Unsedated Patients Research Articles

Prospective randomized controlled trial of water exchange plus cap versus water exchange colonoscopy in unsedated veterans

Background and AimsWater exchange (WE) and cap-assisted colonoscopy (CAC) separately reduced pain during insertion in unsedated patients. We hypothesized that compared with WE, WECAC could significantly lower real-time maximum insertion pain (RTMIP). MethodsVeterans without escort were recruited, randomized, blinded, and examined at three United States Veterans Affairs sites. The primary outcome was RTMIP, highest segmental pain (0 = no pain, 10 = most severe pain) during insertion. ResultsRandomization [WECAC (n = 143) and WE (n = 137)] produced even distribution of a racially diverse group of males and females of low socioeconomic status. Intention-to-treat analysis reported results of WECAC (listed first) and WE (listed second): cecal intubation [93%, 94.2%]; mean (SD) of RTMIP [2.9 (2.5), 2.6 (2.4)]; the proportion with no pain (28.7%, 27.7%); the insertion time [18.6 (15.6), 18.8 (15.9) min]; overall ADR (55.2%, 62.8%), all P values were > 0.05. When RTMIP was binarized as "no pain" (0) vs. "some pain" (1-10), or "low pain" (0-7) vs. "high pain" (8-10), different significant predictors (see text) of RTMIP were identified. ConclusionsUnsedated colonoscopy was appropriate for unescorted Veterans. WE alone was sufficient. Adding a cap did not reduce RTMIP. Patient specific factors and application of WE with insertion suction of infused water contributed to high and low RTMIP, respectively. For unesorted patients, selecting those with low anxiety, avoiding low body mass index, history of depression or self-reported poor health and adhering to the steps of WE can minimize RTMIP to ensure success of unsedated colonoscopy.

Design and Evaluation of ScanCap: A Low-Cost, Reusable Tethered Capsule Endoscope with Blue-Green Illumination Imaging for Unsedated Screening and Early Detection of Barrett's Esophagus.

Esophageal carcinoma is the sixth-leading cause of cancer death worldwide. A precursor to esophageal adenocarcinoma (EAC) is Barrett's Esophagus (BE). Early-stage diagnosis and treatment of esophageal neoplasia (Barrett's with high-grade dysplasia/intramucosal cancer) increase the five-year survival rate from 10% to 98%. BE is a global challenge; however, current endoscopes for early BE detection are costly and require extensive infrastructure for patient examination and sedation. We describe the design and evaluation of the first prototype of ScanCap, a high-resolution optical endoscopy system with a reusable, low-cost tethered capsule, designed to provide high-definition, blue-green illumination imaging for the early detection of BE in unsedated patients. The tethered capsule (12.8 mm diameter, 35.5 mm length) contains a color camera and rotating mirror and is designed to be swallowed; images are collected as the capsule is retracted manually via the tether. The tether provides electrical power and illumination at wavelengths of 415 nm and 565 nm and transmits data from the camera to a tablet. The ScanCap prototype capsule was used to image the oral mucosa in normal volunteers and ex vivo esophageal resections; images were compared to those obtained using an Olympus CV-180 endoscope. Images of superficial capillaries in intact oral mucosa were clearly visible in ScanCap images. Diagnostically relevant features of BE, including irregular Z-lines, distorted mucosa, and dilated vasculature, were clearly visible in ScanCap images of ex vivo esophageal specimens.

Frequency of arrhythmias detected in 9440 feline electrocardiograms by breed, age, and sex

ObjectivesThe purpose of this study was to describe the frequency of arrhythmias detected in unsedated feline patients from general practice settings. AnimalsA total 10,638 feline electrocardiograms (ECGs) were retrospectively collected of which 9440 met the inclusion criteria. MethodsRecordings were evaluated by a board-certified cardiologist. If an arrhythmia was present in the ECG tracing, the cardiologist categorized the arrhythmia using pre-established keywords. ResultsAt least one arrhythmia was observed in 249 cases (2.64%, 95% confidence interval (CI): 2.34–2.98, 249/9440), with the most common arrhythmia encountered being ventricular premature complexes (1.63%, 95% CI: 1.39%–1.91%, 154/9440). Ragdoll cats had the highest odds of arrhythmia (odds ratio (OR): 3.17, 95% CI: 1.43–6.17, P=0.036). Both geriatric (Age: 13+ years, OR: 1.70, 95% CI: 1.24–2.34, P=0.013) and senior (Age: 10–13 years, OR: 1.68, 95% CI: 1.19–2.37, P=0.003) cats had higher odds of having an arrhythmia than adult cats. The odds of male cats having an arrhythmia were slightly higher than female (OR: 1.36, 95% CI: 1.06–1.76, P=0.018). Conclusions and relevanceOf the 9440 ECGs included in this study, at least one arrhythmia was detected in 249 distinct cases. Arrhythmias were more common in older cats, male cats and the Ragdoll cat breed. While it is important to note that the presence of an arrhythmia alone does not always indicate the presence of heart disease, further research on the association between breed cardiac health is needed.

