A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method

Leung, Felix W.; Harker, Judith O.; Jackson, Guy; Okamoto, Kate E.; Behbahani, Omid M.; Jamgotchian, Nora; Aharonian, H. Steven; Guth, Paul H.; Mann, Surinder K; Leung, Joseph

doi:10.1016/j.gie.2010.05.020

Cited by 144 publications

(192 citation statements)

References 36 publications

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“…28 In scheduled unsedated patients, the water method offered a significantly higher success rate than the traditional air method. 30,31 Nurses who have worked with these options 32 considered the following as benefits of not using routine sedation. There is no need for nurse monitoring.…”

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confidence: 99%

“…35 A grave concern in the U.S. regarding unsedated colonoscopy is the belief that the procedure is painful. [10][11][12] Indeed, worldwide the success rate of unsedated colonoscopy have been reported to be 67% 36 , 76% 30,37 , 78% 31,38 , 81% 39,40 , 82% 41 and 83%. 41 A novel method of water infusion in lieu of air insufflation significantly improved the success rate of cecal intubation to 97% in an observational study.…”

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confidence: 99%

“…30 The significant impact was confirmed in a subsequent randomized controlled trial with a cecal intubation rate of 98%. 31 Colonoscopists interested in providing their patients with any of the unsedated option are encouraged to consider evaluating the water method 30,31 in their practice. A description of the water method is included for the consideration of interested colleagues.…”

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confidence: 99%

“…The cecum was then distended by air to confirm visualization of the ileocecal valve and the appendix orifice (cecal intubation). 27,28,30,31 In conclusion, the answer to the question "Is there a place for sedationless colonoscopy?" is "yes", when it is integrated into the various options to minimize patient burden in screening and surveillance colonoscopy.…”

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Is there a place for sedationless colonoscopy?

Leung

2011

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REVIEW REVIEWUnsedated colonoscopy is available on a routine basis in many parts of the world.1 This paper will discuss the components of patient time burden of sedation, 2 tabulate the extent and significance of sedation-related complications 3 and review how various options without routine sedation impact these events in the context of colorectal cancer screening and surveillance. In the end we shall address the question in the title of this manuscript if there is a place for sedationless (unsedated) colonoscopy. Usedated colonoscopy is routinely available in many parts of the world. In the US, only educated professionals appear to be knowledgeable enough to request the unsedated option. Colonoscopists have also been willing to perform unsedated colonoscopy when a patient presents without an escort after undergoing bowel purge preparation. While the actual sideeffects of sedation are minimal, the escort requirement and time burden of sedation are barriers to the uptake of screening colonoscopy in the US. The recent trend of deep sedation with propofol for screening colonoscopy increases the efficiency of the colonoscopists at significant costs (e.g. anesthetist reimbursement). The options of as needed and on demand sedation permit patients to complete colonoscopy without sedation. The latter appears to be potentially less coercive. Nurses with experience in the unsedated options recognize the benefit of the quick turn-around of the examination room and shortened occupancy of the recovery area. Discharge planning can be optimized due to absence of amnesia. Patients completing unsedated colonoscopy have given their endorsement of the options. Pain and discomfort continue to limit the success rate of cecal intubation to about 80%. A recently described water method (warm water infusion in lieu of air insufflation combined with removal of all residual colonic air by suction and residual feces by water exchange) has the potential of decreasing procedural discomfort and enhancing cecal intubation in unsedated colonoscopy. The availability of the novel water method assures colonoscopists that high success rate of cecal intubation can be achieved in the unsedated patients.

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Is there a place for sedationless colonoscopy?

Leung

2011

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“…The water method has been described as efficacious in minimizing discomfort associated with colonoscopy both in unsedated 6 and minimally sedated veterans 7 in the US, as well as in a community population in Italy who were offered sedation on demand. 8 This fact along with the demonstration of an enhanced proximal adenoma detection rate (ADR) 9 serve to make the proposition of an extended flexible sigmoidoscopy more attractive to both the patient and the endoscopist.…”

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The water method—untapped potential in extended flexible sigmoidoscopy for colorectal cancer screening?

Bak¹

2011

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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 proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method

Cited by 144 publications

References 36 publications

Is there a place for sedationless colonoscopy?

Is there a place for sedationless colonoscopy?

The water method—untapped potential in extended flexible sigmoidoscopy for colorectal cancer screening?

Trends in Use of Sedation for Low-Risk Endoscopy

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