Introduction

Procedural sedation and analgesia (PSA) can be associated with respiratory depression that must be recognised rapidly and managed appropriately to avoid the risk of hypoxic brain damage, cardiac arrest, and death. Standard of care monitoring (SOCM) during PSA includes electrocardiogram, respiratory rate, blood pressure, and pulse oximetry but these do not reliably identify airway or respiratory compromise. Capnography can be used to measure exhaled carbon dioxide, providing real-time identification of airway obstruction and respiratory depression. We aimed to measure the real-world impact of using capnography in addition to SOCM on patient safety during PSA for gastroenterology and bronchoscopy procedures.

Aims & Methods

A before-and-after, quality-improvement protocol was followed at four centres in Leuven, Ankara, Madrid, and Toronto using a specialised Microsoft Excel application for data collection. Collected adverse events were death, escalation of care, mild (75–90%; up to 60 seconds (s)) and severe (<75% or <90% for over 60 s) oxygen desaturation, prolonged apnoea (>60 s), bradycardia, tachycardia, airway obstruction, cardiovascular shock or collapse, and cardiac arrest. Data for SOCM were collected first, without modification to the centre’s standard practice for PSA. Then capnography was introduced, including staff training and a 2–4 week wash-in period, after which data collection commenced for capnography. Data were collected between 2017 and 2021 and combined by procedures into those using SOCM and those using SOCM plus capnography (capnography). Patients could have more than one procedure performed.

Results

Data were collected for 6,100 procedures (N=3,100 SOCM and N=3,000 capnography). Procedures were split as follows with 94.7% gastroenterology procedures: colonoscopy (n=2,773), gastroscopy (n=1,868), combined gastroscopy and colonoscopy (n=502), endoscopic ultrasound (n=362), bronchoscopy (n=326), endoscopic retrograde cholangiopancreatography (n=225), and others (n=44). Total adverse events were decreased by 38.53% from 353 (SOCM) to 217 (capnography) events. The relative risk (RR) of at least one adverse event occurring per procedure with capnography versus (vs) SOCM was 0.68 (95% confidence interval: 0.57–0.81; 9.77% vs 6.63%). Escalation of care was decreased when using capnography by RR 0.11 (0.01–0.91; 9 vs 1 events). Oxygen desaturation was decreased with RR 0.64 (0.52–0.79; 223 vs 139 events) for mild and RR 0.44 (0.24–0.82; 33 vs 14 events) for severe cases. Bradycardia and tachycardia were also reduced by RR 0.50 (0.28–0.89; 35 vs 17 events) and RR 0.14 (0.05–0.39; 30 vs 4 events), respectively. Prolonged apnoea was increased by RR 4.39 (1.48–13.04; 4 vs 17 events) when using capnography vs SOCM, potentially due to easier detection of apnoea using capnography. Airway obstruction and cardiovascular events were non-significantly different and no patient deaths were recorded.

Conclusion

In this, to date the largest real-world data set on PSA capnography monitoring, patient safety was found to be significantly improved in those procedures using capnography. Additional analyses, such as patient matching, are required to examine the potential influence of confounders on results.

Disclosure

Conflict of interest: NS is employed by Medtronic, the manufacturer of capnography. FD is employed by and RS is the owner of Coreva Scientific GmbH & Co. KG. They provided data analysis and writing services. RB, MÖ, and IVG declare no conflict of interest.
Funding: This work was funded by Medtronic.

Introduction

Sedation is integral to gastrointestinal (GI) endoscopy to enhance procedural tolerance and efficiency [1]. Traditional agents like midazolam and propofol, while effective, present limitations related to recovery time, safety, and need for anesthesiologist supervision. Remimazolam, a novel benzodiazepine with rapid onset and offset, may enable effective non-anesthesiologist-administered sedation (NAAS) in routine endoscopy [2].

