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• W2071142144 abstract "During water-assisted unsedated colonoscopy, it is possible that the weight of the water causes straightening of the sigmoid colon and that the use of warm water reduces spasm, which together facilitate passage of the colonoscope, particularly through areas of diverticulosis. During water-assisted unsedated colonoscopy, it is possible that the weight of the water causes straightening of the sigmoid colon and that the use of warm water reduces spasm, which together facilitate passage of the colonoscope, particularly through areas of diverticulosis. Colonoscopy, the most widely performed endoscopic procedure in the United States, remains the diagnostic procedure of choice for symptomatic patients, as well as the screening and surveillance procedure of choice for asymptomatic patients at increased risk of colorectal cancer. More recently, colonoscopy has also emerged as the preferred screening test for average-risk patients. Given the aging trends of the population in the United States, the demand for screening colonoscopy will undoubtedly be augmented by the growing number of eligible patients. Consequently, screening more individuals will also create an exponential increase in overall demand, because many of these patients will be entered into surveillance programs upon the detection of adenomatous polyps. The dramatic shift in utilization of colonoscopy from a diagnostic to a screening and/or surveillance tool has not been seamless. The surge in demand for screening has translated into prolonged waiting times in many parts of the country, thus highlighting concerns about capacity.1Seeff L.C. Manninen D.L. Dong F.B. et al.Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States?.Gastroenterology. 2004; 127: 1661-1669Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar Because of budgetary constraints on postgraduate training, increasing productivity through improved efficiency rather than expanding manpower is a more feasible short-term strategy for addressing the problem. Measures aimed at reducing room turnaround time by expanding ancillary staff, space, and equipment have been shown to have the greatest impact on efficiency.2Zamir S. Rex D.K. An initial investigation of efficiency in endoscopy delivery.Am J Gastroenterol. 2002; 97: 1968-1972Crossref PubMed Google Scholar Expediting patient recovery through the use of short-acting hypnotics, eg, propofol, have also been shown to be effective in this regard.3Singh H. Poluha W. Cheung M. et al.Propofol for sedation during colonoscopy.Cochrane Database Syst Rev. 2008; (CD006268)Google Scholar Improved efficiency alone, however, will not suffice. Optimizing productivity also requires the implementation of strategies, eg, patient navigation, that minimize “no show” rates, and cancelled procedures because of poor bowel preparation.4Chen L.A. Santos S. Jandorf L. et al.A program to enhance completion of screening colonoscopy among urban minorities.Clin Gastroenterol Hepatol. 2008; 6: 443-450Abstract Full Text Full Text PDF PubMed Scopus (130) Google Scholar Building capacity by optimizing productivity is only acceptable if quality is not adversely affected. The issue of quality has become increasingly relevant with the surge in demand for screening when an optimal risk-benefit ratio is critical. Numerous quality indicators have been identified and serve as useful parameters for establishing competence in performing colonoscopy and in defining areas for continuous quality improvement.5Rex D.K. Petrini J.L. Baron T.H. et al.Quality indicators for colonoscopy.Am J Gastroenterol. 2006; 101: 873-885Crossref PubMed Scopus (45) Google Scholar Key procedural indicators of a high-quality examination relate to cecal intubation rates, adenoma detection rates, and complication rates. Technologic developments, such as the third-eye retroscope and wide-angle viewing, primarily focused on improved polyp detection. Addressing the technical limits inherent to colonoscopy, however, does not alone guarantee a high-quality examination. Greater diligence to ensure the adequacy of bowel preparation and increased attention to operator-dependent variables, eg, withdrawal times, also play a significant role in quality improvement. In return, attention to quality is likely to improve patient satisfaction. Despite preprocedure concerns about pain, discomfort, and embarrassment, most studies find that colonoscopy is well tolerated and often preferred over other screening modalities because of the use of conscious sedation. Other factors known to influence patient satisfaction include waiting time until the appointment, waiting time in the endoscopy suite before the procedure, explanations, experience with the bowel preparation, and social interactions with the administrative staff, nurses, and physicians.6Del Rio A.S. Baudet J.S. Fernandez O.A. et al.Evaluation of patient satisfaction in gastrointestinal endoscopy.Eur J Gastroenterol Hepatol. 