|
1
|
Manoros N, Thinrungroj N, Wanchaitanawong W, Pinyopornpanish K, Kijdamrongthum P, Leerapun A, Chitapanarux T, Thongsawat S, Praisontarangkul OA. Assessing water-assisted colonoscopy in beginner endoscopists: a randomised controlled trial. BMJ Open Gastroenterol 2025; 12:e001561. [PMID: 40412818 DOI: 10.1136/bmjgast-2024-001561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2024] [Accepted: 05/12/2025] [Indexed: 05/27/2025] Open
Abstract
OBJECTIVE To compare water-assisted colonoscopy (WAC) using the water immersion technique with conventional carbon dioxide insufflation colonoscopy (CC) in novice endoscopists, focusing on procedure time, safety and learning curves. METHODS We conducted a prospective, randomised (1:1), single-centre trial at Chiang Mai University Hospital, Thailand. Six gastroenterology fellows with <150 prior colonoscopies received standardised training before performing elective screening colonoscopies using either WAC or CC techniques. Patients were randomly assigned to WAC or CC groups. The primary outcome was caecal intubation time (CIT). Secondary outcomes included technical failure, procedural difficulty, patient discomfort, complications, withdrawal time and adenoma detection rate (ADR). RESULTS Of 250 randomised patients, 230 completed the protocol (WAC, n=113; CC, n=117). Mean CIT was comparable between groups (10.6±4.2 min vs 9.8±3.9 min; p=0.35). Technical failure occurred in 6.2% of WAC and 5.1% of CC procedures, with no significant differences in procedural difficulty ratings, analgesic requirements or patient discomfort scores. ADR was similar between arms (40.7% vs 33.3%; p=0.25). Learning curves demonstrated parallel, progressive reductions in CIT among fellows in both groups. CONCLUSION WAC is a safe and effective alternative to CC for novice endoscopists, with similar procedure times, learning curves and safety profiles. These findings support the inclusion of WAC in gastroenterology training programmes. TRIAL REGISTRATION NUMBER TCTR20230324001.
Collapse
Affiliation(s)
- Nuttida Manoros
- Division of Gastroenterology, Department of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Nithi Thinrungroj
- Division of Gastroenterology, Department of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Wasuwit Wanchaitanawong
- Division of Gastroenterology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kanokwan Pinyopornpanish
- Division of Gastroenterology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Phuripong Kijdamrongthum
- Division of Gastroenterology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Apinya Leerapun
- Division of Gastroenterology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Taned Chitapanarux
- Division of Gastroenterology, Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Satawat Thongsawat
- Division of Gastroenterology, Department of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Ong-Ard Praisontarangkul
- Division of Gastroenterology, Department of Medicine, Chiang Mai University, Chiang Mai, Thailand
| |
Collapse
|
|
2
|
Jiao TX, Hu Y, Guo SB. Clinical value of sigmoid colon water exchange colonoscopy: a prospective randomized clinical trial. Sci Rep 2023; 13:13704. [PMID: 37608083 PMCID: PMC10444785 DOI: 10.1038/s41598-023-40706-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 08/16/2023] [Indexed: 08/24/2023] Open
Abstract
This prospective randomized controlled trial investigated the clinical value of sigmoid colon water exchange (SWE) colonoscopy by comparing it with air insufflation (AI) colonoscopy in terms of the patient's pain score, insertion time, and screening quality. Consecutive patients who underwent colonoscopy without sedation were randomized into an AI group (n = 267) or an SWE group (n = 255). Patient characteristics, history of abdominal or pelvic surgery, maximum pain score, insertion time, cecal intubation rate, polyp detection rate, and the need for maneuvers were recorded. There was no significant between-group difference in insertion time, cecal intubation rate, assisted maneuvers (abdominal pressure, changing patients' position), or polyp detection rate (P > 0.05). The mean maximum pain score was significantly lower in the SWE group than in the AI group. (3.57 ± 2.01 vs. 4.69 ± 1.83, P < 0.001). For patients with a history of abdominal or pelvic surgery and those who were overweight (body mass index > 24), the maximum pain scores were lower in the SWE group than in the AI group (3.67 ± 1.95 vs. 4.88 ± 1.80, P < 0.001; 3.40 ± 1.96 vs. 4.79 ± 1.97, P < 0.001, respectively). SWE colonoscopy can significantly reduce abdominal pain with non-inferior screening quality and does not increase insertion time.Trial registration number: ChiCTR2200059057 (date April 23, 2022).
Collapse
Affiliation(s)
- Tian-Xiao Jiao
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, 116011, Liaoning Province, People's Republic of China
- Department of Gastroenterology, Dalian Friendship Hospital, Dalian, 116011, Liaoning, People's Republic of China
| | - Yang Hu
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, 116011, Liaoning Province, People's Republic of China
| | - Shi-Bin Guo
- Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, 116011, Liaoning Province, People's Republic of China.
| |
Collapse
|
|
3
|
Gubbiotti A, Spadaccini M, Badalamenti M, Hassan C, Repici A. Key factors for improving adenoma detection rate. Expert Rev Gastroenterol Hepatol 2022; 16:819-833. [PMID: 36151898 DOI: 10.1080/17474124.2022.2128761] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Colonoscopy is a fundamental tool in colorectal cancer (CRC) prevention. Nevertheless, one-fourth of colorectal neoplasms are still missed during colonoscopy, potentially being the main reason for post-colonoscopy colorectal cancer (PCCRC). Adenoma detection rate (ADR) is currently known as the best quality indicator correlating with PCCRC incidence. AREAS COVERED We performed a literature review in order to summarize evidences investigating key factors affecting ADR: endoscopists education and training, patient management, endoscopic techniques, improved navigation (exposition defect), and enhanced lesions recognition (vision defect) were considered. EXPERT OPINION 'Traditional' factors, such as split dose bowel preparation, adequate withdrawal time, and right colon second view, held a significant impact on ADR. Several devices and technologies have been developed to promote high-quality colonoscopy, however artificial intelligence may be considered the most promising tool for ADR improvement, provided that endoscopists education and recording are guaranteed.
Collapse
Affiliation(s)
- Alessandro Gubbiotti
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Marco Spadaccini
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Matteo Badalamenti
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Cesare Hassan
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| | - Alessandro Repici
- Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, Italy.,IRCCS Humanitas Research Hospital, Digestive Endoscopy Unit, Division of Gastroenterology, Rozzano, Italy
| |
Collapse
|
|
4
|
Cadoni S, Ishaq S, Hassan C, Falt P, Fuccio L, Siau K, Leung JW, Anderson J, Binmoeller KF, Radaelli F, Rutter MD, Sugimoto S, Muhammad H, Bhandari P, Draganov PV, de Groen P, Wang AY, Yen AW, Hamerski C, Thorlacius H, Neumann H, Ramirez F, Mulder CJJ, Albéniz E, Amato A, Arai M, Bak A, Barret M, Bayupurnama P, Cheung R, Ching HL, Cohen H, Dolwani S, Friedland S, Harada H, Hsieh YH, Hayee B, Kuwai T, Lorenzo-Zúñiga V, Liggi M, Mizukami T, Mura D, Nylander D, Olafsson S, Paggi S, Pan Y, Parra-Blanco A, Ransford R, Rodriguez-Sanchez J, Senturk H, Suzuki N, Tseng CW, Uchima H, Uedo N, Leung FW. Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations. Gastrointest Endosc 2021; 93:1411-1420.e18. [PMID: 33069706 DOI: 10.1016/j.gie.2020.10.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/08/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR. METHODS Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements. RESULTS In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11). CONCLUSIONS The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.
Collapse
Affiliation(s)
- Sergio Cadoni
- CTO Hospital, Digestive Endoscopy Unit, Iglesias, Italy
| | - Sauid Ishaq
- Russell Hall, Dept. of Gastroenterology, Birmingham, United Kingdom; Birmingham City University, Birmingham, United Kingdom
| | - Cesare Hassan
- Nuovo Regina Margherita Hospital, Digestive Endoscopy Unit, Rome, Italy
| | - Přemysl Falt
- University Hospital and Faculty of Medicine, Palacky University, Olomouc, Czech Republic; Faculty of Medicine, Charles University, Hradec Králové, Czech Republic
| | - Lorenzo Fuccio
- S. Orsola-Malpighi University Hospital, Department of Medical and Surgical Sciences, Bologna, Italy
| | - Keith Siau
- JAG Clinical Fellow, JAG, Royal College of Physicians, London, United Kingdom
| | - Joseph W Leung
- Division of Gastroenterology and Hepatology, Sacramento VA Medical Center and University of California Davis School of Medicine, Sacramento, California, USA
| | - John Anderson
- Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, United Kingdom
| | - Kenneth F Binmoeller
- California Pacific Medical Center, Interventional Endoscopy Services, San Francisco, California, United States
| | | | - Matt D Rutter
- University Hospital North Tees NHS, Department of Gastroenterology, Stockton-on-Tees, United Kingdom; Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, United Kingdom
| | - Shinya Sugimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | | | - Pradeep Bhandari
- Portsmouth University Hospital, Dept. of Gastroenterology, Portsmouth, United Kingdom
| | | | - Piet de Groen
- University of Minnesota, Division of Gastroenterology, Minneapolis, Minnesota, United States
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States
| | - Andrew W Yen
- Division of Gastroenterology and Hepatology, Sacramento VA Medical Center and University of California Davis School of Medicine, Sacramento, California, USA
| | - Chris Hamerski
- California Pacific Medical Center, Interventional Endoscopy Services, San Francisco, California, United States
| | - Henrik Thorlacius
- Lund University Surgery, Department of Gastrointestinal Surgery, Malmö, Sweden
| | - Helmut Neumann
- University Medical Center, Interventional Endoscopy Center, Medizinische Klinik und Poliklinik, Mainz, Germany
| | | | - Chris J J Mulder
- VU University Medical Center, Department of Gastroenterology, Amsterdam, The Netherlands
| | - Eduardo Albéniz
- Gastroenterology Department, Endoscopy Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Arnaldo Amato
- Ospedale Valduce, Gastroenterology Unit, Como, Italy
| | - Makoto Arai
- Chiba University, Gastroenterology Department, Chiba, Japan
| | - Adrian Bak
- University of British Columbia, Department of Medicine, Kelowna, Canada
| | | | - Putut Bayupurnama
- Division of Gastroenterology and Hepatology, Internal Medicine Department, Faculty of Medicine, Gadjah Mada University, Sardjito General Hospital, Yogyakarta, Indonesia
| | - Ramsey Cheung
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, VA Palo Alto, California, United States
| | - Hey-Long Ching
- Sheffield Teaching Hospitals, Gastroenterology Department, Sheffield, United Kingdom
| | - Hartley Cohen
- Department of Medicine, VA Greater Los Angeles Health Care System, Los Angeles, United States; David Geffen School of Medicine at UCLA, Department of Medicine, Los Angeles, California, United States
| | - Sunil Dolwani
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, VA Palo Alto, California, United States
| | - Hideaki Harada
- Department of Gastroenterology, New Tokyo Hospital, Gastroenterology, Matsudo, Chiba, Japan
| | - Yu-Hsi Hsieh
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin Township, Taiwan
| | - Bu Hayee
- King's College Hospital NHS foundation Trust, Gastroenterology Department, London, United Kingdom
| | - Toshio Kuwai
- NHO Kure Medical Center and Chugoku Cancer Center, Gastroenterology Department, Kure, Japan
| | | | - Mauro Liggi
- ASSL Carbonia, Sirai Hospital, Digestive Endoscopy Unit, Carbonia, Italy
| | - Takeshi Mizukami
- NHO Kurihama Medical and Addiction Center, Endoscopy Center, Yokosuka, Japan
| | - Donatella Mura
- ASSL Carbonia, Sirai Hospital, Digestive Endoscopy Unit, Carbonia, Italy
| | - David Nylander
- Newcastle Upon Tyne NHS Foundation Trust, Gastroenterology Department, Newcastle Upon Tyne, United Kingdom
| | - Snorri Olafsson
- Telemark Hospital, Gastroenterology Department, Skien, Norway
| | - Silvia Paggi
- Ospedale Valduce, Gastroenterology Unit, Como, Italy
| | - Yanglin Pan
- Xijing Hospital, Department of Gastroenterology, Xian, Republic of China
| | - Adolfo Parra-Blanco
- NIHR Nottingham Biomedical Research Centre, Department of Gastroenterology, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Rupert Ransford
- Endoscopy Department Hereford County Hospital, Hereford, United Kingdom
| | | | - Hakan Senturk
- Bezmialem Vakif University Medicine Faculty, Department of Medicine, Istanbul, Turkey
| | - Noriko Suzuki
- Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom
| | - Chih-Wei Tseng
- Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin Township, Taiwan
| | - Hugo Uchima
- Hospital Germans Triasi i Pujol, Teknon Medical Center, Gastroenterology, Barcelona, Spain
| | - Noriya Uedo
- Osaka International Cancer Institute, Department of Gastrointestinal Oncology, Osaka, Japan
| | - Felix W Leung
- Department of Medicine, VA Greater Los Angeles Health Care System, Los Angeles, United States; David Geffen School of Medicine at UCLA, Department of Medicine, Los Angeles, California, United States
| |
Collapse
|
|
5
|
Rutter MD, Evans R, Hoare Z, Von Wagner C, Deane J, Esmaily S, Larkin T, Edwards R, Yeo ST, Spencer LH, Holmes E, Saunders BP, Rees CJ, Tsiamoulos ZP, Beintaris I, WASh trial team
BrambleMikeDharAnjanRileyStuartLarkinTonyWhyteSophieKasimAdetayoVeitchAndrewChiltonAndrewWilliamsBen Carter; LynneGreenawayJaneCarterJustinCollinsVickyWestwoodClareLeeTomCraneSarahMacBainJamesLawrenceCatherine. WASh multicentre randomised controlled trial: water-assisted sigmoidoscopy in English NHS bowel scope screening. Gut 2021; 70:845-852. [PMID: 32895334 PMCID: PMC8040154 DOI: 10.1136/gutjnl-2020-321918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVES The English Bowel Cancer Screening Programme invites 55 year olds for a sigmoidoscopy (Bowel Scope Screening (BSS)), aiming to resect premalignant polyps, thus reducing cancer incidence. A national patient survey indicated higher procedural pain than anticipated, potentially impacting on screening compliance and effectiveness. We aimed to assess whether water-assisted sigmoidoscopy (WAS), as opposed to standard CO2 technique, improved procedural pain and detection of adenomatous polyps. DESIGN The WASh (Water-Assisted Sigmoidoscopy) trial was a multicentre, single-blind, randomised control trial for people undergoing BSS. Participants were randomised to either receive WAS or CO2 from five sites across England. The primary outcome measure was patient-reported moderate/severe pain, as assessed by patients on a standard Likert scale post procedure prior to discharge. The key secondary outcome was adenoma detection rate (ADR). The costs of each technique were also measured. RESULTS 1123 participants (50% women, mean age 55) were randomised (561 WAS, 562 CO2). We found no difference in patient-reported moderate/severe pain between WAS and CO2 (14% in WAS, 15% in CO2; p=0.47). ADR was 15% in the CO2 arm and 11% in the WAS arm (p=0.03); however, it remained above the minimum national performance standard in both arms. There was no statistical difference in mean number of adenomas nor overall polyp detection rate. There was negligible cost difference between the two techniques. CONCLUSION In the context of enema-prepared unsedated screening sigmoidoscopies performed by screening-accredited endoscopists, no difference in patient-reported pain was seen when using either a CO2 or WAS intubation technique. TRIAL REGISTRATION NUMBER ISRCTN81466870.
