Colonoscopy, pain and fears: Is it an indissoluble trinomial?

Is the Transverse Colon Overlooked? Establishing a Comprehensive Colonoscopy Database from a Multicenter Cluster-Randomized Controlled Trial

Background and Study Aim: Colonoscopy holds the highest volume of all endoscopic procedures, allowing for large colonoscopy databases to serve as valuable datasets for quality assurance. We aimed to build a comprehensive colonoscopy database for quality assurance and the training of future AIs. Materials and Methods: As part of a cluster-randomized controlled trial, a designated, onsite medical student was used to acquire procedural and patient-specific data, ensuring a high level of data integrity. The following data were thereby collected for all colonoscopies: full colonoscopy vides, colonoscope position (XYZ-coordinates), intraprocedural timestamps, pathological report, endoscopist description, endoscopist planning, and patient-reported discomfort. Results: A total of 1447 patients were included from the 1st of February 2022 to the 21st of November 2023; 1191 colonoscopies were registered as completed, 88 were stopped due to inadequate bowel cleansing, and 41 were stopped due to patient discomfort. Of the 1191 completed colonoscopies, 601 contained polypectomies (50.4%), and 590 did not (49.6%). Comparing colonoscopies with polypectomies to those without the withdrawal time (caecum to extubating the scope) was significantly longer for all parts of the colon (p values < 0.001), except the transverse colon (p value = 0.92). The database was used to train an AI, automatically and objectively evaluating bowel preparation. Conclusions: We established the most thorough database in colonoscopy with previously inaccessible information, indicating that the transverse colon differs from the other parts of the colon in terms of withdrawal time for procedures with polypectomies. To further explore these findings and reach the full potential of the database, an AI evaluating bowel preparation was developed. Several research partners have been identified to collaborate in the development of future AIs.

Effect of Virtual Reality on Pain, Anxiety, and Vital Signs in Endoscopy

AIM

This study was conducted to evaluate the effect of relaxation exercise with VR (Virtual Reality) glasses on pain severity, anxiety level, and vital signs in patients undergoing endoscopy.

METHODS

This is a quasi-experimental study including a control group with a pretest/post-test applied. This study was conducted with a total of 100 patients, including 50 patients in the intervention and 50 patients in the control group. The data were collected by using Personal Information Form, Visual Analogue Scale (VAS), Visual Anxiety Scale, Vital Signs Form and Virtual Reality Glass Application Satisfaction Form.

RESULTS

In the inter group evaluation, the mean systolic and diastolic blood pressure, heart rate and respiratory rate of the patients in the experimental group after endoscopy were found to be lower than the control group (p < .05). When the effect size value (Cohen d) of this finding was examined, it was found that the application of virtual reality glasses had a large effect on systolic and diastolic blood pressure and a moderate effect on respiration and heart rate. It was found that the mean VAS score of the patients in the control group after the endoscopy procedure was significantly higher than their mean values before the procedure (p = .001). There was no statistically significant difference in the mean VAS scores, anxiety scores and O2 saturation values of the patients in the experimental and control groups after the endoscopy. The mean virtual reality glasses satisfaction value of the patients was found to be 6.98.

CONCLUSION

Relaxation exercise performed with virtual reality glasses has positive effects on mean systolic and diastolic blood pressure values, heart rate and respiratory rate in patients undergoing endoscopy. In line with these results, it is recommended that the use of virtual reality glasses during endoscopy should be widespread by nurses.

Nursing Intervention Based on the Interactive Attainment Model

This study aimed to examine the effectiveness of nursing that was based on the interactive attainment model in alleviating anxiety and pain during colonoscopy. This retrospective study included 213 patients, divided into intervention and control groups. Both groups underwent normal or painless colonoscopy. Anxiety and pain were evaluated using the Self-Rating Anxiety Scale and the Visual Analog Scale (VAS), respectively. The intervention group reported significantly lower anxiety and VAS pain scores compared with the control group. The interactive attainment model of nursing effectively reduces patient anxiety and pain and lowers complication rates in patients undergoing colonoscopy.

Acupuncture reduces sedative and anaesthetic consumption and improves pain tolerance in patients undergoing colonoscopy: a Meta-analysis

OBJECTIVE

To evaluate the effects of acupuncture anesthesia on the consumption of sedatives and anesthetics, pain, and time consumption in patients undergoing colonoscopy, thus providing evidence that acupuncture anesthesia should be extended to endoscopists and anesthetists.

METHODS

Four English and four Chinese databases were searched for randomised controlled trials of acupuncture anaesthesia in patients undergoing colonoscopy, published from database inception to 1 March 2023. Outcomes were consumption of sedatives and anaesthetics, pain tolerance, visual analog scale (VAS) score, the meantime consumption of examination, satisfaction, and adverse reactions.

RESULTS

Thirty-one randomized controlled trials with a total of 4790 participants were included. Results showed that acupuncture anaesthesia significantly reduced consumption of sedatives and anaesthetics [9 studies, n = 944, standardized mean difference (SMD) = －0.82, 95% CI (－1.31, －0.33), P = 0.001], VAS score [9 studies, n = 1790, mean difference (MD) = －1.13, 95% CI (－1.70, －0.57), P < 0.001], meantime consumption [21 studies, n = 3799, MD = －2.09, 95% CI (－3.15, －1.03), P<0.001] and adverse reactions of colonoscopy [7 studies, n = 738, odds ratio (OR) = 0.17, 95% CI (0.10, 0.28), P<0.001]. Acupuncture also significantly improved pain tolerance [14 studies, n = 1661, OR = 7.05, 95% CI (3.79, 13.12), P<0.001], while no beneficial effects were found for satisfaction [7 studies, n = 843, SMD = 0.02, 95% CI (－0.38, 0.43), P = 0.91].

CONCLUSION

Acupuncture has beneficial effects on patients undergoing colonoscopy, particularly in reducing consumption of sedatives and anaesthetics, alleviating pain, shortening the time consumption of examination and preventing adverse events. As an alternative, effective, inexpensive, and accessible approach, acupuncture anaesthesia should be extended to endoscopists and anaesthesiologists.

Extended flexible sigmoidoscopy using water exchange facilitates a complete colon examination without sedation in participants undergoing average risk colorectal cancer screening: results from a randomized trial

Colon cancer is a leading cause of cancer deaths. Leading guidelines recommend flexible sigmoidoscopy (FS) every 10 years as a screening option for average-risk people. One area of progress involves a method called water exchange (WE). This is useful for cancer screening. We performed a randomized controlled trial on 90 average-risk individuals aged 50-74. They were tested with 2 methods: unsedated extended FS using either WE or the standard method of gas insufflation (GAS). Both methods showed similar success in examining the whole colon. More participants were satisfied with WE than GAS. Both groups felt little pain. Our study shows that modern methods, especially using WE, are effective and safe. They may remove the need for sedation, making it easier to include in large-scale screening programs.

The Effect of Virtual Reality on Pain, Anxiety, Physiological Parameters, and Postspinal Headache in Patients Undergoing Spinal Anesthesia: A Randomized Controlled Trial

PURPOSE

The purpose of this research was to determine the effect of virtual reality (VR) on pain, anxiety, physiological parameters, and postspinal headache in patients undergoing spinal anesthesia.

DESIGN

This was a randomized controlled experimental trial.

METHODS

The research was conducted in the operating room unit of the state hospital in Hakkari-Şemdinli District Center between May 2021 and June 2022. Data were collected using the Descriptive Information Form, visual analog scale (VAS), verbal category scale (VCS), State-Trait Anxiety Inventory, and the Application Registration Form to record preoperative and postoperative oxygen saturation and heart rate.

FINDINGS

When the groups' VAS and VCS mean scores were compared for head and incision site pain, the mean scores of headache and incision site pain in both groups were found to be significantly lower in the experimental group patients (P < .001). In addition, the difference between the groups in headache VAS and VCS mean scores at all hours was statistically significant; incision site pain VAS and VCS mean scores were significantly lower between the groups at all hours, except the 1st and 2nd hours (P < .001). While there was no significant difference in the State-Trait Anxiety Inventory (SAS) pretest mean scores between the groups (P > .05), the SAS post-test mean scores of the experimental group were significantly lower (P < .05). The mean heart rate in the intraoperative and postoperative periods and the mean saturation in the postoperative period differed significantly between the groups (P < .05). The difference between the blood pressure averages before, during, and after the operation was not statistically significant in both groups (P > .05). While nausea and vomiting was significant in the experimental group only at the 2nd hour (P < .05), it was not statistically significant at the other hours (P > .05).

