Insights into anesthesia administration for elderly individuals undergoing painless gastroenteroscopy: A bibliometric study

Abstract

BACKGROUND

Administering anesthesia to elderly patients undergoing gastroenteroscopy necessitates careful attention due to age-related physiological changes and an increased risk of complications.

AIM

To analyze the research trends in anesthesia management for elderly patients undergoing gastroenteroscopy.

METHODS

We performed a literature search using the Web of Science database to identify articles published between 2004 and 2023. Bibliometric and visual analyses were conducted using CiteSpace, R, and VOSviewer to explore the current research landscape of anesthesia administration in painless gastroenteroscopy for elderly patients and to identify future research directions by examining trends and emerging hotspots in this domain.

RESULTS

A total of 800 articles were examined, revealing a rising trend in annual publication counts. The United States led with 181 articles, followed by China with 112, collectively contributing over 35% of the studies among the top ten countries. The majority of publications appeared in the United States journals, with the top three being Gastrointestinal Endoscopy [impact factor (IF) = 7.7, H-index = 26], Digestive Diseases and Sciences (IF = 3.1), and Endoscopy (IF = 9.3). Six primary research clusters were identified: Obstructive sleep apnea and airway management, surveillance and risk factors, colorectal cancer examination and treatment, sedation and safety of propofol and midazolam, patient satisfaction, and mortality and complications. These findings underscore the pivotal focus areas in anesthesia for elderly patients undergoing gastroenteroscopy.

CONCLUSION

A comprehensive understanding of current research trends and hotspots will aid anesthesiologists in developing more evidence-based practices, thereby improving the safety and outcomes for elderly patients undergoing gastroenteroscopy.

Key Words: Anesthesia; Elderly; Gastroenteroscopy; Bibliometric; CiteSpace; VOSviewer

Core Tip: Anesthesia management for elderly patients undergoing gastroenteroscopy is complex due to physiological changes and increased risks of complications. This study offered a bibliometric analysis of 800 articles (2004-2023), identifying key research trends. The United States and China were the leading contributors. Key areas for future research included: (1) Sedation safety with propofol and midazolam; (2) Airway management with a focus on obstructive sleep apnea; (3) Risk factors for complications and mortality; (4) Colorectal cancer examination and treatment; and (5) Patient satisfaction. These insights will guide anesthesiologists toward more evidence-based practices for improved safety and outcomes in elderly patients.

INTRODUCTION

Painless gastroenteroscopy is a vital medical procedure for diagnosing and treating a range of gastrointestinal disorders. Its popularity is on the rise, with millions of procedures conducted globally each year. Effective anesthesia management is paramount to ensuring patient comfort and safety, especially in elderly patients who face heightened risks of complications due to age-related physiological changes[1-4]. Despite advancements in anesthetic techniques, elderly patients continue to experience significant morbidity and mortality[5].

Given these considerations, the imperative to develop optimal anesthesia management strategies for the elderly population undergoing painless gastroenteroscopy is more pressing than ever. Bibliometric analysis serves as a robust tool for systematically mining, organizing, and interpreting relevant publications. This method enables the identification of research trends, knowledge gaps, and promising avenues for further investigation[6].

Our study aimed to employ bibliometric analysis to collate and synthesize existing evidence on anesthesia administration for elderly patients undergoing painless gastroenteroscopy. By systematically reviewing and analyzing a comprehensive array of the literature, we sought to elucidate current trends and prospective directions in this domain. The insights derived from our study will inform clinical decision-making, refine anesthesia practices, and ultimately enhance patient outcomes within this vulnerable demographic.

MATERIALS AND METHODS

Data source and search strategy

The search procedure followed the sequence outlined in Figure 1. A comprehensive search of the Web of Science database was performed to identify articles focusing on elderly patients undergoing painless gastroenteroscopy from 2004 to 2023. Original and review articles published in English were included. The search terms were typescript (TS) = (“gastroscopic” OR “gastroscopy” OR “gastroscopies” OR “colonoscopy” OR “colonoscopies” OR “colonoscopic” OR “upper endoscopy” OR “lower endoscopy”) AND TS = [(“general anesthesia”) OR (“general anaesthesia”) OR (“general anesthesi”) OR (“general anaesthesi”)] OR [(“Conscious Sedation”) OR (“minimal Sedation”) OR (anxiolysis) OR (“Sedation, Moderate”) OR (“Moderate Sedation”) OR (“Sedation, Conscious”) OR (“Sedation, deep”) OR (“Painless”) OR (“sedation”) OR (“sedative”) OR (“sedated”)] AND TS = (“elderly” OR “aged” OR “old people” OR “old-timer” OR “oldie”).

