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Chen YS, Feng GH, Yue QQ, Wang YF, Liu M, Zhao KH, Tang T, Huang MT, Yi WT, Yan HL, Yan JH, Zeng Y. Effects of non-pharmacological interventions on anxiety in patients undergoing colonoscopy: A network meta-analysis of randomized controlled trials. J Psychosom Res 2025; 191:112065. [PMID: 40043571 DOI: 10.1016/j.jpsychores.2025.112065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2024] [Revised: 01/07/2025] [Accepted: 02/17/2025] [Indexed: 03/16/2025]
Abstract
BACKGROUND Anxiety is a common and significant problem in patients who need to undergo colonoscopy. However, the question of which non-pharmacological intervention is the best strategy to reduce anxiety in patients undergoing colonoscopy remains unanswered. OBJECTIVES To evaluate and rank the effectiveness of various non-pharmacological interventions for reducing anxiety in patients undergoing colonoscopy in order to identify the most effective strategies. METHODS We searched PubMed, Cochrane Library, Embase, Web of Science, and Medline for randomized controlled trials published from the database construction to March 2024. The primary outcome was the difference between pre- and post-intervention anxiety means. A network meta-analysis was conducted utilizing the "gemtc" package based on R4.3.0. RESULTS The analysis encompassed 24 randomized controlled trials, incorporating 2525 participants and evaluating 9 non-pharmacological interventions. All non-pharmacological interventions reduced anxiety in patients undergoing colonoscopy compared to standard care, with music intervention (SMD = -0.52, 95 %CI (-0.84,-0.20)), audiovisual distraction (SMD = -0.54, 95 %CI(-0.96,-0.12)), video information (SMD = -1.47, 95 %CI(-2.03,-0.90)), individual education (SMD = -1.72, 95 %CI(-2.76,-0.70)), and electroacupuncture (SMD = -1.12, 95 %CI(-2.10,-0.13)) having statistically significant effects. SUCRA ranking identified the priority of individual education (SUCRA: 92.5 %) and video information (SUCRA: 87.7 %). Meta-regression and sensitivity analysis further demonstrated the stability of the evidence. The certainty of the evidence was mostly rated as medium to low. CONCLUSION This review highlights the superior effects of individual education and video information in reducing anxiety in patients undergoing colonoscopy. The findings of our review could provide clinical decision-makers and healthcare practitioners, such as doctors and nurses, with evidence-based practices for selecting interventions to reduce anxiety in patients undergoing colonoscopy.
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Affiliation(s)
- Yun-Shan Chen
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Ge-Hui Feng
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Qian-Qian Yue
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Yi-Fei Wang
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Min Liu
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Ke-Hao Zhao
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Tian Tang
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Mao-Ting Huang
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Wen-Ting Yi
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Hui-Ling Yan
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Jia-Hui Yan
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China
| | - Ying Zeng
- Department of International and Humanistic Nursing, Hunan Science Popularization Education Base, School of Nursing, Hengyang Medical School, University of South China, Hengyang, China.; Hunan Engineering Research Center for Early Diagnosis and Treatment of Liver Cancer, Cancer Research Institute, Hengyang Medical School, University of South China; Hunan Province Key Laboratory of Tumor Cellular & Molecular Pathology, Cancer Research Institute, Hengyang Medical School, University of South China, Hengyang, China..
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Leung FW, Cheung R, Friedland S, Jacob N, Leung JW, Pan JY, Quan SY, Sul J, Yen AW, Jamgotchian N, Chen Y, Dixit V, Shaikh A, Elashoff D, Saha A, Wilhalme H. Prospective randomized controlled trial of water exchange plus cap versus water exchange colonoscopy in unsedated veterans. Gastrointest Endosc 2025; 101:402-413.e2. [PMID: 39053653 DOI: 10.1016/j.gie.2024.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/17/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND AND AIMS Water exchange (WE) and cap-assisted colonoscopy separately have been shown to reduce pain during insertion in unsedated patients. We hypothesized that compared with WE, WE cap-assisted colonoscopy (WECAC) could significantly lower real-time maximum insertion pain (RTMIP). METHODS Veterans without escort were recruited, randomized, blinded, and examined at 3 U.S. Veterans Affairs sites. The primary outcome was RTMIP, defined as the highest segmental pain (0 = no pain, 10 = most severe pain) during insertion. RESULTS Randomization (WECAC, 143; WE, 137) produced an even distribution of a racially diverse group of men and women of low socioeconomic status. The intention-to-treat analysis reported results of WECAC and WE for cecal intubation (93% and 94.2%, respectively), mean RTMIP (2.9 [standard deviation {SD}, 2.5] and 2.6 [SD, 2.4]), proportion of patients with no pain (28.7% and 27.7%), mean insertion time (18.6 minutes [SD, 15.6] and 18.8 minutes [SD, 15.9]), and overall adenoma detection rate (48.3% and 55.1%); all P values were >.05. When RTMIP was binarized as "no pain" (0) versus "some pain" (1-10) or "low pain" (0-7) versus "high pain" (8-10), different significant predictors of RTMIP were identified. CONCLUSIONS Unsedated colonoscopy was appropriate for unescorted veterans. WE alone was sufficient. Adding a cap did not reduce RTMIP. Patient-specific factors and application of WE with insertion suction of infused water contributed to high and low RTMIP, respectively. For unescorted patients, selecting those with low anxiety, avoiding low body mass index, history of depression or self-reported poor health, and complying with the steps of WE can minimize RTMIP to ensure success of unsedated colonoscopy. (Clinical trial registration number: NCT03160859.).
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Affiliation(s)
- Felix W Leung
- Veterans Affairs Greater Los Angeles Healthcare System, University of California at Los Angeles, Los Angeles, California, USA
| | - Ramsey Cheung
- Veterans Affairs Palo Alto Healthcare System, Stanford University, Palo Alto, California, USA
| | - Shai Friedland
- Veterans Affairs Palo Alto Healthcare System, Stanford University, Palo Alto, California, USA
| | - Naom Jacob
- Veterans Affairs Greater Los Angeles Healthcare System, University of California at Los Angeles, Los Angeles, California, USA
| | - Joseph W Leung
- Veterans Affairs Northern California Healthcare System, University of California at Davis, Sacramento, California, USA
| | - Jennifer Y Pan
- Veterans Affairs Palo Alto Healthcare System, Stanford University, Palo Alto, California, USA
| | - Susan Y Quan
- Veterans Affairs Palo Alto Healthcare System, Stanford University, Palo Alto, California, USA
| | - James Sul
- Veterans Affairs Greater Los Angeles Healthcare System, University of California at Los Angeles, Los Angeles, California, USA
| | - Andrew W Yen
- Veterans Affairs Northern California Healthcare System, University of California at Davis, Sacramento, California, USA
| | - Nora Jamgotchian
- Veterans Affairs Greater Los Angeles Healthcare System, University of California at Los Angeles, Los Angeles, California, USA
| | - Yu Chen
- Veterans Affairs Palo Alto Healthcare System, Stanford University, Palo Alto, California, USA
| | - Vivek Dixit
- Veterans Affairs Greater Los Angeles Healthcare System, University of California at Los Angeles, Los Angeles, California, USA
| | - Aliya Shaikh
- Veterans Affairs Northern California Healthcare System, University of California at Davis, Sacramento, California, USA
| | - David Elashoff
- Veterans Affairs Greater Los Angeles Healthcare System, University of California at Los Angeles, Los Angeles, California, USA
| | - Angshuman Saha
- Veterans Affairs Greater Los Angeles Healthcare System, University of California at Los Angeles, Los Angeles, California, USA
| | - Holly Wilhalme
- Veterans Affairs Greater Los Angeles Healthcare System, University of California at Los Angeles, Los Angeles, California, USA
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Zelhart MD, Kann BR. Endoscopy. THE ASCRS TEXTBOOK OF COLON AND RECTAL SURGERY 2022:51-77. [DOI: 10.1007/978-3-030-66049-9_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Khan F, Hur C, Lebwohl B, Krigel A. Unsedated Colonoscopy: Impact on Quality Indicators. Dig Dis Sci 2020; 65:3116-3122. [PMID: 32696236 DOI: 10.1007/s10620-020-06491-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/11/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND In the USA, sedation is commonly used for colonoscopies; though colonoscopy can be successfully performed without sedation, outcomes data in this setting are scarce. AIMS To determine patient characteristics associated with undergoing unsedated colonoscopy and whether adenoma detection rate (ADR) and cecal intubation rate (CIR) differ between sedated and unsedated colonoscopy. METHODS Using a single-center electronic endoscopy database, we identified patients who underwent outpatient colonoscopy between 2011 and 2018 with or without sedation. We used multivariable logistic regression to determine factors associated with unsedated colonoscopy, CIR, and ADR. RESULTS We identified 24,795 patients who underwent colonoscopy during the study period. Of these, 179 patients (0.7%) underwent unsedated colonoscopy. ADR was 27.4% in sedated and 21.2% in unsedated colonoscopies (p = 0.06); CIR was 95.8% in sedated and 85.5% in unsedated patients (p < 0.01). On multivariable analysis, male sex (OR 2.06, CI 1.52-2.79) and suboptimal bowel preparation (OR 1.75, CI 1.24-2.45) were associated with undergoing unsedated colonoscopy, while higher BMI was inversely associated with unsedated colonoscopy (BMI 25-29.9: OR 0.44, CI 0.25-0.77). On multivariable analysis, colonoscopy with sedation was associated with CIR (OR 3.79, CI 2.39-6.00) and ADR (OR 1.45, OR 1.00-2.10). CONCLUSION We found that undergoing outpatient colonoscopy with sedation as opposed to no sedation was significantly associated with a higher CIR and ADR. Our findings suggest sedation is necessary to meet current CIR and ADR guidelines; however, given the potential cost and safety benefits of unsedated colonoscopy, further investigation into methods to improve patient selection and colonoscopy quality indicators is warranted.
