patient pain or discomfort, prolonged insertion time; inflammatory bowel disease symptoms, severe colonic inflammation, active lower gastrointestinal bleeding, obstructing malignancy; poor bowel preparation, afternoon colonoscopy, colonoscopy following gastroscopy and unsedated colonoscopy. score after colonoscopy was 1 (0=none, 10=maximum). The proportion achieving cecal intubation within 30 min was 60%. Eight were successful examined to the cecum using water exchange. The patient with bowel adhesion remained a failure of cecal intubation. The endoscope could not be advanced beyond the transverse colon and the color of the mucosa turned pale when insertion pressure on the colonoscope shaft was increased. This patient had incomplete bowel obstruction and subsequently required surgical operation for correction. In the second cecal intubation failure using the water exchange method the colonoscope could not be passed beyond the transverse colon due to difficulty in visualizing the lumen. After distension of the lumen with air, cecal intubation was achieved.In data set 2 post hoc analysis of two RCT at two VA facilities was performed. 12,13 The hypothesis that in patients with a history of abdominal surgery the water exchange method would enhance successful cecal intubation was tested. The primary outcome of the analysis was the proportion of patients achieving cecal intubation without medications. The options for colonoscopy

Colonoscopy fails to reduce proximal colon incident cancers and cancer mortality. Adenoma detection (ADR), but not cecal intubation rate, is an independent predictor of risk of interval cancer after screening colonoscopy. Impact of high-definition, wide-angle endoscope, narrow band imaging, dye-spray chromoendoscopy, withdrawal time >6 min or modifying bowel preparation on detection rate (DR) of proximal diminutive lesions [adenoma or hyperplastic polyp (HP)] is inconclusive. We reviewed the above and reported even proximal diminutive lesions can harbor high risk dysplasia (JIG 2010 in press). The re-evaluation of proximal HP as serrated adenomas (WJG 2009;15:3767; CGH doi:10.1016/j.cgh.2010.09.013) with malignant potentials dramatizes the need to attend to these lesions. A colonoscopist-controlled method to obviate missed proximal diminutive (missed due to small size <10 mm) lesions is needed. The water method albeit non-conventional, when executed correctly increases proximal ADR (AJG 2010;105:S128) merits consideration. We describe the impact of the water method on yield of proximal diminutive lesions (ADR and HPDR) in this report. Two VA RCT were conducted to assess the water method with primary outcome of completion of unsedated colonoscopy when the option of scheduled, unsedated (N=82) or sedation on demand (N=100) was used. The number of screening cases was 52 in the air and 45 in the water method group. Diminutive lesion detection rates (proportion of patients with at least one <10 mm lesion) proximal to the splenic flexure were tracked in both RCT. In screening cases, multiple regression analysis revealed withdrawal time, method and volume of water used were significant determinants of detection of proximal diminutive lesions (ADR and HPDR combined) (p<0.05). Effect of the water method on detection of proximal diminutive lesions is independent of age, body mass index, endoscopist, sedation, cecal intubation rate, bowel cleanliness on withdrawal and total procedure time. No impact of the water method on detection of proximal diminutive lesions in surveillance and diagnostic cases was seen. Male subject predominance, analysis of secondary outcomes of pooled RCT data, limited number of mostly unsedated patients. Impact of the water method on detection of proximal diminutive lesions is more effectively demonstrated when the assessment is made in cases of screening rather than surveillance or diagnostic colonoscopy. (Supported in part by an ACG grant to FWL).Tabled 1Effect of water method on detection of proximal diminutive adenoma and hyperplastic polyp.Number of cases randomizedAir (N=90)Water (N=92)pProximal diminutive lesions in screening cases (n)5245ADR3 (6%)9 (23% of no HP)0.0273aFisher's exact test;HPDR0 (0%)6 (16% of no adenoma)0.0049aFisher's exact test;ADR and HPDR combined3 (6%)14 (31%)0.0012aFisher's exact test;Age (yrs)60 (9)61 (9)0.4725Body mass index29.4 (6.7)29.2 (6.2)0.8466Sedation17 (33%)7 (16%)0.0511Volume of water used (ml)74 (107)1504 (641)0.0001bStudent's t.Cecal intubation rate⁎(n, air=48, water=44);48 (92%)44 (98%)0.2286Bowel cleanliness on withdrawal (1=worst to 4=best)2.36 (0.7)2.42 (0.7)0.6861Withdrawal time (min)⁎(n, air=48, water=44);,⁎⁎Include time for inspection, biopsy and polypectomy.13.7 (6.9)16.3 (7.2)0.0819Total procedure time (min)⁎(n, air=48, water=44);,⁎⁎Include time for inspection, biopsy and polypectomy.33 (18)37 (20)0.3257Recovery time (min)11 (9)8 (6)0.0797Proximal diminutive lesions in surveillance and diagnostic cases (n)3847ADR10 (26%)17 (36%)0.8179HPDR5 (13%)5 (11%)0.7467N, total; n, in subgroup. ADR, adenoma detection rate. HPDR, hyperplastic polyp detection rate. Mean (SD) or frequency (%).a Fisher's exact test;b Student's t. (n, air=48, water=44); Include time for inspection, biopsy and polypectomy. Open table in a new tab

