Introduction

In the Region Zealand 17.000-18.000 colonoscopies are performed annually, predominantly in an outpatient setting with or without sedation. The usage of sedation is often given on an on-demand basis, however, multiple factors like preexisting abdominal pain, preferences of the endoscopist or the patient, and local guidelines may be at play. The most common drugs used as sedatives in our region are midazolam and fentanyl and only to a lesser extend propofol or general anesthesia.

Aims & Methods

The aim of the study is to describe the usage of sedation in relation to elective outpatient colonoscopy stratified for demographics, and to analyze the influence of sedation on the colonoscopy completion rate.
This is a cohort study of patients undergoing elective colonoscopy at any hospital unit in Region Zealand from 01-Jan-2018 to 31-December-2022. All data were entered prospectively into the Endo-Database and analyzed using descriptive statistics and Chi-square test. A multivariate analysis is planned including further data such as examiner factors, but not yet completed. The results given here are therefore preliminary.

Results

From January 1^st, 2018 to December 31^st, 2022 (5 years) 43,364 men and 42,122 woman with a median age of 66 years (range 3-102) underwent colonoscopy. 356 (0.4%) had general anaesthesia, 1272 (1.5%) had propofol, 53,671 (62.8%) had midazolam and fentanyl, and 29,799 (34.9%) had no sedation. A total of 249 endoscopists at all levels of experience performed the examinations.
Significantly more woman than men received sedation during the procedure: 33,421 (79.6%) woman vs. 21,878 (50.7%) men, p<0.00001. This difference were independent of the reason for colonoscopy (cancer control, screening, HNPCC, adenoma control, referral in “cancer package”, or referral for other reasons).
Caecum or the terminal ileum was reached for 91.1% of woman and 91.4% of men, p=0.143. The usage of sedation significantly influenced the completion of the colonoscopy:
For men 93.3% of colonoscopies were complete with sedation versus 91.2% without sedation, p<0.00001. For woman 92.7% of colonoscopies were complete with sedation versus 88.5% without sedation, p<0.00001.

Procedures registered (No)	Endoscopists (No)	Procedures/ endoscopist (mean)	Sedated* (%)	Completion (%)
1-199	137	35	70	86
100-299	40	171	69	90
300-1000	47	564	69	87
1000-2000	18	1519	69	86
2000-3635	7	2956	51	92

*With midazolam and fentanyl

The table show the number of procedures performed by the endoscopists, percent of patients receiving sedation and percent complete procedures (cecum or ileum reached). The endoscopists with >2000 procedures reach cecum even without sedation. Otherwise no clear trend is found.

Conclusion

Woman received sedation significantly more frequently than men. Sedation increased the completion rate of colonoscopy in both genders seemingly more in females. Endoscopists with >2000 procedures in 5 years reached cecum even with a low usage of sedation. The current abstract is limited by univariate analysis at a preliminary stage.

Introduction

This study aimed to analyze the correlation between different attributes of doctors who prescribe colonoscopies and the cleanliness of the intestine to guide the development of colonoscopy application protocols.

Aims & Methods

Data on colonoscopy cases conducted in the gastroenterology department of Hangzhou First People's Hospital between April 2018 and March 2021 were collected. The gender, age, professional attributes of the prescribing doctors, and Boston Bowel Preparation Scale (BBPS) score were recorded. In addition, the correlation between the prescribing doctors' characteristics and the intestine's cleanliness was analyzed.

Results

The study included 22,522 patients with a mean BBPS score of 6.83±1.94. There were 16,459 male and 6,063 female doctors with similar BBPS scores (P = 0.212). The study found no significant difference in BBPS scores between 19,338 physicians and 3,184 non-physicians (P = 0.154). However, BBPS scores differed significantly between 18,168 gastroenterologists and 4,354 non-gastroenterologists (P = 0.016) and between 19,990 intestinal-related specialties and 2,532 non-intestinal-related specialties (P = 0.000). In addition, BBPS scores were significantly different between 18,126 prescribing doctors with colonoscopy ability and 4,352 without (P = 0.014). However, there was no significant difference in BBPS scores among doctors of different ages (P = 0.190). The study found significant differences in BBPS scores between male and female patients and those under or over 40 years (P = 0.000).

