Patient factors predictive of pain and difficulty during sedation-free colonoscopy: A prospective study in Korea

BACKGROUND: Successful colonoscopy depends on insertion of the instrument to the cecum, precise observation, and minimal patient discomfort during the procedure. This prospective study was designed to identify factors, apart from the endoscopist's skill, that predict patient pain and technical difficulty during sedation-free colonoscopy. METHODS: A total of 426 sedation-free colonoscopies performed by one experienced endoscopist were evaluated in a prospective manner. Factors were recorded, including patient pain level, intubation time, demographic data, history of abdominal surgery, bowel preparation status, diverticular disease, bowel habits, anxiety level, and number of previous colonoscopies. These factors were analysed to determine their association with difficulty and pain during the procedure. RESULTS: Four hundred six colonoscopies were completed to the cecum (95.3%). Mean insertion time for complete colonoscopy was 6.5+/-3.5 min. Multivariate logistic regression analyses revealed that older age, lower body mass index, previous hysterectomy, diarrhoea, 1st time colonoscopy and anxiety were predictors of patient pain. Older age, lower body mass index and previous hysterectomy were predictors of difficulty of intubation. CONCLUSIONS: This prospective study identified several factors that may predict patient pain and technical difficulty associated with the procedure. These findings have implications for the practice and teaching of colonoscopy.     

Prospective Evaluation of Factors Predicting Difficulty and Pain During Sedation-Free Colonoscopy

PURPOSE Colonoscopy can be painful for patients and difficult for colonoscopists; however, it is hard to predict how painful or difficult the examination will be. This study was designed to identify factors that predict pain and difficulty during sedation-free colonoscopy.METHODS A total of 848 consecutive sedation-free colonoscopies were evaluated in a prospective manner. Factors were recorded, including patient pain, intubation time, demographic data, history of abdominal surgery, bowel preparation status, diverticular disease, bowel habits, anxiety level, and number of previous colonoscopies. These factors were analyzed to determine their association with pain and difficulty.RESULTS Almost all colonoscopies (845/848; 99.6 percent) were successful. Univariate analyses showed that lower body mass index, younger age, female gender, anxiety level, first time, intubation time, preparation status, previous hysterectomy, and previous gynecologic surgery were predictors of patient pain, and lower body mass index, female gender, anxiety level, preparation status, previous hysterectomy, previous gynecologic surgery, and constipation were predictors of difficulty of intubation. Multivariate logistic regression analyses revealed that lower body mass index, younger age, intubation time, preparation status, previous hysterectomy, and antispasmodic agent use were predictors of patient pain, and lower body mass index, female gender, constipation, preparation status, and previous hysterectomy were predictors of difficulty of intubation.CONCLUSIONS By use of intubation time and patient pain, several patient characteristics were identified that may predict technical difficulty and pain associated with the procedure. These findings have implications for the practice and teaching of colonoscopy.     

Colonoscopy without sedation

PURPOSE AND METHODS: Two hundred fifty-eight consecutive nonsedated colonoscopies were prospectively evaluated over an 18-month period. The cecum was intubated in 250 cases (97 percent). Polypectomies or biopsies were performed in 77 cases (31 percent). Indications for colonoscopy included history of polyps (32 percent), hematochezia (28 percent), family history of colon cancer (16 percent), prior history of colon cancer (9 percent), change in bowel habits (12 percent), abnormal flexible sigmoidoscopy (6 percent), and inflammatory bowel disease (3 percent). RESULTS: Sedation was withheld for the following reasons: patient preference (57 percent), medical problems (2 percent), prior resection (16 percent), surgeon preference (6.5 percent), lack of intravenous access (3 percent), and age (1 percent). Three patients (1.5 percent) required sedation to complete the procedure. Procedure-related pain was based on a scale from zero to three. One hundred thirtynine patients (61 percent) rated their pain as either zero (no pain) or one (mild pain), and 217 percent (8 percent) indicated that they would prefer their next colonoscopy to be performed without sedation. One hundred twelve patients had previously undergone sedated colonoscopy. Ninety-two (92 percent) preferred nonsedated to sedated procedures. Average procedure time was 13.7 (range, 0.5 to 85) minutes. CONCLUSIONS: Several series have studied nonsedated endoscopic upper and lower gastrointestinal evaluations. None, however, have evaluated patient comfort and satisfaction. In our prospective series of 258 consecutive nonsedated colonoscopies, we found the procedure to be safe, effective, and well accepted.Read at the meetings of The American Society of Colon and Rectal Surgeons, Montreal, Quebec, Canada, May 7 to 12, 1995, and the Society of Air Force Clinical Surgeons, Dayton, Ohio, April 22 to 25, 1995.     

