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Carbon dioxide insufflation preferred over air insufflation in colonoscopy screening

In a randomized clinical trial, a group of international researchers evaluated colonoscopy screening for the first time, according to recent findings published in JAMA Internal Medicine.

“Although many Americans regularly undergo colonoscopy screening, no randomized trials have been performed to quantify the effectiveness of such screening on colorectal cancer incidence and mortality,” Michael Bretthauer, MD, in the department of health management and health economy at the University of Oslo in Norway, and colleagues wrote. “The [Nordic European Initiative on Colorectal Cancer (NordICC)] trial is the first, to our knowledge, to investigate the effectiveness of colonoscopy screening vs. no screening.”

Although colorectal cancer is the second-most common cancer in high-income countries, most European countries have not introduced colonoscopy screening. To better inform these countries, Bretthauer and colleagues conducted a randomized trial of population-based colonoscopy screening in Norway, Sweden, Poland and the Netherlands. The trial included 94,959 participants aged 55 to 64 years who were at average risk for colon cancer. The researchers investigated participation rate, adenoma yield, performance and adverse events of colonoscopy screening.

Overall, the colonoscopy screening participation rate was 40%, with individual rates of 60.7% in Norway, 39.8% in Sweden, 33% in Poland and 22.9% in the Netherlands (P < .001). The cecum intubation rate was 97.2%, with 77.4% not receiving sedation. Of those undergoing colonoscopy screening, there was one perforation (0.01%), two postpolypectomy serosal burns (0.02%) and 18 cases of bleeding due to polypectomy (0.14%). In the same group, 62 participants (0.5%) were diagnosed with colorectal cancer. In addition, 30.7% of the participants had adenomas, of which 10.4% were considered high-risk. Recommended benchmarks for cecal intubation (95%) and adenoma detection (25%) were not met by 17.1% and 28.6% of endoscopists, respectively, suggesting that performance differed significantly among endoscopists. In addition, moderate-to-severe abdominal pain was reported by 16.7% of patients examined with standard air insufflation compared with 4.2% who were examined with carbon dioxide insufflation (P < .001).

“We found satisfactory participation, high adenoma yield, and adequate performance for colonoscopy screening in the NordICC trial,” the researchers wrote. “The observed large differences between countries and individual endoscopists deserve further investigation. Air insufflation should be abandoned in favor of insufflation with carbon dioxide in colonoscopy screening.” – by Will Offit

Disclosures: Bretthauer reported serving as a member of the European scientific advisory board of Exact Sciences and receiving equipment for testing in scientific studies from Olympus, Fujinon, Falk Pharma and CSS Healthcare. All other authors report no relevant financial disclosures.