Figure 1  Flowchart illustrating the search strategy.

Bibliometric analysis

A descriptive statistical analysis of annual outputs and growth trends was conducted using Microsoft Office Excel 2017 (Microsoft, Redmond, WA, United States). The Bibliometrix package in R (version 4.2.1) was employed for bibliometric analysis and data visualization. VOSviewer (version 1.6.19) was used to create visualization networks for countries, institutions, authors, and keywords. The co-occurrence analysis in VOSviewer clustered keywords, assigning color codes to highlight emerging research trends.

The journal citation report 2023 supplied essential data, such as the journal’s impact factor, H-index, and category ranking quartiles[7]. CiteSpace software (version 6.2.R3) was employed to detect keywords and references with significant citation bursts and to create co-cited reference and cluster visualization networks. In the CiteSpace network, each entity is depicted as a node, where larger nodes represent more frequent occurrences[8]. Furthermore, centrality analysis indicated that nodes with higher centrality scores are more influential[9].

RESULTS

Overview of publications

In total, 800 publications regarding anesthesia for painless gastroenteroscopy in elderly individuals were identified. These works have collectively accumulated 13497 citations, resulting in an average of 18.90 citations per article. The citation rate highlights the considerable influence of research in this area. Moreover, the H-index for this body of work was determined to be 27, indicating significant academic recognition and contribution to the field.

Annual outputs and growth trends

Research on the anesthetic management for painless gastroenteroscopy in elderly patients has seen a marked rise in outputs and citations between 2004 and 2023 (Figure 2A). The number of yearly publications increased from 17 in 2004 to 42 in 2023, while annual citations surged from 4 to 1551 over this period. Notably, since 2012, there has been a pronounced upward trend in publications, reflecting intensified global focus and rapid advancements in professional theories. Regarding geographical distribution, the United States has emerged as the leading in research contributions, followed by China, Japan, South Korea, and several other nations (Figure 2B). China’s contribution in 2022 was particularly noteworthy, likely due to its rapidly aging population and the consequent emphasis on addressing the healthcare needs of the elderly[10].

Figure 2 Trends in annual publication outputs and collaborations among countries, regions, and institutions. A: The total number of publications and citations regarding anesthetic management for painless gastroenteroscopy in elderly individuals from 2004 to 2023; B: Growth patterns of the top 10 countries; C: Contributions of countries/regions; D: Contributions of institutions to publications.

Distribution of countries/regions and institutions

Figure 2C presents a network visualization of international collaborations. The top ten contributing countries are summarized in Supplementary Table 1, with the United States leading with 181 publications, followed by China (112), Japan (52), South Korea (50), and the United Kingdom (44). Collectively, the United States and China accounted for over 35% of the total publications from these leading nations. The centrality score, a measure of the importance of network nodes, assigned the highest value of 0.39 to the United States. In terms of paper quality, as measured by citation count and H-index, publications from the United States demonstrated the highest performance with 4093 citations and an H-index of 48. Germany, despite having the sixth-highest publication volume (42 articles), ranked second in citations (1727) and H-index (31). China, with 1523 citations and an H-index of 35, was third, indicating substantial output but fewer highly impactful papers relative to its overall contribution. Figure 2D presents the network of institutional collaborations. Among the top ten institutions, Harvard University ranked highest with 17 articles, followed by the Cleveland Clinic Foundation with 16 and the United States Department of Veterans Affairs with 14 (see Supplementary Table 2). Of the ten most prolific institutions, seven were based in the United States, while the remaining three included the University of Antwerp in Belgium, Shanghai Jiao Tong University in China, and the University of Toronto in Canada.

