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Tu1320 Water Exchange Colonoscopy in a Non-Veteran Female Population
Abstracts
CIR and ADR (r⫽0.001, p⫽0.982).The mean ADR in the top quartile was 56.8% compared to 39.8% in the lowest quartile. There was no significant difference between these groups in the CIR, pain or any other measure from the lifetime procedure log. There was a significant difference in the MAP (1.64 compared to 0.77, p⬍0.01). Overall there was a strong correlation between ADR and MAP (r⫽0.59, p⬍0.001). Conclusions: These data show that even in a stratified group of high-performing colonoscopists there is considerable variation in performance in CIR, ADR and MAP. There was no correlation between CIR and ADR but a significant association between CIR and the endoscopic activity the previous year. Colonoscopists performing more procedures in their first year screening patients did not have higher adenoma detection rates. Further studies are needed to ascertain the factors responsible for these differences to try to further improve performance and patient outcomes.
Tu1320 Water Exchange Colonoscopy in a Non-Veteran Female Population Rafiul S. Islam*, Neal C. Patel, Shabana F. Pasha, Francisco C. Ramirez Gastroenterology, Mayo Clinic, Scottsdale, AZ Background: Compared to conventional air insufflation (AI) colonoscopy, water exchange (WE) colonoscopy has improved patient- and procedure-related outcomes. Most data in the US, however, is limited by a predominance of male subjects. Aim: To compare outcomes between AI and WE colonoscopy in female patients with men as controls. Methods: Setting: Endoscopy unit at an academic tertiary medical center.Study population: Patients undergoing outpatient colonoscopy by a single endoscopist experienced in both AI and WE colonoscopy.Study period: Nov 2011-Oct 2012Consecutive colonoscopies were retrospectively reviewed. The insertion phase of the procedure was either using WE or AI. During the withdrawal phase, inspection and polypectomies were performed using air insufflation in both groups. WE colonoscopy was started by turning the air pump off prior to insertion of the colonoscope. Water was infused via a pump connected to the base of the colonoscope and operated by a foot pedal. After cecal intubation was confirmed by suctioning the water and beginning air insufflation, photo documentation was captured. The insertion phase of AI colonoscopy was carried out using conventional air insufflation. Measurements: cecal intubation, withdrawal and total procedure times, and need for technician assistance for advancing the colonoscope (external pressure, change in patient’s position). In addition, adenoma and polyp detection rates (overall and for the proximal colon) as well as mean polyp and adenoma per patient were calculated. Need for intraprocedural sedation was also recorded.Statistics: Continuous data were compared using the Student’s t test and proportional data using Fisher’s exact test. Results: 222 colonoscopies were performed; 112 in the WE group and 110 in the AI group. The gender distribution was similar in both groups (56.3% males in WE; 51.8% males in AI). Outcomes of males and females are shown in Table 1. The need for external pressure was significantly lower in WE (for females only). In females, there was an increase of 12% in proximal polyps and adenomas for WE compared to AI. The lack of statistical significance may be due to a Type II error (small sample size). Conclusions: The water exchange colonoscopy method is a feasible alternative. The data in females confirms previous and current results in males. It is associated with numerically improved patient- and procedure-related outcomes compared to conventional air insufflation colonoscopy in both men and women. A randomized controlled trial with an adequate sample size in a non-veteran population is needed to define more fully the advantages of water exchange in the general population. Table 1. MEN
WOMEN
MEN
WOMEN
Water Air Water Air Exchange insufflation pExchange insufflation (WE) (AI) value (WE) (AI) p-value ADR 32 (51.6%) Proximal ADR 25 (39.7%) Added 23 (36.5%) sedation External 6 (9.5%) pressure Change in 3 (4.8%) position
31 (54.4%) 25 (43.9%) 26 (45.6%)
n.s n.s
21 (42.9%) 16 (32.7%) 39 (79.6%)
19 (35.8%) n.s 11 (20.8%) n.s. (0.20) 40 (75.5%)
11 (19.3%)
n.s
5 (10.2%)
18 (33.9%)
0.0046
4 (7.0%)
n.s
2 (4.1%)
6 (11.3%)
n.s. (0.20)
n.s. Non-significant
