy Clinic. Eighteen patients with post-endoscopic nausea and 190 controls without post-endoscopic nausea were analyzed. We conducted univariate and multivariate logistic regression analyses with respect to patient age; sex; body height; body weight; the use of psychotropic drugs as baseline medications; and the dosing amounts of midazolam, pethidine, flumazenil and naloxone. On univariate analysis, post-endoscopic nausea was significantly related with patient age (odds ratio = 0.946); female sex (odds ratio = 10.85); body weight (odds ratio = 0.975); and the dose per kg body weight of pethidine (odds ratio = 53.03), naloxone (odds ratio = 1.676), and flumazenil (odds ratio = 1.26). On multivariate analysis, the dose per kg body weight of pethidine (odds ratio = 21.67, p = 0.004) and female sex (odds ratio = 13.12, p = 0.047) were the factors independently associated with post-endoscopic nausea. The prevalence of nausea after esophagogastroduodenoscopy was 0.49% (18/3,654). In conclusion, post-endoscopic nausea was associated with the dose of pethidine and female sex.

Carbon dioxide versus air insufflation enteroscopy: a systematic review and meta-analysis based on randomized controlled trials

OBJECTIVES

 To compare the insufflation of CO ₂ and ambient air in enteroscopy.

SEARCH SOURCES

 The investigators researched the electronic databases MedLine, Cochrane Library, Central, LILACS, BVS, Scopus and Cinahl. The grey search was conducted in the base of theses of the University of São Paulo, books of digestive endoscopy and references of selected articles and in previous systematic revisions.

STUDY ELIGIBILITY CRITERIA

 The evaluation of eligibility was performed independently, in a non-blind manner, by two reviewers, firstly by title and abstract, followed by complete text. Disagreements between the reviewers were resolved by consensus.

DATA COLLECTION AND ANALYSIS METHOD

 Through the spreadsheet of data extraction, where one author extracted the data and a second author checked the extraction. Disagreements were resolved by debate between the two reviewers. The quality analysis of the studies was performed using the Jadad score. The software RevMan 5 version 5.3 was used for the meta-analysis.

RESULTS

 Four randomized clinical trials were identified, totaling 473 patients submitted to enteroscopy and comparing insufflation of CO ₂ and ambient air. There was no statistical difference in the intubation depth between the two groups. When CO ₂ insufflation was reduced, there was a significant difference in pain levels 1 hour after the procedure (95 % IC, -2.49 [-4.72, -0.26], P : 0.03, I ² : 20%) and 3 hours after the procedure (95% IC, -3.05 [-5.92, -0.18], P : 0.04, I ² : 0 %). There was a usage of lower propofol dosage in the CO ₂ insufflation group, with significant difference (95 % IC, -67.68 [-115.53, -19.84], P : 0.006, I ² : 0 %). There was no significant difference between the groups in relation to the use of pethidine and to the oxygen saturation.

LIMITATIONS

 Restricted number of randomized clinical trials and nonuniformity of data were limitations to the analysis of the outcomes.

CONCLUSION

 The use of CO ₂ as insufflation gas in enteroscopy reduces the pain levels 1 hour and 3 hours after the procedure, in addition to the reduction of the sedation (propofol) dosage used.

Dexmedetomidine vs propofol for gastrointestinal endoscopy: A meta-analysis

Background and aim

Several randomized controlled trials have compared sedation with dexmedetomidine and propofol in gastrointestinal endoscopy, with contradictory results. We conducted a meta-analysis of data from randomized controlled trials that compared dexmedetomidine with propofol.

Methods

We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database for randomized trials eligible for inclusion in our meta-analysis. We identified six eligible randomized trials from the database search, and compared the effect of propofol versus dexmedetomidine with respect to: (a) patient's satisfaction level, (b) body movement or gagging, (c) cardiopulmonary complications, and (d) change in heart rate. Data from eligible studies were combined to calculate pooled risk difference (RD) or weighted mean difference (WMD).

Results

Compared to propofol, dexmedetomidine significantly decreased the patient's satisfaction level (WMD: -0.678, 95% confidence interval (CI): -1.149 to -0.207, p = 0.0048), and there was no significant heterogeneity among the trial results. The pooled RD for developing body movement or gagging when using dexmedetomidine was 0.107 (95% CI: -0.09 to 0.305, p = 0.288), with no significant differences. Compared with propofol, the pooled RD for hypotension, hypoxia, and bradycardia with dexmedetomidine sedation were -0.029 (95% CI: -0.11 to 0.05), -0.080 (95% CI: -0.178 to 0.018), and 0.022 (95% CI: -0.027 to 0.07), respectively, with no significant differences. Compared to propofol, dexmedetomidine significantly decreased the heart rate (WMD: -10.41, 95% CI: -13.77 to -7.051, p ≤ 0.0001), without significant heterogeneity.

Conclusions

In gastrointestinal endoscopy, patient satisfaction level was higher in propofol administration, when compared to dexmedetomidine. The risk of complications was similar.

Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies

BACKGROUND AND AIM

The efficacy of clipping for preventing delayed bleeding after colorectal endoscopic resection is still controversial. To assess the efficacy of prophylactic clipping, we conducted a meta-analysis of randomized controlled trials.

METHODS

We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database for randomized trials eligible for inclusion in our meta-analysis. We identified seven eligible randomized trials from the database search, and compared the effect of clipping versus non-clipping with respect to delayed bleeding and perforation. Data from eligible studies were combined to calculate pooled odds ratios (ORs).

RESULTS

Postoperative bleeding was observed in 41 of 1526 cases (2.7%) without clipping and in 32 of 1533 cases (2.1%) with clipping (OR 0.76, 95% CI: 0.39-1.47, p = 0.414). There was no significant heterogeneity among the trial results (I-Square = 26.7%, p = 0.22). In the subgroup analysis based on small tumor size (<20 mm) and large tumor size (≥20 mm), there were no significant differences. Compared with non-clipping, the pooled OR of developing perforation with clipping was 1.00 (95% CI: 0.14-7.25), indicating no significant difference between the two groups.

CONCLUSIONS

Prophylactic clipping did not decrease the occurrence of delayed bleeding after colorectal endoscopic resection. Clipping could be of interest in patients with a high risk of bleeding (anticoagulation) or large lesions, but with the available trials data to prove this are scarce.