PURPOSE: Emerging data indicate a colonoscopist-controlled method is needed to avoid missing proximal colon pre-malignant lesions. Screening colonoscopy does not prevent all proximal colon cancers. Even diminutive lesions in the proximal colon harbor dysplasia. In addition to adenomas (presumptive cancer precursors), recent proposals to reevaluate proximal colon hyperplastic polyps as serrated polyps which could be pre-malignant or harbingers of interval neoplasia dramatize the importance of attending to these lesions. The finding that the water method increased yield of proximal diminutive adenomas prompted assessment of the hypothesis that the water method increases yield of all proximal diminutive lesions (adenoma and hyperplastic polyp) in screening cases. METHODS: Two RCT assessed the water method with primary outcome of completion of unsedated colonoscopy when the option of scheduled, unsedated or sedation on demand was used. Diminutive (<10 mm) lesions proximal to the splenic flexure were tracked. RESULTS: In screening cases, 31% and 6% of the water and air group had at least one proximal diminutive lesion (p=0.0012). Regression analysis revealed withdrawal time, method and volume of water used were significant predictors of proximal diminutive lesions. Effect of the water method on detection of proximal diminutive lesions was independent of age, body mass index, endoscopist, sedation, cecal intubation rate, bowel cleanliness score on withdrawal and total procedure time. LIMITATION: Male subject predominance, analysis of secondary outcomes of pooled RCT data. CONCLUSION: The hypothesis that the water method effectively enhances proximal diminutive lesion detection in screening colonoscopy in diverse clinical settings should be tested.

The water method is superior to usual air insufflation for screening and surveillance colonoscopy. In RCT it reduces sedation medication requirement; attenuates discomfort and enhances cecal intubation in unsedated patients. The water method entails the use of warm water infusion in lieu of air insufflation combined with suction removal of residual air to minimize angulations throughout the colon and water exchange to remove feces to clear the luminal view to aid insertion of the colonoscope. Up to one to two liters of water are usually infused and removed during a 15 to 20 min interval of insertion. Most of the infused water is suctioned almost as soon as it is infused to minimize over distension of the colon (GIE 2009;70:505-510, GIE 2010;72:693-700). The safety of the water method, however, has not been critically evaluated. We report the vital signs and serum electrolyte levels before and after large volume water exchange used with the water method. Unsedated patients are chosen for evaluation to avoiding the confounding effects of sedation medications on vital signs. To quantify safety of the water method in terms of the vital signs and serum electrolyte levels before and after large volume water exchange in the colonic lumen used with the water method. We test the hypothesis that these parameters remain stable after colonoscopy is performed using the water method as described above. Patients in 2 RCT comparing the use of air vs. water method for unsedated colonoscopy. Study 1: Patients' vital signs before (immediately before insertion of the colonoscope into the rectum) and after (immediately after removal of the colonoscope from the rectum) colonoscopy were tabulated for analysis. Study 2: Blood samples (2 ml each) were drawn within 5-10 min before and after colonoscopy for measuring the serum Na+ and K+ levels using the Istat machine (for bedside measurement of serum electrolytes). (Tables). Study 1: There were no significant differences in vital signs before and after colonoscopy in either the air or water method group. All patients were in normal sinus rhythm before and after the colonoscopy. Study 2: There were no significant differences between the serum Na+ and K+ before and after colonoscopy in either the air or the water group. Overall, the mean volumes of water used were 1500 ml in the water method and 75 ml in the air method. There were no significant correlations between the change (after minus before) in individual parameters (vital signs or serum electrolyte levels) measured and the volume of water used. Vital signs, cardiac rhythm and serum electrolyte levels are well preserved after large volume water exchange in the colonic lumen used with the water method. The water method is a safe modality for examination of the colon. (Supported in part by an ACG grant to FWL).Tabled 1Effect of water method on vital signsStudy 1Before ColonoscopyAfter ColonoscopyMethodNMBPPulseO2 SaturationMBPPulseO2 SaturationWater4187 (14)69 (11)98 (4)84 (14)66 (10)98 (2)Air3587 (15)69 (11)97 (2)82 (10)67 (10)97 (2)MBP, mean blood pressure in mm Hg. Pulse in beats per min. O2 (oxygen) saturation in %. Data are mean (SD). Open table in a new tab