2007; 19: 896-900Crossref PubMed Scopus (30) Google Scholar Ensuring adequate patient satisfaction likely impacts follow-up rates of adherence for future examinations if indicated, which not only translates into better patient outcomes but also improved productivity. The foregoing discussion highlights the importance of issues related to productivity, quality, and patient satisfaction when evaluating novel techniques or technologies related to screening, surveillance, and/or diagnostic colonoscopy. Unsedated colonoscopy is one such approach, which was first introduced more than a decade ago in an effort to avoid costs and complications related to sedation. More recently, advocates have endorsed unsedated colonoscopy as a strategy for increasing access by minimizing staffing requirements and patient recovery time.7Leung F.W. Unsedated colonoscopy introduced to ensure access is acceptable to a subgroup of veterans.Dig Dis Sci. 2008; 53: 2719-2722Crossref PubMed Scopus (13) Google Scholar Although the feasibility of unsedated colonoscopy is well established, its use in the United States mostly has been limited to unescorted patients. Putative factors that contribute to the limited use of unsedated colonoscopy include a lack of experience during endoscopic training, concerns about patient acceptance because of public perceptions that colonoscopy is painful, patient expectations, and fear among endoscopists in competitive environments that patients who experience pain might leave their practices.8Rex D.K. Imperiale T.F. Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial.Gastrointest Endosc. 1999; 49: 554-559Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar, 9Faulx A.L. Vela S. Das A. et al.The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey.Gastrointest Endosc. 2005; 62: 9-15Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar Regardless, studies to date clearly demonstrated that, although many self-selected patients find the approach acceptable, cecal intubation rates tend to be lower than with sedated colonoscopy.10Thiis-Evensen E. Hoff G.S. Sauar J. et al.Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps.Gastrointest Endosc. 2000; 52: 606-610Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 11Conigliaro R. Rossi A. Implementation of sedation guidelines in clinical practice in Italy: results of a prospective longitudinal multicenter study.Endoscopy. 2006; 38: 1137-1143Crossref PubMed Scopus (31) Google Scholar Published data also find that procedure times tend to be prolonged,8Rex D.K. Imperiale T.F. Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial.Gastrointest Endosc. 1999; 49: 554-559Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar, 12Leung J.W. Mann S. Leung F.W. Options for screening colonoscopy without sedation: a pilot study in United States veterans.Aliment Pharmacol Ther. 2007; 26: 627-631Crossref PubMed Scopus (71) Google Scholar which not only negatively impact on patient satisfaction but also on productivity. One compromise has been the use of “sedation on demand,” but this approach has also failed to engender widespread use. In this month's Gastrointestinal Endoscopy, Leung et al13Leung F.W. Aharonian H.S. Leung J.W. et al.Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans.Gastrointest Endosc. 2009; 69: 546-550Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar provide updated data on the utility of a novel water-instillation technique as a strategy for facilitating successful unsedated colonoscopy. Based both on their prior experience and published literature,14Leung F.W. Mann S.K. Salera R. et al.Options for screening colonoscopy without sedation: sequel to a pilot study in U.S. veterans.Gastrointest Endosc. 2008; 67: 712-717Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 15Leung F.W. Water-related techniques for performance of colonoscopy.Dig Dis Sci. 2008; 53: 2847-2850Crossref PubMed Scopus (32) Google Scholar the investigators postulated that warm-water instillation would enhance cecal intubation rates among unsedated patients and increase the proportion of patients willing to undergo a repeated unsedated colonoscopy compared with the conventional air-insufflation technique. To test this hypothesis, a consecutive group design was used in which the first 62 self-selected patients referred for unsedated colonoscopy were studied by using the conventional air-insufflation method and the next 63 patients were studied by using the water-assisted–colonoscopy method. Outcomes of interest were evaluated with an intention-to-treat analysis; no patients were excluded. The primary end point, cecal intubation, was achieved in 61 of 63 of the patients in the water-instillation group (97%) compared with 47 of 62 in the air-insufflation group (76%) (P < .05). Failure to permit washing during the procedure may partially explain why the rate of colonoscopy completion in the air-insufflation group was lower than that seen in other studies of unsedated colonoscopy with conventional techniques, in which cecal-intubation rates were in the range of 86%10Thiis-Evensen E. Hoff G.S. Sauar J. et al.Patient tolerance of colonoscopy without sedation during screening examination for colorectal polyps.Gastrointest Endosc. 2000; 52: 606-610Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar to 94%.8Rex D.K. Imperiale T.F. Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial.Gastrointest Endosc. 