CONCLUSIONS

VR was found to effectively reduce pain, anxiety, postspinal headache, and increase the oxygen saturation level in the postoperative period in patients who underwent spinal anesthesia. Hence, VR is an effective treatment for patients who have undergone surgery under spinal anesthesia.

The Impact of Visual Distraction Interventions on Patients' Pain and Anxiety During Colonoscopy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVE

Patients undergoing colonoscopy may experience psychological distress related to the procedure, which may deter adherence and acceptance of future colonoscopies. Visual/audiovisual distraction interventions to alleviate colonoscopy-related pain and anxiety have been developed. This study aims to investigate the impact of these interventions on colonoscopy-related outcomes.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) testing the efficacy of visual/audiovisual distraction. Eligible studies were systematically retrieved by searching PubMed, EMBASE, WOS, SCOPUS, and Cochrane through June 2024 and extracted by 2 investigators. Continuous and dichotomous outcome variables were pooled using Cohen's d and risk ratio (RR) with confidence interval (CI) using Stata MP version 17. We assessed heterogeneity using the χ2 test and I2 statistic (PROSPERO ID: CRD42024555902).

RESULTS

We included 13 RCTs with 1439 patients randomized to an active intervention (n=804) or usual care (n=635). Only 3 RCTs were endoscopists-blinded studies, whereas the rest were open-label. The interventions included playing nature scene videos, real-time videos of the colonoscopy, or movies preferred by the patients. The active intervention arm was associated with a significant reduction in the pain experienced during colonoscopy (Cohen's d: -0.57, 95% CI [-0.79, -0.35], P<0.0001), reduced anxiety related to colonoscopy (Cohen's d: -0.66, 95% CI [-1.15, -0.18], P=0.01), and increased patients' satisfaction (Cohen's d: 0.65, 95% CI [0.49, 0.80], P<0.0001) compared with patients who received the usual care during colonoscopy. There were no significant differences between both groups in the willingness to re-undergo the procedure (RR: 1.11, 95% CI [0.98, 1.25], P=0.09), analgesia use (Cohen's d: -0.21, 95% CI [-0.42, 0.0], P=0.05), or total procedure duration (Cohen's d: -0.12, 95% CI [-0.24, 0.0], P=0.06).

CONCLUSIONS

Visual/audiovisual distraction interventions decrease colonoscopy-associated pain and anxiety and increase patients' satisfaction. These are promising interventions to improve patient compliance and quality of care during colonoscopy.

A Patient-Centered Approach to Communication during Endoscopic Procedures: The Importance of Providing Information to Patients

The study aimed to explore patients' experiences and perceptions throughout the various stages of endoscopic procedures and examine the association between patient-centered communication and the patient's experience. A total of 191 patients responded to pre- and post-procedure surveys that inquired about fear and pain, patients' satisfaction regarding the information provided to them, perceptions and experience. Pain was associated with post-procedure fear (r = 0.63, p < 0.01) and negatively associated with reported patient experience at the end of the visit (r = -0.17, p < 0.01). Significant positive associations were found between patient experience and satisfaction from the information provided before (r = 0.47, p < 0.01) and the information provided after the procedure (r = 0.51, p < 0.001). A predictive model found that perceptions toward the physicians, satisfaction from information provided before discharge, and feelings of trust are predictors of the patient experience (F = 44.9, R2 = 0.61, p < 0.001). Patients' satisfaction with information provided before and after the procedure can positively affect the patients' experience, leading to a decrease in fear and anxiety and increasing compliance with medical recommendations. Strategies for PCC with endoscopic patients should be developed and designed in a participatory manner, taking into account the various aspects associated with the patient experience.

Randomized controlled trial of effects of a familiarization video and patient-controlled Entonox inhalation on patient stress levels and clinical efficacy of flexible sigmoidoscopy without analgesia or sedation for investigation of fresh rectal bleeding

BACKGROUND AND AIM

Flexible sigmoidoscopy (FS) without analgesia or sedation can be unpleasant for patients, resulting in unsatisfactory examinations. Prior familiarization videos (FVs) and intra-procedural Entonox inhalation have shown inconsistent effects. This study investigated their effects on undesirable participant factors (anxiety, stress, discomfort, pain, satisfaction, later unpleasant recall of procedure, and vasovagal reactions) and clinical effectiveness (extent of bowel seen, lesions detected, and procedural/recovery times).

METHODS

This cluster-randomized single-center study evaluated 138 participants undergoing FS. There were 46 controls, 49 given access to FV, and 43 access to both FV and self-administered Entonox. Participant factors were measured by self-administered questionnaires, independent nurse assessments, and heart rate variability (HRV) metrics.

RESULTS

Questionnaires showed that the FV group was slightly more tense and upset before FS, but knowledge of Entonox availability reduced anxiety. Nonlinear HRV metrics confirmed reduced intra-procedural stress response in the FV/Entonox group compared with controls and FV alone (P < 0.05). Entonox availability allowed more bowel to be examined (P < 0.001) but increased procedure time (P < 0.05), while FV alone had no effect. FV/Entonox participants reported 1 month after FS less discomfort during the procedure. Other comparisons showed no significant differences between treatment groups, although one HRV metric showed some potential to predict vasovagal reactions.

CONCLUSIONS

Entonox availability significantly improved clinical effectiveness and caused a slight reduction in undesirable participant factors. The FV alone did not reduce undesirable participant factors or improve clinical effectiveness. Nonlinear HRV metrics recorded effects in agreement with stress reduction and may be useful for prediction of vasovagal events in future studies.

Bowel Preparation Burden, Rectal Pain and Abdominal Discomfort: Perspective of Participants Undergoing CT Colonography and Colonoscopy

OBJECTIVE

This study aimed to evaluate bowel preparation burden, rectal pain and abdominal discomfort levels and to determine the association between demographic characteristics and those levels among participants undergoing CT colonography and colonoscopy.

METHODS

A cross-sectional survey was conducted in eligible Thai citizens who consented to participate all four visits of a free colorectal cancer screening protocol. Three levels (mild, moderate and severe) of burden, pain and discomfort were used to ask the perspective of participants at the final visit, one week after undergoing those two procedures.

RESULTS

Data from 1,271 participants completed for analyses - females 815 (64.1%), males 456 (35.9%). The majority of participants experienced mild burden, pain and discomfort. Association between characteristic groups and burden levels differed regarding own income, chronic disease and laxative. Between characteristic groups and pain and discomfort levels differed regarding own income and chronic disease. Participants without their own income rated severe burden lower than those who had (p<0.001), but those without chronic disease rated moderate burden lower than who had (p=0.003). Participants prepared bowel with spilt-dose of PEG rated moderate burden higher than those who prepared with NaP (p<0.001). Participants undergoing CT colonography without their own income and presenting no chronic disease faced severe rectal pain lower than those who had (p<0.001 and p=0.04). Participants without their own income rated moderate and severe abdominal discomfort lower than those who had (p<0.01 and p=0.008). Participants undergoing colonoscopy without their own income and no chronic diseases faced severe rectal pain lower than those who had (p<0.001 and p=0.007). Participants without their own income and no chronic disease rated severe abdominal discomfort lower than those who had (p<0.001 and p=0.005).

CONCLUSION

Evaluating the perspectives of customers alongside quality improvement and innovation to reduce unpleasant experiences remains needed in CT colonography and colonoscopy to promote CRC screening.

The effect of position change and abdominal massage on anxiety, pain and distension after colonoscopy: A randomized clinical trial

CONTEXT

Pain, abdominal distention, and anxiety are major risk factors encountered after colonoscopy. Complementary and alternative treatments, such as abdominal massage and position change, are used to reduce the associated risk factors.

OBJECTIVE

To determine the effect of position change and abdominal massage on anxiety, pain, and distension after colonoscopy.

DESIGN

A randomized three-group experimental trial.

