Underwater technique reduces intraprocedural pain in colorectal endoscopic submucosal dissection performed under conscious sedation

Aims Endoscopic submucosal dissection (ESD) allows en-bloc and R0-resection of colorectal lesions with suspected limited submucosal invasion. Patients’ discomfort could represent a significant challenge to deal with when performing colorectal ESD (c-ESD). Adequate pain control has a pivotal role for patients’ safety and procedure success, especially when ESD is performed under conscious sedation. As far as we know, no data are available about predictive factors of discomfort and technical difficulty in c-ESD. Water assisted colonoscopy has become an established alternative technique to CO₂-insufflation, able to decrease insertion pain, improve patients’ tolerance and allow to complete a difficult colonoscopy. The aim of our study was to identify intraprocedural discomfort determinants during c-ESD.

Methods We retrospectively enrolled 234 patients who underwent colorectal conventional, hybrid (H-ESD) or underwater ESD (U-ESD) at A.S.M.N. Reggio Emilia, Italy, between January 2018 and March 2023. Patients received intravenous (IV) conscious sedation with midazolam and fentanyl. Pre-, intra- and post-procedural data were collected, as well as data regarding drug dosages and intraprocedural discomfort, evaluated according to the modified Gloucester Scale (GS) every 20min and whenever patients reported pain. Patients were divided in group A (no or minimal discomfort – GS 1-2) and B (mild, moderate or severe discomfort – GS 3-4-5). Patients with mild discomfort were administered an additional dose of conscious sedation. In case of persistent pain IV paracetamol 1g was used. Patients with moderate or severe discomfort received an additional dose of conscious sedation and IV paracetamol 1g. [1] [2] [3] [4]

Results Intraprocedural pain was associated at univariate analysis with lesion size≥40mm (OR 1.79, 95%C.I 1.02–3.14), severe fibrosis (OR 1.90, 95%C.I 1.03–3.49) and U-ESD (OR 0.40, 95%C.I 0.21–0.76). Multivariate analysis confirmed lesion size≥40mm (OR 2.36, 95%C.I 1.29–4.31), severe fibrosis (OR 1.95, 95%C.I 1.03–3.71) and U-ESD (OR 0.035, 95%C.I 0.18–0.69) as predictive factors of intraprocedural pain. En-bloc resection and curative resection rates were respectively of 88.7% and 79.9%. Among all outcomes considered, only procedure time was influenced by intraprocedural pain, as it was significantly longer when discomfort was present, compared to the absence of pain (74.7±46.2 min vs 57.1±39.4 min; p=0.002). En-bloc resection rate, adverse events rate, and switch to H-ESD were not significantly influenced by intraprocedural pain.

Conclusions U-ESD can decrease intraoperative discomfort and improve tolerance to the exam, straightening the sigmoid colon and avoiding loops formation, with excellent results in en-bloc and R0-resection rates. Lesion size and severe fibrosis are associated with intraprocedural pain. The adoption of U-ESD could lower intraprocedural discomfort and decrease the need of sedation, limiting also possible drug-related collateral effects.

 

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Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Rutter M., Chilton A.. Quality Assurance Guidelines for Colonoscopy. NHS BCSP Publ 2011; 6: 24
• 2 Cadoni S.. et al. Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations. Gastrointest. Endosc 2021; 93: 1411-1420.e18
• 3 Cadoni S., Leung F.W.. Water-Assisted Colonoscopy. Curr. Treat. Options Gastroenterol 2017; 15: 135-154
• 4 Pimentel-Nunes P.. et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2022. Endoscopy 2022; 54: 591-622

Publikationsverlauf

Artikel online veröffentlicht:
15. April 2024