Govert Veldhuijzen

135 Virtual reality distraction for patients to relieve pain and discomfort during colonoscopy INTRODUCTION The use of colonoscopy as a diagnostic and therapeutic tool is likely to rise. This is mainly caused by the implementation and expansion of colorectal cancer screening projects, targeting ever younger patients. 1 Endoscopic procedures are associated with embarrassment, pain and discomfort. 2 This proves an important barrier to undergo colonoscopy and may subsequently curtail the willingness of patients to be subjected to repeat surveillance colonoscopies. 3,4 Indeed, a relevant proportion of the patients (18-29%) experience anxiety due to concerns related to preparation for, execution of, and anticipation of the result of colonoscopy. 5 Sedatives to relieve anxiety is the method of choice used in order to mitigate discomfort patients experience during colonoscopy. 6 However, drug induced sedation comes with adverse effects related to suppression of pulmonary and circulatory function. 7,8 There is a higher post-procedural risk of pneumonia in elderly patients. 9 Deep sedation even puts patients at an increased risk for the procedural related complication of perforation. 10 Also, the monitoring of patients during and after sedation is both logistically demanding and costly. 11 Therefore, several studies have examined non-pharmacological interventions to reduce anxiety and pain during endoscopy 12-18 . These studies used a mix of visual 13,15,18,19 or auditory stimuli 12,14,18 and found that while true efficacy is not fully established, combined visual and auditory distraction is better in reducing discomfort compared to auditory distraction alone 18 . Virtual reality (VR) integrates computer generated visual and auditory signals to recreate an illusionary perception of the actual physical world. 20,21 . The distraction that comes with immersive VR induces an analgesic effect and has been used as an adjunct to control pain and anxiety during operative procedures. 22,23 . VR technique has become more affordable and better portable, adding to its immersive qualities. 24 VR reduces pain during burn wound debridement 25-27 , and discomfort during dental procedures 28 . A questionnaire study found that up to 25% patients are willing to undergo colonoscopy with VR glasses instead of sedation. Key patient motive is the reduction of sedative use which allows patients to drive their cars home themselves afterwards. 29 But still unknown is the patient acceptance (e.g. feasibility) of performing colonoscopy on patients actually wearing VR glasses. Wearing VR glasses could potentially be disadvantageous to the colonoscopy procedure, as it could obstruct communication with patients. Conversely, the procedure itself might compromise the VR effect, as 7