SETTING AND PARTICIPANTS

This study was conducted with 123 patients who underwent colonoscopy at the endoscopy unit of a hospital located in western Turkey.

METHODS

Three groups were formed: two interventional (abdominal massage and position change) and one control, each including 41 patients. Data were gathered using a personal information form, pre- and post-colonoscopy measurement form, the Visual Analog Scale (VAS), and the Spielberger State-Trait Anxiety Inventory. Pain and comfort levels, abdominal circumference values, and vital signs of the patients were measured at four evaluation times.

RESULTS

In the abdominal massage group, the VAS pain scores and abdominal circumference measurements decreased the most and the VAS comfort scores increased the most 15 min after the patients were taken to the recovery room (p<0.05). Furthermore, bowel sounds were heard, and bloating was relieved in all patients in both intervention groups 15 min after they were taken to the recovery room.

CONCLUSIONS

Abdominal massage and position change can be considered effective interventions for relieving bloating and facilitating flatulence after colonoscopy. Moreover, abdominal massage can be a powerful method for reducing pain and abdominal circumference and increasing patient comfort.

Anxiety and Health Literacy Levels of Patients Undergoing Colonoscopy

This descriptive, correlational study was conducted to determine the anxiety and health literacy levels of patients undergoing colonoscopy and the variables affecting them. The study population consisted of individuals who presented for colonoscopy to the endoscopy department of a state hospital. The sample consisted of 160 individuals who met the inclusion criteria. Three data collection tools (Identifying Information Form, State-Trait Anxiety Inventory, and Health Literacy Scale) were used to determine anxiety and health literacy levels. Findings show that the state-trait anxiety of individuals who would undergo colonoscopy for the first time was moderate, and their health literacy scores were inadequate, problematic, and weak. There was a positive and significant relationship between patients' anxiety and health literacy levels. Variables such as age, gender, marital status, education level, employment status, disease-related symptoms, a family history of cancer, and fear of colonoscopy influenced anxiety and health literacy. Based on these findings, we recommend that individuals' anxiety and health literacy status be determined before a colonoscopy procedure to improve gastroenterology nurses' management of these patients.

Cancer Screening Abstinence Rates and Rationales Among Regular Outpatients at a Rural Hospital in Japan: A Cross-Sectional Study

Purpose

This study aimed to investigate cancer screening rates and the reasons for not undergoing screening among patients who regularly visited the Sanmu Medical Center.

Patients and Methods

This prospective observational study recruited patients aged ≥40 years with regular clinic visits to Sanmu Medical Center during October 2019. We conducted a self-administered survey to determine the patient's sex and whether they underwent cancer screening in 2019, and if not, the reason for the same. The primary outcome measure was the percentage of people who did not undergo cancer screening.

Results

A total of 198 responses (108 male respondents) were obtained. Among them, 189 were valid responses (valid response rate 94.5%). One hundred and twenty-nine patients (68.2%, 76 male) had not undergone screening. The most common reasons provided were "I have regular regular clinic visits and do not think they are necessary" (N = 65, 50.3%), "I underwent a gastroscopy within 2 years, a colorectal camera examination within a few years, and a chest radiography within a year" (42.5%), and "I have a separate complete medical checkup" (N = 15, 11.6%). Of the 65 patients who responded that their cancer screenings were unnecessary, 42 patients (64.6%) had not undergone a gastroscopy within 2 years, a colorectal camera examination within a few years, or a chest radiography or examination within a year.

Conclusion

Roughly half of the respondents who did not undergo cancer screening elected to abstain because they believed that regular hospital visits were sufficient. Encouraging patients who regularly visit medical institutions to receive cancer screening is therefore necessary.

The Effects of Virtual Reality Glasses on Vital Signs and Anxiety in Patients Undergoing Colonoscopy: A Randomized Controlled Trial

Colonoscopy is a painful procedure that causes anxiety and changes in vital signs. Pain and anxiety may cause patients to avoid colonoscopy, which is a preventive and curative healthcare service. The aim of this study was to examine the effects of virtual reality glasses on the vital signs (blood pressure, pulse, respiration, oxygen saturation, and pain) and anxiety in patients undergoing colonoscopy. The population of the study consisted of 82 patients who underwent colonoscopy without sedation between January 2, 2020, and September 28, 2020. Post-power analysis was performed with 44 patients who agreed to participate in the study, met the inclusion criteria, and were followed up for pre- and post-tests. The experimental group participants (n = 22) watched a 360° virtual reality video through virtual reality glasses whereas the control group participants (n = 22) underwent a standard procedure. Data were collected using a demographic characteristics questionnaire, the Visual Analog Scale-Anxiety, Visual Analog Scale-Pain, Satisfaction Evaluation Form, and monitoring of vital signs. The experimental group participants had significantly lower levels of pain, anxiety, systolic blood pressure, and respiratory rate and significantly higher peripheral oxygen saturation during colonoscopy than the control group participants. The majority of the experimental group participants were satisfied with the application. Virtual reality glasses have a positive effect on vital signs and anxiety during colonoscopy.

The Effect of Using a Stress Ball During Endoscopy on Pain, Anxiety, and Satisfaction: A Randomized Controlled Trial

A stress ball is a simple and effective distraction method during painful procedures. The aim of this study was to evaluate the effect of using a stress ball during endoscopy on patients' pain, anxiety, and satisfaction levels. The randomized controlled study included 60 patients who underwent endoscopy in a training and research hospital in Istanbul. Patients were randomly assigned to the stress ball group or the control group. Patients in the stress ball group ( n = 30) squeezed a stress ball during endoscopy, whereas the control group ( n = 30) received no intervention during endoscopy. Data were collected using a sociodemographic form, a postendoscopy questionnaire, the Visual Analog Scale to assess pain and satisfaction, and the State-Trait Anxiety Inventory. Pain scores did not differ significantly between the groups before ( p = .925) or during ( p = .149) the endoscopy procedure but were significantly lower in the stress ball group after the procedure ( p = .008). Similarly, preprocedure anxiety scores were comparable ( p = .743), whereas postprocedure anxiety scores were significantly lower in the stress ball group ( p < .001). The satisfaction score after endoscopy was higher in the stress ball group, but the difference was not statistically significant ( p = .166). This study suggests that use of a stress ball during endoscopy reduces patients' pain and anxiety levels.

Economic benefits of remimazolam compared to midazolam and propofol for procedural sedation in colonoscopies and bronchoscopies

BACKGROUND

Sedation is common practice in endoscopic procedures to suppress a patient's level of consciousness while maintaining the cardio-respiratory function. Midazolam and propofol are the sedatives most frequently used for procedural sedation at the hospitals in Scandinavia. Remimazolam is a new ultra-short-acting benzodiazepine sedative and the present analysis aimed at estimating the economic benefits of introducing remimazolam for procedural sedation in colonoscopies and bronchoscopies in hospitals in Scandinavia.

METHOD

We developed a cost model applying a micro-costing approach that comprised the cost components that are affected by differences in the efficacy of remimazolam, midazolam and propofol, and the model estimated the cost per successful colonoscopy and bronchoscopy when using remimazolam, midazolam or propofol as sedation. A micro-costing approach was applied, and the model consisted of six stages representing the journey for patients undergoing endoscopies and was informed primarily by data from clinical studies on remimazolam.

RESULTS

We found a total cost of DKK 1,200 per successful colonoscopy procedure when using remimazolam, a total cost of DKK 1,320 when using midazolam and a total cost of DKK 1,255 when using propofol. Hence, the incremental saving per successful colonoscopy procedure of using remimazolam was estimated to be DKK 120 compared to midazolam and DKK 55 compared to propofol. The total cost per successful bronchoscopy procedure when using remimazolam was DKK 1,353 and DKK 1,724 for midazolam, resulting in an incremental saving per bronchoscopy of DKK 372 when using remimazolam. Performed sensitivity analyses identified the time in recovery as the largest contributor to uncertainty in the analyses of remimazolam compared to midazolam in colonoscopies and bronchoscopies. In the comparison of remimazolam and propofol in colonoscopies, procedure time was the largest contributor to uncertainty.

CONCLUSION

We found that procedural sedation with remimazolam was associated with economically meaningful savings compared to procedural sedation with midazolam and propofol in colonoscopies and to midazolam in bronchoscopies.

