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Unsedated colonoscopy: Time to revisit this option?
- Consider recommending unsedated colonoscopy to patients who have issues with cost, concerns about sedation, or are unable to get an escort or avoid work following the procedure.
- Explore resources in your area that offer unsedated colonoscopy.
Background Access to potentially life-saving screening colonoscopy is limited by the high cost of sedation. We explored the practicability of having supervised trainees perform unsedated colonoscopies.
Method A nursing shortage at our Veterans Administration gastroenterology training program necessitated discontinuing sedated colonoscopy. We offered the procedure without sedation to restore local access to screening colonoscopy.
Results From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The procedure was done by second-year gastroenterology (GI) fellows who had performed about 100 sedated colonoscopies in their first year of training. Cecal intubation was achieved in 81% of 138 wellpurged patients without obstructive lesions. Implementation obviated the need for 2 registered nurses, the escort requirement, and postprocedure activity restriction. It also eliminated sedation-related complications.
Conclusion This report confirms the feasibility of unsedated colonoscopy performed by supervised trainees. The unsedated option minimizes direct and indirect costs of colonoscopy. Describing unsedated screening colonoscopy to patients as a “sedation risk–free” procedure encouraged them to consider the benefits. We recommend that future studies test primary care providers’ willingness to inform patients of the feasibility of this nonstandard option, and perhaps reshape the practice of colonoscopy for colorectal cancer screening.
Monitored sedation given for colonoscopy is a measure meant to ensure patient safety,1 but its high cost limits access to the potentially life-saving screening procedure.2,3 Unsedated colonoscopy is an option, but a controversial one, raising issues both pro4-6 and con.7-11 In the United States, gastroenterologists perform unsedated colonoscopy both for unescorted patients (~2% of all screening colonos-copies)12,13 and individuals who simply prefer to avoid sedation (~6%).7 Family physicians, too, perform unsedated colonoscopy in both rural and urban settings.14-17
Would it be feasible to make training in unsedated colonoscopy more readily available to providers, and thereby reduce costs and inconvenience for patients? We took advantage of a changing environment at our Veterans Administration program to explore this question.
Method
A nursing shortage in our VA academic GI program necessitated discontinuing sedated colonoscopy. We reviewed the literature on unsedated colonoscopy and found that it is a feasible alternative performed elsewhere.4-7,12,14,16 Our attending staff discussed the options with patients and obtained informed consent18 using the following general message:
“Sedated colonoscopy is usual practice. Even though the risks of sedation are very small, nurses are required to monitor patients continuously. Because of a nursing shortage, we must send you to another VA facility 15 miles away for sedated colonoscopy. You must have an escort, as you will not be allowed to drive after sedation. One of the medicines they administer will make you forget the discomfort you may have experienced, as well as the discussions after the examination.
“Alternatively, you may choose unsedated colonoscopy, which is practiced in the United States and many other countries. Because no medicines are used, there are no medication-induced complications. An escort is not required, and there is no activity restriction afterwards.
“You will feel air in the colon and the endoscope being pushed around inside you. The colonoscopist will talk to you throughout the examination. When you begin to experience discomfort, the colonoscopist will remove air inside the colon or straighten the loops in the colonoscope to minimize the discomfort before it becomes severe. If discomfort does become severe, you and the colonoscopist can agree to stop the advancement of the colonoscope. Complications related to taking biopsies or removing polyps are similar in sedated and unsedated procedures.”
Supervised trainees (second-year GI fellows who had performed about 100 sedated colonoscopies in their first year of training), assisted by a licensed vocational nurse, performed the procedures using appropriate techniques.5-7
The Institution Review Board of the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) approved our review of the patient data for publication.
Results
From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The number of patients choosing this option increased in each successive academic year (31, 50, and 64), as did the wait-time in days (27±4, 46±5, 72±6) (mean±standard error of the mean [SEM]). Seven patients (4%) had poor bowel preparation or obstructing lesions limiting completion. Among the 138 well-purged patients, we achieved cecal intubation in 112 (81%). Discomfort limited completion in the remaining 19%.
Other than transient vasovagal reactions in 2 patients, no complications occurred. Patients with incomplete examinations due to discomfort underwent sedated colonoscopy or barium enema or received no further assessment, depending on the initial findings. Those who subsequently underwent sedated colonoscopy (10%) had to be purged again, escorted, and comply with activity restriction.
Colonoscopy was developed as an unsedated procedure.19,20 Discomfort experienced by some patients during sigmoid intubation led to the use of medications,20,21 which are now administered routinely.22 Interestingly, competency in unsedated colonoscopy is not required of GI fellows.23 Indeed, until recently,18 teaching GI trainees unsedated colonoscopy was deemed impractical.7 Family physicians, on the other hand, have long practiced and taught unsedated colonoscopy,14-17,24 although the actual number of family physicians performing colonoscopy is fairly small.25 One reason so few family physicians offer the service—estimated at 3.7% of the specialty—may be the intensive and costly education required.16 Even more difficult has been gaining privileges to perform the sedated procedure,26 given the training requirements set forth by GI professional societies.27
Many patients would opt for unsedated colonoscopy. The favorable reception of unsedated colonoscopy in our study is evident in the increasing number of veterans each year who opted for the procedure despite the lengthening wait-time (which was due to increased demand rather than decreased availability of endoscopists). In the course of our project, we found that the terms “unsedated,” “no sedation,” or “without sedation” tended to convey the negative connotation that relief of discomfort and induced amnesia are withheld.8,9 The term “sedation risk–free”28 emphasized the benefits of no sedation.
