O R I G I N A L A R T I C L E

Is Unsedated Colonoscopy Gaining Ground

Over Sedated Colonoscopy?
Kaixian Zhang, M.D., Qianqian Yuan, M.D., Shuguang Zhu, M.D., Daheng Xu, M.D., Zhe An, Ph.D.

initiation over four decades ago but has progressed as a safe

Author contributions: Zhu SG, Xu DH contributed to the writing of the manuscript and efficient tool for gastroenterologists worldwide.12 This
and final revision of the article; Zhang KX, Yuan QQ and An Z designed the study,
wrote the manuscript, and revised the final article. procedure can be performed under sedation or without
Conflict of interest: The authors declare no conflict of interest.
sedation (unsedated and sedation-free).13,14 This review
aims to highlight the advantages and disadvantages of
Abstract: Colorectal cancer (CRC) is a prevalent cancer with high global
incidence and a leading cause of cancer death worldwide. CRC screening is
sedated and unsedated colonoscopy and recommend a
important for early cancer detection and prevention. Most premalignant reasonable option in the current scenario. The Pubmed
adenomas can be identified and removed before they become malignant.
Colonoscopy plays a vital role in reducing the risk for developing CRC. Although database was searched for relevant articles with the
screening programs with colonoscopy have been implemented in many countries
and considered beneficial for a number of people, this technique is generally
following keywords: “colonoscopy,” “colorectal cancer
associated with anxiety, embarrassment, pain, and discomfort, resulting in lack of screening,” “unsedated colonoscopy,” “sedation-free colo-
adherence to the recommended screening guidelines. In the US, colonoscopy is
mostly performed under sedation, thereby causing amnesia and analgesia. In
noscopy,” and “sedation colonoscopy.”
contrast to sedated colonoscopy, which has been associated with some
disadvantages, unsedated colonoscopy exhibits advantages and has been
preferred over sedated colonoscopy in numerous cancer centers worldwide. This UNSEDATED COLONOSCOPY
review enumerates the features of sedated and unsedated colonoscopy with the
use of the current relevant evidence-based literature. Unsedated colonoscopy As colonoscopy induces fear and anxiety among patients,
can be a reasonable option for routine and unscheduled CRC screening.
it has been incorporated with hypnosis, music, and aroma
Keywords: Colorectal cancer-Screening-Unsedated colonoscopy-Diagnosis therapies.15e17 Patients opt for unsedated colonoscopy for
various reasons. In a study on unsedated colonoscopy for a
group (n ¼ 123) of Veteran Affairs (VA) personnel, 80%
Author affiliations: Kaixian Zhang, Department of Oncology, Tengzhou Central People’s
Hospital, Tengzhou 277599, China; Qianqian Yuan, Department of Oncology, Tengzhou of the patients were satisfied that an escort was not needed
Central People’s Hospital, Tengzhou 277599, China; Shuguang Zhu, Department of
Gastroenterology, Tengzhou Central People’s Hospital, Tengzhou 277599, China; Daheng
in this technique, 87% became interested after being told
Xu, Department of Gastroenterology, Tengzhou Central People’s Hospital, Tengzhou that they could communicate with the colonoscopist
277599, China; Zhe An, Department of Cardiology, China-Japan Union Hospital of Jilin
University, Changchun 130033, China during the procedure, and 33% were happy that they could
Correspondence: Zhe An, Ph.D., Department of Cardiology, China-Japan Union hospital return to work on the day of the procedure.18
of Jilin University, Changchun 130033, China., email: [email protected] A significant number of colonoscopists worldwide are
ª 2018 by the National Medical Association. Published by Elsevier Inc. All rights proponents of unsedated procedures for their associated ad-
reserved.

http://dx.doi.org/10.1016/j.jnma.2016.12.003
vantages (Table 1).19 Countries such as Japan, Saudi Arabia,
and Italy have pursued unsedated colonoscopy with great
success. In certain countries, such as China, where colonos-
INTRODUCTION copy is not covered by health insurance, the cost of unsedated