Conclusion

To improve colonoscopy preparation quality, priority should be given to doctors in gastroenterology, intestinal-related specialties, and with colonoscopy operation ability. Their expertise may result in better education and improved bowel cleanliness.

Introduction

Colonoscopy is the gold standard of an optimal exploration of the colon. Complete colonoscopy stands as the cornerstone for detecting precancerous lesions and colorectal screening.

Aims & Methods

The aim of our study was to identify factors limiting the completeness of the colonoscopy. We retrospectively colonoscopy reports performed between August 2023 and April 2024. Colonoscopies performed under general anesthesia were excluded from our analysis. Demographics, clinical and endoscopic data were collected. We investigated predictive factors of incomplete examinations.

Results

In total, 400 performed colonoscopies were included. The mean age of the patients was 56.5 years ± 14.22 (ranging from 16 to 91 years) and a male-to-female ratio of 2. History of diabetes was present in 24% of patients, hypertension in 38% of patients, and 7.8% of patients had chronic inflammatory bowel disease. The predominant indications for colonoscopy were constipation in 29% of cases, digestive bleeding in 16.1% of cases, diarrhea in 11% of cases, anemia in 9% of cases, screening in 4.8% of cases, and anal fistula in 3.8% of cases. The cecum was intubated in 381 colonoscopies (79.8% of cases). Interruption of the endoscopic examination were attributed to various causes, including inadequate preparation (45.5%), poor tolerance (32.5%) and irreducible loops (13%). In univariate analysis, anemia (p=0.033), history of benign prostatic hyperplasia, tolerance (p=0.05), and poor preparation (assessed by the Boston Bowel Preparation Scale) (p<0.0001) were identified as associated factors to incomplete colonoscopy. Demographic characteristics, comorbidities, irritable bowel syndrome, body mass index, abdominal hernia, history of anterior abdominal surgery were not associated with incomplete examination. On multivariate analysis, poor tolerance (p<0.0001, OR= 2.45 95%IC: 1.667-3.672), colonic preparation (p<0.0001, OR= 4.04 95%IC: 2.384-6.845) were predictive factors of incomplete colonoscopies.

Conclusion

This study confirms the importance of addressing limiting factors of a complete colonoscopy to avoid rescheduling the procedure and to prevent its psychological impact and delay in management and economic burden. Adequate analgesia and improved preparation are necessary for successful cecal intubation.

Introduction

Colonoscopy is the gold standard for accurate exploration of the colon. Thus, it must be performed as efficiently as possible with the respect of pre-established quality standards to ensure optimal exploration. The patient's tolerance considerably affects the quality of sedation-free examinations and exposes to a high rate of interruption. Pharmacological sedation can solve this issue, however it can expose to significant adverse events and is not always available.

Aims & Methods

The aim of this study was to evaluate the impact of intraprocedural immersive virtual reality (VR) combining visual and auditory distraction in the improvement of the tolerance and the progress during unsedated colonoscopy. We conducted a prospective controlled study from February to April 2023 including outpatients presenting to the endoscopy unit for unsedated colonoscopy after consent. Patients were randomized into two groups: Group 1: colonoscopy with virtual reality headset. Group 2: control group without intervention.The material used was a virtual reality headset provided with a fully adjustable headband. The video content displayed on the hardware is made of several clips showing nature scenes. The audio content was adapted to allow optimal communication with the patient. We have excluded patients with severe visual and/or auditory impairment, dementia, cognitive impairment and epilepsy. All participants initially completed a form covering health issues and a validated anxiety questionnaire (STAI). After colonoscopy, all patients completed a form with questionnaires assessing per-procedural patient comfort (Gloucester), anxiety (STAI) and pain (EVS). In addition, patients in the intervention group completed a satisfaction questionnaire (NPS: net promoter score) assessing their experiences with the VR headset.

