Randomized, double-blinded, placebo-controlled trial of intravenously administered hyoscine N-butyl bromide in patients undergoing colonoscopy with patient-controlled sedation

BACKGROUND: A prospective, double-blinded, placebo-controlled randomized trial was conducted to investigate the effect of the antispasmodic hyoscine N-butyl bromide (Buscopan) during colonoscopy. METHODS: A total of 120 patients undergoing colonoscopy were randomized to receive either 40 mg of hyoscine N-butyl bromide (n=60) or normal saline solution (n=60) intravenously as premedication. Colonoscopy was performed under patient-controlled sedation. Outcome measures included cecal intubation and total procedure time, demanded and administered doses of patient-controlled sedation, spasm score, pain score, endoscopist satisfaction score, patient willingness to repeat colonoscopy, and vital signs (blood pressure, pulse rate) during colonoscopy. RESULTS: Mean cecal intubation time in the hyoscine N-butyl bromide group was significantly longer than the control group (12.20 vs. 9.74 minutes; p=0.04; but correction for multiple testing of data removed this significance). The use of hyoscine N-butyl bromide was associated with a significantly lower endoscopist mean satisfaction score (6.47 vs. 7.30; p=0.04; but correction for multiple testing of data removed this significance), higher demanded and administered mean doses of patient-controlled sedation (respectively, 34.80 and 7.25 vs. 24.20 and 5.87; p=0.045; p=0.04, respectively; but correction for multiple testing of data removed these findings of significance), fewer patients willing to repeat colonoscopy (60% vs. 83.9%; p=0.005), and more hemodynamic instability (p<0.001) when compared with the control group. No significant difference was found in the total procedure time, spasm score, or pain score. CONCLUSIONS: Premedication with intravenously administered hyoscine N-butyl bromide impedes colonoscope insertion and causes greater patient discomfort, as well as hemodynamic instability.     

Relaxation music decreases the dose of patient-controlled sedation during colonoscopy: a prospective randomized controlled trial.

BACKGROUND: A prospective randomized controlled trial was performed to test the hypotheses that music decreases the dose of sedative medication required for colonoscopy and that the combination of music and patient-controlled sedation improves patient acceptance of colonoscopy. METHODS: One hundred sixty-five patients scheduled to undergo elective colonoscopy were randomized to receive 1 of 3 different modes of sedation: Group 1, a combination of music and patient-controlled sedation with a mixture of propofol and alfentanil; Group 2, patient-controlled sedation alone; Group 3, music alone with diazemuls and meperidine administered intravenously if requested by the patient. Each bolus of patient-controlled sedation delivered 4.8 mg propofol and 12 microg alfentenil. Music was provided by means of a portable compact disc machine with headphones. Outcome measures assessed immediately after colonoscopy and 24 hours later included dose of patient-controlled sedation used, complications, recovery time, pain score, satisfaction score, and willingness to repeat the procedure with the same mode of sedation. RESULTS: The mean (SD) dose of propofol used in Group 1 was significantly less than Group 2 (0.84 mg/kg [0.69 mg/kg] vs. 1.15 mg/kg [0.83 mg/kg]; p = 0.02, t test). The mean (SD) satisfaction score was higher in Group 1 (7.8 [2.1]) compared with Group 2 (6.8 [2.3]) and Group 3 (7.4 [2.3]) (p = 0.05, 1-way analysis of variance). The majority of patients in Group 1 were willing to repeat the same mode of sedation when queried immediately after colonoscopy (87%) and 24 hours later (75%), which was significantly different from the corresponding results in the other 2 groups; p = 0.04 and p < 0.01 respectively, chi-square test. CONCLUSIONS: Music can decrease the dose of sedative medication required for colonoscopy. The combination of music and patient-controlled sedation was the best-accepted mode of sedation among 3 groups.     

