Letters to the Editor
nature publishing group
meta-analysis. Therefore, our meta-analysis focuses on outpatients undergoing colonoscopy. We would greatly appreciate any further studies that examine M–G preparation in inpatients given the need for improvement. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Syed A, Hassan T, Kyprianou A Many factors affect the quality of bowel preparation need discussed when comparing different regimes. Am J Gastroenterol 2015;110:473–4 (this issue). 2. Kilgore TW, Abdinoor AA, Szary NM et al. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials. Gastrointest Endosc 2011;73:1240–5. 3. Bucci C, Rotondano G, Hassan C et al. Optimal bowel cleansing for colonoscopy: split the dose! A series of meta-analyses of controlled studies. Gastrointest Endosc 2014;80:566–76. 4. Enestvedt BK, Tofani C, Laine LA et al. 4-Liter split-dose polyethylene glycol is superior to other bowel preparations, based on systematic review and meta-analysis. Clin Gastroenterol Hepatol 2012;10:1225–31. 5. Siddique S, Lopez KT, Hinds AM et al. Miralax with Gatorade for bowel preparation: a metaanalysis of randomized controlled trials. Am J Gastroenterol 2014;109:1566–74.
1
Division of Gastroenterology and Hepatology, University of Missouri Health Sciences Center, Columbia, Missouri, USA; 2Division of Gastroenterology, University of California, Irvine, California, USA. Correspondence: Matthew L. Bechtold, MD, FACP, FASGE, FACG, Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, Missouri 65212, USA. E-mail: [email protected]
The Ideal Insertion Method for Colonoscopy Is in the Eye of the Beholder Joseph D. Feuerstein, MD1
Water Immersion, and Water Exchange During Minimally Sedated Colonoscopy” (1) with great interest. I commend you for trying to clarify an important topic in endoscopy regarding the ideal insertion method for colonoscopy (1). However, I have concerns regarding the study’s generalizability. First off, the cecal intubation rates of 78.9–92.2% are significantly below the recommended minimum of ≥95% in screening colonoscopies (2). Although this rate was improved by changing to the water exchange (WE) method, this does raise the question of whether the endoscopists in the study are more skilled at WE and less so with air insufflation, which had the lowest cecal intubation rate. If this were the case, the findings in the study are not surprising as endoscopists are likely best at what they are most comfortable with. In addition, the use of a onetime dose of intramuscular meperedine with no further sedation is not necessarily the standard sedation in all centers (3). To generalize the study’s findings, it would have been more useful to assess whether the patients in the air insufflation or water immersion group required more sedation compared with the WE group. It is also unclear to me whether the increase in comfort during the insertion is more related to the slow speed used in the WE group or the method itself. Given that there was no statistically significant difference in a patient’s willingness to repeat the procedure, the value of doing a WE method is of significant question. Not only does this markedly increase the duration of the procedure, but it did not result in an overall improved adenoma detection rate. While the ideal insertion method for colonoscopy is an important question that needs to be answered, I think this study only proves that the WE method is effective and comfortable for patients. CONFLICT OF INTEREST The author declares no conflict of interest.
doi:10.1038/ajg.2015.7
REFERENCES
To the Editor: I read the article by Hsieh et al. “A Patient-Blinded Randomized, Controlled Trial Comparing Air Insufflation, © 2015 by the American College of Gastroenterology
1. Hsieh Y-H, Koo M, Leung FW. A patientblinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy. Am J Gastroenterol 2014;109:1390–400.
2. Douglas KR, John LP, Todd HB et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873–85. 3. Cohen LB, Wecsler JS, Gaetano JN et al. Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol 2006;101:967–74. 1 Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. Correspondence: Joseph D. Feuerstein, MD, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street 8E Gastroenterology, Boston, Massachusetts 02215, USA. E-mail: [email protected]
Response to Feuerstein Yu-Hsi Hsieh, MD1, 2 and Felix W. Leung, MD, FACG3, 4 doi:10.1038/ajg.2015.15
To the Editor: We appreciate the opportunity to respond to the comments on our paper (1) by Dr Feuerstein (2). The manuscript of the randomized controlled trial is a report of work in progress. There was no intent to label water-aided methods as the ideal techniques. Details of the application are evolving. The authors had conducted several studies with cecal intubation rates of 98–99% using air insufflation (AI) and minimal sedation (3,4). So, the lead author is quite facile with the AI method. There is a major difference between the present and the past studies (3,4). In the past, the patients had no other choice but to put up with as much insertion pain as necessary, otherwise the colonoscopy would not be competed. In the present study, we have the option of switching to water exchange (WE) when pain was excessive, thus lowering the intention-to-treat, but not the final, success rate of AI. The study included diagnostic and surveillance patients. Only a small percentage was for screening. Minimal sedation is the standard of practice in Taiwan. Patients remain fully awake during the colonoscopy, allowing for the accurate assessment of pain. Lower The American Journal of GASTROENTEROLOGY
475
nature publishing group
meta-analysis. Therefore, our meta-analysis focuses on outpatients undergoing colonoscopy. We would greatly appreciate any further studies that examine M–G preparation in inpatients given the need for improvement. CONFLICT OF INTEREST The authors declare no conflict of interest. REFERENCES 1. Syed A, Hassan T, Kyprianou A Many factors affect the quality of bowel preparation need discussed when comparing different regimes. Am J Gastroenterol 2015;110:473–4 (this issue). 2. Kilgore TW, Abdinoor AA, Szary NM et al. Bowel preparation with split-dose polyethylene glycol before colonoscopy: a meta-analysis of randomized controlled trials. Gastrointest Endosc 2011;73:1240–5. 3. Bucci C, Rotondano G, Hassan C et al. Optimal bowel cleansing for colonoscopy: split the dose! A series of meta-analyses of controlled studies. Gastrointest Endosc 2014;80:566–76. 4. Enestvedt BK, Tofani C, Laine LA et al. 4-Liter split-dose polyethylene glycol is superior to other bowel preparations, based on systematic review and meta-analysis. Clin Gastroenterol Hepatol 2012;10:1225–31. 5. Siddique S, Lopez KT, Hinds AM et al. Miralax with Gatorade for bowel preparation: a metaanalysis of randomized controlled trials. Am J Gastroenterol 2014;109:1566–74.
