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Unsedated colonoscopy: an option for some but not for all
Letters to the Editor
Unsedated colonoscopy: an option for some but not for all To the Editor: We read with interest the article by Paggi et al,1 in which the authors compared unsedated colonoscopy (with the possibility of on-demand sedation) versus sedated colonoscopy. The authors concluded that unsedated colonoscopy was clinically relevant and could be completed in the majority of patients. The final result of this study could influence clinical practice improving the selection of patients and the management of sedoanalgesia. However, we would like to emphasize that there is no mention about what initial medication was used in patients with sedated colonoscopy and, particularly, about on-demand sedation (drugs, doses, time of administration). This is a crucial point because on-demand sedation was permitted in patients allocated to unsedated colonoscopy. Indeed, differences were seen in the cecal intubation rate (which is a colonoscopy good quality indicator). A rate of 81.6% was reached in unsedated colonoscopy, as previously reported,2 and this increased to 97.3% in the on-demand sedation group. On the other hand, lack of previous experience was found associated with better tolerability in unsedated colonoscopy. It would be interesting to add information about how many patients would repeat an unsedated colonoscopy, after first experience. Interestingly, the adenoma detection rate was similar to that previously reported in the literature.3 In conclusion, we agree that unsedated colonoscopy could decrease sedation-related complications, avoid escort requirement, shorten recovery, and allow patients’ return to normal activity earlier after examinations. Some data about what on-demand sedation was used, tolerability after first exploration, and methods to increase detection rate of adenomas could improve its applicability in clinical practice. Javier Ampuero, MD Manuel Romero-Gomez, MD, PhD Unit for the Clinical Management of Digestive Diseases and CIBERehd Hospital Universitario de Valme Sevilla, Spain
REFERENCES 1. Paggi S, Radaelli F, Amato A, et al. Unsedated colonoscopy: an option for some but not for all. Gastrointest Endosc 2012;75:392-8. 2. Leung FW, Aljebreen AM, Brocchi E, et al. Sedation-risk-free colonoscopy for minimizing the burden of colorectal cancer screening. World J Gastrointest Endosc 2010;2:81-9. 3. Ramirez FC, Leung FW. A head-to-head comparison of the water vs. air method in patients undergoing screening colonoscopy. J Interv Gastroenterol 2011;1:130-5. http://dx.doi.org/10.1016/j.gie.2012.03.003
www.giejournal.org
Response: We are very grateful to Dr Ampuero and Dr RomeroGomèz for giving us the opportunity to provide further details about our study. First of all, we do agree that by a strict intention-to-treat approach, we obtained a cecal intubation rate far below the quality standards in unsedated patients. However, by provision of the on-demand medications, this value rises above the benchmark of 95%. This means that unsedated colonoscopy with the option of on-demand sedation can guarantee a high-quality colonoscopy. Moreover, for both unsedated patients requiring ondemand medications and those routinely sedated at the start of the procedure, a single bolus of intravenous midazolam (2.5 mg) and meperidine (50 mg) was administered. In the on-demand group, these medications were provided at the patient’s request during the procedure, any time significant pain or discomfort occurred. It is worth underlining that among 511 patients starting the procedure without premedication, 71 (13.9%) reported they would not be willing to repeat unsedated colonoscopy in the future. Interestingly, of these 71 patients, 54 also belonged to the group (80 patients) requiring sedation during the examination (54/80, 67.5%) and the other 17 were in the group (431 patients) able to complete a medication-free procedure (17/431, 3.9%). These data suggest that besides the lack of previous colonoscopy experience, also a welltolerated unsedated colonoscopy might be associated with the willingness to repeat it under the same conditions in the future. Silvia Paggi, MD Arnaldo Amato, MD Franco Radaelli, MD Division of Gastroenterology Valduce Hospital Como, Italy http://dx.doi.org/10.1016/j.gie.2012.03.174
Closure of persistent gastrocutaneous postpercutaneous endoscopic gastrostomy fistula by simple percutaneous suturing with endoscopic assist To the Editor: A case report from Juan J. Alberti-Flor first described the percutaneous endoscopic suturing method for the closure of post-PEG fistula.1Persistent gastrocutaneous fistula after the removal of a gastrostomy tube is an unusual complication associated with PEG. However, the fistulous tract frequently requires surgical closure, even though the patients are usually considered poor surgical candidates. The endoscopic closure of a fistula, such as by using argon Volume 76, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 699