Complications and adverse effects of colonoscopy with selective sedation

BACKGROUND: Cardiopulmonary adverse effects are commonly observed in patients undergoing colonoscopy with sedation. This study determines the incidence of such events when sedation is given only when required. METHODS: In 2500 consecutive patients, colonoscopies were started without premedication but sedation was offered if significant discomfort occurred. Parameters of blood pressure, heart rate, oxygen saturation and patient appearance were continuously recorded by a nurse assistant. Additional adverse effects occurring during or after the procedure were noted in the patients' protocol. Risk factors for the development of complications were evaluated with the use of a logistic regression model and the odds ratio. RESULTS: Ninety-five percent of all patients required neither sedation nor analgesia. Adverse effects occurred in 59 patients (2. 4%). Twenty-six of these patients (1.0%) had short-lasting episodes of oxygen desaturation and 22 patients (0.9%) experienced vasovagal reactions. Mechanical complications occurred in a total of 8 patients (0.3%) and consisted of 2 perforations and 6 episodes of hemorrhage. In the logistic regression model, impaired physical status was the single most important risk factor for the development of cardiopulmonary complications (odds ratio 4.7; 95% confidence interval [2.0, 11.4]). CONCLUSIONS: In experienced hands, patients undergoing colonoscopy rarely require sedation. If selective sedation is used, cardiopulmonary adverse effects occur in approximately 2% of all patients, most of whom require no medical intervention.     

Sedation during colonoscopy

In order to perform a proper screening for colonic cancer, repeated colonoscopies are required. Comfort during colonoscopy is very important, so that the patient will accept repeated procedures. Currently, there are 3 types of sedation used during colonoscopy: general anesthesia performed by an anesthesiologist; sedo-analgesia performed by an anesthesiologist or by a gastroenterologist; sedo-analgesia performed by a trained nurse. Sedo-analgesia is the most frequently used type of sedation during colonoscopy worldwide. It is realized by combining midazolam with propofol and/or fentanyl (alfentanyl) or pethidine. According to the data obtained from 34 centers performing colonoscopy in Romania, in 2003, 22,162 colonoscopies were performed: 54.5% without anesthesia, 39.5% with sedation with midazolam and 6% with sedo-analgesia. In a study performed in our department we noticed a significant improvement in the outcome of the colonoscopy when sedo-analgesia was used on a regular basis. The percentage of total colonoscopies (excluding those that could not be continued due to stenosis) was 84.2% when sedation was seldomly performed and 92.3% when sedo-analgesia was regularly used (p=0.042). We believe that the strategy of sedation during colonoscopy in Romania should be changed so that all the patients should benefit from sedo-analgesia, proved to be safe and cost/efficient.     

Appropriateness of Colonoscopy in the Era of Colorectal Cancer Screening: A Prospective,Multicenter Study in a Private-Practice Setting (Berlin Colonoscopy Project 1, BECOP 1)