Journals publishing research

In the last 20 years, a total of 250 journals have played a role in the research on anesthesia for painless gastroenteroscopy (Figure 3A). The top ten most prolific journals in this field, predominantly from the United States, are summarized in Supplementary Table 3. These top 10 journals accounted for 28.99% (207 out of 714) of the articles included in our analysis. Leading the publication volume was Gastrointestinal Endoscopy (H-index = 26; impact factor = 7.7), followed by Digestive Diseases and Sciences (impact factor = 3.1) and Endoscopy (impact factor = 9.3). As per the journal citation reports (JCR) for 2022, these three journals were classified as Q1/Q2. The Q1 category included Gastrointestinal Endoscopy, Endoscopy, American Journal of Gastroenterology, and Surgical Endoscopy and Other Interventional Techniques. Those in Q2 included Digestive Diseases and Sciences and World Journal of Gastroenterology, while the Journal of Clinical Gastroenterology was ranked in Q3.

Figure 3 Journals publishing research and contributions of authors. A: Journals publishing papers; B: Joint mapping of high-producing authors on anaesthetic management for painless gastroenteroscopy in elderly individuals from 2004-2023.

Contributions of authors

CiteSpace was employed to visualize the contributions of authors in this field (Figure 3B), revealing a total of 4303 authors who have published articles on this topic. Supplementary Table 4 lists the top 10 researchers with the highest number of publications. Leading the list are Hassan C and Bretthauer M, each with 7 articles and 178 citations. They are followed by Amornyotin S and Capasso R, each with 6 articles and 260 citations. The elevated citation counts signify the quality and impact of these authors’ works, highlighting their important contributions to the field.

Keywords

Cluster analysis of keyword co-occurrence related to research hotspots: In this study, VOSviewer software was employed to analyze the titles and keywords of 800 relevant publications. Figure 4A illustrates the division of the map into 15 clusters, encompassing a total of 712 keywords. Notably, 104 keywords appeared more than 10 times, with the top 10 keywords listed in Supplementary Table 5. The most frequently occurring keywords were “colonoscopy” (237 occurrences), “sedation” (210), “propofol” (173), “endoscopy” (163), “midazolam” (119), and “conscious sedation” (107), highlighting a significant focus on anesthetic sedative drugs. Furthermore, related terms were organized into six primary clusters: (1) Obstructive sleep apnea (OSA) and airway management (105 keywords, indicated by red circles); (2) Surveillance and risk factors (104 keywords, green circles); (3) Colonoscopy applications in colorectal cancer (104 keywords, blue circles); (4) Sedation and safety of propofol and midazolam (55 keywords, yellow circles); (5) Patient satisfaction and mortality (54 keywords, purple circles); and (6) Complications (51 keywords, cyan circles). Figure 4B illustrates the temporal distribution of keywords, with label colors reflecting their chronological order. In the initial decade, research primarily concentrated on anesthetic drugs and their clinical applications. Current trends indicate that airway management and associated risks are likely to emerge as important research hotspots.

Figure 4 Analysis of co-occurrence in global research on anesthetic management for painless gastroenteroscopy in elderly individuals from 2004 to 2023. A: Mapping of keywords within the research domain; B: Distribution of keywords based on their chronological appearance; C: Identification of keywords with the highest citation bursts.

Detection of keyword bursts: We identified the top 25 keyword bursts from 2004 to 2023 (Figure 4C). The timeline is depicted as a straight line featuring blue and red segments, where the red section represents the burst period. The length of this segment indicates the start year, end year, and duration of the burst. Between 2004 and 2023, “upper gastrointestinal endoscopy” (8.12) exhibited the most significant keyword burst, followed by “meperidine” (7.31), “management” (6.5), “conscious sedation” (5.69), “general anesthesia” (5.51), “pain” (5.24), and “gastroenterologist” (5.13). The analysis of keyword burst trends suggested that “adenoma detection rate” (2017–2022), “management” (2018–2022), and “obstructive sleep apnea” (2018–2020) are emerging hotspots for future investigation.

