| Abstract|| |
Background: Colonoscopy is considered a painful procedure requiring routine intravenous sedation, however there are number of potential advantages to performing colonoscopy without sedation. The aim of this study was to determine the effect of unsedated colonoscopy on the success rate of caecal intubation. Patients and methods: All charts of patients who had unsedated colonoscopy from January 2002 to September 2003 were reviewed. Patient characteristics including age, gender, and mode of presentation were collected. The success rate of unsedated colonoscopy was compared with the standard success rate of sedated colonoscopy in the literature. The reasons for incomplete colonoscopy and sites reached were recorded. Results: During the study period, 503 examinations were performed. Patients mean age was 48.5 years, 55.9 % of them were males. Colonic polyps were the predominant abnormal endoscopic finding; occurring in 21.3%. The completion rate in the study population excluding patients with obstructive disease and patients with inadequate preparation was only 67%. Conclusion: In this cohort studiy, sedation probably affects the overall success rate of cecal intubation. A large prospective randomized study comparing sedated with unsedated colonoscopy in terms of completion rate and patient satisfaction is needed
Keywords: colonoscopy sedation, completion rate.
|How to cite this article:|
Aljebreen AM. The completeness rate of colonoscopy in a cohort of unsedated patients. Saudi J Gastroenterol 2004;10:150-4
Colonoscopy is generally performed with the patient sedated and receiving analgesics ,, The combination of benzodiazepine and an opioid, mostly midazolam , and pethidine (meperi dine)  , has become standard sedative practice for this procedure in most countries. However, sedation and analgesia for colonoscopy is associated with a small but definite risk of cardio-respiratory complications, which have been reported in 0.10% to 0.54% of patients, with fatalities occurring in 0.03%  . It has been  estimated that between 50% and 60% of all morbidity and mortality occurring during endoscopic procedures is directly related to the administration of sedatives and narcotics  . Morbidity and mortality due to sedation are mostly related to hypoxemia ,, . Furthermore, the administration of sedative drugs increases the total cost, the pre-procedure preparation, total procedure time, and post-procedure recovery , .
Finally, potential time lost from work for the patient and the accompanying person adds to the overall cost to society. Thus, the ability to perform colonoscopy without sedation and without compromising its efficacy rate could be highly advantageous. The aim of this study was to determine the effect of unsedated colonoscopy on the success rate of caecal intubation.
| Patients and Methods|| |
The charts of all the patients who underwent colonoscopy from January 2002 to September 2003 were reviewed. Patients who had an intravenous sedation or who had only sigmoidoscopy were excluded from the analysis. Patient characteristics including age, gender, and mode of presentation (abdominal pain, rectal bleeding, diarrhea or constipation) were collected from all patients. Endoscopist level of training and the satisfaction of the bowel preparation were also collected. Endoscopic and histological findings were obtained.
A completed procedure was defined as the ability to visualize the cecum as per the procedure report. Any procedure that could not reach cecum was considered incomplete. The reasons for incomplete colonoscopies and sites reached in incomplete examinations were recorded. All procedures were performed by experienced endoscopists and gastroenterology fellows, by means of video-co lonoscopes (EC-3801, Pentax). Colon cleansing was achieved by oral administration of 3 liters of COLOYTE, given 12-18 hrs before the examination. A liquid diet was also recommended to patients 24 hours before the procedure. For all patients, heart rate and oxygen saturation were monitored by pulse oxymeter. The data were entered into a statistical software program (Microsoft excel files). For univariate analysis, comparisons between groups were made by means of Student t test, chi-square, or Fisher exact test, as appropriate.
A two-sided p value of less than 0.05 was considered as statistically significant.
| Results|| |
During the study period, 503 examinations were performed. As shown in [Table - 1], patients mean age was 48.5 years, 56 % of them were males.
Indications for colonoscopy included rectal bleeding (n=122, 24%), abdominal pain (n=117, 23%), diarrhea (n=32, 6%), constipation (n=33, 7%) and other indications (n=199, 40%). Supervised gastroenterology fellows did 230 (46 %) of the colonoscopies. Consultants performed the remaining 273 without trainees participation. The preparation was felt adequate in 431 patients (86%) and biopsies have been done in 226 (45%) patients. The final endoscopic and histologic diagnoses are listed in [Table - 2]. Of the 503 patients, 183 patients (36%) had normal colonoscopies. Colonic polyps were the predominant endoscopic findings; occurring in 107 patients (21%), (58% men with a mean age of 52 years). Ninety of those patients (18%) were found to have adenomatous polyps on histology.
Inflammatory bowel disease was found in only seven patients (1.4 % of the total) while colorectal cancers were found in 13 patients (2.5%). The crude completion rate in the study population as a whole was 56.5% [Table - 3]. When patients with obstructive disease (n=7) and patients with inadequate preparation (n=72) were excluded from the analysis, completion rate raised to 67%. Poor bowel preparation was the most common cause of incomplete insertion (14.3%), followed by abdominal pain or discomfort (n=49) 9.5% of total). There were no difference in completion rate between gastroenterology fellows (133/230; 58%) and consultants (151/273; 55%) or between normal (96/183; 53%) and abnormal (187/320; 58%) colonoscopies. The most common site reached in the incomplete examinations was the ascending colon (59% of patients) followed by transverse colon in 22% of patients. All patients that only reached the rectum were terminated because of pain.
