Duration Of Colonoscopy Research Articles

Cardiopulmonary safety of propofol versus midazolam/meperidine sedation for colonoscopy: a prospective, randomized, double-blinded study.

Background:Different levels of pharmacological sedation ranging from minimal to general anesthesia are often used to increase patient tolerance for a successful colonoscopy. However, sedation increases the risk of respiratory depression and cardiovascular complications during colonoscopy.Objectives:We aimed to compare the propofol and midazolam/meperidine sedation methods for colonoscopy procedures with respect to cardiopulmonary safety, procedure-related times, and patient satisfaction.Patients and Methods:This was a prospective, randomized, double-blinded study, in which 124 consecutive patients undergoing elective outpatient diagnostic colonoscopies were divided into propofol and midazolam/meperidine sedation groups (n: 62, m/f ratio: 26/36, mean age: 46 ± 15 for the propofol group; n: 62, m/f ratio: 28/34, mean age: 49 ± 15 for the midazolam/meperidine group) by computer-generated randomization. The frequency of cardiopulmonary events (hypotension, bradycardia, hypoxemia), procedure-related times (duration of colonoscopy, time to cecal intubation, time to ileal intubation, awakening time, and time to hospital discharge) and patients’ evaluation results (pain assessment, quality of sedation, and recollection of procedure) were compared between the groups.Results:There were no statistically significant differences between the two groups with respect to demographic and clinical characteristics of the patients, the frequency of hypotension, hypoxemia or bradycardia, cecal and ileal intubation times, and the duration of colonoscopy. The logistic regression analysis indicated that the development of cardiopulmonary events was not associated with the sedative agent used or the characteristics of the patients. The time required for the patient to be fully awake and the time to hospital discharge was significantly longer in the propofol group (11 ± 8 and 37 ± 11 minutes, respectively) than the midazolam/meperidine group (8 ± 6 and 29 ± 12 minutes, respectively) (P = 0.009 and P < 0.001, respectively). The patient satisfaction rates were not significantly different between the groups; however, patients in the propofol group experienced more pain than patients in the midazolam/meperidine group (VAS score: 0.31 ± 0.76 vs. 0 ± 0; P = 0.002).Conclusions:Midazolam/meperidine and propofol sedation for colonoscopy have similar cardiopulmonary safety profiles and patient satisfaction levels. Midazolam/meperidine can be preferred to propofol sedation due to a shorter hospital length of stay and better analgesic activity.

Does Mandatory Documentation of Colonoscopy Duration Enhance Adenoma Detection Rate?

Introduction: Our institution has recently mandated documentation of duration of all colonoscopies by endoscopists as a quality improvement initiative. Adenoma detection rate (ADR), an important quality indicator of colonoscopy, is known to be improved with a withdrawal time of at least 6 minutes. However, there is sparse data on influence of mandatory documentation of total colonoscopy times on ADR. Aims of this study were to determine if mandatory documentation of colonoscopy duration enhances ADR and the number of adenomas detected per patient. Methods: Chart review of screening colonoscopies performed at our institution for 6 months in premandatory period (PRE; January 2013 to June 2013) and for 9 months in post-mandatory period (POST; July 2013 to March 2014). Patients over age 50 years undergoing screening or surveillance colonoscopy with adequate bowel preparation and complete colonoscopy were included. Patient demographics and colonoscopy findings such as indication, quality of bowel preparation, and type and amount of sedation were reviewed. Patients with IBD, polyposis syndromes, prior colonic resection, and poor bowel preparation were excluded. ADR was defined as proportion of colonoscopies with at least 1 adenoma detected. Procedure duration was defined as time from endoscope insertion to removal out of the patient. Data is presented as mean plus standard deviation, median (25th, 75th percentiles), or N (%). Univariate analysis, analysis of variance, Kruskal-Wallis tests, Pearson’s Chi-square tests and Wilcoxon rank sum tests were performed, and SAS (version 9.3, SAS institute, Cary, NC) was used for statistical analysis. Results: A total of 578 subjects were included in the analysis (254 in PRE and 324 in POST). Average age at time of colonoscopy was 64±9 years, and 52% were male. Patient demographics and colonoscopy findings were similar in PRE and POST. Mean procedure duration was 25.9+16.8 minutes in POST. ADR was 41.7% in PRE compared to 46.6% in POST (p=0.24). The findings were similar in the subgroup of average risk subjects. There was a trend suggesting that a higher number of adenomas per patient, particularly in the distal colon, were likely to be found in the POST. This trend was not observed in the subgroup of average risk patients (p=0.88). There was only trivial correlation between procedure duration and number of adenomas detected per patient (rho 0.27; 95% CI 0.017, 0.38). Conclusion: Mandatory documentation of colonoscopy duration does not seem to impact ADR. It might increase the number of adenomas detected per patient, mainly in the distal colon. Further studies are needed to evaluate these findings.