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Affiliation(s)
- Fatima Khan
- Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Chin Hur
- Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA.,Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Anna Krigel
- Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA
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Kadhim I, Choi J. Extension Mechanism of a Flexible End for Colonoscopy. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2020; 13:245-258. [PMID: 32982491 PMCID: PMC7508561 DOI: 10.2147/mder.s265313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/25/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction The significance of the distal tip extension mechanism (DTEM) arises when the insertion tube of the colonoscope is no longer able to move further inside the colon, and when a longer insertion tube is needed. The main focus of this research is to investigate the development of a novel distal tip extension mechanism (DTEM). Methods To characterize the performance of the DTEM, the ability of the DTEM to extend the distal tip of the colonoscope 16 cm is investigated. To determine the maximum number of turns that the extension knob needs to make in order to move the distal tip 16 cm, the DTEM is used to displace the distal tip in different colon configurations using the silicon tube of a colonoscopy training model (CTM). The experimentally collected data was presented and discussed to characterize the performance of the DTEM. Results The results showed that the DTEM is able to extend the distal tip 16 cm while the colon is in various configurations. Additionally, the impact of implanting the DTEM on the flexibility of the insertion tube was determined. Discussion The results of this research suggest that the DTEM will be an effective tool to help colonoscopists performing better colonoscopies.
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Affiliation(s)
| | - Junghun Choi
- Department of Mechanical Engineering, Georgia Southern University, Statesboro, GA, USA
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Effects of visual and audiovisual distraction on pain and anxiety among patients undergoing colonoscopy. Gastroenterol Nurs 2016; 38:55-61. [PMID: 25636013 DOI: 10.1097/sga.0000000000000089] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The aim of this study was to test the effects of visual and audiovisual distraction on pain, anxiety, and procedure tolerance among patients undergoing colonoscopy. A prospective, randomized, controlled design was used with 180 consecutive patients who underwent colonoscopy. Subjects were randomly allocated into 3 groups: Group A received visual distraction, Group B received audiovisual distraction, Group C with routine care. Outcome variables included pain, anxiety, and willingness to undergo colonoscopy again if the procedure was to be repeated. No significant difference was found on the pain scores of the 3 groups. However, when groups A and B were further divided into groups A1, A2, A3 (low-, middle-, high-involvement groups), and B1, B2, B3 (low-, middle-, high-involvement groups) according to the level of distraction involvement, significant differences in pain scores were found between 7 groups (A1 and A3, A2 and A3, A1 and B3, A2 and B3, A3 and C, B1 and B3, B3 and C). The pain score of Group A3 was significantly lower than those of groups A1, A2, and C, and the pain score of Group B3 was significantly lower than those of groups B1 and C. The reduction of anxiety levels after procedure was insignificant between the 2 intervention groups and control group. The rates of willingness to undergo colonoscopy again if the procedure was to be repeated of the 2 intervention groups were significantly higher than that of the control group. Visual and audiovisual distraction is effective in promoting pain control for patients undergoing colonoscopy and improving their tolerance of the procedure.
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Umezawa S, Higurashi T, Uchiyama S, Sakai E, Ohkubo H, Endo H, Nonaka T, Nakajima A. Visual distraction alone for the improvement of colonoscopy-related pain and satisfaction. World J Gastroenterol 2015; 21:4707-4714. [PMID: 25914482 PMCID: PMC4402320 DOI: 10.3748/wjg.v21.i15.4707] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 12/02/2014] [Accepted: 12/22/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the effect of a relaxing visual distraction alone on patient pain, anxiety, and satisfaction during colonoscopy.
METHODS: This study was designed as an endoscopist-blinded randomized controlled trial with 60 consecutively enrolled patients who underwent elective colonoscopy at Yokohama City University Hospital, Japan. Patients were randomly assigned to two groups: group 1 watched a silent movie using a head-mounted display, while group 2 only wore the display. All of the colonoscopies were performed without sedation. We examined pain, anxiety, and the satisfaction of patients before and after the procedure using questionnaires that included the Visual Analog Scale. Patients were also asked whether they would be willing to use the same method for a repeat procedure.
RESULTS: A total of 60 patients were allocated to two groups. Two patients assigned to group 1 and one patient assigned to group 2 were excluded after the randomization. Twenty-eight patients in group 1 and 29 patients in group 2 were entered into the final analysis. The groups were similar in terms of gender, age, history of prior colonoscopy, and pre-procedural anxiety score. The two groups were comparable in terms of the cecal insertion rate, the time to reach the cecum, the time needed for the total procedure, and vital signs. The median anxiety score during the colonoscopy did not differ significantly between the two groups (median scores, 20 vs 24). The median pain score during the procedure was lower in group 1, but the difference was not significant (median scores, 24.5 vs 42). The patients in group 1 reported significantly higher median post-procedural satisfaction levels, compared with the patients in group 2 (median scores, 89 vs 72, P = 0.04). Nearly three-quarters of the patients in group 1 wished to use the same method for repeat procedures, and the difference in rates between the two groups was statistically significant (75.0% vs 48.3%, P = 0.04). Patients with greater levels of anxiety before the procedure tended to feel a painful sensation. Among patients with a pre-procedural anxiety score of 50 or higher, the anxiety score during the procedure was significantly lower in the group that received the visual distraction (median scores, 20 vs 68, P = 0.05); the pain score during the colonoscopy was also lower (median scores, 23 vs 57, P = 0.04). No adverse effects arising from the visual distraction were recognized.
CONCLUSION: Visual distraction alone improves satisfaction in patients undergoing colonoscopy and decreases anxiety and pain during the procedure among patients with a high pre-procedural anxiety score.
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Kale R, Koonce D, Drozek D, Choi J. Evaluation of Feedback Enabled Active Colonoscopy Training Model. J Med Device 2013. [DOI: 10.1115/1.4024831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The objective of this research is to evaluate the efficacy of an active colonoscopy training model (ACTM). Colonoscopy is a widely utilized procedure for diagnosing diseases of the lower gastrointestinal tract. Since colonoscopy is a difficult procedure to teach, as well as learn, simulators are often used to teach and practice the procedure. To make learning and assessing the procedural skills easy and interactive, an active training model was developed and evaluated. To measure the applied force and the time to complete the procedure, load cells and light detecting sensors were installed in the training model and were interfaced with a data acquisition system. The user interface was programmed in LabVIEW to record the force data and time taken to complete the procedure. Thirty medical students were recruited to perform a series of three colonoscopies on the ACTM. These students were instructed how to handle the equipment and perform the colonoscopy. The procedure was also performed by experienced endoscopists to establish a benchmark. The collected data were analyzed to determine the effectiveness of the device to (1) distinguish between the participants based on their level of expertise, and (2) to detect improvement in skill of the students with repetitive sessions with the device. The results of this research may be useful to show that the ACTM may be an effective tool to integrate in to the medical training program of medical studies. It can be possibly used for evaluating the skill sets, as well as practicing the procedure before a novice surgeon performs the procedure on a patient.
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Affiliation(s)
- Ravindra Kale
- Research Assistant Mechanical Engineering Department, Ohio University, Athens, OH 45701
| | - David Koonce
- Associate Professor Industrial Systems Engineering Department, Ohio University, Athens, OH 45701
| | - David Drozek
- Assistant Professor of Surgery, Department of Specialty Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, OH 45701
| | - JungHun Choi
- Assistant Professor Mechanical Engineering and Biomedical Engineering Program, Ohio University, Athens, OH 45701
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Holme Ø, Moritz V, Bretthauer M, Seip B, Glomsaker T, de Lange T, Aabakken L, Stallemo A, Høie O, Dahler S, Sandvei PK, Stray N, Ystrøm CM, Hoff G. [Pain in connection with colonoscopy in Norway]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2013; 133:1074-1078. [PMID: 23712171 DOI: 10.4045/tidsskr.12.1467] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Colonoscopies are common examinations at Norwegian hospitals. In contrast to many other countries, the majority of colonoscopies in Norway are conducted without routine sedation or analgesia. We wanted to investigate whether current Norwegian practice offers adequate pain relief. MATERIAL AND METHOD The material consists of prospectively recorded outpatient colonoscopies in the period January 2003-December 2011 performed at Norwegian hospitals in the quality assurance network for gastrointestinal endoscopy (Gastronet). We analysed demographic patient data and data from colonoscopies. Patients' experience of pain (none, slight, moderate or severe pain) in connection with the examination was established with the aid of a validated questionnaire. RESULTS Data from 61,749 colonoscopies (55% on women) performed at 29 different hospitals were analysed. Colonoscopies were perceived as moderately or very painful by 33% of the patients (41% of the women, 24% of the men, p < 0.001). There were substantial differences between hospitals as to the percentage of colonoscopies that were perceived as moderately or very painful (from 9% to 43%, p < 0.001) and the use of sedatives and analgesics for the colonoscopies (from 1% to 92% of the examinations, p < 0.001). Only 23% of those who found the colonoscopy painful received analgesics. Pethidine was used in 95% of the cases in which analgesics were used during the examination. INTERPRETATION Many patients find colonoscopies painful. Pain relief practice varies substantially between hospitals. Pethidine is an analgesic with a slow onset of action, and should perhaps be replaced with more rapidly acting opiates.
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Affiliation(s)
- Øyvind Holme
- Medisinsk avdeling, Sørlandet sykehus, Kristiansand, Norway.
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Cardin F, Minicuci N, Campigotto F, Andreotti A, Granziaera E, Donà B, Martella B, Terranova C, Militello C. Difficult colonoscopies in the propofol era. BMC Surg 2012; 12 Suppl 1:S9. [PMID: 23173918 PMCID: PMC3499204 DOI: 10.1186/1471-2482-12-s1-s9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To study the relationship between endoscopic practice and adverse events during colonoscopy under standard deep sedation induced and monitored by an anesthetist. METHODS We investigated the routine activity of an endoscopy center at the Padova University teaching hospital. We considered not only endoscopic and cardiorespiratory complications, but also the need to use high-dose propofol to complete the procedure, and the inability to complete the procedure. Variables relating to the patient's clinical conditions, bowel preparation, the endoscopist's and the anesthetist's experience, and the duration of the procedure were input in the model. RESULTS 617 procedures under deep sedation were performed with a 5% rate of adverse events. The average dose of propofol used was 2.6 ± 1.2 mg/kg. In all, 14 endoscopists and 42 anesthetists were involved in the procedures. The logistic regression analysis identified female gender (OR=2.3), having the colonoscopy performed by a less experienced endoscopist (OR=1.9), inadequate bowel preparation (OR=3.2) and a procedure lasting longer than 17.5 minutes (OR=1.6) as the main risk factors for complications. An ASA score of 2 carried a 50% risk reduction (OR=0.5). DISCUSSION AND CONCLUSIONS Our model showed that none of the variables relating to anesthesiological issues influenced which procedures would prove difficult.