1
Division of Gastroenterology and Hepatology, University of Missouri Health Sciences Center, Columbia, Missouri, USA; 2Division of Gastroenterology, University of California, Irvine, California, USA. Correspondence: Matthew L. Bechtold, MD, FACP, FASGE, FACG, Division of Gastroenterology and Hepatology, CE405, DC 043.00, University of Missouri Health Sciences Center, Five Hospital Drive, Columbia, Missouri 65212, USA. E-mail: [email protected]
The Ideal Insertion Method for Colonoscopy Is in the Eye of the Beholder Joseph D. Feuerstein, MD1
Water Immersion, and Water Exchange During Minimally Sedated Colonoscopy” (1) with great interest. I commend you for trying to clarify an important topic in endoscopy regarding the ideal insertion method for colonoscopy (1). However, I have concerns regarding the study’s generalizability. First off, the cecal intubation rates of 78.9–92.2% are significantly below the recommended minimum of ≥95% in screening colonoscopies (2). Although this rate was improved by changing to the water exchange (WE) method, this does raise the question of whether the endoscopists in the study are more skilled at WE and less so with air insufflation, which had the lowest cecal intubation rate. If this were the case, the findings in the study are not surprising as endoscopists are likely best at what they are most comfortable with. In addition, the use of a onetime dose of intramuscular meperedine with no further sedation is not necessarily the standard sedation in all centers (3). To generalize the study’s findings, it would have been more useful to assess whether the patients in the air insufflation or water immersion group required more sedation compared with the WE group. It is also unclear to me whether the increase in comfort during the insertion is more related to the slow speed used in the WE group or the method itself. Given that there was no statistically significant difference in a patient’s willingness to repeat the procedure, the value of doing a WE method is of significant question. Not only does this markedly increase the duration of the procedure, but it did not result in an overall improved adenoma detection rate. While the ideal insertion method for colonoscopy is an important question that needs to be answered, I think this study only proves that the WE method is effective and comfortable for patients. CONFLICT OF INTEREST The author declares no conflict of interest.
doi:10.1038/ajg.2015.7
REFERENCES
To the Editor: I read the article by Hsieh et al. “A Patient-Blinded Randomized, Controlled Trial Comparing Air Insufflation, © 2015 by the American College of Gastroenterology
1. Hsieh Y-H, Koo M, Leung FW. A patientblinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy. Am J Gastroenterol 2014;109:1390–400.
2. Douglas KR, John LP, Todd HB et al. Quality indicators for colonoscopy. Am J Gastroenterol 2006;101:873–85. 3. Cohen LB, Wecsler JS, Gaetano JN et al. Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol 2006;101:967–74. 1 Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA. Correspondence: Joseph D. Feuerstein, MD, Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street 8E Gastroenterology, Boston, Massachusetts 02215, USA. E-mail: [email protected]
Response to Feuerstein Yu-Hsi Hsieh, MD1, 2 and Felix W. Leung, MD, FACG3, 4 doi:10.1038/ajg.2015.15
To the Editor: We appreciate the opportunity to respond to the comments on our paper (1) by Dr Feuerstein (2). The manuscript of the randomized controlled trial is a report of work in progress. There was no intent to label water-aided methods as the ideal techniques. Details of the application are evolving. The authors had conducted several studies with cecal intubation rates of 98–99% using air insufflation (AI) and minimal sedation (3,4). So, the lead author is quite facile with the AI method. There is a major difference between the present and the past studies (3,4). In the past, the patients had no other choice but to put up with as much insertion pain as necessary, otherwise the colonoscopy would not be competed. In the present study, we have the option of switching to water exchange (WE) when pain was excessive, thus lowering the intention-to-treat, but not the final, success rate of AI. The study included diagnostic and surveillance patients. Only a small percentage was for screening. Minimal sedation is the standard of practice in Taiwan. Patients remain fully awake during the colonoscopy, allowing for the accurate assessment of pain. Lower The American Journal of GASTROENTEROLOGY
475