Impact of anesthetics on pyloric characteristics measured using the EndoFLIP® system in patients with gastroparesis.

Pyloric distensibility has been reported as a predictive measure in gastroparesis. Measures can be obtained either during endoscopy under anesthesia or in unsedated patients. However, the impact of anesthetic drugs on the results of pyloric characteristics remains unknown. The objective of the present study was to determine the impact of anesthetics on pyloric characteristics measured using EndoFLIP® in patients with gastroparesis. Consecutive patients with gastroparesis from three French tertiary centers were retrospectively analyzed. Patients with a previous history of pyloric intervention were not considered for analysis. Medical records were reviewed for the potential use of anesthetic drugs during EndoFLIP® measurement. One hundred twenty-five patients were included in the present study [median age: 55.0 years (43.0-66.0)]. Thirty-four patients (27.2%) had pyloric assessment without general anesthesia and 91 patients (72.8%) with general anesthesia. Pyloric pressure at 40 mL of distension was higher in patients with general anesthesia in comparison with patients without general anesthesia [18.7 (13.0-25.6) mmHg vs. 15.4 (11.9-20.7) mmHg; p = 0.044)]. In multivariate analysis, suxamethonium chloride administration was associated with decreased pyloric distensibility (OR: 3.9; 95% CI: 1.3-11.4; p = 0.013) while ephedrine was rather associated with increased pyloric distensibility (OR: 0.3; 95% CI: 0.1-0.9; p = 0.036). This study is the first to have found an impact of general anesthesia on pyloric measurement using the EndoFLIP®. Therefore, further studies are needed to confirm these findings, if possible, prospective studies.

Validation of a 3D-Printed Percutaneous Injection Laryngoplasty Simulator: A Randomized Controlled Trial.

Simulation may be a valuable tool in training laryngology office procedures on unsedated patients. However, no studies have examined whether existing awake procedure simulators improve trainee performance in laryngology. Our objective was to evaluate the transfer validity of a previously published 3D-printed laryngeal simulator in improving percutaneous injection laryngoplasty (PIL) competency compared with conventional educational materials with a single-blinded randomized controlled trial. Otolaryngology residents with fewer than 10 PIL procedures in their case logs were recruited. A pretraining survey was administered to participants to evaluate baseline procedure-specific knowledge and confidence. The participants underwent block randomization by postgraduate year to receive conventional educational materials either with or without additional training with a 3D-printed laryngeal simulator. Participants performed PIL on an anatomically distinct laryngeal model via trans-thyrohyoid and trans-cricothyroid approaches. Endoscopic and external performance recordings were de-identified and evaluated by two blinded laryngologists using an objective structured assessment of technical skill scale and PIL-specific checklist. Twenty residents completed testing. Baseline characteristics demonstrate no significant differences in confidence level or PIL experience between groups. Senior residents receiving simulator training had significantly better respect for tissue during the trans-thyrohyoid approach compared with control (p < 0.0005). There were no significant differences in performance for junior residents. In this first transfer validity study of a simulator for office awake procedure in laryngology, we found that a previously described low-cost, high-fidelity 3D-printed PIL simulator improved performance of PIL amongst senior otolaryngology residents, suggesting this accessible model may be a valuable educational adjunct for advanced trainees to practice PIL. NA Laryngoscope, 134:318-323, 2024.

Sleep Architecture Patterns in Critically Ill Patients and Survivors of Critical Illness - A Retrospective Study.