Analysis of research hotspots

Most co-cited papers: In this study, we examined the co-citation relationships among 13497 cited references found in 714 articles and created a clustering network diagram. Figure 5A displays this network, which consists of 242 nodes and 709 links. Each node represents a cited article, with its size indicating the citation frequency. Links between nodes indicated shared citations. Nodes highlighted with purple rings are especially important as they connect the developmental stages of a field. The ten most co-cited articles are detailed in Supplementary Table 6. The study by Gross et al[11] from the University of Connecticut School of Medicine, published in Anesthesiology, was the most cited, with 58 citations. It investigated the potential link between systemic opioid use and the increased incidence of fever in parturients receiving epidural analgesia during childbirth, ultimately finding no such correlation. Another highly cited study, conducted by Cohen et al[12] from the Mount Sinai School of Medicine and published in the American Journal of Gastroenterology, involved a nationwide survey on sedation and monitoring practices during gastrointestinal endoscopic procedures in the United States, garnering 57 citations[12]. Lastly, McQuaid and Laine’s study from the University of California, San Francisco, published in Gastrointestinal Endoscopy, was a systematic review and meta-analysis comparing the efficacy, safety, and efficiency of sedation agents used in routine endoscopic procedures such as esophagogastroduodenoscopy and colonoscopy, also with 57 citations[13].

Figure 5 Analysis of research hotspots. A: Map of co-cited references; B: Cluster network diagram of co-cited references; C: Timeline visualization of co-cited clusters featuring their labels; D: The 25 references exhibiting the highest citation bursts.

Analysis of co-cited references: To identify research hotspots, we ranked articles based on their co-citation frequency within the network. The analysis revealed 11 key clusters of co-cited references: “Controlled trial”, “medication-free colonoscopy”, “average risk population”, “safe method”, “European society”, “preparation premedication”, “intravenous lidocaine”, “stepwise sedation”, “obstructive sleep apnea”, “narrative review”, and “clinical study” (Figure 5B). The timeline representation of the clustering plot in Figure 5C facilitates the identification of emerging research hotspots within this field.

Citation burstness denotes references that have attracted considerable attention from researchers during particular timeframes. Figure 5D displays the 25 most frequently cited articles. Among these, the highest burstness (n = 10.86) was linked to the article “Guidelines for Sedation and Anaesthesia in GI Endoscopy” by Early et al, with the citation burst spanning from 2019 to 2022. This was followed by the 2009 paper “Endoscopist-Directed Administration of Propofol: A Worldwide Safety Experience” by Rex et al. The third most significant burst was associated with “Sedation in Gastrointestinal Endoscopy: Current Issues”. Notably, most of these highly cited articles appeared in journals based in the United States, particularly Gastrointestinal Endoscopy and Gastroenterology.

DISCUSSION

This study performed a bibliometric analysis of 800 original articles and reviews from the Web of Science database to explore trends and research hotspots in anesthesia management for painless gastrointestinal endoscopy in elderly patients over the last two decades. The analysis revealed a consistent annual growth in both publications and citations. Notably, in 2023, China surpassed the United States in the number of annual publications, underscoring the increasing importance of researching safer and more efficient anesthesia management methods in response to the aging global population.

Our findings revealed that the United States excels in publication volume, centrality score, and citation counts within the research network, indicating its substantial contribution and influential role in collaboration and knowledge dissemination. Among the top 10 affiliated institutions, 7 were based in the United States, potentially attributed to the country’s numerous research centers and early engagement in the field. Publications from the United States tend to receive international recognition. Harvard University emerged as the leader in both the number of articles among the top 10 and its centrality score, underscoring its significant role in collaborative research. The influence of collaborative networks is evident in how they facilitate the sharing of resources, expertise, and innovative ideas, which are essential for advancing research quality. Elite institutions like Harvard University often act as hubs within these networks, fostering partnerships that lead to high-impact research outcomes. These collaborations not only enhance the visibility and citation of research but also contribute to setting global research agendas. While interactions between academic institutions worldwide have increased, overall connection and collaboration levels remain relatively weak. To address this, there is a need for strategic initiatives that encourage more robust international partnerships. Such efforts could include joint research programs, shared funding opportunities, and international conferences that bring together diverse expertise. By strengthening these collaborative networks, the research community can drive more effective and impactful outcomes, ultimately advancing the field as a whole.

