Sedation-risk-free colonoscopy for minimizing the burden of colorectal cancer screening

Prospective randomized controlled trial of water exchange plus cap versus water exchange colonoscopy in unsedated veterans

BACKGROUND AND AIMS

Water exchange (WE) and cap-assisted colonoscopy separately have been shown to reduce pain during insertion in unsedated patients. We hypothesized that compared with WE, WE cap-assisted colonoscopy (WECAC) could significantly lower real-time maximum insertion pain (RTMIP).

METHODS

Veterans without escort were recruited, randomized, blinded, and examined at 3 U.S. Veterans Affairs sites. The primary outcome was RTMIP, defined as the highest segmental pain (0 = no pain, 10 = most severe pain) during insertion.

RESULTS

Randomization (WECAC, 143; WE, 137) produced an even distribution of a racially diverse group of men and women of low socioeconomic status. The intention-to-treat analysis reported results of WECAC and WE for cecal intubation (93% and 94.2%, respectively), mean RTMIP (2.9 [standard deviation {SD}, 2.5] and 2.6 [SD, 2.4]), proportion of patients with no pain (28.7% and 27.7%), mean insertion time (18.6 minutes [SD, 15.6] and 18.8 minutes [SD, 15.9]), and overall adenoma detection rate (48.3% and 55.1%); all P values were >.05. When RTMIP was binarized as "no pain" (0) versus "some pain" (1-10) or "low pain" (0-7) versus "high pain" (8-10), different significant predictors of RTMIP were identified.

CONCLUSIONS

Unsedated colonoscopy was appropriate for unescorted veterans. WE alone was sufficient. Adding a cap did not reduce RTMIP. Patient-specific factors and application of WE with insertion suction of infused water contributed to high and low RTMIP, respectively. For unescorted patients, selecting those with low anxiety, avoiding low body mass index, history of depression or self-reported poor health, and complying with the steps of WE can minimize RTMIP to ensure success of unsedated colonoscopy. (Clinical trial registration number: NCT03160859.).

Sedated Colonoscopy may not be Beneficial for Polyp/Adenoma Detection

BACKGROUND

Sedated colonoscopy has been increasingly selected. However, the effect of sedated colonoscopy on polyp/adenoma detection rate (PDR/ADR) remains controversial among studies.

METHODS

In this retrospective study, the medical records of 11 504 consecutive patients who underwent colonoscopy at our department from July 1, 2021 to December 31, 2022 were collected. Patients were divided into sedated and unsedated groups according to the use of intravenous sedation during colonoscopy. Overall PDR/ADR, right-side, transverse, and left-side colon PDR/ADR, and single and multiple PDR/ADR were calculated. By adjusting for age, gender, body mass index, inpatient, screening/surveillance, cecal intubation time, colonoscopy withdrawal time ≥6 min, and an endoscopist's experience ≥5 years, multivariate logistic regression analyses were performed to evaluate the association of sedated colonoscopy with overall PDR/ADR, right-side, transverse, and left-side colon PDR/ADR, and single and multiple PDR/ADR, where the absence of PDR/ADR was used as reference. Odds ratios (ORs) with their 95% confidence intervals (CIs) were calculated.

RESULTS

Overall, 2275 patients were included, of whom 293 and 1982 underwent sedated and unsedated colonoscopy, respectively. Multivariate logistic regression analyses showed that sedated colonoscopy was independently associated with lower overall PDR/ADR (OR = 0.640, 95% CI = 0.460-0.889, P = 0.008), right-side colon PDR/ADR (OR = 0.591, 95% CI = 0.417-0.837, P = 0.003), single PDR/ADR (OR = 0.659, 95% CI = 0.436-0.996, P = 0.048), and multiple PDR/ADR (OR = 0.586, 95% CI = 0.402-0.855, P = 0.005), but not transverse or left-side colon PDR/ADR.

CONCLUSION

Sedated colonoscopy may not be beneficial in terms of overall PDR/ADR, right-side colon PDR/ADR, and number of polyps/adenomas. Thus, it should be selectively recommended. Additionally, it should be necessary to explore how to improve the quality of sedated colonoscopy.

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.

Effectiveness of low-volume split-dose versus same-day morning polyethylene glycol regimen for adequacy of bowel preparation in patients undergoing colonoscopy: A single-blinded randomized controlled trial

BACKGROUND

Successful completion of colonoscopy depends largely on the quality of bowel preparation. Polyethylene glycol (PEG) is a commonly used preparation for colonoscopy. The timing of bowel preparation has evolved from previous day evening to the currently recommended split-dose regimen. It was observed that consumption of entire or a portion of PEG on the previous day can interfere with work and sleep. Hence, we designed this single-blinded randomized controlled trial (RCT) to evaluate the efficacy, tolerability, and acceptability of the same-day PEG as compared with lowvolume split-dose PEG in patients undergoing late morning colonoscopy.

METHODS

A total of 384 patients were randomized to same-day (SD group; n = 192) and split-dose (SPL group; n = 192) bowel preparation. The patients in both the groups received bisacodyl 10 mg at bedtime on the day prior to colonoscopy. The patients in the SD group took 2 L of PEG between 5:00 AM and 7:00 AM on the day of colonoscopy. The SPL group took 1 L of PEG between 6:00 PM and 7:00 PM on the preceding day and another liter between 6:00 AM and 7:00 AM on the day of colonoscopy. The adequacy of bowel preparation was assessed using the Boston Bowel Preparation Scale (BBPS). Tolerability was scored by recording symptoms such as nausea, vomiting, bloating, and abdominal pain. Acceptability was based on the overall satisfaction, willingness to repeat the same preparation, and interference with sleep on the preceding night.