Effect of magnetic endoscope imaging on patient tolerance and sedation requirements during colonoscopy: a randomized controlled trial

BACKGROUND: Pain during colonoscopy is primarily related to mesenteric stretching from looping of the colonoscope insertion tube. Prompt recognition and removal of loops reduces patient discomfort and may lessen sedation requirements. Magnetic endoscope imaging allows real-time visualization of the colonoscope during insertion. The effect of magnetic endoscope imaging on patient pain and sedation requirements was assessed in a prospective randomized controlled trial. METHODS: A total of 122 consecutive patients undergoing routine colonoscopy by a single experienced endoscopist were randomized to have the procedure performed either with the endoscopist viewing the imager display (n = 62), or without the imager view (n = 60). Procedures began with administration of hyoscine-N-butylbromide alone, and sedative medications (midazolam and meperidine) were self-administered by the patient with a patient-controlled analgesia pump. Cardiorespiratory parameters were recorded and patient pain was assessed with a 100-mm visual analogue scale. RESULTS: The number of attempts at straightening the colonoscope was fewer (median 8 [0-66] vs. 15 [0-87], p = 0.0076) and the duration of looping less (median 4.5 min [0-27.3 min] vs. 6.4 min [0-29.4 min]), when the endoscopist was able to see the imager view. The total number of patient demands (by patient-controlled analgesia) for medication (median 1 vs. 2.5) and total doses of midazolam (median 0.44 mg vs. 0.88 mg) and meperidine (median 16.75 mg vs. 32.5 mg) administered did not significantly differ between patients examined with or without the imager. Patient pain scores were also similar. CONCLUSIONS: Magnetic endoscope imaging allows accurate assessment and straightening of loops during colonoscopy, but without a significant reduction in patient requirements for sedative medication or improvement in patient tolerance. However, the dosages of sedation drugs used were small.     

Maximizing the general success of cecal intubation during propofol sedation in a multi-endoscopist academic centre

Background  

Achieving the target of 95% colonoscopy completion rate at centres conducting colorectal screening programs is an important issue. Large centres and teaching hospitals employing endoscopists with different levels of training and expertise risk achieving worse results. Deep sedation with propofol in routine colonoscopy could maximize the results of cecal intubation.     

Usefulness of a small-caliber, variable-stiffness colonoscope as a backup in patients with difficult or incomplete colonoscopy

OBJECTIVES: Although variable-stiffness colonoscopes have been developed, difficult or incomplete colonoscopies occasionally occur. The aim of this study was to evaluate the usefulness of a small-caliber, variable-stiffness colonoscope (scVSC) as a backup in patients with difficult or incomplete colonoscopies. METHODS: First, we retrospectively reviewed the cecal intubation rate of colonoscopies in which an adult standard colonoscope (AC) was immediately switched to an scVSC in all patients in whom a colonoscopy with an AC was incomplete. Second, 374 consecutive patients were randomized to undergo colonoscopy with a pediatric variable-stiffness colonoscope (PVSC, n = 123), AC (n = 125), or scVSC (n = 126). The scVSC was used by the same endoscopist to reattempt colonoscopy immediately after colonoscopy with a PVSC or an AC had been assessed as difficult or incomplete. The cecal intubation rate and time and the ancillary maneuvers used were evaluated. RESULTS: Fifty-two (2.5%) of the 2,056 attempted colonoscopies with an AC did not reach the cecum. Fifty-one of the 52 patients (98.1%) had complete colonoscopies after the switch from the AC to the scVSC. The initial intubation rate and time were not statistically different among the groups: PVSC, 95% and 6.8 min; AC, 91% and 7.5 min; and scVSC, 98% and 8.2 min. Cecal intubation was achieved in all five patients (100%) and in 10 out of 11 (91%) patients, respectively, after the PVSC or AC was switched to the scVSC. CONCLUSIONS: The completion rate markedly improved after switching from an AC or PVSC to an scVSC in difficult or incomplete colonoscopies, although the scVSC does not appear to offer any distinct advantage over the AC or PVSC for routine colonoscopies.     

