Study supports use of no-sedation colonoscopy
■ The option could make screening more available, but experts worry the approach might deter patients.
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A desire to continue providing colonoscopy, combined with a lack of resources, led one physician to offer the procedure without sedation. Now, that solution may lead to no-sedation colonoscopy becoming a more widely considered option.
A few years ago, the Sepulveda Ambulatory Care Center in North Hills, Calif., experienced a nursing shortage, and Felix Leung, MD, a staff gastroenterologist, was faced with two options. He could stop performing the procedure, or he could start offering it without sedatives. The Sepulveda center is part of the Veterans Affairs Greater Los Angeles Healthcare System. In response to patients who didn't want to travel 15 miles to another facility, he offered the no-sedation approach. Quite a few -- 30% between 2002 and 2005 -- accepted.
"The veterans asked if there was an alternative, and we found out that unsedated colonoscopy is done in many parts of the world," said Dr. Leung, who also is a professor of medicine at the David Geffen School of Medicine at the University of California, Los Angeles. "The U.S. seems to be unusual in that we, by and large, only do sedated colonoscopy."
He has since documented his experiences in a series of papers, including one in the December 2008 Journal of Family Practice. This article reported that, from September 2002 to June 2005, 145 out of 483 eligible patients opted to undergo colonoscopy without sedation. Of this group, 112 were able to complete it. Twenty-six could not, because of the discomfort, and later underwent sedated colonoscopy or barium enema. Another seven had poor bowel preparation or obstructing lesions that blocked the procedure. Some physicians said these numbers indicated that unsedated colonoscopy is a viable alternative.
"It's not going to be for everyone, but it's an option that I think patients would want to consider," said Thomas Kintanar, MD, a family physician in Fort Wayne, Ind. "There are some patients who will do just great without any anesthetic." He is also a board member of the American Assn. for Primary Care Endoscopy, although he was speaking for himself.
Colonoscopy without sedation is common in Europe and Asia, and efficacy is comparable.
"There have been several studies that show that if you have motivated patients, a significant fraction of them can have a colonoscopy without sedation," said Douglas Rex, MD, past president of the American College of Gastroenterology. "But what has to be kept in mind is that most American patients actually prefer to be sedated. If you use sedation, there is better patient satisfaction and better physician satisfaction. That's really important."
Dr. Rex, who is also professor of medicine at Indiana University School of Medicine and director of endoscopy at Indiana University Hospital, has performed a small number of colonoscopies on unsedated patients and has undergone one without sedation himself. "For the great majority, having sedation offers a lot of advantages and a lot of positives," he said.
But with the demand for colonoscopy growing, performing it without sedation could reduce both associated work force needs and costs to the health care system. In his efforts, for instance, Dr. Leung eliminated the need for two registered nurses.
Also, a report released Jan. 7 by the Lewin Group, a health care consulting firm, projected that demand for gastroenterologists would grow at a rate nearly double the supply. If this projection bears out, it could impact the availability of traditional colorectal cancer screening, thereby increasing interest in the no-sedation option.
Neither the American Gastrological Assn. nor the ACG has policy regarding no-sedation colonoscopy. In broader terms, ACG policy notes that a well-trained endoscopist is key to a good colonoscopy. The American Academy of Family Physicians takes the position that family physicians trained in colonoscopy should be allowed to perform them and that specialty should not affect privileging.
Going without sedation also could provide some benefits for patients. Dr. Leung discovered many preferred being able to communicate and remember the conversations with the physician during and after. In addition, the unsedated approach is less expensive and does not require patients to have an escort or restrict activities afterward.
"Some patients just didn't have anybody to shuttle them around, and these patients would not have been able to have screening by colonoscopy if this option was not available," Dr. Leung said.
Additionally, this approach cuts to zero the already very low risk of complications associated with the sedative medications and significantly reduces the chance of a perforation.
"You cannot perforate [the bowel of] an awake patient. They will get off the table and smack you," said Ricardo G. Hahn, MD, professor of family medicine at the University of Southern California in Los Angeles. Unsedated colonoscopy is "not a comfortable procedure, but it's only once every five to 10 years."
Dr. Hahn co-authored a paper in the September-October 2007 Journal of the American Board of Family Medicine comparing unsedated colonoscopy with flexible sigmoidoscopy in a family medicine clinic.
Several physicians, however, expressed caution, because unsedated colonoscopy may not be possible or appropriate for everyone. Data from a VA population, which tends to be older and predominantly male, may not apply to the wider world. For example, female physiology tends to make this procedure more difficult.
Experts also worry that an uncomfortable experience may keep a patient from completing this screening.
"The key for us is to ensure a good exam, a comfortable exam for the patient and one that they are willing to repeat," said David A. Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia School of Medicine. He also is an ACG past president.
Dr. Leung's upcoming projects will look at colonoscopy techniques, such as using water infusion without air insufflation, to reduce the discomfort related to the procedure and allow more patients to have it done without or with less sedation.