A Patient-Blinded Randomized, Controlled Trial Comparing Air Insufflation, Water Immersion, and Water Exchange During Minimally Sedated Colonoscopy

Hsieh, Yu–Hsi; Koo, Malcolm; Leung, Felix W.

doi:10.1038/ajg.2014.126

Cited by 106 publications

(172 citation statements)

References 56 publications

(65 reference statements)

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“…A novel method, insertional cleansing, is an integral component of the recently described method termed water-exchange colonoscopy [12,13]. Compared with traditional air insufflation in patients purged with split-dose bowel preparation, the novel technique has been associated with a significant increase in Boston Bowel Preparation scores and ADR in the right colon [12], and a significant reduction in distraction from focused examination during withdrawal [13]. Insertion cleaning, being relatively new, has not yet gained recognition as a component of standard insertion techniques.…”

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Intraprocedural Cleansing for Screening Colonoscopy: Avoiding Brownouts

Leung

2015

Dig Dis Sci

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Adequate bowel preparation has long been considered an essential prerequisite for successful endoscopic procedures since residual feces can obscure mucosal pathology [1], particularly flat polyps termed non-polypoid colorectal neoplasms (NP-CRNs) [2]. Overall, NP-CRNs are more likely to harbor carcinoma (odds ratio *10) than polypoid lesions, irrespective of size [3]. With regard to shape, depressed-type NP-CRNs are associated with a 33 % risk of malignancy, which is the highest of all polyp types [3]. Modifiable factors with an impact on adenoma detection rate (ADR) include increasing the length of time used for withdrawal inspection, looking behind folds, and retroflex examination for the detection of NP-CRNs. There is current emphasis regarding improving bowel cleanliness which improves recognition and facilitates complete resection of NP-CRNs, sessile serrated polyps, and advanced adenomas [4].In this issue of the Digestive Diseases and Sciences, Oh et al. [5] evaluated the impact of the quality of bowel cleansing on detection of NP-CRNs. In a retrospective analysis of screening colonoscopy performed by seven board-certified attending gastroenterologists at one academic teaching hospital, patients underwent recommended split-dose bowel preparation, with endoscopic removal of fecal debris and retained fluid accomplished by forceful irrigation and suction, prior to rating bowel preparation quality. In 6097 asymptomatic, average-risk screening examinations, the preparation quality was rated as adequate (excellent or good) in 5224 (85.7 %), fair in 615 (10.1 %), and poor in 258 (4.2 %) patients. Efforts to improve the preparation quality increased the detection rate of NPCRNs, improving the efficacy of screening colonoscopies. Interestingly, the split-dose bowel preparation, formerly lauded for its efficacy on the basis of clinical trial data, was less perfect in real-life clinical settings, necessitating intraprocedural cleansing.In the study by Oh et al. [5], the primary outcome was a comparison of the adenoma detection rate (ADR) for nonpolypoid lesions according to quality of bowel preparation. The overall ADR of non-polypoid pathology, 12.3 % (747/ 6097) of all colonoscopies, significantly differed between participating endoscopists. The ADR for non-polypoid pathology was significantly lower if preparation was rated as fair or poor quality compared with the ADR associated with adequate preparation. Furthermore, detection of \ 1 cm in lesions in the proximal colon was significantly lower with poor preparation than with adequate preparation. Of 5946 polyps detected in the study population, 4847 were histologically confirmed as adenomas (84.7 %) or serrated polyps (15.3 %). More than half were located in the proximal colon (2590/4847), most were of \1 cm (4570/4847), and almost all were flat (0-IIa or 0-IIb) lesions (4843/4847). The proportion of NP-CRNs among all neoplastic lesions was 40.5 % (1962/4847), with the proportion of advanced neoplasms among NP-CRNs 3.5 % (68/1962).Although the report is limited by...

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Intraprocedural Cleansing for Screening Colonoscopy: Avoiding Brownouts

Leung

2015

Dig Dis Sci

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“…Cecal intubation time averaged 16.4 min in the water exchange arm compared with 5.7 min in water immersion and 6.3 min in air insuffl ation arms. Th e primary end point for the study was the fraction of patients with a painless insertion, which was 61.1 % with water exchange vs. 43.3 % with water immersion vs. 30 % with air ( 9 ). Th ere were no signifi cant diff erences between the treatment arms in patient satisfaction scores or willingness to repeat colonoscopy ( 9 ).…”

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“…report a randomized trial comparing air insuffl ation with water immersion and water exchange ( 9 ). Cecal intubation time averaged 16.4 min in the water exchange arm compared with 5.7 min in water immersion and 6.3 min in air insuffl ation arms.…”

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“…Th e process or basic method for infusing water during intubation has been subdivided into two categories termed " water immersion " and " water exchange " ( 9 ). Water immersion means infusing water solely for the purpose of expanding the lumen and intubating the cecum, with suctioning of the water occurring during withdrawal.…”

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“…Th ere are several problems with understanding whether water exchange accounts for the observed reduction in pain in the trial, and whether water exchange is an important improvement over water immersion. First, the assistant who took the pain measurements was not blinded to the randomization and did not record the pain levels at standardized intervals, which risked bias while taking the measurements ( 9 ). Second, any method of intubation that requires a 250 % increase in intubation time might decrease pain simply because it slows down the process of intubation; that is, water immersion or even gas insuffl ation slowed down to an average of 16 min of intubation time might have a similar eff ect on pain during insertion.…”

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Editorial: Water Exchange vs. Water Immersion During Colonoscope Insertion