RESULTS

The median (interquartile range, [IQR]) BBPS in the SD group was 8 (6-9) while that in the SPL group was 6 (5-8) and this difference was statistically significant (p < 0.001). Similarly, a significantly higher proportion of patients in the SD group (86%) achieved adequate bowel preparation (BBPS score ≥ 6) when compared to those in the SPL group (73.4%) (p = 0.002). Tolerability as assessed by nausea, vomiting, bloating, and abdominal pain was similar in both the groups. There was also no significant difference with respect to overall satisfaction of taking bowel preparation (p = 0.33) or willingness to repeat the same regimen (p = 0.37) between the two groups. Patients in the SPL group had more interference with sleep on the preceding night (54% vs. 14.5%, p < 0.001).

CONCLUSION

Same-day morning PEG regimen can be considered an effective, well-tolerated, and acceptable bowel preparation for colonoscopy.

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.

A novel intubation discomfort score to predict painful unsedated colonoscopy

Pain during colonoscopy is a critical quality indicator and often a limiting factor for unsedated colonoscopy. This study aimed to identify factors associated with pain during colonoscopy and establish a model for predicting a painful colonoscopy.Patients aged 18 to 80 who underwent unsedated colonoscopy were prospectively enrolled in 2 tertiary endoscopic centers in China. The primary outcome was the rate of painful colonoscopy and then we identify high-risk factors associated with painful colonoscopy. A prediction model with an intubation discomfort score (IDS) was developed and validated.Totally 607 patients participated in this study, including 345 in the training cohort and 262 in the validation cohort. Body mass index (BMI) of <18.5 kg/m2 (OR 2.18, 95% CI: 1.09-4.37), constipation (OR 2.45, 95% CI: 1.25-4.80), and anticipating moderate or severe pain (OR 2.06, 95% CI: 1.12-3.79) were identified as independent predictive factors for painful colonoscopy and used to develop the IDS (all P < .05). Patients with IDS ≥1 had increased insertion time [9.32(6.2-13.7)] minutes vs 6.87(5.1-10.4) minutes, P = .038) and decreased cecal intubation rate (96.0% vs 99.6%, P = .044). Abdominal compression (48.4% vs 19.9%, P < .001) and position change (59.7% vs 32.1%, P < .001) were more frequently required in the group of patients with IDS ≥1. These results were externally validated in a validation cohort.The intubation discomfort score developed in this study was useful for predicting pain during colonoscopy, with IDS ≥1 indicating painful colonoscopy.

Screening colonoscopy: The present and the future

In the United States, colorectal cancer (CRC) is the second leading cause of mortality in men and women. We are now seeing an increasing number of patients with advanced-stage diagnosis and mortality from colorectal cancer before 50 years of age, which requires earlier screening. With the increasing need for CRC screening through colonoscopy, and thus endoscopists, easier and simpler techniques are needed to train proficient endoscopists. The most widely used approach by endoscopists is air insufflation colonoscopy, where air distends the colon to allow visualization of the colonic mucosa. This technique is un-comfortable for patients and requires an anesthetist to administer sedation. In addition, patients commonly complain about discomfort post-op as air escapes into the small bowel and cannot be adequately removed. Current research into the use of water insufflation colonoscopies has proved promising in reducing the need for sedation, decreasing discomfort, and increasing the visibility of the colonic mucosa. Future direction into water insufflation colonoscopies which have shown to be simpler and easier to teach may increase the number of proficient endoscopists in training to serve our aging population.

Perception and Practices of Colonoscopy Procedure: A Nationwide Survey of Indian Gastroenterologists

Introduction There is a lack of data and consensus about the practices and policies regarding performing colonoscopy in India. We surveyed gastroenterologists to assess their practices and policies of performing colonoscopy.

Methodology A questionnaire was presented to gastroenterologists all over India regarding their preference of bowel preparation and method of sedation, completeness of cecal and ileal intubation rates, preferences for inflation, use of carbon dioxide and nitrous oxide, and complications faced.

Results Of the 350 surveys, 307 had completely responded (88%). Only 18% of the centers were conducting more than 100 colonoscopies a month and 46% denied following a colon cancer screening policy. Two bottles of liquid polyethylene glycol were the most preferred preparation. A total of 21% did not prefer any sedation at all. Nitrous oxide was used by only 5.6% of doctors. Ileal intubation rate was >96% in 34% of centers and cecal intubation rate >96% in 58% of centers. Air was used for inflation by 58%, while 39% used CO2. A total of 40% of the respondents believe CO2 inflation would improve cecal intubation rate, while 9.4% believed otherwise. While one third found CO2 inflation unnecessary and 14% not cost-effective, three fourths were still interested in setting up a CO2 facility. Reasons for not using nitrous oxide were practical/administrative difficulty (46.6%), side effects (20%), and cost (16%). Still more than half surveyed would consider using Entonox in future. Perforation was the most noted complication faced by respondents.

Conclusions This survey of real-world clinical practices will help to formulate practice guideline regarding colonoscopy in India.

