Přemysl Falt

Combination of water immersion and carbon dioxide insufflation for minimal sedation colonoscopy: a prospective, randomized, single-center trial.

Objective Water immersion insertion and carbon dioxide (CO2) insufflation, as alternative colonoscopic techniques, are able to reduce patient discomfort during and after the procedure. We assessed whether the combination of water immersion and CO2 insufflation is superior in efficacy and patient comfort to other colonoscopic techniques. Methods In a prospective, randomized study, a total of 420 patients were randomized to either water immersion insertion and CO2 insufflation during withdrawal (water/CO2), water insertion and air insufflation during withdrawal (water/air), CO2 insufflation during both insertion and withdrawal (CO2/CO2), or air insufflation during both insertion and withdrawal (air/air). The main outcome was the success of minimal sedation colonoscopy, which was defined as reaching the cecum without switching to another insertion method and without additional sedation beyond the initial 2 mg of midazolam. Patient comfort during and after the procedure was assessed. Results A total of 404 patients were analyzed. The success rate of minimal sedation colonoscopy in the water insertion arm (water/CO2 and water/air) was 97% compared with 83.3% in the gas insertion arm (CO2/CO2 and air/air; P<0.0001). Intraprocedural pain and bloating were significantly lower in the water/CO2 group than in all other groups. Patient discomfort in the water/CO2 group during 24 h after the procedure was comparable with that in the CO2/CO2 group and significantly lower than that in the air groups (water/air and air/air). No complications were recorded during the study. Conclusion The combination of water immersion and CO2 insufflation appears to be an effective and safe method for minimal sedation colonoscopy. Overall patient discomfort was significantly reduced compared with that in other techniques.

Water exchange for screening colonoscopy increases adenoma detection rate: a multicenter, double-blinded, randomized controlled trial

Background and study aims Single-center studies, which were retrospective and/or involved unblinded colonoscopists, have suggested that water exchange, but not water immersion, compared with air insufflation significantly increases the adenoma detection rate (ADR), particularly in the proximal and right colon. Head-to-head comparison of the three techniques with ADR as primary outcome and blinded colonoscopists has not been reported to date. In a randomized controlled trial with blinded colonoscopists, we aimed to evaluate the impact of the three insertion techniques on ADR. Patients and methods A total of 1224 patients aged 50 - 70 years (672 males) and undergoing screening colonoscopy were randomized 1:1:1 to water exchange, water immersion, or air insufflation. Split-dose bowel preparation was adopted to optimize colon cleansing. After the cecum had been reached, a second colonoscopist who was blinded to the insertion technique performed the withdrawal. The primary outcome was overall ADR according to the three insertion techniques (water exchange, water immersion, and air insufflation). Secondary outcomes were other pertinent overall and right colon procedure-related measures. Results Baseline characteristics of the three groups were comparable. Compared with air insufflation, water exchange achieved a significantly higher overall ADR (49.3 %, 95 % confidence interval [CI] 44.3 % - 54.2 % vs. 40.4 % 95 %CI 35.6 % - 45.3 %; P  = 0.03); water exchange showed comparable overall ADR vs. water immersion (43.4 %, 95 %CI 38.5 % - 48.3 %; P  = 0.28). In the right colon, water exchange achieved a higher ADR than air insufflation (24.0 %, 95 %CI 20.0 % - 28.5 % vs. 16.9 %, 95 %CI 13.4 % - 20.9 %; P  = 0.04) and a higher advanced ADR (6.1 %, 95 %CI 4.0 % - 9.0 % vs. 2.5 %, 95 %CI 1.2 % - 4.6 %; P = 0.03). Compared with air insufflation, the mean number of adenomas per procedure was significantly higher with water exchange (P = 0.04). Water exchange achieved the highest cleanliness scores (overall and in the right colon). These variables were comparable between water immersion and air insufflation. Conclusions The design with blinded observers strengthens the validity of the observation that water exchange, but not water immersion, can achieve significantly higher adenoma detection than air insufflation. Based on this evidence, the use of water exchange should be encouraged.Trial registered at ClinicalTrials.gov (NCT02041507).

Cap-assisted water immersion for minimal sedation colonoscopy: Prospective, randomized, single-center trial

Water immersion insertion is able to reduce discomfort and need for sedation during colonoscopy. A cap attached to the colonoscope tip may improve insertion during air insufflation colonoscopy. According to several reports, both techniques alone may result in higher detection of neoplastic lesions. Our study was designed to evaluate the efficacy of cap‐assisted water immersion compared to water immersion colonoscopy in minimally sedated patients.

Cool water vs warm water immersion for minimal sedation colonoscopy: a double‐blind randomized trial

Water‐aided insertion as an alternative colonoscopy technique reduces patient discomfort. Warm water has been used in most published trials, but the use of cool water is easier and, if equally effective, could support the use of the water‐aided technique in routine practice.