Collapse
Affiliation(s)
- Matthew D Rutter
- Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK .,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel Evans
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health, Bangor University, Bangor, UK
| | | | - Jill Deane
- Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | - Shiran Esmaily
- Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | | | - Rhiannon Edwards
- Centre for Health Economics & Medicines Evaluation, Bangor University, Bangor, UK
| | - Seow Tien Yeo
- Centre for Health Economics & Medicines Evaluation, Bangor University, Bangor, UK
| | - Llinos Haf Spencer
- Centre for Health Economics & Medicines Evaluation, Bangor University, Bangor, UK
| | - Emily Holmes
- Centre for Health Economics & Medicines Evaluation, Bangor University, Bangor, UK
| | | | - Colin J Rees
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK,Gastroenterology, South Tyneside NHS Foundation Trust, South Shields, UK
| | | | - Iosif Beintaris
- Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK
| | | |
Collapse
|
|
6
|
Maida M, Sferrazza S, Murino A, Lisotti A, Lazaridis N, Vitello A, Fusaroli P, de Pretis G, Sinagra E. Effectiveness and safety of underwater techniques in gastrointestinal endoscopy: a comprehensive review of the literature. Surg Endosc 2021; 35:37-51. [PMID: 32856154 DOI: 10.1007/s00464-020-07907-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), represent the standard of care for treatment of superficial gastrointestinal lesions. In 2012 a novel technique called underwater endoscopic mucosal resection (U-EMR) was described by Binmoeller and colleagues. This substantial variation from the standard procedure was afterwards applied at endoscopic submucosal dissection (U-ESD) and recently proposed also for peroral endoscopic myotomy (U-POEM) and endoscopic full-thickness resection (U-EFTR). METHODS This paper aims to perform a comprehensive review of the current literature related to supporting the underwater resection techniques with the aim to evaluate their safety and efficacy. RESULTS Based on the current literature U-EMR appears to be feasible and safe. Comparison studies showed that U-EMR is associated with higher "en-bloc" and R0 resection rates for colonic lesions, but lower "en-bloc" and R0 resection rates for duodenal non-ampullary lesions, compared to standard EMR. In contrast to U-EMR, little evidence supporting U-ESD are currently available. A single comparison study on gastric lesions showed that U-ESD had shorter procedural times and allowed a similar "en-bloc" resection rates compared to standard ESD. No comparison studies between U-ESD and ESD are available for colonic lesions. Finally, only some anecdotal experiences have been reported for U-POEM or U-EFTR, and the feasibility and effectiveness of these techniques need to be further investigated. CONCLUSIONS Further prospective studies are necessary to better explore the advantages of underwater techniques compared to the respective standards of care, especially in the setting of U-ESD where consistent data are lacking and where standardization of the technique is needed.
Collapse
Affiliation(s)
- Marcello Maida
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta, Italy.
| | - Sandro Sferrazza
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento, Italy
| | - Alberto Murino
- Royal Free Unit for Endoscopy and University College London (UCL) Institute for Liver and Digestive Health, London, UK
| | - Andrea Lisotti
- Department of Medical and Surgical Sciences, GI Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Nikolaos Lazaridis
- Royal Free Unit for Endoscopy and University College London (UCL) Institute for Liver and Digestive Health, London, UK
| | - Alessandro Vitello
- Gastroenterology and Endoscopy Unit, S. Elia-Raimondi Hospital, Caltanissetta, Italy
| | - Pietro Fusaroli
- Department of Medical and Surgical Sciences, GI Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Giovanni de Pretis
- Gastroenterology and Endoscopy Unit, Santa Chiara Hospital, Trento, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Instituto San Raffaele Giglio, Cefalù, Italy
| |
Collapse
|
|
7
|
Khan F, Hur C, Lebwohl B, Krigel A. Unsedated Colonoscopy: Impact on Quality Indicators. Dig Dis Sci 2020; 65:3116-3122. [PMID: 32696236 DOI: 10.1007/s10620-020-06491-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 07/11/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND In the USA, sedation is commonly used for colonoscopies; though colonoscopy can be successfully performed without sedation, outcomes data in this setting are scarce. AIMS To determine patient characteristics associated with undergoing unsedated colonoscopy and whether adenoma detection rate (ADR) and cecal intubation rate (CIR) differ between sedated and unsedated colonoscopy. METHODS Using a single-center electronic endoscopy database, we identified patients who underwent outpatient colonoscopy between 2011 and 2018 with or without sedation. We used multivariable logistic regression to determine factors associated with unsedated colonoscopy, CIR, and ADR. RESULTS We identified 24,795 patients who underwent colonoscopy during the study period. Of these, 179 patients (0.7%) underwent unsedated colonoscopy. ADR was 27.4% in sedated and 21.2% in unsedated colonoscopies (p = 0.06); CIR was 95.8% in sedated and 85.5% in unsedated patients (p < 0.01). On multivariable analysis, male sex (OR 2.06, CI 1.52-2.79) and suboptimal bowel preparation (OR 1.75, CI 1.24-2.45) were associated with undergoing unsedated colonoscopy, while higher BMI was inversely associated with unsedated colonoscopy (BMI 25-29.9: OR 0.44, CI 0.25-0.77). On multivariable analysis, colonoscopy with sedation was associated with CIR (OR 3.79, CI 2.39-6.00) and ADR (OR 1.45, OR 1.00-2.10). CONCLUSION We found that undergoing outpatient colonoscopy with sedation as opposed to no sedation was significantly associated with a higher CIR and ADR. Our findings suggest sedation is necessary to meet current CIR and ADR guidelines; however, given the potential cost and safety benefits of unsedated colonoscopy, further investigation into methods to improve patient selection and colonoscopy quality indicators is warranted.
Collapse
Affiliation(s)
- Fatima Khan
- Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Chin Hur
- Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA
| | - Benjamin Lebwohl
- Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA.,Celiac Disease Center, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Anna Krigel
- Department of Medicine, College of Physicians and Surgeons, Columbia University Medical Center, 177 Fort Washington Avenue, New York, NY, 10032, USA
| |
Collapse
|
|
8
|
Hsieh YH, Tseng CW, Koo M, Leung FW. Feasibility of sedation on demand in Taiwan using water exchange and air insufflation: A randomized controlled trial. J Gastroenterol Hepatol 2020; 35:256-262. [PMID: 31420895 DOI: 10.1111/jgh.14839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Completion of colonoscopy without sedation eliminates sedation cost and complications. Reported in the United States and Europe, on-demand sedation is not routine practice in Taiwan. Water exchange (WE), characterized by infusion and nearly complete removal of infused water during insertion, reduces insertion pain compared to air insufflation (AI) during colonoscopy. We evaluated the feasibility of on-demand sedation in Taiwan. In a randomized controlled trial of WE vs AI colonoscopy, we also aimed to determine if WE augmented the implementation by reducing insertion pain and decreasing sedation requirement. METHODS This prospective patient-blinded study randomized patients to AI or WE (75 patients/group) to aid insertion. The primary outcome was the proportion of patients completing without sedation. RESULTS In the AI and WE groups, 76.0% and 93.3% (P = 0.006) completed without need for sedation, respectively. The WE group had lower insertion pain score (mean [SD]) (4.0 [2.9] vs 2.1 [2.6], P < 0.001), lower doses of propofol (25.7 [52.7] mg vs 9.1 [35.6] mg, P = 0.012), and less time in the recovery room (3.4 [7.4] vs 1.5 [5.5], P = 0.027) than the AI group. Patient satisfaction scores and willingness to repeat if needed in the future were similar. CONCLUSION On-demand sedation was feasible in Taiwan. The completion rate without sedation was high in patients (76.0% with standard AI) open to the option (no prior intent to receive the standard of full or minimal sedation). WE augmented the implementation by reducing insertion pain and decreasing sedation requirement without adversely affecting patient satisfaction or willingness to repeat.
Collapse
Affiliation(s)
- Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
- School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
| | - Malcolm Koo
- Graduate Institute of Long-term Care, Tzu Chi University of Science and Technology, Hualien, Taiwan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Felix W Leung
- Veterans Affairs Greater Los Angeles Healthcare System, Sepulveda Ambulatory Care Center, North Hill, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
|
9
|
Beintaris I, Esmaily S, Saunders BP, Rees CJ, Von Wagner C, Tsiamoulos Z, Hoare Z, Evans R, Yeo ST, Edwards RT, Larkin T, Veitch A, Chilton A, Bramble MG, Deane J, Rutter MD. The WASh Trial: water-assisted sigmoidoscopy in the English Bowel Scope Screening Programme: study protocol for a randomized multicenter trial. Endosc Int Open 2019; 7:E1574-E1582. [PMID: 31723580 PMCID: PMC6847695 DOI: 10.1055/a-0953-1468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/23/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims The English National Bowel Scope Screening Programme (BSSP) invites 55-year-olds for a one-off, unsedated flexible sigmoidoscopy (FSIG). Data from BSSP participant-reported experience studies shows 1 in 3 participants report moderate or severe discomfort. Water-assisted colonoscopy (WAS) may improve participants' comfort. The primary objective of this study is to ascertain if post-procedural participant-assessed pain is reduced in WAS compared with carbon dioxide (CO 2 ) insufflation, in invitees undergoing FSIG in BSSP. Patients and methods This is a multicenter, prospective, randomized, two-arm, single-blinded trial designed to evaluate the performance of WAS versus CO 2 insufflation in BSSP. Participants will be randomized to either CO 2 or WAS and will be asked to rate pain post-procedure. Key procedure-related data will be analyzed, including adenoma detection rates (ADR) and degree of sigmoid looping. A cost-effectiveness analysis of WAS versus CO 2 and a discrete choice experiment exploring preferences of participants for attributes of sigmoidoscopy will also be performed. Discussion This is the first trial in the United Kingdom (UK) to investigate the effects of WAS in a screening setting. If the trial shows WAS either reduces pain or increases ADR, this may result in a practice change to implement WAS in screening and non-screening endoscopic practice directly impacting on 256,000 people a year who will undergo BSSP FSIG by 2020. Trial funding came from National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) supported by the NIHR Clinical Research Network. The trial is actively recruiting. ID: 35866 ISRCTN: 81466870.
