Unsedated colonoscopy: Time to revisit this option?
This approach is worth considering when cost and sedation-related side effects are a concern
- Consider recommending unsedated colonoscopy to patients who have issues with cost, concerns about sedation, or are unable to get an escort or avoid work following the procedure.
- Explore resources in your area that offer unsedated colonoscopy.
Background Access to potentially life-saving screening colonoscopy is limited by the high cost of sedation. We explored the practicability of having supervised trainees perform unsedated colonoscopies.
Method A nursing shortage at our Veterans Administration gastroenterology training program necessitated discontinuing sedated colonoscopy. We offered the procedure without sedation to restore local access to screening colonoscopy.
Results From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The procedure was done by second-year gastroenterology (GI) fellows who had performed about 100 sedated colonoscopies in their first year of training. Cecal intubation was achieved in 81% of 138 wellpurged patients without obstructive lesions. Implementation obviated the need for 2 registered nurses, the escort requirement, and postprocedure activity restriction. It also eliminated sedation-related complications.
Conclusion This report confirms the feasibility of unsedated colonoscopy performed by supervised trainees. The unsedated option minimizes direct and indirect costs of colonoscopy. Describing unsedated screening colonoscopy to patients as a “sedation risk–free” procedure encouraged them to consider the benefits. We recommend that future studies test primary care providers’ willingness to inform patients of the feasibility of this nonstandard option, and perhaps reshape the practice of colonoscopy for colorectal cancer screening.
Monitored sedation given for colonoscopy is a measure meant to ensure patient safety,1 but its high cost limits access to the potentially life-saving screening procedure.2,3 Unsedated colonoscopy is an option, but a controversial one, raising issues both pro4-6 and con.7-11 In the United States, gastroenterologists perform unsedated colonoscopy both for unescorted patients (~2% of all screening colonos-copies)12,13 and individuals who simply prefer to avoid sedation (~6%).7 Family physicians, too, perform unsedated colonoscopy in both rural and urban settings.14-17
Would it be feasible to make training in unsedated colonoscopy more readily available to providers, and thereby reduce costs and inconvenience for patients? We took advantage of a changing environment at our Veterans Administration program to explore this question.
Method
A nursing shortage in our VA academic GI program necessitated discontinuing sedated colonoscopy. We reviewed the literature on unsedated colonoscopy and found that it is a feasible alternative performed elsewhere.4-7,12,14,16 Our attending staff discussed the options with patients and obtained informed consent18 using the following general message:
“Sedated colonoscopy is usual practice. Even though the risks of sedation are very small, nurses are required to monitor patients continuously. Because of a nursing shortage, we must send you to another VA facility 15 miles away for sedated colonoscopy. You must have an escort, as you will not be allowed to drive after sedation. One of the medicines they administer will make you forget the discomfort you may have experienced, as well as the discussions after the examination.
“Alternatively, you may choose unsedated colonoscopy, which is practiced in the United States and many other countries. Because no medicines are used, there are no medication-induced complications. An escort is not required, and there is no activity restriction afterwards.
“You will feel air in the colon and the endoscope being pushed around inside you. The colonoscopist will talk to you throughout the examination. When you begin to experience discomfort, the colonoscopist will remove air inside the colon or straighten the loops in the colonoscope to minimize the discomfort before it becomes severe. If discomfort does become severe, you and the colonoscopist can agree to stop the advancement of the colonoscope. Complications related to taking biopsies or removing polyps are similar in sedated and unsedated procedures.”
Supervised trainees (second-year GI fellows who had performed about 100 sedated colonoscopies in their first year of training), assisted by a licensed vocational nurse, performed the procedures using appropriate techniques.5-7
The Institution Review Board of the Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) approved our review of the patient data for publication.
Results
From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The number of patients choosing this option increased in each successive academic year (31, 50, and 64), as did the wait-time in days (27±4, 46±5, 72±6) (mean±standard error of the mean [SEM]). Seven patients (4%) had poor bowel preparation or obstructing lesions limiting completion. Among the 138 well-purged patients, we achieved cecal intubation in 112 (81%). Discomfort limited completion in the remaining 19%.
Other than transient vasovagal reactions in 2 patients, no complications occurred. Patients with incomplete examinations due to discomfort underwent sedated colonoscopy or barium enema or received no further assessment, depending on the initial findings. Those who subsequently underwent sedated colonoscopy (10%) had to be purged again, escorted, and comply with activity restriction.
