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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: 1.0] [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.
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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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Hayman CV, Vyas D. Screening colonoscopy: The present and the future. World J Gastroenterol 2021; 27:233-239. [PMID: 33519138 PMCID: PMC7814366 DOI: 10.3748/wjg.v27.i3.233] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 11/10/2020] [Accepted: 12/11/2020] [Indexed: 02/06/2023] Open
Abstract
In the United States, colorectal cancer (CRC) is the second leading cause of mortality in men and women. We are now seeing an increasing number of patients with advanced-stage diagnosis and mortality from colorectal cancer before 50 years of age, which requires earlier screening. With the increasing need for CRC screening through colonoscopy, and thus endoscopists, easier and simpler techniques are needed to train proficient endoscopists. The most widely used approach by endoscopists is air insufflation colonoscopy, where air distends the colon to allow visualization of the colonic mucosa. This technique is un-comfortable for patients and requires an anesthetist to administer sedation. In addition, patients commonly complain about discomfort post-op as air escapes into the small bowel and cannot be adequately removed. Current research into the use of water insufflation colonoscopies has proved promising in reducing the need for sedation, decreasing discomfort, and increasing the visibility of the colonic mucosa. Future direction into water insufflation colonoscopies which have shown to be simpler and easier to teach may increase the number of proficient endoscopists in training to serve our aging population.
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Affiliation(s)
- Chelsea V Hayman
- College of Medicine, California Northstate University, Elk Grove, CA 95757, United States
| | - Dinesh Vyas
- College of Medicine, California Northstate University, Elk Grove, CA 95757, United States
- Department of Surgery, San Joaquin General Hospital, French Camp, CA 95231, United States
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Aziz M, Sharma S, Fatima R, Lee-Smith W, Sodeman T, Nawras A, Adler DG. How to increase proximal adenoma detection rate: a meta-analysis comparing water exchange, water immersion and air/CO 2 insufflation methods for colonoscopy. Ann Gastroenterol 2020; 33:178-186. [PMID: 32127739 PMCID: PMC7049237 DOI: 10.20524/aog.2020.0459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/30/2019] [Indexed: 12/12/2022] Open
Abstract
Background Recent meta-analyses have demonstrated a higher adenoma detection rate using the water exchange method (WE), compared to water immersion (WI) and air/CO2 insufflation (ACI). Proximal adenomas have a high miss rate owing to their location and appearance. We performed a systematic review and meta-analysis of studies comparing the WE and WI methods to the ACI method, with a primary focus on proximal adenoma detection rate. Methods The following databases were searched for our systematic review: Medline, Embase, Cochrane Library, CINAHL, and Web of Sciences. We included both randomized controlled trials and cohort studies. The primary outcome was proximal adenoma detection rate, and secondary outcomes were right adenoma detection rate and cecal intubation rate. Results A total of 12 studies (17 arms) with 5660 patients (2260 ACI, 2281 WE, and 1119 WI) were included. A higher proximal adenoma detection rate (risk ratio [RR] 1.30, 95% confidence interval [CI] 1.11-1.53; P=0.001) and right adenoma detection rate (RR 1.43, 95%CI 1.19-1.71; P≤0.001; I2=0%) were noted for the WE group compared to the ACI group. The WI group did not demonstrate a better detection rate of proximal or right adenomas. Conclusions The water exchange method for colonoscopy holds promise and should be encouraged in the clinical setting to increase proximal and right adenoma detection rates. This will in turn decrease the incidence of colorectal cancer.
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Affiliation(s)
- Muhammad Aziz
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Sachit Sharma, Rawish Fatima)
| | - Sachit Sharma
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Sachit Sharma, Rawish Fatima)
| | - Rawish Fatima
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio (Muhammad Aziz, Sachit Sharma, Rawish Fatima)
| | - Wade Lee-Smith
- Department of Internal Medicine, University of Toledo Libraries, Toledo, Ohio (Wade Lee-Smith)
| | - Thomas Sodeman
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio (Thomas Sodeman, Ali Nawras)
| | - Ali Nawras
- Department of Gastroenterology, University of Toledo Medical Center, Toledo, Ohio (Thomas Sodeman, Ali Nawras)
| | - Douglas G Adler
- Department of Gastroenterology, University of Utah, Salt Lake City, Utah (Douglas G. Adler), USA
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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: 0.7] [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.
