A Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy
A Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy
Background: Colonoscopy visualizes more of the colon than flexible sigmoidoscopy. This study compares the outcomes of an unsedated modified colon endoscopy (MCE) with flexible sigmoidoscopy (FS) in family medicine practice.
Methods: We conducted a retrospective chart review of existing clinical data to compare outcomes for 48 patients undergoing MCE and 35 patients undergoing FS at 3 family medicine practices in Los Angeles. Outcomes of interest included completion rates, number of complications, depth reached, anatomic site visualized, and information about the number and nature of clinical findings.
Results: No significant differences were found between MCE and FS regarding completion rates (83.3% vs 75%, respectively). Expected statistically significant differences were found between the 2 procedures in the anatomic site visualized (P < .01) and depth reached (P < .01). Clinical pathologies were identified in 58% of MCE patients and 37% of FS patients. Four adenocarcinomas were identified in the MCE group in the proximal region of the colon that could not have been detected by FS.
Conclusions: Findings from this study suggest that MCE can be an acceptable alternative to FS in office settings for colorectal cancer screening.
Family physicians routinely provide endoscopic screening services to their patients in the form of flexible sigmoidoscopy (FS). More than a decade ago, Selby et al reported a 60% reduction in colorectal cancer mortality among people undergoing screening sigmoidoscopy. However, traditional FS only reaches a depth of 60 cm and so excludes 80 to 100 cm of colon from examination. Recent studies have suggested that FS may miss as many as half the lesions in the colon, a problem that may be particularly pronounced among women. In a recent study comparing the detection of polyps by colonoscopy and sigmoidoscopy, FS identified only 35.2% of women with advanced colorectal neoplasia compared with 66.3% of matched men. In contrast, standard colonoscopy allows 100% of the cecum (total colon) to be viewed in approximately 76% or greater of procedures and has been shown to be more sensitive than FS for detecting large adenomas and cancers.
Although the US Preventative Services Task Force does not yet recommend the use of one particular method of colorectal cancer screening over another, it strongly recommends that clinicians screen adults with average risk for colorectal cancer with one of a variety of different screening methods, including colonoscopies, beginning at age 50 and then again every 10 years. The American Cancer Society makes similar recommendations for adults at average risk. An excellent overview of colorectal cancer screening recommendations and surrounding controversies is available in Ransohoff's 2005 review of the topic.
Many patients, particularly those who are uninsured or underinsured, do not have access to colonoscopy as a screening option because of the few trained colonoscopists working in medically underserved areas. In Los Angeles County alone, community physicians report that their uninsured and publicly insured patients with indications can wait as long as 8 months for a colonoscopy, and that screening colonoscopies are simply unavailable (phone conversation with G. Floutsis, MD, Medical Director Clinica Msr. Oscar A. Romero Community Health Center, November 2005; e-mail communication with RD Yang, MD, PhD, Division of Gastroenterology and Liver Diseases, Keck School of Medicine, University of Southern California, March 2007).
One solution to the limited capacity for screening colonoscopies in the health care system is to train primary care physicians to perform colonoscopies in the primary care settings. Numerous previous studies have shown that, after the completion of appropriate training, family physicians can perform colonoscopies competently and safely in inpatient and outpatient settings with high patient satisfaction, few to no complications, and reliable and valid clinical findings. Unfortunately, licensing regulations in some states relating to the use of conscious sedation (required for colonoscopy) can make it cost prohibitive for family physicians and other primary care physicians to offer colonoscopy in their practices. In California, full conscious sedation must be administered in a facility that is fully licensed either by the Department of Health Services, the Joint Accreditation Commission of Hospitals and Health Organizations or the American Association of Ambulatory Health Centers (California Senate Bill 595 to 19990816 Amended).
Several studies have compared unsedated colonoscopy with sedated procedures and with FS in specialist settings and have found the unsedated procedure to be comparable to sedated colonscopy and FS in terms of patient tolerance, complications, and completion rates. In one of the earliest of these studies, Thiis-Evensen et al (2000) of Norway evaluated the efficacy of colonoscopy without sedation during screening examination in 451 adult patients. Completion rates and complication rates for unsedated and sedated colonoscopy with an adult endoscope were comparable. Currently, the procedure is the de facto standard of care for colorectal cancer screening by colonoscopy in small provincial clinics and hospitals in Norway (e-mail communication with E. Thiis-Evensen, MD, Department of Medicine Telemark Central Hispital, Skien; Department A of Medicine, Rikshospitalet University Hospital, Oslo, Norway, December 2003). In a gastroenterology setting, Wu et al (2003) obtained similar findings in a comparison of unsedated colonoscopy with an adult colonoscope and FS and using nursing staff to deliver the procedure. Thompson, Springer, and Anderson found no significant differences in patient tolerance and examination duration when comparing unsedated colonoscopy with a pediatric colonoscope and FS.