C
olonoscopy has been advocated as the preferred colonoscopies poses a significant burden to patients. Most
strategy for the prevention and detection of colo- experts in the field agree that experienced endoscopists are
rectal cancer (CRC).1e5 As CRC is the current third most likely to succeed in unsedated colonoscopies because
leading cause of cancer in men and women in the US and a they can maneuver the colon without causing pain and
leading cause of cancer worldwide, it presents a significant discomfort to patients. Hence, most countries have provided
economic burden on healthcare systems.6e8 Colonoscopy robust training programs regarding unsedated colonoscopy.
can be used to detect tumors in asymptomatic patients and is At the primary healthcare delivery level, active coun-
thus vital for CRC screening.9 Colonoscopy screening has seling by primary care physicians (PCP) can increase the
significantly reduced the overall incidence and mortality number of patients opting for unsedated colonoscopy.20
associated with CRC.10,11 Nevertheless, colonoscopy has The rates of patients who preferred unsedated colonos-
been correlated with pain and discomfort among the general copies significantly increased when PCPs provided coun-
public. Colonoscopy presents many challenges upon its seling through leaflet information (39.0%), and more

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL 110, NO 2, APRIL 2018 143
Downloaded for Anonymous User (n/a) at Hacettepe University from ClinicalKey.com by Elsevier on October 03,
2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
COMPARISON BETWEEN UNSEDATED AND SEDATED COLONOSCOPY

procedures. In unsedated patients, air insufflation can cause

Table 1. Advantages of unsedated colonoscopy.
more discomfort by increasing colonic looping and increasing
difficulty of cecal intubation. This limitation can be addressed
 No medications, no side-effects
using the water method. Several trials were performed to
 Does not require an escort explore replacements for air insufflation to allow completion
of scheduled unsedated colonoscopy without causing pain,
 Can immediately resume work anxiety, and discomfort in patients.23 Warm water is theorized
to reduce colonic spasms in the left lateral position adopted by
 No hindrance for self-driving soon after procedure the patient because the weight of water would straighten the
 Can communicate with colonoscopist during sigmoid and prevent looping, thus requiring scope insertion
procedure and reducing pain. In the water immersion method, endo-
scopists can rapidly intubate the cecum. This method has been
 Can alert for pain successfully conducted in unsedated patients, although initial
trials had used minimal sedation or sedation based on demand
 Can be given choice for minimal sedation
(requested/need based)
of the subjects.24 Water may also be infused, and air from the
colon can be removed through an air pump as an exchange
 No need for paramedical staffing/monitoring, total mechanism.25 In cases contaminated with residual fecal
time taken for procedure is decreased matter, the air pump is turned off, the infused water is aspi-
rated, and clear water is reinfused for clear visualization of the
 Total time for overall colonoscopy admission is less colonic lumen while advancing the colonoscope. Water is
 Reduces overall cost to patient and healthcare also aspirated to avoid distension or lengthening of the colon.
facilities Nonetheless, water infused should be minimized to avoid
looping of the colon and 98% of the water infused should be
 Beneficial in reducing burden of colorectal cancer aspirated during scope insertion. A randomized controlled
screening single-center trial from Asia confirmed that water exchange
and water immersion methods were superior to air insuffla-
tion; the former significantly reduced insertion pain than the
patients were willing to participate in colorectal screening latter, but a longer time was consumed for scope insertion and
after counseling. cecal intubation.26 Similar findings were reported in two other
Successful colonoscopy involves cecal intubation recently published randomized controlled trials with head-to-
and visualization. The time needed to reach cecum is head comparison of the three methods; insertion was reported
approximately similar to the time required in sedated to be painless in these trials.27,28 Another head-to head sys-
procedures (12 min vs. 11.7 min).19 Perforation risk is also tematic review on adenoma found that the detection rates of
believed to be less during unsedated colonoscopy because adenomas proximal to the splenic flexure was higher with
the pain felt by patients can alert the endoscopist. Unse- water exchange.29 High polyp detection rates have also been
dated patients could also be discharged 30 min after the reported.30,31
procedure, whereas sedated patients would need at least an The “collapse-submergence method” employs complete
hour and a half of observation before being discharged.14 air suction from the rectum to the descending colon
Furthermore, unsedated patients could immediately through disposable syringes. This method enables a clear
resume their normal routine after the procedure without view through the transparency of water as the medium to
needing an assistant, as evidenced in study on VAs. the straightened recto-sigmoid colon, thereby preventing
Unsedated colonoscopy has been extensively investigated the looping of the colon and eliminating patient discomfort
in the past few years. Various techniques have been developed and pain, even when the procedure was performed by
to avoid discomfort during unsedated colonoscopy. Currently, trainee endoscopists.32 A randomized trial was conducted
colonoscopists can use minimal air insufflation and several to explore pain in subjects (n ¼ 338) who underwent co-
water-related techniques to minimize patient discomfort, lonoscopy with water exchange and air insufflation; the
pain, and the need for minimal sedation, with equal success as results showed that the water group presented lower pain
cecal intubation.21 A meta-analysis of nine randomized and sedation rates but significantly higher overall adenoma
controlled trials reported that sedation rate and pain scores detection rate than the air-insufflation group (25.8% vs.
significantly decreased in water intubation treatment 19.1%); higher proximal adenoma detection rate was also
compared with those in air insufflation.22 The rates of cecal observed in screening-only patients in the water exchange
intubation and disease detection remained at par in both group (18.9% vs. 7.4%; P ¼ 0.015).33

