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Unsedated Colonoscopy: Impact on Quality Indicators

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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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References

  1. Rex DK, Khalfan HK. Sedation and the technical performance of colonoscopy. Gastrointest Endosc Clin N Am. 2005;15:661–672.

    Article  Google Scholar 

  2. Cataldo PA. Colonoscopy without sedation. Dis Colon Rectum. 1996;39:257–261.

    Article  CAS  Google Scholar 

  3. Herman FN. Avoidance of sedation during total colonoscopy. Dis Colon Rectum. 1990;33:70–72.

    Article  CAS  Google Scholar 

  4. Seow-Choen F, Leong AF, Tsang C. Selective sedation for colonoscopy. Gastrointest Endosc. 1994;40:661–664.

    Article  CAS  Google Scholar 

  5. Ristikankare MK, Julkunen RJ. Premedication for gastrointestinal endoscopy is a rare practice in Finland: a nationwide survey. Gastrointest Endosc. 1998;47:204–207.

    CAS  PubMed  Google Scholar 

  6. Williams CB. Comfort and quality in colonoscopy. Gastrointest Endosc. 1994;40:769–770.

    Article  CAS  Google Scholar 

  7. Aljebreen AM. The completeness rate of colonoscopy in a cohort of unsedated patients. Saudi J Gastroenterol. 2004;10:150–154.

    PubMed  Google Scholar 

  8. Ristikankare M, Julkunen R, Mattila M, et al. Conscious sedation and cardiorespiratory safety during colonoscopy. Gastrointest Endosc. 2000;52:48–54.

    Article  CAS  Google Scholar 

  9. Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc. 1991;37:421–427.

    Article  CAS  Google Scholar 

  10. Krigel A, Chen L, Wright JD, Lebwohl B. Substantial increase in anesthesia assistance for outpatient colonoscopy and associated cost nationwide. Clin Gastroenterol Hepatol. 2019;17:2489–2496.

    Article  Google Scholar 

  11. Khiani VS, Soulos P, Gancayco J, Gross CP. Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the medicare population. Clin Gastroenterol Hepatol. 2012;10:58–64.

    Article  Google Scholar 

  12. Petrini JL, Egan JV, Hahn WV. Unsedated colonoscopy: patient characteristics and satisfaction in a community-based endoscopy unit. Gastrointest Endosc. 2009;69:567–572.

    Article  Google Scholar 

  13. Bannert C, Reinhart K, Dunkler D, et al. Sedation in screening colonoscopy: impact on quality indicators and complications. Am J Gastroenterol. 2012;107:1837–1848.

    Article  Google Scholar 

  14. Aljebreen AM, Almadi MA, Leung FW. Sedated vs unsedated colonoscopy: a prospective study. World J Gastroenterol. 2014;20:5113–5118.

    Article  Google Scholar 

  15. Eckardt VF, Kanzier G, Willems D, Eckardt AJ, Bernhard G. Colonoscopy without premedication versus barium enema: a comparison of patient discomfort. Gastrointest Endosc. 1996;44:177–180.

    Article  CAS  Google Scholar 

  16. Yoshikawa I, Honda H, Nagata K, et al. Variable stiffness colonoscopes are associated with less pain during colonoscopy in unsedated patients. Am J Gastroenterol. 2002;97:3052–3055.

    Article  Google Scholar 

  17. Leung FW. Unsedated colonoscopy introduced to ensure access is acceptable to a subgroup of veterans. Dig Dis Sci. 2008;53:2719–2722. https://doi.org/10.1007/s10620-007-0192-8.

    Article  PubMed  Google Scholar 

  18. Rex DK, Imperiale TF, Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc. 1999;49:554–559.

    Article  CAS  Google Scholar 

  19. Aronchick CA, Lipshutz WH, Wright SH, Dufrayne F, Bergman G. A novel tableted purgative for colonoscopic preparation: efficacy and safety comparisons with Colyte and Fleet Phospho-Soda. Gastrointest Endosc. 2000;52:346–352.

    Article  CAS  Google Scholar 

  20. Lai EJ, Calderwood AH, Doros G, Fix OK, Jacobson BC. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc. 2009;69:620–625.

    Article  Google Scholar 

  21. Faulx AL, Vela S, Das A, et al. The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey. Gastrointest Endosc. 2005;62:9–15.

    Article  Google Scholar 

  22. Early DS, Saifuddin T, Johnson JC, King PD, Marshall JB. Patient attitudes toward undergoing colonoscopy without sedation. Am J Gastroenterol. 1999;94:1862–1865.