Rex

2014

American Journal of Gastroenterology

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Water exchange (water infusion with water removal primarily during insertion) and water immersion (water infusion with water removal during withdrawal) reduce patient discomfort during colonoscope insertion compared with air insuffl ation, and represent a major achievement in colonoscopy. Hsieh et al. found that water exchange, relative to water immersion, resulted in more painless insertions to the cecum and improved adenoma detection in the right colon. However, water exchange is also associated with better bowel cleansing and longer insertion and procedure times. These factors are not specifi c to water exchange, but could account for all or part of the better results with water exchange. Additional controlled investigation is needed to defi ne the benefi ts of water exchange compared with water immersion. Am J Gastroenterol 2014; 109:1401 -1403 doi: 10.1038/ajg.2014 Water infusion during colonoscope insertion is increasingly popular. Water infusion, as it is generally understood, involves shutting the insuffl ation gas off and fi lling the colon only with water during insertion. Compared with air insuffl ation, water infusion reduces pain in patients who are lightly sedated or unsedated ( 1 -4 ). Water infusion can facilitate cecal intubation in patients with redundant colons ( 5 ). Many experienced endoscopists, myself included, convert from gas to water when they encounter a challenging sigmoid colon and believe that water helps them pass tight turns. Water infusion should reduce the risk of cecal barotrauma, which is greatest in patients with narrowed or angulated sigmoid colons. When polypectomy in the sigmoid colon is challenging because of " spasm " (the sigmoid is oft en dependent and will not retain insuffl ated gas), fi lling the sigmoid with water provides luminal distention and allows easy underwater polyp visualization and snaring ( 6 ). Water infusion is safe ( 7,8 ), cheap, and makes intuitive sense. Th us, whereas gas insuffl ation moves the sigmoid into the mid abdomen and makes angulations in the sigmoid more acute, water sinks and straightens the sigmoid in patients in the left lateral decubitus position. To the extent that bowel preparation is suboptimal when colonoscopy begins, water infusion improves cleansing. My anecdotal impression is that the only downsides of water infusion are that it takes time to remove the water and that during withdrawal some patients seem to have excess mucus in the rectosigmoid aft er water infusion. Considering the various benefi ts, water infusion is a major achievement in colonoscopy.Th e process or basic method for infusing water during intubation has been subdivided into two categories termed " water immersion " and " water exchange " ( 9 ). Water immersion means infusing water solely for the purpose of expanding the lumen and intubating the cecum, with suctioning of the water occurring during withdrawal. In water exchange, the cecal intubation process proceeds more slowly, with the infused water suctioned during insertion rather than during wi...

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Trends in Use of Sedation for Low-Risk Endoscopy

Leung

2017

JAMA

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Conscious sedation with short-acting opioids and benzodiazepines administered by an endoscopist has increasingly been replaced by deep sedation with monitored anesthesia care supervised by an anesthesiologist for routine endoscopy in fee-for-service practice. 1 Monitored anesthesia care is recommended by the American Society for Gastrointestinal Endoscopy guideline for patients with anticipated intolerance of standard sedatives, certain comorbidities, or potential for airway compromise. 2 The routine use of monitored anesthesia care for average-risk patients undergoing standard lower endoscopic procedures is cost prohibitive. 2 In one retrospective analysis of 699 patients undergoing screening colonoscopy, monitored anesthesia care use improved patient satisfaction, but did not result in an increase in adenoma detection rate. 3 In the March 2017 issue of JAMA Internal Medicine, the report by Adams et al 4 suggested that monitored anesthesia care use, possibly driven by financial considerations, had significantly increased since 2003. The authors cited earlier studies 1,5 that reported the proportion of procedures using monitored anesthesia care increased from 14% in 2003 to more than 30% in 2009 among Medicare and commercially insured patients 5 ; and from 33.7% in 2010 to 47.6% in 2013 among Medicare patients and 38.3% in 2010 to 53.0% in 2013 among commercially insured patients. 1 More than two-thirds of monitored anesthesia care use was for routine endoscopy in healthy, low-risk patients for whom monitored anesthesia care was unnecessary. 1,5 The earlier report 5 estimated that use of anesthesia services for low-risk patients during gastrointestinal endoscopies increased to more than $1.1 billion per year at the national level in 2009. Adams et al 4 investigated whether the rate of monitored anesthesia care use in the Veterans Health Administration (VHA), an institution with less financial incentives to provide monitored anesthesia care, increased during the past 2 decades as it did in the private sector, and, if so, to what extent this increase might be driven by nonfinancial factors.At VHA facilities, endoscopies are performed by physicians with little, if any, financial incentives tied to productivity because the VHA is a capitated health care system. Use of monitored anesthesia care for endoscopy does not result in additional payments to the hospitals or endoscopists and, in fact, increases the costs for performing these procedures.Adams et al 4 reported that among 2 091 590 veterans undergoing endoscopy in the VHA system from 2000-2013, monitored anesthesia care was used in 5.2% of all procedures. In the absence of financial incentives, Adams et al 4 suggested that the potential underuse of monitored anesthesia care in patients who might benefit from it should be further studied.

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A Patient-Blinded Randomized, Controlled Trial Comparing Air Insufflation, Water Immersion, and Water Exchange During Minimally Sedated Colonoscopy

Abstract: This head-to-head comparison of AI vs. WI vs. WE confirmed that WE was superior to WI and AI, with a significantly greater proportion of patients reporting painless insertion. The significantly higher ADR in the right colon in the WE group warrants further investigations.

Cited by 106 publications

References 56 publications

Intraprocedural Cleansing for Screening Colonoscopy: Avoiding Brownouts

Intraprocedural Cleansing for Screening Colonoscopy: Avoiding Brownouts

Editorial: Water Exchange vs. Water Immersion During Colonoscope Insertion

Trends in Use of Sedation for Low-Risk Endoscopy

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