title: Comparison of procedural sequences in same-day bidirectional endoscopy without benzodiazepine and propofol sedation: starting at the bottom or the top.
abstract: OBJECTIVE
  Same-day bidirectional endoscopy including esophagogastroduodenoscopy (EGD) and colonoscopy is routinely performed to evaluate anemia and gastrointestinal bleeding, as well as to conduct cancer surveillance. Numerous questions have been raised regarding the most appropriate procedural sequence and the resulting potential procedure interactions. We compared the quality and feasibility of performing EGD and colonoscopy without sedation in patients subjected to EGD-colonoscopy (Group I) or colonoscopy-EGD (Group II) sequences.
  
  
  METHODS
  A total of 80 patients were prospectively randomized into two groups (40:40). All EGD examinations were recorded on videotape, and the quality of 18 EGD steps was assessed by three endoscopists. In addition, we analyzed the colonoscopic parameters and subjective discomfort scores of patients.
  
  
  RESULTS
  Group I displayed significantly superior quality for retroflexion-related steps (P11-13; all median of Group I vs Group II = 2:3; P < 0.01), visualization of the angular fold (P10; Group I vs Group II = 2:3; P = 0.048), and general assessment of the stomach (P17; Group I vs Group II = 2:3; P = 0.008) and upper GI tract (P15; Group I vs Group II = 2:3; P = 0.047). Colonoscopic insertion time, total time, and prolonged insertion ratio did not differ between the two groups. Questionnaire responses indicated that EGD was perceived to be more stressful in Group II sequence.
  
  
  CONCLUSIONS
  The quality of EGD steps is influenced by the sequence of bidirectional endoscopy. EGD is perceived to be more stressful to patients when preceded by colonoscopy. Therefore, EGD followed by colonoscopy may be the preferable procedural sequence for same-day bidirectional endoscopy.
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Jae Hee
authors.initials: JH
authors.lastname: Cho
authors.forename: Jie Hyun
authors.initials: JH
authors.lastname: Kim
authors.forename: Yong Chan
authors.initials: YC
authors.lastname: Lee
authors.forename: Si Young
authors.initials: SY
authors.lastname: Song
authors.forename: Sang Kil
authors.initials: SK
authors.lastname: Lee
mesh_terms: D000328:Adult; D000368:Aged; D000740:Anemia / Q000209:etiology; D001569:Benzodiazepines / Q000627:therapeutic use; D003113:Colonoscopy / Q000009:adverse effects / Q000523:psychology; D016292:Procedural Sedation; D004066:Digestive System Diseases / Q000150:complications / Q000175:diagnosis*; D016145:Endoscopy, Digestive System / Q000009:adverse effects / Q000523:psychology; D005240:Feasibility Studies; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology; D010147:Pain Measurement; D057240:Patient Preference; D011237:Predictive Value of Tests; D015742:Propofol / Q000627:therapeutic use; D011446:Prospective Studies; D056910:Republic of Korea; D013315:Stress, Psychological / Q000209:etiology; D011795:Surveys and Questionnaires; D014741:Video Recording
chemical_list: D006993:Hypnotics and Sedatives; D001569:Benzodiazepines; D015742:Propofol