1. Moving Toward Universal Colon Cancer Screening: Methods In Unsedated Colonoscopy Christopher Forest, PA-C Darenie Goodman, MD Kelly Jones, MD Wm MacMillan Rodney, MD Ricardo Hahn, MD Keck School of Medicine, Department of Family Medicine Alfred E. Mann Institute for Medical Bioengineering

2. Behavioral Objectives Upon completion, family physicians should be able to: 1. Recognize the viability of unsedated flexible lower GI endoscopy in the ambulatory setting; 2. Describe the technical requirements and experience needed; 3. Implement improved techniques to increase visualization; 4. Effectively increase patient comfort up to 160 cm; 5. Identify suitable candidates; 6. Explain what is, and is not, possible with this technique. Financial Disclosures: No conflicts of interest

3. Overview Introduction Standard Flexible Lower GI Endoscopy The Leung Water-Infusion Technique Standard Air-Infusion Method Informed Consent Patient Selection Increasing Patient Comfort Increasing Visualization 3 Cases Studies Discussion

4. Introduction Colorectal Cancer Data  Third most common cancer in men and women  Incidence rates decreased in the past 20 years  101,700 new cases of colon cancer estimated 2011  Lifetime risk is 1:20 (5.1%) Value of Lower GI Endoscopy in Early Detection  Prevalence of adenomatous polyps at age 50 is 20-25%  90% of colorectal cancers are diagnosed in patients >50  Screening is needed to identify and remove adenomas  Detection at localized stage has a 5-yr survival of 90%

5. Standard Flexible Lower GI Endoscopy The Lower GI Endoscopic Procedure (Rodney) Sedated Lower GI Endoscopy  Advantages and disadvantages  Costs to the system and patient Unsedated Lower GI endoscopy  Advantages and disadvantages  Becoming more common  Multiple methods  Potential for the Family Physician

6. The Leung Water-Infusion Technique Water temperature: 37.6° Celsius Patient is placed in left lateral decubitus position Insertion of scope and air suction Water infusion intermittently Feces is suctioned and replaced by clean water Water volume: 200 to 2000cc Withdrawal: residual water removed for inspection Air insufflation as needed to permit examination

7. The Leung Water-Infusion Technique Physiologic Capabilities of This Technique  Exclusion of air insufflation decreases colon length  Lower pain score and overall tolerance  Increased cecal intubation rate  Rate of incomplete procedure or detection of anomaly comparable to air method Benefits:  Warm water decreases cramping  Cleansing effect may increase adenoma detection Leung FW, Leung JW, Mann SK, et al. Gastrointest Endosc. Accepted for Publication 2011. Used with Permission

8. Limitations of the Water-Infusion Technique Increased artifact due to lowered motility Mucosa appears more “fluffy” or “polyp-like” Difficult to biopsy with the colon full of water  Increased bleeding requiring irrigation and suctioning  Evacuation of water if electrocautery Requires a dedicated suite to allow for water pumps and cleaning

9. Standard Air-Infusion Method History  Risk management involvement  Development of the Informed Consent  Dedicated regular exam room  Over 700 procedures in Family Medicine clinic Patient education  Utilization of nurses and medical assistants  Patient is awake so functionality of all equipment must be tested immediately prior to the procedure  Procedure requires 4 hands

10. Advantages No risk of sedation-related complications Able to observe the procedure Nearly impossible to perforate No escort required No IV sedation side effects (n/v, cramping) No recovery time or activity restriction Financially consistent with screening procedure costs

11. Disadvantages and Limitations Pain or discomfort primarily 20-35 and 110-170 cm Possible need for second prep if the pain is unbearable Intubation of the cecum is painful

12. Informed Consent Promoting informed choice in motivated patients  Each step is explained  We do not offer the option for sedation at that sitting  Second prep would be necessary if sedation indicated Acceptance coincides with  Patient education  Change of cultural expectations

13. Patient Selection Patients who do not do well without sedation:  Female, low BMI (<25), younger (<40)  History of IBS, diverticulosis, pelvic surgery  History of gastritis, indigestion, bloating, constipation  Anxiety or anticipated discomfort Ideal candidates for unsedated colonoscopy  Control freaks who do not want sedation  Those for whom sedation places them at risk  Those who want to watch  Those without an escort home  Uninsured at risk

14. Increasing Patient Comfort Minimal insufflation with air Warm water for irrigation Patience, waiting for lumen to spontaneously open Asking the patient to rotate onto the back when preparing to enter the transverse colon Keeping the patient informed at each step Requesting feedback from the patient

15. Case 1: 73 y.o. Caucasian male presenting for routine screening colonoscopy. No GI complaints. Video used with permission. Consent to videorecord the procedure on file.

16. Case 2: 65 y.o. Hispanic male presenting for routine screening colonoscopy. History reveals probable IBS. Video used with permission. Consent to videorecord the procedure on file.

17. Case 3: Polyp 77 y.o. Caucasian male - routine screening Video used with permission. Consent to videorecord the procedure on file.

18. Summary Unsedated colonoscopies are becoming more common with increased concerns for risks of sedation and rising medical costs Many patients tolerate the procedure well but patient selection and procedural techniques are key Performing this procedure in the office-based setting is feasible and compatible with a busy practice The goal is to increase colon cancer screening while minimizing risk and discomfort to the patient