BACKGROUND: Colonoscopy in unsedated patients in the US is considered to be difficult. Success rate of cecal intubation is limited by discomfort. Colonoscopy in patients with a history of abdominal surgery is also considered to be difficult due to adhesion-related bowel angulations. The water method has been shown to significantly reduce pain during colonoscopy. OBJECTIVE: To test the hypothesis that the water method enhances the completion of colonoscopy in unsedated patients with a history of abdominal surgery. DESIGN: The data bases of two parallel RCT were combined and analyzed. SETTING: Two Veterans Affairs endoscopy units. PATIENT AND METHODS: The water and air methods were compared in these two parallel RCT examining unsedated patients. Those with a history of abdominal surgery were selected for evaluation. MAIN OUTCOME MEASUREMENTS: Completion of unsedated colonoscopy. RESULTS: Among patients with a history of abdominal surgery, the proportion completing unsedated colonoscopy in the water group (19 of 22) was significantly higher than that (11 of 22) in the air group (p=0.0217, Fisher's exact test). LIMITATIONS: Small number of predominantly male veterans, unblinded colonoscopists, not all types of abdominal surgery (e.g. hysterectomy, gastrectomy) predisposing to difficult colonoscopy were represented. CONCLUSION: This proof-of-principle assessment confirms that in patients with a history of abdominal surgery the water method significantly increases the proportion able to complete unsedated colonoscopy. The water method deserves to be evaluated in patients with other factors associated with difficult colonoscopy.

BACKGROUND:An observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy. OBJECTIVE:To confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT). DESIGN:Prospective RCT, intent-to-treat analysis. SETTING:Veterans Affairs ambulatory care facility. PATIENTS:Veterans undergoing scheduled unsedated colonoscopy. INTERVENTIONS:During insertion, the water and traditional air methods were compared. MAIN OUTCOME MEASUREMENTS:Discomfort and procedure-related outcomes. RESULTS:Eighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method (P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort (t = -1.998, P = .049, R(2) = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield. LIMITATIONS:Single site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability. CONCLUSIONS:The RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).

BACKGROUND:Intermittent warm-water infusion in lieu of air insufflation permitted 52% of patients who accepted sedation on demand to complete colonoscopy without sedation.OBJECTIVE:To test the hypothesis that the water method enhances cecal intubation and increases the proportion of patients who report willingness to repeat a scheduled unsedated colonoscopy.DESIGN:Observational study.PATIENTS:Two consecutive groups of veterans.INTERVENTIONS:From June 2005 to May 2006, the usual air insufflation method was used to aid colonoscope insertion. From June 2006 to October 2007, the water method was used.MAIN OUTCOME MEASUREMENTS:Cecal intubation; report of willingness to repeat unsedated colonoscopy.RESULTS:Sixty-two and 63 veterans were examined by the air method and the water method, respectively. Intention-to-treat analysis revealed that the cecal intubation rate with the water method (97% [61/63]) was significantly higher than that with the air method (76% [47/62]). The proportion of patients who reported willingness to repeat unsedated colonoscopy was significantly higher with the water method (90% [57/63]) compared with the air method (69% [43/62]).LIMITATIONS:Single site, nonrandomized, unblinded, small number of elderly male veterans.CONCLUSION:The effects of the water method in the group for scheduled unsedated colonoscopy were sufficiently provocative to warrant calling for their confirmation by a randomized controlled trial.

Compared with air insufflation, water infusion in lieu of air insufflation during colonoscope insertion resulted in improved cecal intubation and enhanced patient willingness to repeat without sedation in scheduled unsedated colonoscopy in US veterans in a non-randomized consecutive group observational study (GIE 2008;67: AB281; manuscript, in press). We are conducting a prospective RCT (2007-present) to determine if this novel method minimizes discomfort of scheduled unsedated colonoscopy at the VA Sepulveda Ambulatory Care Center. The control method is usual air insufflation; the study method is infusion of warm water in lieu of air insufflation. Advancement is terminated at the cecum or when the subject can no longer tolerate the discomfort (unsuccessful), despite pain-reduction maneuvers implemented by the colonoscopist and the assistant. Air insufflation is used during withdrawal in both methods with suction of luminal content as needed. Primary outcome: overall discomfort (0=none, 10=most severe) reported to a blinded observer prior to discharge (10 to 15 min after colonoscopy). Secondary outcomes: report of willingness to repeat unsedated colonoscopy; successful cecal intubation, unsuccessful with good or poor prep; need for abdominal compression or position change; assistant report of satisfaction; and subjects with and without polyps. Results [mean (SD)]: Quality (overall discomfort, cecal intubation rate, need for abdominal compression and position change, polyp yield); subject satisfaction (willingness to repeat) and assistant response (very satisfied) were better with the study method (see Table). Conclusion: This interim report of the RCT shows that the novel study method results in decreased abdominal discomfort which may account for the improved cecal intubation and may enhance patient willingness to repeat. The cleansing effect of the water may contribute to increased polyp yield.