Studies comparing pediatric and adult colonoscopes have found few significant differences between the two in time to cecum, patient tolerance, and endoscopist perception of difficulty, but found a slight superiority in completion rates for the pediatric colonoscope. Saifudden et al (2000) reported higher completion rates in procedures using the pediatric colonoscope compared with those using adult colonoscopies, especially in women. Okamoto et al (2005) found better completion rates with the pediatric compared with adult colonoscope in patients with fixed, angulated colons.
In 2002, in response to their uninsured and publicly insured patients lack of access to screening colonoscopies, 4 clinicians from 3 family medicine practices involved with LA Net, a primary care practice-based research network, began offering unsedated colonoscopy with a pediatric endoscope to adult patients under guidelines recommended by the US Preventative Services Task Force and American Cancer Society and those outlined in Table 1 . The clinicians opted to use a pediatric colonoscope in the procedure based on evidence demonstrating the basic comparability of the 2 devices and a slightly higher completion rate for procedures conducted using the pediatric endoscope. At each practice, modified colon endoscopy (MCE) was offered to all average-risk adult patients eligible for colorectal cancer screening as an alternative to both already-available on-site FS and referral to an off-site specialty clinic for sedated colonoscopy. In a few rare instances, MCE was offered to patients in higher-risk categories after they were referred for off-site sedated colonoscopy while they were waiting for their appointment. In these instances, the patients were likely to experience very lengthy wait times for an off-site appointment because of their insurance status.
All of the family physicians in this study acquired their skills for FS while in residency training. Three of the 4 acquired their skills in colonoscopy over 10 years of practice and continuing medical education procedural courses through the American Academy of Family Physicians and others. One clinician had received formal colonoscopy training during his residency training program before joining the faculty practice. Each received training from the endoscope manufacturer in the use of the equipment and was instructed by the lead investigator (RGH), who has extensive experience in GI endoscopy. All reviewed Hoff's recommendations for conducting unsedated colonoscopy. All clinicians were credentialed by the University of Southern California Faculty Practice Credentialing Committee to perform these procedures.
The goal of this study was to determine whether MCE and FS conducted in a family medicine practice are comparable in terms of completion rates and number of complications, and to determine whether MCE allows the family physician to visualize more of the colon than FS.
Background: Colonoscopy visualizes more of the colon than flexible sigmoidoscopy. This study compares the outcomes of an unsedated modified colon endoscopy (MCE) with flexible sigmoidoscopy (FS) in family medicine practice.
Methods: We conducted a retrospective chart review of existing clinical data to compare outcomes for 48 patients undergoing MCE and 35 patients undergoing FS at 3 family medicine practices in Los Angeles. Outcomes of interest included completion rates, number of complications, depth reached, anatomic site visualized, and information about the number and nature of clinical findings.
Results: No significant differences were found between MCE and FS regarding completion rates (83.3% vs 75%, respectively). Expected statistically significant differences were found between the 2 procedures in the anatomic site visualized (P < .01) and depth reached (P < .01). Clinical pathologies were identified in 58% of MCE patients and 37% of FS patients. Four adenocarcinomas were identified in the MCE group in the proximal region of the colon that could not have been detected by FS.
Conclusions: Findings from this study suggest that MCE can be an acceptable alternative to FS in office settings for colorectal cancer screening.
Family physicians routinely provide endoscopic screening services to their patients in the form of flexible sigmoidoscopy (FS). More than a decade ago, Selby et al reported a 60% reduction in colorectal cancer mortality among people undergoing screening sigmoidoscopy. However, traditional FS only reaches a depth of 60 cm and so excludes 80 to 100 cm of colon from examination. Recent studies have suggested that FS may miss as many as half the lesions in the colon, a problem that may be particularly pronounced among women. In a recent study comparing the detection of polyps by colonoscopy and sigmoidoscopy, FS identified only 35.2% of women with advanced colorectal neoplasia compared with 66.3% of matched men. In contrast, standard colonoscopy allows 100% of the cecum (total colon) to be viewed in approximately 76% or greater of procedures and has been shown to be more sensitive than FS for detecting large adenomas and cancers.
Although the US Preventative Services Task Force does not yet recommend the use of one particular method of colorectal cancer screening over another, it strongly recommends that clinicians screen adults with average risk for colorectal cancer with one of a variety of different screening methods, including colonoscopies, beginning at age 50 and then again every 10 years. The American Cancer Society makes similar recommendations for adults at average risk. An excellent overview of colorectal cancer screening recommendations and surrounding controversies is available in Ransohoff's 2005 review of the topic.
