Sedated vs unsedated colonoscopy: A prospective study

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.

Effect of sedated colonoscopy with different cost coverage on improving compliance with colorectal cancer screening in China

Background

Colorectal cancer is the third most common cancer worldwide. Colonoscopy is the gold standard for colorectal cancer screening. However, the colonoscopy participation rate in China is much lower than that in Europe and the United States. As only non-sedated colonoscopies are offered in colorectal cancer screening programs in China, the absence of sedation may contribute to this gap.

Methods

To explore the effect of free and partially participant-paid sedated colonoscopy on improving colorectal screening participation, we conducted a cross-sectional study under the framework of the Cancer Screening Program in Urban China in Xuzhou from May 2017 to December 2020. The Quanshan district was set as the control group and provided free non-sedated colonoscopy, the Yunlong district was set as a partial cost coverage group and offered partially participant-paid sedated colonoscopy, and the Gulou district was set as the full cost coverage group and offered free sedation colonoscopies. Multivariate logistic regression was used for multivariate analysis of colonoscopy participation and colorectal lesion detection rates between the groups.

Results

From May 2017 to May 2020, 81,358 participants were recruited and completed questionnaire, 7,868 subjects who met high-risk conditions for CRC were invited to undergo colonoscopy. The colonoscopy participation rates in the control group, partially cost coverage, and full cost coverage groups were 17.33% (594/3,428), 25.66% (542/2,112), and 34.41% (801/2,328), respectively. Subjects in the partial and full cost coverage groups had 1.66-fold (95% CI: 1.48-1.86) and 2.49-fold (95% CI: 2.23-2.76) increased rates compared with those in the control group. The adjusted PARs for the partially and the full cost coverage group was 9.08 (95% CI: 6.88-11.28) and 18.97 (95% CI: 16.51-21.42), respectively. The detection rates of CAN in the control, partial-cost coverage, and full-cost coverage groups were 3.54% (21/594), 2.95% (16/542), and 5.12% (41/801), respectively. There were no significant differences in the detection rates between the group. However, sedated colonoscopy increases costs.

Conclusion

Sedated colonoscopy increased colonoscopy participation rates in both the partial and full cost-covered groups. A partial cost coverage strategy may be a good way to increase colorectal cancer participation rates and quickly establish a colorectal cancer screening strategy in underfunded areas.

Minimal water exchange by the air-water valve versus left colon water exchange in unsedated colonoscopy: a randomized controlled trial

BACKGROUND

Water exchange colonoscopy is the least painful method for unsedated colonoscopies. Simplified left colon water exchange (LWE) reduces the cecal intubation time but it is difficult to avoid the use of an additional pump. Minimal water exchange (MWE) is an improved novel method that eliminates the need for pumps, but it is not clear whether MWE has the same efficiency as LWE.

METHODS

This was a prospective, randomized, controlled, noninferiority trial conducted in a tertiary hospital. Enrolled patients were randomized 1:1 to the LWE group or MWE group. The primary outcome was recalled insertion pain measured by a 4-point verbal rating scale. Secondary outcomes included adenoma detection rate (ADR), cecal intubation time, volume of water used, and patient willingness to repeat unsedated colonoscopy.

RESULTS

226 patients were included (LWE n = 113, MWE n = 113). The MWE method showed noninferior moderate/severe pain rates compared with the LWE method (10.6 % vs. 9.7 %), with a difference of 0.9 percentage points (99 % confidence interval [CI] -9.5 to 11.3; threshold, 15 %). ADR, cecal intubation time, and willingness to repeat unsedated colonoscopy were not significantly different between the two groups, but the mean volume of water used was significantly less with MWE than with LWE (163.7 mL vs. 407.2 mL; 99 %CI -298.28 to -188.69).

CONCLUSION

Compared with LWE, MWE demonstrated a noninferior outcome for insertion pain, and comparable cecal intubation time and ADR, but reduced the volume of water used and eliminated the need for a water pump.