Sleep abnormalities are very frequent in critically ill patients during and following ICU stay. Their mechanisms are poorly understood. The odds ratio product (ORP) is a continuous metric (0.0-2.5) of sleep depth measured in 3-sec intervals and derived from the relationship of powers of different EEG frequencies to each other. When expressed as percent of epochs within 10 ORP deciles covering the entire ORP range, it provides information about mechanism(s) of abnormal sleep. To determine ORP architecture types in critically ill patients and survivors of critical illness who had previously undergone sleep studies. Nocturnal polysomnograms of 47 un-sedated critically-ill patients and 23 survivors of critical illness at hospital discharge were analyzed. Twelve critically-ill patients were monitored also during the day and 15 survivors underwent another polysomnogram 6 months after hospital discharge. In all polysomnograms each 30-sec epoch was characterized by the mean ORP of the ten 3-sec epochs. The number of 30-sec epochs with mean ORP within each of 10 ORP deciles covering the entire ORP range (0.0-2.5) was calculated and expressed as % of total recording time. Thereafter, each polysomnogram was characterized by a 2-digit ORP type with the first digit (range 1-3) reflecting increasing levels of deep sleep (ORP<0.5, deciles 1 and 2) and the second digit (range 1-3) reflecting increasing levels of full wakefulness (ORP>2.25, decile 10). Results of patients were compared to 831 age- and gender-matched community dwellers free of sleep disorders. In critically ill patients, types 1,1 and 1,2 (little deep sleep and little or average full wakefulness) dominated (46% of patients). In the community, these types are uncommon (<15%) and seen primarily in disorders that preclude progression to deep sleep (e.g., very severe OSA). Next in frequency (22%) was type 1,3, consistent with hyperarousal. Day ORP sleep architecture was similar to night results. Survivors had similar patterns with little improvement after 6 months. Sleep abnormalities in critically ill patients and survivors of critical illness result primarily from stimuli that preclude progression to deep sleep or from presence of a hyperarousal state.

Quiet Diffusion-weighted MR Imaging of the Brain for Pediatric Patients with Moyamoya Disease.

Diffusion-weighted MRI (DWI) is an essential sequence for evaluating pediatric patients with moyamoya disease (MMD); however, acoustic noise associated with DWI may lead to motion artifact. Compared with conventional DWI (cDWI), quiet DWI (qDWI) is considered less noisy and able to keep children more relaxed and stable. This study aimed to evaluate the suitability of qDWI compared with cDWI for pediatric patients with MMD. In this observational study, MR examinations of the brain were performed either with or without sedation in pediatric patients with MMD between September 2017 and August 2018. Three neuroradiologists independently evaluated the images for artifacts and restricted diffusion in the brain. The differences between qDWI and cDWI were compared statistically using a chi-square test. One-hundred and six MR scans of 56 patients with MMD (38 scans of 15 sedated patients: 6 boys and 9 girls; mean age, 5.2 years; range, 1-9 years; and 68 scans of 42 unsedated patients: 19 boys and 23 girls; mean age, 10.7 years; range, 7-16 years) were evaluated. MR examinations were performed either with or without sedation (except in one patient). In sedated patients, no artifact other than susceptibility was observed on qDWI, whereas four artifacts were observed on cDWI (P = .04). One patient awoke from sedation during cDWI scanning, while no patient awoke from sedation during qDWI acquisition. For unsedated patients, three scans showed artifacts on qDWI, whereas two scans showed artifacts on cDWI (P = .65). Regarding restricted diffusion, qDWI revealed three cases, while two cases were found on cDWI (P = .66). qDWI induced fewer artifacts compared with cDWI in sedated patients, and similar frequencies of artifacts were induced by qDWI and by cDWI in unsedated patients. qDWI showed restricted diffusion comparable to cDWI.

One- or two-operator techniques for oesophago-gastro-duodenoscopy in unsedated patients: A comparative prospective randomized study