Cost factors favoring unsedated colonoscopy. Sedated colonoscopies performed by family physicians have offered substantial health care savings.29,30 It is intuitively obvious that the unsedated option in the hands of those with the necessary skills14-16,24 would be even less costly. Our unsedated colonoscopy project reduced direct costs, which included the cost of having 2 registered nurses on hand. Indirect costs to patients31 were also minimized by avoiding the need for an escort or activity restriction. Moreover, there were no sedation-related complications.32,33
An estimated 40 million healthy Americans are eligible for colorectal cancer screening.34 Primary care providers play a pivotal role in counseling many of these patients, who may find the indirect cost savings of unsedated colonoscopy performed by that same provider appealing.
A logical transition from flexible sigmoidoscopy. An unsedated colonoscopy is very similar to an extended flexible sigmoidoscopy.14-17,35 In patients who can tolerate a flexible sigmoidoscopy well, extended flexible sigmoidoscopy can reach the cecum >70% of the time.36 To enhance the cecal intubation rate among unsedated veterans, we developed (subsequent to the findings reported here) a novel method of water infusion in lieu of air insufflation during insertion of the colonoscope.37 This measure improved the cecal intubation rate from 76% to 97%.38 For family physicians who perform flexible sigmoidoscopy, it is worth considering performing extended flexible sigmoidoscopy or unsedated colonoscopy using this water infusion method37,38 or other methods to minimize discomfort in unsedated patients.39
Limitations of our study, and opportunities. Our report is based on uncontrolled, nonrandomized observational data. Nevertheless, it affirms the feasibility of unsedated colonoscopy performed by supervised trainees, as previously reported by a family practice training program.16 It also underscores the benefits of the unsedated option on direct and indirect costs.
Since only 3.7% of family physicians in a recent survey reported performing colonoscopy,25 it is uncertain whether primary care providers would voluntarily inform patients about the unsedated option. In select settings, gastroenterologists are willing to provide unsedated colonoscopy.6,7,12,13,18 A reasonable hypothesis to test is that primary care providers informing patients about unsedated colonoscopy could reshape the future practice of screening colonoscopy in family medicine and gastroenterology.
Funding/Support
Supported in part by vA medical research Funds and an American Society for Gastrointestinal endoscopy career Development Award (FWl 1985).
Correspondence
Felix W. Leung, MD, Division of Gastroenterology (111G), Sepulveda Ambulatory Care Center, Veterans Affairs Greater los Angeles Healthcare System, 16111 Plummer Street, North Hills, CA 91343; .
1. Comprehensive Accreditation Manual for Hospitals; The Official Handbook. Oakbrook Terrace, III: Joint Commission on Accreditation of Healthcare Organizations; 2005:160-223.
2. Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. N Engl J Med. 2000;343:162-168.
3. El-Serag HB, Petersen L, Hampel H, et al. The use of screening colonoscopy for patients cared for by the Department of Veterans Affairs. Arch Intern Med. 2006;166:2202-2208.
4. Herman FN. Avoidance of sedation during total colonoscopy. Dis Colon Rectum. 1990;33:70-72.
5. Cataldo PA. Colonoscopy without sedation: a viable alternative. Dis Colon Rectum. 1996;39:257-261.
6. Hoffman MS, Butler TW, Shaver T. Colonoscopy without sedation. J Clin Gastroenterol. 1998;26:279-282.
7. Rex DK, Imperiale TF, Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc. 1999;49:554-559.
8. Levenson D. Health quality organization criticizes colonoscopies given without pain medication. Rept Med Guidelines Outcomes Res. 2001;12:9-12.
9. Leo RA. Unsedated endoscopy: you don’t get a medal for it! South Med J. 2004;97:797-798.
10. Faulx AL, Vela S, Das A, et al. The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey. Gastrointest Endosc. 2005;62:9-15.
11. Rex DK, Khalfan HK. Sedation and the technical performance of colonoscopy. Gastrointest Endosc Clin N Am. 2005;15:661-672.
12. Nelson DB, MCQuaid KR, Bond JH, et al. Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc. 2002;55:307-314.
13. Aslinia F, Uradomo L, Steele A, et al. Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a University Hospital. Am J Gastroenterol. 2006;101:721-731.
14. Hopper W, Kyker KA, Rodney WM. Colonoscopy by a family physician: a 9-year experience of 1048 procedures. J Fam Pract. 1996;43:561 -566.
15. Carr KW, Worthington JM, Rodney WM, et al. Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice. Tenn Med. 1998;91:21-26.
16. Rodney WM, Dabov G, Orientale E, et al. Sedation associated with a more complete colonoscopy. J Fam Pract. 1993;36:394-400.
17. Knox L, Hahn RG, Lane C. A comparison of unsedated colonoscopy and flexible sigmoidoscopy in the family medicine setting: an LA Net study. J Am Board Fam Med. 2007;20:444-450.