Collapse
Affiliation(s)
- Iosif Beintaris
- Department of Gastroenterology, University Hospital of North Tees, Stockton-On-Tees, UK
| | - Shiran Esmaily
- Department of Gastroenterology, University Hospital of North Tees, Stockton-On-Tees, UK
| | | | - Colin J Rees
- Department of Gastroenterology, South Tyneside NHS Trust, South Shields UK
| | - Christian Von Wagner
- Research Department of Epidemiology and Public Health, University College London, UK
| | | | - Zoe Hoare
- North Wales Organisation for Randomised Trials in Health, UK
| | - Rachel Evans
- North Wales Organisation for Randomised Trials in Health, UK
| | - Seow Tien Yeo
- Centre for Health Economics and Medicines Evaluation, Bangor University, UK
| | - R T Edwards
- Centre for Health Economics and Medicines Evaluation, Bangor University, UK
| | | | - Andrew Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - Andrew Chilton
- Department of Gastroenterology, Kettering General Hospital NHS Foundation Trust, UK
| | - Michael G Bramble
- Department of Gastroenterology, James Cook University Hospital, Middlesbrough, UK
| | - Jill Deane
- Department of Gastroenterology, University Hospital of North Tees, Stockton-On-Tees, UK
| | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-On-Tees, UK
- School of Medicine Pharmacy and Health, Durham University, UK
- Northern Institute for Cancer Research, Newcastle University, UK
| |
Collapse
|
|
10
|
Facciorusso A, Triantafyllou K, Murad MH, Prokop LJ, Tziatzios G, Muscatiello N, Singh S. Compared Abilities of Endoscopic Techniques to Increase Colon Adenoma Detection Rates: A Network Meta-analysis. Clin Gastroenterol Hepatol 2019; 17:2439-2454.e25. [PMID: 30529731 DOI: 10.1016/j.cgh.2018.11.058] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/22/2018] [Accepted: 11/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Adenoma detection rate (ADR) is a quality metric for colorectal cancer screening. We performed a systematic review and network meta-analysis to assess the overall and comparative efficacies of different endoscopic techniques in adenoma detection. METHODS We performed a systematic review of published articles and abstracts, through March 15, 2018, to identify randomized controlled trials of adults undergoing colonoscopy that compared the efficacy of different devices in detection of adenomas. Our final analysis included 74 2-arm trials that comprised 44948 patients. These studies compared efficacies of add-on devices (cap, endocuff, endo-rings, G-EYE), enhanced imaging techniques (chromoendoscopy, narrow-band imaging, flexible spectral imaging color enhancement, blue laser imaging), new scopes (full-spectrum endoscopy, extra-wide-angle-view colonoscopy, dual focus), and low-cost optimizing existing resources (water-aided colonoscopy, second observer, dynamic position change), alone or in combination with high-definition colonoscopy or each other. Primary outcome was increase in ADR. We performed pairwise and network meta-analyses, and appraised quality of evidence using GRADE. RESULTS Low-cost optimizing existing resources (odds ratio [OR], 1.29; 95% CI,1.17-1.43), enhanced imaging techniques (OR,1.21; 95% CI, 1.09-1.35), and add-on devices (OR,1.18; 95% CI, 1.07-1.29) were associated with a moderate increase in ADR compared with high-definition colonoscopy; there was low to moderate confidence in estimates. Use of newer scopes was not associated with significant increases in ADR compared with high-definition colonoscopy (OR, 0.98; 95% CI, 0.79-1.21). In our comparative efficacy analysis, no specific technology for increasing ADR was superior to others. We did not find significant differences between technologies in detection of advanced ADR, polyp detection rate, or mean number of adenomas/patient. CONCLUSIONS In a network meta-analysis of published trials, we found that low-cost optimization of existing resources to be as effective as enhanced endoscopic imaging, or add-on devices, in increasing ADR during high-definition colonoscopy.
Collapse
Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy.
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Mohammad Hassan Murad
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Larry J Prokop
- Department of Library Services, Mayo Clinic, Rochester, Minnesota
| | - Georgios Tziatzios
- Hepatogastroenterology Unit, Second Department of Internal Medicine - Propaedeutic, Research Institute and Diabetes Center, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Nicola Muscatiello
- Gastroenterology Unit, Department of Medical Sciences, University of Foggia, Foggia, Italy
| | - Siddharth Singh
- Division of Gastroenterology and Biomedical Informatics, University of California San Diego, La Jolla, California; Division of Biomedical Informatics, University of California San Diego, La Jolla, California
| |
Collapse
|
|
11
|
Leung FW, Jia H. Water infusion without near-complete removal during insertion by any other name is still water immersion. Gastrointest Endosc 2019; 89:599-601. [PMID: 30784500 DOI: 10.1016/j.gie.2018.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 12/09/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Felix W Leung
- Division of Gastroenterology, Department of Medicine, Sepulveda Ambulatory Care Center, VAGLAHS and David Geffen School of Medicine at UCLA, North Hills and Los Angeles, California, USA
| | - Hui Jia
- Division of Gastroenterology, Department of Medicine, Sepulveda Ambulatory Care Center, VAGLAHS and David Geffen School of Medicine at UCLA, North Hills and Los Angeles, California, USA; Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| |
Collapse
|
|
12
|
Water Exchange Produces Significantly Higher Adenoma Detection Rate Than Water Immersion: Pooled Data From 2 Multisite Randomized Controlled Trials. J Clin Gastroenterol 2019; 53:204-209. [PMID: 29505552 DOI: 10.1097/mcg.0000000000001012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
GOALS To test the hypothesis that water exchange (WE) significantly increases adenoma detection rates (ADR) compared with water immersion (WI). BACKGROUND Low ADR was linked to increased risk for interval colorectal cancers and related deaths. Two recent randomized controlled trials of head-to-head comparison of WE, WI, and traditional air insufflation (AI) each showed that WE achieved significantly higher ADR than AI, but not WI. The data were pooled from these 2 studies to test the above hypothesis. STUDY Two trials (5 sites, 14 colonoscopists) that randomized 1875 patients 1:1:1 to AI, WI, or WE were pooled and analyzed with ADR as the primary outcome. RESULTS The ADR of AI (39.5%) and WI (42.4%) were comparable, significantly lower than that of WE (49.6%) (vs. AI P=0.001; vs. WI P=0.033). WE insertion time was 3 minutes longer than that of AI (P<0.001). WE showed significantly higher detection rate (vs. AI) of the >10 mm advanced adenomas. Right colon combined advanced and sessile serrated ADR of AI (3.4%) and WI (5%) were comparable and were significantly lower than that of WE (8.5%) (vs. AI P<0.001; vs. WI P=0.039). CONCLUSIONS Compared with AI and WI, the superior ADR of WE offsets the drawback of a significantly longer insertion time. For quality improvement focused on increasing adenoma detection, WE is preferred over WI. The hypothesis that WE could lower the risk of interval colorectal cancers and related deaths should be tested.
Collapse
|
|
13
|
Comparing adenoma and polyp miss rates for total underwater colonoscopy versus standard CO 2: a randomized controlled trial using a tandem colonoscopy approach. Gastrointest Endosc 2019; 89:591-598. [PMID: 30367879 DOI: 10.1016/j.gie.2018.09.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/30/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Although water exchange may improve adenoma detection compared with CO2, it is unclear whether water is a better medium to fill the lumen during withdrawal and visualize the mucosa. Total underwater colonoscopy (TUC) involves the use of water exchange with the air valve off during insertion followed by the inspection of the mucosa under water. Our goal was to compare miss rates for TUC with standard CO2 for polyps and adenomas using a tandem colonoscopy design. METHODS We randomized participants to undergo tandem colonoscopies using TUC or CO2 first. In TUC, water exchange was performed during insertion, and withdrawal was performed under water. For the CO2 colonoscopy, both insertion and withdrawal were performed with CO2. The main outcomes were miss rates for polyps and adenomas for the first examination calculated as the number of additional polyps/adenomas detected during the second examination divided by the total number of polyps/adenomas detected for both examinations. Inspection times were calculated by subtracting the time for polypectomy, and care was taken to keep the times equal for both examinations. RESULTS A total of 121 participants were randomized with 61 having CO2 first. The overall miss rate for polyps was higher for the TUC-first group (81/237; 34%) compared with the CO2-first cohort (57/264; 22%) (P = .002). In addition, the overall miss rate for all adenomas was higher for the TUC-first group (52/146; 36%) compared with the CO2 group (37/159; 23%) (P = .025). However, 1 of the 3 endoscopists had higher polyp/adenoma miss rates for CO2, but these were not statistically significant differences. The insertion time was longer for TUC than for CO2. After adjusting for times, participant characteristics, and bowel preparation, the miss rate for polyps was higher for TUC than for CO2. CONCLUSIONS We found that TUC had an overall higher polyp and adenoma miss rate than colonoscopy performed with CO2, and TUC took longer to perform. However, TUC may benefit some endoscopists, an issue that requires further study. (Clinical trial registration number: NCT03231917.).
Collapse
|
|
14
|
Fuccio L, Frazzoni L, Hassan C, La Marca M, Paci V, Smania V, De Bortoli N, Bazzoli F, Repici A, Rex D, Cadoni S. Water exchange colonoscopy increases adenoma detection rate: a systematic review with network meta-analysis of randomized controlled studies. Gastrointest Endosc 2018; 88:589-597.e11. [PMID: 29981753 DOI: 10.1016/j.gie.2018.06.028] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/21/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Water-aided colonoscopy techniques, such as water immersion (WI) and water exchange (WE), have shown different results regarding adenoma detection rate (ADR). We determined the impact of WI and WE on ADR and other procedural outcomes versus gas (air, AI; CO2) insufflation colonoscopy. METHODS A systematic search of multiple databases for randomized controlled trials comparing WI and/or WE with AI and/or CO2 and reporting ADR was conducted. A network meta-analysis with mixed comparisons was performed. Primary outcome was ADR (overall, in the right side of the colon and by colonoscopy indication). RESULTS Seventeen randomized controlled trials (10,350 patients) were included. WE showed a significantly higher overall ADR versus WI (odds ratio [OR], 1.31; 95% credible interval [CrI], 1.12-1.55) versus AI (OR, 1.40; CrI, 1.22-1.62) versus CO2 (OR, 1.48; 95% CrI, 1.15-1.86). WE achieved the highest ADR also in the right side of the colon and in colorectal cancer screening cases (both significant vs AI and WI) as well as in patients taking a split-dose preparation (significant vs all the other techniques). The Boston Bowel Preparation Scale cleanliness score (vs AI and WI) was significantly higher for WE. Both WI and WE showed increased proportion of unsedated examinations and decreased real-time insertion pain, with WE being the least-painful insertion technique. Withdrawal time was comparable across techniques, but WE showed the longest insertion time (3-5 additional minutes). CONCLUSIONS WE significantly increases overall ADR, ADR in screening cases, and in the right side of the colon; it also improves colon cleanliness but requires a longer insertion time.