Effect Supermint oil (Peppermint oil) on children's pain during Colonoscopy

Introduction: Pain during colonoscopy, especially in children, including the challenges faced by the medical team. The aim of study was investigation the analgesic effect Supermint oil (peppermint oil) on pain in children during colonoscopy. Methods and Materials: In this clinical trial study, 101 children (7-14 years old) candidate colonoscopy were randomly divided into two groups, respectively. About half an hour before the colonoscopy case group (n=51) was administrated oral drops Supermint oil (peppermint oil). Patients were filled a pediatric pain questionnaire. In control group (n=50) filled a questionnaire without any administration. Data were analyzed using SPSS version 11.5 and (T-test and Paired sample t-test, Corraletion,Man withney). Results: Mean value of pain, duration of colonoscopy in control group was 5/60+1/85 and in case group was 4/20+1/70 and this diference was significant (P<0.05). The comparison of pain, between the two groups was significant ,as in control, frequency of abdominal pain were two times at maximum, but in the case for some patients were more than 3 times(p<0.05). In the case group abdominal pain lasting less than 1 minute and the control group were between 1 to 3 minutes, and this diference were significant(P<0.05). Conclusion: We recommend using peppermint oil as a safe, without complications and inexpensive pain medication during child colonoscopy. Key words: Colonoscopy, Pain, Peppermint, Supermint.

Effect Supermint oil (Peppermint oil) on the Patient's and Colonoscopy Team Satisfaction During Colonoscopy in Children

Introduction: Colonoscopy is an invasive method that is painful for patient especially for children. The objective of this research was investigation of the effect of supermint oral drop (peppermint essence) on the patient and colonoscopist group satisfaction during colonoscopy. Materials and Methods: One hundred and one patient's candidate for colonoscopy was randomly divided into two groups. Control group did not receive any drug. Case group was administrated oral drop of supermint 30 minute before colonoscopy. A standard questionnaire was filled during the colonoscopy for satisfaction of the patient and colonoscopist group. Data were analyzed using SPSS software version 15 and T-test. Results: Two percents in control group and 54.9% in case group have a great degree of satisfaction. Besides, mean degress of satisfaction in case group was 64.7% that significantly difference with control group (2%) (P<0.05(. Mean value of pain, duration of colonoscopy in control group was 5/60+1/85 and in case group was 4/20+1/70 and this diference was significant (P<0.05). Conclusion: The results of this study showed that peppermint essence causes increase in satisfaction in both patient and colonoscopy group. Key words: Peppermint, Pain, Colonoscopy, Supermint

Effect Supermint oil (peppermint oil) on Patient Satisfaction and the Colonoscopy team during Colonoscopy