Insertion water exchange increases right colon adenoma and hyperplastic polyp detection rates during withdrawal

BACKGROUND Single site studies in male Veterans in the U.S. reported increased detection of presumptive cancer precursors (adenomas, hyperplastic polyps) in the proximal colon (cecum-splenic flexure) by water exchange. AIMS Assess the reproducibility of the observation. METHODS Analysis of secondary outcomes collected prospectively in 3 similarly designed randomized controlled trials using water exchange, water immersion and insufflation (air or carbon dioxide). MAIN OUTCOME detection rates of adenomas and hyperplastic polyps in proximal, transverse and right colon (cecum-ascending). RESULTS 704 males (173 screening) were evaluated. In the proximal colon, WE showed increased detection of small adenomas (p=0.009) and adenomas plus hyperplastic polyps (p=0.015) (vs insufflation); increased detection of adenomas plus hyperplastic polyps of any size (p=0.045) and of small size (p=0.04) (vs water immersion). In the right colon water exchange increased detection of small adenomas (19% vs 12.1%, p=0.04) (vs insufflation); small adenomas (19% vs 12%, p=0.038), adenomas plus hyperplastic polyps of any size (25% vs 16.7%, p=0.028) and of small size (23.7% vs 14.6%, p=0.012) (vs water immersion). Water exchange significantly improved bowel cleanliness. Sedation had no impact on lesion detection. CONCLUSIONS Water exchange is a superior insertion technique for detection of adenomas and hyperplastic polyps primarily in the right colon, especially those of small size.

Carbon dioxide insufflation during colonoscopy in inflammatory bowel disease patients: a double-blind, randomized, single-center trial

Objective Bowel distension by insufflated air causes abdominal discomfort after colonoscopy. Carbon dioxide (CO2) instead of air insufflation during colonoscopy can reduce postprocedural discomfort in diagnostic and screening cases. Discomfort after colonoscopy and CO2 insufflation have never been studied in inflammatory bowel disease (IBD) patients, characterized by younger age, structural changes of the colon, and need for repeated and frequently uncomfortable colonoscopies. Our trial was designed to evaluate postprocedural discomfort associated with CO2 compared with air insufflation in unsedated or minimally sedated patients with known IBD. Methods In a double-blind, randomized, single-center study, 64 patients were randomized to either CO2 insufflation (CO2) or air insufflation colonoscopy (Air). Abdominal pain, bloating, and flatulence scores during 24 h after colonoscopy were recorded using a continuous scale of 0–10 (0=none, 10=maximum discomfort). The primary endpoint used for power calculation was bloating score at 1 h after colonoscopy. Results Pain, bloating, and flatulence scores at end, 1, and 3 h after colonoscopy were significantly lower in CO2 than in Air arm (P<0.001). Scores at 6, 12, and 24 h were comparable. Procedural parameters such as cecal and terminal ileum intubation rate, intubation and total time, pain during insertion, need for repositioning, and abdominal compression were not different between arms. No complications were recorded in the study. Conclusion Compared with air, CO2 insufflation significantly reduces abdominal pain, bloating, and flatulence scores during at least 3 h after colonoscopy in IBD patients, achieving comparable intraprocedural outcomes.

Endoscopic full-thickness resection for the treatment of local residual neoplastia in the colon – an analysis of 19 cases

P. Falt1,2, T. Hucl3, P. Fojtík4, P. Drastich3, J. Martínek3, R. Andělová5, L. Voska6, J. Špičák3, O. Urban1,2 1 II. interní klinika – gastroenterologie a geriatrie LF UP a FN Olomouc 2 Katedra interních oborů, LF UK v Hradci Králové 3 Klinika hepatogastroenterologie, Transplantcentrum, IKEM, Praha 4 Centrum péče o zažívací trakt, Vítkovická nemocnice a. s., Ostrava 5 Oddělení patologie, Nemocnice Nový Jičín a.s. 6 Pracoviště klinické a transplantační patologie, Transplantcentrum, IKEM, Praha

Comparison of Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in the Treatment of Flat Neoplastic Lesions in the Rectum

Endoscopic submucosal dissection (ESD) is a method used for en bloc removal of colorectal lesions > 20 mm. A comparison of ESD and endoscopic mucosal resection (EMR) in the treatment of rectal flat neoplastic lesions is reported. A total of 27 and 30 patients were included in ESD and EMR group, respectively. En bloc resection was achieved in 21(78 %) vs. 2(7 %), (p < 0,005) while perforation not requiring surgery occurred in 3(11 %) vs. 0 (p= 0,099) and local residual neoplasia in 2(9 %) vs. 9 (41 %) cases (p = 0,017). There was no procedure related letality in either group. ESD seems to be a promising method for the treatment of rectal neoplastic lesions.

Some Clarifications About Water-Aided Colonoscopy

We read with interest the commentary by Dr Rex on our article. We would like to provide some clarifications and a note of appreciation. For the purpose of addressing mechanisms, it was necessary for us to clearly specify the techniques being compared based on published randomized controlled trials (RCTs) and reviews. Suction of residual feces during insertion was not described previously as an integral component of water immersion because it was deemed cumbersome and time consuming. Residual air was not removed because the air compartment was used to facilitate advancement when excessive residual feces were encountered. Although the nomenclatures for water exchange (water in lieu of air, water method, water exchange) evolved over the years, the emphasis has been consistent—to minimize distension and to see clearly to advance to the cecum. Simply put “use no air and remove all the dirty water during insertion.” The rationale of avoiding air, even inadvertently insufflated, is that insufflated air quickly travels to the cecum, lengthening the colon and sharpening the angulations at the flexures. Once air is insufflated, the likelihood of an optimal benefit of water exchange shown in our current RCT will be decreased. Therefore, it would seem prudent to optimize the chance of success of a potentially difficult insertion by using water exchange from the very start. In the current RCT, the improved efficiency (shortened insertion time compared with previous trials) primarily is owing to the infusion and suction of water during insertion being performed nearly simultaneously. Indeed, we should thank Dr Rex for endorsing the conversion from water immersion to water exchange “Water immersion, like water exchange, should permit suctioning of retained gas and exchange of opaque fluid.” SERGIO CADONI, MD Digestive Endoscopy Unit St. Barbara Hospital Iglesias (Carbonia-Iglesias), Italy