Colonoscopy and flexible sigmoidoscopy for follow-up of patients with left-sided diverticulitis

INTRODUCTION

The prevalence of diverticular disease has been increasing in the western world over the last few decades, causing a growing burden on health care systems. This study compared the uses of flexible sigmoidoscopy with colonoscopy as a follow-up investigation for patients diagnosed with acute left-sided diverticulitis and to evaluate the need for using either procedure.

MATERIALS AND METHODS

A retrospective study of 327 patients diagnosed with acute diverticulitis was carried out. Of this total, 240 patients with left-sided diverticulitis diagnosed via computed tomography were included. These patients were categorised into two equal groups: the first 120 patients underwent colonoscopy and the second 120 patients underwent flexible sigmoidoscopy.

RESULTS

All colonoscopes and flexible sigmoidoscopes confirmed the computed tomography diagnosis of sigmoid diverticular disease with no major new findings. All colonoscopes and flexible sigmoidoscopes were reported as having no complications, with nine colonoscopes reported as being difficult compared with only three flexible sigmoidoscopes. All biopsies were reported as no malignancy. Full bowel preparation was required in all colonoscopes, compared with no preparation required for flexible sigmoidoscopes.

CONCLUSIONS

There is no evidence to support the routine use of endoscopic evaluation after an episode of left-sided diverticulitis diagnosed on computed tomography if no worrying radiological findings have been reported. This study supports similar findings from other studies and therefore we disagree with The Royal College of Surgeons of England (Association of Coloproctology of Great Britain and Ireland recommendations) commissioning guide, which advocates routine surveillance of the colon.

Monitoring of colonoscopy quality indicators in an academic endoscopy facility reveals adherence to international recommendations

BACKGROUND

We monitor colonoscopy service quality biannually, by measuring sedation administration, colonoscopy completion, adenoma detection and early complications rates (CR). We herein present our audit results for the years 2013 and 2015.

METHODS

In our endoscopy facility, five rotating senior gastroenterologists perform colonoscopies, on a daily basis. We measured the quality indicators in three cohorts: A, intention for total colonoscopy cases; B, cohort A excluding bowel obstruction cases; C, colorectal cancer (CRC) screening cases.

RESULTS

In 2015, overall sedation administration rate (SAR) was 93.0% (91.6-94.4%), achieving our target to give conscious sedation to >90% of patients undergoing colonoscopy in all three cohorts. Colonoscopy completion rate (CCR) increased significantly (P<0.0001) from 94.8% (93.4-96.2%) to 98.1% (97.3-98.9%) in cohort B and numerically from 96.6% (94.4-98.8%) to 98.6% (97.4-99.7%) in cohort C, at the same periods. In cohort C, adenoma detection rates (ADR) were similar-27.1% (21.7-32.5%) and 27% (22.7-31.3%)-in the two periods. There were only two serious early complications: one cardiorespiratory event and one perforation in 2013 and 2015, respectively. While significant variability regarding SAR (ranging from 80% to 100%) was detected among the participating endoscopists, all but one of them constantly achieved [judged by the lower confidence interval (CI) of the quality indicator] CCRs higher than the recommended by international guidelines. On the contrary ADR was variable among endoscopists during the studied periods.

CONCLUSIONS

Although there is certain variability in endoscopists' performance, the overall colonoscopy quality indicators meet or exceed the internationally recommended standards, in our endoscopy facility.

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.

Psychomotor and cognitive effects of 15-minute inhalation of methoxyflurane in healthy volunteers: implication for post-colonoscopy care

Background and study aims: Colonoscopy with portal inhaled methoxyflurane (Penthrox) is highly feasible with low sedation risk and allows earlier discharge. It is unclear if subjects can return to highly skilled psychomotor skill task shortly after Penthrox assisted colonoscopy. We evaluated the psychomotor and cognitive effects of 15-minute inhalation of Penthrox in adults. Patients and methods: Sixty healthy volunteers (18 to 80 years) were studied on 2 occasions with either Penthrox or placebo in a randomized, double-blind fashion. On each occasion, the subject's psychomotor function was examined before, immediately, 30, 60, 120, 180 and 240 min after a 15-minute inhalation of studied drug, using validated psychomotor tests (Digit Symbol Substitution Test (DSST), auditory reaction time (ART), eye-hand coordination (EHC) test, trail making test (TMT) and logical reasoning test (LRT). Results: Compared to placebo, a 15-minute Penthrox inhalation led to an immediate but small impairment of DSST (P < 0.001), ART (P < 0.001), EHC (P < 0.01), TMT (P = 0.02) and LRT (P = 0.04). In all subjects, the performance of all 5 tests normalized by 30 minutes after inhalation, and was comparable to that with placebo. Although increasing age was associated with a small deterioration in psychomotor testing performance, the magnitude of Penthrox effects remained comparable among all age groups. Conclusions: In all age groups, a 15-minute Penthrox inhalation induces acute but short-lasting impairment of psychomotor and cognitive performance, which returns to normal within 30 minutes , indicating that subjects who have colonoscopy with Penthrox can return to highly skilled psychomotor skills tasks such as driving and daily work the same day.

Development of a murine colonoscopic polypectomy model (with videos)

BACKGROUND AND AIMS

Colonoscopy provides a means for screening and removal of colon adenomas, preventing such lesions from progressing to late-stage carcinoma. No preclinical model currently exists that closely parallels the clinical scenario with respect to polyp resection and recovery after endoscopy.

