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A Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy in the Family Medicine Setting

A Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy in the Family Medicine Setting

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Published by L.A. Net
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.
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.

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Published by: L.A. Net on Mar 17, 2011
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A Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy in the Family Medicine Setting: An LA Net Study 
Lyndee Knox, PhD, Ricardo G. Hahn, MD, and Christianne Lane, MS 
Background:
Colonoscopy visualizes more of the colon than flexible sigmoidoscopy. This study com-pares 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 for48 patients undergoing MCE and 35 patients undergoing FS at 3 family medicine practices in Los Ange-les. Outcomes of interest included completion rates, number of complications, depth reached, anatomicsite 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 2procedures in the anatomic site visualized (
<
.01) and depth reached (
<
.01). Clinical pathologieswere identified in 58% of MCE patients and 37% of FS patients. Four adenocarcinomas were identified inthe 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 of-fice settings for colorectal cancer screening. (J Am Board Fam Med 2007;20:444450.)
Family physicians routinely provide endoscopicscreening services to their patients in the form of flexible sigmoidoscopy (FS). More than a decadeago, Selby et al reported a 60% reduction in colo-rectal cancer mortality among people undergoingscreening sigmoidoscopy.
1
However, traditional FSonly reaches a depth of 60 cm and so excludes 80 to100 cm of colon from examination. Recent studieshave suggested that FS may miss as many as half thelesions in the colon,
2,3
a problem that may be par-ticularly pronounced among women. In a recentstudy comparing the detection of polyps by colonoscopy and sigmoidoscopy, FS identified only 35.2% of women with advanced colorectal neopla-sia compared with 66.3% of matched men.
4
Incontrast, standard colonoscopy allows 100% of thececum (total colon) to be viewed in approximately 76% or greater of procedures
3,5,6
and has beenshown to be more sensitive than FS for detectinglarge adenomas and cancers.
2,4,7
Although the US Preventative Services TasForce does not yet recommend the use of oneparticular method of colorectal cancer screeningover another, it strongly recommends that clini-cians screen adults with average risk for colorectalcancer with one of a variety of different screeningmethods, including colonoscopies, beginning at age50 and then again every 10 years.
8
The AmericanCancer Society makes similar recommendations foradults at average risk.
9
An excellent overview of colorectal cancer screening recommendations andsurrounding controversies is available in Ranso-hoff’s 2005 review of the topic.
10
Many patients, particularly those who are unin-sured or underinsured, do not have access tocolonoscopy as a screening option because of thefew trained colonoscopists working in medically underserved areas.
11–13
In Los Angeles Countalone, community physicians report that their un-insured and publicly insured patients with indica-tions can wait as long as 8 months for a colonos-copy, and that screening colonoscopies are simply 
This article was externally peer reviewed.
Submitted 
6 October 2006; revised 23 March 2007; ac-cepted 2 April 2007.
From
the Department of Family Medicine (LK, RGH)and the Department of Preventative Medicine, Biostatistics(CL), University of Southern California, Los Angeles.
Funding:
none.
Prior presentation:
Unsedated colonoscopy in primary carepractice. North American Primary Care Research Group.October 2005. Quebec City, Quebec, Canada.
Conflict of interest:
none declared.
Corresponding author:
Lyndee Knox, PhD, University of Southern California, Department of Family Medicine, 1420San Pablo St., PMB-B205, Los Angeles, CA 90033 (E-mail:knox@usc.edu).
444
JABFM
SeptemberOctober 2007 Vol. 20 No. 5 http://www.jabfm.org
 
unavailable (phone conversation with G. Floutsis,MD, Medical Director Clinica Msr. Oscar A. Ro-mero 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 SouthernCalifornia, March 2007).One solution to the limited capacity for screen-ing colonoscopies in the health care system is totrain primary care physicians to perform colonos-copies in the primary care settings. Numerous pre-vious studies have shown that, after the completionof appropriate training, family physicians can per-form colonoscopies competently and safely in in-patient and outpatient settings with high patientsatisfaction, few to no complications, and reliableand valid clinical findings.
14–17
Unfortunately, li-censing regulations in some states relating to theuse of conscious sedation (required for colonos-copy) can make it cost prohibitive for family phy-sicians and other primary care physicians to offercolonoscopy in their practices. In California, fullconscious sedation must be administered in a facil-ity that is fully licensed either by the Department of Health Services, the Joint Accreditation Commis-sion of Hospitals and Health Organizations or theAmerican Association of Ambulatory Health Cen-ters (California Senate Bill 595 to 19990816Amended).Several studies have compared unsedatedcolonoscopy with sedated procedures and with FSin specialist settings and have found the unsedatedprocedure to be comparable to sedated colonscopy and FS in terms of patient tolerance, complications,and completion rates. In one of the earliest of thesestudies, Thiis-Evensen et al (2000) of Norway eval-uated the efficacy of colonoscopy without sedationduring screening examination in 451 adult pa-tients.
18
Completion rates and complication ratesfor unsedated and sedated colonoscopy with anadult endoscope were comparable. Currently, theprocedure is the de facto standard of care for colo-rectal cancer screening by colonoscopy in smallprovincial clinics and hospitals in Norway (e-mailcommunication with E. Thiis-Evensen, MD, De-partment of Medicine Telemark Central Hispital,Skien; Department A of Medicine, RikshospitaletUniversity Hospital, Oslo, Norway, December2003). In a gastroenterology setting, Wu et al(2003) obtained similar findings in a comparison of unsedated colonoscopy with an adult colonoscopeand FS and using nursing staff to deliver the pro-cedure.
19
Thompson, Springer, and Andersonfound no significant differences in patient toleranceand examination duration when comparing unse-dated colonoscopy with a pediatric colonoscopeand FS.
20
Studies comparing pediatric and adult colono-scopes have found few significant differences be-tween the two in time to cecum, patient tolerance,and endoscopist perception of difficulty,
21
butfound a slight superiority in completion rates forthe pediatric colonoscope. Saifudden et al (2000)reported higher completion rates in procedures us-ing the pediatric colonoscope compared with thoseusing adult colonoscopies, especially in women.
22
Okamoto et al (2005) found better completion rateswith the pediatric compared with adult colono-scope in patients with fixed, angulated colons.
23
In 2002, in response to their uninsured and pub-licly insured patients’ lack of access to screeningcolonoscopies, 4 clinicians from 3 family medicinepractices involved with LA Net, a primary carepractice-based research network, began offeringunsedated colonoscopy with a pediatric endoscopeto adult patients under guidelines recommended by the US Preventative Services Task Force andAmerican Cancer Society and those outlined inTable 1. The clinicians opted to use a pediatriccolonoscope in the procedure based on evidencedemonstrating the basic comparability of the 2 de-vices and a slightly higher completion rate for pro-cedures conducted using the pediatric endoscope.At each practice, modified colon endoscopy (MCE)was offered to all average-risk adult patients eligiblefor colorectal cancer screening as an alternative toboth already-available on-site FS and referral to anoff-site specialty clinic for sedated colonoscopy. Ina few rare instances, MCE was offered to patientsin higher-risk categories after they were referredfor off-site sedated colonoscopy while they werewaiting 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 acquiredtheir skills for FS while in residency training.Three of the 4 acquired their skills in colonoscopy over 10 years of practice and continuing medicaleducation procedural courses through the Ameri-can Academy of Family Physicians and others. Oneclinician had received formal colonoscopy training
doi: 10.3122/jabfm.2007.05.060175 Unsedated Colonoscopy Versus Flexible Sigmoidoscopy 445
 
