Failed Colonoscopies Referred by Community Colonoscopists for Double-balloon Enteroscopy - Successful Completion by Water Exchange Colonoscopy

Abstract

Purpose: To describe the use of water exchange method for the successful cecal intubation of patients referred for prior incomplete “difficult” colonoscopy performed by community gastroenterologists. Current guidelines recommend a cecal intubation rate >90% for all and 95% for screening cases. Incomplete cases occur in up to 10-17%. Single (GIE 2010;71:1319) and double (Endoscopy 2012;44:38) balloon-assisted examinations have been reported to salvage cecal intubation in these difficult cases. Water exchange method has been proposed as an inexpensive but effective technique for improving cecal intubation rates in difficult colonoscopies (Scand J Gastro 2011;46:517, JIG 2011;1:172). Methods: From Jan 2011 to Mar 2012, 10 patients with prior failed cecal intubation were referred to the UC Davis Medical Center GI Lab for double balloon enteroscopy by community physicians. Water exchange colonoscopy was performed on these patients by a single endoscopist. At the outset, the air pump was turned off. Water was infused through the colonoscope to expand the lumen. Residual air was suctioned as the scope was advanced through the colon. Water containing fecal debris was suctioned and replaced with clean water predominantly during insertion. When the cecum was reached, the air pump was turned on and lumen fully distended to allow for optimal visualization. Patient characteristics and procedural outcomes were reviewed and tabulated retrospectively. Results: (See Table) Ten patients (F/M: 7/3), age 60.3±14.7 yrs (range 37-82) were included. Indication for procedure was surveillance (4), screening (4) and diagnostic (2). Each patient underwent successful completed colonoscopy using the water exchange method. Cecal intubation time was 16.6±8.4 (range 6-28) min. Total procedure time was 28.4±8.5 (range 19- 43) min. Eight of the procedures were completed under conscious sedation (versed, fentanyl, Demerol, Benadryl, phenergan). Two patients had sedation given by anesthesiologist using moderate conscious sedation (versed, fentanyl). One patient was given remifentanyl. Average BMI was 26.4±5.5 (range 19.2-36.3). The polyp detection rate was 60%; adenoma detection rate was 50% in these patients. There were no complications.Table: Table. Reasons for prior failed cecal intubation based on referral documentsConclusion: The results provide proof-of-principle confirmation that water exchange method is effective for completing difficult colonoscopies. Patients with risk factors for difficult colonoscopy such as female sex, low and high BMI, prior abdominal surgery, young or advanced age, unsatisfactory bowel preparation, history of irritable bowel syndrome, or poor pain tolerance should be considered for this technique when undergoing colonoscopy.