The Effect of a Pre-Colonoscopy Education Program on Fear and Anxiety of Patients: A Randomized Clinical Trial Study

Background

Due to the increasing prevalence of intestinal diseases, colonoscopy is considered a safe and fast diagnostic and treatment method for these patients. According to studies, most patients waiting for a colonoscopy experience fear and anxiety. This study aimed to investigate the effect of a pre-colonoscopy education program on the fear and anxiety of patients undergoing colonoscopy.

Materials and Methods

This randomized clinical trial study was conducted on patients undergoing colonoscopy in hospitals in southeast Iran. A total of 90 participants were selected by convenient sampling and randomly assigned to two groups control (n = 45) and intervention (n = 45). The patients in the intervention group received nursing interventions before colonoscopy, while the patients in the control group received only routine care. The data were collected using a researcher-made fear of colonoscopy scale, its Cronbach's alpha coefficient (0.92), and the Spielberger State-Trait Anxiety Inventory. The data were analyzed with a Chi-square t-test and pair t-test.

Results

The data showed that anxiety and fear of colonoscopy in the patients in the intervention group significantly decreased compared to the patients in the control group (p < 0.001).

Conclusions

Using non-pharmacological methods before colonoscopy can reduce the fear and anxiety in patients who are candidates for this procedure and similar invasive procedures. The intervention performed in this study can be used together with other methods to control patients' fear and anxiety. Especially for nurses, It is recommended to do pre-colonoscopy education programs for these clients.

Effect of visual distraction on pain in adults undergoing colonoscopy: a meta-analysis

BACKGROUND

Pain is a contributing factor to the low compliance rate for performing a colonoscopy on screening for colorectal cancer.

PURPOSE

This meta-analysis aimed to evaluate the effect of visual distraction on adults undergoing colonoscopy.

METHODS

We searched PubMed, EMBASE, Web of Science, and Cochrane Library Database from their inception to February 2022. Randomized controlled trials comparing visual distraction with non-visual distraction were considered for inclusion. The fixed-effects and random-effects models were used to pool the data from individual studies and the Cochrane risk of bias assessment tool was used to determine the methodology quality.

RESULTS

This meta-analysis included four studies (N = 301) for pain level and total procedure time, three studies (N = 181) for satisfaction score, three studies (N = 196) for anxiety level, and four studie (N = 402) for willingness to repeat the procedure. The pooled analysis shown that significantly lower pain levels (SMD, - 0.25; 95% CI - 0.47 to - 0.02; P = 0.03), higher satisfaction score with the procedure (SMD, 0.63; 95% CI, 0.33 to 0.93; P < 0.0001), and higher willingness to repeat the procedure (OR, 2.66; 95% CI 1.70 to 4.17; P < 0.0001) in the visual distraction group than those in the non-visual distraction group, with no significant differences in total procedure time (SMD,- 0.07; 95% CI - 0.30 to 0.15; P = 0.53) or anxiety level (SMD,- 0.27; 95% CI - 0.55 to 0.01; P = 0.06).

CONCLUSIONS

Visual distraction improved the patient's pain, satisfaction, and willingness to repeat the procedure. Thus, visual stimulation is an effective way to reduce pain during colonoscopy and should be recommended.

Ketamine as the main analgesic agent during analgesia-based sedation for elective colonoscopy - A randomised, double-blind, control study

AIM

The aim of the study was to compare the analgesic effects of ketamine over fentanyl combined with propofol in analgesia-based elective colonoscopy with purpose of patient safety and satisfaction.

METHODS

This is a double-blinded prospective randomized controlled trial. Ninety patients were included and randomized to either fentanyl-propofol (Group FP, n: 30), ketamine-propofol (Group KP, n: 30) or propofol-control group (Group C, n: 30). Group FP patients received fentanyl and propofol, Group KP received ketamine and propofol and Group C, propofol. In all groups, incremental doses of propofol were used to maintain a Ramsay sedation score (RSS) of 5. Respiratory depression and hemodynamic parameters were monitored for the first minute and every 5 min during endoscopy. Fifteen minutes after the procedure, the degree of pain was assessed using a visual analog scale (VAS), the quality of recovery according to the Aldrete score (ARS), complications during and after the procedure and additional doses of propofol were recorded.

RESULTS

Mean arterial pressure (MAP) at 5 and 30 min (p < 0.05), heart rate (HR) at 15, 25 and 30 min (p < 0.05) and peripheral oxygen saturation (SpO2) at 30 min (p < 0.05) were statistically significant for Group FP. Desaturation (*p = 0.033), and weakness (*p = 0.004) was also significant for Group FP at 20, 25 and 30 min (p < 0.05). Pain was lower assessed for the Group KP according to the VAS (**p = 0.025).

CONCLUSION

In analgesia-based colonoscopy, ketamine provides appropriate analgesia and less incidence of complications compared to fentanyl.

Safety, Efficacy and High-Quality Standards of Gastrointestinal Endoscopy Procedures in Personalized Sedoanalgesia Managed by the Gastroenterologist: A Retrospective Study

Performing GI endoscopy under sedoanalgesia improves the quality-indices of the examination, in particular for cecal intubation and adenoma detection rates during colonoscopy. The implementation of procedural sedoanalgesia in GI endoscopy is also strongly recommended by the guidelines of the major international scientific societies. Nevertheless, there are regional barriers that prevent the widespread adoption of this good practice. A retrospective monocentric analytic study was performed on a cohort of 529 patients who underwent EGDS/Colonoscopy in sedoanalgesia, with personalized dosage of Fentanyl and Midazolam. ASA class, age and weight were collected for each patient. The vital parameters were recorded during, pre- and post-procedure. The rates of cecal intubation and of procedure-related complications were entered. The VAS scale was used to evaluate the efficacy of sedoanalgesia, and the Aldrete score was used for patient discharge criteria. No clinically significant differences were found between vital signs pre- and post-procedure. Both anesthesia and endoscopic-related complications occurring were few and successfully managed. At the end of examination, both the mean Aldrete score (89.56), and the VAS score (<4 in 99.1%) were suitable for discharge. For the colonoscopies, the cumulative adenoma detection rate (25%) and the cecal intubation rate in the general group (98%) and in the colorectal cancer screening group (100%) were satisfying. Pain control management is an ethical and medical issue aimed at increasing both patient compliance and the quality of the procedures. The findings of this work underscore that in selected patients personalized sedoanalgesia in GI endoscopy can be safely managed by gastroenterologists.

The effectiveness of high-flow nasal cannula during sedated digestive endoscopy: a systematic review and meta-analysis

BACKGROUND

Studies evaluating the role of high-flow nasal cannula (HFNC) in sedated digestive endoscopy have reported conflicting results. This meta-analysis evaluates the effectiveness of HFNC in patients undergoing digestive endoscopy procedures under sedation.

METHODS

PubMed, Medline, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science, were searched from inception to 31 July 2021. Only randomized clinical trials comparing HFNC with standard nasal cannula oxygen (SNC) during sedated digestive endoscopy were included. The incidence of hypoxemia was the primary outcome, and the secondary outcome was the percentage of patients who needed airway interventions.

RESULTS

Seven studies that enrolled 2998 patients were included. When compared to SNC, HFNC was associated with a significant reduction in hypoxemia incidence (OR 0.24, 95% CI 0.09 to 0.64) and airway intervention requirements (OR 0.15, 95% CI 0.03 to 0.69), with both high heterogeneity (I² = 81% and 94%). In subgroup analysis, when hypoxemia was defined as pulse oxygen saturation (SpO₂) < 90%, low risk of hypoxemia subjects who received HFNC were associated with a significant reduction in hypoxemia incidence (OR 0.02, 95% CI 0.00 to 0.07; heterogeneity I² = 39%) and airway intervention requirements (OR 0.02, 95% CI 0.01 to 0.04; heterogeneity I² = 15%). However, in the high risk of hypoxemia subjects, there were no significant differences between the two oxygen administration techniques in both primary (OR 0.81, 95% CI 0.36 to 1.78; heterogeneity I² = 0%) and secondary outcomes (OR 0.85, 95% CI 0.46 to 1.59; heterogeneity I² = 0%).