Introduction: Colonoscopy is an invasive method that is painful for patient especially for children. The objective of this research was investigation into the effect of supermint oral drop (peppermint essence) on the patient and colonoscopist group satisfaction during colonoscopy. Material and Methods: In this clinical trial study, 101 children candidate colonoscopy (7-14 years old) in children’s medical center were randomly divided into two groups, case (n=51) and control (n=50) respectively. Control group received placebo and about half an hour before the colonoscopy control group case group was administrated 20 oral drops Supermint oil (peppermint oil). A standard questionnaire was filled after the colonoscopy for satisfaction of the patient and colonoscopist group. Data were analyzed using SPSS version 11.5 (T-test and Corraletion). Results: Two percents in control group and 54.9% in case group have a great degree of satisfaction. Besides, degrees of satisfaction in case group was 64.7% that significantly difference with those of control group (2%) P<0.05). Mean value of pain, duration of colonoscopy in control group was 5/60+1/85 and in case group was 4/20+1/70 and this difference was significant (P<0.05). Conclusion: The results of this study showed that drop Supermint oil on pain relief have a positive influence in during colonoscopy in children, so peppermint essence causes increase in satisfaction in both patient and colonoscopy group. Key words: Colonoscopy, Peppermint, Pain, Supermint.

Effect ssupermint oil (peppermint oil) on children's pain during colonoscopy

Background & Objectives: Pain during colonoscopy, especially in children, including the challenges faced by the medical team. The aim of study was investigation the analgesic effect Supermint oil (peppermint oil) on pain in children during colonoscopy. Materials and Methods: In this clinical trial study, 101 children (7-14 years old) candidate colonoscopy were randomly divided into two groups, respectively. About half an hour before the colonoscopy case group(n=51) was administrated oral drops Supermint oil (peppermint oil). Patients were filled a pediatric pain questionnaire. In control group(n=50) filled a questionnaire without any administration. Data were analyzed using SPSS version 11.5 and (T-test and Paired sample t-test, Corraletion,Man withney). Results: The mean value of pain, duration of colonoscopy in control group (5/60+1/85) was significantly different from case group (4/20+1/70) (p<0.05). Result showed the comparison of pain between two groups was significant ,so in case group, the frequency of abdominal pain were two times at maximum, but in the control group for some patients were more than 3 times(p<0.05). In the case group abdominal pain lasting less than 1 minute and the control group were between 1 to 3 minutes, and this difference was significant(p<0.05). Conclusion: We recommend using peppermint oil as a safe ,without complications and inexpensive pain medication during child colonoscopy.

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On-demand sedation with propofol for colonoscopy—A prospective pilot study of the influence on short-term memory, psychomotor function and postural stability*

Background: After sedated colonoscopy, patients are discharged on the basis of their subjective judgment that they have recovered, corroborated by the nursing staff. The aim of this study was to assess objectively whether patients were in fact fully recovered at the time of discharge, and to demonstrate whether the methods of testing applied could detect any influence of sedation on short-term memory, psychomotor function and postural stability. Methods: Twenty-two patients were investigated. At the beginning of the procedure, a defined bolus of propofol/alfentanil was given intravenously. During the procedure, an additional bolus was injected one or more times as requested by the patient. After colonoscopy, the patients stayed in the recovery room until the patients judged that they had recovered completely, which was also the judgement of the nursing staff at that time. Before colonoscopy and again before discharge, tests were performed of short-term memory, psychomotor function and postural stability (balance). Results: A positive correlation was found between the duration of colonoscopy and the amount of sedative given (p that they have recovered fully, some patients are still affected by the sedative at the time of discharge, as demonstrated by tests of short-term memory, reaction time and postural stability.