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Affiliation(s)
- Fabrizio Cardin
- Department of Surgical and Gastroenterological Sciences, Padova University Hospital, Italy, Via Giustiniani n2, 35126 Padova, Italy.
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Abstract
BACKGROUND AND AIM The present study evaluated the usefulness of a fitted abdominal corset for colonoscopy, enabling proper compression of the abdomen during the entire examination. METHODS Patients undergoing colonoscopy were subjected to either traditional methods or to using a fitted abdominal corset. Two hundred and sixteen patients were divided into two groups: group 1 (conventional colonoscopy) and group 2 (colonoscopy with abdominal corset). Cecal intubation rate and time need for manual compression and change of position were recorded. At the end of each colonoscopic examination, the patient evaluated pain by an 11-point visual analog scale from 0 to 10 (0: no pain, 10: worst pain). RESULTS Cecal intubation time was shorter, the need for extra manual compression and change of position decreased and patients felt less pain during the procedure as denoted by lower visual analog scale scores in the group using a fitted abdominal corset, when compared to the group without a corset, in a statistically proven manner. CONCLUSION Our data confirm the usefulness of the abdominal corset in decreasing the degree of patient pain and it makes colonoscopy easier and quicker with less manipulation, so we propose using a fitted abdominal corset during routine colonoscopic procedures.
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Affiliation(s)
- Ahmet Burak Toros
- Department of Gastroenterology, Istanbul Education and Research Hospital, Istanbul, Turkey.
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Terruzzi V, Paggi S, Amato A, Radaelli F. Unsedated colonoscopy: A neverending story. World J Gastrointest Endosc 2012; 4:137-41. [PMID: 22523614 PMCID: PMC3329613 DOI: 10.4253/wjge.v4.i4.137] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/18/2011] [Accepted: 03/01/2012] [Indexed: 02/05/2023] Open
Abstract
Although sedation and analgesia for patients undergoing colonoscopy is the standard practice in Western countries, unsedated colonoscopy is still routinely provided in Europe and the Far East. This variation in sedation practice relies on the different cultural attitudes of both patients and endoscopists across these countries. Data from the literature consistently report that, in unsedated patients, the use of alternative techniques, such as warm water irrigation or carbon dioxide insufflation, can allow a high quality and well tolerated examination.
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Affiliation(s)
- Vittorio Terruzzi
- Vittorio Terruzzi, Silvia Paggi, Arnaldo Amato, Franco Radaelli, Division of Gastroenterology, Valduce Hospital, I-22100 Como, Italy
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Sousa JBD, Silva SME, Fernandes MBDL, Nobrega ACDS, Almeida RMD, Oliveira PGD. Colonoscopias realizadas por médicos residentes em hospital universitário: análise consecutiva de 1000 casos. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2012; 25:9-12. [DOI: 10.1590/s0102-67202012000100003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
RACIONAL: A colonoscopia tem indicação para diagnóstico em pacientes sintomáticos e é eficaz no rastreamento e vigiância de pacientes assintomáticos. Tem potencial terapêutico em diversas situções, principalmente na remoção das lesões polipóides. A proficiência e a competência do endoscopista é o esteio para o sucesso da colonoscopia diagnóstica e terapêutica. OBJETIVO: Analisar as indicações, os achados diagnósticos, e as complicações de colonoscopias realizadas por médicos residentes em um hospital universitário. MÉTODOS: Foram avaliadas 1.000 colonoscopias consecutivas realizadas por residentes de quarto ano, sob supervisão direta de colonoscopistas experientes. Foram obtidas informações sobre os dados demográficos dos pacientes, o preparo intestinal, as indicações para o procedimento, o sucesso do procedimento, os achados diagnósticos e as complicações. RESULTADOS: Foram examinados total de 596 (59,6%) mulheres e 404 (40,4%) homens. A idade variou de três a 99 anos (média 53,8). O preparo intestinal foi realizado com solução de manitol a 10% em 978 pacientes (97,8%), sendo considerada adequada em 97,6% dos casos. Principais indicações foram: diagnóstico (56,4%), terapêutica (9,6%), rastreamento (17,3%) e vigilância (22%). Taxas de intubação do ceco e válvula ileocecal foram 90,3 e 58,6%, respectivamente. A colonoscopia foi normal em 45,8% dos casos. O diagnóstico mais comum foi diverticulose (18,5%), seguido por pólipos (17%) e neoplasias (6,8%). Achados consistentes com um processo inflamatório foram identificados em 122 pacientes (12,2%) e anomalias vasculares foram detectadas em 11 pacientes (1,1%). Outros diagnósticos representaram 3,9% dos casos. Houve dois casos (0,2%) de complicações (hematoma e hemorragia submucosa), ambos após polipectomia, sem necessidade de intervenção cirúrgica. CONCLUSÃO: Os residentes sob supervisão e orientação de especialistas podem realizar colonoscopias com excelente resultado, baixo índice de complicações e com dados finais comparáveis aos obtidos por endoscopistas experientes.
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Szura M, Bucki K, Matyja A, Kulig J. Evaluation of magnetic scope navigation in screening endoscopic examination of colorectal cancer. Surg Endosc 2011; 26:632-8. [PMID: 21959687 PMCID: PMC3271220 DOI: 10.1007/s00464-011-1930-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2011] [Accepted: 08/31/2011] [Indexed: 02/08/2023]
Abstract
Background Colorectal cancer is the most common cancer in Europe. Early diagnosis and treatment gives the patient a chance for complete recovery. Screening colonoscopies in the symptom-free patients are currently performed on a wide scale. The examinations are performed under local anesthesia which does not eliminate all discomfort and pain related to the examination. The aim of this study was to evaluate magnetic scope navigation in screening endoscopic examinations performed to detect early-stage colorectal cancer. Methods The study group consisted of 200 patients, aged 40–65 years, who were free from colon cancer symptoms. All patients underwent complete colonoscopy under local anesthesia. The equipment could be fitted with the scope that allows three-dimensional observation of instrument localization in the bowel. The examination was performed by three experienced endoscopists, each of whom performed over 5,000 colonoscopies. The patients were randomized to two groups: those whose equipment did not have 3D navigation (group I) and those whose equipment did have 3D navigation (group II). Each group consisted of 100 cases matched by gender, age, and BMI. The authors compared the duration of introducing instrument to cecum, the pulse rate before the examination and at the time the instrument reached the cecum, and subjective pain evaluation by the patient on the visual analog scale. Results Group I consisted of 54 women and 46 men with a mean age of 54.6 years and mean BMI of 27.8 kg/m2, and group II had 58 women and 42 men, mean age of 55.1 years and mean BMI of 26.4 kg/m2. The average time it took for the instrument to reach the cecum was 216s in group I and 181s in group II (P < 0.05). Pain measured on the 10-point VAS scale was 2.44 in group I and 1.85 in group II (P < 0.05). The results showed a significantly shorter time for the instrument to reach the cecum in group II and significantly lower pain intensity during the examination was reported by the group II patients. No significant differences were found in the pulse measurements between the groups (P = 0.5). Conclusions 3D navigation during colonoscopy decreases the time for the instrument to reach the cecum and lowers pain intensity subjectively reported by the patients. The use of 3D and the possibility to observe instrument localization and maneuvers brings more comfort to the patients.
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Affiliation(s)
- Miroslaw Szura
- 1st Department of General and GI Surgery, Medical College Jagiellonian University, Kopernika 40, 31-501, Krakow, Poland.
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Leung FW, Aljebreen AM, Brocchi E, Chang EB, Liao WC, Mizukami T, Schapiro M, Triantafyllou K. Sedation-risk-free colonoscopy for minimizing the burden of colorectal cancer screening. World J Gastrointest Endosc 2010; 2:81-9. [PMID: 21160707 PMCID: PMC2998881 DOI: 10.4253/wjge.v2.i3.81] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Revised: 01/30/2010] [Accepted: 02/06/2010] [Indexed: 02/06/2023] Open
Abstract
Unsedated colonoscopy is available worldwide, but is not a routine option in the United States (US). We conducted a literature review supplemented by our experience and expert commentaries to provide data to support the use of unsedated colonoscopy for colorectal cancer screening. Medline data from 1966 to 2009 were searched to identify relevant articles on the subject. Data were summarized and co-authors provided critiques as well as accounts of unsedated colonoscopy for screening and surveillance. Diagnostic colonoscopy was initially developed as an unsedated procedure. Procedure-related discomfort led to wide adoption of sedation in the US, although unsedated colonoscopy remains the usual practice elsewhere. The increased use of colonoscopy for colorectal cancer screening in healthy, asymptomatic individuals suggests a reassessment of the burden of sedation in colonoscopy for screening is appropriate in the US for lowering costs and minimizing complications for patients. A water method developed to minimize discomfort has shown promise to enhance outcomes of unsedated colonoscopy. The use of scheduled, unsedated colonoscopy in the US appears to be feasible for colorectal cancer screening. Studies to assess its applicability in diverse practice settings deserve to be conducted and supported.