State-of-the-Art Review on Immersive Virtual Reality Interventions for Colonoscopy-Induced Anxiety and Pain

BACKGROUND

Colonoscopy related fear impairs the current gold standard screening of colorectal cancer. Compared to other minimally invasive procedures for cancer screening, colonoscopy-induced anxiety exceeds the procedure through bowel preparation. Immersive virtual reality's (iVR) role in alleviating the complex stress-pain relationship encountered during medical procedures is directly proportional to the rising affordability of state-of-the-art Head-Mounted-Displays (HMDs).

OBJECTIVE

to assess the effect of iVR on patients' colonoscopy-induced anxiety and pain.

MATERIALS AND METHODS

A systematic search was conducted in PubMed, Cochrane Central Register of Controlled Trials, Web of Science, Embase and Scopus databases up to January 2022. Clinical trials evaluating anxiety as an outcome were included without language restriction.

RESULTS

Four clinical trials were included: three on the patients' intraprocedural anxiety and one on patient education. Intraprocedural iVR interventions for colonoscopy-induced anxiety and pain revealed a similar effect as conventional sedation, while a statistically significant reduction was reported for non-sedated patients. iVR patient education improved the quality of bowel preparation and reduced patient anxiety before colonoscopy.

CONCLUSIONS

The current research highlights the need to use high-end HMDs and appropriate interactive iVR software content for colonoscopy-induced anxiety. Methodological frameworks regarding the eligibility of participants, double-blinding and randomization of iVR studies can facilitate the development of iVR implementation for anxiety and pain management.

Application of robotic technologies in lower gastrointestinal tract endoscopy: A systematic review

BACKGROUND

Conventional optical colonoscopy is considered the gold standard investigation for colorectal tract pathology including colorectal malignancy, polyps and inflammatory bowel disease. Inherent limitations exist with current generation endoscopic technologies, including, but not limited to, patient discomfort, endoscopist fatigue, narrow field of view and missed pathology behind colonic folds. Rapid developments in medical robotics have led to the emergence of a variety of next-generation robotically-augmented technologies that could overcome these limitations.

AIM

To provide a comprehensive summary of recent developments in the application of robotics in lower gastrointestinal tract endoscopy.

METHODS

A systematic review of the literature was performed from January 1, 2000 to the January 7, 2021 using EMBASE, MEDLINE and Cochrane databases. Studies reporting data on the use of robotic technology in ex vivo or in vivo animal and human experiments were included. In vitro studies (studies using synthetic colon models), studies evaluating non-robotic technology, robotic technology aimed at the upper gastrointestinal tract or paediatric endoscopy were excluded. System ergonomics, safety, visualisation, and diagnostic/therapeutic capabilities were assessed.

RESULTS

Initial literature searching identified 814 potentially eligible studies, from which 37 were deemed suitable for inclusion. Included studies were classified according to the actuation modality of the robotic device(s) as electromechanical (EM) (n = 13), pneumatic (n = 11), hydraulic (n = 1), magnetic (n = 10) and hybrid (n = 2) mechanisms. Five devices have been approved by the Food and Drug Administration, however most of the technologies reviewed remain in the early phases of testing and development. Level 1 evidence is lacking at present, but early reports suggest that these technologies may be associated with improved pain and safety. The reviewed devices appear to be ergonomically capable and efficient though to date no reports have convincingly shown diagnostic or therapeutic superiority over conventional colonoscopy.

CONCLUSION

Significant progress in robotic colonoscopy has been made over the last couple of decades. Improvements in design together with the integration of semi-autonomous and autonomous systems over the next decade will potentially result in robotic colonoscopy becoming more commonplace.