In our analysis of top journals, we found that a high impact factor is indicative of article quality. Our findings highlighted the top ten most active journals, predominantly based in the United States. Leading in publication volume were Gastrointestinal Endoscopy, Digestive Diseases and Sciences, and Endoscopy. These journals, classified as Q1/Q2 in the 2023 JCR, present significant potential for publishing research on anesthesia management for painless gastrointestinal endoscopy in elderly patients.

Keywords provided information about the core content of the article, and the most frequent and latest keywords can be used to identify the research trends and hotspots in specific fields during the research period[14]. A highly discussed topic in this field is OSA and the management of airway issues. According to estimates, over one billion people worldwide suffered from OSA, with its incidence increasing linearly with body weight and age[15]. OSA had significant impacts on neurofunctional disorders, vascular diseases, metabolic dysfunction, depression, and cancer[16-19]. Patients with OSA face a significant risk of experiencing adverse airway events during sedation and anesthesia[20,21]. Many presumed consequences of OSA overlapped with changes that occurred during the aging process, leading to its frequent under-recognition in the elderly[22]. Propofol, when used in combination with opioids, was the most frequently administered sedative for gastroenteroscopy; however, it poses a risk of airway obstruction and respiratory depression[23]. Consequently, implementing suitable sedation protocols and management strategies is essential to ensure ventilatory safety during painless gastroenteroscopy in elderly patients.

Sedation during endoscopy is commonly employed to reduce patients’ anxiety, discomfort, pain, and the risk of vasovagal reactions. Globally, propofol and midazolam, often used in conjunction with opioids, are the most frequently utilized sedatives for gastroenteroscopy procedures[24,25]. Propofol had a relatively fast renal clearance rate and strong anti-anxiety and amnestic properties[26]. The midazolam and propofol combination exhibited a synergistic effect, significantly reducing the required propofol dosage, thereby minimizing dose-related side effects and enhancing safety in elderly patients[27]. Therefore, midazolam/propofol combination sedation emerged as a valuable option for gastrointestinal endoscopy in elderly patients, especially those with multiple comorbidities.

Eldawlatly et al[28] highlight the general safety of procedural sedation analgesia in elderly patients, emphasizing the need to avoid under-treatment of pain to prevent discomfort. Tailoring sedation to individual needs ensures both safety and comfort during procedures. Xu et al[29] support optimizing post-anesthesia care by demonstrating that intravenous infusion accelerates recovery and enhances patient comfort in elderly patients following painless colonoscopy, encouraging compliance in future procedures. These insights underscore the importance of personalized sedation strategies and post-procedure management to improve outcomes for elderly patients.

This study was intriguing as it conducted a thorough examination of existing literature and data, utilizing bibliometric analysis for the first time to investigate anesthesia management for painless gastroenteroscopy in the elderly. It identified potential future research directions with accurate and objective results. Future research should prioritize refining sedation protocols to minimize respiratory complications, especially in patients with OSA and other age-related conditions. Given the synergistic effects of midazolam and propofol, further studies are needed to optimize drug dosages and combinations specifically tailored for elderly patients with comorbidities. Basic research could also focus on developing new sedatives or adjunct therapies that reduce airway obstruction and respiratory depression while ensuring effective sedation. Additionally, the impact of sedation on long-term cognitive function in elderly patients is a crucial area of study, particularly in light of the global aging population. In conclusion, future research should aim to enhance sedation safety, optimize anesthetic protocols, and address the challenges of airway management, particularly for elderly patients with OSA and multiple comorbidities.

Limitations

Bibliometric analysis has been widely applied in clinical practice and research[30]. However, limitations existed in this study. First, we relied exclusively on the Web of Science Core Collection and did not include other databases such as PubMed and Scopus. Variations in databases could result in different publication and citation counts, potentially influencing our overall findings. Second, focusing solely on English-language articles may have limited article retrieval. Lastly, as our study was time-limited, the article count was subject to change. Rapid research updates might have overlooked certain focal points. Future research should aim to offer a more comprehensive overview and analysis to further investigate this topic.

CONCLUSION

With the population pyramid shifting towards longer lifespans, an increasing number of elderly patients have undergone gastrointestinal examinations, potentially with underlying heart or respiratory conditions and electrolyte disorders from colon preparation. Targeted clinical and observational trials are essential to offer appropriate clinical treatments for these specific elderly population.