Top down or Bottom Up? Does the Order of Bidirectional Endoscopy Matter?

Abstract

Introduction: Same day bidirectional endoscopy (EGD and colonoscopy) is frequently performed for screening and to evaluate various GI conditions. There is debate surrounding the optimal sequence for the procedures. However, there is little data comparing the safety of the two approaches - EGD then colonoscopy (E-C) vs colonoscopy then EGD (C-E). AIM: to assess whether there are any differences in adverse events between the 2 approaches to bidirectional endoscopy: E-C vs C-E in a large ambulatory endoscopy center (AEC). Methods: Data for the study were retrospectively obtained from a large AEC from Feb 2012 until June 2016. A total of 8,611 bidirectional endoscopies were performed (3,444 E-C and 5,167 C-E). CRNA delivered propofol was used for all procedures. All patients were ASA 1 to ASA 3. We recorded adverse events using data from peri-procedural incident reports, follow up phone calls (24 hours post procedure) and reporting of adverse events by physicians. We compared the frequencies of adverse events (cardiac arrhythmia or hyper/hypotension, laryngospasm, aspiration, post procedure bleeding, desaturation, post procedure pain/nausea, post procedure fever and splenic injury) between the 2 models of bidirectional endoscopy using chi square analysis. Results: Total adverse events in the E-C group were 36 (1.0453%). Total adverse events in the C-E group were 22 (0.4258%). The difference was statistically significant with a p value of .00058. Frequency comparison of subgroups resulted in a statistically significant p value of < .05 in 2 subgroups, aspiration (p=.0302) and fever (p=.0135). Average ASA of adverse events in the E-C group was 1.94 compared to 2.22 in the C-E group. There was no data available on BMI or mallampati scores. Conclusion: In a large AEC with over 8,600 bidirectional endoscopies over a greater than 4 year period of time, there was a statistically significant difference in total adverse event rate when comparing order of bidirectional endoscopy. There were greater rates of adverse events with EGD then colonoscopy compared to colonoscopy then EGD, particularly aspiration and fever. Further prospective evaluation of contributing factors, both patient and procedure specific, is warranted.Table 1: Frequency of Adverse Events