Patient characteristics and procedural outcomes of moderate sedation for endoscopic procedures in patients with obesity: A retrospective, propensity score-matched study

Background  Endoscopic procedures are performed commonly with moderate sedation. Obesity can pose a challenge in its safe administration. This study was aimed at assessing outcomes of endoscopy procedures performed with moderate sedation in obese patients. Patients and methods  This was a retrospective study of patients undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy with moderate sedation from July 17, 2017 to December 31, 2019. Demographics, comorbidities, outpatient medications and procedure-related outcomes (procedure time, recovery time, cardiopulmonary adverse events, 7-day post-procedure hospitalization, cecal intubation time, withdrawal time, tolerance of moderate sedation and sedation medications administered) were compared for patient with and without obesity after propensity score matching. Standard statistical methods were used for analysis. Results  A total of 7601 procedures were performed with moderate sedation for 5746 patients. Propensity score matching identified 1360 and 1740 pairs of EGDs and colonoscopies with moderate sedation for patients with and without obesity. Recovery time was found to be shorter for obese patients undergoing EGD (OR: 0.989, 95 % CI: 0.981-.998; P  = 0.01). Obese patients did not differ from non-obese patients in any other procedure-related outcomes for EGDs or colonoscopies. Conclusions  Outcomes for endoscopy procedures performed with moderate sedation were noted to be similar between obese and non-obese patients. These findings suggest that moderate sedation can be used safely for endoscopic procedures in patients with obesity.

Assessment of pain between sedated and unsedated colonoscopy: Double-blind randomized clinical trail

Background

Colonoscopy plays a vital role for the diagnosis and treatment of colonic diseases but can be associated with anxiety and discomfort or pain. We tested whether unsedated colonoscopy impacts quality indicators and investigated predictors of pain during colonoscopy.

Materials and Methods

This randomized controlled trial was performed on candidates for elective colonoscopy at AL Zahra Hospital, Isfahan at 2018-2019. Balanced block randomization was used to allocate 275 cases into two groups. At finally, 124 patients in case and 122 patients in control group enrolled in analysis. Patients in the sedation group received midazolam with/out pethidine before colonoscopy. Pain intensity in rectal examination (PIREX), preprocedural anxiety, pain intensity during colonoscopy, hemodynamics, duration of colonoscopy, polyp detection rate, cecal intubation rate, bloating within 24 h after colonoscopy, and willingness to repeat colonoscopy were assessed and compared between two groups.

Results

Compared to the group with sedation, cecal intubation time was shorter and bloating was less frequent (7% vs. 16%, P = 0.02) in the unsedated group. There was no difference between the two groups regarding polyp detection rate, cecal detection rate, and willingness to repeat colonoscopy. Pain during rectal examination was significantly associated with pain during colonoscopy (P < 0.001, 95% confidence interval; 0.5-1.3).

Conclusion

The assessment of pain intensity during rectal examination may help to identify patients who can benefit from sedation during colonoscopy. Colonoscopy with sedation does not seem to have a negative impact on colonoscopy quality indicators, and may even reduce cecal intubation time and bloating following procedure.

Smartphone-controlled patch electro-acupuncture versus conventional pain relief during colonoscopy: a randomized controlled trial

BACKGROUND

Smartphone-controlled patch electro-acupuncture (SCEA) is a novel device which gives the same analgesic effect as with conventional acupuncture. There are no published articles in the English literature on the use of this device as a primary mode of pain relief during colonoscopy. Primary aims of this study were to investigate the efficacy of SCEA as a substitute for pain relief during colonoscopy.

METHODS

Thirty-seven patients were randomized to receive SCEA (n = 19) or placebo (n = 18) during colonoscopy. Additional rescue sedation was administered to patients if they had pain or discomfort during the procedure. Visual analogue scale was used to quantify the intensity of pain from the beginning to end of the procedure. Other variables analysed were the amount of sedation used, duration from start to caecal intubation, length of time for completion of colonoscopy and recovery time to home discharge.

RESULTS

Patients who received SCEA had a lower median pain score of 4.6 (interquartile range 5.7) compared to the placebo group of 6.0 (interquartile range 3.2). Statistical analysis comparing the groups revealed a non-significant P-value of 0.12, although more than 90% of the patients indicated willingness for SCEA as the primary analgesia if they were to repeat the procedure. Throughout the study, there were no adverse complications that occurred during the use of SCEA.

CONCLUSIONS

Even though this study did not demonstrate, a significance in pain reduction, SCEA remains a safe modality which, more than 90% of patients favoured as a substitute for pain relief during colonoscopy.

Is a Fundamental Design Change for Gastrointestinal Endoscopes Required?

