Water-aided insertion and CO2-assisted withdrawal: Do we still need routine sedation for colonoscopy?

Clinical value of sigmoid colon water exchange colonoscopy: a prospective randomized clinical trial

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).

Water exchange versus air insufflation for colonoscopy: A meta-analysis

BACKGROUND/AIMS

To compare water exchange (WE) method with conventional air insufflation (AI) method for colonoscopy, evaluating the technical quality, screening efficacy, and patients' acceptance.

MATERIALS AND METHODS

Electronic databases were systematically searched for randomized controlled trials comparing WE colonoscopy with AI colonoscopy. The pooled data of procedure-associated and patient-related outcomes were assessed, using the weighted mean difference (WMD) with 95% confidence interval (CI) for continuous variables and relative risk (RR) with 95% CI for dichotomous variables, respectively.

RESULTS

A total of 13 studies involving 7056 patients were included. The cecum intubation rate was similar between WE and AI methods (RR = 1.01, 95% CI = 0.99-1.02,P = 0.37); however, a significantly longer cecum intubation time was shown in WE group (WMD = 1.56, 95% CI = 0.75-2.37,P = 0.002). Compared with AI, WE was associated with a higher risk of adenoma detection rate (ADR) (RR = 1.28, 95% CI = 1.18-1.38,P < 0.00001) and polyp detection rate (PDR) (RR = 1.30, 95% CI = 1.21-1.39,P < 0.00001). Patients in WE group experienced significantly less maximum pain score (WMD = -1.99, 95% CI = -2.68 to -1.30,P < 0.00001) and less requested on-demand sedation (RR = 0.58, 95% CI = 0.44-0.77,P = 0.0002). Likewise, they also experienced less abdominal compression (RR = 0.62, 95% CI = 0.51-0.74,P < 0.00001) and reposition (RR = 0.74, 95% CI = 0.63-0.86,P = 0.0001). Moreover, patients' willingness to repeat colonoscopy was significantly greater for WE (RR = 1.14, 95% CI = 1.07-1.21,P < 0.0001).

CONCLUSION

This meta-analysis confirmed that WE method could significantly increase ADR/PDR and improve patients' acceptance of colonoscopy, while reducing the degree of pain and minimize the need for on-demand sedation and adjunct maneuvers, despite requiring more cecal intubation time.

Do we really need an anesthesiologist for routine colonoscopy in American Society of Anesthesiologist 1 and 2 patients?

PURPOSE OF REVIEW

In an era where healthcare costs are being heavily scrutinized, every expenditure is reviewed for medical necessity. Multiple national gastroenterology societies have issued statements regarding whether an anesthesiologist is necessary for routine colonoscopies in American Society of Anesthesiologist (ASA) 1 and 2 patients.

RECENT FINDINGS

A large percentage of patients are undergoing screening colonoscopy without any sedation at all, which would not require an independent practitioner to administer medications. Advances in technique and technology are making colonoscopies less stimulating. Advantages to administering sedation, including propofol, have been seen even when not administered under the direction of an anesthesiologist and complications seem to be rare. The additional cost of having monitored anesthesia care appears to be a driving factor in whether a patient receives it or not.

SUMMARY

A large multiinstitutional randomized control trial would be necessary to rule out potential confounders and to determine whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients. Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected.

Effect of left lateral tilt-down position on cecal intubation time: a 2-center, pragmatic, randomized controlled trial

BACKGROUND AND AIMS

Colonoscopy insertion is technically challenging, time-consuming, and painful, especially for the sigmoid. Several pilot studies indicated that the (left) tilt-down position could facilitate the insertion procedure, but no formal trials have been published to demonstrate its efficacy. We performed this study to verify the benefits of the left lateral tilt-down position (LTDP) on the insertion process.

METHODS

This 2-center prospective trial randomized unsedated patients to the LTDP or left lateral horizontal position (LHP) to aid insertion. The primary outcome measure was cecal intubation time (CIT). Secondary outcome measures included decending colon intubation time (DIT), pain score of insertion, acceptance of unsedated colonoscopy for future examinations, difficulty score for insertion, and the adverse event rate of colonoscopy.

RESULTS

Two hundred fifty-eight patients were randomized to the LTDP (128) or LHP (130) in 2 centers. The median CIT and DIT were shorter with patients positioned in LTDP than in LHP (CIT, 280.0 vs 339.5 s, P < .001; DIT, 53.0 vs 69.0 s, P < .001, respectively) and patients with high and low body mass index (BMI) benefited more from LTDP than from LHP, as opposed to patients with normal BMI. In addition, colonoscopy insertion in LTDP was less painful (3.4 ± 1.6 vs 4.0 ± 1.7, P = .02) and less difficult (3.1 ± 1.9 vs 3.7 ± 1.4, P < .001), showing a higher tendency to acceptance of unsedated colonoscopy (82.9% vs 73.8%, P = .08). The rates of adverse events were extremely low and did not differ significantly in the 2 groups.

CONCLUSIONS

LTDP for colonoscopy insertion can reduce insertion time and pain, and potentially improves patients' acceptance of unsedated colonoscopy. (Clinical trial registration number: NCT02842489.).