Colorectal polypectomy during insertion and withdrawal or only during withdrawal? A randomized controlled trial

Removal of colorectal polyps is routinely performed during withdrawal of the endoscope. However, polyps detected during insertion of the colonoscope may be missed at withdrawal. We aimed to evaluate whether polypectomy during both insertion and withdrawal increases polyp detection and removal rates compared with polypectomy at withdrawal only, and to assess the duration of both approaches. Patients were included into the study when the first polyp was detected, and randomized into two groups; in group A, polyps ≤ 10 mm in diameter were removed during insertion and withdrawal of the colonoscope, while in group B, these polyps were removed at withdrawal only. Main outcome measures were duration of colonoscopy, number of polyps detected during insertion but not recovered during withdrawal, technical ease, patient discomfort, and complications. 150 patients were randomized to group A and 151 to group B. Mean (± standard deviation [SD]) duration of colonoscopy did not differ between the groups (30.8 ± 15.6 min [A] vs. 28.5 ± 13.8 min [B], P = 0.176). In group A 387 polyps (mean 2.58 per colonoscopy) were detected and removed compared with 389 polyps detected (mean 2.58 per colonoscopy) in group B of which 376 were removed (13 polyps were missed, mean size [SD] 3.2 [1.3] mm; 7.3 % of patients). Patient tolerance was similar in the two groups. Removal of polyps ≤ 10 mm during withdrawal only is associated with a considerable polyp miss rate. We therefore recommend that these polyps are removed during both insertion and withdrawal.

Distal upper extremity musculoskeletal risk factors associated with colonoscopy

Gastroenterologists are at increased risk for developing recurrent thumb, hand, and elbow pain due to colonoscopy procedures. We evaluated forearm muscle loads and wrist postures during routine colonoscopy (N=12 gastroenterologists) to understand distal upper extremity musculoskeletal risk factors associated with the 4 different subtasks of colonoscopy. Bilateral forearm extensor carpiradialis (ECR) and flexor digitorum superficialis (FDS) surface electromyography and bilateral wrist postures were recorded continuously. The mean duration of colonoscopy was 24.2 (± 12.1) minutes and was dominated by the withdrawal subtask [13.7 (± 8.8) min] followed by right colon insertion [5.8 (± 4.8) min], left colon insertion [3.5 (± 3.1) min], and retroflexion [1.2 (± 2.1) min]. Median (APDF50) and peak (APDF90) left forearm muscle activity was significantly greater than right forearm muscle activity across all subtasks. Median and peak ECR muscle activity was significantly greater during the left and right colon insertion subtasks compared to retroflexion. Both wrists were predominantly in wrist extension during all phases of colonoscopy. The left forearm muscle activity was higher than right forearm activity due to differences in wrist posture and grip force. The risk factors for the left hand may be reduced with alternative designs and support mechanisms for the colonoscope head.

Impact of anesthesia on patient and endoscopist satisfaction after colonoscopy — A pilot study

Abstract Introduction Colonoscopy is a standard diagnostic tool for the investigation and surveillance of diseases affecting the colon. The procedure can be uncomfortable and sometimes very painful, resulting in increased cecal intubation time and lower completion rate. However, it seems to be apparent that anesthesia for this procedure increases patient satisfaction; data are lacking about the impact of anesthesia on the technical performance of colonoscopic examination. Aim In our observational survey, we studied patients undergoing colonoscopy with or without anesthesia. We compared patient satisfaction, difficulties in endoscopy, and the impact of anesthesia on the examination room occupancy. Methods We enrolled 60 patients undergoing elective, outpatient colonoscopy because of various reasons. The patients were able to choose between anesthesia and sedation. Difficulties in colonoscopy were evaluated by the endoscopist's rating and by the time to cecal intubation. We assessed patient satisfaction by a numeric rating scale. Results We observed that neither the duration of colonoscopy nor the time spent in the examination room was different in the two groups (p 0.825, 0.998). There was a significant improvement in both patient and endoscopist satisfaction scores in patients undergoing anesthesia (p 0.0007). Conclusion We found that during colonoscopy, compared to sedation, anesthesia increases both endoscopist and patient satisfaction without prolonged occupation of the examination room.

