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Tang CP, Lin TL, Hsieh YH, Hsieh CH, Tseng CW, Leung FW. Polyp detection and false-positive rates by computer-aided analysis of withdrawal-phase videos of colonoscopy of the right-sided colon segment in a randomized controlled trial comparing water exchange and air insufflation. Gastrointest Endosc 2022; 95:1198-1206.e6. [PMID: 34973967 DOI: 10.1016/j.gie.2021.12.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Water exchange (WE) improves lesion detection but misses polyps because of human limitations. Computer-aided detection (CADe) identifies additional polyps overlooked by the colonoscopist. Additional polyp detection rate (APDR) is the proportion of patients with at least 1 additional polyp detected by CADe. The number of false positives (because of feces and air bubble) per colonoscopy (FPPC) is a major CADe limitation, which might be reduced by salvage cleaning with WE. We compared the APDR and FPPC by CADe between videos of WE and air insufflation in the right-sided colon. METHODS CADe used a convolutional neural network with transfer learning. We edited and coded withdrawal-phase videos in a randomized controlled trial that compared right-sided colon findings between air insufflation and WE. Two experienced blinded endoscopists analyzed the CADe-overlaid videos and identified additional polyps by consensus. An artifact triggered by CADe but not considered a polyp by the reviewers was defined as a false positive. The primary outcome was APDR. RESULTS Two hundred forty-five coded videos of colonoscopies inserted with WE (n = 123) and air insufflation (n = 122) methods were analyzed. The APDR in the WE group was significantly higher (37 [30.1%] vs 15 [12.3%], P = .001). The mean [standard deviation] FPPC related to feces (1.78 [1.67] vs 2.09 [2.09], P = .007) and bubbles (.53 [.89] vs 1.25 [2.45], P = .001) in the WE group were significantly lower. CONCLUSIONS CADe showed significantly higher APDR and lower number of FPPC related to feces and bubbles in the WE group. The results support the hypothesis that the strengths of CADe and WE complement the weaknesses of each other in optimizing polyp detection.
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Affiliation(s)
- Chia-Pei Tang
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; School of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Tu-Liang Lin
- Department of Management Information Systems, National Chiayi University, Chiayi, Taiwan
| | - Yu-Hsi Hsieh
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; School of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Chen-Hung Hsieh
- Department of Management Information Systems, National Chiayi University, Chiayi, Taiwan
| | - Chih-Wei Tseng
- Division of Gastroenterology, Department of Internal Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan; School of Medicine, Tzu Chi University, Hualien City, Taiwan
| | - Felix W Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California, USA; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
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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 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: 1.3] [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.
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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
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Adenoma and Advanced Adenoma Detection Rates of Water Exchange, Endocuff, and Cap Colonoscopy: A Network Meta-Analysis with Pooled Data of Randomized Controlled Trials. Dig Dis Sci 2021; 66:1175-1188. [PMID: 32451757 DOI: 10.1007/s10620-020-06324-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/04/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A network meta-analysis showed that low-cost optimization of existing resources was as effective as distal add-on devices in increasing adenoma detection rate (ADR). We assessed the impacts of water exchange (WE), Endocuff, and cap colonoscopy on ADR and advanced adenoma detection rate (AADR). We hypothesized that WE may be superior at improving ADR and AADR. METHODS The literature was searched for all randomized controlled trials (RCTs) that reported ADR as an outcome and included the keywords colonoscopy, and water exchange, Endocuff, or cap. We performed traditional network meta-analyses with random effect models comparing ADR and AADR of each method using air insufflation (AI) as the control and reported the odds ratios with 95% confidence interval. Performances were ranked based on P-score. RESULTS Twenty-one RCTs met inclusion criteria. Fourteen RCTs also reported AADR. Both WE [1.46 (1.20-1.76)] and Endocuff [1.39 (1.17-1.66)] significantly increase ADR, while cap has no impact on ADR [1.00 (0.82-1.22)]. P-scores for WE (0.88), Endocuff (0.79), cap (0.17), and AI (0.17) suggest WE has the highest ADR. WE [1.38 (1.12-1.70)], but not Endocuff [0.96 (0.76-1.21)] or cap [1.06 (0.85-1.32)], significantly increases AADR. P-scores for WE (0.98), cap (0.50), AI (0.31), and Endocuff (0.21) suggest WE is more effective at increasing AADR. The results did not change after adjusting for age, proportion of males, and withdrawal time. CONCLUSION WE may be the modality of choice to maximally improve ADR and AADR.
