RSS-Feed abonnieren
DOI: 10.1055/s-0033-1353604
A two-center randomized controlled trial of water-aided colonoscopy versus air insufflation colonoscopy
Publikationsverlauf
submitted 11. März 2013
accepted after revision 18. September 2013
Publikationsdatum:
11. November 2013 (online)
Background and study aim: Water-aided colonoscopy includes water immersion and water exchange. Several small single-center studies have suggested that the use of water rather than air insufflation during colonoscopy reduces pain on insertion. The aim of this study was to investigate whether water-aided colonoscopy is less painful than air insufflation in a large cohort of patients.
Patients and methods: This was a two-center, randomized controlled trial. Consecutive patients who agreed to start colonoscopy without premedication were included. Sedation was administered on demand. Water-aided colonoscopy was performed using water immersion in the early phase of the study, and subsequently water exchange was used. The primary endpoint was cecal intubation with pain scores of ≤ 2 and sedation with no or ≤ 2 mg midazolam. Secondary outcomes were pain score at discharge, cecal intubation rate and time, and adenoma detection rate (ADR).
Results: A total of 672 patients were randomized to water exchange (n = 338) or air insufflation (n = 334). The primary endpoint was achieved in more patients in the water exchange group (83.8 % vs. 62 %; P < 0.0005). On-demand sedation was also required less (11.5 % vs. 26.0 %; P < 0.0005) and mean pain score was lower (1.3 vs. 2.3; P < 0.0005) in the water exchange group. The cecal intubation rates were comparable. Water exchange had a significantly higher overall ADR (25.8 % vs. 19.1 %; P = 0.041), proximal ADR (10.1 % vs. 4.8 %; P = 0.014), and proximal < 10 mm ADR (7.7 % vs. 3.9 %; P = 0.046); proximal ADR was also higher in screening-only patients in the water exchange group (18.9 % vs. 7.4 %; P = 0.015). No detailed analysis was possible for the air insufflation vs. water immersion comparison.
Conclusion: The current results confirmed that water exchange minimized the requirement for sedation and increased the ADR.
-
References
- 1 Riphaus T, Wehrmann B, Weber JA et al. ESGE guideline: Sedation for gastrointestinal endoscopy 2008. Endoscopy 2009; 41: 787-815
- 2 Leung CW, 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
- 3 Leung FW, Leung JW, Mann SK et al. The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy. Endoscopy 2011; 43: 816-821
- 4 Jang HW, Cheon JH, Nam CM et al. Factors affecting insertion time for colonoscopy performed under intramuscular analgesia in patients with history of colorectal resection. Surg Endosc 2011; 25: 2316-2322
- 5 Radaelli F, Paggi S, Amato A et al. Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial. Gastrointest Endosc 2010; 72: 701-709
- 6 Wasan SK, Schroy PC. Water-assisted unsedated colonoscopy: does the end justify the means?. Gastrointest Endosc 2009; 69: 551-553
- 7 Davila ML, Davila RE. The demise of air insufflation and the rise of the warm water infusion method. Gastrointest Endosc 2009; 70: 511-514
- 8 Robbins DH. Unsedated colonoscopy: just add water?. Gastrointest Endosc 2010; 72: 710-711
- 9 Friedland S. The water immersion technique for colonoscopy insertion. Gastroenterol Hepatol 2010; 6: 555-556
- 10 Leung FW. Water exchange may be superior to water immersion for colonoscopy. Clin Gastroenterol Hepatol 2011; 9: 1012-1014
- 11 Leung FW, Amato A, Ell C et al. Water-aided colonoscopy: a systematic review. Gastrointest Endosc 2012; 76: 657-666
- 12 World Health Organization. World Health Organization Handbook for good clinical research practice (GCP): guidance for implementation. Geneva: WHO; 2005: 21-26
- 13 Brocchi E, Pezzilli R, Tomassetti P et al. Warm water or oil-assisted colonoscopy: toward simpler examinations?. Am J Gastroenterol 2008; 103: 581-587
