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Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic 5min before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I. According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction., (Copyright © 2015 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.)

Adequate bowel cleansing is essential for complete examination of the colon mucosa during colonoscopy. Suboptimal bowel preparation has potential adverse consequences, such as missed pathologic abnormalities, the need for repeated procedures, and increased procedure-related complications. Several factors can predict individuals at increased risk for inadequate bowel preparation. If predictors of inadequate bowel preparation are identified, then education should be intensified and a more aggressive bowel regimen recommended. On completion of this article, you should be able to (1) define the frequency of inadequate colon preparations, (2) identify predictors of poor bowel preparation, and (3) use a more aggressive bowel regimen when clinically indicated., (Copyright © 2015 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Colonoscopy has become the mainstay for screening and surveillance of colorectal cancer. The guidelines for screening and surveillance colonoscopy have recently been updated, particularly in light of greater recognition of the importance of sessile serrated lesions in the role of cancer. It is important for practitioners to be aware of and understand the recommendations for screening and surveillance to optimize patient safety and to decrease health care use. We searched PubMed for articles and guidelines related to screening and surveillance of colonic polyps and serrated adenomas. The related citations feature was also used. The search was conducted from February 22, 2013, to March 2, 2013, and we included the search terms colorectal cancer screening, colonoscopy, guidelines, colorectal polyps, and colorectal surveillance. We selected the most recent guidelines and pertinent articles for this review, in which we discuss the basis of screening and surveillance colonoscopy and provide recommendations for colonoscopy intervals., (Copyright © 2013 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Self-expandable metal stent (SEMS) placement is a minimally invasive option for achieving acute colonic decompression in obstructed colorectal cancer. Colorectal stenting offers nonoperative, immediate, and effective colon decompression and allows bowel preparation for an elective oncologic resection. Patients who benefit the most are high-risk surgical patients and candidates for laparoscopic resection with complete obstruction, because emergency surgery can be avoided in more than 90% of patients. Colonic stent placement also offers effective palliation of malignant colonic obstruction, although it carries risks of delayed complications. When performed by experienced endoscopists, the technical success rate is high with a low procedural complication rate. Despite concerns of tumor seeding following endoscopic colorectal stent placement, no difference exists in oncologic long-term survival between patients who undergo stent placement followed by elective resection and those undergoing emergency bowel resection. Colorectal stents have also been used in selected patients with benign colonic strictures. Uncovered metal stents should be avoided in these patients, and fully covered stents are associated with high risk of migration. Patients with benign colonic stricture with acute colonic obstruction who are at high risk for emergency surgery can gain temporary relief of obstruction after SEMS placement; the stent can be removed en bloc with the colon specimen at surgery. This article reviews the techniques and indications of SEMS placement for benign and malignant colorectal obstructions.

Objective: The purpose is to provide initial validation of a novel simulation model's fidelity and ability to assess competence in colonoscopy skills., Methods: In a prospective, cross-sectional design, each of 39 endoscopists (13 staff, 13 second year fellows, and 13 novices) performed a colonoscopy on a novel bovine simulation model. Staff endoscopists also completed a survey examining different aspects of the model's realism as compared to human colonoscopy. The groups' simulation performances were compared. Additionally, individual performances were correlated to patient-based performance data., Results: Median model realism evaluation scores were favorable for nearly all parameters evaluated with mucosa appearance, endoscopic view, and paradoxical motion parameters receiving the highest scores. During simulation procedures, each group outperformed the less experienced groups in all parameters evaluated. Specifically, median cecal intubation times were: staff 226 s (IQR [interquartile range] 179-273), fellows 340 s (282-568), and novices 1,027 s (970-1,122) (P < 0.05). Median total procedure times on the model were: staff 468 s (416-501), fellows 527 s (459-824), and novices 1,350 s (1,318-1,428) (P < 0.05). Finally, individual cecal intubation times on the simulation model had a very high correlation to their respective patient-based times (r = 0.764)., Conclusions: Overall, this model possesses a favorable degree of realism and is able to easily differentiate users based on their level of colonoscopy experience. More impressive, however, is the strong correlation between individual's simulated intubation times and actual patient-based colonoscopy data. In light of these findings, we speculate that this model has potential to be an effective tool for assessment of colonoscopic competence.

