Endoscopy 2011; 43(9): 816-821
DOI: 10.1055/s-0030-1256407
Innovation forum

© Georg Thieme Verlag KG Stuttgart · New York

The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy

F.  W.  Leung1 , 2 , J.  W.  Leung3,4 , S.  K.  Mann3 , 4 , S.  Friedland5 , 6 , F.  C.  Ramirez7
  • 1Research and Medical Services, Sepulveda Ambulatory Care Center, VAGLAHS, North Hills, California, USA
  • 2David Geffen School of Medicine at University of California, Los Angeles, USA
  • 3Gastroenterology, University of California Davis Medical Center, Sacramento, California, USA
  • 4Sacramento Veterans Affairs Medical Center, Mather, California, USA
  • 5Palo Alto Veterans Affairs Medical Center, Palo Alto, California, USA
  • 6Stanford University School of Medicine, Palo Alto, California, USA
  • 7Carl T Hayden Veterans Affairs Medical center, Phoenix, Arizona, USA (current affiliation: Mayo Medical School, Mayo Clinic, Scottsdale, Arizona)
Further Information

Publication History

30 November 2010

accepted after revision 6 March 2011

Publication Date:
24 May 2011 (online)

Failure of cecal intubation when using air insufflation during scheduled unsedated colonoscopy in veterans prompted a literature search for a less uncomfortable approach. Water-related maneuvers as “adjuncts” to air insufflation were identified as effective in minimizing discomfort, although medication requirement was not reduced and willingness to repeat unsedated colonoscopy was not addressed. These adjunct maneuvers were combined with turning the air pump off to avoid colon elongation during insertion. Warm water infusion in lieu of air insufflation was evaluated in observational studies. Subsequent refinements evolved into the water method – a combination of air exclusion by aspiration of residual air to minimize angulations at flexures and a dynamic process of water exchange to remove feces in order to clear the view and aid insertion. In subsequent randomized controlled trials, the water method significantly reduced medication requirement, increased the proportion of patients in whom complete unsedated colonoscopy could be achieved, reduced patient recovery time burdens (sedation on demand), decreased abdominal discomfort during and after colonoscopy, enhanced cecal intubation, and increased willingness to repeat the procedure (scheduled unsedated). Supervised education of trainees and self-learning by an experienced colonoscopist were feasible. Lessons learned in developing the water method for optimizing patient-centered outcomes are presented. These proof-of-principle observations merit further research assessment in diverse settings.

References

  • 1 Leung F W. Water-related method for performance of colonoscopy.  Dig Dis Sci. 2008;  53 2847-2850
  • 2 Leung J W, Salera R, Toomsen L et al. A pilot feasibility study of the method of water infusion without air insufflation in sedated colonoscopy.  Dig Dis Sci. 2009;  54 1997-2001
  • 3 Leung J W, Mann S, Leung F W. Option for screening colonoscopy without sedation – a pilot study in United States veterans.  Aliment Pharmacol Ther. 2007;  26 627-631
  • 4 Leung F W, Aharonian H S, Leung J W et al. Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans.  Gastrointest Endosc. 2009;  69 546-550
  • 5 Leung C W, Kaltenbach T, Soetikno R et al. Colonoscopy insertion technique using water immersion versus standard technique: a randomized trial showing promise for minimal-sedation colonoscopy.  Endoscopy. 2010;  42 557-562
  • 6 Leung J W, Mann S K, Siao-Salera R et al. A randomized, controlled comparison of warm water infusion in lieu of air insufflation versus air insufflation for aiding colonoscopy insertion in sedated patients undergoing colorectal cancer screening and surveillance.  Gastrointest Endosc. 2009;  70 505-510
  • 7 Ransibrahmanakul K, Leung J W, Mann S K et al. Comparative effectiveness of water vs. air methods in minimal sedation colonoscopy performed by supervised trainees in the US – a RCT.  Am J Clin Med. 2010;  7 113-118
  • 8 Leung J W, Mann S K, Siao-Salera R et al. A proof-of-concept RCT to confirm the beneficial effects of the water method on US veterans undergoing colonoscopy with the option of on demand sedation.  Gastrointest Endosc. 2011;  73 103-110
  • 9 Leung F W, Harker J O, Jackson G et al. A proof-of-principle, prospective, randomized controlled trial (RCT) demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method.  Gastrointestinal Endoscopy. 2010;  72 693-700
  • 10 Ramirez F C, Leung F W. Adopting the water method: lessons, tips and pitfalls learned.  Am J Clin Med. 2010;  7 137-139
  • 11 Leung F W. Is there a place for sedationless colonoscopy?.  J Interv Gastroenterol. 2011;  1 19-22

F. W. Leung MD

Division of Gastroenterology (111G)
David Geffen School of Medicine at University of California, Los Angeles
Sepulveda Ambulatory Care Center
Veterans Affairs Greater Los Angeles Healthcare System

16111 Plummer Street
Sepulveda, CA 91343
USA

Fax: +1-818-895-9516

Email: felix.leung@va.gov