18. Leung FW, Aharonian HS, Guth PH, et al. Involvement of trainees in routine unsedated colonoscopy—review of pilot experience. Gastrointest Endosc. 2008;67:718-722.
19. Wolff WI, Shinya H. Colonofiberoscopy. JAMA. 1971;217:1509-1512.
20. Williams C, Teague RH. Colonoscopy. Gut. 1973;14:990-1003.
21. Waye JD. Colonoscopy. Surg Clin North Am. 1972;52:1013-1024.
22. National Cancer Institute Web Site. Available at: http://www.cancer.gov/cancertopics/types/colon-and-rectal. Accessed January 23, 2008.
23. Gastroenterology required curriculum. Chicago, III: Accreditation council on Graduate medical education; 2005.
24. Edwards JK, Norris TE. Colonoscopy in rural communities: can family physicians perform the procedure with safe and efficacious results? J Am Board Fam Pract. 2004;17:353-358.
25. Wilkins T, Wagner P, Thomas A, et al. Attitudes toward performance of endoscopic colon cancer screening by family physicians. Fam Med. 2007;39:578-584.
26. Frank M. American Academy of Family Physicians response to American college of Gastroenterology’s letter and legal opinion. Sent to hospital administrators on December 12, 2005.
27. Faigel D, Baron T, Lewis B, et al. Ensuring competence in endoscopy. Prepared by the ASGe Taskforce on ensuring competence in endoscopy and American college of Gastroenterology executive and Practice management committees, 2005: 1-36.
28. Leung FW. Should minimization of cue be an option as a quality indicator in colonoscopy performed for colorectal cancer screening? Gastroin-test Endosc. 2008;67:579-580.
29. Short MW, Kelly KM, Runser lA. Colonoscopy by a family physician: a case series demonstrating health care savings. Mil Med. 2007;172:1089-1092.
30. Perry RE, Christensen JB, Christensen MA, et al. Office colonoscopy—a safe procedure in selected patients. Dis Colon Rectum. 1989;32:1031-1033.
31. Glied S. Estimating the indirect cost of illness: an assessment of the forgone earnings approach. Am J Public Health. 1996;86:1723-1728.
32. Arrowsmith JB, Gerstman BB, Fleischer DE, et al. Results from the American Society for Gastrointestinal endoscopy/uS Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastroin-test Endosc. 1991;37:421-427.
33. Sharma VK, Nguyen CC, Crowell MD, et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc. 2007;66:27-34.
34. Seeff LC, Manninen DL, Dong FB, et al. Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the united States? Gastroenterology. 2004;127:1661-1669.
35. Dervin JV. Feasibility of 105-cm flexible sigmoidoscopy in family practice. J Fam Pract. 1986;23:341-344.
36. Lee JG, Lum D, Urayama S, et al. Unsedated extended flexible sigmoidoscopy for colorectal cancer screening: a pilot study. Aliment Pharmacol Ther. 2006;23:945-951.
37. Leung JW, Mann S, Leung FW. Option of screening colonoscopy without sedation—a pilot study in united States veterans. Aliment Pharmacol Ther. 2007;26:627-631.
38. Leung FW, Aharonian HS, Leung JW, et al. Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans. Gastrointest Endosc. In press.
39. Leung FW. Methods of reducing discomfort during colonoscopy. Dig Dis Sci. 2008;53:1462-1467.
- Consider recommending unsedated colonoscopy to patients who have issues with cost, concerns about sedation, or are unable to get an escort or avoid work following the procedure.
- Explore resources in your area that offer unsedated colonoscopy.
Background Access to potentially life-saving screening colonoscopy is limited by the high cost of sedation. We explored the practicability of having supervised trainees perform unsedated colonoscopies.
Method A nursing shortage at our Veterans Administration gastroenterology training program necessitated discontinuing sedated colonoscopy. We offered the procedure without sedation to restore local access to screening colonoscopy.
Results From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The procedure was done by second-year gastroenterology (GI) fellows who had performed about 100 sedated colonoscopies in their first year of training. Cecal intubation was achieved in 81% of 138 wellpurged patients without obstructive lesions. Implementation obviated the need for 2 registered nurses, the escort requirement, and postprocedure activity restriction. It also eliminated sedation-related complications.
Conclusion This report confirms the feasibility of unsedated colonoscopy performed by supervised trainees. The unsedated option minimizes direct and indirect costs of colonoscopy. Describing unsedated screening colonoscopy to patients as a “sedation risk–free” procedure encouraged them to consider the benefits. We recommend that future studies test primary care providers’ willingness to inform patients of the feasibility of this nonstandard option, and perhaps reshape the practice of colonoscopy for colorectal cancer screening.
Monitored sedation given for colonoscopy is a measure meant to ensure patient safety,1 but its high cost limits access to the potentially life-saving screening procedure.2,3 Unsedated colonoscopy is an option, but a controversial one, raising issues both pro4-6 and con.7-11 In the United States, gastroenterologists perform unsedated colonoscopy both for unescorted patients (~2% of all screening colonos-copies)12,13 and individuals who simply prefer to avoid sedation (~6%).7 Family physicians, too, perform unsedated colonoscopy in both rural and urban settings.14-17
Would it be feasible to make training in unsedated colonoscopy more readily available to providers, and thereby reduce costs and inconvenience for patients? We took advantage of a changing environment at our Veterans Administration program to explore this question.