Although colonoscopies performed for diarrhea, abdominal pain and anemia [Table - 4] had a relatively low diagnostic yield (19%), there was no statistical significance when they were compared with colonoscopies performed for rectal bleeding (29%), constipation (38%) and weight loss (29%) (p>0.05). There were no perforations in the 503 colonoscopies performed. Gastrointestinal bleeding occurred in only one patient (0.19% of procedures). There were no mortality or major cardiovascular complications.
| Discussion|| |
Most physicians share their patients' prejudice that colonoscopy is always a painful and distressing procedure. As a consequence, almost all patients undergoing this procedure are pre-medicated with various sedatives and narcotics  , which will increase the risk of cardiopulmonary complications and the total cost, the preprocedure preparation, total procedure time, and post-procedure recovery. Any effort to minimize possible side effects and total cost of sedated colonoscopy should not compromise the effectiveness of this procedure. In a prospective study, Eckardt et al showed that colonoscopy with sedation on demand does not cause more discomfort than doing both barium enema and sigmoidoscopy. Eighty-seven percent of all patients undergoing colonoscopy stated that they would prefer no pre-medication in the event of repeated examinations and only 5% of all patients undergoing endoscopy required sedation [l2] . Unfortunately, colonoscopy was not compared to barium enema only and sedation was given per patient request during the procedure. In another prospective randomized study, Terruzzi et al recently showed that administration of sedative and analgesic drugs routinely before colonoscopy is superior to "on demand" sedation in terms of tolerance and importantly is not associated with an increase in side effects  . In this study, 22% of patients of the "on demand" sedation group would not be willing to undergo colonoscopy again comparing with only 9% of the "routine" sedation group (p < 0.005). Interestingly, 66% of the "on demand" group required sedation throughout the procedure which is contrary to the previous study.
In both previous studies, cecum was intubated successfully in 95% and 93% respectively with no significant difference between routine and "on demand" sedation. In sedated screening colonoscopies, success rate ranges from 97 to 98% , .
In this study, all of the patients did not receive sedation and the completion rate was only 67%. When we compare this number with the success rate of sedated colonoscopy, it is clearly obvious that sedation affects the success rate of colonoscopy. In 451 patients who underwent screening unsedated colonoscopy, Thiis-Evensen et al showed that cecum can be intubated in 82% of the patients, 50% of these individuals found the examination to be uncomfortable  . Although this success rate is lower than both sedated and "on demand" sedation, it is still higher than our success rate. This difference is probably because of selection bias (patient choosing unsedated colonoscopy) and because of the indication (screening colonoscopies comparing with our study where all of our patients were symptomatic). The limitation of our study is that it is a retrospective data and the reason to terminate the procedure was not documented in all patients. In conclusion, in this cohort of unsedated colonoscopies, sedation probably affect the overall success rate of cecal intubation. A prospective randomized study comparing sedated with unsedated colonoscopy in terms of completion rate and patient satisfaction is needed.
| References|| |
|1.||Keeffe EB, O'Connor KW. 1989 A/S/G/E Survey of endoscopic sedation and monitoring practices. Gastrointest Endosc 1990; 36: S13-S18. [PUBMED] |
|2.||Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB. Results from the American Society for gastrointestinal Endoscopy/ US. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc 1991; 37: 421-7. |
|3.||Froehlich F, Gonvers JJ, Fried M. Conscious sedation, clinically relevant complications and monitoring of endoscopy: Results of a nationwide survey in Switzerland. Endoscopy 1994; 26: 231-4. [PUBMED] |
|4.||Keeffe EB, O'Connor KW. 1989 A/S/G/E Survey of endoscopic sedation and monitoring practices. Gastrointest Endosc 1990; 36: S13-S18. [PUBMED] |
|5.||Lazzaroni M, Bianchi PG. Preparation, Premedication and Surveillance. Endoscopy 2003; 35: 103-11. |
|6.||Bianchi PG, Lazzaroni M. Preparation, Premedication and Surveillance. Endoscopy 1992. 24: 1-8. |
|7.||Bell GD. Review Article: Premedication and intravenous sedation for upper gastrointestinal endoscopy. Aliment Pharmacol Ther 1990; 4: 103-22. [PUBMED] |
|8.||O'Connor KW, Jones S. Oxygen desaturation is common and clinically underappreciated during elective endoscopic procedures. Gastrointest Endosc 1990; 36: S2-S4. [PUBMED] |
|9.||Scott-Coombes DM, Thompson JN. Hypoxia during upper gastrointestinal endoscopy is caused by sedation. Endoscopy 1993; 25: 308-9. [PUBMED] |
|10.||Lazzaroni M, Bianchi PG. Preparation, Premedication and Surveillance. Endoscopy 2003; 35: 103-11. |
|11.||Cataldo PA. Colonoscopy without sedation. Dis Colon Rectum 1996; 39: 257-61. [PUBMED] |
|12.||Eckardt VF, Kanzier G, Williems D, Eckardt AJ, Bernhard G. Colonoscopy without predmedication versus barium enema: A Comparison of patient discomfort. Gastrointest Endosc 1996; 44: 177-80. |
|13.||Terruzzi V, Meucci G, Radaelli F, Terreni N, Monoli G. Routine versus "on demand" sedation and analgesia for colonoscopy: A prospective randomized controlled trial. Gastrointest Endosc 2001; 54: 169-74. |
|14.||Nelson DB, McQuaid KR, Bond JH, Lieberman DA, Weiss DG, Johonston TK. Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc 2002; 55: 307-314. |
|15.||Waye JD, Bashkoff E, Total colonoscopy: Is it always possible? Gastrointest Endosc 1991; 37: 152-4. |
|16.||Thiis-evensen E, Hoff GS, Sauar J, Vatn MH. Patient tolerance of colonoscopy without sedation during screening examination for colorectal plyps. Gastrointest Endosc 2000; 52: 606-10. [PUBMED] [FULLTEXT]|
Abdulrahman Mohammed Aljebreen
Department of Medicine, King Khalid University Hospital, P 0 Box 2925, Riyadh 11461
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3], [Table - 4]