Tu1321 Does Water Assisted Colonoscopy Improve the Performance of Colonoscopy and Reduce Sedation Requirements?: Interim Analysis of a Randomized Trial Michael P. Swan*, Maria Cirocco, Gabor Kandel, Spiro Raftopoulos, Marios Efthymiou, Juan Antonio Chirinos Vega, Alan Moss, Fergal Donnellan, Gary R. May, Paul P. Kortan, Norman E. Marcon Division of Gastroenterology, St Michael’s Hospital, Toronto, ON, Canada Aim: Conventional colonoscopy involves the use of gas insufflation to provide adequate luminal distension for intubation. Water immersion colonoscopy has recently been described as a possible alternative to conventional gas insufflation. In this study we examined a hybrid intubation technique - water assisted colonoscopy- to facilitate the colonoscopy procedure. Method: Randomized trial of 300ml warm water instillation in the distal sigmoid colon followed by conventional gas insufflation versus standard gas insufflation in consecutive patients presenting for a routine colonoscopy. Exclusion criteria included previous bowel resection, known inflammatory bowel disease and current inpatients. All procedures were performed by a consultant gastroenterologist or experienced endoscopy fellow using an Olympus 180 series paediatric colonoscope. Sedation/analgesia was administered by the Endoscopist. Increased time to intubation, increased sedation requirement and requirement for pressure application and/or position change were used as markers for a more difficult colonoscopy. Results: 409 patients were enrolled and underwent randomization up to November 2011. Average age of the population was 60.4 years with 54% male. Majority of cases were performed for colorectal cancer screening (49%) or polyp surveillance (27%). Caecal intubation rate was 98% with a 34% adenoma detection rate. Female sex, previous pelvic operation and BMI⬎30 were identified as significant risk factors for a more difficult procedure as defined by time to intubation, pressure application and increased use of sedation. Water assisted colonoscopy did not significantly improve colonoscopy performance in all defined parameters of difficult colonoscopy in any subgroup. The use of water assisted colonoscopy reduced time to intubation in patients with BMI⬎30 [mean time reduction 2.9 minutes, p⫽0.02] and reduced requirement of pressure application in female patients (p⬍0.05). No difference in sedation requirements was noted with water assisted colonoscopy. Conclusion: Water assisted colonoscopy does not significantly improve the performance of colonoscopy in an average risk population. There is a significant trend to improved performance in patients with identifiable risk factors (female sex, BMI⬎30 and previous pelvic intervention) for a more difficult colonoscopy. No change in sedative requirements was noted.
Water Air Water Air Exchange insufflation pExchange insufflation (WE) (AI) value (WE) (AI) p-value Number Age Cecal intubation rate Time to cecum Time withdrawal Total time Polyps PDR Proximal PDR Adenomas
63 58.4 100%
57 59.5 100%
49 59.6 100%
8.4⫹/⫺4.2
7.7⫹/⫺ 5.8
n.s
9.9 ⫹/⫺ 4.0 8.3⫹/⫺4.4
14.7⫹6.9
15.9⫹/⫺ 6.6
n.s
23.1⫹/⫺ 8.5 23.6⫹/⫺ 9.3 90 104 42 (66.7%) 38 (66.7%) 27 (42.9%) 32 (56.1%) 58 71
n.s
12.4 ⫹/⫺ 3.8 22.2⫹/⫺5.7 59 28 (57.1%) 21 (42.9%) 40
n.s n.s
53 57.2 100%
0.054
14.2⫹/⫺8.6 n.s (0.20) 22.2⫹/⫺10.2 n.s 56 29 (54.7%) n.s 16 (30.2%) n.s (0.20) 27
Tu1322 Water Exchange Enhanced Cecal Intubation in Potentially Difficult Colonoscopy - Unsedated Patients With Prior Abdominal or Pelvic Surgery: a Prospective Randomized, Controlled Trial Hui Luo1, Yanglin PAN*1, Linhui Zhang1, Xiaodong Liu1, Felix W. Leung2, Xuegang Guo1, Daiming Fan1 1 Department of Gastroenterology, Xijing Hospital, Fourth Military Medical University, Xi’an, China; 2Sepulveda ACC, VAGLAHS, North Hill, CA Background: A hypothesis paper suggested that water exchange colonoscopy (WEC) may be effective in potentially difficult colonoscopy in unsedated patients with a history of abdominal or pelvic surgery (Scand J Gastro 2011;46:517). Objective: To assess the application of WEC in such patients. Design: Prospective, RCT with patient blinding (NCT01485133). Setting: Tertiary care
AB498 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
CIR and ADR (r⫽0.001, p⫽0.982).The mean ADR in the top quartile was 56.8% compared to 39.8% in the lowest quartile. There was no significant difference between these groups in the CIR, pain or any other measure from the lifetime procedure log. There was a significant difference in the MAP (1.64 compared to 0.77, p⬍0.01). Overall there was a strong correlation between ADR and MAP (r⫽0.59, p⬍0.001). Conclusions: These data show that even in a stratified group of high-performing colonoscopists there is considerable variation in performance in CIR, ADR and MAP. There was no correlation between CIR and ADR but a significant association between CIR and the endoscopic activity the previous year. Colonoscopists performing more procedures in their first year screening patients did not have higher adenoma detection rates. Further studies are needed to ascertain the factors responsible for these differences to try to further improve performance and patient outcomes.
