Complications and Anesthesia for Colonoscopy: Culprit or Accomplice?

I read with great interest the recent paper by Wernli et al1Wernli K.J. et al.Gastroenterology. 2016; 150: 888-894Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar and its accompanying editorial.2Rex D.K. Vargo J.J. Gastroenterology. 2016; 150: 801-803Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar As a practicing anesthesiologist, it is always interesting to read other specialties’ literature involving my own specialty. I believe, however, that this paper and editorial perpetuate misconceptions and look to point fingers in the wrong direction. The authors’ principal finding is that, using billing data from the MarketScan databases, colonoscopies with billing codes for anesthetic care had an increased incidence of multiple complications, including perforation and hemorrhage. Their statistical methods are generally sound and they use validated measures. The weakness in this paper and accompanying editorial, however, is relying on several assumptions. First, they assume that the presence of an anesthesia billing code equals the administration of propofol. Second, they assume that the administration of propofol, ipso facto, produces deeper sedation than commonly-used benzodiazepine/opioid regimens. The American Society of Anesthesiologists Definition of General Anesthesia and Levels of Sedation/Analgesia3American Society of Anesthesiologists Quality Management and Departmental Administration Committee. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. Available: www.asahq.org. Accessed April 9, 2016.Google Scholar recognizes multiple levels of sedation during the provision of monitored anesthesia care, any of which is possible during care by an anesthesia provider. Third, they assume that the quality and type of anesthetic care given is constant, regardless of provider qualification (physician vs nurse anesthetist) and patient comorbidity. These assumptions plus a statistical association led to a logical fallacy: anesthetic care increases postprocedural complications. A more plausible explanation for their finding of an association is that the involvement of an anesthesia provider includes an expectation by the patient (or endoscopist) for deeper sedation and produces (1) a more comfortable patient and (2) an overconfident endoscopist. If a patient is not complaining of discomfort during a procedure, how does one assign responsibility for complications? In other words, does the involvement of an anesthesia provider facilitate overly aggressive endoscopy? The authors also note that a greater proportion of cases involving anesthetic care had a gastroenterologist as the endoscopist. There was no analysis, however, of any association between endoscopist specialty and incidence of complications. One might just as easily (and erroneously) argue that gastroenterologists cause more postprocedural complications than surgeons. Sedation for endoscopy is a complicated and difficult area of research. There are competing financial interests, some of which are often not clearly disclosed. The push for deeper endoscopist-directed sedation has led to the creation of a computerized propofol administration system (Sedasys, Johnson and Johnson [New Brunswick, NJ], recently withdrawn from the market) and other means to circumvent Food and Drug Administration labeling requirements for propofol administration such as the development of alternate propofol formulations (fospropofol) or rapidly acting nonpropofol sedatives (remimazolam, Paion AG, Aachen, Germany). In this environment, the wise reader will have a healthy dose of skepticism. Risks Associated With Anesthesia Services During ColonoscopyGastroenterologyVol. 150Issue 4PreviewWe aimed to quantify the difference in complications from colonoscopy with vs without anesthesia services. Full-Text PDF ReplyGastroenterologyVol. 151Issue 3PreviewWe thank the authors who have responded to our recent work on the relationship between anesthesia services and short-term colonoscopy outcomes,1 and welcome the opportunity to respond to their questions concerning our methods and interpretation. Full-Text PDF