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Affiliation(s)
- Felix W Leung
- Felix W Leung, Research and Medical Services, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA 91343, United States
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Khalid O, Srivastava R, Mulhall A, Paladugu A, Stoddard M, Lippmann S. Conscious Sedation: For a TEE, Is It Always Required? Echocardiography 2010; 27:74-6. [DOI: 10.1111/j.1540-8175.2009.01049.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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A prospective evaluation of the feasibility of primary screening with unsedated colonoscopy. Gastrointest Endosc 2009; 70:724-31. [PMID: 19560142 DOI: 10.1016/j.gie.2009.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Accepted: 03/11/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Colonoscopy is the most effective screening tool for colorectal cancer. In Taiwan, colonoscopy is used much less than sigmoidoscopy for screening because sedation significantly increases the cost and is not readily available, and unsedated colonoscopy is considered to be poorly tolerated. However, unsedated colonoscopy has been shown to be well accepted and may improve the cost-effectiveness and access to colonoscopic screening. OBJECTIVES To compare the feasibility of unsedated colonoscopy and sigmoidoscopy for primary screening and to analyze factors associated with acceptance of the procedures and need for sedation. DESIGN Single center, prospective. SETTING National Taiwan University Medical Center. POPULATION AND INTERVENTIONS: A consecutive series of 261 subjects without history of colonoscopy or sigmoidoscopy who underwent unsedated colonoscopy (n = 176) or sigmoidoscopy (n = 85) for primary screening. MAIN OUTCOME MEASUREMENTS Pain scores, acceptance, and need for sedation. RESULTS No significant differences in pain, acceptance, and need for sedation were found between the colonoscopy and sigmoidoscopy groups. Only 9.6% in the colonoscopy group and 10.1% in the sigmoidoscopy group considered sedation necessary. Multivariate analyses revealed that the examinee's sex and the endoscopist, but not the type of endoscopic examination, were associated with the severity of pain and need for sedation. LIMITATIONS Nonrandomized study design. CONCLUSIONS Unsedated colonoscopy for primary screening is well accepted in nine tenths of examinees who accept this option and is similar to sigmoidoscopy in pain, acceptance, and need for sedation. Primary screening with unsedated colonoscopy is feasible, as with sigmoidoscopy.
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Puttler K, Jaklic B, Rieg TS, Lucha PA. Reduction of conscious sedation requirements by olfactory stimulation: a prospective randomized single-blinded trial. J Altern Complement Med 2009; 15:381-5. [PMID: 19388860 DOI: 10.1089/acm.2008.0257] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This study investigated the possibility that olfactory stimulation would decrease sedation needed for colonoscopy and therefore decrease the recovery time needed after conscious sedation. MATERIALS AND METHODS Patients were randomized to receive a cherry-flavoredscent in oxygen flowing at a 4 L per minute rate via nasal cannula or oxygen alone. The scent was provided in a cherry-flavored oil. A Bispectral Index (BIS) monitor (Aspect Medical Systems, Newton, MA) was placed and scores were recorded every 5 minutes during the procedure to control for different sedation patterns between different endoscopists. The recovery area nurse was unaware of whether a given patient was in the aroma or plain oxygen group, and based each patient's discharge on preexisting standardized criteria. RESULTS Two hundred and eighty-four (284) patients completed the study. Both the procedure times and the recovery times were not statistically significant between the two groups. The doses of sedatives used, BIS scores at 5 minute intervals, and rate of change in BIS scores were also not statistically significant between the two groups. CONCLUSIONS Overall, there is no difference between olfactory stimulation and inhaled oxygen with regard to amount of sedation used and recovery times for colonoscopy. An inhaled cherry- scent may not have as great a calming effect as other scents that have been studied.
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Affiliation(s)
- Krista Puttler
- Department of General Surgery, Naval Medical Center, Portsmouth, VA, USA
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Patient satisfaction with colonoscopy: a literature review and pilot study. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2009; 23:203-9. [PMID: 19319384 DOI: 10.1155/2009/903545] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current guidelines recommend that colonoscopic colorectal cancer screening be undertaken every 10 years after the age of 50 years. However, because the procedure does not meet criteria that promote screening uptake, patient satisfaction with colonoscopy may encourage repeat screening. OBJECTIVE To systematically review the literature and conduct a pilot study of patient satisfaction with the colonoscopy experience. METHODS All cohort studies from January 1997 to August 2008 in the MEDLINE database that measured either patient satisfaction with colonoscopy, patient willingness to return for colonoscopy under the same conditions or patient preference for colonoscopy compared with other large bowel procedures were identified. The search was supplemented by journal citation lists in the retrieved articles. RESULTS Of the 29 studies identified, 15 met the inclusion criteria. Consistently, the vast majority of patients (approximately 95%) were very satisfied with their colonoscopy experience. Patient satisfaction was similar for screening and nonscreening colonoscopy. Patient willingness to return for the procedure ranged from 73% to 100%. Of the five studies that examined modality preference, three studies reported the majority of patients preferred colonography to colonoscopy and two studies reported the reverse. Our pilot study findings mirrored those of other studies that were conducted in the United States. The major limitation of the included studies was that patients who were most dissatisfied may have gone elsewhere to have their colonoscopy. CONCLUSIONS Patients were very satisfied with colonoscopy. The majority were willing to return for repeat testing under the same conditions, and colonoscopy was not preferred over other modalities. However, studies were limited by methodological shortcomings.
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Robertson DJ, Jacobs DP, Mackenzie TA, Oringer JA, Rothstein RI. Clinical trial: a randomized, study comparing meperidine (pethidine) and fentanyl in adult gastrointestinal endoscopy. Aliment Pharmacol Ther 2009; 29:817-23. [PMID: 19154568 DOI: 10.1111/j.1365-2036.2009.03943.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is little evidence to guide choice between meperidine (pethidine) and fentanyl for sedation for gastrointestinal endoscopy. AIM To compare meperidine with fentanyl in terms of procedure time and analgesia. METHODS Single centre randomized controlled trial. Patients received narcotic doses and midazolam at the discretion of the attending endoscopist who was unaware of narcotic assignment. Endoscopy and recovery times were then recorded. The main outcome was total procedure time, defined as endoscopy time plus recovery time. Patient discomfort was assessed prior to discharge via visual analogue scale (VAS). RESULTS In total, 55 patients were randomized to meperidine [44 colonoscopy and 11 esophagogastroduodenoscopy (EGD)] and 56 to fentanyl (45 colonoscopy and 11 EGD). Total procedure time was shorter for those receiving fentanyl (mean = 87.7 min) than for those receiving meperidine (mean = 102.9 min) (P = 0.05). The difference between the groups was explained by a shorter mean recovery time in the fentanyl group (63.0 min) than in the meperidine group (76.2 min) (P = 0.07). Based on post procedure pain scores, examinations with meperidine (mean = 1.99) were less painful when compared with those receiving fentanyl (mean = 2.86, P = 0.03). CONCLUSIONS Fentanyl shortened total procedure time by reducing recovery time. A simple change in narcotic choice could increase endoscopy unit efficiency.
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Affiliation(s)
- D J Robertson
- VA Medical Center, White River Junction, VT 05009, USA.
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Petrini JL, Egan JV, Hahn WV. Unsedated colonoscopy: patient characteristics and satisfaction in a community-based endoscopy unit. Gastrointest Endosc 2009; 69:567-72. [PMID: 19231501 DOI: 10.1016/j.gie.2008.10.027] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Accepted: 10/20/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients who have a colonoscopy performed in the United States are usually given moderate to deep sedation. OBJECTIVE We report our prospective experience with patients willing to have colonoscopy performed without analgesia or sedation. DESIGN From June 6, 2006, to December 7, 2006, a total of 2091 patients underwent colonoscopy in our ambulatory endoscopy unit and were offered their procedure with sedation or no sedation. SETTING Single-center outpatient ambulatory surgery unit. PATIENTS Consecutive patients who had colonoscopy in our outpatient unit, excluding those who had combined-procedure EGD and colonoscopy. INTERVENTIONS Patients who elected to start colonoscopy without medications could request medication at any point during the procedure. Those who requested medication received narcotics or benzodiazepines. MAIN OUTCOMES MEASUREMENTS Time to cecum, extent of examination, pain level experienced, and willingness to have the procedure with the same, more, or less medication in the future were evaluated. RESULTS A total of 578 patients (27.6%) chose to start without sedation; 470 of those (81.1%, 95% CI, 77.9%-89.3%) completed the examination without medication, 353 men (85%, 95% CI, 84.0%-90.5%) and 117 women (67%, 95% CI, 59.6%-73.4%). Cecal intubation was 1501 of 1512 (99.3%, 95% CI, 98.7%-99.6%) for medicated, 467 of 470 (99.4%, 95% CI, 98.1%-99.8%) for unsedated, and 107 of 108 (99.1%, 95% CI, 93.5%-99.5%) for those who were medicated during the procedure. A total of 458 of the 470 unsedated patients (97.4%, 95% CI, 95.6%-98.5%) were satisfied with their comfort level during the procedure and are willing to have their next colonoscopies without sedation. LIMITATIONS The study is not randomized or blinded. CONCLUSIONS Colonoscopy without sedation is feasible, effective, and well tolerated in a typical U. S. population.
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Affiliation(s)
- John L Petrini
- Current affiliations: Sansum Clinic, Santa Barbara, California, USA
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Sedation on demand and lubrication during colonoscopy: should we change our minds? Gastrointest Endosc 2008; 68:1028-9; author reply 1029. [PMID: 18984116 DOI: 10.1016/j.gie.2008.03.1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 03/17/2008] [Indexed: 02/08/2023]
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Leung FW. Promoting informed choice of unsedated colonoscopy: patient-centered care for a subgroup of US Veterans. Dig Dis Sci 2008; 53:2955-9. [PMID: 18461456 DOI: 10.1007/s10620-008-0253-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Accepted: 03/26/2008] [Indexed: 01/03/2023]
Abstract
BACKGROUND In the United States, colonoscopy is usually performed under sedation. In practice, 2.3-7% actually requested unsedated colonoscopy and 1.4% received it because of no escorts. Efforts to increase usage would likely require increased patient counseling and education. AIM We tested the hypothesis that knowledge conveyed by education-a key attribute of patient-centered care-is associated with acceptance of the "non-usual" option. METHODS After patients underwent discussions and expressed acceptance of sedated colonoscopy, the pros and cons of and local experience with unsedated colonoscopy were added. The patients who changed from accepting sedated to unsedated colonoscopy and outcomes of their examinations were recorded. RESULTS From January to November 2006, 49 of 176 consecutive patients (28%) changed their choice from sedated to unsedated colonoscopy after being informed of the latter. Forty-eight had satisfactory bowel preparation. Cecal intubation rate was 93.7% (45 of 48). Thirty-six reported good experience and 43, likely to repeat. Cecal intubation, withdrawal, and discharge times were 23.0 +/- 1.4 min, 15.0 +/- 1.0 min, and 5.0 +/- 0.5 min, respectively (n = 45). Ability to communicate with the colonoscopist during and after the examination was the most frequently ranked reason for choosing unsedated colonoscopy. CONCLUSION Our uncontrolled, non-randomized, single-site observational data revealed that for selected veterans, acceptance of unsedated colonoscopy coincides with knowledge of the option dispensed by patient counseling and education.