144 VOL. 110, NO 2, APRIL 2018 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Downloaded for Anonymous User (n/a) at Hacettepe University from ClinicalKey.com by Elsevier on October 03,
2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 COMPARISON BETWEEN UNSEDATED AND SEDATED COLONOSCOPY

Table 2. Sedation-related influences in colonoscopy.

Advantages Disadvantages
 Analgesia  Risk of hypotension, hypoxemia

 Amnesia  Risk of perforation

 Anxiolysis  Escort needed to drive patient home

 Safe and effective computerized  In patients with advanced age

delivery system
 Requires specially qualified medical team comprising
 Easy scope advancement of nurse, anesthetist

 Less examination time  Requires at least 2 h in-patient observation, delayed discharge

 Better cecal intubation rates  Increases cost, and screening burden

SEDATION COLONOSCOPY suitably monitored.40,41 A center-based study found that

propofolefentanyl combination could be a feasible and
Colonoscopy is the cornerstone for colorectal screening,
comfortable option during elective sedated colonoscopy;
and sedation colonoscopy can provide minimum discom-
this combination reduced the need for additional propofol
fort to patients during the procedure. Sedation colonos-
doses and decreased the recovery times of patients.42 The
copy is routinely used in the US for diagnostic
propofol bolus technique has been known to cause un-
examination of colon, particularly colorectal screening,
wanted respiratory and hemodynamic side effects.43
and for therapeutic procedures.34 Novel techniques adop-
Colonic perforation is another risk associated with co-
ted during colonoscopy, such as image-guided colon
lonoscopy.44 The risk for colonic perforation is found to be
visualization, superior bowel preparation, and improved
higher in therapeutic than that in diagnostic colonos-
sedation medications, have popularized the sedated
copies.45 This finding was supported by a large retro-
version of colonoscopy.35 Sedation calms and relaxes the
spective study (n ¼ 118,004 colonoscopies), which
patient, thus colonoscopists can easily advance the endo-
reported a threefold increased risk in therapeutic colo-
scope, resulting analgesia and amnesia. However, sedation
noscopies in patients sedated with propofol.46
also presents certain disadvantages, as shown in Table 2.
Adenoma detection rates are not influenced by sedation.
Sedation is optimally provided by an experienced
A study from Austria analyzed data of 52,506 cases
anesthesia specialist, and propofol is the most widely used
screening sedated colonoscopies which was performed by
safe and well-tolerated sedative for short procedures, such
196 endoscopists; the findings showed that sedation did
as endoscopy. Evidence from 20 studies published in the
not significantly influenced adenoma detection rate, and
Cochrane database indicated that faster recovery and
cecal intubation rates increased in men and women
discharge times were observed in propofol-sedated pa-
subjects.47 The analysis concluded that the patient’s age,
tients during colonoscopy.36,37 In addition, propofol
sex, and experience of the colonoscopist were important
sedation decreased the examination time and aided endo-
indicators for the success of the procedure. Cecal intuba-
scopes to easily advance the colonoscope.38 The present
tion rates were 98% in procedures with deep sedation, and
availability of mechanical and computerized loading and
a mean cecal intubation time of 5.6 ± 3.2 min was reported
the maintenance delivery system with propofol lead to
in another data analysis.48 Another study further indicated
minimal side effects, such as hypoxemia; this finding was
that cecal intubation rates could be influenced by the type
confirmed by a prospective, randomized multicenter study
of colonoscope used in sedated patients.49
that utilized the SEDASYS® propofol delivery system
against conventional sedation using midazolam and
opioid.39 The US Food and Drug Administration approved MINIMAL SEDATION COLONOSCOPY
this system after the study reported that clinicians and Water-based colonoscopies reduce pain, increase cecal
patients were satisfied. Apnea can precede hypoxemia intubation, require minimal sedation, and present higher
during propofol sedation, and respiration rate must be adenoma detection rates than air-insufflation procedures.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL 110, NO 2, APRIL 2018 145
Downloaded for Anonymous User (n/a) at Hacettepe University from ClinicalKey.com by Elsevier on October 03,
2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
COMPARISON BETWEEN UNSEDATED AND SEDATED COLONOSCOPY

