Colonoscopy by Water Method: Learning Curve and Observations of an Experienced Colonoscopist in a U.S. Community Practice

Abstract

Purpose: The water method (Endoscopy 2011 May 24; JIG 2011;1:8-13) has been reported to have beneficial effects in veterans settings; use of the water method in a community practice setting is less well-known. Aim: To assess the water method learning curve and record observations of an experienced colonoscopist in a U.S. community practice. Methods: 1. An experienced colonoscopist (LSF) was coached by FWL in 7 sedated colonoscopies using the water method. 2. In a performance improvement project (3/21/2011 to 5/26/2011), 132 consecutive sedated patients were examined by LSF. All examinations were initiated using the water method. If “difficulty” was encountered, air insufflation was utilized to ensure completion of the examination in a timely manner (30 or 45 minute scheduled time allotment). Intent-to-treat (ITT) and final cecal intubation rates were recorded. Results: 1. During the coaching session, cecal intubation success: ITT=71%, Final=100%; mean insertion time: 15.3 (5.9) min. 2. Data tabulation was set up using patients 1 to 66 (Early Group), and patients 67 to 132 (Later Group). Table 1. shows the demographic and procedure-related variables. Table 2. shows the comparison of ITT success and failure in cecal intubation. ITT success was not influenced by gender, indications for colonoscopy, or history of abdominal surgery. ITT success was influenced by volume of water infused, and possibly influenced by pressure to complete the examination in a timely manner, disconnection of the air pump, application of abdominal pressure, and quality of bowel preparation.Table 1: . No Caption available.Table 2: . No Caption available.Conclusion: Use of the water method does not preclude cecal intubation upon conversion back to air insufflation if needed. With practice, the ITT cecal intubation rate increases significantly with the water method alone. In ITT success of cecal intubation, significantly larger volumes of water were infused and the insertion time was slightly (1.8 min) but significantly shorter. The data in this pilot study suggest that learning the water method in the context of a performance improvement program, and tracking the progress of a busy colonoscopist in community practice are feasible. The impact of incorporating all of the components described for the water method, including water exchange during insertion, deserves further evaluation. [Supported in part by VA and ACG research funds (FWL)].