Comparison of procedural sequence in same-day bidirectional endoscopy: a systematic review and meta-analysis

Abstract

Background/Aims: To compare the efficacy and safety of procedural sequence in same-day bidirectional endoscopy. Methods: We searched OVID-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar to identify randomized controlled trials that compared the procedural sequences in same-day bidirectional endoscopy, including esophagogastroduodenoscopy (EGD) and colonoscopy. The sedative and analgesic doses required, discomfort and satisfaction scores, procedure time, recovery time, adenoma detection rate, and failed cecal intubation were evaluated. Adverse effects, including respiratory and cardiovascular complications, were also assessed. Results: We included six studies, with 1,848 patients in total. The requirement for sedative treatment was significantly lesser in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (standardized mean difference [SMD], -0.39; 95% confidence interval [CI], -0.54 to -0.24; p = 0.12; I 2 = 49%). Discomfort, scored by patients during the EGD procedure, was significantly lesser in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (SMD, -0.45; 95% CI, -0.80 to -0.09; p = 0.02; I 2 = 73%), while it was comparable during colonoscopy between the two sequences. Recovery time was significantly shorter in the EGD-colonoscopy sequence than in the colonoscopy-EGD sequence (SMD, -0.47; 95% CI, -0.65 to -0.30; p = 0.28; I 2 = 21%). Total procedure duration, EGD, colonoscopy, cecal intubation time and incidence, incidences of pathologic findings, and adenoma detection were comparable between the two sequences. There was no significant difference in the incidences of desaturation, hypotension, hypertension, bradycardia, and tachycardia between the two sequences. Conclusions: When conducting same-day bidirectional endoscopy, EGD followed by colonoscopy is the most beneficial sequence to be used because patients require lower sedative doses, recover faster, and report lesser discomfort.

Comparison of Procedural Sequences in Sedated Same-Day Bidirectional Endoscopy with Water-Exchange Colonoscopy: A Randomized Controlled Trial

“…Previous studies on the optimal sequence of BDE using air-insufflated colonoscopy did not show a significant difference in the cecal-intubation time or total procedure time of colonoscopy [ 4 , 7 , 10 , 11 , 12 , 13 ]. In contrast, the current study showed that the EGD-first group had a longer cecal-intubation time and total procedure time.…”

“…Post-colonoscopy abdominal pain was associated with the female sex, older age, an unsedated procedure, a longer procedure time, the use of air instead of carbon dioxide (CO 2 ) and the timing of assessment [24,27,28]. Although a recent metaanalysis [13] reported lower discomfort scores after both procedures in the EGD-first group, the conclusion could be misleading because the analysis mostly included studies evaluating discomfort during the procedures, and the lower discomfort score actually occurred during EGD, which was correctly reported by another meta-analysis [7] (Supplementary Table S1).…”

“…Our current study showed that the EGD-first group required fewer doses of propofol during BDE than the colonoscopy-first group. Previous randomized controlled trials and meta-analyses on BDE with moderate or deep sedation also demonstrated that the EGD-first sequence required fewer doses of sedatives [ 4 , 5 , 7 , 8 , 10 , 13 , 24 ]. Two previous randomized controlled trials on propofol-sedated BDE proved that less propofol was required when EGD was performed first [ 4 , 12 ].…”

“…Traditionally, air insufflation is used to open the lumen of the colon during colonoscopy. Multiple studies have been performed to determine the optimal sequence (i.e., EGD-first or colonoscopy-first) of same-day BDE using air insufflation for colonoscopy [ 4 , 5 , 7 , 8 , 9 , 10 , 11 , 12 ]. Most of them favored the EGD-first sequence because of the lower sedative requirement [ 4 , 5 , 7 , 8 , 10 , 13 ], the faster recovery [ 4 , 5 , 8 ], and the reduced patient discomfort during EGD [ 8 , 11 , 12 ] compared to the colonoscopy-first sequence.…”

Bidirectional Endoscopy—A Trend for Future in COVID Era

“…In same-day BDE, EGD first followed by colonoscopy is the favored order of the procedures due to lower discomfort scores in earlier meta-analysis. 5 Abdominal bloating caused by colonoscopy first in BDE might reduce tolerance to subsequent EGD. 12 In our study, all the procedures in BDE were performed as EGD first with an aerosol chamber followed by colonoscopy.…”