Is the variable-stiffness paediatric colonoscope more effective than a standard adult colonoscope for outpatient adult colonoscopy?: A randomised controlled trial

BACKGROUND: Trials with variable-stiffness colonoscopes have yielded conflicting results regarding efficacy and patient tolerance. AIM: We compared a variable-stiffness paediatric colonoscope with a standard adult colonoscope. METHODS: Two hundred and forty consecutive adult outpatients presenting for colonoscopy were randomised to either a variable-stiffness paediatric colonoscope or an adult colonoscope. If there was difficulty in performing colonoscopy with the assigned scope, the endoscopist was given the option of switching to the alternative instrument. In the condition of a severely fixed, angulated sigmoid colon, a final 'salvage' (backup) option was that of switching to an even thinner diameter paediatric colonoscope. RESULTS: The initial frequency of total colonoscopy was similar with the variable-stiffness paediatric colonoscope and adult colonoscope (95.8% versus 96.6%, p=1.0). Factoring in scope changes, the final frequency was 98.3% versus 99.2% (p=1.0). There was no statistical difference between the two groups in terms of insertion time, doses of sedative medications, scales of procedure difficulty, or patient satisfaction. CONCLUSIONS: Adult colonoscope and variable-stiffness paediatric colonoscope are both effective instruments for routine colonoscopy. In cases when the use of the initial scope is unsuccessful, switching to the alternative scope may permit passage to the caecum. There are occasional patients with fixed, angulated sigmoid colons in whom use of an even thinner diameter paediatric colonoscope can be helpful.     

Colonoscopy: go small for success?

Colonoscopy using standard adult colonoscopes can be difficult in patients with fixed, angulated sigmoid colons. An earlier study from the same center suggested that in women who have had hysterectomy, successful colonoscopy occurred with greater frequency when initiated with a pediatric colonoscope versus an adult colonoscope. This follow-up study was a nonblinded clinical trial comparing the use of a pediatric colonoscope with an adult colonoscope for routine colonoscopy in women with previous hysterectomy. A total of 100 female patients presenting for an outpatient colonoscopy were randomized to use the pediatric (Olympus PCF-100) or adult (Olympus CF-100L or CF-Q140L) colonoscope.
The primary outcome was the comparative rate of cecal intubation. Secondary outcomes included total procedure time, cecal insertion time, sedative administration, procedural difficulty, and patients' experience. Endoscopists encountering difficult insertion had the opportunity to use the alternate scope. The cecum was reached in 49 of 51 (96.1%) women when using the pediatric colonoscope versus 35 of 49 (71.4%) women when using the adult colonoscope. Of the 14 incomplete examinations initiated with an adult colonoscope, the pediatric colonoscope was used 12 times, and the cecum was reached in nine, adjusting the rate of successful colonoscopy to 44 of 49 (89.8%). There was no statistical difference in total procedure time, cecal insertion time, sedative drug dosages, procedural difficulty, or patient comfort using either scope.
When performing routine colonoscopy in women with previous hysterectomy, the authors recommend either starting with a pediatric colonoscope or having one available in the advent of a fixed, angulated sigmoid colon.     

Method of colonoscopy in 42 consecutive patients presenting after prior incomplete colonoscopy

OBJECTIVES: Cecal intubation is one of the goals of colonoscopy. We sought to describe the methodology used by a single experienced examiner to perform colonoscopy in a consecutive group of patients with challenging colons. METHODS: Records of 42 consecutive patients with one or more prior unsuccessful attempts at colonoscopy by a gastroenterologist or surgeon and referred for a repeat attempt at colonoscopy were reviewed. RESULTS: Colonoscopy was complete to the cecum in 40 of the 42 patients (95%). An array of methods was employed, including propofol sedation (n = 2), pediatric colonoscope (n = 8), an external straightener (n = 9), external straightener with pediatric colonoscope (n = 2), upper endoscope (n = 8), guidewire exchange (n = 3), and enteroscope with a colon straightener (n = 1) or an enteroscope straightener (n = 1). CONCLUSIONS: A variety of methods and instruments were employed to achieve a high cecal intubation rate during colonoscopy in a group of patients with prior incomplete colonoscopies. Others may find one or more of these methods useful in patients with challenging colons.     