The standard oesophago-gastro-duodenoscopy procedure is performed with a single endoscopist (SE). Nurse-assisted (NA) oesophago-gastro-duodenoscopies have not yet been studied. We aimed to evaluate the efficacy of an NA endoscopy compared to an SE endoscopy. A prospective, single-center, randomized trial, in which 500 adult patients were divided into two groups. In the first group, patients underwent an endoscopy with an SE. In the second group, the endoscopy was performed with an NA. The ease of the procedure (scores 1–4; 1 difficult , 2 satisfactory , 3 easy , 4 very easy ), evaluation of patient satisfaction (scores 1–4; 1 uncomfortable , 2 satisfactory , 3 comfortable , 4 very comfortable ), total time of the procedure and vocal cord observation were determined as quality indicators. Mean patient satisfaction scores in groups 1 and 2 were 2.98 ± 0.79 and 3.11 ± 0.78, respectively ( p = 0.043), with uncomfortable ratings in 5.2% vs 4%, satisfactory in 16.8% vs 13.2%, comfortable in 53.2% vs 50.4%, and very comfortable in 24.8% vs 32.4% of patients in groups 1 and 2, respectively. Retching rates during the procedure were 54.4% and 45.2% ( p = 0.040) in groups 1 and 2, respectively. No differences were seen in vocal cord observation (54.4% vs 56.0%), total procedure time (2.35 ± 1.56 vs 2.41 ± 1.48 min) and easy score (3.26 ± 0.603 vs 3.25 ± 0.64) in groups 1 and 2 for the procedures. Very easy, easy, satisfactory , and difficult ratings were given by 33.6% vs 34.8%, 60.4% vs 56.4%, 4.8% vs 7.6% and 1.2% vs 1.2% of groups 1 and 2, respectively. Compared with the conventional method, the assisted endoscopic technique provides more comfort and less gag reflex without increasing the processing time or difficulty of performing the procedure. El procedimiento estándar de esofagogastroduodenoscopia se realiza con un solo endoscopista (SE). La esofagogastroduodenoscopia realizada con una enfermera asistida (NA, por sus siglas en inglés) aún no se ha estudiado. Nuestro objetivo es evaluar la eficacia de una endoscopia asistida por una enfermera en comparación con un SE. Se trata de un ensayo prospectivo, monocéntrico y aleatorizado. Quinientos pacientes adultos fueron divididos en 2 grupos. En el primer grupo, los pacientes se sometieron a una endoscopia con un SE; en el segundo grupo, la endoscopia se realizó con una NA. Se determinaron como indicadores de calidad la facilidad del procedimiento (puntuaciones 1-4; 1 difícil, 2 satisfactorio, 3 fácil y 4 muy fácil), la evaluación de la satisfacción del paciente (puntuaciones 1-4; 1 incómodo, 2 satisfactorio, 3 cómodo y 4 muy cómodo), el tiempo total del procedimiento y la observación de las cuerdas vocales. Las puntuaciones medias de satisfacción del paciente en los grupos 1 y 2 fueron de 2,98 ± 0,79 y 3,11 ± 0,78, respectivamente (p = 0,043), con puntuaciones de incómodo en el 5,2 frente al 4%, satisfactorio en el 16,8 frente al 13,2%, cómodo en el 53,2 frente al 50,4% y muy cómodo en el 24,8 frente al 32,4% de los pacientes de los grupos 1 y 2, respectivamente. Las tasas de arcadas durante el procedimiento fueron del 54,4 y el 45,2% (p = 0,040) en los grupos 1 y 2, respectivamente. No se observaron diferencias en la observación de las cuerdas vocales (54,4 frente al 56,0%), el tiempo total del procedimiento (2,35 ± 1,56 frente al 2,41 ± 1,48 min) y la puntuación de fácil (3,26 ± 0,603 frente al 3,25 ± 0,64) en los grupos 1 y 2 para los procedimientos. Muy fácil, fácil, satisfactorio y difícil fueron calificados por el 33,6 frente al 34,8%, el 60,4 frente al 56,4%, el 4,8 frente al 7,6% y el 1,2 frente al 1,2% de los grupos 1 y 2, respectivamente. En comparación con el método convencional, la técnica endoscópica asistida proporciona más comodidad y menos reflejo nauseoso sin aumentar el tiempo de tratamiento ni la dificultad de realizar el procedimiento.

Feasibility of salvage colonoscopy by water exchange for failed air-insufflated patients: a prospective, randomized, controlled trial

