Combination of on-demand sedation, water exchange, cap-assisted colonoscopy and underwater polypectomy - a novel approach of minimally invasive colonoscopy and polypectomy associated with plausible increased value for screening

Abstract

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)