Many patients, particularly those who are uninsured or underinsured, do not have access to colonoscopy as a screening option because of the few trained colonoscopists working in medically underserved areas. In Los Angeles County alone, community physicians report that their uninsured and publicly insured patients with indications can wait as long as 8 months for a colonoscopy, and that screening colonoscopies are simply unavailable (phone conversation with G. Floutsis, MD, Medical Director Clinica Msr. Oscar A. Romero Community Health Center, November 2005; e-mail communication with RD Yang, MD, PhD, Division of Gastroenterology and Liver Diseases, Keck School of Medicine, University of Southern California, March 2007).
One solution to the limited capacity for screening colonoscopies in the health care system is to train primary care physicians to perform colonoscopies in the primary care settings. Numerous previous studies have shown that, after the completion of appropriate training, family physicians can perform colonoscopies competently and safely in inpatient and outpatient settings with high patient satisfaction, few to no complications, and reliable and valid clinical findings. Unfortunately, licensing regulations in some states relating to the use of conscious sedation (required for colonoscopy) can make it cost prohibitive for family physicians and other primary care physicians to offer colonoscopy in their practices. In California, full conscious sedation must be administered in a facility that is fully licensed either by the Department of Health Services, the Joint Accreditation Commission of Hospitals and Health Organizations or the American Association of Ambulatory Health Centers (California Senate Bill 595 to 19990816 Amended).
Several studies have compared unsedated colonoscopy with sedated procedures and with FS in specialist settings and have found the unsedated procedure to be comparable to sedated colonscopy and FS in terms of patient tolerance, complications, and completion rates. In one of the earliest of these studies, Thiis-Evensen et al (2000) of Norway evaluated the efficacy of colonoscopy without sedation during screening examination in 451 adult patients. Completion rates and complication rates for unsedated and sedated colonoscopy with an adult endoscope were comparable. Currently, the procedure is the de facto standard of care for colorectal cancer screening by colonoscopy in small provincial clinics and hospitals in Norway (e-mail communication with E. Thiis-Evensen, MD, Department of Medicine Telemark Central Hispital, Skien; Department A of Medicine, Rikshospitalet University Hospital, Oslo, Norway, December 2003). In a gastroenterology setting, Wu et al (2003) obtained similar findings in a comparison of unsedated colonoscopy with an adult colonoscope and FS and using nursing staff to deliver the procedure. Thompson, Springer, and Anderson found no significant differences in patient tolerance and examination duration when comparing unsedated colonoscopy with a pediatric colonoscope and FS.
Studies comparing pediatric and adult colonoscopes have found few significant differences between the two in time to cecum, patient tolerance, and endoscopist perception of difficulty, but found a slight superiority in completion rates for the pediatric colonoscope. Saifudden et al (2000) reported higher completion rates in procedures using the pediatric colonoscope compared with those using adult colonoscopies, especially in women. Okamoto et al (2005) found better completion rates with the pediatric compared with adult colonoscope in patients with fixed, angulated colons.
In 2002, in response to their uninsured and publicly insured patients lack of access to screening colonoscopies, 4 clinicians from 3 family medicine practices involved with LA Net, a primary care practice-based research network, began offering unsedated colonoscopy with a pediatric endoscope to adult patients under guidelines recommended by the US Preventative Services Task Force and American Cancer Society and those outlined in Table 1 . The clinicians opted to use a pediatric colonoscope in the procedure based on evidence demonstrating the basic comparability of the 2 devices and a slightly higher completion rate for procedures conducted using the pediatric endoscope. At each practice, modified colon endoscopy (MCE) was offered to all average-risk adult patients eligible for colorectal cancer screening as an alternative to both already-available on-site FS and referral to an off-site specialty clinic for sedated colonoscopy. In a few rare instances, MCE was offered to patients in higher-risk categories after they were referred for off-site sedated colonoscopy while they were waiting for their appointment. In these instances, the patients were likely to experience very lengthy wait times for an off-site appointment because of their insurance status.
All of the family physicians in this study acquired their skills for FS while in residency training. Three of the 4 acquired their skills in colonoscopy over 10 years of practice and continuing medical education procedural courses through the American Academy of Family Physicians and others. One clinician had received formal colonoscopy training during his residency training program before joining the faculty practice. Each received training from the endoscope manufacturer in the use of the equipment and was instructed by the lead investigator (RGH), who has extensive experience in GI endoscopy. All reviewed Hoff's recommendations for conducting unsedated colonoscopy. All clinicians were credentialed by the University of Southern California Faculty Practice Credentialing Committee to perform these procedures.
The goal of this study was to determine whether MCE and FS conducted in a family medicine practice are comparable in terms of completion rates and number of complications, and to determine whether MCE allows the family physician to visualize more of the colon than FS.
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