Background A complete colonoscopy is crucial for screening colorectal diseases and colorectal cancer. However, a failure rate of up to 43% still exists. Several studies have indicated that the water exchange method can enhance the cecal intubation rate while reducing discomfort of the patient. Water exchange colonoscopy (WEC) might be a salvage treatment for the patients who failed from air insufflation colonoscopy (AIC). We aimed to assess the feasibility of WEC as a salvage measure following the failure of conventional AIC Methods Patients willing to undergo unsedated colonoscopy at a tertiary-care referral center in China were randomly assigned 1:1 to WEC or AIC group for salvage after the initial AIC attempt failed. Patients were blinded to group assignment. The primary outcome was cecal intubation rate, the secondary outcomes included time to the cecum, maximum pain scores, and technical difficulty level. Results Recruited 104 patients were randomized to the WEC (n = 52) or AIC (n = 52) group. WEC significantly increased the cecal intubation rate (92.3% vs 73.1%; p = .02). The maximum pain scores and technical difficulty level in the WEC group were significantly lower than the AIC group during salvage procedure (p < .001). Conclusions This randomized, controlled trial confirms that the WEC significantly enhanced cecal intubation rate in difficult colonoscopy in unsedated patients after the failure of standard AIC. The increased cecal intubation rate, lower pain scores and technical difficulty level suggest WEC is a good alternative for incomplete unsedated colonoscopy. Clinical trial registration number: ChiCTR2100051483.

Comparative effectiveness of lidocaine sprays between sitting and supine position for patients undergoing upper gastrointestinal endoscopy: a prospective randomized controlled trial.

Topical pharyngeal anesthesia has improved esophagogastroduodenoscopy (EGD) efficiency with smooth insertion, reducing pain and discomfort. Lidocaine spray is one of the safe and widely used methods. In practice, the patients walk, sit in a wheelchair, or lie on a trolley bed, and the lidocaine sprays are applied to those in sitting or supine positions for pre-endoscopic preparation. Although there is no current guidance technique, this study aims to compare the effects of lidocaine sprays between sitting (Group A; Gp A) and supine positions (Group B; Gp B) for patients undergoing unsedated EGD. This study was a single-center prospective randomized controlled trial. Unsedated EGD patients were randomly allocated the lidocaine spray in sitting or lidocaine spray in the supine position. Lidocaine spray treatments were significantly different in the gag reflex (NRS; Gp A: 1.28 ± 0.67, Gp B: 1 ± 0.63, p = 0.0003), ease of esophageal instrumentation (NRS; Gp A: 7.68 ± 0.91, Gp B: 7.95 ± 0.66, p = 0.0042), and pain score (NRS; Gp A: 5.16 ± 2.08, Gp B: 4.53 ± 1.93, p = 0.0059). When considering modified Mallampati classification (MMC), MMC classes III and IV were significantly different in the same direction but MMC classes I and II were not. The technique of spraying in the supine position was associated with less gagging, less pain, and easier esophageal instrumentation, especially in patients with MMC classes III and IV.

Persephin as a diagnostic marker of acute brain injury in critically ill newborns: a clinical trial

Aim. To study the correlation of serum persephin with clinical, instrumental and biochemical indicators of brain damage and with an adverse outcome in critically ill newborns.Materials and Methods. The study included 44 critically ill newborns. Blood samples were collected on the 1stand 7thday of life. Brain injury was assessed by recording Apgar score, depression of consciousness and brainstem reflexes in unsedated patients over 7 days of life, convulsions, neurosonographic signs of cerebral edema, serum protein S100B on the 1stand 7thday of life, and using indicators of adverse neurological outcome. The correlation of serum persephin on the 1stand 7thday of life with signs of brain damage was evaluated using the Spearman's rank correlation coefficient and Mann-Whitney U-test.Results. No statistically significant correlation was found between the concentrations of serum persephin on the 1stand 7thday of life and Apgar score (p = 0.721 and 0.222, respectively), depression of consciousness and stem reflexes (p &lt; 0.05), convulsions (p = 0.673 and 0.432, respectively), cerebral edema (p = 0.737 and 0.558, respectively), and serum protein S100B both on the 1stday (p = 0.095 and 0.475, respectively) and 7thday of life (p = 0.988 and p = 0.775, respectively). Further, there was no statistically significant association of the serum persephin on the 1stday of line with an unfavorable outcome (p = 0.294). Yet, we revealed an association of serum persephin on the 7thday of life with an unfavorable outcome (p = 0.013), with a cut-off point of 828 ng/mL, a sensitivity of 39%, and a specificity of 100%.Conclusion. Persephin has poor diagnostic and prognostic significance for assessing the severity of brain damage in critically ill newborns. The obtained data on the correlation of the concentration of persephin for 7 days with an unfavorable outcome are doubtful due to the lack of data on its correlation with signs of severe brain damage.