Aims & Methods

A prospective, multicenter, real-world study was conducted between November 2024 and March 2025. Adult patients undergoing elective upper or lower gastrointestinal (GI) endoscopy under procedural sedation-analgesia (PSA) without the presence of an anesthesiologist were enrolled. Inclusion criteria were: age ≥18 years, American Society of Anesthesiologists (ASA) physical status I–III, and a body mass index (BMI) between 18 and 51 kg/m². Exclusion criteria included: known allergy to anesthetic drugs or a history of anesthesia-related adverse reactions; glucose-6-phosphate dehydrogenase deficiency; severe respiratory disease; and pregnancy. All patients undergoing emergency or urgent GI endoscopy were excluded.The primary outcomes were the sedative efficacy and safety of remimazolam during endoscopy. Efficacy was defined as successful completion of the procedure without interruption due to inadequate sedation. Adverse events (AEs) were recorded and classified by severity (major or minor) and type (e.g., hypotension, hypoxia, bradycardia, nausea, vomiting, and injection site pain). Remimazolam was administered by trained endoscopists: induction was achieved with 5–7 mg intravenously, titrated based on individual risk factors, with 2.5 mg supplemental doses as needed (maximum cumulative dose: 33 mg).

Results

A total of 182 patients (EGD n=75; colonoscopy n=112) were included. Procedure completion was achieved in 175 cases (96.3%), with success rates of 97.3% for EGD and 95.5% for colonoscopy. All sedation failures (n=7) were attributed to inadequate sedation and not to ASA class. No serious AEs were reported. Minor AEs included hypotension (n=4), bradycardia (n=1), nausea (n=1), vomiting (n=4), and hiccups (n=1), all managed conservatively. Median cumulative remimazolam doses were 10.9 mg (colonoscopy) and 10.0 mg (EGD), with median recovery times of 6.25 and 5.9 minutes, respectively. No patients required flumazenil or rescue sedation. Among obese patients (BMI >40), remimazolam was both effective and safe.

Conclusion

Remimazolam provides a highly effective and safe sedation alternative for GI endoscopy in real-world NAAS settings, ensuring rapid recovery and minimal AEs, even in patients with elevated ASA status or obesity. This study was prospective real-world and had several limitations. First the number of patients was too small to accurately assess rare adverse events. Further randomized controlled trials with larger populations are recommended to confirm these results.

References

1. Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017;15:456-66. doi: 10.5217/ir.2017.15.4.456.
2. Hu Q, Liu X, Wen C, et al. Remimazolam: an updated review of a new sedative and anaesthetic. Drug Des Devel Ther 2022;16:3957-74. doi: 10.2147/DDDT.S384155.

Introduction

Irritable bowel syndrome with praedominant constipation (IBS-C) is the most common subtype of IBS. Opioids prescription rate has increased worldwide over the last two decades. Opioids are not recommended for pain management in gut-brain interaction disorders.

Aims & Methods

The aim of this study was to assess the prevalence of opioids use among patients diagnosed with Rome IV IBS-C and to compare their clinical characteristics with those of IBS-C patients who do not use opioids. Data were retrospectively collected (January 2016 – December 2021) from consecutive outpatients diagnosed with IBS-C at a single tertiary care neurogastroenterology clinic in UK. A standardized template was used to collect data on age, sex, gastrointestinal (GI) symptoms, medications, and opioid use/discontinuation. Patients taking opioids were advised to discontinue opioids in line with the Centers for Disease Control and Prevention recommendations. Improvement in GI symptoms after opioids discontinuation was documented. Data are presented as median [interquartile range (IQR)] or frequency (%). Chi square test or Mann-Whitney’s U test was used, when appropriate.

Results

A total of 157 IBS-C patients were included, of whom 70 (27.2%) were on opioids. Compared with non-users, opioids users had a higher median age, more comorbidities, more concomitant medications, more surgeries and more hospital admissions (Table 1). A significantly higher proportion of opioids users reported dysphagia compared to non-users (P=.02). Fifty-eight patients (82.9%) were asked to stop opioids before introducing other medications. Twenty-two patients (31.4%) stopped opioids and, of these, 12 (54.5%) reported improvement in IBS-C symptoms:6 improved in constipation, 1 in abdominal pain and 5 in both.

