Unsedated colonoscopy: Time to revisit this option?

Discussion

Colonoscopy was developed as an unsedated procedure.^19,20 Discomfort experienced by some patients during sigmoid intubation led to the use of medications,^20,21 which are now administered routinely.²² Interestingly, competency in unsedated colonoscopy is not required of GI fellows.²³ Indeed, until recently,¹⁸ teaching GI trainees unsedated colonoscopy was deemed impractical.⁷ Family physicians, on the other hand, have long practiced and taught unsedated colonoscopy,^14-17,24 although the actual number of family physicians performing colonoscopy is fairly small.²⁵ One reason so few family physicians offer the service—estimated at 3.7% of the specialty—may be the intensive and costly education required.¹⁶ Even more difficult has been gaining privileges to perform the sedated procedure,²⁶ given the training requirements set forth by GI professional societies.²⁷

Many patients would opt for unsedated colonoscopy. The favorable reception of unsedated colonoscopy in our study is evident in the increasing number of veterans each year who opted for the procedure despite the lengthening wait-time (which was due to increased demand rather than decreased availability of endoscopists). In the course of our project, we found that the terms “unsedated,” “no sedation,” or “without sedation” tended to convey the negative connotation that relief of discomfort and induced amnesia are withheld.^8,9 The term “sedation risk–free”²⁸ emphasized the benefits of no sedation.

Cost factors favoring unsedated colonoscopy. Sedated colonoscopies performed by family physicians have offered substantial health care savings.^29,30 It is intuitively obvious that the unsedated option in the hands of those with the necessary skills^14-16,24 would be even less costly. Our unsedated colonoscopy project reduced direct costs, which included the cost of having 2 registered nurses on hand. Indirect costs to patients³¹ were also minimized by avoiding the need for an escort or activity restriction. Moreover, there were no sedation-related complications.^32,33

An estimated 40 million healthy Americans are eligible for colorectal cancer screening.³⁴ Primary care providers play a pivotal role in counseling many of these patients, who may find the indirect cost savings of unsedated colonoscopy performed by that same provider appealing.

A logical transition from flexible sigmoidoscopy. An unsedated colonoscopy is very similar to an extended flexible sigmoidoscopy.^14-17,35 In patients who can tolerate a flexible sigmoidoscopy well, extended flexible sigmoidoscopy can reach the cecum >70% of the time.³⁶ To enhance the cecal intubation rate among unsedated veterans, we developed (subsequent to the findings reported here) a novel method of water infusion in lieu of air insufflation during insertion of the colonoscope.³⁷ This measure improved the cecal intubation rate from 76% to 97%.³⁸ For family physicians who perform flexible sigmoidoscopy, it is worth considering performing extended flexible sigmoidoscopy or unsedated colonoscopy using this water infusion method^37,38 or other methods to minimize discomfort in unsedated patients.³⁹

Limitations of our study, and opportunities. Our report is based on uncontrolled, nonrandomized observational data. Nevertheless, it affirms the feasibility of unsedated colonoscopy performed by supervised trainees, as previously reported by a family practice training program.¹⁶ It also underscores the benefits of the unsedated option on direct and indirect costs.

Since only 3.7% of family physicians in a recent survey reported performing colonoscopy,²⁵ it is uncertain whether primary care providers would voluntarily inform patients about the unsedated option. In select settings, gastroenterologists are willing to provide unsedated colonoscopy.^6,7,12,13,18 A reasonable hypothesis to test is that primary care providers informing patients about unsedated colonoscopy could reshape the future practice of screening colonoscopy in family medicine and gastroenterology.

Funding/Support

Supported in part by vA medical research Funds and an American Society for Gastrointestinal endoscopy career Development Award (FWl 1985).

Correspondence
Felix W. Leung, MD, Division of Gastroenterology (111G), Sepulveda Ambulatory Care Center, Veterans Affairs Greater los Angeles Healthcare System, 16111 Plummer Street, North Hills, CA 91343; .