Since the first fiberoptic instruments, gastrointestinal endoscopy has shaped the field of gastroenterology and is now a key diagnostic and therapeutic tool. Compared with the initial fiberoptic endoscopes state-of-the-art optical chips (or charge-coupled device technology) allowed a quantum leap in image quality. Despite these advances, gastrointestinal endoscopy is far from being perfect. The diagnostic yield (eg, for adenoma detection rates) is highly operator dependent and there is still the need for sedation or even anesthesia to address discomfort during the procedure. Despite highly standardized cleaning and high-level disinfection the reuse of contemporary (and difficult to clean) endoscopes with multiple channels exposes patients to the risk of transmission of infections. Artificial intelligence and pattern recognition should eliminate interindividual variability including polyp detection rates, self-propelled, and (potentially remotely controlled) scopes with a soft shaft could reduce the discomfort during procedures and abolish the need for sedation and anesthesia altogether and single-use designs should eliminate the risk of patient-to-patient transmission of infections. While these innovations are feasible and could be implemented rapidly utilizing available technology, they require a paradigm shift affecting all levels of the value chain from the supplier of the instruments to the end-users. Some may negate the need for a paradigm shift, but it is evident that a major redesign of the endoscopic equipment is overdue to fully utilize novel technologies and most importantly ensure the best possible outcomes for patients.

Unsedated Colonoscopy: Impact on Quality Indicators

BACKGROUND

In the USA, sedation is commonly used for colonoscopies; though colonoscopy can be successfully performed without sedation, outcomes data in this setting are scarce.

AIMS

To determine patient characteristics associated with undergoing unsedated colonoscopy and whether adenoma detection rate (ADR) and cecal intubation rate (CIR) differ between sedated and unsedated colonoscopy.

METHODS

Using a single-center electronic endoscopy database, we identified patients who underwent outpatient colonoscopy between 2011 and 2018 with or without sedation. We used multivariable logistic regression to determine factors associated with unsedated colonoscopy, CIR, and ADR.

RESULTS

We identified 24,795 patients who underwent colonoscopy during the study period. Of these, 179 patients (0.7%) underwent unsedated colonoscopy. ADR was 27.4% in sedated and 21.2% in unsedated colonoscopies (p = 0.06); CIR was 95.8% in sedated and 85.5% in unsedated patients (p < 0.01). On multivariable analysis, male sex (OR 2.06, CI 1.52-2.79) and suboptimal bowel preparation (OR 1.75, CI 1.24-2.45) were associated with undergoing unsedated colonoscopy, while higher BMI was inversely associated with unsedated colonoscopy (BMI 25-29.9: OR 0.44, CI 0.25-0.77). On multivariable analysis, colonoscopy with sedation was associated with CIR (OR 3.79, CI 2.39-6.00) and ADR (OR 1.45, OR 1.00-2.10).

CONCLUSION

We found that undergoing outpatient colonoscopy with sedation as opposed to no sedation was significantly associated with a higher CIR and ADR. Our findings suggest sedation is necessary to meet current CIR and ADR guidelines; however, given the potential cost and safety benefits of unsedated colonoscopy, further investigation into methods to improve patient selection and colonoscopy quality indicators is warranted.

A Prospective Study of Factors Associated with Abdominal Pain in Patients during Unsedated Colonoscopy Using a Magnifying Endoscope