Does Polyp Detection Rate During Screening Colonoscopy Drop as the Day Progresses? An Urban Community Hospital Experience

Purpose: Reduction in polyp detection rate (PDR) as the day progresses has been demonstrated in some recent studies. Endoscopist fatigue and duration of colonoscopy have been attributed to the decline in PDR. This study analyzed data at our urban community based teaching hospital. Colonoscopies were performed from 8AM to 5PM at a standard endoscopist to patient ratio. This study looked at outcome analysis regarding PDR in the 8AM to 12N block (AM Block) and 12N to 5PM block (PM Block). Methods: In this retrospective study, 1000 outpatient colonoscopies over 6 months were reviewed. Colonoscopies with indications other than screening and with incomplete data were excluded. PDR (colonoscopies with 1 or more polyps divided by total number of colonoscopies) was used as the primary outcome measure. Results: 1000 colonoscopies were reviewed. 563 were performed for screening and met inclusion criteria. 438 [77.7%] had good bowel preparation (GPG) and 125 (22.2%) had fair to poor preparation (PPG). In the GPG, 271 [61%] were performed during the AM Block and 167 (39%) were performed during the PM Block. 40% of subjects were male in AM Block and 38% male in the PM Block. Ethnicity was equally distributed in both blocks — 66% African Americans, 25% Hispanics and 10% Other (Caucasian and Asian). PDR in AM Block was 47.6% and 39.5% in PM Block. The difference was not statistically significant. Additionally, PDR in the poor prep group was 32.4% in AM Block and 24% in PM Block. This result was also not statistically significant. PDR in GPG was 44% and PDR in PPG was 28% and was statistically significant (P Value 0.001). PDR in GPG was 47% versus 32% in PPG in the AM Block (P Value 0.01). PDR in GPG was 39.5% versus 24% in PPG in the PM Block (P Value 0.06). Conclusion: This study did not show statistically significant differences in polyp detection rates (PDR) for screening colonoscopy performed during AM Block (8AM-12N) versus PM Block (12N to 5PM). As expected, there was a statistically significant reduction in PDR if the prep was suboptimal.

Provider acceptance, safety, and effectiveness of a computer-based decision tool for colonoscopy preparation

Purpose To assess provider acceptance of recommendations by a decision tool that scans the electronic medical record and determines whether sodium phosphate may be taken. In addition, to determine decision tool effects on a composite outcome of colonoscopies canceled, rescheduled, aborted, or repeated sooner than recommended due to preparation (prep) quality; prep quality; colonoscopy duration; and patient satisfaction with and tolerance of the preparation. Methods We used 4 alternating 4-week periods to compare the decision tool with usual care for outpatient colonoscopy. All decision tool decisions were reviewed in real-time by gastroenterology nurses and/or physicians. Patients completed a survey about the prep process. Endoscopists blindly rated prep quality. Colonoscopy duration and findings were recorded. Results Of 354 persons in the decision tool group, 4 prep decisions were overridden because of patient preference or prior prep failure, but none for medical reasons. Sodium phosphate was used more frequently in the decision tool group (73% vs. 41%; P < 0.01). There was no difference between the decision tool and usual care groups in the composite outcome (26% vs. 30%, respectively; P = 0.29), acceptable prep quality (62% vs. 56%; P = 0.22), colonoscopy duration (28 vs. 30 min; P = 0.17), patient satisfaction ( P = 0.38), or preparation tolerance ( P = 0.37). Conclusions An electronic medical record-based decision tool can safely and effectively tailor the prep for colonoscopy and may improve colonoscopy efficiency and patient satisfaction. Limitations This study was performed at a single VA medical center and endoscopy unit, relies on the presence of relevant medical conditions and laboratory data in the electronic medical record, and had a higher than expected use of sodium phosphate during usual care.