Method
A nursing shortage in our VA academic GI program necessitated discontinuing sedated colonoscopy. We reviewed the literature on unsedated colonoscopy and found that it is a feasible alternative performed elsewhere.4-7,12,14,16 Our attending staff discussed the options with patients and obtained informed consent18 using the following general message:
“Sedated colonoscopy is usual practice. Even though the risks of sedation are very small, nurses are required to monitor patients continuously. Because of a nursing shortage, we must send you to another VA facility 15 miles away for sedated colonoscopy. You must have an escort, as you will not be allowed to drive after sedation. One of the medicines they administer will make you forget the discomfort you may have experienced, as well as the discussions after the examination.
“Alternatively, you may choose unsedated colonoscopy, which is practiced in the United States and many other countries. Because no medicines are used, there are no medication-induced complications. An escort is not required, and there is no activity restriction afterwards.
“You will feel air in the colon and the endoscope being pushed around inside you. The colonoscopist will talk to you throughout the examination. When you begin to experience discomfort, the colonoscopist will remove air inside the colon or straighten the loops in the colonoscope to minimize the discomfort before it becomes severe. If discomfort does become severe, you and the colonoscopist can agree to stop the advancement of the colonoscope. Complications related to taking biopsies or removing polyps are similar in sedated and unsedated procedures.”
Supervised trainees (second-year GI fellows who had performed about 100 sedated colonoscopies in their first year of training), assisted by a licensed vocational nurse, performed the procedures using appropriate techniques.5-7
The Institution Review Board of the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) approved our review of the patient data for publication.
Results
From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The number of patients choosing this option increased in each successive academic year (31, 50, and 64), as did the wait-time in days (27±4, 46±5, 72±6) (mean±standard error of the mean [SEM]). Seven patients (4%) had poor bowel preparation or obstructing lesions limiting completion. Among the 138 well-purged patients, we achieved cecal intubation in 112 (81%). Discomfort limited completion in the remaining 19%.
Other than transient vasovagal reactions in 2 patients, no complications occurred. Patients with incomplete examinations due to discomfort underwent sedated colonoscopy or barium enema or received no further assessment, depending on the initial findings. Those who subsequently underwent sedated colonoscopy (10%) had to be purged again, escorted, and comply with activity restriction.
Colonoscopy was developed as an unsedated procedure.19,20 Discomfort experienced by some patients during sigmoid intubation led to the use of medications,20,21 which are now administered routinely.22 Interestingly, competency in unsedated colonoscopy is not required of GI fellows.23 Indeed, until recently,18 teaching GI trainees unsedated colonoscopy was deemed impractical.7 Family physicians, on the other hand, have long practiced and taught unsedated colonoscopy,14-17,24 although the actual number of family physicians performing colonoscopy is fairly small.25 One reason so few family physicians offer the service—estimated at 3.7% of the specialty—may be the intensive and costly education required.16 Even more difficult has been gaining privileges to perform the sedated procedure,26 given the training requirements set forth by GI professional societies.27
Many patients would opt for unsedated colonoscopy. The favorable reception of unsedated colonoscopy in our study is evident in the increasing number of veterans each year who opted for the procedure despite the lengthening wait-time (which was due to increased demand rather than decreased availability of endoscopists). In the course of our project, we found that the terms “unsedated,” “no sedation,” or “without sedation” tended to convey the negative connotation that relief of discomfort and induced amnesia are withheld.8,9 The term “sedation risk–free”28 emphasized the benefits of no sedation.
Cost factors favoring unsedated colonoscopy. Sedated colonoscopies performed by family physicians have offered substantial health care savings.29,30 It is intuitively obvious that the unsedated option in the hands of those with the necessary skills14-16,24 would be even less costly. Our unsedated colonoscopy project reduced direct costs, which included the cost of having 2 registered nurses on hand. Indirect costs to patients31 were also minimized by avoiding the need for an escort or activity restriction. Moreover, there were no sedation-related complications.32,33
An estimated 40 million healthy Americans are eligible for colorectal cancer screening.34 Primary care providers play a pivotal role in counseling many of these patients, who may find the indirect cost savings of unsedated colonoscopy performed by that same provider appealing.
A logical transition from flexible sigmoidoscopy. An unsedated colonoscopy is very similar to an extended flexible sigmoidoscopy.14-17,35 In patients who can tolerate a flexible sigmoidoscopy well, extended flexible sigmoidoscopy can reach the cecum >70% of the time.36 To enhance the cecal intubation rate among unsedated veterans, we developed (subsequent to the findings reported here) a novel method of water infusion in lieu of air insufflation during insertion of the colonoscope.37 This measure improved the cecal intubation rate from 76% to 97%.38 For family physicians who perform flexible sigmoidoscopy, it is worth considering performing extended flexible sigmoidoscopy or unsedated colonoscopy using this water infusion method37,38 or other methods to minimize discomfort in unsedated patients.39
Limitations of our study, and opportunities. Our report is based on uncontrolled, nonrandomized observational data. Nevertheless, it affirms the feasibility of unsedated colonoscopy performed by supervised trainees, as previously reported by a family practice training program.16 It also underscores the benefits of the unsedated option on direct and indirect costs.