Patient-controlled sedation versus intravenous sedation for colonoscopy in elderly patients: a prospective randomized controlled trial

BACKGROUND: A prospective randomized trial was conducted to compare the safety, effectiveness, and patient acceptance of patient-controlled sedation and intravenous sedation for colonoscopy in a group of elderly patients undergoing outpatient colonoscopy. METHODS: One hundred patients over 65 years of age were recruited and randomized to patient-controlled sedation (n = 50) or intravenous sedation (n = 50) groups by means of computer-generated numbers. In the patient-controlled sedation group, a mixture of propofol and alfentanil was delivered by means of a patient-controlled pump; each bolus delivered 4.8 mg propofol and 12 microg alfentanil. No loading dose was used and the lockout time was set at zero. In the intravenous sedation group, fixed doses of diazemuls (0.1 mg/kg) and meperidine (0.5 mg/kg) were given with further increases in dosages administered at the discretion of the endoscopist. Outcome measures assessed included cardiopulmonary complications, recovery time, pain score, and satisfaction score. RESULTS: The mean (SD) age of patients in the patient-controlled sedation and intravenous sedation groups were, respectively, 72.4 years (5.3) and 73.5 years (6.1). The mean dose of propofol consumed in the patient-controlled sedation group was 0.79 (0.46) mg/kg. The mean doses of diazemuls and meperidine consumed in intravenous sedation group were, respectively, 5.8 (1.3) mg and 30.1 (6.8) mg. Hypotension occurred in 2 (4%) patients in the patient-controlled sedation group and 14 (28%) in the intravenous sedation group (p < 0.01). Oxygen desaturation was recorded for 4 patients (8%) in the intravenous sedation group. The median (interquartile range [IQR]) recovery time was significantly shorter in the patient-controlled sedation group compared with the intravenous sedation group (respectively, 0 minutes [IQR 0-5] vs. 5 minutes [IQR 5-10]; p < 0.01). There were no statistically significant differences between groups for pain and satisfaction scores. CONCLUSIONS: Patient-controlled sedation appears to be safer than intravenous sedation, with comparable effectiveness and acceptance, in elderly patients undergoing elective outpatient colonoscopy.     

Tapered colonoscope performs better than the pediatric colonoscope in female patients: a direct comparison through tandem colonoscopy

BACKGROUND: The pediatric variable-stiffness colonoscope (PVSC) is used by many endoscopists to negotiate the colon that requires a flexible colonoscope; it has a smaller diameter, but may lead to excessive looping. A prototype colonoscope tapers from an adult width to a pediatric diameter at approximately 25 cm. The tapered colonoscope (TC), while retaining the flexibility of the PVSC, has the column strength of the adult colonoscope to help negotiate the proximal colon. OBJECTIVE: Our hypothesis is that use of the TC in female patients would be associated with less looping than the PVSC during the procedure, fewer required maneuvers, and thus a quicker examination. DESIGN: Direct comparison through tandem colonoscopies. SETTING: University endoscopy suite. PATIENTS: Forty unselected female patients. INTERVENTIONS: Tandem colonoscopies with PVSC and TC. MAIN OUTCOME MEASUREMENTS: Time to the cecum and the ability to retroflex in the cecum. RESULTS: Compared with the PVSC, the TC had faster times to achieve cecal intubation (mean [standard deviation], 8.83+/-4.68 minutes versus 6.88+/-4.08 minutes; P=.013) and a higher rate of retroflexion in the cecum (31/40 patients vs 39/40 patients; P<.01). Use of the TC was associated with a decreased need for abdominal pressure (P<.001). CONCLUSIONS: The TC achieved faster cecal intubation rates and had a higher success of cecal retroflexion than a PVSC. This performance likely was because of diminished looping and thus a decreased need for maneuvers. The TC may be preferable to the PVSC for female patients.     