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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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Abstract
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.
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Affiliation(s)
- Yang Liu
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Qing-Ke Huang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Xiu-Li Dong
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, China
| | - Piao-Piao Jin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang Province, 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: 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.
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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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Chaubal A, Pandey V, Patel R, Poddar P, Phadke A, Ingle M, Sawant P. Difficult colonoscopy: air, carbon dioxide, or water insufflation? Intest Res 2018; 16:299-305. [PMID: 29743844 PMCID: PMC5934604 DOI: 10.5217/ir.2018.16.2.299] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/26/2017] [Accepted: 06/26/2017] [Indexed: 12/28/2022] Open
Abstract
Background/Aims This study aimed to compare tolerance to air, carbon dioxide, or water insufflation in patients with anticipated difficult colonoscopy (young, thin, obese individuals, and patients with prior abdominal surgery or irradiation). Methods Patients with body mass index (BMI) less than 18 kg/m2 or more than 30 kg/m2, or who had undergone previous abdominal or pelvic surgeries were randomized to air, carbon dioxide, or water insufflation during colonoscopy. The primary endpoint was cecal intubation with mild pain (less than 5 on visual analogue scale [VAS]), without use of sedation. Results The primary end point was achieved in 32.7%, 43.8%, and 84.9% of cases with air, carbon dioxide and water insufflation (P<0.001). The mean pain scores were 5.17, 4.72, and 3.93 on the VAS for air, carbon dioxide, and water insufflation (P<0.001). The cecal intubation rate or procedure time did not differ significantly between the 3 groups. Conclusions Water insufflation was superior to air or carbon dioxide for pain tolerance. This was seen in the subgroups with BMI <18 kg/m2 and the post-surgical group, but not in the group with BMI >30 kg/m2.
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Affiliation(s)
- Alisha Chaubal
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Vikas Pandey
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Ruchir Patel
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Prateik Poddar
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Aniruddha Phadke
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Meghraj Ingle
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Prabha Sawant
- Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
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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: 0.3] [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.
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Hsieh YH, Leung FW. Response to Feuerstein. Am J Gastroenterol 2015; 110:475-476. [PMID: 25743719 DOI: 10.1038/ajg.2015.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Yu-Hsi Hsieh
- 1] Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan [2] Tzu Chi University, School of Medicine, Hualien, Taiwan
| | - 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
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Tutticci N, Bourke MJ. Advances in colonoscopy. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2014; 12:119-139. [PMID: 24615389 DOI: 10.1007/s11938-014-0009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Colonoscopy with polypectomy has been established as the major prevention and detection strategy for colorectal cancer for over a decade. Over this period advances in colonoscopic imaging, polyp detection, prediction of histopathology and polypectomy techniques have all been seen; however, the true magnitude of the limitations of colonoscopy has only recently been widely recognized. The rate and location of missed or interval cancers after complete colonoscopy appears to be influenced by the operator-dependency of colonoscopy and failure of conventional practices to detect and treat adenomatous, and possibly more importantly, non-adenomatous colorectal cancer precursors. Consequently, studies that expand our understanding of these factors and advances that aim to improve colonoscopy, polypectomy, and cancer protection are of critical importance.
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Affiliation(s)
- Nicholas Tutticci
- Department of Gastroenterology and Hepatology, Westmead Hospital, 106A/151 Hawkesbury Road, Westmead, NSW, 2145, Australia,
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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.
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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.