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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: 0.8] [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.
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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
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Water Exchange Insertion Colonoscopy-How You Can Do It Too. Am J Gastroenterol 2019; 114:703-704. [PMID: 30829676 DOI: 10.14309/ajg.0000000000000172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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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: 1.0] [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
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Leung JW, Yen AW, Jia H, Opada C, Melnik A, Atkins J, Feller C, Wilson MD, Leung FW. A prospective RCT comparing combined chromoendoscopy with water exchange (CWE) vs water exchange (WE) vs air insufflation (AI) in adenoma detection in screening colonoscopy. United European Gastroenterol J 2019; 7:477-487. [PMID: 31065365 DOI: 10.1177/2050640619832196] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/22/2019] [Indexed: 12/15/2022] Open
Abstract
Background A low adenoma detection rate (ADR) increases risks of interval cancers (ICs). Proximal colon flat polyps, e.g. serrated lesions (SLs), are difficult to find. Missed proximal colon flat lesions likely contribute to IC. Aims We compared chromoendoscopy with water exchange (CWE), water exchange (WE) and air insufflation (AI) in detecting adenomas in screening colonoscopy. Methods After split-dose preparation, 480 veterans were randomized to AI, WE and CWE. Results Primary outcome of proximal ADR (55.6% vs 53.4% vs 52.2%, respectively) were similar in all groups. Adenoma per colonoscopy (APC) and adenoma per positive colonoscopy (APPC) were comparable. Detection rate of proximal colon SLs was significantly higher for CWE and WE than AI (26.3%, 23.6% and 11.3%, respectively, p = 0.002). Limitations: single operator; SLs only surrogate markers of but not IC. Conclusions When an endoscopist achieves high-quality AI examinations with overall ADR twice (61.6%) the recommended standard (30%), use of WE and CWE does not produce further improvement in proximal or overall ADR. Comparable APC and APPC confirm equivalent withdrawal inspection techniques. WE alone is sufficient to significantly improve detection of proximal SLs. The impact of increased detection of proximal SLs by WE on prevention of IC deserves to be studied. This study is registered at ClinicalTrial.gov (NCT#01607255).
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Affiliation(s)
- J W Leung
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA.,Division of Gastroenterology and Hepatology, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - A W Yen
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - H Jia
- Department of Gastroenterology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - C Opada
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - A Melnik
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - J Atkins
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - C Feller
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - M D Wilson
- Clinical and Translational Science Center, Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, Sacramento, CA, USA
| | - F W Leung
- Sepulveda Ambulatory Care Center, Veteran Affairs Greater Los Angeles Healthcare System (VAGLAHS) and David Geffen School of Medicine at UCLA, North Hills, CA, USA
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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: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [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.
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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
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Leung FW, Jia H. Expert endorsement, a prerequisite to general acceptance, marked a significant milestone in the history of water exchange colonoscopy. Gastrointest Endosc 2018; 88:598-600. [PMID: 30217238 DOI: 10.1016/j.gie.2018.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Felix W Leung
- Departments of Gastroenterology and Medicine, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, California, USA; David Geffen School of Medicine at UCLA, North Hills and Los Angeles, California, USA
| | - Hui Jia
- Departments of Gastroenterology and Medicine, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, California, USA; 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
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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: 1.3] [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.
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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
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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: 1.0] [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.
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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
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Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017; 15:456-466. [PMID: 29142513 PMCID: PMC5683976 DOI: 10.5217/ir.2017.15.4.456] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/03/2017] [Accepted: 08/03/2017] [Indexed: 02/07/2023] Open
Abstract
Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.
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Affiliation(s)
- Otto S Lin
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, WA, USA
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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: 2.4] [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.).
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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
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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: 6] [Impact Index Per Article: 0.8] [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.
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Affiliation(s)
- Hyun Gun Kim
- Institute for Digestive Research, Soon Chun Hyang University College of Medicine, Seoul, Korea
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Abstract
Colonoscopy is an important and frequently performed procedure. It is effective in the prevention of colorectal cancer and is an important test in the investigation of many gastrointestinal symptoms. This review focuses on developments over the last 5 years that have led to changes in aspects of colonoscopy, including patient preparation, technical factors, therapeutic procedures, safety, and quality.