1999; 49: 554-559Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar The investigators also mention that discomfort prevented completion in 8 patients by the air method and in only one by the water method. As might be surmised, a significantly higher percentage of patients who underwent the water method reported a willingness to repeat the procedure (90% vs 69%, P < .05). The results of this study are important for several reasons. First, the findings strongly suggest that water instillation not only increases cecal-intubation rates among unsedated patients compared with air-insufflation alone but also that rates comparable with those seen with conscious sedation are achievable, thus mitigating concerns about quality. Although the precise mechanism remains unknown, it is possible that the weight of the water causes straightening of the sigmoid colon and that the use of warm water reduces spasm, which together facilitate passage of the colonoscope, particularly through areas of diverticulosis.16Church J.M. Warm water irrigation for dealing with spasm during colonoscopy: simple, inexpensive, and effective.Gastrointest Endosc. 2002; 56: 672-674Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar, 17Hamamoto N. Nakanishi Y. Morimoto N. et al.A new water instillation method for colonoscopy without sedation as performed by endoscopists-in-training.Gastrointest Endosc. 2002; 56: 825-828Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Second, the water instillation method also appears to enhance patient satisfaction, as defined by patient willingness to undergo a repeated unsedated colonoscopy, as well as the observation that fewer procedures had to be aborted because of pain and/or discomfort. Third, the available data suggest a trend toward improved adenoma detection in the water-instillation group (36.5% vs 25.8%), which is particularly intriguing, because the rate of adenoma detection in the air-insufflation group appears to be consistent with those reported in the literature for veterans of similar age with conventional sedated colonoscopy.18Lieberman D.A. Weiss D.G. Bond J.H. et al.Use of colonoscopy to screen asymptomatic adults for colorectal cancer. Veterans Affairs Cooperative Study Group 380.N Engl J Med. 2000; 343: 162-168Crossref PubMed Scopus (1626) Google Scholar Despite its positive findings, the study also has several notable limitations. First, the use of a nonrandomized, unblinded study design compromises the internal validity of the findings because of concerns about bias. No information is provided regarding patient identification, recruitment, or inclusion and exclusion criteria. Consequently, it is impossible to discern whether the groups were balanced with respect to variables known to influence cecal-intubation rates in unsedated patients (eg, age, sex, and the presence of abdominal pain8Rex D.K. Imperiale T.F. Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial.Gastrointest Endosc. 1999; 49: 554-559Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar). Moreover, failure to use irrigation to wash adherent stool in the air-insufflation group and lack of blinding may have also biased the results in favor of the water-instillation group, as acknowledged by the investigators. Second, the study population was restricted to a Veteran's Affairs population and hence concerns about generalizability to other patient groups, particularly those with higher rates of incomplete unsedated colonoscopy, are warranted. Third, the prolonged procedure time, albeit similar to the air-insufflation method, is a major deterrent to more widespread use. Procedure times of nearly 40 minutes undoubtedly offset potential gains in efficiency related to reduced staffing requirements and patient recovery time. Fourth, failure to recommend a repeated colonoscopy or further imaging for all patients with incomplete examinations for reasons such as “nonsignificant findings” is concerning and should not be endorsed. In conclusion, the study by Leung et al13Leung F.W. Aharonian H.S. Leung J.W. et al.Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans.Gastrointest Endosc. 2009; 69: 546-550Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar provides new data that suggest that the use of water instillation is superior to use of air insufflation for unsedated colonoscopy with respect to cecal-intubation rates, patient satisfaction, and, possibly, adenoma detection rates. Although the results are promising, we concur with the investigators that future randomized control trials are warranted to further validate the findings of this study among more diverse patient populations willing to undergo unsedated colonoscopy. Future studies are also needed to evaluate the impact of water instillation on cecal intubation and adenoma detection rates among patients undergoing sedated colonoscopy. Pending completion of the studies, it remains unknown whether the end justifies the means. The following author disclosed financial relationships relevant to this publication: P. C. Schroy III: Receives grant support from the National Cancer Institute, EXACT Sciences, Inc, and AmberGen, Inc, and serves on Ambergen's scientific advisory board. The other author disclosed no financial relationships relevant to this publication." @default.
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• W2071142144 title "Water-assisted unsedated colonoscopy: does the end justify the means?" @default.
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