Table 1. General characteristics of IBS-C patients taking or not taking opioids. Numbers are frequency (%) or median (IQR)
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Conclusion

Up to 27% of IBS-C patients consume opioids at their first outpatient consultation. Patients on opioids show a more severe clinical profile and higher healthcare resources utilization. Opioid cessation leads to IBS-C symptoms improvement in up to 55% of patients without further intervention.

Introduction

Propofol (PPF) is a short-acting, highly lipophilic intravenous agent with sedative, hypnotic, antiemetic, and amnestic properties. Acting through GABA receptor agonism and NMDA antagonism, it ensures rapid onset (30–45 seconds) and swift recovery, making it ideal for gastrointestinal endoscopic procedures. Since 1995, the American Society of Anesthesiologists has supported the use of non-anaesthesiologist providers for sedation in endoscopy. Countries including Colombia have adopted this approach, especially given the limited availability of anaesthesiologists. In the United States, fewer than 20% of colonoscopy sedations are delivered by anaesthesiologists. Recent studies report comparable safety profiles for trained non-anaesthesiologist and anaesthesiologist-administered sedation, with reduced cardiovascular complications and lower healthcare costs. However, Latin American real-world data on this model remain scarce.

Aims & Methods

This prospective, analytical prevalence study assessed the safety and effectiveness of propofol sedation administered by a general physician with specific training in sedation, airway management, and intensive care, within an ambulatory endoscopy unit. From March 2023 to April 2024, adult patients (≥18 years) undergoing colonoscopy at the Centro de Gastroenterología y Endoscopia in Bogotá were included. The physician administered age-tailored propofol bolus and maintenance doses according to clinical guidelines and procedure duration. Exclusion criteria included ASA IV status or contraindications to propofol. Sedation regimens were as follows:

• <40 years: 180 mg IV bolus; 60 mg maintenance every 5 min
• 41–70 years: 160 mg IV bolus; 50 mg maintenance every 5 min
• ≥71 years: 150 mg IV bolus; 30 mg maintenance every 5 min

Results

A total of 2,032 patients were enrolled; mean age 64 years (95% CI: 62.8–65.1), 60% female. The mean BMI was 27 (95% CI: 25.8–27.1). Colonoscopy indications included screening (35%), diagnostic evaluation (40%), surveillance (20%), and therapeutic intervention (5%), including 101 patients undergoing polypectomy. Comorbidity prevalence was notable: cardiovascular (30%), gastrointestinal (30%), respiratory (15%), neurological (5%), allergic (3%), and haematological (3%).
ASA risk classification revealed:

• ASA I: 14% (n=284)
• ASA II: 60% (n=1,219)
• ASA III: 26% (n=528)

Conclusion

This real-world study confirms that propofol sedation administered by non-anaesthesiologist physicians with critical care training is both safe and effective for the vast majority of patients undergoing colonoscopy in ambulatory settings. These findings support a task-sharing model that maximises resource efficiency while maintaining patient safety. In health systems with limited anaesthesiologist availability, this approach allows specialists to focus on higher-risk ASA IV patients in tertiary-level settings. Widespread adoption of this model, with appropriate training, could reduce costs, increase procedural throughput, and improve access to high-quality endoscopic care in Latin America and similar settings.

References

• Sato M, Horiuchi A, Tamaki M, et al. Safety and effectiveness of nurse-administered propofol sedation in outpatients undergoing gastrointestinal endoscopy. Clin Gastroenterol Hepatol. 2019;17(6):1098–1104.e1. doi:10.1016/j.cgh.2018.06.025.
• Ferreira AO, Torres J, Barjas E, et al. Non-anesthesiologist administration of propofol sedation for colonoscopy is safe in low-risk patients: results of a noninferiority randomized controlled trial. Endoscopy. 2016;48(8):747–753. doi:10.1055/s-0042-105560.
• Lucendo AJ, Olveira A, Friginal-Ruiz AB, et al. Nonanesthesiologist-administered propofol sedation for colonoscopy is safe and effective: a prospective Spanish study over 1000 consecutive exams. Eur J Gastroenterol Hepatol. 2012;24(7):787–792. doi:10.1097/MEG.0b013e328353fcbc.

