1Division of Gastroenterology, sepulveda ambulatory care center and West Los angeles Va Medical center, Va Greater Los angeles healthcare system, and David Geffen school of Medicine at UcLa, Los angeles, ca, Usa; 2Department of Medicine, cedars-sinai Medical center, Los angeles, ca, Usa; 3UcLa Division of Digestive Diseases, David Geffen school of Medicine at UcLa, Los angeles, ca, Usa; 4West Los angeles Va Medical center, Va Greater Los angeles healthcare system, Los angeles, ca, Usa
Introduction: Implementation of scheduled unsedated colonoscopy to manage no shows due to no escorts saw an increase in patients accepting the unsedated option. Patient centered care would call for provision of the least painful insertion method to ensure success and satisfaction in these unsedated patients. While the impact of cap-assisted colonoscopy on insertion pain is mixed, attenuation of insertion pain during colonoscopy aided by air insufflation has been reported repeatedly by the addition of a cap to the tip of the colonoscope. Water exchange (WE) during the insertion phase of colonoscopy significantly reduced maximum insertion pain in unsedated patients. Pilot observations were made to determine if the combination of cap-assisted and WE colonoscopy would further decrease insertion pain. Methods: In a performance improvement project, cap-assisted colonoscopy combined with WE was carried out as previously described in unsedated patients. Demographic variables, maximum insertion pain, and other outcome measures were reviewed in a database. The data were compared to those of a previously reported unsedated cohort examined by WE alone. Results:Table 1.Table 1: Demographic Variables and Outcomes of Unsedated ColonoscopyConclusion: When WE is combined with cap-assisted colonoscopy, a significantly lower mean maximum insertion pain score was achieved. The pilot data suggest the hypothesis that the combination significantly reduces insertion pain in the unsedated patient should be tested in a RCT. The increased proximal colon adenoma detection rate, in part may be due to the use of high-definition colonoscope in the current study. Nonetheless, the data confirmed the results of a similar study in the proximal colon in sedated patients, lending additional credibility and validity to the current findings.
The prevalence of advanced histological features in diminutive (≤5 mm) and small (6-9 mm) colon polyps is low, and they are considered to have low potential for malignant transformation. Performing a polypectomy increases the costs associated with a colonoscopy as well as the risk of complications. Newer diagnostic techniques have prompted the approach of ‘predict, resect and discard’ for diminutive and small polyps, a strategy whereby real time diagnosis of polyps would serve as a substitute for histopathological diagnosis to reduce costs.
Insufflation of the colon is necessary to distend the lumen for exploration. Carbon dioxide (CO2) insufflation instead of air insufflation (AI) has shown conflicting results about decreasing pain or discomfort during the procedure, even when coupled with water immersion or water exchange method of insertion. CO2 insufflation is associated with a reasonably consistent decrease in bloating and pain scores in the post-procedure period. Other advantages are a decrease in toilet use, less incontinence and less flatulence after colonoscopy. No definitive results are available about the effect of CO2 on the need and dosage of sedation medication(s). Association with water-aided methods appears to show promise in decreasing pain during and after the procedure, achieve higher rates of minimally sedated or unsedated colonoscopy, with less postprocedure bloating and flatulence. Further studies are needed to investigate the impact of combining water-aided methods with CO2 on clinically relevant parameters.
Introduction: The explanation for why insertion water exchange (WE) increases proximal colon adenoma detection rates compared to air insufflation (AI) is unknown. Our aim was to test the hypothesis that compared with AI, insertion WE significantly reduces the number of multitasking-related distractions from mucosal inspection. Methods: Prospectively recorded videos of screening colonoscopies comparing AI and WE were edited to remove the insertion phase of examination. Two reviewers blinded to insertion techniques evaluated recordings using a validated scoring system. Distractions from mucosal inspection were defined as water infusion, suctioning to clean the mucosa, and colonic spasms. The number of each distraction was analyzed by colonic segment. Withdrawal techniques, total withdrawal time, and bowel preparation quality scores were assessed. Intervention involving polypectomy and/or biopsy was considered yield of quality outcome.Table 1Results: When WE and AI were compared, no significant differences were noted for withdrawal techniques, total withdrawal and active inspection time, or bowel preparation scores. Compared with AI (n=42), insertion WE (n=24) consistently and significantly decreased the number of distractions of water infusion and suctioning during withdrawal in the right colon (cecum and ascending colon; p<0.0001). Yield of quality outcome was significantly increased in the right colon (p=0.01). Conclusion: Insertion WE is associated with fewer multitasking-related distractions during withdrawal inspection. Fewer multitasking-related distractions during colonoscope withdrawal may be a plausible explanation for the enhanced yield of quality outcomes in the right colon in earlier reports.
Objective: In a performance improvement project, the novel approach of combining water exchange, cap-assisted colonoscopy and on demand sedation (minimizing complications of invasive sedation) and underwater polypectomy (obviating sideeffects of invasive sub-mucosal injection) was assessed. Subjects/methods: Veterans undergoing screening and surveillance at VA Greater lA Healthcare System began colonoscopy with the novel approach. Air insufflation was used during withdrawal for inspection, biopsy and polypectomy of small ( 1 cm) polyps. Results: Fifty-five males were offered the option of on demand sedation by the author. Six (3 sedated, 3 unsedated) were excluded due to poor bowel preparation. Of the 49 evaluable Veterans, 15 (31%) declined the option, 34 (69%) accepted. Final cecal intubation was 100% (49/49). Of the 34 who started without medication, 5 (15%) required sedation during colonoscopy, 29 (85%) completed without. Success of unsedated colonoscopy with the novel approach was 97% (28/29) [one changed to air insufflation]. 55% (16/29) of the unsedated patients completed with no pain. Compared with historical on demand sedation cohorts worldwide, the novel approach achieved the highest completion rate without sedation, and without pain. Amongst the unsedated, overall (57%) and proximal (50%) colon adenoma detection rates (A dR)
Eating problems afflict up to 86% of patients with advanced dementia, and approximately 39% of these patients die within 6 mo of developing these problems. More than one in three patients with advanced dementia living in nursing homes is fed via feeding tube. This paper reviews the evidence for the use of feeding tubes in patients with advanced dementia as well as information on logistic and systems issues that may explain the high prevalence for the use of feeding tubes in this setting.
Selective cannulation is essential and is considered the most difficult part of an ERCP procedure. Selective cannulation may became difficult when the papilla is swollen, tiny, hooknose-shaped or in an abnormal position. Precut technique is sometimes required to achieve cannulation in difficult patients. However, it may be dangerous when the papilla is small. We report a case with successful cannulation by using a triple lumen needle knife (NF) without precutting. A 42-year-old woman with recurrent upper abdominal pain was admitted to our hospital. Her serum amylase level was 411 (normal 10-60) IU/L. MRCP revealed a mildly dilated pancreatic duct of 7mm (Fig. 1a). The pancreas otherwise was normal. Patient was suspected to have type I pancreatic sphincter of Oddi dysfunction (SOD). During ERCP, a tiny rigid major papilla was found (Fig. 1b). Attempted cannulation of the pancreatic duct with a guidewire-preloaded (Jagwire, Boston, Marborough, MA) sphincterotome (Clevercut, Olympus, Japan) and sequentially a 5 Fr cannula (PR-126Q-1, Olympus, Japan) were tried. Then guidewire was extended outside for direct cannulation with the help of the sphincterotome. However, all of the regular methods failed because the papilla was firm and the opening was small. After 40 min of attempting, we switched to a triple lumen needle knife
