Cap-assisted water immersion colonoscopy – a prospective, randomized trial

Czech version

Authors: P. Falt ¹; V. Šmajstrla ¹; P. Fojtík ¹; M. Liberda ¹; M. Kliment ¹; J. Tvrdík ²; O. Urban ^1,3
Authors‘ workplace: Centrum péče o zažívací trakt, Vítkovická nemocnice, Ostrava ¹; Přírodovědecká fakulta, Ostravská univerzita v Ostravě ²; Lékařská fakulta, Ostravská univerzita v Ostravě ³
Published in: Gastroent Hepatol 2013; 67(2): 118-123
Category: Digestive Endoscopy: Original Article

Overview

Objectives:
Water immersion insertion can reduce discomfort and need for sedation during colonoscopy. A cap attached to the colonoscope tip may improve insertion during air insufflation colonoscopy. According to several reports, both techniques used independently may result in higher detection of neoplastic lesions. Our study was designed to evaluate the efficacy of cap-assisted water immersion compared to water immersion colonoscopy in minimally sedated patients.

Methods:
A total of 208 patients meeting the inclusion criteria were randomized to either the cap-assisted water immersion (Cap Water) or the water immersion colonoscopy (Water). The primary endpoint was cecal intubation time.

Results:
The cecal intubation time was 6.9 ± 2.9 minutes in Cap Water and 7.4 ± 4.2 minutes in Water arm (p = 0.73). The success rate of minimal sedation colonoscopy was equal in both groups (92.9%; p = 1.00). There were non-significant trends toward lower discomfort (p = 0.06), less need for abdominal compression (p = 0.06) and lower difficulty score from the endoscopist's point of view (p = 0.05) during the Cap Water colonoscopy. The adenoma detection rate was similar in both arms (44% in Cap Water vs 45% in Water group; p = 0.88). There were no complications recorded in the study.

Conclusions:
In comparison with water immersion without cap, the cap-assisted water immersion colonoscopy was not able to shorten the cecal intubation time. However, it has some potential to reduce patient discomfort and difficulty of colonoscope insertion. Potential impact on improved detection of neoplastic lesions has to be evaluated by further studies.

Key words:
cap – colonoscopy – colorectal cancer – water immersion

Sources

1. Leung FW, Harker JO, Jackson G et al. A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method. Gastrointest Endosc 2010; 72(4): 693–700.

2. Radaelli F, Paggi S, Amato A et al. Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial. Gastrointest Endosc 2010; 72(4): 701–709.

3. Leung CW, Kaltenbach T, Soetikno R et al. Water immersion versus standard colonoscopy insertion technique: randomized trial show promise for minimal sedation. Endoscopy 2010; 42(7): 557–563.

4. Leung JW, Mann SK, Siao-Salera R et al. A randomized, controlled trial to confirm the beneficial effects of the water Metod on U.S. veterans undergoing colonoscopy with the option of on-demand sedation. Gastrointest Endosc 2011; 73(1): 103–110.

5. Pohl J, Messer I, Behrens A et al. Water infusion for cecal intubation increases patient tolerance, but does not improve intubation of unsedated colonoscopies. Clin Gastroenterol Hepatol 2011; 9(12): 1012–1014.

6. Falt P, Liberda M, Smajstrla V et al. Combination of water immersion and carbon dioxide insufflation for minimal sedation colonoscopy: a prospective, randomized, single-center trial. Eur J Gastroenterol Hepatol 2012; 24(8): 971–977.

7. Leung FW, Leung JW, Mann SK et al. The water method significantly enhances patient-centered outcomes in sedated and unsedated colonoscopy. Endoscopy 2011; 43(9): 816–821.

8. Leung FW, Leung JW, Mann SK et al. DDW 2011 cutting edge colonoscopy techniques – state of the art lecture master class – warm water infusion/CO2 insufflation for colonoscopy. J Interv Gastroenterol 2011; 1(2): 78–82.

9. Leung FW, Leung JW, Siao-Salera RM et al. The water method significantly enhances detection of diminutive lesions (adenoma and hyperplastic polyp combined) in the proximal colon in screening colonoscopy – data derived from two RCT in US veterans. J Interv Gastroenterol 2011; 1(2): 48–52.

10. Leung FW, Harker JO, Leung JW et al. Removal of infused water predominantly during insertion (water exchange) is consistently associated with an increase in adenoma detection rate - review of data in randomized controlled trials (RCTs) of water-related methods. J Interv Gastroenterol 2011; 1(3): 121–126.

11. Kondo S, Yamaji Y, Satane H et al. A randomized controlled trial evaluating the usefullness of a transparent hood attached to the tip of the colonoscope. Am J Gastroenterol 2007; 102(1): 75–81.

12. Harada Y, Hirasawa D, Fujita N et al. Impact of a transparent hood on the performance of total colonoscopy: a randomized controlled trial. Am J Gastroenterol 2009; 69 (3 Pt 2): 637–644.

13. Lee YT, Lai LH, Hui AJ et al. Efficacy of cap-asssisted colonoscopy in comparison with regular colonoscopy: a randomized controlled trial. Am J Gastroenterol 2009; 104(1): 41–46.

14. Shida T, Katsuura Y, Terakoto O et al. Transparent hood attached to the colonoscope: does it really work for all types of colonoscopes? Surg Endosc 2008; 22(12): 2654–2658.

15. Dai J, Feng N, Lu H et al. Transparent cap improves patients´ tolerance of colonoscopy and shortens examination time by inexperienced endoscopists. J Dig Dis 2010; 11(6): 364–368.

16. Lee YT, Hui AJ, Wong VWS et al. Improved colonoscopy success rate with a distally attached mucosectomy cap. Endoscopy 2006; 38(7): 739–742.

17. Hewett DG, Rex DK. Cap-fitted colonoscopy: a randomized, tandem colonoscopy study of adenoma miss rates. Gastrointest Endosc 2010; 72(4): 775–781.

18. Tee HP, Corte C, Al-Ghamdi H et al. Prospective randomized controlled trial evaluating cap-assisted colonoscopy vs standard colonoscopy. World J Gastroenterol 2010; 16(31): 3905–3910.

19. Horiuchi A, Nakayama Y, Kato N et al. Hood-assisted colonoscopy is more effective in detection of colorectal adenomas than narrow-band imaging. Clin Gastroenterol Hepatol 2010; 8(4): 379–383.

20. Takeuchi Y, Inoue T, Hanaoka N et al. Autofluorescence imaging with a transparent hood for detection of colorectal neoplazma: a prospective, randomized trial. Gastrointest Endosc 2010; 72(5): 1006–1013.

21. Westwood DA, Alexakis N, Conner SJ et al. Transparent cap-assisted colonoscopy versus standard adult colonoscopy: a systematic review and meta-analysis. Dis Colon Rectum 2012; 55(2): 218–225.

22. Yague AS, Kaltenbach T, Anglemyer A et al. To CAP or not to CAP during screening colonoscopy: a meta-analysis. Gastrointest Endosc 2012; 75(4): Suppl.AB166-167 (Abstract).

23. BSG Guidelines on safety and sedation during endoscopic procedures, 2003, British Society of Gastroenterology. Available at http://www.bsg.org.uk. Accessed 15.02.2010.