Purpose The introduction of reimbursement for screening colonoscopy in Germany more than one year ago raised concerns that the consequent workload might lead to underuse of diagnostic colonoscopy for symptomatic patients. Available appropriateness criteria for diagnostic colonoscopy have been rarely tested in a realistic outpatient setting. This study was designed to test current appropriateness criteria for diagnostic colonoscopy to better select patients and potentially provide more capacity for screening cases. Secondary goals were yield and quality control in both the diagnostic and screening cases. Methods A prospective study was initiated in 39 private-practice offices to collect data on consecutive colonoscopies conducted during a 6-day study period. A detailed questionnaire was developed to define indications and symptoms, and all findings at colonoscopy were recorded. Colonoscopies were further analyzed and stratified into a screening and a diagnostic group. In the diagnostic group, indications were assessed according to the current guidelines for appropriateness (American Society for Gastrointestinal Endoscopy, European Panel for the Appropriateness of Gastrointestinal Endoscopy), and the results were correlated with the percentage of relevant findings (tumors, inflammatory conditions). Results During the study period, 1,397 colonoscopies (57 percent screening, 43 percent diagnostic) were analyzed (male/female ratio = 39/61 percent; mean age, 61 years). Fourteen percent and 37 percent, respectively, of the 605 diagnostic colonoscopies were regarded as inappropriate relative to the criteria of the American Society for Gastrointestinal Endoscopy and the European Panel for the Appropriateness of Gastrointestinal Endoscopy. However, the percentage of relevant inflammatory and neoplastic findings (polyps, cancer, inflammatory bowel disease, benign strictures) was only 5 to 10 percent higher in the appropriate group than in the inappropriate group. On the basis of these data, a hypothetical model for selecting appropriate indications was developed: if patients older than aged 50 years with pain, bleeding, and diarrhea, but not constipation, are regarded as having an appropriate indication, such an approach would save 20 percent of colonoscopies in these main indication groups (bleeding, pain, diarrhea, constipation), with a hypothetical miss rate for relevant findings (as defined above) of 5 percent. Conclusions Currently used appropriateness criteria for diagnostic colonoscopy increase the yield of relevant findings but lead to a miss rate for relevant findings in the range of 10 to 15 percent. Simple selection criteria based on age and symptoms could be more suitable and should be tested in a larger group of patients. *For members participating in this study, see the Appendix. Supported by unrestricted grants from Olympus Co. Europe/Hamburg and Falk Foundation/Freiburg, Germany.     

Improvement in caecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: a randomized trial of patients referred for colonoscopy

OBJECTIVE: Use of magnetic endoscope imaging (MEI) during colonoscopy has the potential to ease caecal intubation and patient discomfort and to reduce dependence on sedation and/or analgesics (SAs). However, pain reduction by using MEI has not been demonstrated so far, probably because of the liberal use of SAs. The aim of the present study was to evaluate the effect of MEI on caecal intubation and patient pain during unsedated colonoscopy performed by experienced and inexperienced colonoscopists. MATERIAL AND METHODS: A consecutive series of outpatients referred for colonoscopy were randomly allocated to examination with (imager group) or without (standard group) the use of MEI. Patients agreeing to SAs being given only on demand were included in the study. End-points were caecal intubation and pain, the latter to be graded by category on a form to be completed on the day after the examination. RESULTS: The proportion of colonoscopies performed without SAs was similar when comparing imager and standard groups and experienced with inexperienced colonoscopists; altogether 367(88%) out of 419 colonoscopies. The caecal intubation rate was higher in the imager group (190/212 (90%)) than in the standard group (153/207(74%)) (p<0.001), both collectively and separately for experienced and inexperienced colonoscopists. A pain-reducing effect of MEI was shown only when performed by experienced colonoscopists, with severe pain in 10/137 patients (7.3%) in the imager group and 21/132 patients (16%) in the standard group (p=0.03). CONCLUSIONS: In colonoscopy without the routine use of SAs, MEI significantly improves the caecum intubation rate and reduces pain during the procedure.     

Propofol sedation in outpatient colonoscopy by trained practice nurses supervised by the gastroenterologist: a prospective evaluation of over 3000 cases

BACKGROUND AND STUDY AIMS: Propofol has several advantages for sedation in endoscopic procedures. Sedation administered by anaesthesiologists is associated with high costs. In this study the safety of propofol sedation administered by trained practice nurses under the supervision of the gastroenterologist in a cohort of outpatients of an ambulatory practice for gastroenterology in Germany is evaluated. METHODS: During a period of 21 months all patients referred to colonoscopy were eligible for this prospective observational study. The familiar CRC risk of the individuals, indication, completeness and results of the colonoscopy were registered together with the dose of propofol used. Propofol was administered by intermittent intravenous bolus titration by trained practice nurses under supervision of the gastroenterologist. Oxygen saturation, heart rate and blood pressure were recorded constantly during the procedure and adverse cardiopulmonary events were monitored by the endoscopy team. A respiratory event was defined as an episode of apnoea or laryngospasm requiring assisted ventilation. 23 % of the patients received supplemental oxygen. RESULTS: A total of 3641 colonoscopies were recorded. 33 individuals were sedated with midazolam and were excluded from the evaluation. 3610 individuals were sedated with propofol (119 +/- 39 mg, mean dose +/- S. D.). 40 % of the procedures were performed as combined gastroscopy and colonoscopy. The cecum was reached in 99 % of the colonoscopies. Respiratory events occurred in five patients (0.14 %). Assisted ventilation in all cases was performed by mask ventilation. Bradycardia (HF < 60/min) and arterial hypotension (RR < 90 mmHg) occurred in 0.5 and 0.3 % of the colonoscopies, respectively, but medical intervention was necessary only in 0.2 % for both types of event. Minor events of hypoxaemia were observed in 51 patients (1.4 %), but only 1/3 of these events occurred in patients supplemented with oxygen. CONCLUSIONS: Propofol can be administered safely for ambulatory colonoscopy by trained practice nurses, with careful monitoring under supervision of the gastroenterologist.     