Factors that influence cecal intubation rate during colonoscopy in deeply sedated patients

Background and Aim: The technical performance of colonoscopy performed in deeply sedated patients differs from that performed without sedation or under minimal to moderate sedation. The aim of this study is to evaluate the factors affecting cecal intubation during colonoscopy performed under deep sedation. Methods: A total of 5352 consecutive subjects who underwent a screening colonoscopy as part of a health check‐up between January 2008 and December 2008 at an academic hospital were reviewed. All endoscopies were performed with deep sedation using combination propofol or propofol alone. Data collected included characteristics of the patients (age, gender, body mass index, bowel habits, history of abdominal or pelvic surgery, quality of bowel preparation, and presence/absence of colonic diverticula) and characteristics of the colonoscopists (experience level, colonoscopy procedure volume, and instrument handling method). These factors were analyzed to evaluate their impact on cecal intubation rates. Results: The crude cecal intubation rate was 98% and the adjusted cecal intubation rate was 98.3%. The mean cecal intubation time was 5.6 ± 3.2 min. Multivariate logistic regression analysis demonstrated that patient age greater than 60 years, constipation, poor colon preparation and a two‐person colonoscopy procedure were independently associated with lower cecal intubation rates. Conclusions: Colonoscopy performed under deep sedation by experienced colonoscopists results in high cecal intubation rates. Among the significant patient‐related predictors influencing the cecal intubation, the quality of the bowel preparation was the only modifiable factor. When performed by experienced hands, the one‐person method was associated with higher cecal intubation rates than the two‐person method.     

Water-Related Techniques for Performance of Colonoscopy

Background Passage through difficult colonic segments, cecal intubation rate, time to reach the cecum, procedure-related discomfort, and medication requirement are important outcome measures of a colonoscopic examination. Several techniques of water infusion to aid insertion have been described. Raising awareness of these simple inexpensive methods may help to enhance colonoscopists’ performance. Aim To review water-related methods that facilitated colonoscope insertion. Method A literature search (Medline, PubMed) was conducted using the following terms: sigmoidoscopy, colonoscopy, and water infusion, irrigation, or loading. The effects of water infusion in sedated and unsedated patients are tabulated and discussed. Results Five reports described the use of water infusion in conjunction with usual air insufflation. Enhanced cecal intubation, decreased time to reach the cecum, and attenuated abdominal discomfort were reported. Dose of medication used for sedation was not reduced. The sixth report described a novel method of water infusion in lieu of air insufflation during insertion. When patients accepted sedation on demand, the novel method permitted 52% to complete colonoscopy without sedation. Conclusion Warm water infusion as an adjunct to usual air insufflation enhances colonoscopy outcome. Randomized controlled trials comparing the novel method with usual air insufflation deserve to be considered.     

Sedation-free colonoscopy using an upper endoscope is tolerable and effective in patients with low body mass index: a prospective randomized study

OBJECTIVE: Small-caliber upper endoscopes can be used safely and effectively for sedation-free colonoscopy. The objective of the study is to assess the efficacy of a small-caliber upper endoscope (9.2 mm) comparing with a standard colonoscope (12.2 mm). METHODS: In a prospective trial, patients undergoing sedation-free colonoscopy were randomly assigned to the upper endoscope (E) or the standard colonoscope (C). Outcome measures included patient self-assessed pain score (4-point scale), endoscopist-assessed pain score (4-point scale), cecal intubation rate, difficult cecal intubation rate (>900 s), number of polyps detected, and complication rates. RESULTS: A total of 244 patients were entered. Clinical characteristics were not different between the two groups. Cecal intubation was achieved in 91.0% of the patients in each group. The mean patient self-assessed pain score (SD) was significantly lower in the E group compared with the C group: 1.44 (0.81) versus 2.08 (1.10), p < 0.001. The mean endoscopist assessment of patient pain score (SD) was significantly lower in the E group compared with the C group as well: 1.27 (0.67) versus 1.58 (0.90), p= 0.003. In patients with low body mass index (BMI < 22 kg/m(2)), the cecal intubation rate was significantly higher in the E group (97.7%vs 79.4%, p= 0.026) and the difficult cecal intubation rate was significantly lower in the E group (9.3%vs 32.4%, p= 0.011). There were no significant differences in the number of polyps detected and complication rates between the two groups. CONCLUSION: A small-caliber upper endoscope is tolerable and effective for sedation-free colonoscopy, especially in patients with low BMI.     