Objective With the advent of endoscopic treatment, the detailed diagnosis of colorectal neoplasms made using magnifying colonoscopy has become increasingly important. However, insertion difficulty causes pain in unsedated colonoscopy. The aim of this prospective observational study was to clarify the factors associated with a patient's pain in unsedated colonoscopy using a magnifying endoscope. Methods Patient pain was assessed using a numerical rating scale (0-10) immediately after the procedure. We defined 5 as mild enough pain that patients would not be reluctant to undergo another colonoscopy. Acceptable pain was defined as 5 or less and severe pain was defined as 8 to 10. Univariate and multivariate linear regression analyses were performed using the pain scale score as a dependent variable. Results A total of consecutive 600 patients undergoing unsedated colonoscopies were evaluated to assess their abdominal pain. The completion rate was 99.5% (597/600). The mean pain scale score was 3.88±2.38. The rate of acceptable pain was 80.5% (483/600). The rate of severe pain was 6.7% (40/600) including the incomplete cases. A comparison of polyp-positive and polyp-negative cases revealed no marked difference in patient pain (3.82±2.24 vs. 3.94±2.49, respectively; p=0.590) or insertion time (6.62±3.98 vs. 6.29±4.21, p=0.090), while more observation time was needed in polyp-positive cases than in polyp-negative ones (16.30±4.95 vs. 13.08±4.69, p<0.01). Univariate and multivariate linear regression analyses revealed that an older age, colectomy, antispasmodic agent use, and a small-diameter endoscope were significant factors associated with less patient pain. In particular, a small-diameter endoscope induces significantly more acceptable pain than a non-small diameter endoscope [85.63% (274/320) vs. 73.93% (207/280), p=0.00003]. Conclusion Unsedated colonoscopy using a magnifying endoscope by an expert may result in acceptable pain levels. The use of an antispasmodic agent, particularly hyoscine N-butyl bromide, and a small-diameter endoscope are recommended for reducing abdominal pain during unsedated colonoscopy.

Factors associated with polyp detection during colonoscopy: A retrospective observational study

The polyp detection rate (PDR) is an important quality indicator for colonoscopy. Several factors have been shown to be associated with PDR. However, whether the moderate sedation is a factor for polyp detection remains controversial. This study aims to assess factors associated with polyp detection including the moderate sedation factor during colonoscopy. Patients who underwent colonoscopy from June 1, 2014 to May 31, 2015 were enrolled into this retrospective study. Patients with poor colon preparation and failure to reach the cecum were excluded. The clinical factors, including patient's sex, age, midazolam/fentanyl sedation, indications, endoscopist colonoscopy volume, and use of antispasmodic agent were evaluated by multivariate analysis. A total of 3373 patients were included in this study. The mean age was 55.8 years, and 1980 patients (58.7%) were male. Among the 3373 patients, 2513 (74.5%) underwent midazolam/fentanyl-based sedated colonoscopy. The multivariate analysis showed that male sex, age over 50 years old, midazolam/fentanyl sedation and indications of screening and surveillance were significantly associated with polyp detection. Moreover, when stratified by sex and age, the midazolam/fentanyl sedation was associated with polyp detection in male patients and patients over 50 years old. This study has highlighted the role of midazolam/fentanyl sedation administered by colonoscopists as a modifiable factor that may increase polyp detection during colonoscopy.

Effect of conscious sedation with midazolam and fentanyl on the overall quality of colonoscopy: a prospective and randomized study

INTRODUCTION

a prospective, randomized study was performed to assess the influence of conscious sedation on the overall quality of colonoscopy, simultaneously quantifying its effect on the scientific quality, perceived quality and patient safety.

METHODS

patients referred for a colonoscopy were included in the study and were randomized to receive or not receive sedation. Demographic data, indication for colonoscopy, cecal intubation, introduction and withdrawal time, resected adenomas and complications during the exploration were collected. Thirty days later, a satisfaction questionnaire was performed (GHAA 9-me) and patients were asked about complications after the examination.

RESULTS

a total of 5,328 patients were included, the average age was 62 ± 15.22 years, 47% were male, 3,734 were sedated and 1,594 were not sedated. The sedated patients had a shorter endoscope insertion time (7'20 ± 2'15 min vs 6'15 ± 3'12 min, p < 0.019), a higher rate of cecal intubations (96% vs 88%, p < 0.05), longer withdrawal time (7'20 ± 2'15 min vs 6'15 ± 3'12 min, p < 0.01) and higher adenoma detection rates (22% vs 17%, p < 0.05). The use of sedation reduced discomfort during and after the exploration, without increasing the complications. The satisfaction questionnaire score was higher (23.6 ± 1.5 vs 16.6 ± 4.8, p < 0.001) in the sedated patients.

CONCLUSIONS

superficial sedation not only reduces patient discomfort but also improves the overall quality of the colonoscopy. Therefore, we must consider the use of sedation as an essential part of colonoscopy.