    Article  CAS  Google Scholar 

  23. Subramanian S, Liangpunsakul S, Rex DK. Preprocedure patient values regarding sedation for colonoscopy. J Clin Gastroenterol. 2005;39:516–519.

    Article  Google Scholar 

  24. Paggi S, Radaelli F, Amato A, et al. Unsedated colonoscopy: an option for some but not for all. Gastrointest Endosc. 2012;75:392–398.

    Article  Google Scholar 

  25. Holme Ø, Bretthauer M, de Lange T, et al. Risk stratification to predict pain during unsedated colonoscopy: results of a multicenter cohort study. Endoscopy. 2013;45:691–696.

    Article  Google Scholar 

  26. Saunders BP, Fukumoto M, Halligan S, et al. Why is colonoscopy more difficult in women? Gastrointest Endosc. 1996;43:124–126.

    Article  CAS  Google Scholar 

  27. Crispin A, Birkner B, Munte A, Nusko G, Mansmann U. Process quality and incidence of acute complications in a series of more than 230,000 outpatient colonoscopies. Endoscopy. 2009;41:1018–1025.

    Article  CAS  Google Scholar 

  28. Conigliaro R, Rossi A, Italian Society of Digestive Endoscopy (SIED) Sedation Commission. Implementation of sedation guidelines in clinical practice in Italy: results of a prospective longitudinal multicenter study. Endoscopy. 2006;38:1137–1143.

    Article  CAS  Google Scholar 

  29. Radaelli F, Meucci G, Sgroi G, Minoli G, Italian Association of Hospital Gastroenterologists (AIGO). Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators. Am J Gastroenterol. 2008;103:1122–1130.

    Article  Google Scholar 

  30. Thiis-Evensen E, Hoff GS, Sauar J, Vatn MH. Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps. Gastrointest Endosc. 2000;52:606–610.

    Article  CAS  Google Scholar 

  31. Leung FW, Mann SK, Salera R, et al. Options for screening colonoscopy without sedation: sequel to a pilot study in U.S. veterans. Gastrointest Endosc. 2008;67:712–717.

    Article  Google Scholar 

  32. Leung FW, Harker JO, Jackson G, et al. A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method. Gastrointest Endosc. 2010;72:693–700.

    Article  Google Scholar 

  33. Pohl J, Messer I, Behrens A, Kaiser G, Mayer G, Ell C. Water infusion for cecal intubation increases patient tolerance, but does not improve intubation of unsedated colonoscopies. Clin Gastroenterol Hepatol. 2011;9:1039–1043.

    Article  Google Scholar 

  34. Cadoni S, Falt P, Gallittu P, et al. Water exchange is the least painful colonoscope insertion technique and increases completion of unsedated colonoscopy. Clin Gastroenterol Hepatol. 2015;13:1972–1980.

    Article  Google Scholar 

  35. Sato K, Ito S, Kitagawa T, et al. A prospective randomized study of the use of an ultrathin colonoscope versus a pediatric colonoscope in sedation-optional colonoscopy. Surg Endosc. 2017;31:5150–5158.

    Article  Google Scholar 

  36. Nakshabendi R, Berry AC, Munoz JC, John BK. Choice of sedation and its impact on adenoma detection rate in screening colonoscopies. Ann Gastroenterol. 2016;29:50–55.

    PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA

    Fatima Khan, Chin Hur, Benjamin Lebwohl & Anna Krigel

  2. Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA

    Benjamin Lebwohl

  3. Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA

    Benjamin Lebwohl

Authors
  1. Fatima Khan
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  2. Chin Hur
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  3. Benjamin Lebwohl
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  4. Anna Krigel
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Contributions

FK, AK, CH, and BL contributed to study concept and design and critical revision of the manuscript for important intellectual content; FK and AK acquired the data and drafted the manuscript; FK, AK, and BL analyzed and interpreted the data; AK contributed to statistical analysis; BL and AK supervised the study. All authors approved the final manuscript submitted, and they approved the authorship list.

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Correspondence to Fatima Khan.

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This analysis was approved by the Institutional Review Board of Columbia University.

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Khan, F., Hur, C., Lebwohl, B. et al. Unsedated Colonoscopy: Impact on Quality Indicators. Dig Dis Sci 65, 3116–3122 (2020). https://doi.org/10.1007/s10620-020-06491-0

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  • DOI: https://doi.org/10.1007/s10620-020-06491-0

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