DDW 2009: Cancer Detection Rates Higher With Deep Sedation During Colonoscopy

Martha Kerr

June 01, 2009

June 1, 2009 (Chicago, Illinois) — Deep sedation allows for better visualization of the colon and inspection of polyps during colonoscopy and has a significantly higher diagnostic yield than moderate conscious sedation, according to an analysis of data from the Clinical Outcomes Research Initiative (CORI). Moderate conscious sedation is currently recommended by American Cancer Society (ACS) guidelines.

In addition, patient satisfaction is higher with deep sedation, and deep sedation may actually increase efficiency of the endoscopist and the endoscopy unit, researchers report.

CORI is a database that receives endoscopy results from 61 centers across the United States. An analysis of the database was presented here today during Digestive Disease Week 2009 by Katherine M. Hoda, MD, senior fellow in the Department of Gastroenterology at Oregon Health & Science University in Portland.

Dr. Hoda and colleagues analyzed results of all screening colonoscopies performed between January 2002 and December 2007 to evaluate the diagnostic yield of those done with moderate conscious sedation compared with those performed with deep sedation.

A total of 101,367 procedures were done under moderate conscious sedation and 3501 were done under deep sedation. Mean ages were 61.3 years and 60.8 years, respectively (P < .0002). There was no difference in preparation quality between the 2 groups.

Men made up 54.6% of those undergoing moderate sedation and 51.1% of those undergoing deep sedation (P < .0001). The majority of of colonoscopies, regardless of approach, were performed in the community/health maintenance organization setting.

Approximately two thirds of colonoscopies were done in patients with American Society of Anesthesiologists (ASA) class II disease (ie, patients with mild systemic disease).

More Polyps Found With Deep Sedation

"Significantly more large polyps were found with deep sedation," Dr. Hoda told meeting attendees.

The researchers found 251 polyps that were greater that 9 mm in diameter among the 3501 procedures done under deep sedation (7.2%) compared with 6109 polyps greater than 9 mm (6.0%) found with moderate conscious sedation (P = .01).

After controlling for age, sex, race, ASA class, and location of the polyps, "...patients sedated using deep sedation were more likely to have large polyps detected compared with moderate conscious sedation," Dr. Hoda reported (odds ratio, 1.25; 95% confidence interval, 1.09 - 1.42).

"Our study suggests that deep sedation finds more polyps, which could have an impact on the way physicians conduct colonoscopies," she said. "We don't know for sure whether these polyps would have been found if the patients were examined under moderate sedation, but the goal is maximizing visualization without patient discomfort," she said.

As to why there is a difference between the 2 approaches, she told Medscape Gastroenterology that with moderate conscious sedation, "the focus of the gastroenterologist might be on the patient, keeping the patient comfortable and adequately sedated, rather than on the procedure. Moderate conscious sedation provides for a lot of distraction, which can interfere with the procedure, even to the extent of being able to complete the procedure."

Timely Findings

"These findings are very timely, as an FDA advisory committee just voted to recommend approval of a device by Johnson and Johnson that allows the gastroenterologist to provide deep sedation without the need for an anesthesiologist," Kenneth K. Wang, MD, professor of medicine and director of the Advanced Endoscopy Group and Esophageal Neoplasia Clinic at the Mayo Clinic in Rochester, Minnesota, told Medscape Gastroenterology. "It has something that is unfortunately known as a 'dead man switch.' " (A spokesperson from Ethicon Endo-Surgery stressed to Medscape Gastroenterology that the device recommended for approval, the SEDASYS System, is only being evaluated for minimal to moderate sedation. It is not intended for deep sedation.)

"At the moment, propoferol, which is used for deep sedation, carries a black box warning that the physician must be trained in anesthesia. We hope this changes," Dr. Wang said.

"There is some evidence that the use of deep sedation is actually increasing, and it may actually increase efficiency of the endoscopy unit. Patients can be put under more quickly and they may actually come out of it faster," Dr. Hoda commented.

"Patient satisfaction is higher with deep sedation," Dr. Wang added. "They are not only more comfortable, but visualization is better.... At the moment, we routinely recommend against deep sedation, according to the [ACS] guidelines, but if we can show that it is better, if we can safely provide that service, that would be a real advantage."

The study did not receive commercial support. Dr. Hoda and Dr. Wang have disclosed no relevant financial relationships.

Digestive Disease Week (DDW) 2009: Abstract 722. Presented June 1, 2009.


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