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Affiliation(s)
- Felix W Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA 91343, USA.
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Unsedated colonoscopy introduced to ensure access is acceptable to a subgroup of veterans. Dig Dis Sci 2008; 53:2719-22. [PMID: 18274901 DOI: 10.1007/s10620-007-0192-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2007] [Accepted: 12/21/2007] [Indexed: 01/28/2023]
Abstract
BACKGROUND Nurses for monitoring and recovery are required for sedated colonoscopy. A nursing shortage necessitated discontinuation of sedated colonoscopy at a VA academic training program. AIM Elements of a case series that documented acceptance of unsedated colonoscopy are reviewed to raise awareness of the feasibility of this option. METHOD The pros and cons of sedation and no sedation were summarized. After discussion, patients who chose the unsedated option were scheduled for examination locally while those who desired sedation were scheduled at another VA site. Colonoscopy was performed by supervised trainees. RESULTS From September 2002 to June 2005 scheduled unsedated colonoscopy was accepted by 145 of 483 veterans. Cecal intubation was achieved in 81%. Thus, of the cohort 30% had local access to and 24% completed unsedated colonoscopy. Implementation of unsedated colonoscopy obviated the need for two registered nurses previously required for sedated colonoscopy. CONCLUSION Unsedated colonoscopy offered as an option to ensure access was acceptable to a subgroup of our veteran patients. Implementation required less nursing resources. Techniques to enhance the cecal intubation rate of unsedated colonoscopy performed by supervised trainees deserves to be assessed in future studies.
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Abstract
In the United States sedation for colonoscopy is usual practice. Unsedated colonoscopy is limited to a small proportion of unescorted patients and those with a personal preference for no sedation. Over 80% of patients who accept the option of as-needed sedation can complete colonoscopy without sedation. Colonoscopy in these unsedated patients is performed with techniques similar to those used in the sedated patients. Uncontrolled observations indicate willingness to repeat colonoscopy amongst these patients was correlated significantly with low discomfort score during the examination. Methods reported to minimize patient discomfort or enhance cecal intubation during sedated or unsedated colonoscopy included use of pediatric colonoscope, variable stiffness colonoscope, gastroscope, and inhalation of nitrous oxide or insufflation of carbon dioxide, hypnosis, music, audio distraction, or simply allowing the patients to participate in administration of the medication. Research focusing on confirming the efficacy of a simple inexpensive nonmedication dependent method for minimizing discomfort will likely improve the outcome of care and more importantly will ensure compliance with future surveillance in patients accepting the unsedated option.
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Leung FW, Aharonian HS, Guth PH, Chu SK, Nguyen BD, Simpson P. Involvement of trainees in routine unsedated colonoscopy: review of a pilot experience. Gastrointest Endosc 2008; 67:718-22. [PMID: 18374030 DOI: 10.1016/j.gie.2007.11.040] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Accepted: 11/12/2007] [Indexed: 12/19/2022]
Abstract
BACKGROUND Unsedated colonoscopy is not required by the Accreditation Council of Graduate Medical Education in the curriculum of GI trainees. OBJECTIVE We describe our pilot experience with trainee participation in unsedated colonoscopy. DESIGN A retrospective review of a performance improvement program to provide access to colonoscopy. SETTING A Veteran's Affair ambulatory care facility that discontinued sedated colonoscopy because of a nursing shortage. PATIENTS A total of 145 of 483 patients who chose unsedated colonoscopy after both sedated and unsedated options were discussed. INTERVENTIONS GI fellows performed unsedated colonoscopy under the supervision of the attending physician. MAIN OUTCOME MEASUREMENTS Cecal intubation rate, patient assessment of the reasons for the choice, the unsedated experience, willingness to have another colonoscopy, and the rate of return for unsedated colonoscopy among eligible patients. RESULTS Cecal intubation was achieved in 112 of 145 patients. The adjusted success rate (excluding inadequate bowel preparation and an obstructing lesion) was 81%. The most frequently acknowledged reason for the choice was the ability to communicate with the colonoscopist. Eighty-six patients reported a good experience and were likely to accept another unsedated colonoscopy. To date, all 8 patients eligible for 3-year follow-up successfully completed another unsedated examination. LIMITATION An uncontrolled, nonrandomized review in predominantly male older veterans. CONCLUSIONS An unsedated colonoscopy might be acceptable to some populations, particularly when communication with clinicians and procedural convenience are highly valued. Involvement of trainees is feasible. Randomized controlled comparisons of sedated and unsedated options in terms of safety (eg, sedation and procedure-related complications) and cost in settings with and without a nursing shortage deserve to be considered.
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Affiliation(s)
- Felix W Leung
- Research and Medical Services, Sepulveda Ambulatory Care Center and Nursing Home, VAGLAHS, North Hills, CA 91343, USA
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Leung FW, Mann SK, Salera R, Toomsen L, Cabrera H, Prather D, Gutierrez R, Leung JW. Options for screening colonoscopy without sedation: sequel to a pilot study in U.S. veterans. Gastrointest Endosc 2008; 67:712-7. [PMID: 18279868 DOI: 10.1016/j.gie.2007.10.028] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2007] [Accepted: 10/08/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Sedation on demand combined with a novel water infusion technique enabled 23 of 44 veterans to complete screening colonoscopy without sedation. OBJECTIVE With use of the usual air insufflation technique, we determined the proportion of patients who could complete colonoscopy without sedation. DESIGN Retrospective review of prospectively collected data in a performance improvement project to minimize the burden of sedation. SETTING A Veterans Affairs open access screening colonoscopy program. SUBJECTS Ninety-three consecutive veterans who accepted on-demand sedation or scheduled no sedation. METHOD Usual air insufflation during colonoscope insertion. Medications were administered at the veteran's request. RESULTS Twenty-three veterans chose scheduled unsedated colonoscopy; 22 were completed without sedation. Sedation on demand enabled 54 to complete the procedure without medications; 16 requested medications to complete colonoscopy. Nurses' expectations indicated that the choices were credible options. CONCLUSIONS Options for screening colonoscopy without sedation combined with usual air insufflation are feasible among U.S. veterans. Confirmation by randomized controlled trial and evaluation of the impact on institutional costs and patient adherence to screening and surveillance colonoscopy deserve to be considered.
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Affiliation(s)
- Felix W Leung
- Division of Gastroenterology, Medical and Research Services, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California, Los Angeles, California, USA
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Brocchi E, Pezzilli R, Tomassetti P, Campana D, Morselli-Labate AM, Corinaldesi R. Warm water or oil-assisted colonoscopy: toward simpler examinations? Am J Gastroenterol 2008; 103:581-7. [PMID: 18076732 DOI: 10.1111/j.1572-0241.2007.01693.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Completion rates, pain, and difficulties during the exam are still problems in colonoscopy. New methods of lubrication, rarely considered a matter of study, may help in this respect. Our aim was to compare an oil-assisted technique with a modified warm water method applied during colonoscopy. METHODS A prospective, randomized, and controlled study was planned in which three groups of patients were submitted to colonoscopy: a standard lubricating method (water-soluble jelly: group A, 170 patients) was adopted in a control group, whereas the standard method plus injection into the colon of corn seed oil (group B, 170 patients) or warm water (group C, 170 patients) were employed in the other groups. The main variables evaluated were: the success rate for total intubation, the time required to reach the cecum and the time needed to examine the colon at withdrawal, and the level of pain and degree of difficulty associated with the examination. RESULTS Successful intubation to the cecum was significantly more frequent (P < 0.01 and P < 0.001, respectively) in the oil group (group B, 155/166) and in the warm water group (group C, 156/163) than in the control group (group A, 138/164), and less time was needed (P < 0.001); no significant difference was found between group B and C. Furthermore, no significant differences were found with regard to time for examination at withdrawal among the three groups. Level of pain and degree of difficulty during colonoscopy were significantly lower in the oil (P < 0.001) and in the warm water (P < 0.001) groups than in the control group, but no significant difference was found between group B and C. Neither side effects were observed for patients nor damage to the instrument. CONCLUSIONS Warm water and oil-assisted colonoscopy could be simple, safe, and inexpensive methods for easier and less painful examinations.
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Affiliation(s)
- Emilio Brocchi
- Department of Internal Medicine and Gastroenterology, University of Bologna, Bologna, Italy
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Park DI, Kim HJ, Park JH, Cho YK, Sohn CI, Jeon WK, Kim BI, Ryu SH, Sung IK. Factors affecting abdominal pain during colonoscopy. Eur J Gastroenterol Hepatol 2007; 19:695-9. [PMID: 17625440 DOI: 10.1097/01.meg.0000219097.32811.24] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The actual degree of pain or discomfort experienced during colonoscopy varies between patients. This prospective study was conducted to determine what variables, apart from the endoscopist's skill, are associated with a patient's discomfort during this procedure. DESIGN/METHODS From December 2003 to September 2004, 646 colonoscopy examinations performed by three experienced endoscopists were analysed. Midazolam and meperidine were administered intravenously 10 min before the procedure. The degree of patient discomfort was assessed by asking more than five times during the procedure and by using a visual analogue pain scale (0-10) examined up to 7 days after the procedure. Patients were divided into sub-groups as follows: (1) comfortable group (n=304), no complaint during the procedure; and (2) uncomfortable group (n=342), more than one complaint during the procedure. RESULTS The correlation between the degree of patient discomfort and the results of the visual analogue pain scale was statistically significant (r2=0.118, P<0.01). Chi-squared analyses demonstrated that female gender, younger age (<or=40 years), presence of symptoms of inflammatory bowel syndrome, history of previous abdomino-pelvic surgery, poorer bowel preparation, longer insertion time (>480 s), technically difficult insertion, and lower body mass index (BMI) are factors associated with uncomfortable procedure. Multivariate analysis demonstrated that younger age, female gender, lower BMI, difficulty of examination, and previous gynaeco-pelvic surgery in female gender are independent factors associated with discomfort during colonoscopy. CONCLUSIONS An uncomfortable colonoscopic procedure will be expected in younger, female patients with a history of gynaeco-pelvic surgery.