CONCLUSIONS

Compared to SNC, HFNC not only reduce the incidence of hypoxemia but also reduce the requirements for airway interventions during sedated digestive endoscopy procedures, especially in patients at low risk for hypoxemia. In high risk of hypoxemia patients, there were no significant differences between the two oxygen administration techniques. Trial registration PROSPERO International prospective register of systematic reviews on 28 July 2021, registration no. CRD42021264556.

Do difficulties in emotional processing predict procedure pain and shape the patient's colonoscopy experience?

OBJECTIVES

Pain and fear of colonoscopy are inter-related; they make the colonoscopy experience unpleasant and impede adherence to colorectal cancer screening and prevention campaigns. According to previous research, fear and pain have been found to depend on patients' maladaptive cognitions and exaggerated emotional responses. The present study investigated whether emotional processing difficulties predicted colonoscopy pain and the associated catastrophising thoughts.

DESIGN

Prospective, observational, blinded.

METHOD

A sample of 123 patients was assessed for specific emotional processing difficulties (ie, suppression of emotions, unprocessed emotions, failure to control emotions, avoidance of emotional triggers and impoverished emotional experience) and anxiety-related variables (ie, worry, anxiety and depression) before colonoscopy. A trained medical doctor rated patients' behavioural manifestations of pain during colonoscopy. After complete recovery from sedation, the patients rated the endoscopy experience using perceived pain and situation-specific pain catastrophising scales.

RESULTS

About half of the patients were above the cut-off for anxiety before the procedure. Notwithstanding sedation, behavioural manifestations of pain during colonoscopy indicated probable or moderate pain for about one-third of the patients. Failure to control emotions, poor emotional experience and avoiding emotional triggers were positively correlated with behavioural manifestations of pain, self-reported pain and pain catastrophising. Regression analyses, controlling for gender, age, colonoscopy experience and sedation, revealed that avoidance of emotional triggers uniquely contributed to predicting pain outcomes.

CONCLUSIONS

Early identification of emotional processing difficulties associated with pain catastrophising can help define personalised psychological preparation paths to manage negative emotions in patients who fear colonoscopy pain.

Comparing the Efficacy and Safety of Dexmedetomidine/Ketamine with Propofol/Fentanyl for Sedation in Colonoscopy Patients: A Doubleblinded Randomized Clinical Trial

BACKGROUND

In this double-blinded randomized clinical trial, we aimed to compare the safety and efficacy of a combination of Dexmedetomidine and Ketamine (DK) with Propofol and Fentanyl (PF) for sedation in colonoscopy patients.

METHODS

In this study, 64 patients who underwent colonoscopy were randomized into two groups: 1) A, which received PF, and 2) B, which received DK for sedation. Among 64 patients, 31 patients were included in PF, and 33 patients were included in the DK group. Both groups were similar in terms of demographics. Patients' sedation score (based on Ramsay sedation scale) and vital signs were recorded at 2, 5, 10, and 15 minutes. Complications including apnea, hypotension, hypoxia, nausea, and vomiting, along with gastroenterologist satisfaction and patients' pain score (based on Wong-Baker faces pain assessment scale), were recorded by a checklist. Data were analyzed by SPSS v.18 software, using chi-square, independent t-tests, and repeated measures analysis with p<0.05 as the criterion for significant differences.

RESULTS

The mean score of sedation was 4.82±0.49 in the DK group and 5.22±0.45 in the PF group (p value=0.001). Serious complications, including hypotension (p value=0.005) and apnea (p value=0.10) were significantly higher in the PF group. Satisfaction of gastroenterologist (p value= 0.400) and patients' pain score (p value = 0.900) were similar among groups.

CONCLUSION

Combination of DK provides sufficient sedation with fewer complications in comparison with PF in colonoscopy patients.

Psychological interventions for reducing anxiety in patients undergoing first-time colonoscopy: a pilot and feasibility study

OBJECTIVES

To assess the feasibility of a randomized controlled trial (RCT), evaluating the efficacy and patients' perceptions of a psychological intervention aimed at reducing anxiety levels in adults undergoing first-time colonoscopy.

METHODS

Adults undergoing first-time colonoscopy were randomized to a psychological intervention vs. sham intervention. The primary outcome was feasibility, defined as a recruitment rate of >50%. Patients' state anxiety was assessed before and after the intervention using the state-trait inventory for cognitive and somatic anxiety (STICSA) score. Follow-up interviews were performed within 1 week with a sample of patients and focus groups with clinical staff.

RESULTS

A total of 130 patients were recruited from 180 eligible patients (72%). Eighty were randomized and completed the study (n = 39) in the psychological intervention group and (n = 41) in the sham. In the psychological intervention group, pre- and postmedian STICSA scores were 29 and 24 (P < 0.001), respectively. In the sham group, pre- and postmedian scores were 31 and 25 (P < 0.001), respectively. Follow-up interviews with patients (n = 13) suggested that 100% of patients perceived the psychological intervention as beneficial and would recommend it to others.

CONCLUSION

The study was feasible. Patients in both groups improved their anxiety scores, but there were no significant differences between arms. Despite this, patients receiving psychological intervention perceived a benefit from the relaxation exercises.

The Structure of the Emotional Processing Scale (EPS-25)

Abstract. The Emotional Processing Scale (EPS) assesses emotional processing in terms of suppression, signs of unprocessed emotion, controllability of emotions, avoidance of emotional triggers, and impoverished emotional experience. Previous confirmatory factor analyses (CFA) yielded insufficient fit and questioned the EPS factors’ discriminant validity. The present study aimed to test unidimensional, five-factor, and bifactor models using exploratory structural equation modeling (ESEM) and CFA. We administered the scale to 350 Italian participants in good health and 346 gastrointestinal patients referred for endoscopy because of mild-to-severe gastrointestinal symptoms. ESEM models outperformed corresponding CFA models. The bifactor ESEM model was a good fit in single group analyses and achieved metric and scalar invariance in multigroup analyses. The inspection of latent mean differences revealed a consistent trend for patients to avoid emotional triggers and have less general emotional processing difficulties. The study clarified the EPS factor structure and supported its use to assess the emotional processing of medical patients and community participants.

The effectiveness of using an abdominal binder during colonoscopy: a randomized, double-blind, sham-controlled trial

BACKGROUND

Prolongation of cecal intubation time (CIT) directly affects the comfort of the patient and the colonoscopist. In this study, the effectiveness of using an abdominal binder (AB) during colonoscopy on procedure time and colonoscopy outcomes was investigated.

METHODS

We conducted a parallel randomized double-blind sham-device-controlled study of patients who underwent elective outpatient colonoscopy between 1 May 2020, and 31 August 2020. Participants were randomly assigned to AB (n = 173) and sham binder (SB) (n = 173) groups. The primary outcome was CIT. Secondary outcomes were the need for auxiliary maneuvers, the cecum intubation length (CIL) of the colonoscope, visual analog scale (VAS) score, narcotic analgesic dose, and colonoscopy results. Moreover, subgroup analysis was performed in terms of age and obesity indices.

RESULTS

A total of 346 patients were enrolled in the study. The mean CIT was similar between groups (AB group 240 secs, control group 250 secs, p > .05). Manual pressure requirement was less in the AB group (27 vs. 36%, p = .069). VAS score and the need for extra narcotic analgesic drugs were prominently lower in the AB group (p < .001, p = .016, respectively). In the subgroup analyses, in participants at the age of <60 and waist-to-height ratio (WHtR) ≥0.5, manual pressure requirements were significantly shorter in the AB group (p = .017, p = .032, respectively).

CONCLUSION

AB use in selected patients may be advantageous during colonoscopy because it reduces the need for analgesics and post-procedure pain, and reduces the need for auxiliary maneuvers in relatively young and obese patients.

The Effect of Music Listening on Pain in Adults Undergoing Colonoscopy: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the role of music listening in reducing pain in adults undergoing colonoscopy.

DESIGN

This is a systematic review and meta-analysis of randomized control trials (RCTs) that evaluated the effect of music in reducing pain in adults undergoing colonoscopy.