METHODS

When we used the polyposis in rat colon (Pirc) model, a new polypectomy methodology was developed. A novel PLC classification system (polyp number/location/clockwise orientation) also was devised in order to accurately and reproducibly specify the location of each lesion within the colon.

RESULTS

One week after surgery, injuries to the polypectomy site were confined to the submucosa, indicating that little or no damage occurred to the inner muscle layer of the colon. Polypectomy sites occasionally continued to show ulcer formation, whereas others exhibited tissue regeneration. A pilot study (n = 6 animals), involving a total of 37 polypectomies, confirmed that the new methodology could be applied by using either air insufflation or water-assisted techniques, with either hot or cold snare. As a general observation, polyps tended to be more fully distended and less flattened against the colon mucosa by using the water-assisted protocol, increasing the technical ease of ensnaring and resecting lesions. The PLC system proved to be straightforward and facilitated longitudinal studies by allowing the investigator to track each polypectomy site on repeated examination.

CONCLUSIONS

The Pirc model was ideally suited to colonoscopy with polypectomy. Because the main cause of morbidity in the Pirc model is blockage of the colon, polypectomy can be used as a preventive strategy and will likely facilitate long-term investigations of single agent and combination therapies with potential direct clinical relevance.

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

BACKGROUND AND STUDY AIMS

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic and therapeutic applications of water-immersion colonoscopy

Colonoscopy techniques combining or replacing air insufflation with water infusion are becoming increasingly popular. They were originally designed to reduce colonic spasms, facilitate cecal intubation, and lower patient discomfort and the need for sedation. These maneuvers straighten the rectosigmoid colon and enable the colonoscope to be inserted deeply without causing looping of the colon. Water-immersion colonoscopy minimizes colonic distension and improves visibility by introducing a small amount of water. In addition, since pain during colonoscopy indicates risk of bowel perforation and sedation masks this important warning, this method has the potential to be the favored insertion technique because it promotes patient safety without sedation. Recently, this water-immersion method has not only been used for colonoscope insertion, but has also been applied to therapy for sigmoid volvulus, removal of lesions, lower gastrointestinal bleeding, and therapeutic diagnosis of abnormal bowel morphology and irritable bowel syndrome. Although a larger sample size and prospective head-to-head-designed studies will be needed, this review focuses on the usefulness of water-immersion colonoscopy for diagnostic and therapeutic applications.

Modified sevoflurane-based sedation technique versus propofol sedation technique: A randomized-controlled study

Background:

The aim of this study was to evaluate the safety and efficacy of sevoflurane-based sedation technique for colonoscopy in geriatric patients as compared with that using propofol.

Materials and Methods:

Sixty elderly patients, who were scheduled for colonoscopy, participated in this controlled prospective study and were randomly allocated into two groups; P and S. The patients were sedated using either propofol in P group or sevoflurane in S group. Complications (including apnea, the need for airway intervention, occurrence of general anesthesia [GA], hemodynamic instability and others), the fentanyl requirement and the times of the procedure, recovery, and discharge were recorded in both groups.

Results:

The patients in P group had more frequent apnea attacks, need for airway intervention and occurrence of GA compared to the patients in S group. However, both groups were comparable regarding the other measured variables.

Conclusion:

For geriatric colonoscopy, sevoflurane can provide safe and effective sedation alternative to propofol.

Effectiveness and clinical results of endoscopic management of sigmoid volvulus using unsedated water-immersion colonoscopy

BACKGROUND AND AIM

Although intestinal obstruction as a result of sigmoid volvulus (SV) may be successfully resolved using endoscopic detorsion, surgical treatment remains the main therapeutic strategy. We evaluated the endoscopic detorsion procedure using unsedated water-immersion colonoscopy for the treatment of SV.

METHODS

A retrospective chart review was conducted on the clinical background and prognosis of 21 SV patients who underwent 71 endoscopic detorsion procedures using unsedated, water-immersion colonoscopy.

RESULTS

In all, 14 (67%) male and seven (33%) female patients, with a mean age of 73 years (range, 54-95 years) were enrolled; 86% were >70 years of age. Among these patients, 90% had a background of key predisposing factors. In the 21 patients, endoscopic detorsion was successfully done using unsedated water-immersion colonoscopy. SV recurred in 10 patients at a median of 180 days. Endoscopic detorsion for recurrent SV was successfully achieved in all cases, and none of the secondary cases became severe. Only male patients were observed to experience three or more recurrent episodes of SV.

CONCLUSIONS

SV occurred most commonly in elderly patients with a surgical risk. Our experience suggests that conservative endoscopic treatment using unsedated water-immersion colonoscopy is a safe, reasonable, conservative endoscopic approach for elderly patients in the absence of necrotic findings. We currently use this procedure in most of our cases.

Sedated vs unsedated colonoscopy: A prospective study

AIM: To compare sedated to unsedated colonoscopy in terms of duration, pain and the patient’s willingness to repeat the procedure.

METHODS: Consecutive patients who underwent colonoscopies over a 2-year period were invited to participate. All patients who were to undergo our endoscopy unit were offered sedation with standard intravenous sedatives and analgesics, or an unsedated colonoscopy was attempted. Demographic details were recorded. The patient anxiety level prior to the procedure, time to reach the cecum, total discharge time, patient and endoscopist pain assessments, satisfaction after the examination and the patient’s willingness to return for the same procedure in the future were recorded.