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Affiliation(s)
- Dong I Park
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Early DS. How to deliver the news. Gastrointest Endosc 2007; 66:113-5. [PMID: 17591483 DOI: 10.1016/j.gie.2007.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2007] [Accepted: 02/05/2007] [Indexed: 12/10/2022]
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Holubar S, Dwivedi A, Eisendorfer J, Levine R, Strauss R. Splenic Rupture: An Unusual Complication of Colonoscopy. Am Surg 2007. [DOI: 10.1177/000313480707300417] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Splenic injury is a known, albeit rare, complication of diagnostic and therapeutic colonoscopy. Within a 6-month period, we observed two colonoscopic splenic injuries. We report these two cases of splenic injury who presented differently after colonoscopy: one presented as frank hemorrhagic shock, and the other as a subacute splenic hemorrhage with symptomatic anemia. The first patient presented with hemorrhagic shock several hours after a diagnostic colonoscopy and required an emergency splenectomy. The second patient presented with symptomatic anemia several days after a diagnostic colonoscopy and was treated by angiographic embolization. Clinical presentation and discussion of the mechanisms of injury, available treatment options, and strategies for preventing colonoscopic splenic injuries are presented. Awareness of this complication is paramount in early recognition and management of this potentially life-threatening injury.
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Affiliation(s)
- Stefan Holubar
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
| | - Amit Dwivedi
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
| | - J. Eisendorfer
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
| | - R. Levine
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
| | - R. Strauss
- Department of General Surgery, North Shore University-Long Island Jewish Hospital, Manhasset, New York
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Bouvet L, Chassard D, Boselli E. Can continuous infusion be a better choice than patient-controlled sedation for colonoscopy during monitored anaesthesia care? Acta Anaesthesiol Scand 2007; 51:382-3. [PMID: 17155940 DOI: 10.1111/j.1399-6576.2006.01201.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Blondon H, Compan F. Feasibility of colonoscopy without sedation. A retrospective study of 502 procedures. ACTA ACUST UNITED AC 2006; 30:328-9. [PMID: 16565675 DOI: 10.1016/s0399-8320(06)73182-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Lee JG, Lum D, Urayama S, Mann S, Saavedra S, Vigil H, Vilaysak C, Leung JW, Leung FW. Extended flexible sigmoidoscopy performed by colonoscopists for colorectal cancer screening: a pilot study. Aliment Pharmacol Ther 2006; 23:945-51. [PMID: 16573797 DOI: 10.1111/j.1365-2036.2006.02838.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Caecal intubation can be achieved by extended flexible sigmoidoscopy in 32% of patients. AIM To assess the feasibility of extended flexible sigmoidoscopy performed by colonoscopists for colorectal cancer screening. METHODS We enrolled 41 patients referred for screening flexible sigmoidoscopy. After purging, examination was performed with a colonoscope. All patients completed sigmoidoscopy (success in meeting referral goal); 93% and 71% had examination to the transverse or ascending colon, and caecum, respectively. Overall yield and right-sided polyps was 56% and 27%, respectively. Caecal intubation and complete examination with polypectomy took 6.0 +/- 2.5 and 18.3 +/- 5.1 min, respectively; with no complications. Twelve patients requested colonoscope withdrawal because of discomfort. Although 46% reported moderate to severe discomfort, 39% and 36%, respectively, were definitely or probably willing to repeat flexible sigmoidoscopy. RESULTS Unsedated colonoscopy introduced as extended flexible sigmoidoscopy emphasizes the benefits of added yield rather than the negative image of withholding of discomfort relief. The patient can choose to accept the equivalent of an unsedated colonoscopy or reject the option based on perceived discomfort during extended flexible sigmoidoscopy performed by the colonoscopist. CONCLUSION Extended flexible sigmoidoscopy is a feasible option in carefully selected patients, fully prepared and by an experienced colonoscopist.
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Affiliation(s)
- J G Lee
- Research and Medical Services, Veterans Affairs Northern California Health Care System, University of California Davis Medical Center, Sacramento, USA
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35
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Crepeau T, Poincloux L, Bonny C, Lighetto S, Jaffeux P, Artigue F, Walleckx P, Bazin JE, Dapoigny M, Bommelaer G. Significance of patient-controlled sedation during colonoscopy. Results from a prospective randomized controlled study. ACTA ACUST UNITED AC 2006; 29:1090-6. [PMID: 16505753 DOI: 10.1016/s0399-8320(05)82172-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In France, general anesthesia is given to more than 90% of patients undergoing colonoscopy although in several countries sedation is limited to intolerant patients. This study was carried out to determine whether Patient-Controlled Sedation (PCS) could provide a lighter sedation than general anesthesia adapted to the patient's individual requirement. METHODS Patients aged from 18 to 80 scheduled for elective colonoscopy were prospectively randomized to receive either standard sedation (control group) or patient-controlled-sedation (PCS). In the control group, patients received a continuous infusion of propofol. Patients in the PCS group were connected to an infusion pump containing propofol and self-administered 20-mg boluses as often as they required. An anesthetist was present throughout the procedure. Patient satisfaction measured on a visual analog scale four hours after colonoscopy was the main outcome criterion. RESULTS From December 2002 to September 2003, 402 patients underwent elective colonoscopy, 173 of them were eligible and were asked to participate in the study. Seventy-two gave their informed consent and were prospectively randomized. The patients' mean satisfaction scores were not statistically different between the two groups: 84.7 mm (PCS group) vs. 91.5 mm (control group); P = 0.24. Mean doses of propofol (60 mg vs. 248 mg; P <0.001), depth of sedation and time before discharge (1.75 hours vs. 4.45 hours) were significantly lower for patients in the PCS group; nine of them (25.7%) did not use the pump and had total colonoscopy without sedation. There were no statistically significant differences between the two groups regarding total duration of colonoscopy (19.4 min (PCS) vs. 18 min (control)) difficulty and therapeutic procedures (biopsy or polypectomy). Two weeks after the procedure, 96.5% of patients in the PCS group were willing to repeat the examination under the same conditions vs. 72.5% of patients in the control group (P = 0.03). CONCLUSIONS Our results demonstrate that need of sedation is widely overestimated in France. A subset of our patients is willing to consider colonoscopy without general anesthesia. For them, PCS with propofol is an effective and very well accepted form of sedation.
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Affiliation(s)
- Thomas Crepeau
- Service d'Hépato-gastroentérologie, Hôtel-Dieu. thomas.crepeau@wanadoo
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Tu RH, Grewall P, Leung JW, Suryaprasad AG, Sheykhzadeh PI, Doan C, Garcia JC, Zhang N, Prindiville T, Mann S, Trudeau W. Diphenhydramine as an adjunct to sedation for colonoscopy: a double-blind randomized, placebo-controlled study. Gastrointest Endosc 2006; 63:87-94. [PMID: 16377322 DOI: 10.1016/j.gie.2005.08.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2004] [Accepted: 08/03/2005] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intravenous benzodiazepines in combination with opiates are used to achieve moderate sedation for colonoscopy. Although effective, these agents have potential adverse effects, such as respiratory depression and hypotension. Diphenhydramine hydrochloride possesses central nervous system depressant effects that theoretically could provide a synergistic effect for sedating patients. OBJECTIVE The objective was to assess the efficacy of adding diphenhydramine hydrochloride as an adjunct to improve sedation and to reduce the amount of standard sedatives used during colonoscopy. DESIGN We conducted a prospective, randomized, double-blind, placebo-controlled study. SETTING The study was conducted in a university hospital with an active GI fellowship training program. PATIENTS The study group comprised 270 patients undergoing screening/diagnostic/therapeutic colonoscopy were enrolled. INTERVENTIONS Patients were randomized to receive either 50 mg of diphenhydramine or placebo, given intravenously 3 minutes before starting conscious sedation with intravenous midazolam and meperidine. MAIN OUTCOME MEASUREMENTS The main outcome measure was anesthetic effect as assessed by the endoscopy team and by the patient; quantity of adjunctive sedatives to achieve adequate sedation. RESULTS Of 270 patients, data were analyzed for 258 patients, with 130 patients in the diphenhydramine group and 128 patients in the placebo group. There was a 10.1% reduction in meperidine usage and 13.7% reduction in midazolam usage in favor of the diphenhydramine group. The mean evaluation scores as judged by the faculty, the fellows, and the nurses were statistically significant in favor of the diphenhydramine group. In addition, patient scores for overall sedation and pain level favored the group that received diphenhydramine. CONCLUSIONS Intravenous diphenhydramine given before initiation of standard sedation offers a significant benefit to conscious sedation for patients undergoing colonoscopy.
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Affiliation(s)
- Raymond H Tu
- Department of Transplantation, The Permanente Medical Group, Inc, Santa Teresa Medical Center, San Jose, California, USA
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Abstract
The use of sedation for routine endoscopic procedures, including colonoscopy, varies widely across cultures. This variation in sedation practice is greater than any other culturally based variation in the technical performance of endoscopy. This article sequentially reviews the technical performance of colonoscopy in patients who undergo unsedated colonoscopy, sedation with narcotics and benzodiazepines, and deep sedation with propofol. For each of these approaches to colonoscopy, the advantages and disadvantages also are listed and discussed.