Avoidance of sedation during total colonoscopy

A prospective study of the necessity of sedation, or analgesia, or both in total colonoscopy was performed. The procedures were performed in the office on 212 consecutive, nonselected patients. Intravenous sedation was not started initially, and all procedures were begun without medication. If the patient developed significant discomfort or sharp pain, intravenous diazepam (Valium, Roche, Nutley, NJ) or midazolam (Versed, Roche, Nutley, NJ) was given. Total colonoscopy was successful in 201 (95 percent) patients. Of these procedures, 173 (82 percent) patients required no analgesia or sedation. In the remaining 39 (18 percent) patients, only small doses of Valium or Versed were necessary. There were 2 (1 percent) complications, but they were directly related to polypectomy (stalk bleeding, serosal burn) and not to the colonoscopy. Patient acceptance was high because most of the patients were able to leave the office immediately after the procedure and many (at least 82 percent) were able to return to work or resume normal activities that same day. Intravenous sedation is routinely used during total colonoscopy by most practitioners and is considered the standard of care in most communities. However, the need for sedation during total colonoscopy has never been proven and is probably not necessary in most cases. Furthermore, when sedation is necessary, most patients are probably over-anesthetized. This is significant, as it may make total colonoscopy more accessible, less expensive, and safer.     

Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam

BACKGROUND: Propofol provides several benefits over benzodiazepine and narcotic agents as a sedative medication for endoscopic procedures, including faster recovery and improved patient satisfaction. However, its use generally has been limited to anesthesiologists because of the risks associated with deep sedation. METHODS: One hundred patients undergoing colonoscopy or EGD were sedated with low-dose propofol, midazolam, and fentanyl (or meperidine). Depth of sedation was assessed at 2-minute intervals by an independent observer by using the American Society of Anesthesiologists criteria. Recovery time was determined by using paired neuropsychometric tests. A post-procedure satisfaction survey and 24-hour follow-up questionnaires were administered. RESULTS: For colonoscopy and EGD, respectively, the mean propofol dose was 98 mg and 79 mg, the mean midazolam dose was 0.9 mg and 0.8 mg, the mean fentanyl dose was 69 mcg and 63 mcg, and the mean meperidine dose was 42 mg (for both procedures). There were 628 assessments of the level of sedation performed during 74 colonoscopies and 101 assessments during 26 EGDs. The level of sedation was minimal in 77%, moderate in 21%, and deep in 2% of assessments. Nine of the 13 episodes of deep sedation were recorded during colonoscopy and 4 during EGD. In no instance was more than a single assessment of deep sedation recorded during one procedure. Ninety-eight percent of patients were satisfied with the sedation, and 71% returned to their usual activities within 2 hours of discharge. There was no serious adverse event. CONCLUSIONS: Endoscopic sedation with low-dose propofol, a narcotic agent, and midazolam produces a moderate level of sedation. The quality of sedation and measures of recovery are comparable with the results reported with standard-dose propofol.     

Safety of propofol administration by the staff of a gastrointestinal endoscopy unit

Deep sedation controlled by the staff of gastrointestinal endoscopy units is currently controversial. In the last few years, numerous studies have provided data supporting the safety of propofol use in these techniques. We present a large series of patients who underwent gastroscopy or colonoscopy under endoscopist-controlled deep sedation. A total of 875 procedures (297 gastroscopies and 578 colonoscopies) were included. In all procedures intravenous propofol with or without intravenous midazolam was administered. In gastroscopies, complications attributable to the sedation were found in only 6.7% of the patients, mostly due to desaturation, which was resolved without the need for intubation. In colonoscopies, complications were found in 11.2%, the most frequent being bradycardia and desaturation, none of which were serious. No association was found between the presence of complications and the propofol dose administered. In the group of patients undergoing colonoscopy, simultaneous midazolam administration allowed reduction of the propofol dose required to achieve deep sedation. In conclusion, propofol shows a good safety profile and excellent tolerance in patients undergoing gastroscopy and colonoscopy and can be administrated by the endoscopy team. At least in the case of colonoscopy, the associated use of midazolam allows the propofol dose to be decreased, thus, theoretically, reducing the drug's adverse effects.     