Results

In total, 63 patients were included in the final analysis: intervention group G1 (n=33) and control group G2 (n=30). The mean age was of 57 years. No patient encountered a technical problem with the equipment used and no adverse events occurred during the immersive experience. The two groups were comparable in terms of age, gender, comorbidities, body mass index (BMI) and colonic preparation assessed by the Boston score. A slightly lower time to caecal intubation was noted in the intervention group without significant difference (G1: 19 min vs G2: 26 min, p=0.07). Patients with VR mask expressed lower levels of post-procedural anxiety than those in the control group (Mean STAI G1: 47 vs G2: 53, p<0.01) and a significant decrease in the STAI score compared to pre-endoscopy values (8 points vs 4 points, p<0.01). The per-procedural pain assessed by EVS was significantly lower in the patients using VR (Mean G1: 0.44 vs G2 :1,32, p<0.01). Moreover, endoscopic examination was found to be more comfortable with virtual reality based on the Gloucester scale p <0.01. No patient reported any impediment to communication with medical staff due to the VR mask. Four patients were not satisfied with the resolution of the videos and 8 patients have expressed their preference to choose the content themselves. Patients of the intervention group were greatly satisfied with the VR experience with a mean NPS at 30.

Conclusion

Immersive VR technology is a promising, non-invasive and well-accepted simple tool for improving tolerance by reducing colonoscopy induced pain and anxiety allowing an optimized examination. It can be a useful alternative to conventional sedation if undesired or contraindicated or in health care institutions with a lack of adequate anesthesia facilities.

Introduction

Early detection of colon adenomas and polyps lowers the risk of colorectal cancer development. Quality indicators for screening or diagnostic colonoscopy encompass the adenoma detection rate (ADR), polyp detection rate (PDR), and cecal intubation rate (CIR). Previous research on ADR, PDR, and CIR in groups of patients who were deeply sedated with propofol versus those who underwent colonoscopy without sedation is undetermined.

Aims & Methods

The objective of this study was to analyze the effects of deep sedation versus no sedation on ADR, PDR, and CIR in a population of elderly patients.

This was a retrospective cohort study that included adult patients over the age of 60, presenting for a first screening or diagnostic colonoscopy performed in the period from January 2017 to September 2023 at our clinical center. The exclusion criteria were emergency colonoscopies, inflammatory bowel diseases, intent therapeutic colonoscopies, and bowel preparation quality (based on the Boston Bowel Preparation Score, BBPS) of less than 6. Participants’ characteristics were assessed using descriptive statistics. Normal distribution was assessed using Kolmogorov-Smirnov and Shapiro-Wilk tests. Continuous variables were analyzed using Mann–Whitney test and categorical variables using Chi-square or Fisher exact test. Binary logistic regression was conducted to identify significant predictors of the outcomes. Two-tailed tests were conducted, and statistical significance was considered when p <0.05.

Results

Among 2034 patients (46.4% female; mean age: 70 years) deep sedation was performed in 622 patients (30.6%). Total PDR was 51.65%, ADR was 33.3%, and CIR was 94.25%. Patients' characteristics are shown in table 1.
After adjusting for confounders (age, gender, BMI, BBPS for PDR/ADR and age, gender, BMI, BBPS, previous abdominal/pelvic operation, diverticulosis for CIR) no significant difference was shown in PDR, ADR and CIR between no-sedation and deep sedation groups. Higher BMI (B = .041, p < .01) and male gender (B = .36, p = .02) were independent predictors for ADR.

	No-sedation (N=1412)	Deep sedation with propofol (N=622)
Age*	70 (65-76)	68 (64-73)
Female gender *	655 (46,4%)	359 (57,7%)
BMI	27 (24,3 - 30,5)	27,1 (23,7 - 29,9)
BBPS	9 (6-9)	9 (6-9)
PDR	731 (51,8%)	320 (51,5%)
ADR	472 (33,5%)	202 (32,5%)
CIR	1316 (93,2%)	593 (95,3%)
Abdominal/pelvic operation	488 (34,6%)	186 (29,9)
Diverticulosis *	523 (37,1%)	272 (43,8%)

Table 1; Patient s' characteristics, BMI; Body mass index, BBPS; Boston bowel preparation scale, PDR; Polyp detection rate, ADR; Adenoma detection rate, CIR; Cecal intubation rate, *gender χ2(3, N =2034)=27,37, p<0.01, *diverticulosis χ2(1, N =2031)=8,14, p<0.01, *age U=367989, z=-5,78; p<0,01, PDR: χ2(1, N =2033)=0,01, p=.92, ADR: χ2(1, N =2031)=0,17, p=.68

Conclusion

In our mixed cohort of elderly patients undergoing screening and diagnostic colonoscopies, propofol-induced deep sedation did not enhance ADR, PDR, or CIR. Further research is needed to determine the impact of deep sedation on colonoscopy quality parameters in elderly patients.