Effect of hysterectomy on colonoscopy completion rate

BACKGROUND:

Several studies show that colonoscopies are technically more difficult to perform in women than men, especially in women who have undergone abdominal and gynecological surgeries. A review of the literature indicates an increased rate of noncompletion of colonoscopies in most cases; however, no studies have investigated the procedural complication rate, sedation requirements and perception of pain in colonoscopies.

OBJECTIVE:

To determine whether women who have undergone a previous hysterectomy have a higher noncompletion rate when undergoing a colonoscopy, and to assess whether there is a higher percentage of complications. Furthermore, the present study also aimed to ascertain whether these women required more sedation and whether their perception of pain is greater than that of women who did not undergo previous abdominal surgeries.

METHODS:

The present study was a prospective cohort study of women, 45 to 80 years of age, who underwent colonoscopy (n=508). A total of 229 patients were eligible for the study; they completed a questionnaire, and were subsequently divided into control and hysterectomy groups. Gastroenterologists performed all procedures. After colonoscopy, the patient and endoscopist completed a pain perception questionnaire. Cecal intubation rates were also recorded.

RESULTS:

No significant difference for cecal intubation rates were detected between the two groups (95.7% and 98.7% in hysterectomy and control groups, respectively; P=0.176). The crude OR for the success rate was 0.29 (95% CI 0.05 to 1.90). There was no significant difference between groups regarding sedation or the type of colonoscope. No correlation between the gastroenterologists’ evaluation of pain and patients’ pain was observed.

CONCLUSION:

Hysterectomy did not significantly diminish the cecal intubation rate, and there was no detectable difference in pain perception or sedative dose. Colonoscopy remains an excellent screening and diagnostic tool for all women.     

A randomized controlled trial evaluating the usefulness of a transparent hood attached to the tip of the colonoscope

OBJECTIVES: Considering the increasing demand for colonoscopy, auxiliary devices that could facilitate the examination would be useful. A hood attached to the tip of the colonoscope has been reported to be helpful in detecting and removing colorectal polyps. However, its usefulness in aiding scope intubation has not been fully evaluated. METHODS: Patients for colonoscopy between July 2004 and May 2005 in Tokyo University Hospital were enrolled to this randomized controlled trial, and assigned to colonoscopy with a transparent hood, a short hood, or no hood. Colonoscopies were conducted by trainees without sedation. The evaluated outcomes were cecal intubation rate, trainee intubation rate (cecal intubation within 15 min), cecal intubation time, and polyp detection rate. RESULTS: Enrolled 684 patients were randomly assigned to transparent hood (N = 221), short hood (N = 228), and no hood (N = 235) groups. The overall cecal intubation rate was 95.3% (652/684) and did not differ among the groups. The overall trainee intubation rate was 55.1% (377/684) and significantly higher in the transparent hood group than in the no hood group for female patients (60.7%vs 37.4%, P = 0.003). Cecal intubation time was 11.5, 13.5, and 14.0 min in the transparent, short, and no hood groups, respectively, and significantly shorter in the transparent hood group than in the no hood group among overall (P = 0.008), female (P = 0.001), and old (P = 0.04) patients. Polyp detection rate was higher in the transparent hood group than in the no hood group (49.3%vs 39.1%, P = 0.04). CONCLUSIONS: The transparent hood was useful in shortening the cecal intubation time especially in difficult cases.     