Since only 3.7% of family physicians in a recent survey reported performing colonoscopy,25 it is uncertain whether primary care providers would voluntarily inform patients about the unsedated option. In select settings, gastroenterologists are willing to provide unsedated colonoscopy.6,7,12,13,18 A reasonable hypothesis to test is that primary care providers informing patients about unsedated colonoscopy could reshape the future practice of screening colonoscopy in family medicine and gastroenterology.
Funding/Support
Supported in part by vA medical research Funds and an American Society for Gastrointestinal endoscopy career Development Award (FWl 1985).
Correspondence
Felix W. Leung, MD, Division of Gastroenterology (111G), Sepulveda Ambulatory Care Center, Veterans Affairs Greater los Angeles Healthcare System, 16111 Plummer Street, North Hills, CA 91343; .
- Consider recommending unsedated colonoscopy to patients who have issues with cost, concerns about sedation, or are unable to get an escort or avoid work following the procedure.
- Explore resources in your area that offer unsedated colonoscopy.
Background Access to potentially life-saving screening colonoscopy is limited by the high cost of sedation. We explored the practicability of having supervised trainees perform unsedated colonoscopies.
Method A nursing shortage at our Veterans Administration gastroenterology training program necessitated discontinuing sedated colonoscopy. We offered the procedure without sedation to restore local access to screening colonoscopy.
Results From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The procedure was done by second-year gastroenterology (GI) fellows who had performed about 100 sedated colonoscopies in their first year of training. Cecal intubation was achieved in 81% of 138 wellpurged patients without obstructive lesions. Implementation obviated the need for 2 registered nurses, the escort requirement, and postprocedure activity restriction. It also eliminated sedation-related complications.
Conclusion This report confirms the feasibility of unsedated colonoscopy performed by supervised trainees. The unsedated option minimizes direct and indirect costs of colonoscopy. Describing unsedated screening colonoscopy to patients as a “sedation risk–free” procedure encouraged them to consider the benefits. We recommend that future studies test primary care providers’ willingness to inform patients of the feasibility of this nonstandard option, and perhaps reshape the practice of colonoscopy for colorectal cancer screening.
Monitored sedation given for colonoscopy is a measure meant to ensure patient safety,1 but its high cost limits access to the potentially life-saving screening procedure.2,3 Unsedated colonoscopy is an option, but a controversial one, raising issues both pro4-6 and con.7-11 In the United States, gastroenterologists perform unsedated colonoscopy both for unescorted patients (~2% of all screening colonos-copies)12,13 and individuals who simply prefer to avoid sedation (~6%).7 Family physicians, too, perform unsedated colonoscopy in both rural and urban settings.14-17
Would it be feasible to make training in unsedated colonoscopy more readily available to providers, and thereby reduce costs and inconvenience for patients? We took advantage of a changing environment at our Veterans Administration program to explore this question.
Method
A nursing shortage in our VA academic GI program necessitated discontinuing sedated colonoscopy. We reviewed the literature on unsedated colonoscopy and found that it is a feasible alternative performed elsewhere.4-7,12,14,16 Our attending staff discussed the options with patients and obtained informed consent18 using the following general message:
“Sedated colonoscopy is usual practice. Even though the risks of sedation are very small, nurses are required to monitor patients continuously. Because of a nursing shortage, we must send you to another VA facility 15 miles away for sedated colonoscopy. You must have an escort, as you will not be allowed to drive after sedation. One of the medicines they administer will make you forget the discomfort you may have experienced, as well as the discussions after the examination.
“Alternatively, you may choose unsedated colonoscopy, which is practiced in the United States and many other countries. Because no medicines are used, there are no medication-induced complications. An escort is not required, and there is no activity restriction afterwards.
“You will feel air in the colon and the endoscope being pushed around inside you. The colonoscopist will talk to you throughout the examination. When you begin to experience discomfort, the colonoscopist will remove air inside the colon or straighten the loops in the colonoscope to minimize the discomfort before it becomes severe. If discomfort does become severe, you and the colonoscopist can agree to stop the advancement of the colonoscope. Complications related to taking biopsies or removing polyps are similar in sedated and unsedated procedures.”
Supervised trainees (second-year GI fellows who had performed about 100 sedated colonoscopies in their first year of training), assisted by a licensed vocational nurse, performed the procedures using appropriate techniques.5-7
The Institution Review Board of the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) approved our review of the patient data for publication.
Results
From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The number of patients choosing this option increased in each successive academic year (31, 50, and 64), as did the wait-time in days (27±4, 46±5, 72±6) (mean±standard error of the mean [SEM]). Seven patients (4%) had poor bowel preparation or obstructing lesions limiting completion. Among the 138 well-purged patients, we achieved cecal intubation in 112 (81%). Discomfort limited completion in the remaining 19%.
Other than transient vasovagal reactions in 2 patients, no complications occurred. Patients with incomplete examinations due to discomfort underwent sedated colonoscopy or barium enema or received no further assessment, depending on the initial findings. Those who subsequently underwent sedated colonoscopy (10%) had to be purged again, escorted, and comply with activity restriction.