RESULTS: Among the 403 observed patients, more males were observed in the unsedated group (66.2% vs 55.2%, P = 0.04). Additionally, the unsedated group patients were less anxious prior to the procedure (5.1 vs 6.0, P < 0.01). The colonoscopy completion rates were comparable between the 2 groups (85.9% vs 84.2%, P = 0.66). The time to reach the cecum was also comparable (12.2 min vs 11.8 min); however, the total discharge times were shorter in the unsedated group (20.7 min vs 83.0 min, P < 0.01). Moreover, the average patient pain score (3.4 vs 5.7, P < 0.01) was lower in the sedated group, while the satisfaction score (8.8 vs 7.8, P < 0.01) was significantly higher. There was no significant difference, however, between the groups in terms of willingness to repeat the procedure if another was required in the future (83.3% vs 77.3%, P = 0.17).

CONCLUSION: Unsedated colonoscopy is feasible in willing patients. The option saves the endoscopy units up to one hour per patient and does not affect the patient willingness to return to the same physician again for additional colonoscopies if a repeated procedure is needed.

[Pain in connection with colonoscopy in Norway]

BACKGROUND

Colonoscopies are common examinations at Norwegian hospitals. In contrast to many other countries, the majority of colonoscopies in Norway are conducted without routine sedation or analgesia. We wanted to investigate whether current Norwegian practice offers adequate pain relief.

MATERIAL AND METHOD

The material consists of prospectively recorded outpatient colonoscopies in the period January 2003-December 2011 performed at Norwegian hospitals in the quality assurance network for gastrointestinal endoscopy (Gastronet). We analysed demographic patient data and data from colonoscopies. Patients' experience of pain (none, slight, moderate or severe pain) in connection with the examination was established with the aid of a validated questionnaire.

RESULTS

Data from 61,749 colonoscopies (55% on women) performed at 29 different hospitals were analysed. Colonoscopies were perceived as moderately or very painful by 33% of the patients (41% of the women, 24% of the men, p < 0.001). There were substantial differences between hospitals as to the percentage of colonoscopies that were perceived as moderately or very painful (from 9% to 43%, p < 0.001) and the use of sedatives and analgesics for the colonoscopies (from 1% to 92% of the examinations, p < 0.001). Only 23% of those who found the colonoscopy painful received analgesics. Pethidine was used in 95% of the cases in which analgesics were used during the examination.

INTERPRETATION

Many patients find colonoscopies painful. Pain relief practice varies substantially between hospitals. Pethidine is an analgesic with a slow onset of action, and should perhaps be replaced with more rapidly acting opiates.

Continuous quality improvement of colorectal cancer screening

Quality assurance is a key issue in colorectal cancer screening, because effective screening is able to improve primary prevention of the cancer. The quality measure may be described in terms: how well the screening test tells who truly has a disease (sensitivity) and who truly does not have a disease (specificity). This paper raises concerns about identification of the optimal screening test for colorectal cancer. Colonoscopy vs flexible sigmoidoscopy in colorectal cancer screening has been a source of ongoing debate. A multicentre randomised controlled trial comparing flexible sigmoidoscopy with usual care showed that flexible sigmoidoscopy screening is able to diminish the incidence of distal and proximal colorectal cancer, and also mortality related to the distal colorectal cancer. However, colonoscopy provides a more complete examination and remains the more sensitive exam than flexible sigmoidoscopy. Moreover, colonoscopy with polypectomy significantly reduces colorectal cancer incidence and colorectal cancer-related mortality in the general population. The article considers the relative merits of both methods and stresses an ethical aspect of patient’s involvement in decision-making. Patients should be informed not only about tests tolerability and risk of endoscopy complications, but also that different screening tests for bowel cancer have different strength to exclude colonic cancer and polyps. The authorities calculate effectiveness and costs of the screening tests, but patients may not be interested in statistics regarding flexible sigmoidoscopy screening and from an ethical point of view, they have the right to chose colonoscopy, which is able to exclude a cancer and precancerous lesions in the whole large bowel.

Water-aided colonoscopy: a systematic review

BACKGROUND

Water-aided methods for colonoscopy are distinguished by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange).

OBJECTIVE

To discuss the impact of these approaches on colonoscopy pain and adenoma detection rate (ADR).

DESIGN

Systematic review.

SETTING

Randomized, controlled trial (RCT) that compared water-aided methods and air insufflation during colonoscope insertion.

PATIENTS

Patients undergoing colonoscopy.

INTERVENTION

Medline, PubMed, and Google searches (January 2008-December 2011) and personal communications of manuscripts in press were considered to identify appropriate RCTs.

MAIN OUTCOME MEASUREMENTS

Pain during colonoscopy and ADR. RCTs were grouped according to whether water immersion or water exchange was used. Reported pain scores and ADR were tabulated based on group assignment.

RESULTS

Pain during colonoscopy is significantly reduced by both water immersion and water exchange compared with traditional air insufflation. The reduction in pain scores was qualitatively greater with water exchange as compared with water immersion. A mixed pattern of increases and decreases in ADR was observed with water immersion. A higher ADR, especially proximal to the splenic flexure, was obtained when water exchange was implemented.

LIMITATIONS

Differences in the reports limit application of meta-analysis. The inability to blind the colonoscopists exposed the observations to uncertain bias.

CONCLUSION

Compared with air insufflation, both water immersion and water exchange significantly reduce colonoscopy pain. Water exchange may be superior to water immersion in minimizing colonoscopy discomfort and in increasing ADR. A head-to-head comparison of these 3 approaches is required.