Bowel preparation for colonoscopy: Enema versus Sodium Phosphate

Colonoscopy is considered to be the gold standard investigation for assessing the colonic mucosa. Good bowel preparation is essential in order to achieve optimal visualisation of the mucosa. Traditionally water enema is used for bowel preparation in most centres in Nigeria. This prospective study was performed at the Gastrointestinal Endoscopy Unit of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria between July 2008 and June 2009. This study compared patients' tolerability, adverse effects, efficacy and mean duration of colonoscopy of water enema and sodium phosphate (NaP) for bowel preparation toward colonoscopy. Standard structured questionnaire was completed by 64 patients and the colonoscopist assessing tolerability, adverse effect, efficacy and mean duration of the procedure. There were sixty four patients aged between 22 to 86 years. The mean age was 58.16 ± 15.790. Thirty eight (59.4%) patients were in patients and 26 (40.6%) were out patients. Forty one (64.1%) patients had water enema while 23 (35.9%) patients were included in the NaP group. The median age for patients in both groups was 62.0 years. Patients in NaP group rated their bowel preparation as more tolerable and found the dietary restriction much easier than those in water enema group (p < 0.0001). Better colon cleansing score was found in patient in NaP group as compared with those in water enema group in all region of the colon. The procedure took significantly longer time in patients in water enema group as compared with those in NaP group (p < 0.0001). NaP has a better bowel cleansing score for colonoscopy than water. It has better tolerability, side effect profile, efficacy and gives a shorter mean duration for the procedure.

Pico-Salax versus polyethylene glycol for bowel cleanout before colonoscopy in children: a randomized controlled trial

Comparison of bowel preparation for colonoscopy in children with either Pico-Salax (sodium picosulphate with magnesium citrate) or polyethylene glycol with electrolyte solution (PEG-ELS). In this investigator-blinded, randomized controlled trial, 83 children (12.5 +/- 3.1 years) requiring elective colonoscopy at a referral hospital were randomly allocated to Pico-Salax (n = 43) or PEG-ELS (n = 40), and an intention-to treat analysis was applied. Pico-Salax was administered in two doses, one the evening before and one on the morning of the procedure. PEG-ELS was administered over 4 hours. Efficacy was scored using the Ottawa scale and other constructs. Tolerability and toxicity were measured by patient and nursing questionnaires and serum biochemistry. 35 of Pico-Salax patients (81 %) were satisfied or very satisfied with the cleanout, compared with 19 (48 %) in the PEG-ELS group (P = 0.001). No differences were found in bowel cleanout effectiveness, as judged by the Ottawa score (P = 0.24), completion rates (P = 0.69), colonoscopy duration (P = 0.59), need for enemas (P = 0.25), or physician's global impression (P = 0.7). Except for one case of mild dehydration in the Pico-Salax group, no clinically significant adverse events were recorded. Serum biochemistry results were similar between groups except for more hypermagnesemia associated with Pico-Salax and hypokalemia with PEG-ELS; neither was clinically significant. Children tolerate Pico-Salax better than PEG-ELS for bowel cleanout before colonoscopy. This study did not demonstrate superiority of effectiveness or safety for either regimen.

Remifentanil vs. Meperidine for Patient-Controlled Analgesia During Colonoscopy: A Randomized Double-Blind Trial