Colonoscopy using an abdominal bandage

BACKGROUND/AIMS: This study evaluated usefulness of an abdominal bandage for colonoscopy which enables proper compression of the abdomen during the entire examination. METHODOLOGY: Patients undergoing colonoscopy were subjected to either traditional methods or using an abdominal bandage. Two hundred and twelve patients were divided into two groups: group A (colonoscopy using traditional methods) and group B (colonoscopy using the abdominal bandage). After the examination, each patient completed a form that assessed the degree of pain during the procedure (no pain, mild, moderate, severe). RESULTS: There was no significant difference in total colonoscopy completion rate between the two groups. With regard to the degree of pain, the results for groups A and B were, respectively: no pain= 10.3% and 14.3%, mild = 29.0% and 51.4%, moderate = 48.6% and 27.6%, severe=12.1% and 6.7% (P=0.03). CONCLUSIONS: The abdominal bandage decreased the degree of patient pain compared with traditional methods.     

Conditions of practice and results of colonoscopy in non-university hospitals. Results of a cross sectional, multicenter ANGH study (1)

OBJECTIVES: The aim of the study was to describe the conditions of practice and results of colonoscopies performed in non university hospital endoscopy units. METHODS: A study was suggested to all members of the National Association of non university Hospital Gastroenterologists (ANGH). During one week a questionnaire was filled out by the gastroenterologists for each colonoscopy. RESULTS: Eighty six hospitals (229 gastroenterologists) took part in this study including 840 explorations. Ninety one percent of them were complete and the result was abnormal in 49%: cancers (3%), polyps > or =1 cm (8%), polyps < 1 cm (20%) and colitis (5%). Colonoscopies were ambulatory in half of the cases. Sedation was used in 95% of the patients, 80% by the anesthesist and 15% by the gastroenterologist (conscious sedation). The recommendations of the French Society of Anesthesia and Intensive Care for ambulatory sedation were not totally respected (15% of patients left the endoscopy unit without assistance). Only 6% of colonoscopies were not well tolerated, because of pain or incidents rarely necessitating intensive care monitoring (5 cases) or prolonged hospitalization (2 cases). CONCLUSION: Colonoscopy provides good diagnostic yield although conditions of use can be improved.     

No increased risk of perforation during colonoscopy in patients undergoing Nurse Administered Propofol Sedation

Abstract

Objective. Nurse Administered Propofol Sedation (NAPS) contributes to a deeper sedation of the patients, making them unable to respond to pain and an increased incidence of perforations has been speculated. The objective of this study was to evaluate the risk of perforations during colonoscopies performed with either NAPS or conventional sedation regimes. Material and methods. Data were retrospectively retracted from medical journals from 1 January 2007 to 31 December 2011. All journals were examined and cross-referenced to reveal any perforations. We analyzed all colonoscopies in regard to nature of the procedure (diagnostic vs therapeutic), experience of the endoscopist and ASA-classification of the patients. Results. A total of 6371 colonoscopies were performed, of which 3155 were performed under propofol sedation. There were 16 perforations (0.25%); 10 of these performed during NAPS and 6 during conventional colonoscopy (p = 0.454, OR: 1.7 (95% CI: 0.6–5.7)). There were 4874 diagnostic and 1497 therapeutic colonoscopies, with a majority of the perforations (94%) occurring during a diagnostic procedure (p = 0.389). No statistically difference was found in the incidence of perforations caused by an experienced or less experienced endoscopist (p = 0.589). Conclusion. The risk of colonic perforations during colonoscopy was not found to be significantly higher in patients undergoing NAPS compared to patients undergoing conventional sedation, although a tendency may exist. Furthermore, we found no correlation to neither experience of the endoscopist, nature of the procedure nor sex of the patients. Larger and prospective studies are needed to further evaluate on this subject.     