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

Introduction: Limited data exist on the role of aspirin in increasing the risk of clinically significant postpolypectomy bleeding (PPB), which is defined as lower gastrointestinal (GI) hemorrhage following colonoscopic polyp removal requiring transfusion, hospitalization, endoscopic intervention, angiography, or surgery., Objectives: To determine if aspirin use prior to colonoscopy increases the risk of clinically significant PPB., Methods: A case-control study of patients with clinically significant PPB at Mayo Clinic Scottsdale and Rochester was performed. Information collected included age, gender, recent use of aspirin or NSAIDs (within three days of colonoscopy), polyp characteristics, and polypectomy technique. The control group consisted of patients matched for age (+/-3 yr), gender, and cardiovascular morbidity who had undergone polypectomy without any complications. The populations were compared to determine the odds ratio (OR) of PPB with aspirin use., Results: During the study period, 20,636 patients underwent colonoscopy with polypectomy at the two institutions and 101 patients presented with clinically significant PPB. Twenty patients were excluded from analysis because of prior anticoagulant use. The remaining 81 patients were matched to 81 patients who had undergone colonoscopy without complications. The two groups were comparable in terms of polyp size (97%< or = 10 mm, bleeding group; 95%< or = 10 mm, control group). Aspirin use prior to polypectomy was 40% in the bleeding group and 33% in the control group (OR 1.41; 95% C.I. 0.68 to 3.04)., Conclusion: Postpolypectomy bleeding is an uncommon but important complication of endoscopic polypectomy. There was no statistically relevant difference in prior aspirin use before polypectomy in the bleeding group and the matched controls.

Aims: There is little published literature evaluating the accuracy of patients' perceptions of the quality of their own bowel preparation for colonoscopy. The aim of this article was to compare patients' perceptions of the adequacy of their bowel preparation with the endoscopists' rating at colonoscopy., Methods: Outpatients undergoing elective colonoscopy completed surveys assessing bowel preparation. Patient responses regarding quality of bowel preparation were compared with endoscopists' assessment of colonic preparation. A residual stool score was also calculated for each subject based on the amount of stool, consistency of residual stool, and percentage of bowel visualized., Results: A total of 474 patients were enrolled. Patients' perceptions of the quality of their bowel preparation were inaccurate when compared to the endoscopists' rating (sensitivity, 75%; specificity, 34%; accuracy, 50%). Overall correlation with endoscopists' rating was low, r = 0.08. Young patient age (<61 yr) was an independent predictor of both adequate bowel preparation ( p= 0.009) and agreement of patient/endoscopist ratings ( p= 0.003)., Conclusions: Patients are unreliable judges of the quality of their own bowel preparation, tending to overestimate the cleanliness of their colon. Conversely, a patient's fear that their preparation is suboptimal is also inaccurate. A colonoscopy should not be canceled on the basis of a patient's perception that the quality of their preparation is poor.

Self-expandable metal stents (SEMS) are useful for the non-surgical relief of malignant colonic obstruction. They may be used both as a palliative measure and as a pre-operative bridge to facilitate a one-stage surgical resection of primary colonic tumours. SEMS may be placed endoscopically or by interventional radiologists without the use of endoscopy. In experienced centres SEMS can be successfully placed in approximately 90% of cases. Although it is known that the placement of these devices is feasible, there are no prospective trials comparing stent placement for colonic obstruction to routine surgical care. Additionally, there are no studies comparing the outcome of the method of placement (endoscopic versus radiological). This chapter reviews the types of expandable metal stent used for treatment of colonic obstruction, the indications for their insertion, their methods of insertion, and outcomes following insertion. Future research directions using expandable stents for colonic tumours are also addressed.

Background and Aims: Since Medicare approval for reimbursement of screening colonoscopies, the number of colonoscopy requests has increased. Physician resources have often been inadequate to meet the demand. We sought to reduce the demand for colonoscopy in an open endoscopy system by using a guideline-based triage system to eliminate inappropriate procedures and to align the timing of surveillance colonoscopies with recommendations made by national organizations., Methods: This was a cohort study with primary care outpatients. From October 2002 to February 2003, 498 consecutive patients on a waiting list of 2400 awaiting colonoscopy for all indications were triaged and are the focus of the study. Selection of patients for appropriate colonoscopy was based on consensus guidelines developed for institutional use by using established published guidelines for appropriate colonoscopy indications., Results: Of the 498 consecutive patients triaged, 139 (28%) were deemed inappropriate. The most common reason was inappropriate referral for surveillance of colorectal polyps. The percentage of inappropriate referrals by the 3 largest referring specialties (internal medicine, family medicine, and gastroenterology) combined was also 28% with no statistically significant differences between specialties., Conclusions: Most referrals for colonoscopy in an open-access endoscopy system were appropriate, although about 1 in 4 were not. Use of triage and further education of physicians regarding colonoscopy may optimize colonoscopy utilization.