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.

Modifiable factors associated with patient-reported pain during and after screening colonoscopy

OBJECTIVE

Pain associated with colonoscopy is a major burden for patients. We investigated modifiable factors associated with patient-reported pain during and after colonoscopy.

DESIGN

This cross-sectional analysis included database records from 23 centres participating in a population-based colonoscopy screening programme in Poland. Colonoscopies were performed under three sedation modalities: none, benzodiazepine-opioid sedation or propofol sedation. We used Gastronet (a validated tool) to assess patients' pain during and after colonoscopy; pain was scored on a four-point scale (no, little, moderate or severe pain), with moderate to severe defined as painful. We used multivariate logistic regression models to estimate ORs for painful colonoscopy and calculated risk-adjusted ratios of painful colonoscopies per endoscopist and compared it to the mean rate.

RESULTS

Of 35 216 screening colonoscopies in 2014 and 2015 included in our study, 22 725 (64.5%) patients returned valid Gastronet questionnaires. The proportion of examinations described as causing pain during (after) the procedure was 22.5% (14.2%) for unsedated, 19.9% (13.5%) for benzodiazepine-opioid sedation and 2.5% (7.5%) for propofol sedation. Propofol sedation, higher case volume of endoscopists, newest endoscope generation and adequate bowel preparation were significantly associated with lower odds of painful colonoscopy. Pain scores after colonoscopy showed similar associations. Adjusted pain rates during and after colonoscopy varied 11 and over 23-fold, respectively, between endoscopists.

CONCLUSION

We identified several independent, modifiable factors associated with pain during and after colonoscopy, of which individual endoscopist was the most important. Dedicated training should be considered to decrease variability among endoscopists.

Prospective study of the factors associated with poor tolerance to ambulatory colonoscopy under conscious sedation

BACKGROUND

conscious sedation with benzodiazepines and opiates for colonoscopy is a widespread clinical practice.

OBJECTIVE

to determine the patient's tolerance to colonoscopy and identify the factors associated with lower tolerance.

METHODS

a prospective, single-center, descriptive study of patients undergoing ambulatory colonoscopy under conscious sedation. The pain was assessed using a visual analogue scale with a score of 0 to 100 and also qualitatively.

RESULTS

three hundred patients with a median age of 54 years completed the study (p25-75: 45-64); 138 were men (46%). Tolerance was good in 273 cases (91%). The median value of tolerance was 13 (p25-p75: 4-33). Pain was considered as mild in 215 (71.7%), moderate in 57 (19%) and intense in 28 (9.3%). In the univariate study, greater pain was associated with females, anxiety, the indication for the procedure, the length of time and difficulty of the examination, and the doses of sedatives. In the multivariate study, both the indication (OR 2.92, 95% CI = 1.03-8.2, p < 0.05) and the difficulty of the examination (OR 4.68, 95% CI = 1.6-13.6, p < 0.01) were significant. Complications were found in 16 patients (5.3%), although all of them were insignificant.

CONCLUSIONS

tolerance of patients undergoing ambulatory colonoscopy under conscious sedation is good in most cases and complications are infrequent and minor. A worse tolerance to the test is associated with women patients, individuals with anxiety prior to colonoscopy, indication, difficult and longer exploration and lower doses of sedatives.

Prospective study of anxiety in patients undergoing an outpatient colonoscopy

BACKGROUND

Undergoing a colonoscopy can cause anxiety in patients and this is something which has not been closely studied.

OBJECTIVE

To determine the frequency and intensity of anxiety prior to a colonoscopy and the factors which are related to the procedure.

METHODS

This is a prospective study of patients undergoing outpatient colonoscopy in our hospital. Anxiety was assessed using a visual analogue scale of 0 to 100. The severity of anxiety was rated as mild (1-29), moderate (30-79) or severe (80-100).