Unsedated colonoscopy: an option for some but not for all To the Editor: We read with interest the article by Paggi et al,1 in which the authors compared unsedated colonoscopy (with the possibility of on-demand sedation) versus sedated colonoscopy. The authors concluded that unsedated colonoscopy was clinically relevant and could be completed in the majority of patients. The final result of this study could influence clinical practice improving the selection of patients and the management of sedoanalgesia. However, we would like to emphasize that there is no mention about what initial medication was used in patients with sedated colonoscopy and, particularly, about on-demand sedation (drugs, doses, time of administration). This is a crucial point because on-demand sedation was permitted in patients allocated to unsedated colonoscopy. Indeed, differences were seen in the cecal intubation rate (which is a colonoscopy good quality indicator). A rate of 81.6% was reached in unsedated colonoscopy, as previously reported,2 and this increased to 97.3% in the on-demand sedation group. On the other hand, lack of previous experience was found associated with better tolerability in unsedated colonoscopy. It would be interesting to add information about how many patients would repeat an unsedated colonoscopy, after first experience. Interestingly, the adenoma detection rate was similar to that previously reported in the literature.3 In conclusion, we agree that unsedated colonoscopy could decrease sedation-related complications, avoid escort requirement, shorten recovery, and allow patients’ return to normal activity earlier after examinations. Some data about what on-demand sedation was used, tolerability after first exploration, and methods to increase detection rate of adenomas could improve its applicability in clinical practice. Javier Ampuero, MD Manuel Romero-Gomez, MD, PhD Unit for the Clinical Management of Digestive Diseases and CIBERehd Hospital Universitario de Valme Sevilla, Spain
REFERENCES 1. Paggi S, Radaelli F, Amato A, et al. Unsedated colonoscopy: an option for some but not for all. Gastrointest Endosc 2012;75:392-8. 2. Leung FW, Aljebreen AM, Brocchi E, et al. Sedation-risk-free colonoscopy for minimizing the burden of colorectal cancer screening. World J Gastrointest Endosc 2010;2:81-9. 3. Ramirez FC, Leung FW. A head-to-head comparison of the water vs. air method in patients undergoing screening colonoscopy. J Interv Gastroenterol 2011;1:130-5. http://dx.doi.org/10.1016/j.gie.2012.03.003
www.giejournal.org
Response: We are very grateful to Dr Ampuero and Dr RomeroGomèz for giving us the opportunity to provide further details about our study. First of all, we do agree that by a strict intention-to-treat approach, we obtained a cecal intubation rate far below the quality standards in unsedated patients. However, by provision of the on-demand medications, this value rises above the benchmark of 95%. This means that unsedated colonoscopy with the option of on-demand sedation can guarantee a high-quality colonoscopy. Moreover, for both unsedated patients requiring ondemand medications and those routinely sedated at the start of the procedure, a single bolus of intravenous midazolam (2.5 mg) and meperidine (50 mg) was administered. In the on-demand group, these medications were provided at the patient’s request during the procedure, any time significant pain or discomfort occurred. It is worth underlining that among 511 patients starting the procedure without premedication, 71 (13.9%) reported they would not be willing to repeat unsedated colonoscopy in the future. Interestingly, of these 71 patients, 54 also belonged to the group (80 patients) requiring sedation during the examination (54/80, 67.5%) and the other 17 were in the group (431 patients) able to complete a medication-free procedure (17/431, 3.9%). These data suggest that besides the lack of previous colonoscopy experience, also a welltolerated unsedated colonoscopy might be associated with the willingness to repeat it under the same conditions in the future. Silvia Paggi, MD Arnaldo Amato, MD Franco Radaelli, MD Division of Gastroenterology Valduce Hospital Como, Italy http://dx.doi.org/10.1016/j.gie.2012.03.174
Closure of persistent gastrocutaneous postpercutaneous endoscopic gastrostomy fistula by simple percutaneous suturing with endoscopic assist To the Editor: A case report from Juan J. Alberti-Flor first described the percutaneous endoscopic suturing method for the closure of post-PEG fistula.1Persistent gastrocutaneous fistula after the removal of a gastrostomy tube is an unusual complication associated with PEG. However, the fistulous tract frequently requires surgical closure, even though the patients are usually considered poor surgical candidates. The endoscopic closure of a fistula, such as by using argon Volume 76, No. 3 : 2012 GASTROINTESTINAL ENDOSCOPY 699