Assessment of the quality of colonoscopy in Romania

We performed a national prospective multicentric study in order to assess the quality of colonoscopies performed in Romania. Between the 1st and 30th of November 2004, we performed a questionnaire-type study with regard to the practice of colonoscopy, addressed to all the centers in Romania known to perform digestive endoscopy. Thirty centers responded to our questionnaire, resulting in a number of 2,559 colonoscopies that were performed in Romania during the month of November (a mean of 85 colonoscopies/center/month). The percentage of cecal intubations performed nationwide was 70.5%, 74.1% in university hospitals, as compared to nonuniversity ones (64.6%) (p=0.000027). Regarding sedation during colonoscopy, in 46% of the cases the colonoscopy was performed without sedation and in 54% of the cases with sedation (or sedo-analgesia).     

困难无镇静结肠镜检查的危险因素

背景:结肠镜检查因其在结直肠疾病筛查、诊断和治疗中的重要意义而得到广泛开展。无镇静检查所致的不适和疼痛是结肠镜检查操作失败的原因之一。目的:分析无镇静结肠镜检查操作难度的影响因素。方法:纳入2017年1月—12月在同济大学附属第十人民医院行无镇静结肠镜检查的18~80岁患者,采集临床资料和既往史,术前在护士帮助下完成艾森克人格问卷。检查由富有经验的内镜医师进行,术后采用渥太华肠道准备评分量表和VAS量表评估肠道准备质量和检查中的疼痛程度。结果:结肠镜检查成功率为97.1%(198/204)。192例完成艾森克人格问卷的患者纳入分析,其中24例被判定为困难结肠镜检查(内镜插入回盲部时间>10 min)。单因素分析显示性别、年龄、体质指数(BMI)、手术史、疼痛程度和艾森克人格问卷E量表(内向/外向)评分与困难结肠镜检查显著相关(P均<0.05)。多因素分析显示,盆腔手术史是困难结肠镜检查的危险因素(OR=6.833,95%CI:2.396~19.488,P<0.001),超重(OR=0.190,95%CI:0.038~0.962,P=0.045)和人格介于内、外向之间(OR=0.367,95%CI:0.150~0.896,P=0.028)则是保护因素。结论:盆腔手术史、低BMI以及内向和外向人格可能增加无镇静结肠镜检查的操作难度。初级内镜医师在行无镇静结肠镜检查前可使用艾森克人格问卷E量表对受检者进行筛选以提高检查成功率。     

The Norwegian Gastronet project: Continuous quality improvement of colonoscopy in 14 Norwegian centres

OBJECTIVE: The burden on colonoscopy capacity is considerable and expected to increase further as colorectal cancer screening programmes gain a foothold in Europe. In this situation, it is particularly important to evaluate the quality of the service given. In this article we present our first year of experience with a quality network of endoscopy centres in Norway (Gastronet). MATERIAL AND METHODS: A questionnaire focusing on caecal intubation rate and pain was completed by the endoscopist (on site) and patient (on the day after the examination). Fourteen centres participated with registration of 7370 colonoscopies by 73 endoscopists. RESULTS: There was 100% endoscopist participation, 87% coverage of colonoscopies and an estimated 76% questionnaire coverage of the patient population. Overall caecal intubation rate was 91%, range 83% to 97% between centres (p < 0.001). Patients reporting severe pain during colonoscopy differed from 2 to 24% between centres (p < 0.001). Variations could only partly be explained by differences in procedure practice (sedation, CO2 insufflation). For individual endoscopists, improvement after feedback on performance was restricted to the group of endoscopists having contributed with only 50-99 registered colonoscopies. CONCLUSIONS: In quality assurance programmes we recommend a limited number of variables for registration in order to secure high compliance by endoscopists and patients. One year of experience with Gastronet disclosed a satisfactory overall caecal intubation rate, but considerable variation between centres in practice and ability to offer painless colonoscopy. This suggests a need for formal, centralized training of colonoscopists or the development of quality standards for colonoscopy training and practice.     