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Affiliation(s)
- Thomas J.W. Lee
- North Tyneside General Hospital, North Shields, UK
- Northern Region Endoscopy Group, North Shields, UK
| | - Shelley Nair
- North Tyneside General Hospital, North Shields, UK
| | | | - Matthew D. Rutter
- Northern Region Endoscopy Group, North Shields, UK
- University Hospital of North Tees, Stockton on Tees, UK
- School of Medicine, Pharmacy and Health, Durham University, Stockton-on-Tees, UK
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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: 0.4] [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.
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Rodríguez-García JL, Carmona-Sánchez R, Rosas-Vitorino C. Usefulness of oil lubrication during colonoscopy: A comparative study with the conventional technique. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:28-34. [PMID: 26780984 DOI: 10.1016/j.rgmx.2015.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 12/02/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND The different forms of lubrication are among the most simple, accessible, and economic techniques that have been implemented for improving the diagnostic performance of colonoscopy. AIM To determine whether the use of oil improved the number of complete colonoscopies, facilitated the procedure, reduced pain, or improved the study's diagnostic performance, compared with the conventional lubrication technique. PATIENTS AND METHODS One hundred and seventy-five patients referred for colonoscopy were alternately allocated to receive treatment with the standard lubrication method with chlorhexidine gel (group 1) or lubrication with corn oil administered through the working channel (group II). The number of complete colonoscopies, the length of time needed to reach the cecum, the degree of difficulty estimated by the endoscopist and the assistant, the level of pain at the end of the study estimated by the patient, and the endoscopic findings were all determined. RESULTS Eighty-eight patients made up group I and 87 made up group II. No statistically significant differences were found between the two groups in relation to general characteristics, the number of complete colonoscopies (93 vs. 97%, respectively), the time needed to reach the cecum (8:00 vs. 8:41min, respectively), the level of pain at the end of the study, or the detection of polyps. The degree of difficulty was slightly lower in group II, but with no statistical significance. CONCLUSIONS Lubrication with oil during colonoscopy did not improve the number of complete colonoscopies, did not facilitate the study, nor did it reduce pain or increase the diagnostic performance of the study, when compared with the conventional technique.
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Affiliation(s)
| | | | - C Rosas-Vitorino
- Departamento de Enfermería, Hospital Ángeles-CMP, San Luis Potosí, México
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Rodríguez-García J, Carmona-Sánchez R, Rosas-Vitorino C. Usefulness of oil lubrication during colonoscopy: A comparative study with the conventional technique. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2015.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Cadoni S, Falt P, Gallittu P, Liggi M, Mura D, Smajstrla V, Erriu M, Leung FW. Water Exchange Is the Least Painful Colonoscope Insertion Technique and Increases Completion of Unsedated Colonoscopy. Clin Gastroenterol Hepatol 2015; 13:1972-80.e1-3. [PMID: 25956838 DOI: 10.1016/j.cgh.2015.04.178] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 04/17/2015] [Accepted: 04/21/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Unsedated colonoscopy is acceptable for diagnostic, surveillance, and screening indications worldwide. However, insertion of the colonoscope can be painful; it is not clear which technique is least painful and thereby increases the likelihood of colonoscopy completion. We performed a head-to-head comparison of air insufflation (AI), carbon dioxide (CO2) insufflation, water immersion (WI), and water exchange (WE) to determine which combination of insertion techniques produces the least amount of pain. METHODS In a patient-blinded prospective trial, 624 subjects were assigned randomly to groups that underwent colonoscopy with AI-AI, CO2-CO2, WI-AI, WE-AI, WI-CO2, or WE-CO2 insertion and withdrawal techniques, including on-demand sedation, at the St. Barbara Hospital (Iglesias, Italy) or the Vìtkovice Hospital (Ostrava, Czech Republic), from October 2013 through June 2014. The primary outcome was real-time maximum insertion pain (0 = none, 10 = worst), recorded by an unblinded nurse assistant. At discharge, a blinded observer recorded the recalled maximum insertion pain and patients' and investigators' guesses about method or gas used. RESULTS Patients and investigators correctly guessed the method used for fewer than 44% of procedures, confirming adequate blinding. The correlation between real-time and recalled maximum insertion pain (r = 0.9; P < .0005) confirmed internal validation of the primary outcome. The WE group had the lowest scores: mean pain values were 5.2 for AI-AI (95% confidence interval [CI], 4.6-5.8), 4.9 for CO2-CO2 (95% CI, 4.3-5.4), 4.3 for WI-CO2 (95% CI, 3.8-4.9), 4.0 for WI-AI (95% CI, 3.5-4.5), 3.1 for WE-CO2 (95% CI, 2.7-3.4), and 3.1 for WE-AI (95% CI, 2.7-3.6) (P < .0005). The highest proportions of patients completing unsedated colonoscopy were in the WE groups. WE groups also had significantly better colon cleanliness, particularly in the transverse and right colon (P < .0005). One limitation of the study was that colonoscopists and assistants were not blinded to water-aided insertion methods. CONCLUSIONS In a prospective study of colonoscopy insertion methods, CO2 insufflation did not reduce real-time maximum insertion pain. Compared with AI or CO2, WI and WE reduced insertion pain. The least painful technique was WE, which significantly increased completion of unsedated colonoscopy and bowel cleanliness without prolonging insertion time. ClinicalTrials.gov number: NCT01954862.