Collapse
Affiliation(s)
- Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Marina La Marca
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Valentina Paci
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Veronica Smania
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Nicola De Bortoli
- Department of Translational Research and New Technology in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research and University Hospital, Rozzano (MI), Italy
| | - Douglas Rex
- Division of Gastroenterology/Hepatology, Indiana University Hospital, Indianapolis, Indiana, USA
| | - Sergio Cadoni
- Digestive Endoscopy Unit, CTO Hospital, Iglesias, Italy
| |
Collapse
|
|
15
|
Chen Z, Li Z, Yu X, Wang G. Is water exchange superior to water immersion for colonoscopy? A systematic review and meta-analysis. Saudi J Gastroenterol 2018; 24:259-267. [PMID: 29873319 PMCID: PMC6151995 DOI: 10.4103/sjg.sjg_52_18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Recently, water exchange (WE) instead of water immersion (WI) for colonoscopy has been proposed to decrease pain and improve adenoma detection rate (ADR). This systematic review and meta-analysis is conducted to assess whether WE is superior to WI based on the published randomized controlled trials (RCTs). Materials and Methods We searched studies from PubMed, Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE. Only RCTs were eligible for our study. The pooled risk ratios (RRs), pooled mean difference (MD), and pooled 95% confidence intervals (CIs) were calculated by using the fixed-effects model or random-effects model based on heterogeneity. Results Five RCTs consisting of 2229 colonoscopies were included in this study. WE was associated with a significantly higher ADR than WI (RR = 1.18; CI = 1.05-1.32; P = 0.004), especially in right colon (RR = 1.31; CI = 1.07-1.61; P = 0.01). Compared with WI, WE was confirmed with lower pain score, higher Boston Bowel Preparation Scale score, but more infused water during insertion. There was no statistical difference between WE and WI in cecal intubation rate and the number of patients who had willingness to repeat the examination. Furthermore, both total procedure time and cecal intubation time in WE were significantly longer than that in WI (MD = 2.66; CI = 1.42-3.90; P < 0.0001; vs MD = 4.58; CI = 4.01-5.15; P < 0.0001). Conclusions This meta-analysis supports the hypothesis that WE is superior to WI in improving ADR, attenuating insertion pain and providing better bowel cleansing, but inferior in time and consumption of infused water consumption during insertion.
Collapse
Affiliation(s)
- Zhihao Chen
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhengqi Li
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Xinying Yu
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| | - Guiqi Wang
- Department of Endoscopy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People's Republic of China
| |
Collapse
|
|
16
|
Shi X, Tian D, Ye X, Wu Q, Pan Y, Yang Z, Fan D. Is water exchange superior to water immersion in detecting adenomas during colonoscopies? Results from a Bayesian network meta-analysis. Oncotarget 2018; 9:30679-30693. [PMID: 30093978 PMCID: PMC6078142 DOI: 10.18632/oncotarget.25504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/08/2018] [Indexed: 12/13/2022] Open
Abstract
AIM Water-assisted colonoscopy (water exchange [WE] and water immersion [WI]) has been shown to improve the adenoma detection rate. However, few studies have compared these two methods head-to-head. Thus, we conducted a network meta-analysis to integrate both direct and indirect evidence comparing the effectiveness of these two procedures. METHOD We searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for original papers and abstracts published up to March 2018. Randomized controlled trials (RCTs) reporting data in accordance with the eligibility criteria were included in this study. We performed a Bayesian random effects network meta-analysis with mixed comparisons. RESULTS Twenty-nine studies (n = 11464 patients) including 6 direct and 23 indirect comparisons were included in this network meta-analysis. There was a statistically significant difference in the efficacy of adenoma detection when WE was compared with WI (risk ratio [RR]: 1.2, 95% credible interval [CrI]: 1.1-1.3), air insufflation (AI; RR: 1.3, 95% CrI: 1.1-1.4), and carbon dioxide (CO2) insufflation (RR: 1.2, 95% CrI: 1.1-1.5). The different methods were ranked in order from the most to least effective in adenoma detection as follows: WE, WI, AI, and CO2. Moreover, although there were no significant differences in pain scores, willingness to repeat, caecal intubation rate, or total procedure time between WI and WE colonoscopy, WE required a longer caecal intubation time than WI. CONCLUSION This network meta-analysis supposes that WE may be superior to WI in detecting adenomas during colonoscopies without affecting other technical features or patient acceptance.
Collapse
Affiliation(s)
- Xin Shi
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Dan Tian
- Office of Educational Administration, Fourth Military Medical University, Xi’an, China
| | - Xiaofei Ye
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Qiong Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| |
Collapse
|
|
17
|
Zhang Z, Wu Y, Sun G, Zhang J, Li J, Qiu C, Zheng X, Wang B, Yang L, Wang X. Bayesian network meta-analysis: Efficacy of air insufflation, CO 2 insufflation, water exchange, and water immersion in colonoscopy. Dig Endosc 2018; 30:321-331. [PMID: 29334136 DOI: 10.1111/den.13012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 01/08/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIM Colonoscopy is an excellent screening tool for colorectal cancer. There are four colonoscopy techniques: air insufflation, CO2 insufflation, water exchange, and water immersion. Some studies reported that the latter three methods are better than the criterion standard (air insufflation), whereas some studies did not. In order to evaluate the efficacy of the four colonoscopy techniques, a network meta-analysis was carried out. METHODS We searched randomized controlled trials (RCT) published up to September 2017 from PubMed, Embase, Cochrane library, and Web of Science. Studies referencing the comparison between at least two of air insufflation, CO2 insufflation, water exchange, and water immersion were selected. Primary outcomes included pain score during insertion, polyp detection rate, and adenoma detection rate, and secondary outcomes included cecal intubation time and cecal intubation rate. Mean differences or odds ratios and their corresponding 95% credible intervals were pooled with Bayesian modeling. RESULTS Forty RCT with 13 734 patients were included in this network meta-analysis. Our analysis showed that air insufflation had the highest pain score (surface under the cumulative ranking curve [SUCRA]: 98.8%) and the lowest detection rate of adenoma (SUCRA: 21.3%) and polyp (SUCRA: 16.8%). Water exchange had the lowest pain score (SUCRA: 1.1%) and highest detection rate of adenoma (SUCRA: 96.0%) and polyp (SUCRA: 98.9%), although it led to the longest cecal intubation time (SUCRA: 86.9%). CONCLUSIONS Air insufflation might be the most unsatisfactory colonoscopy. Meanwhile, water exchange might be the most efficient colonoscopy.
Collapse
Affiliation(s)
- Zhen Zhang
- Graduate School of Tianjin Medical University, Tianjin, China
- Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, Tianjin, China
| | - Yifeng Wu
- Tianjin People's Hospital Tianjin Union Medical Center, Tianjin, China
| | - Guangge Sun
- Tianjin People's Hospital Tianjin Union Medical Center, Tianjin, China
| | - Jing Zhang
- Graduate School of Tianjin Medical University, Tianjin, China
- Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, Tianjin, China
| | - Jiaxin Li
- Graduate School of Tianjin Medical University, Tianjin, China
- Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, Tianjin, China
| | - Chongyang Qiu
- Graduate School of Tianjin Medical University, Tianjin, China
- Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, Tianjin, China
| | - Xin Zheng
- Graduate School of Tianjin Medical University, Tianjin, China
- Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, Tianjin, China
| | - Botao Wang
- Graduate School of Tianjin Medical University, Tianjin, China
- Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, Tianjin, China
| | - Lei Yang
- Tianjin Institute of Acute Abdominal Disease of Integrated Traditional Chinese and Western Medicine, Tianjin, China
| | - Ximo Wang
- Tianjin Hospital of Integrated Traditional Chinese and Western Medicine, Tianjin, China
| |
Collapse
|
|
18
|
Cadoni S, Ishaq S. How to perform water-aided colonoscopy, with differences between water immersion and water exchange: a teaching video demonstration. VideoGIE 2018; 3:169-170. [PMID: 29916455 PMCID: PMC6004423 DOI: 10.1016/j.vgie.2018.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Sergio Cadoni
- Digestive Endoscopy Unit, Centro Traumatologico-Ortopedico Hospital, Iglesias, Italy
| | - Sauid Ishaq
- Department of Gastroenterology, Dudley Group Hospitals NHS Foundation Trust, Dudley, United Kingdom.,Birmingham City University, Birmingham, United Kingdom
| |
Collapse
|
|
19
|
Noh CK, Lee KM. Can water insufflation and carbon dioxide overcome the difficulties of colonoscope insertion? Intest Res 2018; 16:166-167. [PMID: 29743829 PMCID: PMC5934589 DOI: 10.5217/ir.2018.16.2.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/07/2018] [Accepted: 03/07/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Choong-Kyun Noh
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| | - Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
| |
Collapse
|
|
20
|
Hsieh YH, Tseng CW, Hu CT, Koo M, Leung FW. Prospective multicenter randomized controlled trial comparing adenoma detection rate in colonoscopy using water exchange, water immersion, and air insufflation. Gastrointest Endosc 2017; 86:192-201. [PMID: 27988288 DOI: 10.1016/j.gie.2016.12.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 12/04/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Adenoma detection rate (ADR), defined as the proportion of patients with at least one adenoma of any size, is a quality indicator. We tested the hypothesis that water exchange (WE) improves ADR but water immersion (WI) has no adverse effect on ADR compared with air insufflation (AI). METHODS A prospective study was conducted at the Dalin Tzu Chi Hospital in southern Taiwan and the Hualien Tzu Chi Hospital in eastern Taiwan on patients randomly assigned to WE, WI, or AI with stratification by the 3 study colonoscopists. The primary outcome was ADR. RESULTS From July 2013 to December 2015, 651 patients were recruited and randomized into 3 groups with a 1:1:1 ratio (217 patients per group). Overall, ADR met quality standards: WE 49.8% (95% CI, 43.2%-56.4%), AI 37.8% (95% CI, 31.6%-44.4%), and WI 40.6% (95% CI, 34.2%-47.2%). Compared with AI, WE significantly increased ADR (P = .016). There was no difference between WI and WE. ADRs of WI and AI were comparable. Compared with AI, WE confirmed a longer insertion time, higher cleanliness score, but similar adenoma per positive colonoscopy (APPC) and withdrawal time with polypectomy. Subgroup analysis found WE significantly increased ADR in propofol-sedated patients. Multivariate generalized linear mixed model analysis revealed that age ≥50 years, WE (vs AI), colonoscopy indication, no previous history of colonoscopy, and withdrawal time >8 minutes were significant predictors of increased ADR. CONCLUSIONS Confirmation of prior reports showing WE, but not WI, increased ADR further strengthened the validity of our observations. WE significantly increased ADR in propofol-sedated patients. The outcome differences justify assessment of the role of WE in colorectal cancer prevention. Similar APPC and withdrawal times suggest that adequate inspection was performed on colonoscope withdrawal in each of the study arms. (Clinical trial registration number: NCT01894191.).
Collapse
Affiliation(s)
- Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan
| | - Chi-Tan Hu
- School of Medicine, Buddhist Tzu Chi University, Hualien, Taiwan; Department of Gastroenterology, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Malcolm Koo
- Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Felix W Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill, California, USA; David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
|
21
|
|
|
22
|
Cadoni S, Falt P, Gallittu P, Liggi M, Smajstrla V, Leung FW. Impact of carbon dioxide insufflation and water exchange on postcolonoscopy outcomes in patients receiving on-demand sedation: a randomized controlled trial. Gastrointest Endosc 2017; 85:210-218.e1. [PMID: 27207825 DOI: 10.1016/j.gie.2016.05.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/04/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Water exchange (WE) is the least painful insertion method during colonoscopy. Its impact on postcolonoscopy discomfort has not been well-described. Carbon dioxide (CO2) insufflation consistently reduced postcolonoscopy discomfort. We compared postcolonoscopy outcomes of various combinations of insertion and withdrawal techniques (insertion-withdrawal modality): WE-CO2, WE-air insufflation (WE-AI), and CO2-CO2. METHODS A total of 240 patients undergoing on-demand sedation diagnostic colonoscopy were randomized to WE-CO2 (n = 79), WE-AI (n = 80), CO2-CO2 (n = 81), with postprocedural data collected up to 24 hours. The primary outcome was postcolonoscopy bloating. Other postcolonoscopy outcomes included pain scores, flatus and incontinence episodes, toilet use, interference with normal activities, patient satisfaction, and patient willingness to repeat the procedure. RESULTS Demographic and procedural data were comparable. Compared with WE-AI, WE-CO2 and CO2-CO2 resulted in significantly less bloating (all P < .0005) and lower pain scores (P values ranged from .008 to < .0005) up to 3 hours and fewer flatus episodes up to 6 hours (P values ranged from .003 to < .0005). WE-CO2 resulted in less interference with same-day activities compared with WE-AI (P = .043). The differences in postprocedural outcomes were significant, but the magnitude was small. Patient satisfaction and willingness to repeat the procedure were high and comparable among groups. WE was the least painful insertion technique (P < .0005). CONCLUSIONS The combination WE-CO2 appears to be the optimal choice to decrease pain during the examination and to reduce bloating and other undesired procedural outcomes afterward. If a CO2 insufflator is already available, it seems advisable to adopt the combination WE-CO2. In the absence of a CO2 insufflator, the cost effectiveness of the addition of withdrawal CO2 to WE in diagnostic and nondiagnostic settings needs to be critically assessed. (Clinical trial registration number: NCT02409979.).