Safety and effectiveness of propofol sedation during and after outpatient colonoscopy

AIM

To study the safety and effectiveness of propofol sedation for outpatient colonoscopy.

METHODS

Propofol was given by bolus injection with an age-adjusted standard protocol consisting of 60 mg for patients < 70 years old, 40 mg for patients age 70-89 years, and 20 mg for those ≥ 90 years, and additional injections of 20 mg propofol were given up to a maximum of 200 mg. The principal parameters were the occurrence of adverse events within 24 h after colonoscopy and overall satisfaction for this procedure. Secondary parameters included successful procedure, respiratory depression, and other complications.

RESULTS

Consecutive patients were entered prospectively and all 2101 entered successfully completed outpatient colonoscopy. The mean dose of propofol used was 96.4 mg (range 40-200 mg). Younger patients required higher doses of propofol than older patients (20-40 years vs ≥ 61 years: 115.3 ± 32 mg vs 89.7 ± 21 mg, P < 0.001). Transient supplemental oxygen supply was needed by five patients (0.2%); no other complications occurred. The questionnaires were completed by 1820 (87%) of 2101 patients and most rated their overall satisfaction as excellent (80%) or good (17%). The majority (65%) of patients drove home or to their office after their colonoscopy. Most (99%) were willing to repeat the same procedure. No incidents occurred within 24 h after colonoscopy.

CONCLUSION

Propofol sedation using a dose < 200 mg proved both safe and practical for outpatient colonoscopy.

Randomized trial of standard versus magnetic endoscope imaging colonoscopes for unsedated colonoscopy

BACKGROUND

Unsedated colonoscopy has potential benefits, including decreased costs and decreased risks.

OBJECTIVE

To determine whether patient comfort during unsedated colonoscopy can be improved through the use of a magnetic endoscopic imaging (MEI) colonoscope compared with a standard colonoscope.

DESIGN

Prospective, patient-blinded, randomized, controlled trial.

SETTING

San Francisco Veterans Affairs Medical Center.

PATIENTS

Veterans undergoing outpatient screening or surveillance colonoscopy.

INTERVENTIONS

Use of a standard or MEI colonoscope during unsedated colonoscopy.

MAIN OUTCOME MEASUREMENT

The primary outcome variable was patient perception of pain using a 7-point scale. The secondary endpoint was patient willingness to undergo a future unsedated colonoscopy.

RESULTS

Of the 160 patients enrolled, 140 completed an unsedated colonoscopy in the study protocol. In a per-protocol analysis, the mean and median pain score was 3.12 (standard deviation 1.22) and 4 (interquartile range 2-4) for the standard colonoscope group and 3.06 (standard deviation 1.13) and 3 (interquartile range 2-4) for the MEI group, where 3 was mild pain (P = not significant). Overall, 80% of subjects were willing to undergo a future unsedated colonoscopy for screening or surveillance. In an intention-to-treat analysis, 80% of subjects (64/80) in the standard colonoscope arm and 79% in the MEI arm (63/80) were willing to undergo a future unsedated colonoscopy (P = not significant).

LIMITATIONS

Single-center study of mostly male veterans.

CONCLUSIONS

This patient-blinded, randomized, controlled trial did not demonstrate any difference in patient perception of pain or willingness to undergo unsedated examinations when using the MEI versus the conventional colonoscope. Unsedated colonoscopy is generally feasible and well tolerated and is associated with high patient satisfaction rates.

Health care providers' acceptance of unsedated colonoscopy before and after a state-of-the-art lecture on the feasibility of the option

BACKGROUND/AIM

The impact of education on acceptance of unsedated colonoscopy by health care providers is unknown. To test the hypothesis that knowledge imparted by a lecture on unsedated colonoscopy is associated with its enhanced acceptance.

SETTINGS AND DESIGN

At the State-of-the-Art Lecture on "Unsedated colonoscopy: Is it feasible?" presented at the 8 th Pan-Arab Conference on Gastroenterology, February, 2011, Riyadh, Saudi Arabia, a questionnaire survey of the audience was undertaken.

MATERIALS AND METHODS

An expectation questionnaire was administered before and after the lecture. Attendees responded anonymously.

STATISTICAL ANALYSIS USED

The responses of a convenient sample of 49 attendees who provided completed responses to the questionnaire both before and after the lecture were analyzed. Data are expressed as frequency counts and means±SEM. Repeated measures analysis of variance (ANOVA), ANOVA with contrasts and Chi-square analysis (Statview II Program for Macintosh computers) were used to assess the data. A P value of <0.05 is considered significant.

RESULTS AND CONCLUSIONS

The mean±SEM credibility score (maximum possible score=50) was 25.8 ± 1.8 before and 33.3 ± 2.1 after the lecture, with a significant improvement in mean score of 7.5 ± 1.3 (P=0.001, paired t test). Nineteen (39%) respondents were not willing to consider unsedated colonoscopy for themselves before the lecture. This number decreased to 13 (27%) after the lecture. Before the lecture only 4 (8%) respondents were willing to consider unsedated colonoscopy for themselves. After the lecture this number increased to 8 (16%). The data suggest education of healthcare professionals regarding the feasibility of unsedated colonoscopy appears to enhance its acceptance as a credible patient care option at a Pan-Arab Gastroenterology Conference.

