Water immersion versus standard colonoscopy insertion technique: randomized trial shows promise for minimal sedation

Leung, Cynthia W.; Kaltenbach, Tonya; Soetikno, Roy; Wu, Kuan-Yu; Leung, Felix W.; Friedland, Shai

doi:10.1055/s-0029-1244231

Cited by 100 publications

(88 citation statements)

References 9 publications

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“…The practice of minimal sedation has been proposed. 25,26 Patients receive less than the full amount at the outset and receive additional medications if they experience discomfort.…”

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confidence: 99%

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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“…The practice of minimal sedation has been proposed. 25,26 Patients receive less than the full amount at the outset and receive additional medications if they experience discomfort.…”

mentioning

confidence: 99%

Is there a place for sedationless colonoscopy?

Leung

2011

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“…41,43,64 Removal of residual air by suction 37 and removal of residual feces by water exchange 65 were subsequently incorporated. With a simplified nomenclature, the "water method" was evaluated in RCT.…”

Section: Development Of the Water Methodsmentioning

confidence: 99%

“…Since deep sedation with propofol can increase colonoscopists' productivity by at least 2/3, 33 there is a 34,35 A majority of colonoscopy performed with traditional conscious sedation employs a combination of a narcotic pain medication which provides pain control, and a benzodiazepine which promotes amnesia. The practice of minimal sedation has also been proposed 36,37 -less than the full amount administered at the outset followed by additional medications if patients experience discomfort. Conscious sedation can also be provided as needed or on demand.…”

Section: Options Of Colonoscopy With and Without Routine Sedationmentioning

confidence: 99%

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

Leung¹

2011

Intest Res

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A decade ago, failure of cecal intubation due to pain in ~20% of scheduled unsedated patients in the author's veterans practice prompted the search for a less uncomfortable approach. Methods that minimized discomfort or enhance cecal intubation included use of pediatric, variable stiffness, computer-assisted, 3-dimensional magnetic imaging colonoscope, gastroscope, and inhalation of nitrous oxide or insufflation of carbon dioxide; use of hypnosis, music, audio distraction, or simply allowing patients to participate in medication administration. In addition, several water-related techniques (as adjuncts to air insufflation) enhanced speed and success of intubation, reduced discomfort but did not appear to alter the amount of medications used. Because of simplicity, the water-related techniques added to turning off of the air pump were evaluated in a series of trial-and-error modifications. The result was the development of a water infusion in lieu of air insufflation method. Subsequent refinements included suction removal of all residual air to minimize angulations at flexures. Water exchange during insertion was used to suspend and removal feces to clear the luminal view while distention of the colonic lumen was minimize. Observational studies followed by randomized controlled trials confirmed the water method (simplified nomenclature) had significant impacts on discomfort both during and after colonoscopy: reduction of medication requirement; attenuation of insertion-related discomfort, enhancement of cecal intubation, decrease of pain after colonoscopy, increase in reported willingness to repeat unsedated colonoscopy in the patients examined without sedation and reduction of recovery time burden in patients accepting the option of sedation on demand. (Intest Res 2011;9:73-84)

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“…It has been also suggested using carbon dioxide, which is rapidly absorbed and excreted through lungs, as an insufflating gas for colonoscopy to reduce these symptoms [54,55]. Also water immersion technique instead of air insufflation has been proposed to reduce these minor events especially in cases of minimal sedation [56] (Leung 2010).…”

Section: Abdominal Pain and Other Minor Gi Symptomsmentioning

confidence: 99%