INTRODUCTION

Adverse events can occur in lower gastrointestinal (GI) endoscopy, including colonoscopy, flexible sigmoidoscopy, ileoscopy via stoma, and pouchoscopy. Therapeutic lower GI endoscopy carries a higher risk of the development of procedure-associated complications than diagnostic lower GI endoscopy. These complications can lead to additional adverse consequences (i.e., complication’s complications), such as admission to the intensive care unit, bowel resection, or mortality. In a National Inpatient Sample (NIS) study, elderly patients, Whites, inflammatory bowel disease (IBD), end-stage renal disease, and polypectomy were shown to be risk factors for colonoscopy-induced perforation in hospitalized patients. Common indications for colorectal surgery are IBD, colorectal cancer (CRC), and diverticular diseases. Colorectal surgeries have some of the highest complication rates in the surgical field. In addition to cardiopulmonary complications and anastomotic complications, urinary, sexual, and defecatory dysfunction can also occur, resulting mainly from sympathetic and parasympathetic nerve damage during mobilization and resection of the sigmoid colon and rectum. There are scant data on the impact of these procedure-associated complications on the quality of life (QoL) or mental health in the literature.

The assessment of comorbidities before and after endoscopy and surgery and after complications is important for the preparation, planning, and management. A variety of instruments are used for the assessment of comorbidity, severity of procedure-associated complications, QoL, and mental health which have been applied to lower GI endoscopy and colorectal surgery.

CLASSIFICATION OF ADVERSE EVENTS OF ENDOSCOPY AND SURGERY

Conscious sedation, monitored anesthesiology care, or general anesthesia are commonly used before endoscopy or surgery. The American Society of Anesthesiologists (ASA) is routinely used for the assessment of disease and comorbidities ranging from ASA Class I to IV. In addition, the Charlson Comorbidity Index (CCI) is also used to evaluate comorbidities. ^, The severity of surgical complications has been measured by the Clavien-Dindo Complication Classification (CDCD), ranging from Grade I to Grade V.

From an endoscopy perspective, the American Society for Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) have published a series of guidelines on adverse events of GI endoscopy. The ASGE and UESG classifications are based on the type of endoscopy (upper or lower GI), and the frequency, location, and nature of complications. For colonoscopy, the ASGE guidelines listed the following categories: cardiopulmonary complications, perforation, hemorrhage, postpolypectomy electrocoagulation syndrome, infection, gas explosion, abdominal pain or discomfort, mortality, and miscellaneous complications. Complications from special endoscopic procedures (such as colonic dilation stent placement and foreign body removal) are described.

Modified from the Clavien-Dindo classification, the adverse events in gastrointestinal endoscopy (AGREE) classification was proposed. The AGREE classification consists of no adverse event; Grade I—adverse events with any deviation of the standard postprocedural course, without the need for pharmacological treatment or endoscopic, radiological, or surgical interventions (presentation at the emergency ward, without any intervention or hospital admission <24 hours, without any intervention, or allowed therapeutic regimens are drugs as antiemetics, antipyretics, analgesics, and electrolytes or allowed diagnostic tests: radiology and laboratory tests; Grade II—adverse events requiring pharmacological treatment with drugs other than those allowed for Grade I adverse events or blood or blood product transfusions or hospital admission >24 hours; Grade III—adverse events requiring endoscopic, radiologic, or surgical intervention; Grade IIIa—endoscopic or radiologic intervention; Grade IIIb—surgical intervention; Grade IV—adverse events requiring intensive care unit/critical care unit admission; Grade IVa—single-organ dysfunction; Grade IVb—multiorgan dysfunction; and Grade V—death of patient.