Clinical Efficacy of Novel Patient-Covering Negative-Pressure Box for Shielding Virus Transmission during Esophagogastroduodenoscopy: A Prospective Observational Study.

Esophagogastroduodenoscopy (EGD) has a high risk of virus transmission during the current coronavirus disease 2019 era, and preventive measures are under investigation. We investigated the effectiveness of a newly developed patient-covering negative-pressure box system (Endo barrier®) (EB) for EGD. Eighty consecutive unsedated patients who underwent screening EGD with EB use were prospectively enrolled. To examine the aerosol ratio before, during, and after EGD, 0.3- and 0.5-μm aerosols were measured every 60 s using an optical counter. Moreover, the degree of contamination of the examiners’ goggles and vinyl gowns was assessed before and after EGD using a rapid adenosine triphosphate (ATP) test for simulated droplets. Data were available in 73 patients and showed that 0.3- and 0.5-μm particles did not increase in 95.8% (70/73) and 94.5% (69/73) of patients during EGD under EB. There were no significant differences in the total 0.3- or 0.5-μm particle counts before versus after EGD. The difference in the ATP levels before and after EGD was −0.6 ± 16.6 relative light units (RLU) on goggles and 1.59 ± 19.9 RLU on gowns (both within the cutoff value). EB use during EGD may provide a certain preventive effect against aerosols and droplets, decreasing examiners’ exposure to viruses.

Effects of Sedatives on Sleep Architecture Measured With Odds Ratio Product in Critically Ill Patients.

Retrospective study. A 16-bed medical-surgical ICU. Twenty-three mechanically ventilated patients who had previously undergone two nocturnal sleep studies, one without and one with sedation (propofol, n = 12; dexmedetomidine, n = 11). None. Sleep architecture was evaluated with odds ratio product analysis by the distribution of 30-second epochs with different odds ratio product values. Electroencephalogram spectral patterns and frequency of wake intrusions (3-s odds ratio product > 1.75) were measured at different odds ratio product levels. Thirty-seven normal sleepers were used as controls. Compared with normal sleepers, unsedated critically ill patients spent little time in stable sleep (percent odds ratio product < 1.0: 31% vs 63%; p < 0.001), whereas most of the time were either in stage wake (odds ratio product > 1.75) or in a transitional state (odds ratio product 1.0-1.75), characterized by frequent wake intrusions. Propofol and dexmedetomidine had comparable effects on sleep. Sedation resulted in significant shift in odds ratio product distribution toward normal; percent odds ratio product less than 1.0 increased by 54% (p = 0.006), and percent odds ratio product greater than 1.75 decreased by 48% (p = 0.013). In six patients (26%), sedation failed to improve sleep. In stable critically ill unsedated patients, sleep quality is poor with frequent wake intrusions and little stable sleep. Light sedation with propofol or dexmedetomidine resulted in a shift in sleep architecture toward normal in most, but not all, patients.

Ambulante Phonochirurgie

Wesentliche und neue Impulse, die das Behandlungskonzept für ambulante phonochirurgische Eingriffe am unsedierten Patienten betreffen, stammen aktuell aus dem angloamerikanischen Sprachraum. Die dort etablierten „office-based procedures“ werden als eine Alternative zu vielen konventionellen operativen Larynxeingriffen in Vollnarkose propagiert. Maßgeblich für diese Entwicklung ist der Einsatz neuer endoskopischer Techniken in Kombination mit photoangiolytischen Laserverfahren (KTP-Laser und blauer Laser), die eine sichere und effiziente ambulante Phonochirurgie ermöglichen. Die Akzeptanz seitens der Patienten ist hoch, da ambulante Eingriffe als risikoärmer gelten. Ungeachtet der verbreiteten Euphorie fehlen weiterführende Studien, welche die medizinischen Entscheidungskriterien und das Sicherheitsmanagement bei dieser neuen ambulanten Ausrichtung der Kehlkopfchirurgie bewerten.

