Introduction

Water exchange, replacing air insufflation during colonoscopy's insertion phase, has become popular for its effectiveness in enhancing endoscopic quality. Its adoption by novices, who show improved performance, raises questions about its benefits for experienced colonoscopists. This study examines the adaptation process of three seasoned colonoscopists to water exchange, evaluating if they achieve similar improvements, to understand its broader utility.

Aims & Methods

In this study, three expert colonoscopists, each with over 10,000 air insufflation colonoscopies, first conducted 100 standard procedures. They then switched to the water exchange technique for 100 more procedures across four groups. Key outcomes—cecal intubation rates, learning curves, pain scores, polyp detection, complications, abdominal compression, position changes, and bowel preparation quality—were compared between methods to evaluate the water exchange's effectiveness and patient experience.

Results

Cecal intubation success rates and median times for water exchange groups were over 90% and below 6 minutes, matching results from traditional air insufflation methods. No notable differences were found in intubation times between endoscopists A and B, but endoscopist C showed significant time variations, especially in the third quartile, indicating a performance shift (P<0.001). A slight, non-significant decrease in abdominal compression was observed for endoscopist A, while endoscopist B's transition to water exchange significantly reduced compression needs (37% vs. 21%; P<0.05), showcasing its advantages. No changes were evident for endoscopist C. Position change demands differed significantly between methods for endoscopists B and C, hinting at endoscopist C's preference for air insufflation (P=0.001). In this study, the pain scores in the water exchange group were significantly lower than those in the air insufflation group (P=0.008) for only one expert. For the other experts, although the number of patients with a pain score of 10 decreased and the number of patients with a pain score of 0 increased in the water exchange group, no significant difference was observed. This suggests that for seasoned professionals, the water method primarily played a significant role in reducing severe abdominal pain. For patients with mild pain, the effect was unclear. An analysis of the learning curve, considering cecal intubation success and time, found no correlation with the number of water exchange procedures performed, indicating all endoscopists quickly adapted to the method without a marked learning curve, maintaining success rates above 90%.

Conclusion

The study found the water method effectively reduced severe abdominal pain, with its impact on mild pain less clear. Experts showed proficiency with this technique from the start, achieving 95% success rates in cecal intubation, indicating quick adaptation. Despite this, traditional colonoscopy's known drawbacks weren't significantly highlighted. However, experts familiar with conventional techniques found the water method more challenging and saw no major advantages for colorectal screening.

References

1. Leung FW. Water Exchange to Facilitate Unsedated Colonoscopy-Reply. Jama, 2017,318:754-755.
2. de Groen PC. Water Exchange Insertion Colonoscopy-How You Can Do It Too. Am J Gastroenterol, 2019,114:703-704.
3. Cadoni S, Hassan C, Frazzoni L, et al. Impact of water exchange colonoscopy on endoscopy room efficiency: a systematic review and meta-analysis. Gastrointest Endosc, 2019,89:159-167.e113.

Introduction

Colonoscopy is the gold standard of an optimal exploration of the colon. Complete colonoscopy stands as the cornerstone for detecting precancerous lesions and colorectal screening.

Aims & Methods

The aim of our study was to identify factors limiting the completeness of the colonoscopy. We retrospectively colonoscopy reports performed between August 2023 and April 2024. Colonoscopies performed under general anesthesia were excluded from our analysis. Demographics, clinical and endoscopic data were collected. We investigated predictive factors of incomplete examinations.

Results

In total, 400 performed colonoscopies were included. The mean age of the patients was 56.5 years ± 14.22 (ranging from 16 to 91 years) and a male-to-female ratio of 2. History of diabetes was present in 24% of patients, hypertension in 38% of patients, and 7.8% of patients had chronic inflammatory bowel disease. The predominant indications for colonoscopy were constipation in 29% of cases, digestive bleeding in 16.1% of cases, diarrhea in 11% of cases, anemia in 9% of cases, screening in 4.8% of cases, and anal fistula in 3.8% of cases. The cecum was intubated in 381 colonoscopies (79.8% of cases). Interruption of the endoscopic examination were attributed to various causes, including inadequate preparation (45.5%), poor tolerance (32.5%) and irreducible loops (13%). In univariate analysis, anemia (p=0.033), history of benign prostatic hyperplasia, tolerance (p=0.05), and poor preparation (assessed by the Boston Bowel Preparation Scale) (p<0.0001) were identified as associated factors to incomplete colonoscopy. Demographic characteristics, comorbidities, irritable bowel syndrome, body mass index, abdominal hernia, history of anterior abdominal surgery were not associated with incomplete examination. On multivariate analysis, poor tolerance (p<0.0001, OR= 2.45 95%IC: 1.667-3.672), colonic preparation (p<0.0001, OR= 4.04 95%IC: 2.384-6.845) were predictive factors of incomplete colonoscopies.

Conclusion

This study confirms the importance of addressing limiting factors of a complete colonoscopy to avoid rescheduling the procedure and to prevent its psychological impact and delay in management and economic burden. Adequate analgesia and improved preparation are necessary for successful cecal intubation.