Colonoscopy was developed as an unsedated procedure.19,20 Discomfort experienced by some patients during sigmoid intubation led to the use of medications,20,21 which are now administered routinely.22 Interestingly, competency in unsedated colonoscopy is not required of GI fellows.23 Indeed, until recently,18 teaching GI trainees unsedated colonoscopy was deemed impractical.7 Family physicians, on the other hand, have long practiced and taught unsedated colonoscopy,14-17,24 although the actual number of family physicians performing colonoscopy is fairly small.25 One reason so few family physicians offer the service—estimated at 3.7% of the specialty—may be the intensive and costly education required.16 Even more difficult has been gaining privileges to perform the sedated procedure,26 given the training requirements set forth by GI professional societies.27
Many patients would opt for unsedated colonoscopy. The favorable reception of unsedated colonoscopy in our study is evident in the increasing number of veterans each year who opted for the procedure despite the lengthening wait-time (which was due to increased demand rather than decreased availability of endoscopists). In the course of our project, we found that the terms “unsedated,” “no sedation,” or “without sedation” tended to convey the negative connotation that relief of discomfort and induced amnesia are withheld.8,9 The term “sedation risk–free”28 emphasized the benefits of no sedation.
Cost factors favoring unsedated colonoscopy. Sedated colonoscopies performed by family physicians have offered substantial health care savings.29,30 It is intuitively obvious that the unsedated option in the hands of those with the necessary skills14-16,24 would be even less costly. Our unsedated colonoscopy project reduced direct costs, which included the cost of having 2 registered nurses on hand. Indirect costs to patients31 were also minimized by avoiding the need for an escort or activity restriction. Moreover, there were no sedation-related complications.32,33
An estimated 40 million healthy Americans are eligible for colorectal cancer screening.34 Primary care providers play a pivotal role in counseling many of these patients, who may find the indirect cost savings of unsedated colonoscopy performed by that same provider appealing.
A logical transition from flexible sigmoidoscopy. An unsedated colonoscopy is very similar to an extended flexible sigmoidoscopy.14-17,35 In patients who can tolerate a flexible sigmoidoscopy well, extended flexible sigmoidoscopy can reach the cecum >70% of the time.36 To enhance the cecal intubation rate among unsedated veterans, we developed (subsequent to the findings reported here) a novel method of water infusion in lieu of air insufflation during insertion of the colonoscope.37 This measure improved the cecal intubation rate from 76% to 97%.38 For family physicians who perform flexible sigmoidoscopy, it is worth considering performing extended flexible sigmoidoscopy or unsedated colonoscopy using this water infusion method37,38 or other methods to minimize discomfort in unsedated patients.39
Limitations of our study, and opportunities. Our report is based on uncontrolled, nonrandomized observational data. Nevertheless, it affirms the feasibility of unsedated colonoscopy performed by supervised trainees, as previously reported by a family practice training program.16 It also underscores the benefits of the unsedated option on direct and indirect costs.
Since only 3.7% of family physicians in a recent survey reported performing colonoscopy,25 it is uncertain whether primary care providers would voluntarily inform patients about the unsedated option. In select settings, gastroenterologists are willing to provide unsedated colonoscopy.6,7,12,13,18 A reasonable hypothesis to test is that primary care providers informing patients about unsedated colonoscopy could reshape the future practice of screening colonoscopy in family medicine and gastroenterology.
Funding/Support
Supported in part by vA medical research Funds and an American Society for Gastrointestinal endoscopy career Development Award (FWl 1985).
Correspondence
Felix W. Leung, MD, Division of Gastroenterology (111G), Sepulveda Ambulatory Care Center, Veterans Affairs Greater los Angeles Healthcare System, 16111 Plummer Street, North Hills, CA 91343; .
1. Comprehensive Accreditation Manual for Hospitals; The Official Handbook. Oakbrook Terrace, III: Joint Commission on Accreditation of Healthcare Organizations; 2005:160-223.
2. Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. N Engl J Med. 2000;343:162-168.
3. El-Serag HB, Petersen L, Hampel H, et al. The use of screening colonoscopy for patients cared for by the Department of Veterans Affairs. Arch Intern Med. 2006;166:2202-2208.
4. Herman FN. Avoidance of sedation during total colonoscopy. Dis Colon Rectum. 1990;33:70-72.
5. Cataldo PA. Colonoscopy without sedation: a viable alternative. Dis Colon Rectum. 1996;39:257-261.
6. Hoffman MS, Butler TW, Shaver T. Colonoscopy without sedation. J Clin Gastroenterol. 1998;26:279-282.
7. Rex DK, Imperiale TF, Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc. 1999;49:554-559.
8. Levenson D. Health quality organization criticizes colonoscopies given without pain medication. Rept Med Guidelines Outcomes Res. 2001;12:9-12.
9. Leo RA. Unsedated endoscopy: you don’t get a medal for it! South Med J. 2004;97:797-798.
10. Faulx AL, Vela S, Das A, et al. The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey. Gastrointest Endosc. 2005;62:9-15.
11. Rex DK, Khalfan HK. Sedation and the technical performance of colonoscopy. Gastrointest Endosc Clin N Am. 2005;15:661-672.