As minimal sedation attenuates pain, patients are willing to Key issues

undergo repeat colonoscopies.27,28,50 Among water tech-
niques, water exchange does not require heavy sedation.33  Colorectal cancer (CRC) is a prevalent cancer with a
Under minimal sedation, patients receive less than the full high global incidence and a leading cause of cancer
amount of sedation but receive additional medications if death worldwide.
they experience discomfort. Minimal sedation is some-  Colonoscopy screening plays a significant role in
times required “by demand” from patients experiencing reducing the risk of developing CRC.
pain or unbearable discomfort.51 The other option is  Although sedated colonoscopy is commonly used
sedation “as needed” as perceived by the colonoscopist and regarded as acceptable, it presents certain
when the patient manifests discomfort or the procedure is disadvantages.
difficult. In these options, recovery times are faster than  Sedated colonoscopy requires at least 2 h in-patient
those in deep-sedation colonoscopy.34 observation, delayed discharge.
 Unsedated colonoscopy presents several advantages
supported by evidence and is thus considered an
CONCLUSION effective option in routine and unscheduled CRC
As screening colonoscopies present a burden on healthcare screening.
systems, selection of a procedure that reduces the cost and  Unsedated colonoscopy does not require an escort,
the overall time for hospital stay is needed. Thus, unse- can immediately resume work.
dated colonoscopy is preferred over sedated colonoscopy  Unsedated colonoscopy is preferred over sedated
by willing patients. colonoscopy by willing patients.