Feasibility of full-spectrum endoscopy:Korea’s first full-spectrum endoscopy colonoscopic trial

AIM: To evaluate the full-spectrum endoscopy(FUSE) colonoscopy system as the first report on the utility thereof in a Korean population.METHODS: We explored the efficacy of the FUSE colonoscopy in a retrospective, single-center feasibility study performed between February 1 and July 20, 2015. A total of 262 subjects(age range: 22-80) underwent the FUSE colonoscopy for colorectal cancer screening, polyp surveillance, or diagnostic evaluation. The cecal intubation success rate, the polyp detection rate(PDR), the adenoma detection rate(ADR), and the diverticulum detection rate(DDR), were calculated. Also, the success rates of therapeutic interventions were evaluated with biopsy confirmation.RESULTS: All patients completed the study and the success rates of cecal and terminal ileal intubation were 100% with the FUSE colonoscope; we found 313 polyps in 142 patients and 173 adenomas in 95. The overall PDR, ADR and DDR were 54.2%, 36.3%, and 25.2%, respectively, and were higher in males, and increased with age. The endoscopists and nurses involved considered that the full-spectrum colonoscope improved navigation and orientation within the colon.No colonoscopy was aborted because of colonoscope malfunction.CONCLUSION: The FUSE colonoscopy yielded a higher PDR, ADR, DDR than did traditional colonoscopy, without therapeutic failure or complications, showing feasible, effective, and safe in this first Korean trial.     

Ultrathin colonoscope with a diameter of 9.8 mm for total colonoscopy

BACKGROUND: The pediatric colonoscope is superior to the standard colonoscope in some patients with a fixed, angulated colon. A colonoscope thinner than the pediatric one is thought to outperform even the pediatric colonoscope in such cases. This study was conducted to assess the efficacy of an ultrathin colonoscope, 9.8 mm in diameter, comparing it with pediatric and standard colonoscopes. METHODS: Three types of colonoscopes were used: ultrathin, pediatric, and standard. A total of 287 consecutive patients were assigned to three groups: ultrathin (n=94), pediatric (n=98), and standard (n=95). First assessment was the ratio of cecal intubation and the reasons for unsuccessful colonoscopy. The second was the time to cecal intubation. RESULTS: Cecal intubation rates were not different among three groups (96% in each). The main reasons for failed colonoscopy were looping in the ultrathin group, and angulation or stricture in the pediatric and standard groups. Mean time to the cecum was slightly longer in the ultrathin group (6.5 minutes) than the pediatric group (5.6 minutes) and standard group (6.1 minutes), but there were no significant differences among three groups. CONCLUSION: Colonoscopy with the ultrathin colonoscope was as successful as with the pediatric and standard colonoscopes. The advantage of the ultrathin colonoscope might be notable in cases with stricture or severe angulation.     

A survey of sedation practices for colonoscopy in Canada

BACKGROUND:

There are limited data regarding the use of sedation for colonoscopy and concomitant monitoring practices in different countries.

METHODS:

A survey was mailed to 445 clinician members of the Canadian Association of Gastroenterology and 80 members of the Canadian Society of Colon and Rectal Surgeons in May and June 2009.

RESULTS:

Sixty-five per cent of Canadian Association of Gastroenterology members and 69% of Canadian Society of Colon and Rectal Surgeons members responded with the full survey. Most endoscopists reported using sedation for more than 90% of colonoscopies. The most common sedation regimen was a combination of midazolam and fentanyl. Propofol, either alone or with another drug, was used in 12% of cases. A higher proportion (94%) of adult gastroenterologists who routinely used propofol were highly satisfied compared with those using other sedative agents (45%; P<0.001). Fifty per cent of adult gastroenterologists and 29% of surgeons who were not currently using propofol expressed interest in starting to use it for routine colonoscopies. Only a single nurse was present in the endoscopy room during colonoscopy performed by two-thirds of the endoscopists.

CONCLUSIONS:

Results of the present survey suggest that gastroenterologists in Canada use sedation for colonoscopy in more than 90% of their patients. There was higher satisfaction among gastroenterologists who used propofol routinely for all colonoscopies. Most endoscopy rooms were staffed by a single nurse, which may limit further increases in the use of propofol. Further studies are needed to determine optimal staffing of endoscopy units with and without the use of propofol. Sedation practices of general surgery endoscopists need to be evaluated.     