The aim was to compare patients' and endoscopists' satisfaction in terms of efficacy and safety of remifentanil patient-controlled analgesia (PCA) during colonoscopy with that of a combination of midazolam and meperidine. Sixty patients undergoing colonoscopy were randomly assigned to two groups. All of the patients received midazolam 0.03 mg/kg intravenously for premedication. In the remifentanil group, a bolus dose of remifentanil was given, and a patient-controlled sedation analgesia (PCSA) pump was set to inject further bolus doses with no "lockout" time. Patients in the meperidine group received a bolus of meperidine and sham PCSA. Non-invasive arterial blood pressure, electrocardiography, and pulse oximetry were monitored throughout the study. The Observer's Assessment of Alertness and Sedation Scale (OAA/S) was performed at baseline, every 5 min during, and after colonoscopy. Assessment of pain and satisfaction with sedoanalgesia was scheduled after colonoscopy and 24-72 h later by a 100 mm visual analog scale (VAS). The technical difficulty of the examination and the gastroenterologist's satisfaction were assessed similarly. The degree of pain, the level of satisfaction with sedoanalgesia by patients and gastroenterologists, and the degree of difficulty experienced by the endoscopist were not different in the two groups. The time to reach an Aldrete score > or = 9 was significantly shorter in the remifentanil group (P < 0.0001); discharge times did not differ between the groups (P = 0.36). There was no difference between the groups regarding the duration of colonoscopy (P = 0.82) and the stability of vital signs. At the end of the procedure, OAA/S was significantly higher in the remifentanil group (P = 0.03). Remifentanil PCA is safe and effective to induce sedoanalgesia during colonoscopy. Further studies should address the optimization of dosing and lock out setting.

Improving quality of colonoscopy by adding simethicone to sodium phosphate bowel preparation

To evaluate the effectiveness of simethicone in enhancing visibility and efficacy during colonoscopy. A prospective, double-blind, randomized, placebo-controlled study was conducted. One hundred and twenty-four patients were allocated to receive 2 doses of sodium phosphate plus 240 mg of tablet simethicone or placebo as bowel preparation. Visibility was blindly assessed for the amount of air bubbles and adequacy of colon preparation. Total colonoscopic time, side effects of the medication, endoscopist and patient satisfaction were also compared. Sodium phosphate plus simethicone, compared to sodium phosphate plus placebo, improved visibility by diminishing air bubbles (100.00% vs 42.37%, P < 0.0001) but simethicone failed to demonstrate improvement in adequacy of colon preparation (90.16% vs 81.36%, P = 0.17). Endoscopist and patient satisfaction were increased significantly in the simethicone group. However, there was no difference in the total duration of colonoscopy and side effects of the medication. The addition of simethicone is of benefit for colonoscopic bowel preparation by diminishing air bubbles, which results in enhanced visibility. Endoscopist and patient satisfaction is also increased.

Work and Resources Needed for Endoscopic Resection of Large Sessile Colorectal Polyps

Large sessile colon polyps often are referred for surgical resection, even when amenable to endoscopic resection. The aim of this study was to describe the resource use of endoscopic resection of large sessile colon polyps compared with small polyps with respect to physician time and equipment use. Retrospectively, procedure time, medication use, and equipment use were recorded for 184 consecutive patients with sessile colorectal polyps 2 cm or larger in size and for 184 consecutive control patients with only sessile polyps less than 2 cm in size or pedunculated polyps. The mean duration of colonoscopy in patients with large sessile colon polyps averaged 51.4 (SD, 25.6) minutes compared with 20.0 (SD, 8.6) minutes for the control group (P < .0001). The large-polyp group required much more equipment to complete the polypectomy (eg, injection catheters and cautery probes) (P < .0001). Our results indicate that the costs of endoscopic large sessile adenoma resection in physician work and equipment are substantially greater than the costs of resection of small adenomas. These costs may be a deterrent to endoscopic resection of large sessile adenomas and may warrant increased reimbursement for those procedures, particularly if predictions that colonoscopic procedures will become more complex in the future are realized.

Colonoscopy in elderly Asians: A prospective evaluation in routine clinical practice