A122 WATER EXCHANGE FACILITATES HIGH CECAL INTUBATION RATE FOLLOWING INCOMPLETE COLONOSCOPY

Abstract Background Incomplete colonoscopy is a complex problem that negatively affects the success of colon cancer screening programs. Failure to intubate the cecum is associated with a significant risk of missed colorectal cancer and increases costs through missed diagnoses and salvage investigations. Water exchange (WE) colonoscopy is associated with a high rate of patient comfort and cecal intubation (CI) and may be of value in preventing and following up on incomplete colonoscopy. Aims To estimate effectiveness of WE colonoscopy as initial salvage of incomplete colonoscopy. Methods All patients referred to the Kelowna Gastroenterology group for incomplete colonoscopy between Jan 2010 to Dec 2019 were included. Demographic, clinical, procedural, and pathological information were collected via retrospective chart review. Patients underwent WE colonoscopy by a single endoscopist. The outcomes evaluated were CI rate, sedation requirements, and adenoma detection. Results 116 patients met study criteria and underwent WE colonoscopy after a previously failed or incomplete colonoscopy for technical reasons. The mean age was 66 years (range 21–89). 83 (72%) patients were female. 53 (46%) patients had previous abdominal surgery, and 42 (36%) had previous pelvic surgery. 65 (56%) patients had previous bowel disease. 81 (70%) patients had previously incomplete conventional air insufflation (AI) colonoscopy, 9 (8%) patients had previously incomplete WE colonoscopy, and 5 (4%) patients underwent unsuccessful combination of WE and AI colonoscopy. 17 (15%) patients had previously incomplete flexible sigmoidoscopy, and 4 (3%) patients had previously incomplete water immersion colonoscopy. The most common cause of unsuccessful CI was redundant colon (n=39, 34%) followed by strictures/angulations (n=16, 14%). 105 (91%) patients underwent repeat WE colonoscopy only, while 7 (6%) patients had combination WE and AI colonoscopy and 4 (3%) patients had concurrent gastroscopy. CI was successful in 114 (98%) patients and unsuccessful in 2 (2%) patients. 87 (75%) study patients received conscious sedation, 16 (14%) opted for no sedation, and 7 (6%) attempted no sedation then switched to conscious sedation. 5 patients (4%) required general anesthesia. CI was achieved in all 16 unsedated patients. 236 polyps were identified in 79 (68%) patients, 2 (1%) of which were malignant. Conclusions There is no standardized approach to incomplete colonoscopy. In this cohort of patients with previous failed attempt at colonoscopy, WE as a primary technique was associated with a high success rate with minimal need for general anesthesia and a high rate of polyp detection. A significant rate of colon cancer was identified, similar to that seen in general screening populations. Funding Agencies None

One- or two-operator techniques for oesophago-gastro-duodenoscopy in unsedated patients: A comparative prospective randomized study

BackgroundThe standard oesophago-gastro-duodenoscopy procedure is performed with a single endoscopist (SE). Nurse-assisted (NA) oesophago-gastro-duodenoscopies have not yet been studied. We aimed to evaluate the efficacy of an NA endoscopy compared to an SE endoscopy. MethodsA prospective, single-center, randomized trial, in which 500 adult patients were divided into two groups. In the first group, patients underwent an endoscopy with an SE. In the second group, the endoscopy was performed with an NA. The ease of the procedure (scores 1–4; 1 difficult, 2 satisfactory, 3 easy, 4 veryeasy), evaluation of patient satisfaction (scores 1–4; 1 uncomfortable, 2 satisfactory, 3 comfortable, 4 verycomfortable), total time of the procedure and vocal cord observation were determined as quality indicators. ResultsMean patient satisfaction scores in groups 1 and 2 were 2.98±0.79 and 3.11±0.78, respectively (p=0.043), with uncomfortable ratings in 5.2% vs 4%, satisfactory in 16.8% vs 13.2%, comfortable in 53.2% vs 50.4%, and very comfortable in 24.8% vs 32.4% of patients in groups 1 and 2, respectively. Retching rates during the procedure were 54.4% and 45.2% (p=0.040) in groups 1 and 2, respectively. No differences were seen in vocal cord observation (54.4% vs 56.0%), total procedure time (2.35±1.56 vs 2.41±1.48min) and easy score (3.26±0.603 vs 3.25±0.64) in groups 1 and 2 for the procedures. Very easy, easy, satisfactory, and difficult ratings were given by 33.6% vs 34.8%, 60.4% vs 56.4%, 4.8% vs 7.6% and 1.2% vs 1.2% of groups 1 and 2, respectively. ConclusionsCompared with the conventional method, the assisted endoscopic technique provides more comfort and less gag reflex without increasing the processing time or difficulty of performing the procedure.