Collapse
Affiliation(s)
- Sergio Cadoni
- Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias, Italy
| | - Přemysl Falt
- Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic
| | - Paolo Gallittu
- Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias, Italy
| | - Mauro Liggi
- Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias, Italy
| | - Vit Smajstrla
- Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic
| | - Felix W Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California, USA; David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
| |
Collapse
|
|
23
|
Rondonotti E, Andrealli A, Amato A, Paggi S, Conti CB, Spinzi G, Radaelli F. Technical interventions to increase adenoma detection rate in colonoscopy. Expert Rev Gastroenterol Hepatol 2016; 10:1349-1358. [PMID: 27701933 DOI: 10.1080/17474124.2016.1245143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Adenoma detection rate (ADR) is the most robust colonoscopy quality metric and clinical studies have adopted it as the ideal method to assess the impact of technical interventions. Areas covered: We reviewed papers focusing on the impact of colonoscopy technical issues on ADR, including withdrawal time and technique, second evaluation of the right colon, patient positional changes, gastrointestinal assistant participation during colonoscopy, water-aided technique, optimization of bowel preparation and antispasmodic administration. Expert commentary: Overall, technical interventions are inexpensive, available worldwide and easy to implement. Some of them, such as the adoption of split dose regimen and slow scope withdrawal to allow a careful inspection, have been demonstrated to significantly improve ADR. Emerging data support the use of water-exchange colonoscopy. According to published studies, other technical interventions seem to provide only marginal benefit to ADR. Unfortunately, the available evidence has methodological limitations, such as small sample sizes, the inclusion of expert endoscopists only and the evaluation of single technical interventions. Additionally, larger studies are needed to clarify whether these interventions might have a higher benefit on low adenoma detectors and whether the implementation of a bundle of them, instead of a single technical maneuver, might have a greater impact on ADR.
Collapse
Affiliation(s)
| | | | - Arnaldo Amato
- a Gastroenterology Unit , Ospedale Valduce , Como , Italy
| | - Silvia Paggi
- a Gastroenterology Unit , Ospedale Valduce , Como , Italy
| | | | | | | |
Collapse
|
|
24
|
Kim HG. Painless Colonoscopy: Available Techniques and Instruments. Clin Endosc 2016; 49:444-448. [PMID: 27744665 PMCID: PMC5066405 DOI: 10.5946/ce.2016.132] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 09/19/2016] [Accepted: 09/19/2016] [Indexed: 12/21/2022] Open
Abstract
During colonoscopy, air insufflation to distend the lumen and facilitate careful inspection and scope insertion can induce pain and cause discomfort. Carbon dioxide (CO2) insufflation can decrease abdominal pain and discomfort during and after colonoscopy. The advantage of CO2 insufflation is the rapid absorption of the gas across the intestine. Another painless option is water-assisted colonoscopy. Two methods for water-assisted colonoscopy are available: water immersion and water exchange. In a recent direct comparison, the water exchange method was superior to water immersion, CO2 insufflation, and air insufflation with respect to pain during colonoscopy, although it still had the disadvantage of being a time-consuming procedure. Cap-assisted colonoscopy is a simple technique involving the use of a small transparent cap attached to the tip of the scope. Three studies showed an advantage of this technique in terms of reduced patient discomfort compared with the conventional method. Three robotic colonoscopy systems (Endotics System [Era Endoscopy], NeoGuide [NeoGuide Systems Inc.], and Invendoscope [Invendo Medical]) have been introduced to evaluate pain reduction during colonoscopy, but none has been widely adopted and used in practice. In this review, clinical trials of several techniques and new devices for painless colonoscopy are described and summarized.
Collapse
Affiliation(s)
- Hyun Gun Kim
- Institute for Digestive Research, Soon Chun Hyang University College of Medicine, Seoul, Korea
| |
Collapse
|
|
25
|
Ertem F, Dashwood WM, Rajendran P, Raju G, Rashid A, Dashwood R. Development of a murine colonoscopic polypectomy model (with videos). Gastrointest Endosc 2016; 83:1272-6. [PMID: 26658879 PMCID: PMC4875801 DOI: 10.1016/j.gie.2015.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/20/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Colonoscopy provides a means for screening and removal of colon adenomas, preventing such lesions from progressing to late-stage carcinoma. No preclinical model currently exists that closely parallels the clinical scenario with respect to polyp resection and recovery after endoscopy. METHODS When we used the polyposis in rat colon (Pirc) model, a new polypectomy methodology was developed. A novel PLC classification system (polyp number/location/clockwise orientation) also was devised in order to accurately and reproducibly specify the location of each lesion within the colon. RESULTS One week after surgery, injuries to the polypectomy site were confined to the submucosa, indicating that little or no damage occurred to the inner muscle layer of the colon. Polypectomy sites occasionally continued to show ulcer formation, whereas others exhibited tissue regeneration. A pilot study (n = 6 animals), involving a total of 37 polypectomies, confirmed that the new methodology could be applied by using either air insufflation or water-assisted techniques, with either hot or cold snare. As a general observation, polyps tended to be more fully distended and less flattened against the colon mucosa by using the water-assisted protocol, increasing the technical ease of ensnaring and resecting lesions. The PLC system proved to be straightforward and facilitated longitudinal studies by allowing the investigator to track each polypectomy site on repeated examination. CONCLUSIONS The Pirc model was ideally suited to colonoscopy with polypectomy. Because the main cause of morbidity in the Pirc model is blockage of the colon, polypectomy can be used as a preventive strategy and will likely facilitate long-term investigations of single agent and combination therapies with potential direct clinical relevance.
Collapse
Affiliation(s)
- Furkan Ertem
- Center for Epigenetics & Disease Prevention, Texas A&M
Health Science Center, Houston, Texas, USA
| | - Wan-Mohaiza Dashwood
- Center for Epigenetics & Disease Prevention, Texas A&M
Health Science Center, Houston, Texas, USA
| | - Praveen Rajendran
- Center for Epigenetics & Disease Prevention, Texas A&M
Health Science Center, Houston, Texas, USA
| | - Gottumukkala Raju
- Department of Gastroenterology, Hepatology & Nutrition, MD
Anderson Cancer Center, Houston, Texas, USA
| | - Asif Rashid
- Department of Pathology, MD Anderson Cancer Center, Houston, Texas,
USA
| | - Roderick Dashwood
- Center for Epigenetics & Disease Prevention, Texas A&M
Health Science Center, Houston, Texas, USA,Department of Nutrition & Food Science, Texas A&M
University, College Station, Texas,Department of Molecular & Cellular Medicine, College of
Medicine, Texas A&M University, College Station, Texas,Department of Clinical Cancer Prevention, MD Anderson Cancer Center,
Houston, Texas, USA
| |
Collapse
|
|
26
|
Response. Gastrointest Endosc 2016; 83:677-8. [PMID: 26897057 DOI: 10.1016/j.gie.2015.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 11/10/2015] [Indexed: 12/11/2022]
|
|
27
|
Cadoni S, Falt P, Leung FW. Some Clarifications About Water-Aided Colonoscopy. Clin Gastroenterol Hepatol 2016; 14:323. [PMID: 26375611 DOI: 10.1016/j.cgh.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 09/08/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Sergio Cadoni
- Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias (Carbonia-Iglesias), Italy
| | - Přemysl Falt
- Digestive Diseases Center, Vìtkovice Hospital, Ostrava, Czech Republic
| | - Felix W Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California; David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California
| |
Collapse
|
|
28
|
Cadoni S, Liggi M, Falt P, Sanna S, Argiolas M, Fanari V, Gallittu P, Mura D, Porcedda ML, Smajstrla V, Erriu M, Leung FW. Evidence to suggest adoption of water exchange deserves broader consideration: Its pain alleviating impact occurs in 90% of investigators. World J Gastrointest Endosc 2016; 8:113-121. [PMID: 26839651 PMCID: PMC4724028 DOI: 10.4253/wjge.v8.i2.113] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 08/18/2015] [Accepted: 12/15/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To determine whether observations were reproducible among investigators.
METHODS: From March 2013 through June 2014, 18-85-year-old diagnostic and 50-70-year-old screening patients were enrolled at each center to on-demand sedation colonoscopy with water exchange (WE), water immersion (WI) and insufflation with air or CO2 for insertion and withdrawal [air or carbon dioxide (AICD)]. Data were aggregated for analysis. Primary outcome: Variations in real-time maximum insertion pain (0 = none, 1-2 = discomfort, 10 = worst).
RESULTS: One thousand and ninety-one cases analyzed: WE (n = 371); WI (n = 338); AICD (n = 382). Demographics and indications were comparable. The WE group had the lowest real-time maximum insertion pain score, mean (95%CI): WE 2.8 (2.6-3.0), WI 3.8 (3.5-4.1) and AICD 4.4 (4.1-4.7), P < 0.0005. Ninety percent of the colonoscopists were able to use water exchange to significantly decrease maximum insertion pain scores. One investigator had high insertion pain in all groups, nonetheless WE achieved the lowest real-time maximum insertion pain score. WE had the highest proportions of patients with painless unsedated colonoscopy (vs WI, P = 0.013; vs AICD, P < 0.0005); unsedated colonoscopy with only minor discomfort (vs AICD, P < 0.0005), and completion without sedation (vs AICD, P < 0.0005).
CONCLUSION: Aggregate data confirm superiority of WE in lowering colonoscopy real-time maximum insertion pain and need for sedation. Ninety percent of investigators were able to use water exchange to significantly decrease maximum insertion pain scores. Our results suggest that the technique deserves consideration in a broader scale.
Collapse
|
|
29
|
Schmidt-Tänzer W, Eickhoff A. What Influences the Quality of Prevention Colonoscopy? VISZERALMEDIZIN 2015; 30:26-31. [PMID: 26288579 PMCID: PMC4513811 DOI: 10.1159/000358747] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Colorectal cancer still has a high incidence and mortality. Although colonoscopy is considered as gold standard of colorectal cancer screening, there still exists an unsatisfactory level of adenomas missed in screening and surveillance colonoscopy. Furthermore, patients bear the burden of potentially unpleasant and painful examination and preparation procedures. Method A search of the literature using PubMed was carried out, supplemented by a review of the programs of the Digestive Disease Week (DDW) and the United European Gastroenterology Week (UEGW) 2011-2013. Results Several new approaches to colonoscopy were described: water, CO2 and cap colonoscopy, and application of spasmolytics such as hyoscine butylbromide and glucagon. The use of these methods does not necessitate the purchase of new endoscopes. They are feasible and safe, facilitate achieving the aim of more comfort and less pain, and perhaps allow lower doses of sedatives to be used. However, a clear effect on procedure time is lacking. Furthermore, the published data do not consistently answer the question of whether these techniques have a positive impact on the most important goal, the better detection of carcinoma precursors. Conclusion More efforts to optimize bowel preparation have to be made to improve visualization of the mucosal surface. The most reliable criteria for the quality of screening and surveillance colonoscopy remain a minimum cecal intubation rate of >90%, a withdrawal time of at least 6 or better 9 min, and an adenoma detection rate of >20%. These results should be achieved with a complication rate lower than 1%, including polypectomy.
Collapse
Affiliation(s)
- Wolfgang Schmidt-Tänzer
- Medizinische Klinik II, Klinik für Gastroenterologie, Diabetologie und Infektiologie, Klinikum Hanau GmbH, Hanau, Germany
| | - Axel Eickhoff
- Medizinische Klinik II, Klinik für Gastroenterologie, Diabetologie und Infektiologie, Klinikum Hanau GmbH, Hanau, Germany
| |
Collapse
|
|
30
|
Wang X, Luo H, Xiang Y, Leung FW, Wang L, Zhang L, Liu Z, Wu K, Fan D, Pan Y, Guo X. Left-colon water exchange preserves the benefits of whole colon water exchange at reduced cecal intubation time conferring significant advantage in diagnostic colonoscopy - a prospective, randomized controlled trial. Scand J Gastroenterol 2015; 50:916-23. [PMID: 25639787 DOI: 10.3109/00365521.2015.1010569] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Whole-colon water exchange (WWE) reduces insertion pain, increases cecal intubation success and adenoma detection rate, but requires longer insertion time, compared to air insufflation (AI) colonoscopy. We hypothesized that water exchange limited to the left colon (LWE) can speed up insertion with equivalent results. METHODS This prospective, randomized controlled study (NCT01735266) allocated patients (18-80 years) to WWE, LWE or AI group (1:1:1). The primary outcome was cecal intubation time. RESULTS Three hundred subjects were randomized to the WWE (n = 100), LWE (n = 100) or AI group (n = 100). Ninety-four to ninety-five per cent of patients underwent diagnostic colonoscopy. Baseline characteristics were balanced. The median insertion time was shorter in LWE group (4.8 min (95%CI: 3.2-6.2)) than those in WWE (7.5 min (95%CI: 6.0-10.3)) and AI (6.4 min (95%CI: 4.2-9.8)) (both p < 0.001) groups. The cecal intubation rates in unsedated patients of the two water exchange methods (WWE 99%, LWE 99%) were significantly higher than that (89.8%) in AI group (p = 0.01). The final success rates were comparable among the three groups after sedation was given. Maximum pain scores and number of patients needing abdominal compression between WWE and LWE groups were comparable, both lower than those in AI group (p < 0.05). No significant difference was observed regarding PDR, although the PDR in right colon tended to be higher in WWE group. CONCLUSION By preserving the benefits of WWE and reducing insertion time, LWE is appropriate for diagnostic colonoscopy, especially in settings with tight scheduling of patients. The higher PDR in the right colon in WWE group deserves to be further investigated.