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Affiliation(s)
- Douglas K Rex
- Indiana University Hospital, 550 North University Boulevard, Indianapolis, IN 46202, USA.
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Nahas SC, Marques CFS, Araújo SA, Aisaka AA, Nahas CSR, Pinto RA, Kiss DR. [Colonoscopy as a diagnostic and therapeutic method of the large bowel diseases: analysis of 2,567 exams]. ARQUIVOS DE GASTROENTEROLOGIA 2005; 42:77-82. [PMID: 16127561 DOI: 10.1590/s0004-28032005000200003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Since the sixties, when the optic fibers were reported, colonoscopy had emerged as the first line imaging investigation of the colon. AIM To review the results of diagnostic and therapeutic colonoscopy at the Discipline of Coloproctology of the University of São Paulo Medical School, São Paulo, SP, Brazil, respecting the characteristics of an institution of medical education. METHODS Retrospective analysis of basis related to 2,567 fibro colonoscopies between 1984 and 2002. The procedure was performed in hospitalized and in outpatients. The most common indications for colonoscopy were investigation of rectal bleeding and anemia (22.4%), change of bowel habit (14.76%), inflammatory bowel disease (8.65%) and carcinoma (7.25%). Bowel preparation with manitol was used by most of the patients. Sedation, when not contra-indicated, was administered. The most common combination was meperidine and benzodiazepine. All the exams were monitored with pulse oximeter. A normal colonoscopy to the point of maximum insertion was reported in 42.42% of procedures. The most common diagnosis was polyps (15.47%), followed by diverticular disease (12.86%). Inflammatory disease was recorded in 11.88% and carcinoma in 10.21%. Polypectomy was undertaken in 397 patients (2.21 polypectomy per patient with polyps). Colonoscopy was considered incomplete (when the colonoscope did not pass to the cecum or terminal ileum) in 181 (7.05%) cases. Perforation was reported in one patient who had a subestenosing retossigmoid tumor. In 0.42%, reasons for failing to complete the procedure included complication related to sedation, with no further prejudice for the patients. CONCLUSIONS Colonoscopic examination of the entire colon remains the standard for visualization, biopsy and treatment of colonic affections. The incidence of complication of endoscopy of the large bowel is quite low, even in a school hospital.
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Affiliation(s)
- Sergio Carlos Nahas
- Serviço de Coloproctologia, Hospital das Clínicas da Faculdade de Medicina de Universidade de São Paulo, SP
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Abstract
PURPOSE The administration of sedative drugs at colonoscopy has its drawbacks, such as increasing the rate of complications and the cost. There are a number of potential advantages to performing colonoscopy without sedation. The aim of this study is to evaluate patient tolerance and acceptance during sedation-free colonoscopy. METHODS Pain during sedation-free colonoscopy was evaluated in consecutive series of 675 patients in a prospective manner from January 1, 2003, to February 18, 2004. We recorded the degree of patient pain during colonoscopy, willingness to undergo sedation-free colonoscopy in the future, the complication rate, and the intubation time. The assisting endoscopy nurses and patients independently assessed the pain level immediately after the procedure using a four-point pain scale (nil, mild, moderate, severe). RESULTS Almost all colonoscopies (99.6 percent: 672/675) were successful. There were four complications related to colonoscopy (bleeding after polypectomy). Patients and nurses rated pain by a four-point pain scale as follows. For the patients: nil, 69.6 percent (470/675); mild, 28.0 percent (189/675); moderate, 2.2 percent (15/675); severe, 0.1 percent (1/675). For the nurses: nil, 76.1 percent (514/675); mild, 22.7 percent (153/675); moderate, 0.9 percent (6/ 675); severe, 0.3 percent (2/675). Patients rarely suffered from severe pain during carefully performed colonoscopies. The pain level of almost all colonoscopies was acceptable by patients, with only six patients (1.0 percent) stating that they would never undergo a colonoscopy without sedation in the future because of unbearable pain. CONCLUSIONS This study suggests that carefully performed sedation-free colonoscopy rarely causes complications and is well accepted by most patients. Sedation-free colonoscopy is more cost-effective, may be safer, and should be offered as an alternative to colonoscopy with sedation.
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Affiliation(s)
- Yuuichi Takahashi
- Division of Gastroenterology and Endocrinology, Department of Medicine, Tomishiro Chuo Hospital, Okinawa, Japan.
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40
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López-Cepero Andrada JM, Amaya Vidal A, Castro Aguilar-Tablada T, García Reina I, Silva L, Ruiz Guinaldo A, Larrauri De la Rosa J, Herrero Cibaja I, Ferré Alamo A, Benítez Roldán A. Anxiety during the performance of colonoscopies: modification using music therapy. Eur J Gastroenterol Hepatol 2004; 16:1381-6. [PMID: 15618849 DOI: 10.1097/00042737-200412000-00024] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND STUDY AIMS Colonoscopies are usually performed using pharmacological sedation. This process entails certain risks. In the search for alternative methods, some studies have analysed the effect music can have on patients during the procedure when used as a complement to sedation. We present a prospective, randomized study in which we assess the anxiolytic action music has when it is administered during a single colonoscopy. PATIENTS AND METHODS We included 118 patients who were scheduled for ambulatory colonoscopies. They were randomly assigned to the control group (n = 55) and the experimental group (n = 63). We determined their levels of anxiety using the State-Trait Anxiety Inventory Test (STAI) form, which they filled in before and after the examination. Patients listened to music through personal headphones. RESULTS The score on the STAI form before the examination was 25.25 +/- 10.49 and 28.16 +/- 11.43 in the control and experimental groups, respectively (P > 0.05). The decrease of the score on the STAI scale after the colonoscopy in the control and experimental groups was 6.27 (95% confidence interval, 3.26-9.28) and 11.35 (95% confidence interval, 8.64-14.05), respectively (P < 0.01). CONCLUSIONS Listening to music during ambulatory colonoscopies decreases the level of anxiety that is inherent to the process without other anxiolytic methods.
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Affiliation(s)
- J M López-Cepero Andrada
- Department of Medicine, Division of Gastroenterology, Hospital de Jerez, Jerez de la Frontera, Cádiz, Spain
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Madan A, Minocha A. Who is willing to undergo endoscopy without sedation: patients, nurses, or the physicians? South Med J 2004; 97:800-5. [PMID: 15455958 DOI: 10.1097/01.smj.0000129794.97798.a5] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Some studies suggest that the majority of the United States population is now willing to undergo unsedated endoscopy. We studied the willingness of patients, nurses, and physicians to undergo endoscopy without sedation. METHODS Adult patients presenting to us for outpatient endoscopy at two large tertiary care level 1 trauma hospitals were asked to fill out a survey questionnaire recording their demographic information, prior experience with endoscopy and sedation, and whether they were willing to undergo unsedated endoscopy. Their anxiety level was assessed using the Beck Anxiety Inventory. After the endoscopic procedure, patients were asked whether they had any change in their decision regarding unsedated endoscopy. A random convenience sample of physicians and nurses were also given a questionnaire asking about their experience with endoscopy and whether they were willing to undergo such procedures without sedation. RESULTS A total of 127 patients, 117 nurses, and 51 physicians participated in the study. Only 19.5% of patients were willing to undergo upper endoscopy without sedation. Among patients, the willingness dropped to 6.75% postprocedurally. Results were similar for colonoscopy. Physicians were least likely to agree to an unsedated procedure (2.2%). Gastroenterology (GI) nurses were more likely to undergo unsedated esophagogastroduodenoscopy (39.3%) as opposed to non-GI nurses (7.1%, P < 0.001). 19.6% of GI nurses agreed to unsedated colonoscopy versus 0% in the non-GI group (P = 0.001). Preprocedure anxiety level was not found to be a predictor for willingness to undergo unsedated endoscopy. Female patients were more likely to forego sedation preprocedurally (OR = 5.75; 95% CI = 2.05-16.2). However, postprocedurally, gender was no longer a significant predictor. Similarly, among the nurses and physicians, neither age nor gender was a significant predictor of willingness to undergo unsedated endoscopy. Patients with a high school (OR = 0.01; 95% CI = 0.01-0.06) or associates degree (OR = 0.02; 95% CI = 0.01-0.35) were less likely to forego sedation. CONCLUSION In contrast to reports from some major medical centers, the current study found that most patients as well as medical professionals were unwilling to undergo endoscopy without sedation.
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Affiliation(s)
- Anand Madan
- Division of Gastroenterology, Southern Illinois University School of Medicine, Springfield, IL, USA
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Campbell L, Imrie G, Doherty P, Porteous C, Millar K, Kenny GNC, Fletcher G. Patient maintained sedation for colonoscopy using a target controlled infusion of propofol. Anaesthesia 2004; 59:127-32. [PMID: 14725514 DOI: 10.1111/j.1365-2044.2004.03580.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In this study, we evaluated safety and recovery using a patient maintained, target controlled infusion of propofol for sedation in 20 patients undergoing colonoscopy. Using a handset with a two-minute lockout interval, patients could make 0.2 micro g.ml(-1) increments to an initial target plasma concentration of 1 micro g.ml(-1) up to a maximum 4.5 micro g.ml(-1). Four patients became oversedated but required no airway or circulatory interventions. Subjects had a significant reduction in mean (SD) heart rate: 78.7 (15) vs. 69.8 (13.5) (p < 0.001) and in systolic blood pressure 121.1 (13.2) mmHg vs. 96.5 (8.6) mmHg (p < 0.001). Choice reaction time testing 15 min after colonoscopy showed a significant median (IQR [range]) rise of 162 (- 16, 383.3 [-199-859]) ms (p < 0.05). Six patients had faster reaction times postcolonoscopy. All patients denied unpleasant recall and were satisfied with the system. Although oversedation was a problem in this model, we conclude that patient maintained propofol sedation could be possible for colonoscopy.
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Affiliation(s)
- L Campbell
- Department of Anaesthetics, The Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, UK.