Colonoscopy is believed to be more complicated in elderly patients in Western countries. It is uncertain if the situation holds true among Asians. This study is to determine differences in colonoscopy performance and sedation complications between patients aged<65 years and those>or=65 years of age in an Asian population. A prospective, cross-sectional study of adults attending outpatient colonoscopy at a tertiary institution. Clinical and endoscopic data were obtained from all consenting adults. Two hundred and one patients (70 elderly and 131 aged<65 years) were enrolled. Compared to the patients aged<65 years, the elderly patients had similar levels of good (42.9%vs 45.8%), satisfactory (42.9%vs 33.6%) and poor (14.3%vs 20.6%) bowel preparations (P=NS). Cecal intubation was achieved in 60 (85.7%) of the elderly patients and 116 (88.5%) of the younger adults (P=NS). The differences in mean total colonoscopy duration was not significant (30+/-13 vs 27+/-11 min). Although the elderly patients received lower mean sedation doses of midazolam (4.7 vs 5.1 mg) and pethidine (37.8 vs 46.4 mg) compared to the younger adults, the hypotension rates were significantly higher in the elderly patients (7.1%vs 0.8%, P=0.01). The elderly patients had in additional one or more co-morbid illnesses (P=0.001), with significantly higher rates of diabetes (P=0.004), ischemic heart disease (P=0.03), hypertension (P=0.001) and stroke disease (P=0.004). Colonoscopy performance in elderly Asians is similar to that in younger adults. However, the conscious sedation of these patients results in a higher rate of cardio-vascular complications.

Upper Endoscope for Colonoscopy: Evidence Is Still Too Sparse to Utilize

TO THE EDITOR: We read with interest the article by Park et al. in the November issue of this journal (1). We applaud their efforts to highlight the possibility of implementing a small-caliber scope to achieve individualized and successful colonoscopy, especially with the current global need for screening for colorectal cancer. However, we would like to add constructive comments on this study. In this single-operator study, the colonoscopy withdrawal time was not mentioned. Adequate withdrawal time has been suggested to decrease the adenoma miss rate (2, 3), and at least 6 min of withdrawal time is recommended (3). In addition, the authors did not clarify whether a one-man maneuver or two-man maneuver was adopted in colonoscopic insertion, since a two-man maneuver is still popular in many Asian countries. Comparison of the use of a two-man maneuver with a standard colonoscope and the use of a one-man maneuver with an upper endoscope may exaggerate the advantage of the upper endoscope. Likewise, the question of whether a small-caliber upper endoscope (9.2 mm) can be inadvertently withdrawn faster than a large-caliber standard colonoscope (12.2 mm) remains to be answered. Another question concerns patients with past histories of abdominal or pelvic surgery. Kozarek et al. have reported the usefulness of a small-caliber endoscope after unsuccessful standard colonoscopy because of stenosis or angulation (4). It would be interesting to see the comparative performance in these specific subgroups to test a potentially beneficial role of an upper endoscope in these patients. In this study, multivariate logistic regression analysis revealed three independent predictors of painful colonoscopy: using an upper endoscope, female gender, and lower BMI. Our previous work has similarities and dissimilarities with this study (5, 6). Patient characteristics are similar and so is the number of polyps detected in each examinee (1.7 per examinee in our study) (5). In our previous prospective study on the factors determining postcolonoscopy abdominal pain (6), female gender similarly increased the likelihood of postcolonoscopy abdominal pain, as did the duration of colonoscopy. However, BMI (23.76 ± 3.29 kg/m2 in our participants) did not contribute significantly to pain in our study. A major dissimilarity is that up to 88% of our colonoscopies were under conscious sedation in a screening setting. Application of this study to all colonoscopists might have some limitations since only one operator was included (1). As cases of colorectal cancers are increasing worldwide, more studies and discussions on high-quality colonoscopy for individualized patients are certainly needed. Yet, the evidence for routine use of an upper endoscope in colonoscopy may still be too sparse to utilize. Tsung-Chun Lee, M.D.1 Han-Mo Chiu, M.D.2 Yi-Chia Lee, M.D.2 Hsiu-Po Wang, M.D.3 Shih-Pei Huang, M.D., Ph.D.2 Ming-Shiang Wu, M.D., Ph.D.2 Jaw-Town Lin, M.D., Ph.D.2 1Department of Internal Medicine National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan Departments of 2Internal Medicine and 3Emergency Medicine, National Taiwan University Hospital and College of Medicine National Taiwan University Taipei, Taiwan