RESULTS

Three hundred and twenty-seven patients completed the study, of whom 154 (47.1%) were men with a median age of 54 years (p25-75: 45-65). Three hundred and nine (94.5%) patients were found to suffer a certain degree of anxiety. The median value on the visual analogue scale was 31 (p25-75: 10-53). Anxiety levels were mild in 136 patients (44%), moderate in 141 (45.6%) and severe in 32 (10.4%). Greater anxiety was associated with female patients (mean 40.38 vs 31.99, p = 0.01) and a poorly tolerated previous colonoscopy (mean 50.67 vs 28.44, p = 0.01) and correlated inversely with age (r = -0.170, p = 0.02).

CONCLUSIONS

Colonoscopy causes some degree of anxiety in most patients. Being female, younger and having experienced poor tolerance to a previous scan are associated with greater degrees of anxiety. These findings should be taken into account in the implementation of measures to improve the quality and tolerance of colonoscopy.

Colonoscopy quality with Entonox®vs intravenous conscious sedation: 18608 colonoscopy retrospective study

AIM

To compare colonoscopy quality with nitrous oxide gas (Entonox®) against intravenous conscious sedation using midazolam plus opioid.

METHODS

A retrospective analysis was performed on a prospectively held database of 18608 colonoscopies carried out in Lothian health board hospitals between July 2013 and January 2016. The quality of colonoscopies performed with Entonox was compared to intravenous conscious sedation (abbreviated in this article as IVM). Furthermore, the quality of colonoscopies performed with an unmedicated group was compared to IVM. The study used the following key markers of colonoscopy quality: (1) patient comfort scores; (2) caecal intubation rates (CIRs); and (3) polyp detection rates (PDRs). We used binary logistic regression to model the data.

RESULTS

There was no difference in the rate of moderate-to-extreme discomfort between the Entonox and IVM groups (17.9% vs 18.8%; OR = 1.06, 95%CI: 0.95-1.18, P = 0.27). Patients in the unmedicated group were less likely to experience moderate-to-extreme discomfort than those in the IVM group (11.4% vs 18.8%; OR = 0.71, 95%CI: 0.60-0.83, P < 0.001). There was no difference in caecal intubation between the Entonox and IVM groups (94.4% vs 93.7%; OR = 1.08, 95%CI: 0.92-1.28, P = 0.34). There was no difference in caecal intubation between the unmedicated and IVM groups (94.2% vs 93.7%; OR = 0.98, 95%CI: 0.79-1.22, P = 0.87). Polyp detection in the Entonox group was not different from IVM group (35.0% vs 33.1%; OR = 1.01, 95%CI: 0.93-1.10, P = 0.79). Polyp detection in the unmedicated group was not significantly different from the IVM group (37.4% vs 33.1%; OR = 0.97, 95%CI: 0.87-1.08, P = 0.60).

CONCLUSION

The use of Entonox was not associated with lower colonoscopy quality when compared to intravenous conscious sedation using midazolam plus opioid.

Is Unsedated Colonoscopy Gaining Ground Over Sedated Colonoscopy?

Colorectal cancer (CRC) is a prevalent cancer with high global incidence and a leading cause of cancer death worldwide. CRC screening is important for early cancer detection and prevention. Most premalignant adenomas can be identified and removed before they become malignant. Colonoscopy plays a vital role in reducing the risk for developing CRC. Although screening programs with colonoscopy have been implemented in many countries and considered beneficial for a number of people, this technique is generally associated with anxiety, embarrassment, pain, and discomfort, resulting in lack of adherence to the recommended screening guidelines. In the US, colonoscopy is mostly performed under sedation, thereby causing amnesia and analgesia. In contrast to sedated colonoscopy, which has been associated with some disadvantages, unsedated colonoscopy exhibits advantages and has been preferred over sedated colonoscopy in numerous cancer centers worldwide. This review enumerates the features of sedated and unsedated colonoscopy with the use of the current relevant evidence-based literature. Unsedated colonoscopy can be a reasonable option for routine and unscheduled CRC screening.

Discovery of a novel trimebutine metabolite and its impact on N-desmethyltrimebutine quantification by LC–MS/MS

Hélène Montpetit has a Bachelor of Science in Biochemistry from the University du Québec at Montreal. For the past 15 years, she has worked in the bioanalysis field in CROs environment as well as in a big Pharma. She currently holds a position as scientific reviewer in the method development group at Algorithme Pharma.