Expert commentary
The colonoscopy screening has significantly prevented the
REFERENCES
incidence of colorectal cancer, and played an important
1. American Cancer Society recommendations for colorectal
role in early detection of CRC. In the current article, we
cancer early detection.(2015). Available at: http://www.
compared the important role of unsedated colonoscopy
cancer.org/cancer/colonandrectumcancer/moreinformation/
and sedated colonoscopy in the CRC screening, and
colonandrectumcancerearlydetection/colorectal-cancer-early-
emphasize that although sedated colonoscopy was detection-acs-recommendations#.
commonly used in clinic, several disadvantages have been
displayed such as side effects. Evidence suggested that 2. Update Summary: Colorectal Cancer: Screening. U.S. Preven-
tive Services Task Force.(February 2014). Available at: http://
water or air aided colonoscopy or optimized sedation
www.uspreventiveservicestaskforce.org/Page/Document/Upd
colonoscopy can improve the quality and reduce
ateSummaryDraft/colorectal-cancer-screening2?ds¼1&s¼colo
uncomfortableness. In contrast, unsedated colonoscopy rectalcancer.
showed advantages on not requiring an escort, capable to
immediately resume work, can alert pain, and so on, 3. Jorgensen, B., & Knudtson, J. (2015). Stop cancer colon. Colo-
rectal cancer screening e updated guidelines. S D Med, Spec No,
which can be accepted by willing patients. We believe that
82e87. Updated guidelines for colorectal cancer screening.
with the development of technology and improvement of
screening system as well as the education of patients, the 4. Lieberman, D. A., Rex, D. K., Winawer, S. J., et al. (2012).
care of patients will be enhanced, the risk of CRC will be Guidelines for colonoscopy surveillance after screening and
reduced. polypectomy: a consensus update by the US Multi-Society
Task Force on Colorectal Cancer. Gastroenterology, 143,
844e857.
Five-year view
5. Brenner, H., Altenhofen, L., Stock, C., & Hoffmeister, M. (2015).
The application of colonoscopy screening has shown a Prevention, early detection, and overdiagnosis of colorectal
trend of reduced CRC incidence and mortality. We expect cancer within 10 years of screening colonoscopy in Germany.
to see a significant progress in the next 5 years toward Clin Gastroenterol Hepatol, 13, 717e723. A 10-year analysis of
patient education to accept colonoscopy screening and colonoscopy screening for colorectal cancer, confirmed that
adherence to screening. Also, we hope more clinical ex- screening colonoscopies have large potential for prevention
perts with experience to conduct the screening. Moreover, and early detection of CRC.
the improved technology will provide novel strategies for 6. Altobelli, E., Lattanzi, A., Paduano, R., et al. (2014). Colorectal
the screening and diagnosis of CRC, thus benefiting for cancer prevention in Europe: burden of disease and status of
human welfare. screening programs. Prev Med, 62, 132e141.

146 VOL. 110, NO 2, APRIL 2018 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Downloaded for Anonymous User (n/a) at Hacettepe University from ClinicalKey.com by Elsevier on October 03,
2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
 COMPARISON BETWEEN UNSEDATED AND SEDATED COLONOSCOPY

7. Colorectal Cancer Statistics.(2014). Available at: http://www. unsedated colonoscopy: a multicenter randomized controlled
cdc.gov/cancer/colorectal/statistics/. trial. Endoscopy, 47, 192e199.