QUALITY OF LIFE AND MENTAL HEALTH SCORES

Quality of life has become a part of the outcome measurement of endoscopic and surgical therapy for IBD and colorectal disease along with the treatment of other disorders. Multiple instruments have been developed for the measurement of QoL before and after endoscopic or surgical therapy from different perspectives. For example, the Inflammatory Bowel Disease Questionnaire (IBDQ) is used in adult patients with IBD. The IBDQ-32 captures the patient’s experience of IBD in four domains: bowel symptoms; systemic symptoms; emotional function; and social function, with a 32 items and 7-point scale with 1 indicating the highest symptom frequency/severity and 7 indicating the lowest symptom frequency/severity. The 10-item Short Inflammatory Bowel Disease Questionnaire (SIBDQ). The 3-item Cleveland Global Quality of Life (CGQL) score or the Fazio score was initially proposed to measure health-related QoL in patients with restorative proctocolectomy (RPC) and ileal pouch-anal anastomosis (IPAA). CGQL consists of the current quality of life (0–10 points), the current quality of health (0–10 points), and the current energy level (0–10 points) with a total score of 30. The total score is then divided by 30, giving a range of final scores from 1 to 10 with 10 being the best. Functional bowel diseases can occur concomitantly with IBD or colorectal disease or after surgery. For example, irritable pouch syndrome (IPS) is common in patients with RPC and IPAA. To characterize the disease and assess outcomes, irritable bowel syndrome-quality of life (IBS-QOL) has been used in patients with IPS. ^,

One of the commonly used tools to assess QoL in patients with cancer is the European Organization for Research and Treatment of Cancer (EORTC QLQ-C30). Various subtypes of EORTC were proposed. The EORTC-C30 consists of the physical, role, emotional, cognitive, and functional domains. The European Organization for Research and Treatment of Cancer (EORTC QLQ-CR38) was specifically designed for CRC, which consists of four functional scales (body image, future perspective, sexual function, and sexual enjoyment) and eight symptom scales (micturition, GI disorders, defecation, stoma-related and sexual problems, nausea and vomiting, and weight loss). The scores have been used to assess QoL in patients undergoing colorectal surgery as a part of outcomes and the adverse impact of postoperative complications.

Various scores have been used to measure the mental health of patients before and after endoscopy and surgery in colorectal diseases. These instruments include the Center for Epidemiological Studies-Depression (CES-D), State-Trait Anxiety Inventory (STAI), and Medical Outcomes Study 36-item Short Form 36 (SF-36) questionnaires. In addition, the World Health Organization quality of life assessment instrument (short version, WHOQOL-BREF) is the short version of the WHOQOL-100 and has 24 questions in four domains (physical health, psychological health, social relationships, and environment) and two questions belonging to the general evaluative facet. The Depression, Anxiety, and Stress Scale (DASS-21) provides a self-report measure of anxiety and depression with maximum discrimination between the two scales. The DASS-21 is a 21-item version that was shown to be a reliable and valid measure of depression, anxiety, and tension/stress in clinical and nonclinical populations of adults and different cultural and ethnic groups. The Work and Social Adjustment Scale (WSAS) is a valid five-item self-report scale of functional impairment in the areas of work, home, and personal activities, attributable to an identifiable health problem. WSAS scores above 20 tend to suggest moderately severe or worse interference. Scores between 10 and 20 are associated with significant functional impairment but less severe clinical symptomatology. Scores below 10 appear to be associated with subclinical populations. The brief COPE scale is a 28-item (14 scales of 2 items each) measure to assess 14 conceptually differentiable coping reactions. There are scant published data on mental health instruments in endoscopic or surgical complications.

MENTAL HEALTH IN PATIENTS UNDERLYING ENDOSCOPY OR SURGERY

Complications can occur in any lower GI endoscopy and colorectal surgery. Bleeding and perforation are the main endoscopy-associated complications, while anastomotic leaks (AL) after colorectal resections for CRC are a leading cause of postoperative morbidity, long length of stay (LOS), and mortality. Both endoscopy and surgery are invasive, creating anxiety in patients. Mental health issues exist before and after endoscopy or surgery and persist even more in case of “unfavorable” diagnosis or procedure-associated complications occur. Anxiety is common in patients undergoing diagnostic and therapeutic colonoscopies. A meta-analysis of 58 studies involving 24,490 patients undergoing colonoscopy or flexible sigmoidoscopy with some using the STAI scale showed the mean anxiety level higher than that in the general population. In a study of 218 patients undergoing colorectal surgery, the surgery significantly increased depressive symptoms and anxiety levels. A total of 130 (59.6%) had complications. Severely complicated postoperative course adversely affected health status, most notably at 6 weeks postoperatively with the largest effects in the physical-, mental-, social-, and vitality domains in CES-D, STAI, and SF-36 scores. Education and teaching may help relieve preprocedural anxiety. For example, patients’ use of Web-based preparation instruction and video was shown to reduce procedural worry.