Background: A failure in incurred sample reanalysis (ISR) for N-desmethyltrimebutine (NDMT), during the analysis of a trimebutine-containing drug GIC-1001 Phase I study, led to the discovery of a never-before reported metabolite of trimebutine. Results: A positive bias for NDMT during the ISR and post-reconstitution stability evaluations indicated the presence of an unstable metabolite of NDMT. Precursor ion scans performed on freshly extracted samples enabled the identification of this metabolite to be the NDMT glucuronide conjugate and its fragmentation pattern suggested that the glucuronide moiety was attached at the N-terminal of NDMT. Conclusions: An acidification step was introduced in the extraction procedure to completely hydrolyze the glucuronide and measure the total NDMT in plasma, rendering this method a successful fit-for-purpose assay.

A randomized controlled trial comparing continuous and as-required nitrous oxide use during screening colonoscopy

BACKGROUND AND STUDY AIMS

Entonox is a 50 : 50 combination of nitrous oxide and oxygen, which may be used to manage pain during colonoscopy. The optimal mode of Entonox administration is unknown. The aim of this study was therefore to compare continuous and as-required Entonox use.

PATIENTS AND METHODS

Patients attending for screening colonoscopy at a single centre were randomized to continuous or as-required Entonox use. The primary outcome measure was the patient's overall pain rating at the time of discharge (verbally administered numerical ratings scale, 0=no pain and 10=extreme pain). Secondary outcome measures included the patients' experience of pain during the colonoscopy (rated every 2 min), side effects and the need for rescue intravenous medications.

RESULTS

A total of 108 patients were randomized, and 100 completed the study (46 continuous, 54 as required). The overall pain scores at discharge did not differ between those who used Entonox continuously and as required (mean=2.4 vs. 3.2, P=0.08). There were also no differences in the experience of pain during colonoscopy (mean=1.8 vs. 2.2, P=0.28; peak=4.2 vs. 4.8, P=0.26; and area under curve=23 vs. 30, P=0.24). Patients with high anxiety had greater overall pain scores (mean=3.7 vs. 2.4, P=0.03). Light headedness occurred more often with continuous Entonox use (48 vs. 21%, P=0.009).

CONCLUSION

Among patients attending for screening colonoscopy, comfort ratings were similar in those using Entonox continuously and as required, but light headedness was more common with continuous use (NCT identifier: 01865721).

Carbon dioxide insufflation vs conventional air insufflation for colonoscopy: a systematic review and meta-analysis of published randomized controlled trials

AIM

Conventional air insufflation (AI) may cause prolonged abdominal bloating, excessive abdominal pain and discomfort during colonoscopy. Carbon dioxide may be an acceptable alternative to avoid these complications. The object of this study was to evaluate systematically the effectiveness of carbon dioxide insufflation (CI) for colonoscopy compared with AI.

METHOD

Randomized controlled trials (RCTs) comparing the effectiveness of CI with that of AI during colonoscopy were retrieved from medical electronic databases and combined analysis was performed using the RevMan statistical package. The combined outcome of dichotomous and continuous variables was expressed as an odds ratio (OR) and standardized mean difference (SMD).

RESULTS

Twenty-one RCTs comprising 3607 patients were included in the study. There was statistically significant heterogeneity among included studies. CI showed a significant trend towards reduced procedural pain [SMD -1.34; 95% confidence interval (95% CI) -2.23 to -0.45; z = 2.96; P < 0.003] and also postprocedural pain at 1 h (SMD -1.11; 95% CI -1.83 to -0.38; z = 2.97; P < 0.003), 6 and 24 h (OR 0.44; 95% CI 0.23-0.85; z = 2.44; P < 0.01). CI was associated with faster caecal intubation (SMD -0.20; 95% CI -0.37 to -0.02; z = 2.23; P < 0.03) but the caecal intubation rate was similar (P = 0.59) in both colonic insufflation techniques .

CONCLUSION

CI seems to have clinical advantages over AI for colonoscopy with regard to pain during and after the procedure.