Tu1320 Water Exchange Colonoscopy in a Non-Veteran Female Population Rafiul S. Islam*, Neal C. Patel, Shabana F. Pasha, Francisco C. Ramirez Gastroenterology, Mayo Clinic, Scottsdale, AZ Background: Compared to conventional air insufflation (AI) colonoscopy, water exchange (WE) colonoscopy has improved patient- and procedure-related outcomes. Most data in the US, however, is limited by a predominance of male subjects. Aim: To compare outcomes between AI and WE colonoscopy in female patients with men as controls. Methods: Setting: Endoscopy unit at an academic tertiary medical center.Study population: Patients undergoing outpatient colonoscopy by a single endoscopist experienced in both AI and WE colonoscopy.Study period: Nov 2011-Oct 2012Consecutive colonoscopies were retrospectively reviewed. The insertion phase of the procedure was either using WE or AI. During the withdrawal phase, inspection and polypectomies were performed using air insufflation in both groups. WE colonoscopy was started by turning the air pump off prior to insertion of the colonoscope. Water was infused via a pump connected to the base of the colonoscope and operated by a foot pedal. After cecal intubation was confirmed by suctioning the water and beginning air insufflation, photo documentation was captured. The insertion phase of AI colonoscopy was carried out using conventional air insufflation. Measurements: cecal intubation, withdrawal and total procedure times, and need for technician assistance for advancing the colonoscope (external pressure, change in patient’s position). In addition, adenoma and polyp detection rates (overall and for the proximal colon) as well as mean polyp and adenoma per patient were calculated. Need for intraprocedural sedation was also recorded.Statistics: Continuous data were compared using the Student’s t test and proportional data using Fisher’s exact test. Results: 222 colonoscopies were performed; 112 in the WE group and 110 in the AI group. The gender distribution was similar in both groups (56.3% males in WE; 51.8% males in AI). Outcomes of males and females are shown in Table 1. The need for external pressure was significantly lower in WE (for females only). In females, there was an increase of 12% in proximal polyps and adenomas for WE compared to AI. The lack of statistical significance may be due to a Type II error (small sample size). Conclusions: The water exchange colonoscopy method is a feasible alternative. The data in females confirms previous and current results in males. It is associated with numerically improved patient- and procedure-related outcomes compared to conventional air insufflation colonoscopy in both men and women. A randomized controlled trial with an adequate sample size in a non-veteran population is needed to define more fully the advantages of water exchange in the general population. Table 1. MEN
WOMEN
MEN
WOMEN
Water Air Water Air Exchange insufflation pExchange insufflation (WE) (AI) value (WE) (AI) p-value ADR 32 (51.6%) Proximal ADR 25 (39.7%) Added 23 (36.5%) sedation External 6 (9.5%) pressure Change in 3 (4.8%) position
31 (54.4%) 25 (43.9%) 26 (45.6%)
n.s n.s
21 (42.9%) 16 (32.7%) 39 (79.6%)
19 (35.8%) n.s 11 (20.8%) n.s. (0.20) 40 (75.5%)
11 (19.3%)
n.s
5 (10.2%)
18 (33.9%)
0.0046
4 (7.0%)
n.s
2 (4.1%)
6 (11.3%)
n.s. (0.20)
n.s. Non-significant