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Young PE, Womeldorph CM. Colonoscopy for colorectal cancer screening. J Cancer 2013; 4:217-26. [PMID: 23459594 PMCID: PMC3584835 DOI: 10.7150/jca.5829] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 02/08/2013] [Indexed: 02/07/2023] Open
Abstract
Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Many, if not most, cases arise from premalignant lesions (adenomas) which may be identified and removed prior to becoming frankly malignant. For over a decade, colonoscopy has been the preferred modality for both CRC screening and prevention in the US. Early reports suggested that colonoscopic screening imparted a 90% risk reduction for colorectal cancer. Subsequent studies showed that estimate to be overly optimistic. While still an outstanding CRC screening and detection tool, colonoscopy has several important limitations. Some of these limitations relate to the mechanics of the procedure such as the risk of colonic perforation, bleeding, adverse consequences of sedation, and the inability to detect all colonic polyps. Other limitations reflect issues with patient perception regarding colonoscopy which, at least in part, drive patient non-adherence to recommended testing. This review examines the literature to address several important issues. First, we analyze the effect of colonoscopy on CRC incidence and mortality. Second, we consider the patient-based, periprocedural, and intraprocedural factors which may limit colonoscopy as a screening modality. Third, we explore new techniques and technologies which may enhance the efficacy of colonoscopy for adenoma detection. Finally, we discuss the short and long-term future of colonoscopy for CRC screening and the factors which may affect this future.
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Affiliation(s)
- Patrick E Young
- 1. Fellowship Director, National Capital Consortium Gastroenterology Fellowship, Walter Reed National Military Medical Center, Bethesda, MD 20889, Associate Professor of Medicine, Uniformed Service University of Health Sciences, Bethesda, MD, USA
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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.
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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
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Rastogi A. Best of both worlds - combining water-exchange and cap assisted colonoscopy. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:120-121. [PMID: 23805390 DOI: 10.4161/jig.23731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 08/03/2012] [Indexed: 01/18/2023]
Affiliation(s)
- Amit Rastogi
- Kansas City VA Medical Center, University of Kansas, United States
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Leung FW. Benchmarking and quality-screening colonoscopy. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:100-102. [PMID: 23805385 DOI: 10.4161/jig.23726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 05/07/2012] [Accepted: 05/08/2012] [Indexed: 12/17/2022]
Affiliation(s)
- Felix W Leung
- Gastroenterology, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill ; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Leung JW, Thai A, Yen A, Ward G, Abramyan O, Lee J, Smith B, Leung F. Magnetic endoscope imaging (ScopeGuide) elucidates the mechanism of action of the pain-alleviating impact of water exchange colonoscopy - attenuation of loop formation. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:142-146. [PMID: 23805397 DOI: 10.4161/jig.23738] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 10/15/2012] [Accepted: 10/15/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND The explanation why water exchange colonoscopy produces a significant reduction of pain during colonoscopy is unknown. A recent editorial recommended use of magnetic endoscope imaging (MEI) to elucidate the explanation. OBJECTIVE In unselected patients to show that MEI documents less frequent loop formation when water exchange is used. DESIGN Observational, performance improvement. SETTING Veterans Affairs outpatient endoscopy. PATIENTS Routine colonoscopy cases. INTERVENTIONS Colonoscopy using air or water exchange method was performed as previously described. The MEI equipment (ScopeGuide, Olympus) with built-in magnetic sensors displays the configuration of the colonoscope inside the patient. During sedated colonoscopy the endoscopist was blinded to the ScopeGuide images which were recorded and subsequently reviewed. MAIN OUTCOME MEASURES Loop formation based on a visual guide provided by Olympus. RESULTS There were 41 and 32 cases in the water exchange and air group, respectively. The sigmoid N loop was most common, followed by the sigmoid alpha loop, and exaggeration of scope curvature at the splenic flexure/transverse colon. Of these, 20/32 vs. 9/41 patients (p=0.0007) had sigmoid looping, and 17/32 vs. 9/41 patients (p=0.0007) had sigmoid/splenic looping when the scope tip was in the transverse colon, in the air and water exchange group, respectively. LIMITATIONS Colonoscopy method was not blinded and non randomized. CONCLUSION MEI data objectively demonstrated significantly fewer loops during water exchange colonoscopy, elucidating its mechanism of pain alleviation - attenuation of loop formation. Since MEI feedback enhances cecal intubation by trainees, the role of MEI combined water exchange in speeding up trainee learning curves deserves further evaluations.
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Affiliation(s)
- Joseph W Leung
- Gastroenterology, Sacramento VA Medical Center, Mather, CA ; Gastroenterology, UC Davis Medical Center, Sacramento
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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.
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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
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