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 well purged 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.

Cancer surgery can be complex and there is an associated risk of major haemorrhage. Haemorrhage during cancer surgery may result from vascular injury, cancer-related alterations to haemostasis or both and is frequently complicated by coagulopathy. In the last few years, our knowledge of normal haemostasis has evolved and ‘cell-based model of coagulation’ has been widely accepted. Optimal management of massive haemorrhage requires a good understanding of this model in order to facilitate administration of appropriate blood products and pharmacological alternatives. Successful outcome depends on good anaesthetic and surgical techniques, excellent communication (particularly with transfusion medicine colleagues) and appropriate postoperative intensive care management. In this article, the relevant issues regarding haemostatic resuscitation related to haemorrhage during major cancer surgery are discussed.

Turning from enunciation of sustainability to implementation, this paper focuses on the Local Agenda 21 (LA 21) policy envelope, emanating from the 1992 Rio Earth Summit. Agenda 21 challenges local authorities to adopt policy goals encompassing not only sustainable development but also to incorporate participative, collaborative processes, which involve local communities in defining their own sustainable futures. This can and should include tourism development as a significant environmental, economic and social agent. The impacts LA21 is having on tourism are assessed, using the UK as a case example, but with wider relevance. The paper evidences that while sustainable development in tourism practice is emerging, this remains largely outside the LA21 process, the significance of which and the relevance to tourism has been slow to be recognised. More attention to LA21's relevance to tourism is advocated and quintessentially sustainable forms of tourism development, such as cycle tourism initiatives, are used to example the largely unrealised potential for the convergence of the LA21 and sustainable tourism policy fields.

Submammary pacemaker implantation offers women a cosmetically acceptable alternative to the standard pectoral implant. We present a novel method of submammary implantation performed on ten women aged 13-54 years. The lead electrodes are tunneled from the infraclavicular to the inframammary incision using a long needle, guidewire, and introducers/dilators in a manner analogous to the retained guidewire technique used for standard lead insertion. The procedure can generally be performed under local anesthesia. All patients tolerated the procedure well without acute complications. Over 2- to 23-month follow-up, there were no lead dislodgments. No patients developed mastitis or incisional complications, and all have been extremely satisfied with the cosmetic results. With proper technique, submammary pacemaker implantation can be performed under local anesthesia with minimal patient discomfort and optimal cosmesis.

OBJECTIVES:This study was conducted to identify the determinants of successful nonthoracotomy cardioverter-defibrillator implantation.BACKGROUND:Until recently, either median sternotomy or thoracotomy was necessary to implant the electrodes used for internal cardioverter-defibrillator systems. A number of manufacturers have developed nonthoracotomy lead systems comprising two transvenous coil electrodes and a subcutaneous patch electrode. At present, the factors associated with the success or failure of a nonthoracotomy approach are unknown.METHODS:A total of 101 consecutive patients requiring a cardioverter-defibrillator underwent an initial nonthoracotomy approach. Factors associated with successful nonthoracotomy implantation were prospectively determined.RESULTS:A nonthoracotomy system was implanted in 72 (71%) of 101 patients. Twenty-nine patients (29%) required thoracotomy. Univariate predictors of successful nonthoracotomy implantation included smaller cardiac size (p < 0.0001), smaller cardiothoracic ratio (p < 0.0002), QRS duration < 120 ms (p = 0.003), female gender (p = 0.006), ventricular fibrillation as the presenting arrhythmia (p = 0.03) and smaller echocardiographic left ventricular size (p = 0.04). Multivariate predictors included smaller cardiac size (p < 0.002) and female gender (p < 0.007). Total actuarial survival over a mean (+/- SD) follow-up interval of 12 +/- 7 months was 91 +/- 0.03% and was not different in the thoracotomy and nonthoracotomy groups.CONCLUSIONS:A nonthoracotomy cardioverter-defibrillator system can be implanted in a majority of patients. Smaller cardiac size and female gender are associated with a high probability of successful implantation.