A prospective trial of variable stiffness pediatric vs. standard instrument colonoscopy

BACKGROUND: The pediatric variable stiffness colonoscope is believed to have theoretical advantages over the standard colonoscope, however a systematic evaluation of this instrument in routine clinical practice involving adult patients is lacking. METHODS: Consecutive patients (blinded) undergoing colonoscopy in an outpatient endoscopy center by one of 4 experienced colonoscopists had the procedure performed with a standard colonoscope (n=384) or pediatric variable stiffness colonoscope (n=413). Failure to negotiate the sigmoid colon within 10 minutes was regarded as a failure and, if suitable, the patient was crossed over to colonoscopy with the alternative instrument. RESULTS: Median (95% CI) time to the cecum was significantly faster in the pediatric variable stiffness colonoscope group (odds ratio 5.0: 95% CI[4.7,5.3] minutes) compared with the standard colonoscope group (odds ratio 5.5: 95% CI[5.2,5.8] minutes, p=0.01). There were 22 failures overall (2.8%), 14 in the standard colonoscope group (3.6%) and 8 in the pediatric variable stiffness colonoscope group (1.9%; p=0.1). With regard to the 14 failures in the standard colonoscope group, colonoscopy was attempted with the pediatric variable stiffness colonoscope in 13 and completed successfully in 12 (92%). The pediatric variable stiffness colonoscope was superior in cases of severe stenosing diverticular disease; two of 27 examinations with the pediatric variable stiffness colonoscope were rated as failed vs. 12 of 18 with the standard colonoscope (p<0.001). CONCLUSIONS: Intubation time was faster with the pediatric variable stiffness colonoscope, but use of this instrument was not associated with a superior cecal intubation rate compared with the standard colonoscope. However, in patients with severe stenosing diverticular disease, the intubation rate with the pediatric variable stiffness colonoscope was superior.     

Midazolam-pain, but one cannot remember it: a survey among Southern German endoscopists

BACKGROUND: Benzodiazepines, especially midazolam, are the most frequently used agents for gastrointestinal endoscopy worldwide. Among other parameters the quality of sedation is determined by patients' satisfaction assessed after endoscopy. This approach is misleading as the potent amnestic effect of midazolam conceals pain actually suffered during the endoscopic procedure involving distraction of the endoscopists from their actual tasks by audible reactions and defense movements. In this study, we eliminated the influence of patients' amnesia on the assessment of the quality of sedation and rather interviewed endoscopists and their assistant personnel about their experience with midazolam sedation. We replaced the mostly vague term 'compliance' by terms which unequivocally describe the reactions of the patient during an unpleasant endoscopy. METHODS: A short survey consisting of 12 questions was developed. The questionnaires were distributed to the participants - 115 endoscopists and their assistants - of a tutorial about sedation for gastrointestinal endoscopy in three major Southern German cities. The questionnaire retrieved the endoscopists' experience regarding patients' discomfort or pain under sedation with midazolam, their wish for better sedative agents, their preferred sedative regimens, their medical specialty and their professional experience. RESULTS: Participants were highly experienced with the majority having more than 10,000 procedures and a median of 18 years of endoscopic experience; 77% of endoscopists utilized midazolam for sedation. Ninety-eight percent of the questioned physicians felt that patients have pain during endoscopy with midazolam+/-opioid, but do not remember later. Ninety-two percent reported that it happens that patients moan aloud because of pain and almost half of the endoscopists (48%) reported of screaming. The majority of the endoscopists (91%) reported fierce defense movements with midazolam or the need to hold the patient down on the examination couch because of fierce movements, respectively (75%). Seventy percent of the endoscopists wished to have the rooms for endoscopy preferably soundproof away from the waiting room and 93% wished for better sedative agents. CONCLUSIONS: Midazolam was rated as insufficient for sedation by both endoscopists and their assistant personnel. A wish for better sedative drugs exists.