Feasibility and Safety of Tethered Capsule Endomicroscopy in Patients With Barrett’s Esophagus in a Multi-Center Study

Tethered capsule endomicroscopy (TCE) involves swallowing a small tethered pill that implements optical coherence tomography (OCT) imaging, procuring high resolution images of the whole esophagus. Here, we demonstrate and evaluate the feasibility and safety of TCE and a portable OCT imaging system in patients with Barrett's esophagus (BE) in a multi-center (5-site) clinical study. Untreated patients with BE as per endoscopic biopsy diagnosis were eligible to participate in the study. TCE procedures were performed in unsedated patients by either doctors or nurses. After the capsule was swallowed, the device continuously obtained 10-μm-resolution cross-sectional images as it traversed the esophagus. Following imaging, the device was withdrawn through mouth, and disinfected for subsequent reuse. BE lengths were compared to endoscopy findings when available. OCT-TCE images were compared to volumetric laser endomicroscopy (VLE) images from a patient who had undergone VLE on the same day as TCE. 147 patients with BE were enrolled across all sites. 116 swallowed the capsule (79%), 95/114 (83.3%) men and 21/33 (63.6%) women (P = .01). High-quality OCT images were obtained in 104/111 swallowers (93.7%) who completed the procedure. The average imaging duration was 5.55 ± 1.92 minutes. The mean length of esophagus imaged per patient was 21.69 ± 5.90 cm. A blinded comparison of maximum extent of BE measured by OCT-TCE and EGD showed a strong correlation (r = 0.77-0.79). OCT-TCE images were of similar quality to those obtained by OCT-VLE. The capabilities of TCE to be used across multiple sites, be administered to unsedated patients by either physicians or nurses who are not expert in OCT-TCE, and to rapidly and safely evaluate the microscopic structure of the esophagus make it an emerging tool for screening and surveillance of BE patients. Clinical trial registry website and trial number: NCT02994693 and NCT03459339.

Tethered capsule en face optical coherence tomography for imaging Barrett’s oesophagus in unsedated patients

ObjectiveBarrett’s oesophagus (BE) screening outside the endoscopy suite can identify patients for surveillance and reduce mortality. Tethered capsule optical coherence tomography (OCT) can volumetrically image oesophageal mucosa in unsedated patients...

The Effectiveness of Right- vs Left-lateral Starting Position in Unsedated Diagnostic Colonoscopy with Modified-water Immersion Method: A Randomized Controlled Trial Study.

ObjectiveA colonoscopy study in sedated patients with air insufflation showed that right-lateral starting position (RLP) improved abdominal discomfort and reduced cecal intubation time. The aim of this study was to determine if RLP vs left-lateral starting position (LLP) may produce similar results in unsedated patients examined with a modified-water immersion (m-WI) method.MethodsConsecutive patients for diagnostic colonoscopy meeting the inclusion criteria were randomized. Patients and colonoscopist were unblinded. The m-WI method entailed suction during insertion not only for fecal debris evacuation but also to facilitate passage through difficult or angulated colonic flexures. Water was infused as needed when any difficulty was encountered during insertion. A bowel visualization scale (BVS) (0=totally blurred visualization; 1=blurred lumen visualization; 2=small fecal debris with clear mucosa visualization; 3= clear visualization) was used to evaluate the interference of fecal debris with cecal intubation rate and time.ResultsA total of 142 patients (72 in RLP and 70 in LLP) were enrolled. The respective pain score, visual analog scale, (VAS) and cecal intubation rate were not significantly different. The cecal intubation time was nearly significantly different (13.4±4.5 min vs 11.7±5.4 min; p=0.054) and was significantly different in the constipation subgroup (16.0±3.5 min vs 8.6±3.8 min; p=0.001). The cecal intubation time based on BVS showed significant difference between RLP and LLP in Scale 2 (13.9±4.6 min vs 10.3±4.2 min; p=0.003) and Scale 2 and 3 combined (13.2±4.3 min vs 10.6±4.8 min; p=0.01), respectively.ConclusionRLP did not improve the pain score, and LLP showed better performance in unsedated m-WI colonoscopy patients (ClinicalTrial.gov, NCT03489824).

Unsedated Colonoscopy: Impact on Quality Indicators.

In the USA, sedation is commonly used for colonoscopies; though colonoscopy can be successfully performed without sedation, outcomes data in this setting are scarce. 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. 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. 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). 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.