during his residency training program before join-ing the faculty practice. Each received trainingfrom the endoscope manufacturer in the use of theequipment and was instructed by the lead investi-gator (RGH), who has extensive experience in GIendoscopy. All reviewed Hoff’s recommendationsfor conducting unsedated colonoscopy.
24
All clini-cians were credentialed by the University of South-ern California Faculty Practice CredentialingCommittee to perform these procedures.The goal of this study was to determine whetherMCE and FS conducted in a family medicine prac-tice are comparable in terms of completion ratesand number of complications, and to determinewhether MCE allows the family physician to visu-alize more of the colon than FS.
Methods
Patients
Billing records were used to identify all patientswho underwent MCE or FS at the 3 family medi-cine practices between 2003 and 2005. A total of 48patients underwent MCE and 35 patients under-went FS during this period. Table 2 provides pa-tient demographics.
Data
Data were abstracted from existing medical recordsby the lead investigator (RGH) and a research as-sistant as part of a quality improvement effort.
Modified Colon Endoscopy
Patients who opted for MCE received instructionsabout preprocedure colon preparation using a stan-dard protocol. They also received the proper bowelcleansing solutions and tablets and were providedwith instructions regarding proper positioning, re-laxation techniques based on recommendations
Table 1. Guidelines for Modified Colon Endoscopy 
Primary indications:
Screening for colorectal cancer in asymptomatic patientsaccording to ACS guidelines
Rescreening of patients with history of treated coloncancer–Known familial colon cancer history 
Diagnostic examinations:–Evaluation of positive FOBT–Evaluation of rectal bleeding–Evaluation of change in bowel habits–Follow-up of selected patients previously found to havebenign lesionsContraindications:
Multiple previous abdominal surgical procedures
Known active inflammatory bowel disease or diverticulitis
Inability to complete or tolerate bowel prep
Inability to cooperate because of mental illness, dementiaor disability Reasons to terminate procedure and refer to consultantendoscopist:
Inability to advance endoscope with reasonable effort andwithin reasonable time
Excessive patient discomfort
Extensive diverticulosis with inability to identify lumen
Discovery of active inflammatory bowel disease ordiverticulitis
Discovery of multiple lesions that will require extensivepolypectomy 
Discovery of obstructing lesion
Discovery of obvious cancer
Visual recognition of incompletely removed dysplasticlesionLesions to biopsy using biopsy forceps:
All polyps
Most abnormal mucosaLesions to NOT biopsy using biopsy forceps:
Diverticuli (perforation risk)
Flat lesions within diverticuli (perforation risk)Lesions to remove with snare:
Pedunculated polypsLesions to NOT remove with snare:
Broad-based polyps (perforation risk)
Lesions within diverticuli (perforation risk)
Table 2. Sample Characteristics for Modified ColonEndoscopy and Flexible Sigmoidoscopy Groups
Characteristic MCE(n
48) FS(n
35)Age*
40 years 2 (4.2) 6 (17.1)4049 6 (12.5) 8 (22.9)5059 16 (33.3) 12 (34.3)6069 17 (35.4) 6 (17.1)70
6 (12.5) 2 (5.7)Female 16 (33.3) 14 (40.0)Ethnicity Caucasian 22 (45.8) 24 (68.6)Black/AfricanAmerican4 (8.3) 1 (2.9)Latino 14 (29.2) 5 (14.3)Asian 5 (10.4) 4 (11.4)Other 2 (4.2) 1 (2.9)*
.05.†Mean, 59.6, SD, 12.5; range, 31.2–86.2.‡Mean, 51.3, SD, 13.4; range, 25.7–80.0.All data shown as N (%). MCE, modified colon endoscopy; FS,flexible sigmoidoscopy.
446
JABFM
SeptemberOctober 2007 Vol. 20 No. 5 http://www.jabfm.org

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