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Affiliation(s)
- Sergio Cadoni
- Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias (Carbonia-Iglesias), Italy.
| | - Přemysl Falt
- Digestive Diseases Center, Vìtkovice Hospital, Zálužanského, Ostrava, Czech Republic
| | - Paolo Gallittu
- Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias (Carbonia-Iglesias), Italy
| | - Mauro Liggi
- Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias (Carbonia-Iglesias), Italy
| | - Donatella Mura
- Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias (Carbonia-Iglesias), Italy
| | - Vit Smajstrla
- Digestive Diseases Center, Vìtkovice Hospital, Zálužanského, Ostrava, Czech Republic
| | - Matteo Erriu
- Department of Surgical Sciences, University of Cagliari, Italy
| | - Felix W Leung
- Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California; David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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Falt P, Šmajstrla V, Fojtík P, Urban O, Hill M. Water-Aided Colonoscopy in Inflammatory Bowel Disease Patients-A Randomised, Single-Centre Trial. J Crohns Colitis 2015; 9:720-4. [PMID: 26040317 DOI: 10.1093/ecco-jcc/jjv093] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 05/20/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Water-aided colonoscope insertion reduces patients' discomfort and need for sedation in unsedated and minimally sedated patients. However, water-aided technique has never been studied in inflammatory bowel disease patients, characterised by younger age, structural changes of the colon and need for repeated colonoscopies. Our trial was designed to evaluate discomfort associated with water-aided colonoscopy compared with air insufflation in on-demand sedated patients with known inflammatory bowel disease. METHODS In a randomised, single-centre study, 92 patients were randomised to either water-aided insertion and air insufflation during withdrawal [Water] or air insufflation during both insertion and withdrawal [Air]. The main outcome measured was success rate of unsedated colonoscopy, defined as reaching the caecum without requiring sedation and with discomfort during insertion of less than or equal to 5 using 0-10 continuous scale [0 = none, 10 = maximum pain]. RESULTS Success rate of caecal intubation without sedation or invoking a discomfort score greater than 5 was significantly higher in the Water arm compared with the Air arm [73.9 vs 45.7%, p = 0.01]. Discomfort score during insertion [mean ± SD] was significantly lower in the Water than in the Air arm [3.8±2.4 vs 5.4±1.9, p < 0.001]. Other outcomes including procedural times, success rate of terminal ileum intubation, need for abdominal compression, and repositioning were comparable. There were no complications recorded in the study. CONCLUSIONS Compared with air insufflation, water-aided colonoscopy significantly reduces discomfort in on-demand sedated patients with inflammatory bowel disease, achieving comparable procedural outcomes.
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Affiliation(s)
- Přemysl Falt
- Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Vít Šmajstrla
- Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic
| | - Petr Fojtík
- Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic
| | - Ondřej Urban
- Digestive Diseases Center, Vítkovice Hospital, Ostrava, Czech Republic Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Martin Hill
- Institute of Endocrinology, Prague, Czech Republic
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Abstract
Adenoma detection rate (ADR) has emerged as a key quality metric for colonoscopy. Despite limitations, its major strength is based on its proven correlation with interval colorectal cancer. This has prompted extensive efforts to identify factors and interventions that improve ADR. Potentially modifiable factors that may influence ADR can be patient related (eg, bowel preparation), endoscopist related (eg, withdrawal time, quality of mucosal inspection, additional observers), or procedure related (eg, water infusion, additional examination of right colon, change in position, antispasmodics, colonoscopic equipment, and accessories). Providing endoscopists with educational material and/or feedback also seems to improve ADR.
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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: 5.0] [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.
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