SAN DIEGO — One third of veterans offered colonoscopy without sedation agreed to the procedure, which was conducted safely and successfully with high levels of patient satisfaction, according to results of a prospective study presented at the annual Digestive Disease Week.
A key to the good results seems to have been the use of water infusion in place of air insufflation in about half of the patients studied.
In 2002, the staff at Sepulveda Ambulatory Care Center began offering unsedated colonoscopy because of a nursing shortage in the Los Angeles area, said Dr. Felix Leung, professor of medicine at the University of California, Los Angeles. Sepulveda is part of the VA of Greater Los Angeles HealthCare system.
Veterans could choose to have an unsedated procedure at Sepulveda, or go to a facility in West Los Angeles for a sedated colonoscopy. Speaking with reporters, Dr. Leung said that unsedated colonoscopy is fairly common in most of the world, and that in the United States, acceptance has ranged from 1% to 7%, according to the literature.
At Sepulveda, about a third of patients needing colonoscopy have agreed to have it without sedation over the last 5 years, and about a quarter have agreed to this at the VA Northern California health care system facility, said Dr. Leung, who is also chief of gastroenterology at Sepulveda. When a colonoscopy is required, patients are told about the pros and cons, he said. On the plus side, they are told that they can talk during the exam, that they can drive themselves home, and that there is no recovery time. However, they are told “that they would feel every little thing that we do to them, including pain and discomfort,” Dr. Leung said.
“I try to do everything I can to not coerce them” into having a procedure without sedation, he added.
Physicians explain that they will do everything possible to minimize the discomfort, but patients are not given any pharmaceutical agents, such as diazepam (Valium), Dr. Leung said in an interview.
Dr. Leung and his colleagues had been looking for a simple, inexpensive method of easing discomfort, one that could be controlled by the endoscopist. In doing a literature search, they determined that using water infusion might be appropriate. Most published accounts described using water as an adjunct to air. Dr. Leung and his colleagues decided to try water in place of air, to make it easier to train fellows, he said.
Dr. Leung and his colleagues prospectively tracked patients who underwent colonoscopy without sedation during a period of about 2 years and 4 months (July 2005 to June 2006 and July 2006 to November 2007). In 2006, colonoscopies were performed with air insufflation, but in 2007, the new water method was used.
With the water method, aliquots of 30–60 mL of warm water were used to open the collapsed lumen at the start of the sigmoid colon. When the water became turbid, it was suctioned out and replaced with new, clean water.
The air cohort included 62 patients, and the water group had 66. Among the 62 in the first group, 54 (87%) had satisfactory bowel prep; 8 (13%) could not complete because of poor bowel prep, and 7 (11%) could not complete because of discomfort. Forty-seven of the 54 who completed (87%) had a successful cecal intubation. Forty-one (76%) said they had a good experience, and 42 (78%) were willing to repeat it without sedation.
Results were much better for the water infusion group, partly “because the water method provided us with a more complete look at the colon,” said Dr. Leung, noting that this was an incidental finding. Based on this study and accumulating experience, he believes that the water makes it easier to pass through narrow segments and does not significantly lengthen the colon, as air does.
The water method also resulted in fewer procedures being rescheduled for poor bowel prep, an especially common occurrence with the older veterans, he said.
The rescheduling rate went from 13% in 2006 to 1.5% in 2007. Only 1 of the 66 patients who had unsedated procedures had an incomplete exam because of poor bowel prep in 2007, he said. Two patients could not complete the study because of discomfort. Of the 66 patients, 63 (97%) had successful cecal intubation, 55 (85%) had a good experience, and 60 (92%) said they would repeat the procedure without sedation.
The water method is not a standard of practice yet. But Dr. Leung said he and his colleagues are now conducting a prospective study in which they are randomly assigning unsedated patients to either air or water.