Resumo A colonoscopia é um dos procedimentos mais feitos. Sedação e analgesia diminuem a ansiedade e o desconforto e minimizam riscos. Em razão disso, os pacientes preferem que o exame seja feito sob anestesia, embora não tenha sido determinada a melhor combinação de fármacos. A associação de benzodiazepínicos com opioides é usada para aliviar a dor e o desconforto do paciente. Mais recentemente, o propofol assumiu posição de destaque. Este estudo, prospectivo e randomizado, é único na literatura médica e especificamente comparou o uso do propofol e fentanil associado ou não ao midazolam na sedação para colonoscopia feita por anestesiologistas. Os objetivos do estudo foram avaliar os efeitos colaterais da sedação, as condições de alta, a qualidade da sedação e o consumo de propofol durante a colonoscopia, com ou sem o midazolam como pré‐anestésico. Envolveu 140 pacientes submetidos à colonoscopia, no Hospital Universitário da Universidade Federal de Juiz de Fora. Os pacientes foram divididos em dois grupos. O Grupo I recebeu, por via endovenosa, midazolam como pré‐anestésico, cinco minutos antes da sedação, seguido do fentanil e propofol. O Grupo II recebeu, por via endovenosa, anestesia com fentanil e propofol. Os pacientes do Grupo II apresentaram maior incidência de reação (motora ou verbal) à introdução do colonoscópio, bradicardia, hipotensão arterial e maior consumo de propofol. A satisfação dos pacientes foi maior no Grupo I . De acordo com a metodologia empregada, a associação de midazolam ao propofol e fentanil para sedação em colonoscopia reduz o consumo de propofol e cursa com maior satisfação do paciente. Colonoscopy is one of the most common procedures. Sedation and analgesia decrease anxiety and discomfort and minimize risks. Therefore, patients prefer to be sedated when undergoing examination, although the best combination of drugs has not been determined. The combination of opioids and benzodiazepines is used to relieve the patient's pain and discomfort. More recently, propofol has assumed a prominent position. This randomized prospective study is unique in medical literature that specifically compared the use of propofol and fentanyl with or without midazolam for colonoscopy sedation performed by anesthesiologists. The aim of this study was to evaluate the side effects of sedation, discharge conditions, quality of sedation, and propofol consumption during colonoscopy, with or without midazolam as preanesthetic. The study involved 140 patients who underwent colonoscopy at the University Hospital of the Federal University of Juiz de Fora. Patients were divided into two groups: Group I received intravenous midazolam as preanesthetic five minutes before sedation, followed by fentanyl and propofol; Group II received intravenous anesthesia with fentanyl and propofol. Patients in Group II had a higher incidence of reaction (motor or verbal) to the colonoscope introduction, bradycardia, hypotension, and increased propofol consumption. Patient satisfaction was higher in Group I . According to the methodology used, the combination of midazolam, fentanyl, and propofol for colonoscopy sedation reduces propofol consumption and provides greater patient satisfaction. [ABSTRACT FROM AUTHOR]

Background: Most cases of microbial transmission to patients via contaminated endoscopes have resulted from nonadherence to reprocessing guidelines. We evaluated the occurrence, features, and implications of reprocessing lapses to gauge the nature and breadth of the problem in the context of widely available and accepted practice guidelines. Methods: We examined peer-reviewed and non-peer-reviewed literature to identify lapses reported in North America during 2005 to 2012 resulting in patient exposure to potentially contaminated gastrointestinal endoscopes. Results: Lapses occurred in various types of facilities and involved errors in all major steps of reprocessing. Each lapse continued for several months or years until the problem was discovered except for one that was described as a single incident. There were significant implications for patients, including notification and testing, microbial transmission, and increased morbidity and mortality. Only 1 reprocessing lapse was found in a peer-reviewed journal article, and other incidents were reported in governmental reports, legal documents, conference abstracts, and media reports. Conclusion: Reprocessing lapses are an ongoing and widespread problem despite the existence of guidelines. Lack of publication in peer-reviewed literature contributes to the perception that lapses are rare and inconsequential. Reporting requirements and epidemiologic investigations are needed to develop better evidence-based policies and practices. [Copyright &y& Elsevier]