Collapse
Affiliation(s)
- Xiangping Wang
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University , Xi'an , China
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
31
|
Sugimoto S, Mizukami T. Diagnostic and therapeutic applications of water-immersion colonoscopy. World J Gastroenterol 2015; 21:6451-6459. [PMID: 26074684 PMCID: PMC4458756 DOI: 10.3748/wjg.v21.i21.6451] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/15/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023] Open
Abstract
Colonoscopy techniques combining or replacing air insufflation with water infusion are becoming increasingly popular. They were originally designed to reduce colonic spasms, facilitate cecal intubation, and lower patient discomfort and the need for sedation. These maneuvers straighten the rectosigmoid colon and enable the colonoscope to be inserted deeply without causing looping of the colon. Water-immersion colonoscopy minimizes colonic distension and improves visibility by introducing a small amount of water. In addition, since pain during colonoscopy indicates risk of bowel perforation and sedation masks this important warning, this method has the potential to be the favored insertion technique because it promotes patient safety without sedation. Recently, this water-immersion method has not only been used for colonoscope insertion, but has also been applied to therapy for sigmoid volvulus, removal of lesions, lower gastrointestinal bleeding, and therapeutic diagnosis of abnormal bowel morphology and irritable bowel syndrome. Although a larger sample size and prospective head-to-head-designed studies will be needed, this review focuses on the usefulness of water-immersion colonoscopy for diagnostic and therapeutic applications.
Collapse
|
|
32
|
Hafner S, Zolk K, Radaelli F, Otte J, Rabenstein T, Zolk O, Cochrane Colorectal Cancer Group. Water infusion versus air insufflation for colonoscopy. Cochrane Database Syst Rev 2015; 2015:CD009863. [PMID: 26011829 PMCID: PMC11257032 DOI: 10.1002/14651858.cd009863.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Colonoscopy is a widely used diagnostic and therapeutic modality. A large proportion of the population is likely to undergo colonoscopy for diagnosis and treatment of colorectal diseases, or when participating in colorectal cancer screening programs. To reduce pain, water infusion instead of traditional air insufflation during the insertion phase of the colonoscopy has been proposed, thereby improving patients' acceptance of the procedure. Moreover, the water infusion method may improve early detection of precancerous neoplasms. OBJECTIVES To compare water infusion techniques with standard air insufflation, specifically evaluating technical quality and screening efficacy, as well as patients' acceptance of the water infusion procedure. SEARCH METHODS We searched the Cochrane Colorectal Cancer Group Specialized Register (February 2014), the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to February 2014), Ovid EMBASE (1974 to February 2014), and ClinicalTrials.gov (1999 to February 2014) for eligible randomised controlled trials. SELECTION CRITERIA We included randomised controlled trials comparing water infusion (water exchange or water immersion methods) against standard air insufflation during the insertion phase of the colonoscopy. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the studies for inclusion and extracted data from eligible studies. We performed analysis using Review Manager software (RevMan 5). MAIN RESULTS We included 16 randomised controlled trials consisting of 2933 colonoscopies. Primary outcome measures were cecal intubation rate and adenoma detection; secondary outcomes were time needed to reach the cecum, pain experienced by participants during the procedure, completion of cecal intubation without sedation/analgesia, and adverse events. Completeness of colonoscopy, that is cecal intubation rate, was similar between water infusion and standard air insufflation (risk ratio 1.00, 95% confidence interval (CI) 0.97 to 1.03, P = 0.93). Adenoma detection rate, that is number of participants with at least one detected adenoma, was slightly improved with water infusion (risk ratio 1.16, 95% CI 1.04 to 1.30, P = 0.007). Assuming the fraction of patients undergoing screening colonoscopy who had one or more adenomas detected was 20 per 100 with standard colonoscopy, the use of water colonoscopy may increase the fraction to 23 per 100 individuals. From our findings, it is possible that up to 68,000 more of the 1.7 million outpatient screening colonoscopies performed annually in the United States, could detect adenomas if water infusion colonoscopy was used. In addition, with water infusion participants experienced significantly less pain (mean difference in pain score on a 0 to 10 scale: -1.57, 95% CI -2.00 to -1.14, P < 0.00001) and a significantly lower proportion of participants requested on-demand sedation or analgesia, or both (risk ratio 1.20, 95% CI 1.14 to 1.27, P < 0.00001). Qualitative analysis suggests that water infusion colonoscopy was not associated with a markedly increased rate of adverse events compared with the standard procedure. AUTHORS' CONCLUSIONS Completeness of colonoscopy, that is cecal intubation rate, was not improved by water infusion compared with standard air insufflation colonoscopy. However, adenoma detection, assessed with two different measures (that is adenoma detection rate and number of detected adenomas per procedure), was slightly augmented by the water infusion colonoscopy. Improved adenoma detection might be due to the cleansing effects of water infusions on the mucosa. Detection of premalignant lesions during standard colonoscopy is suboptimal, and so improvements in adenoma detection by water infusion colonoscopy, although small, may help to reduce the risk of interval colorectal carcinoma. The most obvious benefit of water infusion colonoscopy was reduction of procedure-related abdominal pain, which may enhance the acceptance of screening/surveillance colonoscopy.
Collapse
Affiliation(s)
- Susanne Hafner
- University Hospital UlmInstitute of Pharmacology of Natural Products & Clinical PharmacologyHelmholtzstrasse 20UlmBaden‐WürttembergGermany89081
| | - Karsten Zolk
- Westpfalz HospitalDepartment of Internal Medicine ‐ AngiologyIm Flur 1KuselWestphaliaGermany66869
| | - Franco Radaelli
- Valduce HospitalGastrenterology UnitVia Dante 11ComoItaly22100
| | - Jörg Otte
- Friedrich‐Alexander‐UniversitätInstitute of Pharmacology and ToxicologyErlangenGermany
| | - Thomas Rabenstein
- Diakonissen Stiftungs KrankenhausDepartment of MedicineHilgardstrasse 26SpeyerRhineland PalatinateGermany67346
| | - Oliver Zolk
- University Hospital UlmInstitute of Pharmacology of Natural Products and Clinical PharmacologyHelmholtzstrasse 20UlmBaden‐WürttembergGermany89081
| | | |
Collapse
|
|
33
|
Abstract
The successful intubation of the cecum during screening or surveillance colonoscopy is vital to ensure complete mucosal inspection of the colon on withdrawal. Even when performed by an experienced endoscopist, colonoscope insertion can sometimes be challenging. Water-aided colonoscopy can be used to assist the endoscopist in navigating colons with anatomies that may be challenging owing to severe angulation or redundancy. Water-assisted colonoscopy involves the infusion of water without air and subsequent suctioning during insertion (exchange) or withdrawal (immersion or infusion). This review discusses the technique, effectiveness, safety of water-assisted colonoscopy as well as the application in sedationless endscopy.
Collapse
Affiliation(s)
- Joseph C Anderson
- Department of Veterans Affairs Medical Center, Department of Medicine, 215 North Main Street, White River Junction, VT 05009, USA; The Geisel School of Medicine at Dartmouth Medical, Department of Medicine, Hanover, NH 03755, USA.
| | | | | | | |
Collapse
|
|
34
|
A randomized, controlled trial comparing real-time insertion pain during colonoscopy confirmed water exchange to be superior to water immersion in enhancing patient comfort. Gastrointest Endosc 2015; 81:557-66. [PMID: 25262100 DOI: 10.1016/j.gie.2014.07.029] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 07/09/2014] [Indexed: 01/05/2023]
Abstract
BACKGROUND A recent American Society for Gastrointestinal Endoscopy Technology Status Evaluation Report recommended comparative studies of water-aided colonoscopy methods to refine the optimal insertion technique. OBJECTIVE Air insufflation (AI), water immersion (WI), and water exchange (WE) were compared head-to-head to test the hypothesis that WE produces the least insertion pain. DESIGN Patient-blinded, prospective, randomized, controlled trials. SETTING Two community hospitals in Italy. PATIENTS First-time diagnostic or screening colonoscopy in unsedated patients with the option of on-demand sedation. INTERVENTION Colonoscopy with AI, WI, or WE. MAIN OUTCOME MEASUREMENTS Real-time maximum insertion pain (0 = none, 10 = worst). To avoid interventional bias, the timing of recording was at the discretion of the nurse assistant. Adjunct measures were implemented to ensure patient perception of minimal discomfort. Recalled pain and patients' guess of insertion methods were recorded after colonoscopy. RESULTS Results were merged for 576 randomized patients. Correct patient guesses lower than 33% confirmed adequate blinding. Significant correlation (Pearson coefficient 0.6, P < .0005) between real-time and recalled pain provided internal validation of the former as the primary outcome. Real-time pain (95% confidence interval [CI]: AI, 4.1 [3.7-4.5]; WI, 3.5 [3.0-3.9]; and WE, 2.5 [2.2-2.9] [P < .0005] was the lowest in the WE group. The proportions of patients completing unsedated colonoscopy based on the assigned methods were significantly different (WE, 74.7% vs WI, 62.4%; P = .009; vs AI, 65.3%; P = .04). WE required the least implementation of adjunct maneuvers. LIMITATIONS Unblinded colonoscopists. CONCLUSION The current findings with an internally validated primary outcome in adequately blinded patients support the hypothesis that WE is superior to WI in attenuating real-time insertion pain and enhancing completion of unsedated colonoscopy.
Collapse
|
|
35
|
Morales AL, Magulick JP, Womeldorph C, Young PE. Colonoscopy for Colorectal Cancer Screening: Current Challenges and Future Directions. CURRENT COLORECTAL CANCER REPORTS 2015. [DOI: 10.1007/s11888-014-0257-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
|
36
|
Sajid MS, Caswell J, Bhatti MI, Sains P, Baig MK, Miles WFA. Carbon dioxide insufflation vs conventional air insufflation for colonoscopy: a systematic review and meta-analysis of published randomized controlled trials. Colorectal Dis 2015; 17:111-23. [PMID: 25393051 DOI: 10.1111/codi.12837] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 08/06/2014] [Indexed: 12/16/2022]
Abstract
AIM Conventional air insufflation (AI) may cause prolonged abdominal bloating, excessive abdominal pain and discomfort during colonoscopy. Carbon dioxide may be an acceptable alternative to avoid these complications. The object of this study was to evaluate systematically the effectiveness of carbon dioxide insufflation (CI) for colonoscopy compared with AI. METHOD Randomized controlled trials (RCTs) comparing the effectiveness of CI with that of AI during colonoscopy were retrieved from medical electronic databases and combined analysis was performed using the RevMan statistical package. The combined outcome of dichotomous and continuous variables was expressed as an odds ratio (OR) and standardized mean difference (SMD). RESULTS Twenty-one RCTs comprising 3607 patients were included in the study. There was statistically significant heterogeneity among included studies. CI showed a significant trend towards reduced procedural pain [SMD -1.34; 95% confidence interval (95% CI) -2.23 to -0.45; z = 2.96; P < 0.003] and also postprocedural pain at 1 h (SMD -1.11; 95% CI -1.83 to -0.38; z = 2.97; P < 0.003), 6 and 24 h (OR 0.44; 95% CI 0.23-0.85; z = 2.44; P < 0.01). CI was associated with faster caecal intubation (SMD -0.20; 95% CI -0.37 to -0.02; z = 2.23; P < 0.03) but the caecal intubation rate was similar (P = 0.59) in both colonic insufflation techniques . CONCLUSION CI seems to have clinical advantages over AI for colonoscopy with regard to pain during and after the procedure.