The water method is effective in difficult colonoscopy - it enhances cecal intubation in unsedated patients with a history of abdominal surgery

BACKGROUND: Colonoscopy in unsedated patients in the US is considered to be difficult. Success rate of cecal intubation is limited by discomfort. Colonoscopy in patients with a history of abdominal surgery is also considered to be difficult due to adhesion-related bowel angulations. The water method has been shown to significantly reduce pain during colonoscopy. OBJECTIVE: To test the hypothesis that the water method enhances the completion of colonoscopy in unsedated patients with a history of abdominal surgery. DESIGN: The data bases of two parallel RCT were combined and analyzed. SETTING: Two Veterans Affairs endoscopy units. PATIENT AND METHODS: The water and air methods were compared in these two parallel RCT examining unsedated patients. Those with a history of abdominal surgery were selected for evaluation. MAIN OUTCOME MEASUREMENTS: Completion of unsedated colonoscopy. RESULTS: Among patients with a history of abdominal surgery, the proportion completing unsedated colonoscopy in the water group (19 of 22) was significantly higher than that (11 of 22) in the air group (p=0.0217, Fisher's exact test). LIMITATIONS: Small number of predominantly male veterans, unblinded colonoscopists, not all types of abdominal surgery (e.g. hysterectomy, gastrectomy) predisposing to difficult colonoscopy were represented. CONCLUSION: This proof-of-principle assessment confirms that in patients with a history of abdominal surgery the water method significantly increases the proportion able to complete unsedated colonoscopy. The water method deserves to be evaluated in patients with other factors associated with difficult colonoscopy.

Removal of infused water predominantly during insertion (water exchange) is consistently associated with a greater reduction of pain score - review of randomized controlled trials (RCTs) of water method colonoscopy

INTRODUCTION: Variation in the outcomes in RcTs comparing water-related methods and air insufflation during the insertion phase of colonoscopy raises challenging questions regarding the approach. This report reviews the impact of water exchange on the variation in attenuation of pain during colonoscopy by water-related methods. METHODS: Medline (2008 to 2011) searches, abstracts of the 2011 Digestive Disease Week (DDW) and personal communications were considered to identify RcTs that compared water-related methods and air insufflation to aid insertion of the colonoscope. Results: Since 2008 nine published and one submitted RcTs and five abstracts of RcTs presented at the 2011 DDW have been identified. Thirteen RcTs (nine published, one submitted and one abstract, n=1850) described reduction of pain score during or after colonoscopy (eleven reported statistical significance); the remaining reports described lower doses of medication used, or lower proportion of patients experiencing severe pain in colonoscopy performed with water-related methods compared with air insufflation (Tables 1 and 2). The water-related methods notably differ in the timing of removal of the infused water - predominantly during insertion (water exchange) versus predominantly during withdrawal (water immersion). Use of water exchange was consistently associated with a greater attenuation of pain score in patients who did not receive full sedation (Table 3). CONCLUSION: The comparative data reveal that a greater attenuation of pain was associated with water exchange than water immersion during insertion. The intriguing results should be subjected to further evaluation by additional RcTs to elucidate the mechanism of the pain-alleviating impact of the water method.

DDW 2011 cutting edge colonoscopy techniques - state of the art lecture master class - warm water infusion/CO(2) insufflation for colonoscopy

Pain limits the success of cecal intubation in unsedated patient. Carbon dioxide infusion instead of air insufflation and water infusion as an adjunction to air insufflation have both been investigated as modalities to minimize pain associated with colonoscopy. Multiple RCT support an effect of carbon dioxide in reducing pain after colonoscopy. A modern method of water infusion as the sole modality for aiding colonoscope insertion has been shown to reduce pain during and after colonoscopy. Favorable effects in reducing discomfort have been documented in both sedated and unsedated patients. Because of the need to perform water exchange in the patients with suboptimal bowel perparation, a serendipitous consequence of salvage cleansing is evident with application of the water method. The associated increase in adenoma detection especially in the proximal colon is most intriguing. The hypothesis that the water method during insertion combined with carbon dioxide insufflation during withdrawal will optimally decrease colonoscopy pain should be evaluated. The implications of increased adenoma detection by the water method also deserve to be studied.

A randomized, controlled trial to confirm the beneficial effects of the water method on U.S. veterans undergoing colonoscopy with the option of on-demand sedation

BACKGROUND

Sedation for colonoscopy discomfort imposes a recovery-time burden on patients. The water method permitted 52% of patients accepting on-demand sedation to complete colonoscopy without sedation. On-site and at-home recovery times were not reported.

OBJECTIVE

To confirm the beneficial effect of the water method and document the patient recovery-time burden.

DESIGN

Randomized, controlled trial, with single-blinded, intent-to-treat analysis.

SETTING

Veterans Affairs outpatient endoscopy unit.

PATIENTS

This study involved veterans accepting on-demand sedation for screening and surveillance colonoscopy.

INTERVENTION

Air versus water method for colonoscope insertion.

MAIN OUTCOME MEASUREMENTS

Proportion of patients completing colonoscopy without sedation, cecal intubation rate, medication requirement, maximum discomfort (0 = none, 10 = severe), procedure-related and patient-related outcomes.

