Fighting Lengthy Cecal Intubation Times With Proning

Abstract

Introduction: Patients with significant abdominal fat often present an endoscopic challenge as it is difficult to provide adequate manual pressure to aid progression of the colonoscope. Some small studies and our own experience with overweight patients suggests that prone position is particularly effective in facilitating colonoscopy without significant risks such as airway related adverse events. We performed a randomized, controlled trial to evaluate different patient positioning among obese patients and present results here. Methods: Patients with BMI >30 presenting for colonoscopy were randomized to either the prone or left lateral decubitus position and markers of procedural difficulty including cecal intubation time and sedation use were recorded. Patients enrolled were randomized to control or treatment intervention with use of prepared sequentially numbered, sealed envelopes derived from a computer-generated scheme. Wilcoxon rank-sum test was used for hypothesis testing. SAS (version 9.4) was used for all statistical analysis. Results: After enrollment of 43 patients, an early analysis was conducted. 65% of patients were female with an average age of 60.0 years. Average BMI of patients was 35.8 kg/m2 randomized to the left lateral decubitus position and 37.6 kg/m2 in the prone position. Median cecal intubation time was 4 minutes 25 seconds in the left lateral group and 3 minutes 18 seconds in the prone group (p=0.39). Mean sedation use was 6.6 mg midazolam in the prone group vs 5.5 mg in the left lateral decubitus group (p=0.05), and 112.0 mg of fentanyl in the prone group vs 105.7 mg in the left lateral decubitus group (p=0.45). Endoscopists’ subjective sense of ease of procedure (ranked 1-10 with 10 being the hardest), scored a median of 4 for the prone group and 5 for the left lateral group with p=0.30. No adverse events, including oxygen desaturation, were noted in either group. A single patient in the left lateral group had to be rolled towards the prone position to complete the procedure. Conclusion: In this analysis comparing colonoscopy position, we showed that prone colonoscopy is a safe and efficacious positioning strategy for obese patients. Our cecal intubation time trended towards faster procedures with prone positioning, consistent with improved endoscopists’ perceived ease of procedure in the prone position, but these were not statistically significant. We expect that with the full trial enrollment our data may reach statistical significance.484_A Figure 1 No Caption available.484_B Figure 2 No Caption available.484_C Figure 3 No Caption available.