Collapse
Affiliation(s)
- M S Sajid
- Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex
| | - J Caswell
- Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex
| | - M I Bhatti
- Department of General and Colorectal Surgery, Queen Elizabeth Hospital, King's Lynn NHS Foundation Trust, King's Lynn, Norfolk, UK
| | - P Sains
- Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex
| | - M K Baig
- Department of General, Endoscopic and Laparoscopic Colorectal Surgery, Western Sussex Hospitals NHS Trust, Worthing Hospital, Worthing, West Sussex
| | - W F A Miles
- Department of General and Colorectal Surgery, Queen Elizabeth Hospital, King's Lynn NHS Foundation Trust, King's Lynn, Norfolk, UK
| |
Collapse
|
|
37
|
Hsieh YH, Koo M, Leung FW. A patient-blinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy. Am J Gastroenterol 2014; 109:1390-1400. [PMID: 24890443 DOI: 10.1038/ajg.2014.126] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 03/18/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Minimal sedation obviates patient recovery burdens, but intolerable pain limits success of cecal intubation. Painless or minimally uncomfortable insertion ensures success of cecal intubation, current patient satisfaction, and willingness to repeat future colonoscopy with minimal sedation. Water immersion (WI) and water exchange (WE), when separately compared with air insufflation (AI), significantly reduced insertion pain. To assess comparative effectiveness, we conducted a randomized controlled trial with head-to-head comparison of these three methods. We hypothesized that WE could produce the highest proportion of patients reporting painless insertion. METHODS This prospective patient-blinded trial (NCT01535326) enrolled minimally sedated (25 mg intramuscular meperidine) patients randomized to AI, WI, or WE (90 patients/group) to aid insertion. The previously validated primary outcome was the proportion of patients reporting painless insertion. RESULTS Painless insertion was reported by 30.0% (AI), 43.3% (WI), and 61.1% (WE) of patients (P<0.001). Multivariate logistic regression analysis revealed that, after adjusting for gender, body mass index, abdominal compression, position change, insertion time to cecum, and length of scope at cecum, only WE was significantly associated with painless insertion compared with AI (odds ratio (OR)=0.08, 95% confidence interval (CI)=0.03-0.24, P<0.001) or WI (OR=0.14, 95% CI=0.05-0.40, P<0.001). Adenoma detection rate (ADR) in the right (cecum and ascending) colon was 11.1% (AI), 14.4% (WI), and 26.7% (WE) (P=0.015). The limitations included single site study with unblinded colonoscopist and assistant. CONCLUSIONS 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.
Collapse
Affiliation(s)
- Yu-Hsi Hsieh
- 1] Division of Gastroenterology, Department of Medicine, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan [2] Buddhist Tzu Chi University, School of Medicine, Hualien, Taiwan
| | - Malcolm Koo
- 1] Department of Medical Research, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan [2] Dalla Lana School of Public Health, University of Toronto, Ontario, Canada
| | - Felix W Leung
- 1] Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill, California, USA [2] David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
|
38
|
Dik VK, Moons LMG, Siersema PD. Endoscopic innovations to increase the adenoma detection rate during colonoscopy. World J Gastroenterol 2014; 20:2200-2211. [PMID: 24605019 PMCID: PMC3942825 DOI: 10.3748/wjg.v20.i9.2200] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Revised: 12/06/2013] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Up to a quarter of polyps and adenomas are missed during colonoscopy due to poor visualization behind folds and the inner curves of flexures, and the presence of flat lesions that are difficult to detect. These numbers may however be conservative because they mainly come from back-to-back studies performed with standard colonoscopes, which are unable to visualize the entire mucosal surface. In the past several years, new endoscopic techniques have been introduced to improve the detection of polyps and adenomas. The introduction of high definition colonoscopes and visual image enhancement technologies have been suggested to lead to better recognition of flat and small lesions, but the absolute increase in diagnostic yield seems limited. Cap assisted colonoscopy and water-exchange colonoscopy are methods to facilitate cecal intubation and increase patients comfort, but show only a marginal or no benefit on polyp and adenoma detection. Retroflexion is routinely used in the rectum for the inspection of the dentate line, but withdrawal in retroflexion in the colon is in general not recommended due to the risk of perforation. In contrast, colonoscopy with the Third-Eye Retroscope® may result in considerable lower miss rates compared to standard colonoscopy, but this technique is not practical in case of polypectomy and is more time consuming. The recently introduced Full Spectrum Endoscopy™ colonoscopes maintains the technical capabilities of standard colonoscopes and provides a much wider view of 330 degrees compared to the 170 degrees with standard colonoscopes. Remarkable lower adenoma miss rates with this new technique were recently demonstrated in the first randomized study. Nonetheless, more studies are required to determine the exact additional diagnostic yield in clinical practice. Optimizing the efficacy of colorectal cancer screening and surveillance requires high definition colonoscopes with improved virtual chromoendoscopy technology that visualize the whole colon mucosa while maintaining optimal washing, suction and therapeutic capabilities, and keeping the procedural time as low and patient discomfort as optimal as possible.
Collapse
|
|
39
|
Abstract
Water-aided methods for colonoscopy include the established water immersion and the recent novel modification of water exchange. Water immersion entails the use of water as an adjunct to air insufflations to facilitate insertion. Water exchange evolved from water immersion to facilitate completion of colonoscopy without discomfort in unsedated patients. Infused water is removed predominantly during insertion rather than withdrawal. A higher adenoma detection rate has been reported with water exchange. Aggregate data of randomized controlled trials suggest that water exchange may be superior to water immersion in attenuating colonoscopy discomfort and optimizing adenoma detection, particularly in the proximal colon.
Collapse
Affiliation(s)
- Felix W Leung
- Division of Gastroenterology, Department of Medicine, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, 111G, 16111 Plummer Street, North Hill, CA 91343, USA.
| |
Collapse
|
|
40
|
Falt P, Šmajstrla V, Fojtík P, Liberda M, Kliment M, Tvrdík J, Urban O. Cap-assisted water immersion for minimal sedation colonoscopy: prospective, randomized, single-center trial. Dig Endosc 2013; 25:434-9. [PMID: 23808948 DOI: 10.1111/j.1443-1661.2012.01402.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 09/19/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Water immersion insertion is able to reduce discomfort and need for sedation during colonoscopy. A cap attached to the colonoscope tip may improve insertion during air insufflation colonoscopy. According to several reports, both techniques alone may result in higher detection of neoplastic lesions. Our study was designed to evaluate the efficacy of cap-assisted water immersion compared to water immersion colonoscopy in minimally sedated patients. METHODS A total of 208 consecutive outpatients were randomized to either cap-assisted water immersion (Cap Water) or water immersion colonoscopy (Water). The primary endpoint was cecal intubation time. RESULTS Cecal intubation time was 6.9 ± 2.9 min in Cap Water and 7.4 ± 4.2 min in the Water arm (P = 0.73). Success rate of minimal sedation colonoscopy was equal in both groups (92.9%, P = 1.00). From the endoscopist's point of view, there were non-significant trends towards lower discomfort (P = 0.06), less need for abdominal compression (P = 0.06) and lower difficulty score (P = 0.05) during Cap Water colonoscopy. Adenoma detection rate was similar in both arms (44% in Cap Water vs 45% in the Water group, P = 0.88). There were no complications recorded in the present study. CONCLUSIONS In comparison with water immersion without cap, cap-assisted water immersion colonoscopy was not able to shorten the cecal intubation time. However, it has the possibility of reducing patient discomfort and difficulty of colonoscope insertion. Potential impact on improved detection of neoplastic lesions has to be evaluated by further studies.
Collapse
Affiliation(s)
- Přemysl Falt
- Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic.
| | | | | | | | | | | | | |
Collapse
|
|
41
|
Water infusion versus air insufflation for colonoscopy: a meta-analysis of randomized controlled trials. Tech Coloproctol 2013; 17:487-96. [PMID: 23652813 DOI: 10.1007/s10151-013-1023-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 04/18/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this meta-analysis was to determine whether water infusion colonoscopy (WIC) is a more effective diagnostic tool than standard air insufflation colonoscopy (AIC). METHODS All articles pertinent to a comparison of water-related methods and air insufflation to facilitate insertion of the colonoscope were retrieved from PubMed, Web of Science, Embase, and Cochrane databases. Pooling results were derived by using the Review Manager Software. Outcomes were assessed using the weighted mean difference (MD) with 95 % confidence intervals (CI) for continuous variables and the odds ratios (OR) with 95 % CI for dichotomous variables. RESULTS Eighteen studies involving 2,797 patients were included. WIC was associated with a significantly higher cecal intubation rate than AIC (OR = 1.90; 95 % CI 1.21-2.99; p = 0.005). The intubation time was similar for the two types of colonoscopy, but in WIC there was a significantly lower visual analog scale score for abdominal pain than in AIC (MD = -1.30; 95 % CI -2.03 to -0.58; p < 0.001) without sacrificing the polyp detection rate (OR = 1.17; 95 % CI 0.78-1.77; p = 0.44). Statistically, the patient's willingness to repeat colonoscopy was significantly greater for WIC than for AIC (OR = 1.74; 95 % CI 1.14-2.67; p < 0.01). Furthermore, in the subgroup for trainees, the WIC group achieved a higher cecal intubation rate (OR = 1.83; 95 % CI 1.15-2.93; p = 0.01) and a shorter intubation time (MD = -1.72 min; 95 % CI -3.34 to -0.11; p = 0.04) than the AIC group. CONCLUSIONS In contrast to AIC, WIC improved cecal intubation, alleviated abdominal pain, and increased patients' willingness to repeat the procedure.
Collapse
|
|
42
|
Luo H, Zhang L, Liu X, Leung FW, Liu Z, Wang X, Xue L, Wu K, Fan D, Pan Y, Guo X. Water exchange enhanced cecal intubation in potentially difficult colonoscopy. Unsedated patients with prior abdominal or pelvic surgery: a prospective, randomized, controlled trial. Gastrointest Endosc 2013; 77:767-73. [PMID: 23394837 DOI: 10.1016/j.gie.2012.12.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 12/09/2012] [Indexed: 12/25/2022]
Abstract
BACKGROUND Colonoscopy is widely used for management of colorectal diseases. A history of abdominal or pelvic surgery is a well-recognized factor associated with difficult colonoscopy. Although water exchange colonoscopy (WEC) was effective in small groups of male U.S. veterans with such a history, its application in other cultural settings is uncertain. OBJECTIVE To investigate the application of WEC in such patients. DESIGN Prospective, randomized, controlled, patient-blinded study. SETTING Tertiary-care referral center in China. PATIENTS Outpatients with prior abdominal or pelvic surgery undergoing unsedated diagnostic, screening, or surveillance colonoscopy. INTERVENTION Patients were randomized to examination by either WEC or conventional air colonoscopy (AC). MAIN OUTCOME MEASUREMENTS Cecal intubation rate. RESULTS A total of 110 patients were randomized to the WEC (n = 55) or AC (n = 55) group. WEC significantly increased the cecal intubation rate (92.7% vs 76.4%; P = .033). The maximum pain scores (± standard deviation) were 2.1 ± 1.8 (WEC) and 4.6 ± 1.7 (AC), respectively (P < .001). Multivariate analysis showed that the colonoscopy method was the only independent predictor of failed colonoscopy (odds ratio 11.44, 95% confidence interval, 1.35-97.09). A higher proportion of patients examined by WEC would be willing to have a repeat unsedated colonoscopy (90.9% vs 72.7%, P = .013). LIMITATIONS Single center; unblinded but experienced endoscopists. CONCLUSION This randomized, controlled trial confirms that the water exchange method significantly enhanced cecal intubation in potentially difficult colonoscopy in unsedated patients with prior abdominal or pelvic surgery. The lower pain scores and higher proportion accepting repeat of the unsedated option suggest that WEC is promising. It may enhances compliance with colonoscopy in specific populations. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01485133.).