RESULTS

One hundred veterans were randomized to the air (n = 50) or water (n = 50) method. The proportions of patients who could complete colonoscopy without sedation in the water group (78%) and the air group (54%) were significantly different (P = .011, Fisher exact test), but the cecal intubation rate was similar (100% in both groups). Secondary analysis (data as Mean [SD]) shows that the water method produced a reduction in medication requirement: fentanyl, 12.5 (26.8) μg versus 24.0 (30.7) μg; midazolam, 0.5 (1.1) mg versus 0.94 (1.20) mg; maximum discomfort, 2.3 (1.7) versus 4.9 (2.0); recovery time on site, 8.4 (6.8) versus 12.3 (9.4) minutes; and recovery time at home, 4.5 (9.2) versus 10.9 (14.0) hours (P = .049; P = .06; P = .0012; P = .0199; and P = .0048, respectively, t test).

LIMITATIONS

Single Veterans Affairs site, predominantly male population, unblinded examiners.

CONCLUSION

This randomized, controlled trial confirms the reported beneficial effects of the water method. The combination of the water method with on-demand sedation minimizes the patient recovery-time burden. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00920751.).

Unsedated colonoscopy: is it feasible?

Unsedated colonoscopy has been an evolving subject ever since its initial description four decades ago. Failure in unsedated diagnostic cases due to patient pain led to the introduction of sedation. Extension to screening cases, albeit logical, created a sedation-related barrier to colonoscopy screening. In recent years a water method has been developed to combat the pain during unsedated colonoscopy in the US. In randomized controlled trials the water method decreases pain, increases cecal intubation success, and enhances the proportion of patients who complete unsedated colonoscopy. The salvage cleansing of suboptimal bowel preparation by the water method serendipitously may have increased the detection of adenoma in both unsedated and sedated patients. The state-of-the-art lecture concludes that unsedated colonoscopy is feasible. The hypothesis is that recent advances, such as the development of the water method, may contribute to reviving unsedated colonoscopy as a potentially attractive option for colon cancer screening and deserves to be tested.

The water method significantly enhances proximal diminutive adenoma detection rate in unsedated patients

BACKGROUND: Colonoscopy has been reported to fail to prevent some post screening colonoscopy incident cancers or minimize cancer mortality in the proximal colon. These reports question the effectiveness of colonoscopy in detecting all proximal adenomas. Diminutive ones which can be obscured by residual feces are particularly at risk. The water method provides salvage cleansing of sub-optimal preparations. OBJECTIVE: To test the hypothesis that the water method enhances proximal diminutive adenoma detection rate (ADR). DESIGN: The data bases of two parallel RCT were combined and analyzed. SETTING: Two Veterans Affairs endoscopy units. PATIENT AND METHODS: The water and air methods were compared in these two parallel RCT examining unsedated patients. MAIN OUTCOME MEASUREMENTS: The combined data on diminutive and overall ADR in the proximal colon, overall ADR, cecal intubation rate, withdrawal time and global bowel cleanliness score. RESULTS: Data in the water (n=92) and the air (n=90) groups were assessed. The water method yielded a significantly higher proximal diminutive ADR, 28.3% vs. 14.4% (p=0.0298); cecal intubation rate, 99% vs. 90% (p=0.0091); mean withdrawal time 19 (10) vs. 15 (8) min (p=0.0065) and mean global bowel cleanliness score during withdrawal, 2.6 (0.7) vs. 2.3 (0.6) (p=0.0032). Increase in proximal overall ADR in the water group approached significance, 29.3% vs. 16.7% (p=0.0592). LIMITATION: Small number of predominantly male veterans. CONCLUSION: The significantly higher cecal intubation rate, longer mean withdrawal time and better mean global bowel cleanliness score favor the outcome of significantly enhanced proximal diminutive ADR in the water group.

Is there a place for sedationless colonoscopy?

Usedated colonoscopy is routinely available in many parts of the world. In the US, only educated professionals appear to be knowledgeable enough to request the unsedated option. Colonoscopists have also been willing to perform unsedated colonoscopy when a patient presents without an escort after undergoing bowel purge preparation. While the actual side-effects of sedation are minimal, the escort requirement and time burden of sedation are barriers to the uptake of screening colonoscopy in the US. The recent trend of deep sedation with propofol for screening colonoscopy increases the efficiency of the colonoscopists at significant costs (e.g. anesthetist reimbursement). The options of as needed and on demand sedation permit patients to complete colonoscopy without sedation. The latter appears to be potentially less coercive. Nurses with experience in the unsedated options recognize the benefit of the quick turn-around of the examination room and shortened occupancy of the recovery area. Discharge planning can be optimized due to absence of amnesia. Patients completing unsedated colonoscopy have given their endorsement of the options. Pain and discomfort continue to limit the success rate of cecal intubation to about 80%. A recently described water method (warm water infusion in lieu of air insufflation combined with removal of all residual colonic air by suction and residual feces by water exchange) has the potential of decreasing procedural discomfort and enhancing cecal intubation in unsedated colonoscopy. The availability of the novel water method assures colonoscopists that high success rate of cecal intubation can be achieved in the unsedated patients.

A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method

BACKGROUND

An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy.

OBJECTIVE

To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT).

DESIGN

Prospective RCT, intent-to-treat analysis.

SETTING

Veterans Affairs ambulatory care facility.

PATIENTS

Veterans undergoing scheduled unsedated colonoscopy.

INTERVENTIONS

During insertion, the water and traditional air methods were compared.

MAIN OUTCOME MEASUREMENTS

Discomfort and procedure-related outcomes.

RESULTS

Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method (P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort (t = -1.998, P = .049, R(2) = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield.

LIMITATIONS

Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability.

CONCLUSIONS

The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).