12. Nelson DB, MCQuaid KR, Bond JH, et al. Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc. 2002;55:307-314.
13. Aslinia F, Uradomo L, Steele A, et al. Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a University Hospital. Am J Gastroenterol. 2006;101:721-731.
14. Hopper W, Kyker KA, Rodney WM. Colonoscopy by a family physician: a 9-year experience of 1048 procedures. J Fam Pract. 1996;43:561 -566.
15. Carr KW, Worthington JM, Rodney WM, et al. Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice. Tenn Med. 1998;91:21-26.
16. Rodney WM, Dabov G, Orientale E, et al. Sedation associated with a more complete colonoscopy. J Fam Pract. 1993;36:394-400.
17. Knox L, Hahn RG, Lane C. A comparison of unsedated colonoscopy and flexible sigmoidoscopy in the family medicine setting: an LA Net study. J Am Board Fam Med. 2007;20:444-450.
18. Leung FW, Aharonian HS, Guth PH, et al. Involvement of trainees in routine unsedated colonoscopy—review of pilot experience. Gastrointest Endosc. 2008;67:718-722.
19. Wolff WI, Shinya H. Colonofiberoscopy. JAMA. 1971;217:1509-1512.
20. Williams C, Teague RH. Colonoscopy. Gut. 1973;14:990-1003.
21. Waye JD. Colonoscopy. Surg Clin North Am. 1972;52:1013-1024.
22. National Cancer Institute Web Site. Available at: http://www.cancer.gov/cancertopics/types/colon-and-rectal. Accessed January 23, 2008.
23. Gastroenterology required curriculum. Chicago, III: Accreditation council on Graduate medical education; 2005.
24. Edwards JK, Norris TE. Colonoscopy in rural communities: can family physicians perform the procedure with safe and efficacious results? J Am Board Fam Pract. 2004;17:353-358.
25. Wilkins T, Wagner P, Thomas A, et al. Attitudes toward performance of endoscopic colon cancer screening by family physicians. Fam Med. 2007;39:578-584.
26. Frank M. American Academy of Family Physicians response to American college of Gastroenterology’s letter and legal opinion. Sent to hospital administrators on December 12, 2005.
27. Faigel D, Baron T, Lewis B, et al. Ensuring competence in endoscopy. Prepared by the ASGe Taskforce on ensuring competence in endoscopy and American college of Gastroenterology executive and Practice management committees, 2005: 1-36.
28. Leung FW. Should minimization of cue be an option as a quality indicator in colonoscopy performed for colorectal cancer screening? Gastroin-test Endosc. 2008;67:579-580.
29. Short MW, Kelly KM, Runser lA. Colonoscopy by a family physician: a case series demonstrating health care savings. Mil Med. 2007;172:1089-1092.
30. Perry RE, Christensen JB, Christensen MA, et al. Office colonoscopy—a safe procedure in selected patients. Dis Colon Rectum. 1989;32:1031-1033.
31. Glied S. Estimating the indirect cost of illness: an assessment of the forgone earnings approach. Am J Public Health. 1996;86:1723-1728.
32. Arrowsmith JB, Gerstman BB, Fleischer DE, et al. Results from the American Society for Gastrointestinal endoscopy/uS Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastroin-test Endosc. 1991;37:421-427.
33. Sharma VK, Nguyen CC, Crowell MD, et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc. 2007;66:27-34.
34. Seeff LC, Manninen DL, Dong FB, et al. Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the united States? Gastroenterology. 2004;127:1661-1669.
35. Dervin JV. Feasibility of 105-cm flexible sigmoidoscopy in family practice. J Fam Pract. 1986;23:341-344.
36. Lee JG, Lum D, Urayama S, et al. Unsedated extended flexible sigmoidoscopy for colorectal cancer screening: a pilot study. Aliment Pharmacol Ther. 2006;23:945-951.
37. Leung JW, Mann S, Leung FW. Option of screening colonoscopy without sedation—a pilot study in united States veterans. Aliment Pharmacol Ther. 2007;26:627-631.
38. Leung FW, Aharonian HS, Leung JW, et al. Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans. Gastrointest Endosc. In press.
39. Leung FW. Methods of reducing discomfort during colonoscopy. Dig Dis Sci. 2008;53:1462-1467.
1. Comprehensive Accreditation Manual for Hospitals; The Official Handbook. Oakbrook Terrace, III: Joint Commission on Accreditation of Healthcare Organizations; 2005:160-223.
2. Lieberman DA, Weiss DG, Bond JH, et al. Use of colonoscopy to screen asymptomatic adults for colorectal cancer. N Engl J Med. 2000;343:162-168.
3. El-Serag HB, Petersen L, Hampel H, et al. The use of screening colonoscopy for patients cared for by the Department of Veterans Affairs. Arch Intern Med. 2006;166:2202-2208.
4. Herman FN. Avoidance of sedation during total colonoscopy. Dis Colon Rectum. 1990;33:70-72.
5. Cataldo PA. Colonoscopy without sedation: a viable alternative. Dis Colon Rectum. 1996;39:257-261.
6. Hoffman MS, Butler TW, Shaver T. Colonoscopy without sedation. J Clin Gastroenterol. 1998;26:279-282.
7. Rex DK, Imperiale TF, Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc. 1999;49:554-559.
8. Levenson D. Health quality organization criticizes colonoscopies given without pain medication. Rept Med Guidelines Outcomes Res. 2001;12:9-12.