Background: Esophagogastroduodenoscopy (EGD) is commonly used in the diagnosis and treatment of gastrointestinal (GI) disorders. Our aim was to define the risk of perforation associated with EGD and identify patients who required operative intervention. Methods: We retrospectively reviewed 72 patients from our institution plus 5 transferred patients who sustained EGD-associated perforations from January 1996 through July 2008. Percutaneous endoscopic gastrostomy, endoscopic ultrasonography, endoscopic retrograde cholangiopancreatography, transthoracic echocardiography, and concurrent colonoscopy procedures were excluded. Results: Perforations in 72 of 217,507 EGD procedures were identified (incidence, 0.033%); 124,844 EGDs included an interventional procedure and 92,663 were examination only. The incidence of perforation was similar whether an interventional procedure was performed or not (0.040% vs 0.029%; P = .181). The esophagus was injured most commonly (51%), followed by the duodenum (32%), jejunum (6%), stomach (3%), and common bile duct (3%). Overall mortality after perforation was 17% with a morbidity rate of 40%. Thirty-eight patients (49%) were initially treated nonoperatively, 7 of whom (18%) failed nonoperative management. The only factors we could determine that were associated with failure were free fluid or contrast extravasation on computed tomography (75% vs 23% [P < .005] and 33% vs 0% [P = .047], respectively). The morbidity of failures was equivalent to those who underwent initial operative management (63% vs 61%; P = .917), with mortality seeming to be greater (43% vs 21%; P = .09). Conclusion: EGD is safe in the majority of patients; however, iatrogenic perforation is associated with considerable morbidity and mortality. Nonoperative management of GI perforation can be successful if there is no evidence of contrast extravasation or free fluid on radiographic studies. If nonoperative management fails, the outcomes may be worse than those treated initially with operative repair. [Copyright &y& Elsevier]

The article focuses on approaches for the endoscopic management of acute lower gastrointestinal (LGI) bleeding. The approach for diagnosis and treatment was derived primarily from experience accumulated through the Mayo GI Bleeding Team practice. Colonoscopy remains the mainstay of diagnosis and therapy for acute LGI bleeding.

The article presents the guidelines on bowel preparation before colonoscopy prepared by three leading gastrointestinal societies in the U.S. Dietary regimens should include clear liquids and low-residue foods on the first four days as it has been proven to be a beneficial adjunct to other mechanical cleansing systems. Tap water or sodium phosphate enemas are given on the evening prior to the procedure in conjunction with dietary restrictions or cathartics.

OBJECTIVE:Acute colonic pseudoobstruction (ACPO) most commonly develops after surgery, with narcotic administration, or in association with severe illness. Most cases resolve with conservative management. Colonoscopic decompression may be required in patients failing to respond to conservative treatment. Neostigmine has been proposed as an effective treatment for ACPO as an alternative to colonoscopic decompression. We sought to identify factors associated with spontaneous resolution of ACPO and to identify variables associated with a response to i.v. administration of neostigmine for the treatment of ACPO.METHODS:Retrospective analysis of Mayo Clinic’s diagnostic index revealed all patients who developed ACPO between July, 1999 and September, 2001 at the Mayo Clinic Medical Center. We separately analyzed those patients who did not resolve ACPO with conservative management and to whom i.v. neostigmine was administered. Patient records were abstracted for demographic data, etiology of ACPO, management, and response to treatment.RESULTS:A total of 151 patients were identified with ACPO between July, 1999 and September, 2001; 117 patients (77%) had spontaneous resolution of symptoms. Of the 34 “nonresolvers,” 18 patients received neostigmine, whereas 16 did not receive neostigmine. Of those 16 patients, 11 required colonoscopic decompression, two underwent surgery, and three died of underlying illness. “Spontaneous resolvers” were less likely to be taking narcotics (59% vs 74%, p = 0.08). Of the 16 nonresolvers who did not receive neostigmine, only one had a contraindication to neostigmine use. Of the 18 patients that who received neostigmine, 16 patients (89%) had prompt evacuation (<30 min) of flatus or stool. Sustained clinical response to neostigmine was noted in 11 of 18 (61%); the remaining seven patients (39%) required colonoscopic decompression or surgery for recurrent or persistent colonic dilation. Neostigmine-responders were more likely to be older (mean age, 76 yr vs 54 yr, p = 0.03), than nonresponders. Preneostigmine cecal diameter did not differ significantly between responders (median, 12 cm) and nonresponders (median, 13 cm), p = 0.9. Median time to resolution of ACPO in spontaneous resolvers was 4 days compared to 2 days in patients responding to neostigmine; p = 0.038.CONCLUSIONS:Most patients with ACPO respond to conservative treatment. Female gender and older age are associated with a response to neostigmine in those patients who do not respond to conservative management. Neostigmine appears to be under-used in patients with ACPO who do not have a true contraindication to its use. [Copyright &y& Elsevier]

A response by the author to the comments of Dr. E. Hassall and Dr. T. E. Lobe concerning the utilization of sodium phosphate (NaP) in children. He clarifies that the statement that was cited in the intersociety guideline on bowel preparation for colonoscopy implies that caution is also needed for the underlying medical conditions as well as for extremes of age. He asserts that Hassall and Lobe may be over-interpreting the statement regarding the safety of NaP.