Introduction

Endoscopic radical excision in the rectum may offer a curative, organ-preserving strategy, potentially reducing the need for surgery and its associated morbidity and mortality.¹ The muscle-retracting sign (MRS) detected using the pocket-detection method (PDM) has shown moderate to high diagnostic accuracy for real-time submucosal invasion (SMI) depth assessment in rectal lesions.² This study evaluated the technical and clinical outcomes of a structured algorithm combining PDM and MRS for real-time invasion depth assessment with endoscopic resection of rectal lesions.

Aims & Methods

We prospectively included consecutive patients with rectal lesions at risk of SMI at a tertiary care centre between September 2023 and March 2025. We excluded lesions with nodal metastases on radiological staging and subepithelial lesions. A management algorithm was applied, incorporating PDM for MRS status evaluation and invasion assessment, followed by endoscopic resection based on MRS status, lesion size, and location: endoscopic submucosal dissection (ESD; MRS-, all locations), endoscopic intermuscular dissection (EID; MRS+ or severe fibrosis, distal rectum), knife-assisted full-thickness resection (kFTR; MRS+ or severe fibrosis, any size, proximal extraperitoneal rectum), or device-assisted full-thickness resection (FTRD; MRS+ or severe fibrosis, ≤15 mm, intraperitoneal rectum). Primary outcomes were technical success, en-bloc and R0 resection and adverse events.

Results

37 rectal lesions were included (mean patient age 68.8 years [SD 10.1]; 56.8% male). The median lesion size was 30 mm (IQR 20–40), mostly located in the distal rectum (23/37; 62.2%), and distributed as anterior (n = 12), lateral (n = 11), and posterior (n = 14). 5 lesions (13.5%) were classified as JNET 2b, 15 (40.5%) as JNET 3.
Among MRS-negative lesions (23/37; 62.2%), 22 underwent ESD, and 1 underwent EID for submucosal fibrosis. In MRS-positive lesions (14/37; 37.8%), the selected treatments included EID in 7, kFTR in 6, and FTRD in 1.
Technical success of PDM and endoscopic resection was achieved in 36/37 cases (97.3%). En-bloc resection was achieved in 36/37 (97.3%) cases, and R0 resection in 34/36 (94.4 %). Pathology revealed deeply invasive (>pT1sm1) adenocarcinoma in 14/37 (37.8%), with 83.8% diagnostic accuracy of PDM + MRS. Curative resection was achieved in 26/37 cases (70.3%). Adverse events occurred in 4/37 patients (10.8%), including delayed bleeding in 3 (8.1%) and pneumonia in 1 (2.7%). No delayed perforation occurred. The median length of hospital stay was 1 day (IQR 1-1).
Rectal preservation was achieved in 34/37 patients (91.9%), with a median follow-up of 8.8 months (IQR 5.3-10.8). We observed no loco-regional recurrences, distant metastases, or deaths. Surgery was performed for technical failure in one case (kFTR aborted due to massive invasion, pT2N0 adenocarcinoma) and for non-curative resections in 2 cases (one with pT0N1 and another with pT0N0 in surgical specimens).

Conclusion

The PRIME endoscopic algorithm demonstrated high technical success, en-bloc and R0 resection rates for rectal lesions at risk of SMI. This minimally invasive approach allowed rectal preservation in the majority of patients with a low rate of complications, making it a promising alternative to surgery for such lesions.

