[Gastroenterology Insights 2010; 2:e4] [page 13] Propofol-based sedation does not increase rate of perforation during colonoscopic procedure Somchai Amornyotin, 1 Ungkab Prakanrattana, 1 Udom Kachintorn, 2 Wiyada Chalayonnavin, 1 Siriporn Kongphlay 1 1 Department of Anesthesiology; 2 Department of Medicine, Siriraj GI Endoscopy Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand Abstract Sedation-related colonoscopic perforation (CP) has been under much debate. Our aim was to assess and compare the CP rate during colonoscopy by using sedation with or without propofol adjuvant. All patients who underwent colonoscopic procedure at the WGO Endoscopy Training Center, Siriraj Hospital, Thailand from March 2005 to October 2007 by using the intra- venous sedation (IVS) technique were ana- lyzed. The primary outcome was the CP rate; the secondary outcomes were sedation-related com- plications and death during and immediately after the procedure. There were 6140 colonos- copies and 1532 flexible sigmoidoscopies dur- ing the study period, of which 6122 colonoscop- ic procedures were performed by using IVS. All of these procedures were categorized into two groups: group A, the IVS technique was propo- fol-based sedation and group B, the IVS tech- nique was non-propofol-based sedation. After matching the indications of procedure, there were 2022 colonoscopies in group A and 512 colonoscopies in group B. Colonoscopic proce- dures were performed by staff endoscopists (10.8%) or residents and fellows (89.2%). The characteristics of patients and sedative agents used in perforated patients in both groups were not significantly different. In group A, five patients (0.25%) suffered from perforation and two of them died. In group B, one patient (0.20%) had CP; the difference was not signifi- cant (P=0.829). Our data showed that colonoscopy under propofol-based sedation did not increase the perforation rate. Serious com- plications are uncommon. Introduction Colonoscopy is the most common diagnostic and therapeutic tool for colorectal carcinoma and is considered a routine procedure for patients with large bowel symptoms. Although colonoscopy is regarded as a relatively safe pro- cedure, it causes significant morbidity and rarely mortality. The most serious complication of colonoscopy is perforation. 1-6 The incidence of colonoscopic perforation (CP) could be as low as 0.02% in diagnostic colonoscopy and as high as 0.6% in therapeutic colonoscopy. 7,8 In addi- tion, this procedure is uncomfortable and often causes sharp pain to patients. Controversy in safely using analgesics and sedatives during colonoscopy has always existed. The key con- cern is on perforation rate between colonoscopy with or without anesthesia. Since 1974, colonoscopic procedures with sedation and/or anesthesia were thought by some people to be a risk factor for perforation. 9- 12 However, a previous report by Kjaergard et al. 13 concluded that anesthesia administered by experienced staff is harmless and that general anesthesia for colonoscopy did not raise the risk of CP. Additionally, there is controversy regard- ing the frequency of sedation-related complica- tions of colonoscopies especially for CP. Propofol-based sedation usually tends to deepen the sedation level and mask the earlier signs and symptoms of CP. The purpose of our study was to discover whether there is a difference in the incidence of CP between patients who received colonoscopy with or without propofol- based sedation. Materials and Methods Patients A total of 7672 consecutive patients from the WGO Endoscopy Training Center, Siriraj Hospital, Bangkok, Thailand were eligible for the study. These patients underwent colonos- scopies (6140) and flexible sigmoidoscopies (1532) from March 2005 to October 2007. Inclusion criteria were age of ≥18 years and colonoscopic procedures performed using the intravenous sedation (IVS) technique. Exclusion criteria were patients younger than 18 years of age, procedures performed in the intensive care units, procedures performed without sedation, or procedures performed under monitored anesthesia care and general anesthesia. Study design This is a retrospective descriptive study. The primary outcome of the study was the CP rate during and immediately after the procedure. The secondary outcomes were sedation-related complications during and immediately after the procedure and mortality rate. Assessment of colonoscopic perforation After colonoscopy, all patients were observed in the recovery room for at least two hours before being discharged to the ward or home. We did not call each patient for a day after the procedure. However, the patients suspected of colonoscopic complications and those who underwent difficult procedures were admitted. In addition, all patients visited their endo- scopists on the seventh day postendoscopy. The CP rate in both groups was recorded. Additionally, perforation site, type of endos- copist, and mortality rate in the two groups were assessed. Sedation-related complications All sedation-related complications were recorded. These complications were defined as: hypertension or hypotension (increase or decrease in blood pressure by 20% from base- line and above or below normal for age); tachy- cardia or bradycardia (increase or decrease in heart rate by 20% from baseline and above or below normal for age); any cardiac arrhyth- mias; hypoxia (oxygen desaturation, SpO2 <90%); airway obstruction. Statistical analysis Results were expressed as mean±SD or per- centage (%), when appropriate. Comparisons between groups A and B were made by using c 2 - tests (i.e. for categorical variables), c 2 -tests for trend (for ordinal variables), and the two- sample independent t-test (for continuous vari- ables). The statistical software package SPSS for Window Version 11 (SPSS Inc., Chicago, IL) was used to analyze the data. All statistical comparisons were made with the two-sided 5% level of significance. Gastroenterology Insights 2010; volume 2:e4 Correspondence: Somchai Amornyotin, Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand. E-mail: sisam@mahidol.ac.th Key words: intravenous sedation, propofol, colonoscopy, perforation. Conflict of interest: the authors report no con- flicts of interest. Received for publication: 30 November 2009. Revision received: 14 January 2010. Accepted for publication: 19 January 2010. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright S. Amornyotin et al., 2010 Licensee PAGEPress, Italy Gastroenterology Insights 2010; 2:e4 doi:10.4081/gi.2010.e4 Non-commercial use only