Introduction

Colonoscopy techniques is an independent factor of adenoma detection rate. However, the colonoscope insertion methods and cecal intubation time is often ignored compared with relevant technology or colonoscopy performance indicator in withdrawal stage. The effect of water exchange (WE) method characterized by water infusion with water removal primarily during insertion stage on colonoscopy has remained controversial. We aimed to carry out a meta-analysis to systematically evaluate the relationship between WE and quality of colonoscopy compared with the conventional methods include air insufflation and carbon dioxide insufflation.

Aims & Methods

Aims: To evaluate the effect of water exchange method versus conventional methods including air insufflation and carbon dioxide insufflation method for the quality of colonoscopy.
Methods: ​We searched randomized controlled trials published up to October 2022 from PubMed, Web of Science, the Cochrane Library, CNKI, Wanfang, SinoMed databases. Two reviewers independently searched the literatures based on standards to extract the data and evaluate the quality. The primary outcomes were cecal intubation time and adenoma detection rate. The secondary outcomes included cecal intubation rate, quality of bowel preparation, pain score, number of abdominal compression, number of position change. Meta-analysis was conducted by RevMan5.4.1.The study protocol was registered in PROSPERO (CD42022327954).

Results

A total of 23 studies involving 10654 patients were included. Although cecal intubation time was prolonged in WE (MD=1.81, 95%CI: 1.28, 2.35; P < 0.001), WE had higher adenoma detection rate (OR=1.40，95%CI：1.26, 1.55；P<0.001), cecal intubation rate (OR=1.62；95%CI：1.24,2.10；P<0.001) and quality of bowel preparation (MD=0.61；95%CI：0.42, 0.79；P<0.001) compared with conventional colonoscopy. In addition, WE had significantly lower pain sores (MD=-1.07；95%CI：-1.39,-0.76；P<0.001), number of abdominal compression (OR=0.42；95%CI：0.29,0.60；P<0.001) and number of position change (OR=0.59；95%CI：0.42,0.82；P=0.002) than conventional colonoscopy.

Conclusion

Despite WE colonoscopy prolonged cecal intubation time, it could significantly increase adenoma detection rate, cecal intubation rate and quality of bowel preparation. And beyond that, WE reduced patient pain, the proportion of abdominal compression and position change. WE is a better choice for high-quality colonoscopy.

Introduction

Colonoscopy is the gold standard for accurate exploration of the colon. Thus, it must be performed as efficiently as possible with the respect of pre-established quality standards to ensure optimal exploration. The patient's tolerance considerably affects the quality of sedation-free examinations and exposes to a high rate of interruption. Pharmacological sedation can solve this issue, however it can expose to significant adverse events and is not always available.

Aims & Methods

The aim of this study was to evaluate the impact of intraprocedural immersive virtual reality (VR) combining visual and auditory distraction in the improvement of the tolerance and the progress during unsedated colonoscopy. We conducted a prospective controlled study from February to April 2023 including outpatients presenting to the endoscopy unit for unsedated colonoscopy after consent. Patients were randomized into two groups: Group 1: colonoscopy with virtual reality headset. Group 2: control group without intervention.The material used was a virtual reality headset provided with a fully adjustable headband. The video content displayed on the hardware is made of several clips showing nature scenes. The audio content was adapted to allow optimal communication with the patient. We have excluded patients with severe visual and/or auditory impairment, dementia, cognitive impairment and epilepsy. All participants initially completed a form covering health issues and a validated anxiety questionnaire (STAI). After colonoscopy, all patients completed a form with questionnaires assessing per-procedural patient comfort (Gloucester), anxiety (STAI) and pain (EVS). In addition, patients in the intervention group completed a satisfaction questionnaire (NPS: net promoter score) assessing their experiences with the VR headset.

Results

In total, 63 patients were included in the final analysis: intervention group G1 (n=33) and control group G2 (n=30). The mean age was of 57 years. No patient encountered a technical problem with the equipment used and no adverse events occurred during the immersive experience. The two groups were comparable in terms of age, gender, comorbidities, body mass index (BMI) and colonic preparation assessed by the Boston score. A slightly lower time to caecal intubation was noted in the intervention group without significant difference (G1: 19 min vs G2: 26 min, p=0.07). Patients with VR mask expressed lower levels of post-procedural anxiety than those in the control group (Mean STAI G1: 47 vs G2: 53, p<0.01) and a significant decrease in the STAI score compared to pre-endoscopy values (8 points vs 4 points, p<0.01). The per-procedural pain assessed by EVS was significantly lower in the patients using VR (Mean G1: 0.44 vs G2 :1,32, p<0.01). Moreover, endoscopic examination was found to be more comfortable with virtual reality based on the Gloucester scale p <0.01. No patient reported any impediment to communication with medical staff due to the VR mask. Four patients were not satisfied with the resolution of the videos and 8 patients have expressed their preference to choose the content themselves. Patients of the intervention group were greatly satisfied with the VR experience with a mean NPS at 30.

Conclusion

Immersive VR technology is a promising, non-invasive and well-accepted simple tool for improving tolerance by reducing colonoscopy induced pain and anxiety allowing an optimized examination. It can be a useful alternative to conventional sedation if undesired or contraindicated or in health care institutions with a lack of adequate anesthesia facilities.