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Waring JP, Baron TH, Hirota WK, Goldstein JL, Jacobson BC, Leighton JA, Mallery JS, Faigel DO. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc 2003; 58:317-22. [PMID: 14528201 DOI: 10.1067/s0016-5107(03)00001-4] [Citation(s) in RCA: 224] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.
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Abstract
BACKGROUND Colonoscopy may be associated with discomfort when performed without sedation. A study was conducted to determine whether instillation of water into the colon at the beginning of the procedure reduces intubation time as well as patient discomfort and pain. METHODS Colonoscopy was performed in 259 patients by 3 endoscopists-in-training with limited experience. Patients were randomly allocated to 2 groups. In one, a technique was used in which 500 to 1000 mL of water is instilled into the colon by enema at the beginning of the procedure (instillation group, n = 130). In the other, patients underwent a conventional colonoscopy (control group, n = 129). Intubation time was measured and compared between the groups, and subjective discomfort experienced by the patients was measured upon completion of the examination. RESULTS Success rates for insertion to the cecum were similar, (95.4%, instillation group; 96.1%, control group). Detection rates for any colorectal diseases were not different between the groups (30.0% vs. 32.6%). Mean time to cecal intubation was 10.5 minutes in the instillation group and 16.2 minutes in the control group (p < 0.0001). The proportion of patients who complained of abdominal pain during the procedure was 17.1% in the instillation group and 33.3% in the control group (p < 0.001). CONCLUSIONS When used by endoscopists-in-training, the water-instillation colonoscopy technique was associated with less discomfort and faster cecal intubation with no decrease in the rate of detection of colorectal diseases.
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Radaelli F, Meucci G, Terruzzi V, Spinzi G, Imperiali G, Strocchi E, Lenoci N, Terreni N, Mandelli G, Minoli G. Single bolus of midazolam versus bolus midazolam plus meperidine for colonoscopy: a prospective, randomized, double-blind trial. Gastrointest Endosc 2003; 57:329-35. [PMID: 12612511 DOI: 10.1067/mge.2003.104] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The aim of this study was to determine whether a single bolus of meperidine in addition to midazolam improves patient tolerance during colonoscopy. METHODS Consecutive patients undergoing outpatient colonoscopy were randomly assigned in double-blind fashion to receive a single rapid intravenous bolus of 5 mg of midazolam and placebo (Group A, n = 125) or 5 mg midazolam plus 50 mg meperidine (Group B, n = 128). Tolerance (4-point scale: 1 excellent, 4 unbearable), pain (4-point scale: 1 none, 4 severe) and willingness to undergo another colonoscopy were assessed 24 to 48 hours later in a telephone interview conducted by an independent observer blinded to the regimen of sedative medication. RESULTS Significantly more patients in Group A reported moderate or severe pain (28% vs. 9%; p < 0.001), poor or unbearable tolerance (18% vs. 6%; p < 0.01) and unwillingness to undergo colonoscopy again in the future (14% vs. 5%; p < 0.05). By multivariate analysis, randomization to the midazolam group and younger age were the only variables independently associated with the risk of reporting at least one of these outcomes. Recovery time, frequency of oxygen desaturation, and need for supplemental oxygen were not significantly different between the 2 groups. CONCLUSIONS The addition of a single bolus of meperidine to midazolam improves patient tolerance and lessens pain during colonoscopy without significantly increasing the frequency of side effects or prolonging recovery time.
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Thiis-Evensen E, Hoff GS, Sauar J, Majak BM, Vatn MH. The effect of attending a flexible sigmoidoscopic screening program on the prevalence of colorectal adenomas at 13-year follow-up. Am J Gastroenterol 2001; 96:1901-7. [PMID: 11419846 DOI: 10.1111/j.1572-0241.2001.03891.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Understanding the epidemiology of colorectal adenomas is a prerequisite for designing follow-up programs after polypectomy. The aim of the study was to investigate the effect of polypectomy on the long-term prevalence of adenomas. METHODS In 1983, a total of 799 men and women aged 50-59 yr were drawn from the general population register. Of these, 400 comprised a screening group and 399 a matched control group. The screenees were invited to undergo a once-only flexible sigmoidoscopy. Persons with polyps had a baseline colonoscopy with follow-ups in 1985 and 1989. In 1996, both the screenees and the controls were invited to a colonoscopic examination. RESULTS In 1996, a total of 451 (71%) individuals attended. Adenomas were found in 78 (37%) individuals in the screening group and 103 (43%) in the control group, relative risk (95% confidence interval): 0.9 (0.7-1.1), p = 0.3, and high-risk adenomas (severe dysplasia, adenomas > or = 10 mm, villous components) were found in 16 (8%) and 32 (13%), respectively; relative risk (95% confidence interval): 0.6 (0.3-1.0), p = 0.07. CONCLUSIONS There was no significant difference in adenoma prevalence between the group after the screening program and the controls after the usual care. There was a trend toward more high-risk adenomas in the control group. This suggests a very limited effect of one-time screening sigmoidoscopy with surveillance colonoscopy on the prevalence of adenomas, but a preventive effect on the development of high-risk adenomas consistent with the reported effect on cancer prevention.
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Affiliation(s)
- E Thiis-Evensen
- Department of Medicine, Telemark Central Hospital, Skien, Norway
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Theodorou T, Hales P, Gillespie P, Robertson B. Total intravenous versus inhalational anaesthesia for colonoscopy: a prospective study of clinical recovery and psychomotor function. Anaesth Intensive Care 2001; 29:124-36. [PMID: 11314831 DOI: 10.1177/0310057x0102900206] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
A randomized, prospective study was conducted on 69 patients comparing recovery after two different anaesthetic techniques for ambulatory colonoscopy. Thirty-five patients received an intravenous fentanyl (1 microg/kg), midazolam (0.05 to 0. 075 mg/kg) and propofol (10 to 20 mg boluses as required) combination. 34 patients received sevoflurane in 67% nitrous oxide. Drug administration was titrated to clinical signs. At baseline and 30, 60, 90 and 120 minutes after the procedure patient performance on a comprehensive battery of psychomotor tests was recorded. Emergence times were noted. Depth of sedation was assessed at 5 minute intervals for 30 minutes after the end of the procedure. Emergence times were faster in the fentanyl/midazolam/propofol group by 2.2 minutes. A lower sedation score was detected at 20 minutes in the sevoflurane/nitrous oxide group. Psychomotor impairment was of a greater magnitude and more prolonged by 30 to 90 minutes in the fentanyl/midazolam/propofol group. It is concluded that a sevoflurane/nitrous oxide anaesthetic has a suitable recovery profile for ambulatory colonoscopy and results in faster recovery of cognitive function compared with a fentanyl, midazolam and propofol combination.
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Affiliation(s)
- T Theodorou
- Department of Anaesthesia, Westmead Hospital, Sydney, New South Wales
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Affiliation(s)
- L J Brandt
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467, USA
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Kim WH, Cho YJ, Park JY, Min PK, Kang JK, Park IS. Factors affecting insertion time and patient discomfort during colonoscopy. Gastrointest Endosc 2000; 52:600-5. [PMID: 11060182 DOI: 10.1067/mge.2000.109802] [Citation(s) in RCA: 155] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Successful colonoscopy depends on insertion of the instrument to the cecum, precise observation, and minimal patient discomfort during the procedure. The aim of this prospective study was to determine whether certain variables are associated with insertion time and patient discomfort during colonoscopy. METHODS Nine hundred nine consecutive colonoscopic examinations performed by a single endoscopist in patients without obstructive disease of the colorectum were analyzed. Four liters of Colonlyte (Taejun, Seoul, Korea) were used for bowel cleansing, and meperidine (25 mg) was administered intramuscularly 10 minutes before the procedure. The degree of patient discomfort was assessed using a 5-level Likert scale. RESULTS Among 909 study patients, colonoscopy was completed to the cecum in 876 patients (96.4%). The adjusted completion rate was 98% and mean insertion time for complete colonoscopy was 6.9+/-4.2 minutes. Colonoscopy caused less patient discomfort than barium enema or esophagogastroduodenoscopy. Multivariate logistic regression analysis demonstrated that inadequate bowel cleansing, advanced age, and constipation as an indication are independent factors associated with prolonged insertion time (>10 minutes). Female gender was the only independent factor associated with significant discomfort (> or = level 4) during colonoscopy. CONCLUSIONS Among the factors affecting insertion time and patient discomfort during colonoscopy, unsatisfactory bowel preparation was the only correctable factor.
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Affiliation(s)
- W H Kim
- Division of Gastroenterology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.
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Thiis-Evensen E, Hoff GS, Sauar J, Vatn MH. Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps. Gastrointest Endosc 2000; 52:606-10. [PMID: 11060183 DOI: 10.1067/mge.2000.109804] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The administration of sedative drugs at colonoscopy has its drawbacks such as increases in the rate of complications and cost. Our aim was to study how individuals, drawn from a population registry and invited to undergo screening colonoscopy for colorectal polyps, experienced the procedure without conscious sedation. METHODS Four hundred fifty-one individuals underwent the screening examination (median age 67 years, range 63 to 72). The cecum was intubated in 369 (82%). Fourteen days after the examination, 429 of the attendees received a questionnaire designed to evaluate their tolerance of the procedure. RESULTS Four hundred nine participants (95%) replied.Twenty-one (5%) of these individuals found the examination very uncomfortable, 184 (45%) found it moderately uncomfortable, and 204 (50%) did not find it uncomfortable. A larger proportion of women than men, 110 (63%) versus 79 (41%), found the procedure very or moderately uncomfortable (p<0.001). Three hundred sixty-eight (90%) individuals stated that they would undergo repeat colonoscopy in 5 years. CONCLUSION In this screening setting, routine use of conscious sedation did not seem to be necessary, as most participants found the examination to be only moderately uncomfortable or not at all uncomfortable. Colonoscopy without conscious sedation may, however, reduce the rate of intubation of the cecum and increase the risk of missing adenomas and cancers.
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Affiliation(s)
- E Thiis-Evensen
- Department of Medicine, Telemark Central Hospital, Skien, Norway.
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