Tu1321 Does Water Assisted Colonoscopy Improve the Performance of Colonoscopy and Reduce Sedation Requirements?: Interim Analysis of a Randomized Trial Michael P. Swan*, Maria Cirocco, Gabor Kandel, Spiro Raftopoulos, Marios Efthymiou, Juan Antonio Chirinos Vega, Alan Moss, Fergal Donnellan, Gary R. May, Paul P. Kortan, Norman E. Marcon Division of Gastroenterology, St Michael’s Hospital, Toronto, ON, Canada Aim: Conventional colonoscopy involves the use of gas insufflation to provide adequate luminal distension for intubation. Water immersion colonoscopy has recently been described as a possible alternative to conventional gas insufflation. In this study we examined a hybrid intubation technique - water assisted colonoscopy- to facilitate the colonoscopy procedure. Method: Randomized trial of 300ml warm water instillation in the distal sigmoid colon followed by conventional gas insufflation versus standard gas insufflation in consecutive patients presenting for a routine colonoscopy. Exclusion criteria included previous bowel resection, known inflammatory bowel disease and current inpatients. All procedures were performed by a consultant gastroenterologist or experienced endoscopy fellow using an Olympus 180 series paediatric colonoscope. Sedation/analgesia was administered by the Endoscopist. Increased time to intubation, increased sedation requirement and requirement for pressure application and/or position change were used as markers for a more difficult colonoscopy. Results: 409 patients were enrolled and underwent randomization up to November 2011. Average age of the population was 60.4 years with 54% male. Majority of cases were performed for colorectal cancer screening (49%) or polyp surveillance (27%). Caecal intubation rate was 98% with a 34% adenoma detection rate. Female sex, previous pelvic operation and BMI⬎30 were identified as significant risk factors for a more difficult procedure as defined by time to intubation, pressure application and increased use of sedation. Water assisted colonoscopy did not significantly improve colonoscopy performance in all defined parameters of difficult colonoscopy in any subgroup. The use of water assisted colonoscopy reduced time to intubation in patients with BMI⬎30 [mean time reduction 2.9 minutes, p⫽0.02] and reduced requirement of pressure application in female patients (p⬍0.05). No difference in sedation requirements was noted with water assisted colonoscopy. Conclusion: Water assisted colonoscopy does not significantly improve the performance of colonoscopy in an average risk population. There is a significant trend to improved performance in patients with identifiable risk factors (female sex, BMI⬎30 and previous pelvic intervention) for a more difficult colonoscopy. No change in sedative requirements was noted.
Water Air Water Air Exchange insufflation pExchange insufflation (WE) (AI) value (WE) (AI) p-value Number Age Cecal intubation rate Time to cecum Time withdrawal Total time Polyps PDR Proximal PDR Adenomas
63 58.4 100%
57 59.5 100%
49 59.6 100%
8.4⫹/⫺4.2
7.7⫹/⫺ 5.8
n.s
9.9 ⫹/⫺ 4.0 8.3⫹/⫺4.4
14.7⫹6.9
15.9⫹/⫺ 6.6
n.s
23.1⫹/⫺ 8.5 23.6⫹/⫺ 9.3 90 104 42 (66.7%) 38 (66.7%) 27 (42.9%) 32 (56.1%) 58 71
n.s
12.4 ⫹/⫺ 3.8 22.2⫹/⫺5.7 59 28 (57.1%) 21 (42.9%) 40
n.s n.s
53 57.2 100%
0.054
14.2⫹/⫺8.6 n.s (0.20) 22.2⫹/⫺10.2 n.s 56 29 (54.7%) n.s 16 (30.2%) n.s (0.20) 27
Tu1322 Water Exchange Enhanced Cecal Intubation in Potentially Difficult Colonoscopy - Unsedated Patients With Prior Abdominal or Pelvic Surgery: a Prospective Randomized, Controlled Trial Hui Luo1, Yanglin PAN*1, Linhui Zhang1, Xiaodong Liu1, Felix W. Leung2, Xuegang Guo1, Daiming Fan1 1 Department of Gastroenterology, Xijing Hospital, Fourth Military Medical University, Xi’an, China; 2Sepulveda ACC, VAGLAHS, North Hill, CA Background: A hypothesis paper suggested that water exchange colonoscopy (WEC) may be effective in potentially difficult colonoscopy in unsedated patients with a history of abdominal or pelvic surgery (Scand J Gastro 2011;46:517). Objective: To assess the application of WEC in such patients. Design: Prospective, RCT with patient blinding (NCT01485133). Setting: Tertiary care
AB498 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org