References

1. Argenziano, M.E.*, Sorge, A.*, Hoorens, A., Montori, M., Poortmans, P.J., Smeets, S., Tornai, T., Debels, L.K., Desomer, L. and Tate, D.J. (2025), Knife-assisted full-thickness resection guided by the pocket-detection method for posterior deeply invasive rectal cancer: A novel endoscopic approach (with video). DEN Open, 5: e70116. https://doi.org/10.1002/deo2.70116
2. Argenziano, M E*; Sorge, A*; Montori, M; Poortmans, P J; Tornai, T; Smeets, S; Al-Dury, S; Debels, L; Desomer, L; Tate, D J Accuracy of the Muscle Retraction Sign for determining deep Submucosal Invasion During Endoscopic Resection of Rectal Lesions. Endoscopy 2025; 57(S02): 14 - 14 DOI: 10.1055/s-0045-1805114

Introduction

Effective withdrawal time (EWT), as measured by EndoScreener QC (Wision A.I.), is a novel artificial intelligence (AI)-derived colonoscopy quality metric, which measures the actual duration of clear images obtained during scope withdrawal from cecum to rectum. We have previously demonstrated the superiority of EWT to standard withdrawal time (SWT) on adenoma detection rate (ADR) in a retrospective study.(1) This prospective study determines the association between EWT and colonic lesion detection rates.

Aims & Methods

This was a prospective evaluation of the use of real-time determination of EWT, as measured by the EndoScreener QC, of endoscopists who were blinded to the output of the system. Patients were recruited in our hospital from Nov 2023 to Feb 2024. All examination was performed with high-definition endoscopes (EVIS-EXERA 290 video system, Olympus Optical, Tokyo, Japan) under white light. In all examination, colonoscope was first advanced to the cecum as confirmed by identification of the appendiceal orifice and ileocecal valve or by intubation of the ileum. After cecal intubation, the colonoscopy was slowly withdrawn. The AI derived (AI) real time effective mucosal examination monitor system (EndoScreen QC) was initiated during scope withdrawal, starting from cecum to anus. The SWT was defined as total withdrawal time from cecum to rectum after excluding polypectomy and biopsy time. All detected polyps were removed during scope withdrawal only. The size (measured with biopsy forceps), location and morphology of each polyp was recorded by an independent observer. The bowel preparation quality was graded according to the Boston Bowel Preparation Scale. The primary outcome was the correlation between EWT and ADR, which was determined by the Pearson correlation coefficient (r); and compared with SWT. Other outcomes included correlation between EWT and polyp detection rate (PDR) or serrated lesion detection rate (SDR).

Results

In the prospective analysis, 185 colonoscopies performed by 9 endoscopists were analyzed. The mean age was 67.4 year (SD: 10.5) and 57.3% (n=106) were male. 83.9% (n=154) were diagnostic colonoscopy. The median Boston Bowel Preparation score (BBPS) was 7. The mean ADR was 49.2% (95% CI: 41.6-56.2, n=91), mean EWT was 4.4 (95% CI: 4.1-4.6) minutes and mean SWT was 7.1 (95% CI: 6.7-7.5) minutes. The correlation between EWT and ADR was significantly higher (r=0.98, 95%CI: 0.96-1.00) than between SWT and ADR (r=0.80, 95%CI: 0.53-0.98, p<0.01). For PDR, the correlation between EWT and PDR was also significantly higher than between SWT and PDR (r=0.97, 95%CI: 0.95-1.00 vs r=0.73, 95%CI: 0.30-0.98, p=0.02). However, there was no significant difference between EWT and SWT on SDR [r=0.92, 95%CI: 0.72-1.00 vs r=0.93, 95%CI: 0.86-0.98, p=0.89].

Table 1: Baseline characteristics and outcomes of the study

Conclusion

The novel AI-derived EWT demonstrated better correlation with ADR and PDR than SWT in this prospective study. Further studies should evaluate the role of applying real-time monitoring EWT on endoscopy training and quality improvement of endoscopists with low ADR.

References

1. Lui TKL, Ko MKL, Liu JJ, Xiao X, Leung WK. Artificial intelligence-assisted real-time monitoring of effective withdrawal time during colonoscopy: a novel quality marker of colonoscopy. Gastrointest Endosc. 2024;99(3):419-27.e6.

Disclosure

The following companies had given donation to our team for research.
Olympus, Fujifilm, Medronic, Wision AI, Insign Medical Co Ltd