title: Water immersion versus standard colonoscopy insertion technique: randomized trial shows promise for minimal sedation.
abstract: OBJECTIVE
  Water immersion is an alternative colonoscopy technique that may reduce discomfort and facilitate insertion of the instrument. This was a prospective study to compare the success of colonoscopy with minimal sedation using water immersion and conventional air insufflation.
  
  
  METHODS
  A total of 229 patients were randomized to either water immersion or the standard air insertion technique. The primary outcome was success of minimal sedation colonoscopy, which was defined as reaching the cecum without additional sedation, exchange of the adult colonoscope or hands-on assistance for trainees. Patient comfort and satisfaction were also assessed.
  
  
  RESULTS
  Successful minimal-sedation colonoscopy was achieved in 51 % of the water immersion group compared with 28 % in the standard air group (OR, 2.66; 95 % CI 1.48 - 4.79; P = 0.0004). Attending physicians had 79 % success with water immersion compared with 47 % with air insufflation (OR, 4.19; 95 % CI 1.5 - 12.17; P = 0.002), whereas trainees had 34 % success with water compared with 16 % using air (OR, 2.75; 95 % CI 1.15 - 6.86; P = 0.01). Using the water method, endoscopists intubated the cecum faster and this was particularly notable for trainees (13.0 +/- 7.5 minutes with water vs. 20.5 +/- 13.9 minutes with air; P = 0.0001). Total procedure time was significantly shorter with water for both experienced and trainee endoscopists ( P < 0.05). Patients reported less intraprocedural pain with water compared with air (4.1 +/- 2.7 vs. 5.3 +/- 2.7; P = 0.001), with a similar level of satisfaction. There was no difference in the neoplasm detection rates between the groups.
  
  
  CONCLUSIONS
  Colonoscopy insertion using water immersion increases the success rate of minimal sedation colonoscopy. Use of the technique leads to a decrease in discomfort, time to reach the cecum, and the amount of sedative and analgesic used, without compromising patient satisfaction.
authors.affiliation: Veterans Affairs Palo Alto, Stanford University School of Medicine, Stanford, California, USA.
authors.forename: C W
authors.initials: CW
authors.lastname: Leung
authors.forename: T
authors.initials: T
authors.lastname: Kaltenbach
authors.forename: R
authors.initials: R
authors.lastname: Soetikno
authors.forename: K K
authors.initials: KK
authors.lastname: Wu
authors.forename: F W
authors.initials: FW
authors.lastname: Leung
authors.forename: S
authors.initials: S
authors.lastname: Friedland
mesh_terms: D000388:Air; D003113:Colonoscopy / Q000009:adverse effects / Q000379:methods*; D016292:Procedural Sedation; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007101:Immersion; D007327:Insufflation; D008874:Midazolam / Q000008:administration & dosage*; D010146:Pain / Q000188:drug therapy* / Q000209:etiology; D010147:Pain Measurement; D017060:Patient Satisfaction; D011446:Prospective Studies; D016896:Treatment Outcome; D014867:Water
chemical_list: D006993:Hypnotics and Sedatives; D014867:Water; D008874:Midazolam