Water immersion versus standard colonoscopy insertion technique: randomized trial shows promise for minimal sedation

Background and study aims: Water immersion is an alternative colonoscopy technique that may reduce discomfort and facilitate insertion of the instrument. This was a prospective study to compare the success of colonoscopy with minimal sedation using water immersion and conventional air insufflation.

Patients and methods: A total of 229 patients were randomized to either water immersion or the standard air insertion technique. The primary outcome was success of minimal sedation colonoscopy, which was defined as reaching the cecum without additional sedation, exchange of the adult colonoscope or hands-on assistance for trainees. Patient comfort and satisfaction were also assessed.

Results: Successful minimal-sedation colonoscopy was achieved in 51 % of the water immersion group compared with 28 % in the standard air group (OR, 2.66; 95 % CI 1.48 – 4.79; P = 0.0004). Attending physicians had 79 % success with water immersion compared with 47 % with air insufflation (OR, 4.19; 95 % CI 1.5 – 12.17; P = 0.002), whereas trainees had 34 % success with water compared with 16 % using air (OR, 2.75; 95 % CI 1.15 – 6.86; P = 0.01). Using the water method, endoscopists intubated the cecum faster and this was particularly notable for trainees (13.0 ± 7.5 minutes with water vs. 20.5 ± 13.9 minutes with air; P = 0.0001). Total procedure time was significantly shorter with water for both experienced and trainee endoscopists (P < 0.05). Patients reported less intraprocedural pain with water compared with air (4.1 ± 2.7 vs. 5.3 ± 2.7; P = 0.001), with a similar level of satisfaction. There was no difference in the neoplasm detection rates between the groups.

Conclusion: Colonoscopy insertion using water immersion increases the success rate of minimal sedation colonoscopy. Use of the technique leads to a decrease in discomfort, time to reach the cecum, and the amount of sedative and analgesic used, without compromising patient satisfaction.

References

• 1 Subramanian S, Liangpunsakul S, Rex D F. Preprocedure patient values regarding sedation for colonoscopy.  J Clin Gastroenterol. 2005;  39 516-519
• 2 Madan A, Minocha A. Who is willing to undergo endoscopy without sedation: patients, nurses, or the physicians?.  South Med J. 2004;  97 800-805
• 3 Early D S, Saifuddin T, Johnson J C. et al . Patient attitudes toward undergoing colonoscopy without sedation.  Am J Gastroenterol. 1999;  94 1862-1865
• 4 Rex D K, Khalfan H K. Sedation and the technical performance of colonoscopy.  Gastrointest Endosc Clin N Am. 2005;  15 661-672
• 5 Sharma V K, Nguyen C C, Crowell M D. et al . A national study of cardiopulmonary unplanned events after GI endoscopy.  Gastrointest Endosc. 2007;  66 27-34
• 6 Rex D K. Colonoscopy.  Gastrointest Endosc Clin N Am. 2000;  10 135-160
• 7 Hoff G, Bretthauer M, Dahler S. et al . Improvement in cecal intubation rate and pain reduction by using 3-dimensional magnetic imaging for unsedated colonoscopy: a randomized trial of patients referred for colonoscopy.  Scand J Gastroenterol. 2007;  42 885-889
• 8 Falchuk Z M, Griffin P H. A technique to facilitate colonoscopy in areas of severe diverticular disesase [letter].  New Engl J Med. 1984;  310 598
• 9 Abe K, Hara S, Takada Y. et al . A trial on water pouring method during colonoscopic insertion (In Japanese).  Yakuri To Chiryou. 1986;  14 108-112
• 10 Mizukami T, Maruyama K, Iwao T, Ishii H. ‘Collapse-submergence method’ and ‘self-abdominal manipulation’ are useful in the technically difficult case of colonoscopy (In Japanese).  Gastroenterol Endosc. 2004;  46 610
• 11 Mizukami T, Yokoyama A, Imaeda H, Kumai K. Collapse-submergence method: simple colonoscopic technique combining water infusion with complete air removal from the rectosigmoid colon.  Dig Endosc. 2007;  19 43-48
• 12 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
• 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 Church J M. Warm water irrigation for dealing with spasm during colonoscopy: simple, inexpensive, and effective.  Gastrointest Endosc. 2002;  56 672-674
• 15 Leung J W, Mann S K, Siao-Salera R. et al . Randomized controlled comparison of warm water infusion in lieu of air insufflation vs. air insufflation for aiding colonoscopy insertion in sedated patients undergoing colorectal cancer (CRC) screening and surveillance.  Gastrointest Endosc. 2009;  70 505-510
• 16 Evans S, Day S, Royston P. Minim: Allocation by minimisation in clinical trials: St George’s, University of London. http://Available from: www.sgul.ac.uk/depts/chs/discipline-groups/stat_guide/random.cfm
• 17 Williams C B. Insertion techniques. In: Waye J, Rex DK, Williams CB (eds). Colonosopy principles and practice. Malden, MA; Blackwell Publishing 2003: 318-338
• 18 Kim L S, Koch J, Yee J. et al . Comparison of patients’ experiences during imaging tests of the colon.  Gastrointest Endosc. 2001;  54 67-74
• 19 Leung J W, Mann S, Leung F W. Options for screening colonoscopy without sedation: a pilot study in United States veterans.  Aliment Pharmacol Ther. 2007;  26 627-631
• 20 Joint Commission of Accreditation of Healthcare Organizations .Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Joint Commission of Accreditation of Healthcare Organizations 2005