Introduction

Colonic diverticular bleeding (CDB) is the most common cause of acute lower gastrointestinal bleeding (ALGIB). In a recent Japanese multicenter retrospective cohort study, 63.6% of patients with ALGIB were ultimately diagnosed with CDB [1]. It has also been reported that CDB in ALGIB is reportedly more severe than in other entities [2, 3]. However, few reports have demonstrated the efficacy and safety of bowel preparation for patients undergoing urgent colonoscopy.

Aims & Methods

We aim to clarify choice a of bowel preparation for urgent colonoscopy in patients with colonic diverticular bleeding. In a multicenter retrospective cohort study at 10 institutions, we analyzed the endoscopic findings and clinical course of patients diagnosed with CDB who underwent urgent colonoscopy within 24 hours after admission. Bowel preparation consisted of oral consumption of 1 to 2 L of polyethylene glycol lavage (PEL); enemas were not used. We compared those CDB patients who underwent PEL (PEL group) with a control group who did not undergo PEL (non-PEL group) before and after propensity score matching. For the matching, we selected variables known at the time of hospital admission (i.e. age, sex, comorbidities, medications, performance status, and laboratory data). The primary endpoint of the study was length of hospital stay, and secondary endpoints included blood transfusion requirements, rebleeding rates, endoscopic findings, and complications.

Results

242 patients were enrolled in this study. The median age was 76 years, and 60.7% of patients were men (n = 147). Approximately half of the patients underwent bowel preparation with PEL prior to urgent colonoscopy (n = 129). We compared with clinical findings between the PEL and non-PEL groups. The length of hospital stay was shorter in the PEL group (8.0 ± 5.1 days vs 10.9 ± 5.8 days; mean ± SD; P < 0.001). Further, the PEL group was significantly younger (72.2 ± 12.1 vs 75.4 ± 13.1; mean ± SD; P = 0.036), had fewer patients with hypertension (62.0% vs 75.2%; P = 0.027) and malignant neoplasm (1.6% vs 10.6%; P = 0.002), and had better performance statuses (86.1% vs 76.1%; P = 0.047). Patients in the PEL group received fewer blood transfusions (25.6% vs 44.3%; P = 0.002), had a higher rate of cecal completion (88.3% vs 49.6%; P < 0.001), and shorter endoscopic observation times (20.8 ± 16.2 min vs 29.9 ± 24.8 min; mean ± SD; P = 0.006). After propensity score matching, there were 91 patients each in PEL group and in non-PEL group. PEL group had a significantly shorter hospital stay (7.9 ± 4.6 days vs 10.7 ± 5.8 days; mean ± SD; P < 0.001), a higher cecum completion rate (87.8% vs 48.3%; P < 0.001), and a shorter endoscopic observation time (20.7 ± 16.8 min vs 28.9 ± 24.1 min; mean ± SD; P = 0.031) than non-PEL group. There were no significant differences in blood transfusion requirements, rebleeding rates, identification of SRH, need for endoscopic hemostatic treatment, or complication rates.

Conclusion

In patients with CDB, urgent colonoscopy under PEL resulted in shorter hospital stays, higher cecal completion rates, and shorter endoscopic observation time in urgent colonoscopy. The safety of urgent colonoscopy with PEL was comparable to colonoscopy without PEL. These results suggest that PEL is preferrable for urgent colonoscopy in patients with CDB.

References

1. Nagata N, Kobayashi K, Yamauchi A, et al. Identifying bleeding etiologies by endoscopy affected outcomes in 10,342 cases with hematochezia: CODE BLUE-J study. Am J Gastroenterol 2021; 116: 2222-2234.
2. Aoki T, Nagata N, Shimbo T, et al. Development and validation of a risk scoring system for severe acute lower gastrointestinal bleeding. Clin Gastroenterol Hepatol 2016; 14: 1562-1570.e2.
3. Xavier SA, Machado FJ, Magalhães JT, et al. Acute lower gastrointestinal bleeding: are STRATE and BLEED scores valid in clinical practice? Colorectal Dis 2019; 21: 357-364.