Gastroscopy Should Come Before Colonoscopy Using CO(2) Insufflation in Same Day Bidirectional Endoscopies: A Randomized Controlled Trial

BACKGROUND AND AIMS: Same day bidirectional endoscopies (esophagogastroduodenoscopies [EGD]s and colonoscopies) are routinely performed. However, the best sequence of procedures is unknown, as is whether the use of carbon dioxide (CO(2)) affects the preferred sequence of procedures. This study aims to determine the preferred sequence of procedures and choice of insufflation gas (air or CO(2)) in patients undergoing same day bidirectional endoscopies. METHODS: Two hundred adults with a clinical indication for same day bidirectional endoscopies were randomized equally into four groups: A1 (EGD first, CO(2) as insufflator); A2 (EGD first, air as insufflator); B1 (colonoscopy first, CO(2) as insufflator); and B2 (colonoscopy first, air as insufflator). All procedures were performed with conscious sedation (Midazolam/Fentanyl). The primary outcome was patients’ overall comfort/satisfaction with the procedures and sedation received, as assessed by questionnaires and validated scoring scales (Nurse-Assessed Patient Comfort Score [NAPCOMS], La Crosse [WI]) collected during the procedures, before discharge, and on day 7 postprocedure. RESULTS: Two hundred patients were randomized, with data available for 186. Mean Midazolam dose between groups was significantly less in the EGD first groups (P=0.01). During the procedures, no differences were found in patients’ comfort as per the nurse reported NAPCOMS scores (P=0.19) or the Lacrosse (WI) endoscopy scores (P=0.05). On postprocedure days 0 and 7, no differences were found in the patients’ reported Lacrosse (WI) scores, nausea, sore throat, dizziness, satisfaction with sedation or overall level of procedural satisfaction (P>0.05 for each). However, bloating and discomfort were significantly lower in the CO(2) arms (P<0.001). CONCLUSIONS: This randomized controlled trial using validated patient comfort scoring assessments for same day bidirectional endoscopies demonstrated that the sequence of procedures affects the sedation used but does not affect overall patient comfort or satisfaction. Lesser sedation is needed in the EGD first group, and less postprocedural abdominal pain/discomfort and bloating is seen with CO(2) insufflation.