9. Leo RA. Unsedated endoscopy: you don’t get a medal for it! South Med J. 2004;97:797-798.
10. Faulx AL, Vela S, Das A, et al. The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey. Gastrointest Endosc. 2005;62:9-15.
11. Rex DK, Khalfan HK. Sedation and the technical performance of colonoscopy. Gastrointest Endosc Clin N Am. 2005;15:661-672.
12. Nelson DB, MCQuaid KR, Bond JH, et al. Procedural success and complications of large-scale screening colonoscopy. Gastrointest Endosc. 2002;55:307-314.
13. Aslinia F, Uradomo L, Steele A, et al. Quality assessment of colonoscopic cecal intubation: an analysis of 6 years of continuous practice at a University Hospital. Am J Gastroenterol. 2006;101:721-731.
14. Hopper W, Kyker KA, Rodney WM. Colonoscopy by a family physician: a 9-year experience of 1048 procedures. J Fam Pract. 1996;43:561 -566.
15. Carr KW, Worthington JM, Rodney WM, et al. Advancing from flexible sigmoidoscopy to colonoscopy in rural family practice. Tenn Med. 1998;91:21-26.
16. Rodney WM, Dabov G, Orientale E, et al. Sedation associated with a more complete colonoscopy. J Fam Pract. 1993;36:394-400.
17. Knox L, Hahn RG, Lane C. A comparison of unsedated colonoscopy and flexible sigmoidoscopy in the family medicine setting: an LA Net study. J Am Board Fam Med. 2007;20:444-450.
18. Leung FW, Aharonian HS, Guth PH, et al. Involvement of trainees in routine unsedated colonoscopy—review of pilot experience. Gastrointest Endosc. 2008;67:718-722.
19. Wolff WI, Shinya H. Colonofiberoscopy. JAMA. 1971;217:1509-1512.
20. Williams C, Teague RH. Colonoscopy. Gut. 1973;14:990-1003.
21. Waye JD. Colonoscopy. Surg Clin North Am. 1972;52:1013-1024.
22. National Cancer Institute Web Site. Available at: http://www.cancer.gov/cancertopics/types/colon-and-rectal. Accessed January 23, 2008.
23. Gastroenterology required curriculum. Chicago, III: Accreditation council on Graduate medical education; 2005.
24. Edwards JK, Norris TE. Colonoscopy in rural communities: can family physicians perform the procedure with safe and efficacious results? J Am Board Fam Pract. 2004;17:353-358.
25. Wilkins T, Wagner P, Thomas A, et al. Attitudes toward performance of endoscopic colon cancer screening by family physicians. Fam Med. 2007;39:578-584.
26. Frank M. American Academy of Family Physicians response to American college of Gastroenterology’s letter and legal opinion. Sent to hospital administrators on December 12, 2005.
27. Faigel D, Baron T, Lewis B, et al. Ensuring competence in endoscopy. Prepared by the ASGe Taskforce on ensuring competence in endoscopy and American college of Gastroenterology executive and Practice management committees, 2005: 1-36.
28. Leung FW. Should minimization of cue be an option as a quality indicator in colonoscopy performed for colorectal cancer screening? Gastroin-test Endosc. 2008;67:579-580.
29. Short MW, Kelly KM, Runser lA. Colonoscopy by a family physician: a case series demonstrating health care savings. Mil Med. 2007;172:1089-1092.
30. Perry RE, Christensen JB, Christensen MA, et al. Office colonoscopy—a safe procedure in selected patients. Dis Colon Rectum. 1989;32:1031-1033.
31. Glied S. Estimating the indirect cost of illness: an assessment of the forgone earnings approach. Am J Public Health. 1996;86:1723-1728.
32. Arrowsmith JB, Gerstman BB, Fleischer DE, et al. Results from the American Society for Gastrointestinal endoscopy/uS Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastroin-test Endosc. 1991;37:421-427.
33. Sharma VK, Nguyen CC, Crowell MD, et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc. 2007;66:27-34.
34. Seeff LC, Manninen DL, Dong FB, et al. Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the united States? Gastroenterology. 2004;127:1661-1669.
35. Dervin JV. Feasibility of 105-cm flexible sigmoidoscopy in family practice. J Fam Pract. 1986;23:341-344.
36. Lee JG, Lum D, Urayama S, et al. Unsedated extended flexible sigmoidoscopy for colorectal cancer screening: a pilot study. Aliment Pharmacol Ther. 2006;23:945-951.
37. Leung JW, Mann S, Leung FW. Option of screening colonoscopy without sedation—a pilot study in united States veterans. Aliment Pharmacol Ther. 2007;26:627-631.
38. Leung FW, Aharonian HS, Leung JW, et al. Impact of a novel water method on scheduled unsedated colonoscopy in U.S. veterans. Gastrointest Endosc. In press.
39. Leung FW. Methods of reducing discomfort during colonoscopy. Dig Dis Sci. 2008;53:1462-1467.