METHODS

We searched CINAHL, Embase, MEDLINE, PsycINFO, and PubMed for RCTs that reported on the effects of music listening in reducing pain in adult patients undergoing colonoscopy from database inception to March 15, 2020, when the search was completed. Studies published in English with adult participants testing the efficacy of music during colonoscopy were eligible for inclusion. Studies reporting the results of combined nonpharmacological interventions were excluded. The methodological quality of each included RCT was assessed using the Cochrane Collaboration tool for assessing the risk of bias. Two authors independently abstracted data and assessed risks of bias.

FINDINGS

Seven RCTs with a total of 622 adult participants fulfilled our inclusion criteria and were, therefore, included. A random-effects model estimated the summary effect of the 7 included studies as -1.83 ± 0.98, P = 0.06.

CONCLUSIONS

Although our meta-analysis demonstrated a small treatment effect, this effect was clinically not statistically significant. Substantial heterogeneity among the included trials limits the certainty of our findings. Additional trials investigating the effects of listening to music on pain in adults undergoing colonoscopy are needed to generate further evidence to establish the analgesic effect of music in adults undergoing 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.

Evaluation of an Objective Measurement Tool for Stress Level Reduction by Individually Chosen Music During Colonoscopy-Results From the Study "ColoRelaxTone"

Background and Aims: Colonoscopy as standard procedure in endoscopy is often perceived as uncomfortable for patients. Patient's anxiety is therefore a significant issue, which often lead to avoidance of participation of relevant examinations as CRC-screening. Non-pharmacological anxiety management interventions such as music might contribute to relaxation in the phase prior and during endoscopy. Although music's anxiolytic effects have been reported previously, no objective measurement of stress level reduction has been reported yet. Focus of this study was to evaluate the objective measurement of the state of relaxation in patients undergoing colonoscopy.

Methods: Prospective study (n = 196) performed at one endoscopic high-volume center. Standard colonoscopy was performed in control group. Interventional group received additionally self-chosen music over earphones. Facial Electromyography (fEMG) activity was obtained. Clinician Satisfaction with Sedation Instrument (CSSI) and Patients Satisfaction with Sedation Instrument (PSSI) was answered by colonoscopists and patients, respectively. Overall satisfaction with music accompanied colonoscopy was obtained if applicable.

Results: Mean difference measured by fEMG via musculus zygomaticus major indicated a significantly lower stress level in the music group [7.700(±5.560) μV vs. 4.820(±3.330) μV; p = 0.001]. Clinician satisfaction was significantly higher with patients listening to music [82.69(±15.04) vs. 87.3(±15.02) pts.; p = 0.001]. Patient's satisfaction was higher but did not differ significantly.

Conclusions: We conclude that self-chosen music contributes objectively to a reduced stress level for patients and therefore subjectively perceived satisfaction for endoscopists. Therefore, music should be considered as a non-pharmacological treatment method of distress reduction especially in the beginning of endoscopic procedures.

Robotic-Assisted Colonoscopy Platform with a Magnetically-Actuated Soft-Tethered Capsule

Background and Aims: Colorectal cancer (CRC) is a major cause of morbidity and mortality worldwide. Despite offering a prime paradigm for screening, CRC screening is often hampered by invasiveness. Endoo is a potentially painless colonoscopy method with an active locomotion tethered capsule offering diagnostic and therapeutic capabilities. Materials and Methods: The Endoo system comprises a soft-tethered capsule, which embeds a permanent magnet controlled by an external robot equipped with a second permanent magnet. Capsule navigation is achieved via closed-loop interaction between the two magnets. Ex-vivo tests were conducted by endoscopy experts and trainees to evaluate the basic key features, usability, and compliance in comparison with conventional colonoscopy (CC) in feasibility and pilot studies. Results: Endoo showed a 100% success rate in operating channel and target approach tests. Progression of the capsule was feasible and repeatable. The magnetic link was lost an average of 1.28 times per complete procedure but was restored in 100% of cases. The peak value of interaction forces was higher in the CC group than the Endoo group (4.12N vs. 1.17N). The cumulative interaction forces over time were higher in the CC group than the Endoo group between the splenic flexure and mid-transverse colon (16.53Ns vs. 1.67Ns, p < 0.001), as well as between the hepatic flexure and cecum (28.77Ns vs. 2.47Ns, p = 0.005). The polyp detection rates were comparable between groups (9.1 ± 0.9% vs. 8.7 ± 0.9%, CC and Endoo respectively, per procedure). Robotic colonoscopies were completed in 67% of the procedures performed with Endoo (53% experts and 100% trainees). Conclusions: Endoo allows smoother navigation than CC and possesses comparable features. Although further research is needed, magnetic capsule colonoscopy demonstrated promising results compared to CC.

Frontiers of Robotic Colonoscopy: A Comprehensive Review of Robotic Colonoscopes and Technologies

Flexible colonoscopy remains the prime mean of screening for colorectal cancer (CRC) and the gold standard of all population-based screening pathways around the world. Almost 60% of CRC deaths could be prevented with screening. However, colonoscopy attendance rates are affected by discomfort, fear of pain and embarrassment or loss of control during the procedure. Moreover, the emergence and global thread of new communicable diseases might seriously affect the functioning of contemporary centres performing gastrointestinal endoscopy. Innovative solutions are needed: artificial intelligence (AI) and physical robotics will drastically contribute for the future of the healthcare services. The translation of robotic technologies from traditional surgery to minimally invasive endoscopic interventions is an emerging field, mainly challenged by the tough requirements for miniaturization. Pioneering approaches for robotic colonoscopy have been reported in the nineties, with the appearance of inchworm-like devices. Since then, robotic colonoscopes with assistive functionalities have become commercially available. Research prototypes promise enhanced accessibility and flexibility for future therapeutic interventions, even via autonomous or robotic-assisted agents, such as robotic capsules. Furthermore, the pairing of such endoscopic systems with AI-enabled image analysis and recognition methods promises enhanced diagnostic yield. By assembling a multidisciplinary team of engineers and endoscopists, the paper aims to provide a contemporary and highly-pictorial critical review for robotic colonoscopes, hence providing clinicians and researchers with a glimpse of the major changes and challenges that lie ahead.

Procedural Anxiety, Pain Catastrophizing, and Procedure-Related Pain during EGD and Colonoscopy

OBJECTIVES

Although sedatives and analgesic drugs defuse anxiety and relieve pain, digestive endoscopy still is uncomfortable and painful for some patients. Identifying patients who tolerate digestive endoscopy less well remains difficult. The present study evaluated the relations between procedural anxiety, catastrophizing thoughts, and pain, using a prospective design and multimodal assessments of pain.

METHODS

A total of 118 consecutive patients were assessed for procedural anxiety before endoscopy. During endoscopy, a doctor rated the patients' pain behavior. Before discharge, the patients retrospectively rated endoscopy pain and related catastrophizing thoughts.

RESULTS

Notwithstanding sedation, our study revealed large between-subject variability in pain. Catastrophizing thoughts mediated the relation between procedure-related pain observed by the doctor and pain intensity reported by the patient. Catastrophizing thoughts also mediated the effect of procedural anxiety. Our study showed that anxiety exacerbates endoscopy pain when the patient engages in ruminative thinking and feels unable to cope with unpleasant bodily sensations.

CONCLUSIONS

This study shows that catastrophizing thoughts account for between-subject differences in endoscopy pain. Rumination and helplessness but not magnification explain how procedural anxiety may evolve in a painful endoscopy experience. To the extent that one can address catastrophizing thoughts, endoscopy pain can be mitigated, especially for patients who are difficult to sedate.

Factors Associated With Adenoma Detection in Propofol-sedated Patients

GOALS

To assess the factors associated with adenoma detection in propofol-sedated patients.

BACKGROUNDS

Low adenoma detection rate (ADR) are linked to increased risk of interval cancer and related deaths. Compared with air insufflation (AI) colonoscopy, the method of water exchange (WE) significantly decreased insertion pain and increased ADR in unsedated patients. Deep sedation with propofol has been increasingly used in colonoscopy. One report suggested that WE significantly increased ADR in propofol-sedated patients, but the factors associated with adenoma detection were not analyzed.

STUDY

Post hoc multiple logistic regression analyses were performed based on pooled data from 2 randomized controlled trials to assess the factors associated with adenoma detection in propofol-sedated patients.