Colonoscopy in the Elderly: Low Risk, Low Yield in Asymptomatic Patients

Purpose Current colonoscopy guidelines do not address the issue of when to stop performing screening and surveillance colonoscopy in the elderly. We reviewed our experience and results of colonoscopy in patients aged 80 years and older to assess the risks and diagnostic yield in this population. Methods We reviewed retrospectively the endoscopic and pathologic reports from consecutive colonoscopies performed on patients aged 80 years and older at a single, high-volume endoscopy center between August 1999 and May 2003. Patient characteristics, indications for examination, findings at colonoscopy, and complications were recorded and analyzed. Results A total of1,199 colonoscopic examinations were performed on 1,112 patients. Average age was 83.1 (range, 80–100) years. Male:female distribution was 1:1.7. Leading exclusive indications for colonoscopy included: polyp surveillance, 227 (19 percent); altered bowel habits, 168 (14 percent); iron-deficiency anemia, 132 (11 percent); and cancer follow-up, 108 (9 percent). Eighty-six examinations (7 percent) were performed solely for an indication of colorectal cancer screening. Twenty-two percent of patients had more than one indication for colonoscopy. Forty-five malignancies were found (3.7 percent). No cancers were found in the screening group, and two malignancies (0.7 percent) were detected in patients undergoing colonoscopy for polyp surveillance. There were eight (0.6 percent) reported major complications. Conclusions Colonoscopy can be performed safely in patients aged 80 years and older. However, the diagnostic yield is low, particularly in patients undergoing routine screening or surveillance examinations. Colonoscopy should for the most part be limited to elderly patients with symptoms or specific clinical findings. Read at the meeting of The American Society of Colon and Rectal Surgeons, Philadelphia, Pennsylvania, May 2 to 5, 2005.     

Evidence to suggest adoption of water exchange deserves broader consideration: Its pain alleviating impact occurs in 90% of investigators

AIM: To determine variations in colonoscopy real-time insertion pain among investigators using three different insertion techniques.METHODS: From March 2013 through June 2014, 18-85-year-old diagnostic and 50-70-year-old screening patients were enrolled at each center to on-demand sedation colonoscopy with water exchange(WE), water immersion(WI) and insufflation with air or CO2 for insertion and withdrawal [air or carbon dioxide(AICD)]. Data were aggregated for analysis. Primary outcome: Variations in real-time maximum insertion pain(0 = none, 1-2 = discomfort, 10 = worst).RESULTS: One thousand and ninety-one cases analyzed: WE(n = 371); WI(n = 338); AICD(n = 382). Demographics and indications were comparable. The WE group had the lowest real-time maximum insertion pain score, mean(95%CI): WE 2.8(2.6-3.0), WI 3.8(3.5-4.1) and AICD 4.4(4.1-4.7), P 0.0005. Ninety percent of the colonoscopists were able to use water exchange to significantly decrease maximum insertion pain scores. One investigator had high insertion pain in all groups, nonetheless WE achieved the lowest real-time maximum insertion pain score. WE had the highest proportions of patients with painless unsedated colonoscopy(vs WI, P = 0.013; vs AICD, P 0.0005); unsedated colonoscopy with only minor discomfort(vs AICD, P 0.0005), and completion without sedation(vs AICD, P 0.0005).CONCLUSION: Aggregate data confirm superiority of WE in lowering colonoscopy real-time maximum insertion pain and need for sedation. Ninety percent of investigators were able to use water exchange to significantly decrease maximum insertion pain scores. Our results suggest that the technique deserves consideration in a broader scale.     

Does deep sedation with propofol affect adenoma detection rates in average risk screening colonoscopy exams?

AIM To determine the effect of sedation with propofol on adenoma detection rate(ADR) and cecal intubation rates(CIR) in average risk screening colonoscopies compared to moderate sedation.METHODS We conducted a retrospective chart review of 2604 firsttime average risk screening colonoscopies performed at MD Anderson Cancer Center from 2010-2013. ADR and CIR were calculated in each sedation group. Multivariable regression analysis was performed to adjust for potential confounders of age and body mass index(BMI). RESULTS One-third of the exams were done with propofol(n = 874). Overall ADR in the propofol group was significantly higher than moderate sedation(46.3% vs 41.2%, P = 0.01). After adjustment for age and BMI differences, ADR was similar between the groups. CIR was 99% for all exams. The mean cecal insertion time was shorter among propofol patients(6.9 min vs 8.2 min; P 0.0001).CONCLUSION Deep sedation with propofol for screening colonoscopy did not significantly improve ADR or CIR in our population of average risk patients. While propofol may allow for safer sedation in certain patients(e.g., with sleep apnea), the overall effect on colonoscopy quality metrics is not significant. Given its increased cost, propofol should be used judiciously and without the implicit expectation of a higher quality screening exam.