8. Siegel, R., Ma, J., Zou, Z., & Jemal, A. (2014). Cancer statistics, 22. Lin, S., Zhu, W., Xiao, K., et al. (2013). Water intubation method
2014. CA Cancer J Clin, 64, 9e29. can reduce patients’ pain and sedation rate in colonoscopy: a
meta-analysis. Dig Endosc, 25, 231e240.
9. Young, P. E., & Womeldorph, C. M. (2013). Colonoscopy for
colorectal cancer screening. J Cancer, 4, 217e226. Review on 23. Leung, F., Friedland, S., Leung, J., et al. (2013). Water-aided
colonoscopy screening of colorectal cancer. methods for colonoscopy e a review of VA experience. J Interv
Gastroenterol, 3, 43e48.
10. Siegel, R., Desantis, C., & Jemal, A. (2014). Colorectal cancer
statistics. CA Cancer J Clin, 2014(64), 104e117. 24. Leung, C. W., Kaltenbach, T., Soetikno, R., et al. (2010). Water
immersion versus standard colonoscopy insertion technique:
11. Shroff, J., Thosani, N., Batra, S., et al. (2014). Reduced incidence
randomized trial shows promise for minimal sedation. Endos-
and mortality from colorectal cancer with flexible-
copy, 42, 557e563.
sigmoidoscopy screening: a meta-analysis. World J Gastro-
enterol, 20, 18466e18476. 25. Leung, F. W. (2011). Water exchange may be superior to water
immersion for colonoscopy. Clin Gastroenterol Hepatol, 9,
12. Leung, F. W., & Aljebreen, A. M. (2011). Unsedated colonos-
1012e1014.
copy: is it feasible? Saudi J Gastroenterol, 17, 289e292.
26. Hsieh, Y. H., & Leung, F. W. (2013). A randomized, controlled trial
13. Triantafyllou, K., Sioulas, A. D., Kalli, T., et al. (2015). Optimized
comparing air insufflation, water immersion and water ex-
sedation improves colonoscopy quality long-term. Gastro-
change during minimally sedated colonoscopy e an interim
enterol Res Pract, 2015, 195093.
report. J Interv Gastroenterol, 3, 96e99.
14. Aljebreen, A. M., Almadi, M. A., & Leung, F. W. (2014).
27. Hsieh, Y. H., Koo, M., & Leung, F. W. (2014). A patient-blinded
Sedated vs unsedated colonoscopy: a prospective study.
randomized, controlled trial comparing air insufflation, water
World J Gastroenterol, 20, 5113e5118. Excellent article
immersion, and water exchange during minimally sedated
on clinical comparison of sedated and unsedated
colonoscopy. Am J Gastroenterol, 109, 1390e1400.
colonoscopy.
28. Schloss, J., Colosimo, M., & Vitetta, L. (2016). New insights into
15. Elkins, G., White, J., Patel, P., et al. (2006). Hypnosis to manage
potential prevention and management options for
anxiety and pain associated with colonoscopy for colorectal
chemotherapy-induced peripheral neuropathy. Asia Pac J
cancer screening: case studies and possible benefits. Int J Clin
Oncol Nurs, 3, 73e85.
Exp Hypn, 54, 416e431.
29. Leung, F. W., Amato, A., Ell, C., et al. (2012). Water-aided colo-
16. Costa, A., Montalbano, L. M., Orlando, A., et al. (2010). Music
noscopy: a systematic review. Gastrointest Endosc, 76, 657e666.
for colonoscopy: a single-blind randomized controlled trial. Dig
Liver Dis, 42, 871e876. 30. Leung, J. W., Mann, S. K., Do, L., et al. (2010). More polyps are
seen on screening colonoscopy with water infusion in lieu of air
17. Hu, P. H., Peng, Y. C., Lin, Y. T., et al. (2010). Aromatherapy for
insufflation (water method) compared with usual air insuffla-
reducing colonoscopy related procedural anxiety and physi-
tion. Am J Clin Med, 7, 121e123.
ological parameters: a randomized controlled study. Hep-
atogastroenterology, 57, 1082e1086. 31. Melosky, B. (2016). Meeting an unmet need in metastatic
colorectal carcinoma with regorafenib. Asia-Pacific J Oncol
18. Leung, F. W. (2010). Scheduled, unsedated colonoscopy pro-
Nurs, 3, 58e65.
vides access to colonoscopy in a VA setting with unexpected,
unplanned discoveries. Am J Clin Med, 7, 130e133. 32. Mizukami, T., Yokoyama, A., Imaeda, H., & Kumai, K. (2007).
Collapse-submergence method: simple colonoscopic
19. Leung, F. W., Aljebreen, A. M., Brocchi, E., et al. (2010). Seda-
technique combining water infusion with complete air
tion-risk-free colonoscopy for minimizing the burden of colo-
removal from the rectosigmoid colon. Dig Endosc, 19,
rectal cancer screening. World J Gastrointest Endosc, 2,
43e48.
81e89. Summarizes the advantages of unsedated
colonoscopy. 33. Cadoni, S., Gallittu, P., Sanna, S., et al. (2014). A two-center
randomized controlled trial of water-aided colonoscopy versus
20. Boguradzka, A., Wiszniewski, M., Kaminski, M. F., et al. (2014).
air insufflation colonoscopy. Endoscopy, 46, 212e218.
The effect of primary care physician counseling on participa-
tion rate and use of sedation in colonoscopy-based colorectal 34. Leung, F. W. (2011). Is there a place for sedationless colonos-
cancer screening program e a randomized controlled study. copy? J Interv Gastroenterol, 1, 19e22.
Scand J Gastroenterol, 49, 878e884.
35. Lewis, J. R., & Cohen, L. B. (2013). Update on colonoscopy
21. Garborg, K., Kaminski, M. F., Lindenburger, W., et al. (2015). preparation, premedication and sedation. Expert Rev Gastro-
Water exchange versus carbon dioxide insufflation in enterol Hepatol, 7, 77e87.

JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION VOL 110, NO 2, APRIL 2018 147
Downloaded for Anonymous User (n/a) at Hacettepe University from ClinicalKey.com by Elsevier on October 03,
2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.
COMPARISON BETWEEN UNSEDATED AND SEDATED COLONOSCOPY

36. Singh, H., Poluha, W., Cheung, M., et al. (2008). Propofol for 44. Hamdani, U., Naeem, R., Haider, F., et al. (2013). Risk factors for
sedation during colonoscopy. Cochrane Database Syst Rev, colonoscopic perforation: a population-based study of 80118
CD006268. cases. World J Gastroenterol, 19, 3596e3601.

37. Mandel, J. E., Tanner, J. W., Lichtenstein, G. R., et al. (2008). 45. Lohsiriwat, V. (2010). Colonoscopic perforation: incidence, risk
A randomized, controlled, double-blind trial of patient- factors, management and outcome. World J Gastroenterol,
controlled sedation with propofol/remifentanil versus mid- 16, 425e430.
azolam/fentanyl for colonoscopy. Anesth Analg, 106, 434e439
46. Adeyemo, A., Bannazadeh, M., Riggs, T., et al. (2014). Does
[table of contents].
sedation type affect colonoscopy perforation rates? Dis Colon
38. Korman, L. Y., Haddad, N. G., Metz, D. C., et al. (2014). Effect of Rectum, 57, 110e114. A large retrospective study on risk of
propofol anesthesia on force application during colonoscopy. colonoscopic perforation under sedation colonoscopy.
Gastrointest Endosc, 79, 657e662.
47. Bannert, C., Reinhart, K., Dunkler, D., et al. (2012). Sedation in
39. Pambianco, D. J., Vargo, J. J., Pruitt, R. E., et al. (2011). Com- screening colonoscopy: impact on quality indicators and
puter-assisted personalized sedation for upper endoscopy and complications. Am J Gastroenterol, 107, 1837e1848.
colonoscopy: a comparative, multicenter randomized study.
48. Hsu, C. M., Lin, W. P., Su, M. Y., et al. (2012). Factors that
Gastrointest Endosc, 73, 765e772.
influence cecal intubation rate during colonoscopy in
40. Anand, G. W., & Heuss, L. T. (2014). Feasibility of breath moni- deeply sedated patients. J Gastroenterol Hepatol, 27,
toring in patients undergoing elective colonoscopy under 76e80.
propofol sedation: a single-center pilot study. World J Gastro-
49. Lei, W. Y., Yi, C. H., Liu, T. T., & Chen, C. L. (2012). Colonoscopic
intest Endosc, 6, 82e87.
performance in a sedated health screening population: influ-
41. Goudra, B. G., Singh, P. M., & Chandrasekhara, V. (2014). ence of colonoscope type. Hepatogastroenterology, 59,
SEDASYS(®), airway, oxygenation, and ventilation: anticipating 436e439.
and managing the challenges. Dig Dis Sci, 59, 920e927.
50. Sarkar, S., Athwal, V., Sturgess, R. P., et al. (2012). The effect of
42. Turk, H. S., Aydogmus, M., Unsal, O., et al. (2013). Sedation- high quality assurance measures in bowel cancer screening on
analgesia in elective colonoscopy: propofol-fentanyl versus patient satisfaction of colonoscopy. J Gastrointestin Liver Dis,
propofol-alfentanil. Braz J Anesthesiol, 63, 352e357. 21, 251e258.

43. Ramsay, M. A., Newman, K. B., Jacobson, R. M., et al. (2014). 51. Siao-Salera, R., Leung, J. W., Mann, S. K., et al. (2011). Options of
Sedation levels during propofol administration for outpatient sedation or no sedation for colonoscopy e the perspective of
colonoscopies. Proc (Bayl Univ Med Cent), 27, 12e15. the GI nurses and technicians. J Interv Gastroenterol, 1, 37e41.

148 VOL. 110, NO 2, APRIL 2018 JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
Downloaded for Anonymous User (n/a) at Hacettepe University from ClinicalKey.com by Elsevier on October 03,
2024. For personal use only. No other uses without permission. Copyright ©2024. Elsevier Inc. All rights reserved.