RESULTS

Propofol-sedated patients (n=510) were randomized to AI and WE. The baseline characteristics were comparable. Multiple logistic regression analyses show that age, withdrawal time, indications (screening vs. diagnostic), and WE were significantly and independently associated with higher ADR. WE had fewer patients with inadequate Boston Bowel Preparation Scale score of <6. Despite a significantly shorter inspection time, WE had significantly higher overall ADR than AI, especially in those with adequate Boston Bowel Preparation Scale of ≥6. Right colon ADR (17.5% vs. 10.5%), flat ADR (32.3% vs. 19.4%), combined advanced and sessile serrated ADR (13.1% vs. 7.4%) of WE were significantly higher than those of AI.

CONCLUSIONS

WE enhanced quality of colonoscopy in propofol-sedated patients by significantly improving colon cleanliness and overall ADR. Colonoscopists with patients under propofol sedation might consider evaluating WE method for performance improvement.

High-Flow Nasal Cannula and Mandibular Advancement Bite Block Decrease Hypoxic Events during Sedative Esophagogastroduodenoscopy: A Randomized Clinical Trial

During sedated endoscopic examinations, upper airway obstruction occurs. Nasal breathing often shifts to oral breathing during open mouth esophagogastroduodenoscopy (EGD). High-flow nasal cannula (HFNC) which delivers humidified 100% oxygen at 30 L min⁻¹ may prevent hypoxemia. A mandibular advancement (MA) bite block with oxygen inlet directed to both mouth and nose may prevent airway obstruction during sedated EGD. The purpose of this study was to evaluate the efficacy of these airway devices versus standard management. One hundred and eighty-nine patients were assessed for eligibility. One hundred and fifty-three were enrolled. This study randomly assigned eligible patients to three arms: the standard bite block and standard nasal cannula, HFNC, and MA bite block groups. EGD was performed after anaesthetic induction. The primary endpoint was the oxygen desaturation area under curve at 90% (AUC_Desat). The secondary endpoints were percentage of patients with hypoxic, upper airway obstruction, and apnoeic and rescue events. One hundred and fifty-three patients were enrolled. AUCdesat was significantly lower for HFNC and MA bite blocks versus the standard management (p= 0.019). The HFNC reduced hypoxic events by 18% despite similar airway obstruction and apnoeic events as standard group. The MA bite block reduced hypoxic events by 12% and airway obstructions by 32%. The HFNC and MA groups both showed a 16% and 14% reduction in the number of patients who received rescue intervention, respectively, compared to the standard group. The HFNC and MA bite block may both reduce degree and duration of hypoxemia. HFNC may decrease hypoxemic events while maintaining nasal patency is crucial during sedative EGD. The MA bite block may prevent airway obstruction and decrease the need for rescue intervention.

Effects of easy listening music intervention on satisfaction, anxiety, and pain in patients undergoing colonoscopy: a pilot randomized controlled trial

Purpose: The purpose of this study was to examine the effects of an easy listening music intervention on satisfaction, anxiety, pain, sedative and analgesic medication requirements, and physiological parameters in Chinese adult patients undergoing colonoscopy in Hong Kong. Patients and methods: Patients undergoing colonoscopy, aged 45 or older, able to communicate in Chinese, and hemodynamically stable were invited for the study. A randomized controlled trial was adopted. Eligible patients were randomly assigned either to a music group, which received standard care and additional easy listening music (a series of 15 popular non-rock Chinese songs) through earphones and MP3 for 20 mins before and during the procedure, or to a control group which received standard care only. Standard care comprised of all nursing and medical care provided for patients undergoing colonoscopy. Measures comprised of the State-Trait Anxiety Inventory, visual analog scales of pain level, procedure satisfaction and satisfaction with pain management, the use of sedative and analgesic drugs, heart rate, and blood pressure data were collected at baseline (T0), during (T1) and 30 mins after the procedure (T2). Results: Eighty participants (40 music vs 40 control) completed the study with no attrition. Participants in the music group reported significantly higher levels in both procedure satisfaction (p=0.043) and satisfaction with pain management (p=0.045) than those in the control group. No significant difference was found between groups on anxiety, pain, additional sedative and analgesic use, heart rate, and systolic and diastolic blood pressure (p>0.05). Nevertheless, most participants appreciated the songs provided in MP3 and found it helpful for relaxation during the procedure and would prefer it again (p<0.001). Conclusion: Easy music listening can enhance patients' satisfaction in both procedure and pain management for adults undergoing a colonoscopy procedure.

Intolerance of Uncertainty and Anxiety-Related Dispositions Predict Pain During Upper Endoscopy

Although sedatives can defuse anxiety and relieve pain, Esophagogastroduodenoscopy (EGD) still is uncomfortable and threatening for some patients. Identifying patients who tolerate digestive endoscopy less well remains difficult. Using a prospective design and a multimodal assessment of pain, the present study evaluated how anxiety-related variables predicted subsequent pain outcomes. Sixty-two consecutive patients referred for elective EGD were assessed for intolerance of uncertainty (IU), procedure-related worries, anxiety sensitivity and health distress before endoscopy. During endoscopy, a doctor rated patients’ pain behavior. After complete recovery from sedation, the patients retrospectively rated endoscopy pain and situation specific catastrophizing thoughts. Descriptive analyses showed that patients undergoing EGD for the first time were more distressed and anxious than patients accustomed to the procedure and needed a higher sedative dose. Notwithstanding sedation, the behavioral rating of pain was above the cut-off value for probable pain for more than half of the patients. IU assessed before endoscopy predicted situational pain catastrophizing (PC) and self-reported pain after endoscopy through procedure related worries. Situational PC not only mediated the effect of worry, but also female gender and younger age were associated with self-reported pain through increased catastrophizing thoughts. Health distress and anxiety sensitivity predicted PC only for women, younger patients, and those not accustomed to the procedure. Our study showed that psychological preparation before sedation is needed especially for first-timers, women, and younger patients, addressing maladaptive cognitive beliefs and acquainting patients with the somatic sensations that they might experience during the procedure.

Treating the patient not the symptoms: Acupuncture to improve overall health - Evidence, acceptance and strategies

Documented mechanisms of acupuncture suggest the possibility of whole body effects in addition to local and regional effects. Traditional theories of acupuncture predict whole body effects. Does this permit the possibility of applying treatment to target overall health improvement of the patient rather than the symptom? After introducing the term 'health improvement' this paper explores situations where it might be advantageous to do this, giving examples of how health authorities in some countries have proposed broader treatment approaches that focus on health improvement. It also discusses cases where acupuncture has been recommended as a treatment method in a number of these proposals and gives some clinical examples of this kind of whole body 'health improvement' targeted treatment effects. Given that health authorities have already recognised this potential for the application of acupuncture the author then explores evidence of more whole-body 'health improvement' effects from systematic reviews and examples of health experts recommending acupuncture to take advantage of them. Research strategies and foci are then proposed and explored to develop this evidence. What are the best treatment approaches to create these effects? By what mechanisms can 'health improvement' be produced? How can one measure these effects? It is likely that treatments based on 'pattern identification' (PI) may provide the best strategies for producing 'health improvement', thus PI-based acupuncture treatments are likely to be the best strategy for clinical research investigating these effects.

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.

Serbian Translation and Cross-Cultural Validation of the Questionnaire for Assessing Patient Satisfaction with Endoscopic Examination of the Digestive Tract

Patient satisfaction is a key indicator to assess the quality of gastrointestinal endoscopy. The aim of this study was to examine the Serbian translation and cross-cultural validation of the questionnaire for the assessment of satisfaction in patients who underwent gastrointestinal endoscopy.

After obtaining the consent of the author of the original questionnaire, translation and cross-cultural validation of the GESQ (Gastrointestinal Endoscopy Satisfaction Questionnaire) were carried out in accordance with the conductors of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). The study was conducted in the Center for Gastroenterohepatology (GEH) of the Kragujevac Clinical Center and included 165 patients. The reliability of the Serbian translation of the GESQ was estimated by calculating Cronbach’s alpha for the whole questionnaire in order to implement the structural validation. The overall score of the questionnaire was compared and correlated with the total scores on the Short Subjective Well-being scale (KSB) and visual analogue scale (VAS), which were administered to the same patients.