- 14 Pohl J, Messer I, Behrens A et al. Water infusion for cecal intubation increases patient tolerance, but does not improve intubation of unsedated colonoscopies. Clin Gastroenterol Hepatol 2011; 9: 1039-1043
- 15 Rex DK, Petrini JL, Baron TH et al. Quality indicators for colonoscopy. ASGE/ACG Taskforce on Quality in Endoscopy. Am J Gastroenterol 2006; 101: 873-885
- 16 Leung FW, Harker JO, Jackson G et al. A proof-of-principle, prospective, randomized controlled trial (RCT) demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method. Gastrointest Endosc 2010; 72: 693-700
- 17 Vemulapalli KC, Rex DK. Water immersion simplifies cecal intubation in patients with redundant colons and previous incomplete colonoscopies. Gastrointest Endosc 2012; 76: 812-817
- 18 Leung JW, Mann S, Leung FW. Option for screening colonoscopy without sedation – a pilot study in United States veterans. Aliment Pharmacol Ther 2007; 26: 627-631
- 19 Leung FW, Aharonian HS, Leung JW et al. Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans. Gastrointest Endosc 2009; 69: 546-550
- 20 Leung JW, Thai A, Yen A et al. Magnetic endoscope imaging (ScopeGuide) elucidates the mechanism of action of the pain-alleviating impact of water exchange colonoscopy – attenuation of loop formation. J Interv Gastroenterol 2013; 2: 150-154
- 21 Fischer LS, Lumsden A, Leung FW. Water exchange method for colonoscopy: learning curve of an experienced colonoscopist in a U.S. community practice setting. J Interv Gastroenterol 2012; 2: 136-140
- 22 Takahashi Y, Tanaka H, Kinjo M et al. Prospective evaluation of factors predicting difficulty and pain during sedation-free colonoscopy. Dis Colon Rectum 2005; 48: 1295-1300
- 23 Luo H, Zhang L, Liu W et al. Water exchange enhanced cecal intubation in potentially difficult colonoscopy. Unsedated patients with prior abdominal or pelvic surgery: a prospective, randomized, controlled trial. Gastrointest Endosc 2013; 77: 767-773
- 24 Leung JW, Mann SK, Siao-Salera RM et al. A randomized, controlled trial to confirm the beneficial effects of the water method on U.S. veterans undergoing colonoscopy with the option of on-demand sedation. Gastrointest Endosc 2011; 73: 103-110
- 25 Al-Awabdy B, Wilcox MC. Use of anesthesia on the rise in gastrointestinal endoscopy. World J Gastrointest Endosc 2013; 5: 1-5
- 26 Maple JT, Banerjee S, Barth BA et al. ASGE technology status evaluation report. Methods of luminal distention for colonoscopy. Gastrointest Endosc 2013; 77: 519-525
- 27 Bressler B. Colonoscopic miss rates for right-sided colon cancer: a population-based analysis. Gastroenterology 2004; 127: 452-456
- 28 Baxter NN, Goldwasser MA, Paszat LF et al. Association of colonoscopy and death from colorectal cancer: a population-based, case–control study. Ann Intern Med 2009; 150: 1-8
- 29 Stock C, Pulte D, Haug U et al. Subsite-specific colorectal cancer risk in the colorectal endoscopy era. Gastrointest Endosc 2012; 75: 621-630
- 30 Kaminski MF, Regula J, Kraszewska E et al. Quality indicators for colonoscopy and the risk of interval cancer. New Engl J Med 2010; 362: 1795-1803
- 31 Ramirez FC, Leung FW. A head-to-head comparison of the water vs. air method in patients undergoing screening colonoscopy. J Interv Gastroenterol 2011; 1: 130-135
- 32 Leung FW, Leung JW, Siao-Salera RM et al. The water method significantly enhances detection of diminutive lesions (adenoma and hyperplastic polyp combined) in the proximal colon in screening colonoscopy – data derived from two RCT in US veterans. J Interv Gastroenterol 2011; 1: 48-52
- 33 Leung FW, Harker JO, Leung JW et al. Removal of infused water predominantly during insertion (water exchange) is consistently associated with an increase in adenoma detection rate – review of data in randomized controlled trials (RCTs) of water-related methods. J Interv Gastroenterol 2011; 1: 121-126
- 34 Rabenstein T, Radaelli F, Zolk O. Warm water infusion colonoscopy: a review and meta-analysis. Endoscopy 2012; 44: 940-948