Patients with underlying mental health issues may have a higher risk for the development of colectomy-associated mental or physical complications than those without. In a study of 292,191 patients undergoing colon and rectal surgery from the Nationwide Inpatient Sample (NIS), a preoperative diagnosis of depression was present in 20,039 (6.9%) patients. The presence of a preoperative diagnosis of depression is associated with a prolonged hospital stay (10.4 days; 95% confidence interval [CI]: 10.04–10.76) as compared with those without depression (9.64 days; 95% CI: 9.48–9.81). In a separate study of 4,212,125 patients undergoing colorectal resection surgery from NIS, depression diagnosis was present in 6.72% of patients with colectomy and 6.54% of patients with proctectomy. Patients with a depression diagnosis who underwent colectomies had an increased risk of delirium (OR = 2.11; 95% CI: 1.93–2.32), wound infection (OR = 1.08; 95% CI: 1.03–1.12), urinary tract infection (OR 1.15; 95% CI: 1.10–1.20), paralytic ileus (OR =1.06; 95% CI: 1.03–1.09), and AL (OR = 1.37; 95% CI: 1.30–1.43). Similar findings were reported in those with proctectomy. In a study of 88,981 patients from the United States of The IBM MarketScan Research Databases (2010–2017) undergoing colectomy for main indications of CRC, IBD, or diverticular diseases, 21,878 (24.6%) had a history of depression. Multivariable analysis showed that patients with a history of depression had significantly longer LOS (incidence rate ratio [IRR] = 1.06; 95% CI: 1.05, 1.07), increased inpatient charge (β = 467, 95% CI: 167, 767), and increased odds of in-hospital mortality (OR = 1.37; 95% CI: 1.08, 1.73) respiratory complication (IRR = 1.18; 95% CI: 1.09, 1.27), pneumonia (IRR = 1.16; 95% CI: 1.05, 1.29), and delirium (IRR = 1.90; 95% CI: 1.52, 2.37).

IMPACT OF ENDOSCOPY AND SURGERY AND THEIR COMPLICATIONS ON QUALITY OF LIFE AND MENTAL HEALTH STATUS

While the measurement of QoL has become an integral part of surgical outcomes, it is not routine clinical practice in lower GI endoscopy in IBD or CRC. The endoscopy community may learn from surgeon colleagues. To incorporate QoL scores into daily clinical practice, the instrument should be simple, responsive, and easy to use. The classic example is Dr. Victor Fazio’s colorectal surgery group at the Cleveland Clinic in which CGQL is integrated into routine pre- and postoperative care. There is a good correlation between the simple, three-item CGQL and the more complicated Crohn’s Disease Activity Index and SF-36. ^, Therefore, CGQL is amenable to routine clinical practice. Unfortunately, there is limited literature on the impact of procedure-associated complications on patients’ mental health status.

SUMMARY AND RECOMMENDATIONS

A variant of QoL and mental health instruments is developed and used in the medical, endoscopic, and surgical treatment of IBD, CRC, and other colorectal diseases. Current literature in QoL and mental health in colorectal disease is mainly focused on the outcome of medical therapy and postoperative applications. With the progression of corrective endoscopy and surgery in colorectal diseases, the measurement of QoL and mental health status should be integrated into quality and outcome measurements. One of the best examples of routine application of QoL is the Cleveland Global Quality of Life in the RPC and ileal pouch-anastomosis. Complications are common in endoscopy (particularly therapeutic endoscopy) and surgery (particularly in obese patients or those with radiation therapy) for colorectal surgery. The severity of endoscopy or surgery-associated complications is classified with the common use of the Clavien-Dindo Complication Classification and its variants. More studies are needed to incorporate QoL and mental health scores in corrective endoscopy and corrective surgery.