Collapse
Affiliation(s)
- Hui Luo
- Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, China
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
43
|
Lin S, Zhu W, Xiao K, Su P, Liu Y, Chen P, Bai Y. Water intubation method can reduce patients' pain and sedation rate in colonoscopy: a meta-analysis. Dig Endosc 2013; 25:231-240. [PMID: 23368955 DOI: 10.1111/den.12018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 11/06/2012] [Indexed: 12/23/2022]
Abstract
Several randomized controlled trials (RCT) have shown that water infusion in lieu of air insufflation reduces sedation rate and pain score and increases cecal intubation rate in colonoscopy. The aim of the present study was to confirm the beneficial effects of the water intubation method over the air method. Electronic databases were searched to identify RCT reporting colonoscopy detection using the water method. The pooled data of sedation rate, pain score and other procedure-related outcomes were analyzed. Then, 15 full-text articles were selected and assessed. Nine trials with high-quality scores were enrolled into this meta-analysis including a total of 1414 participants. Pooled odds ratio (OR) of sedation rate was 0.392 (95% confidence interval (CI): 0.288-0.533, P = 0.000). Pooled weighted mean difference (WMD) of pain score was -1.543 (95% CI: -2.107--1.069,P = 0.000). Pooled OR of cecal intubation rate was 1.90 (95% CI: 1.29-2.82, P = 0.001). Pooled OR of polyp detection rate and adenoma detection rate were 0.805 (95% CI: 0.606-1.069, P = 0.134) and 0.913 (95% CI: 0.681-1.223, P = 0.168), respectively. Pooled WMD of cecal intubation time was 0.701 (95% CI: -0.486-1.889, P = 0.247). This meta-analysis confirmed that the water method significantly reduced sedation rate and degree of pain without decreasing cecal intubation rate and disease detection rate and without requiring more cecal intubation time, suggesting that the novel water method is better than the conventional air method in colonoscopy detection.
Collapse
Affiliation(s)
- Siheng Lin
- Department of Gastroenterology, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | | | | | | | | | | | | |
Collapse
|
|
44
|
Maple JT, Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Song LMWK, Rodriguez SA. Methods of luminal distention for colonoscopy. Gastrointest Endosc 2013; 77:519-25. [PMID: 23415258 DOI: 10.1016/j.gie.2012.09.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 02/08/2023]
|
|
45
|
Jun WU, Bing HU. Comparative effectiveness of water infusion vs air insufflation in colonoscopy: a meta-analysis. Colorectal Dis 2013; 15:404-9. [PMID: 22889295 DOI: 10.1111/j.1463-1318.2012.03194.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Colonoscopy with air insufflation is known to result in abdominal pain and discomfort. We aimed to determine the effectiveness of water infusion during colonoscopy through a meta-analysis. METHOD Original papers and abstracts published up to October 2011 were searched in MEDLINE, EMBASE, Cochrane Library Database and important meeting abstracts. Clinical appraisal and data extraction were conducted by two reviewers independently. Statistical analysis was performed by meta-analysis using a fixed effects model or a random effects model. RESULTS Seven studies involving 872 patients were included. Meta-analysis showed that the water infusion group had fewer patients requiring abdominal compression or position change [risk ratio (RR) 0.73, 95% CI 0.59, 0.91], a lower mean pain score (RR -1.10, 95% CI -1.26, -0.95), lower maximum pain score (RR -2.34, 95% CI -2.92, -1.76) and fewer patients requiring on-demand sedation (RR 0.45, 95% CI 0.31, 0.66) than the air insufflation group during colonoscopy. There were no significant differences in caecal intubation rate, caecal intubation time, total procedure time and adenoma detection rate. CONCLUSION Water infusion significantly decreases patient discomfort and abdominal pain during colonoscopy without affecting operation time and intubation success rate.
Collapse
Affiliation(s)
- W U Jun
- Department of Endoscopy, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai, China
| | | |
Collapse
|
|
46
|
Vemulapalli KC, Rex DK. Water immersion simplifies cecal intubation in patients with redundant colons and previous incomplete colonoscopies. Gastrointest Endosc 2012; 76:812-7. [PMID: 22901988 DOI: 10.1016/j.gie.2012.05.033] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/23/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Interest in effective ways to complete colon examinations in patients who had previously undergone failed colonoscopies has increased recently. OBJECTIVE To determine whether water immersion decreased the need for ancillary equipment to achieve cecal intubation in patients who had previously undergone incomplete colonoscopies. DESIGN Retrospective cohort study. SETTING Tertiary academic center. PATIENTS A total of 345 consecutive patients referred to a tertiary center for the indication of a previous incomplete colonoscopy. INTERVENTIONS Colonoscopy with or without water immersion insertion. MAIN OUTCOME MEASUREMENTS Cecal intubation rates, type of equipment, and maneuvers used. RESULTS Cecal intubation was achieved in 332 of 345 patients (96.2%) and was similar in those with and without water immersion (170/178, 95.5% vs 162/167, 97%, P = .58). An external straightening device was used in 6 of 178 cases with water immersion (3.4%) compared with 25 of 168 cases with air insufflation (15%) (P < .0001). Among patients with a redundant colon as the sole cause of previously incomplete examinations, water immersion required an external straightener in 7% compared with 37% with air insufflation during insertion (P < .0001), and position change was required in 5% of those with water immersion compared with 22% with air insufflation (P = .01). LIMITATIONS Retrospective review; single-center, single-endoscopist study. CONCLUSION Water immersion decreases the need for external straightening devices and position change maneuvers in patients with redundant colons and previously incomplete colonoscopies.
Collapse
Affiliation(s)
- Krishna C Vemulapalli
- Department of Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | |
Collapse
|
|
47
|
Leung FW, Amato A, Ell C, Friedland S, Harker JO, Hsieh YH, Leung JW, Mann SK, Paggi S, Pohl J, Radaelli F, Ramirez FC, Siao-Salera R, Terruzzi V. Water-aided colonoscopy: a systematic review. Gastrointest Endosc 2012; 76:657-66. [PMID: 22898423 DOI: 10.1016/j.gie.2012.04.467] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 04/25/2012] [Indexed: 12/14/2022]
Abstract
BACKGROUND Water-aided methods for colonoscopy are distinguished by the timing of removal of infused water, predominantly during withdrawal (water immersion) or during insertion (water exchange). OBJECTIVE To discuss the impact of these approaches on colonoscopy pain and adenoma detection rate (ADR). DESIGN Systematic review. SETTING Randomized, controlled trial (RCT) that compared water-aided methods and air insufflation during colonoscope insertion. PATIENTS Patients undergoing colonoscopy. INTERVENTION Medline, PubMed, and Google searches (January 2008-December 2011) and personal communications of manuscripts in press were considered to identify appropriate RCTs. MAIN OUTCOME MEASUREMENTS Pain during colonoscopy and ADR. RCTs were grouped according to whether water immersion or water exchange was used. Reported pain scores and ADR were tabulated based on group assignment. RESULTS Pain during colonoscopy is significantly reduced by both water immersion and water exchange compared with traditional air insufflation. The reduction in pain scores was qualitatively greater with water exchange as compared with water immersion. A mixed pattern of increases and decreases in ADR was observed with water immersion. A higher ADR, especially proximal to the splenic flexure, was obtained when water exchange was implemented. LIMITATIONS Differences in the reports limit application of meta-analysis. The inability to blind the colonoscopists exposed the observations to uncertain bias. CONCLUSION Compared with air insufflation, both water immersion and water exchange significantly reduce colonoscopy pain. Water exchange may be superior to water immersion in minimizing colonoscopy discomfort and in increasing ADR. A head-to-head comparison of these 3 approaches is required.
Collapse
Affiliation(s)
- Felix W Leung
- Research and Medical Services, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, Los Angeles, California 91343, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
48
|
Yen AW, Leung JW, Leung FW. A new method for screening and surveillance colonoscopy: Combined water-exchange and cap-assisted colonoscopy. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:114-119. [PMID: 23805389 DOI: 10.4161/jig.23730] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Revised: 06/01/2012] [Accepted: 06/02/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Colonoscopy plays an important and central role in current colorectal cancer screening and prevention programs, but it is an imperfect tool. Adjunct techniques may help improve the performance of colonoscopy to increase the detection of polyps with neoplastic potential. This study investigates the novel approach of combined water-exchange and cap-assisted colonoscopy (WCC) and its impact on adenoma detection. METHODS A single-center single-colonoscopist consecutive group observational study to compare WCC with conventional air insufflation colonoscopy was performed. Data were collected from 50 consecutive patients undergoing outpatient colorectal cancer screening or polyp surveillance with WCC. Adenoma detection rates (ADR) and adenomas detected per colonoscopy (APC) were compared to a control group of 101 consecutive patients examined with conventional air colonoscopy during the immediate prior period. RESULTS Cecal intubation was achieved in all patients. As an emerging and alternative quality metric for colonoscopy, APC was significantly higher in the WCC group (3.08 vs. 1.50, p=0.0021). The conventional quality metric, overall ADR, was higher in the WCC group compared to the air colonoscopy group (70.0% vs. 59.4%, p=0.22). This difference was not statistically significant, likely due to a type II error. CONCLUSION The observational data suggest APC is a more sensitive indicator of quality colonoscopy than ADR. WCC shows promise as a novel technique that merges two simple adjunct methods to help improve the performance of colonoscopy. The data suggest larger, prospective studies are necessary to determine the true impact of water-exchange combined with cap-assisted maneuvers.
Collapse
Affiliation(s)
- Andrew W Yen
- Division of Gastroenterology, Sacramento Veterans Affairs Medical Center, VANCHCS ; Division of Gastroenterology and Hepatology, University of California Davis Medical Center
| | | | | |
Collapse
|
|
49
|
Fischer LS, Lumsden A, Leung FW. Water exchange method for colonoscopy: learning curve of an experienced colonoscopist in a U.S. community practice setting. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:128-132. [PMID: 23805393 DOI: 10.4161/jig.23734] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Revised: 06/15/2012] [Accepted: 06/05/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND Water exchange colonoscopy has been reported to reduce examination discomfort and to provide salvage cleansing in unsedated or minimally sedated patients. The prolonged insertion time and perceived difficulty of insertion associated with water exchange have been cited as a barrier to its widespread use. AIM To assess the feasibility of learning and using the water exchange method of colonoscopy in a U.S. community practice setting. SETTING Quality improvement program in nonacademic community endoscopy centers. SUBJECTS Patients undergoing sedated diagnostic, surveillance, or screening colonoscopy. METHODS After direct coaching by a knowledgeable trainer, an experienced colonoscopist initiated colonoscopy using the water method. Whenever >5 min elapsed without advancing the colonoscope, conversion to air insufflation was made to ensure timely completion of the examination. PRIMARY OUTCOME Water Method Intention-to-treat (ITT) cecal intubation rate (CIR). RESULTS Female patients had a significantly higher rate of past abdominal surgery and a significantly lower ITTCIR. The ITTCIR showed a progressive increase over time in both males and females to 85-90%. Mean insertion time was maintained at 9 to 10 min. The overall CIR was 99%. CONCLUSION Use of water exchange did not preclude cecal intubation upon conversion to usual air insufflation in sedated patients examined by an experienced colonoscopist. With practice ITTCIR increased over time in both male and female patients. Larger volumes of water exchanged were associated with higher ITTCIR and better quality scores of bowel preparation. The data suggest that learning water exchange by a busy colonoscopist in a community practice setting is feasible and outcomes conform to accepted quality standards.
Collapse
|
|
50
|
Leung F, Cheung R, Fan R, Fischer L, Friedland S, Ho S, Hsieh Y, Hung I, Li M, Matsui S, McQuaid K, Ohning G, Ojuri A, Sato T, Shergill A, Shoham M, Simons T, Walter M, Yen A. The water exchange method for colonoscopy-effect of coaching. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:122-125. [PMID: 23805391 DOI: 10.4161/jig.23732] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 06/05/2012] [Accepted: 06/07/2012] [Indexed: 02/07/2023]
Abstract
The growing popularity of water immersion is supported by its long history as an adjunct to air insufflation; after facilitating colonoscope passage, the infused water is conveniently removed during withdrawal. Water exchange, a modification of water immersion to minimize discomfort in scheduled unsedated patients in the U.S. is new. Even though it may be superior in reducing pain and increasing adenoma detection, the paradigm shift to complete exclusion of air during insertion necessitates removal of infused water containing residual feces, a step often perceived as laborious and time-consuming. The nuances are the efficient steps to remove infused water predominantly during insertion to maintain minimal distension and deliver salvage cleansing. Mastery of the novel maneuvers with practice returns insertion time towards baseline. In this observational study the impact of direct verbal coaching on the primary outcome of intention-to-treat cecal intubation was assessed. The results showed that 14 of 19 (74%) experienced colonoscopists achieved 100% intention-to-treat cecal intubation. Initiation of the examination with water exchange did not preclude completion when conversion to the more familiar air insufflation method was deemed necessary to achieve cecal intubation (total 98%). The overall intention-to-treat cecal intubation rate was 88%, 90% in male and 87% in female. Only 2.7% of bowel preparation was rated as poor during withdrawal. The mean volume of water infused and cecal intubation time was 1558 ml and 18 min, respectively. Direct coaching appears to facilitate understanding of the nuances of the water exchange method. Studies of individual learning curves are necessary.
Collapse
Affiliation(s)
- Fw Leung
- Gastroenterology, Sepulveda ACC, VAGLAHS, North Hills, CA, United States ; Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|