The Serbian translation of the GESQ showed high reliability with a Cronbach’s alpha coefficient of 0.763, good structure and homogeneity by randomly sharing the questionnaire into two parts. Exploratory factor analysis indicated the existence of four factors that explain 57.200% of the variability.

The Serbian version of the GESQ showed similar psychometric characteristics to the original English questionnaire, with a similar factor structure, and represented a valid, reliable and acceptable tool for the assessment of patient satisfaction with the endoscopic examination of the digestive tract.

Combination of serum lipids and cancer antigens as a novel marker for colon cancer diagnosis

Background

Colon cancer is a malignancy of the large intestine with high mortality and economic burden. Recent studies reveal a new relationship between blood lipids and the risk of cancer. The presents study aims to investigate the combination of serum lipids with cancer antigens as a novel diagnostic marker for colon cancer.

Methods

Two hundred of colon cancer patients or healthy subjects were recruited. Serum lipids and cancer antigens such as total cholesterol (TC), high-density lipoprotein (HDL), carcinoembryonic antigen (CEA) and carbohydrate antigen 19–9 (CA19–9) were measured.

Results

There were significantly lower level of serum TC or HDL, and significantly higher level of serum CEA or CA19–9 in patients than in healthy subjects. Serum TC or HDL in patients with advanced colon cancer was significantly lower than the ones with early stage disease. The level of serum TC or HDL in patients after surgical removal of colon cancer was significantly higher compared to the ones before surgery, but serum CEA or CA19–9 after surgery was significantly reduced in comparison with the ones before surgery. Combined TC, HDL, CEA and CA19–9 as a diagnostic marker for colon cancer had the highest positive predictive rate in comparison with individual, two or three of the parameters.

Conclusions

The combination of serum TC, HDL, CEA and CA19–9 can be used as an effective marker for colon cancer, and offers a novel strategy for clinical diagnosis and monitoring the disease.

Efficacy and safety of using premedication with simethicone/Pronase during upper gastrointestinal endoscopy examination with sedation: A single center, prospective, single blinded, randomized controlled trial

BACKGROUND AND AIM

To investigate the efficacy and safety of premedication with simethicone/Pronase during esophagogastroduodenoscopy (EGD) with sedation.

METHODS

Six hundred and ten patients were randomly allocated to two groups based on type of premedication given. Premedication used in the control group was 10 mL lidocaine hydrochloride mucilage (LHM, N = 314) and premedication used in the intervention group was 80 mL simethicone/Pronase solution plus 10 mL lidocaine hydrochloride mucilage (SP/LHM, N = 296). EGD was done under sedation. Visibility scores, number of mucosal areas that needed cleansing, water consumption for cleansing, time taken for examination, diminutive lesions, pathological diagnosis, patients' gag reflex and oxygenation (pulse oximetry) were recorded.

RESULTS

SP/LHM has significantly lower total visibility score than LHM (7.978 ± 1.526 vs 6.348 ± 1.097, P < 0.01). During the procedure, number of intragastric areas that needed cleansing and amount of water consumed were significantly less in the SP/LHM than in the LHM group (P < 0.01). In SP/LHM (P = 0.01), endoscopy procedure duration was significantly longer. Although there was no significant difference in rate of detection of diminutive lesions between LHM and SP/LHM, the endoscopist carried out more biopsies in SP/LHM. This led to a higher rate of diagnosis of atrophic gastritis (P = 0.014) and intestinal metaplasia (P = 0.024). There was no significant difference in gag reflex (P = 0.604) and oxygenation during the endoscopy procedure for either group of patients.

CONCLUSION

Routine use of premedication with simethicone/Pronase should be recommended during EGD with sedation.

Can Water Exchange Improve Patient Tolerance in Unsedated Colonoscopy A Prospective Comparative Study

Background & Aims

Unsedated colonoscopy can be painful, poorly tolerated by patients, and associated with unsatisfactory technical performance. Previous studies report an advantage of water exchange over conventional air insufflation in reducing pain during unsedated colonoscopy. Our goal was to analyze the impact of water exchange colonoscopy on the level of maximum pain reported by patients submitted to unsedated colonoscopy, compared to conventional air insufflation.

Methods

We performed a single-center, patient-blinded, prospective randomized comparative study, where patients were either allocated to the water group, in which the method of colonoscopy used was water exchange, or the standard air group, in which the examination was accomplished with air insufflation.

Results

A total of 141 patients were randomized, 70 to the water and 71 to the air group. The maximum level of pain reported by patients during unsedated colonoscopy, measured by a numeric scale of pain (0-10), was significantly lower in the water group (3.39 ± 2.32), compared to the air group (4.94 ± 2.10), p < 0.001. The rate of painless colonoscopy was significantly higher in the water group (12.9 vs. 1.4%, p = 0.009). There were no significant differences between the two groups regarding indications for the procedure, quality of bowel preparation, cecal intubation time, withdrawal time, number of position changes, adenoma detection rate, and postprocedural complications. Only the number of abdominal compressions was significantly different, showing that water exchange decreases the number of compressions needed during colonoscopy.

Conclusions

Water exchange was a safe and equally effective alternative to conventional unsedated colonoscopy, associated with less intraprocedural pain without impairing key performance measures.

The Effect of Psychological Preparation on the Level of Anxiety before Upper Gastrointestinal Endoscopy

INTRODUCTION

Anxiety is one of the problems in patients undergoing invasive procedures. One way to control anxiety is through psychological preparation.

AIM

This study was aimed to evaluate the effect of psychological preparation on anxiety level in patients undergoing upper gastrointestinal endoscopy.

MATERIALS AND METHODS

The present study consisted of 98 patients which were referred to Ahvaz Golestan Hospital for upper gastrointestinal endoscopy. They were randomly (table of random numbers) divided into a control group and an experimental group. All of the participants filled out Spielberg State-Trait Anxiety Inventory (STAI). The experimental group was psychologically prepared for endoscopy (given information about endoscopy and behavioural intervention), and then both groups were asked to complete STAI again an hour before endoscopy. The collected data were analysed through Mann-Whitney, Kruskal-Wallis, and Chi-square tests using SPSS 17.0.

RESULTS

Before the intervention was carried out, there was no significant difference between the two groups in terms of the rate of state and trait anxiety (p>0.05). After the intervention, the rate of state and trait anxiety decreased significantly (p<0.05) in experimental group.

CONCLUSION

In patients subjected to endoscopy, psychological preparation was effective in reducing their anxiety and thus this can be considered as an efficient method in decreasing anxiety.

Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures

BACKGROUND AND AIMS

Sedation for GI endoscopy directed by anesthesia professionals (ADS) is used with the intention of improving throughput and patient satisfaction. However, data on its safety are sparse because of the lack of adequately powered, randomized controlled trials comparing it with endoscopist-directed sedation (EDS). This study was intended to determine whether ADS provides a safety advantage when compared with EDS for EGD and colonoscopy.

METHODS

This retrospective, nonrandomized, observational cohort study used the Clinical Outcomes Research Initiative National Endoscopic Database, a network of 84 sites in the United States composed of academic, community, health maintenance organization, military, and Veterans Affairs practices. Serious adverse events (SAEs) were defined as any event requiring administration of cardiopulmonary resuscitation, hospital or emergency department admission, administration of rescue/reversal medication, emergency surgery, procedure termination because of an adverse event, intraprocedural adverse events requiring intervention, or blood transfusion.

RESULTS

There were 1,388,235 patients in this study that included 880,182 colonoscopy procedures (21% ADS) and 508,053 EGD procedures (23% ADS) between 2002 and 2013. When compared with EDS, the propensity-adjusted SAE risk for patients receiving ADS was similar for colonoscopy (OR, .93; 95% CI, .82-1.06) but higher for EGD (OR, 1.33; 95% CI, 1.18-1.50). Additionally, with further stratification by American Society of Anesthesiologists (ASA) class, the use of ADS was associated with a higher SAE risk for ASA I/II and ASA III subjects undergoing EGD and showed no difference for either group undergoing colonoscopy. The sample size was not sufficient to make a conclusion regarding ASA IV/V patients.

CONCLUSIONS

Within the confines of the SAE definitions used, use of anesthesia professionals does not appear to bring a safety benefit to patients receiving colonoscopy and is associated with an increased SAE risk for ASA I, II, and III patients undergoing EGD.