Is there a place for sedationless colonoscopy?

Abstract

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.

DDW "Cutting Edge" Colonoscopy Techniques 2011 State-of-the-Art Lecture: Warm water infusion/CO2 insufflation for colonoscopy

“…2,3 Where it is available, conscious sedation has become standard, and even adopted for screening cases. Deep sedation enhances efficiency, but also markedly increases cost.…”

The water method combined with chromoendoscopy enhances adenoma detection

“…Since the water method [1][2][3][4][5][6][7][8][9] and use of chromoendoscopy [10][11][12][13][14] were reported to have beneficial impacts, a performance improvement project evaluating their utility was carried out at the Sacramento VA Medical Center in Mather, California. Data were collected prospectively to monitor performance and analyzed retrospectively.…”

“…The water method has recently been reported to be superior to air method [1][2][3][4][5][6][7][8][9] , produces less sedation medication requirement in the sedated veterans [1][2][3] , and minimizes discomfort and enhances cecal intubation in the unsedated veterans [4][5][6] . Retrospective review of data in sedated veterans showed that the water method increased adenoma detection rate (ADR).…”

Unsedated Colonoscopy and the Water Method for Minimizing Discomfort in the Unsedated Patients

“…9 Unsedated colonoscopy offered to patients who consume the purge solution and arrive without an escort and do not object to having the colonoscopy done without sedation is the only unscheduled option. In community 31 and VA 32 practice settings 1-2% of colonoscopy patients are managed in this manner.…”

“…The in- creasing interest in the use of deep sedation for colonoscopy even in Korea, 8 possibly as a consequence of the recognition that unsedated colonoscopy can be uncomfortable, highlights the importance and timeliness of this review, in drawing attention to the use of the water method for colonoscopy in CRC screening and surveillance. Parts of this review were presented as a Keynote address 9 and two separate State of the Art lectures.…”