Colonoscopy without sedation. Possible..but does it miss the point?

January 18, 2009

Colonoscopy, repeated at 5-10 year intervals, is recommended to detect colon cancer after age 50. As the American (and global) population ages, more colonoscopies will be performed, and more colonoscopists are needed.

One controversy is – who is qualified to perform a colonoscopy? Family physicians with special training argue that they are, and this would certainly ease the pressure on gastroenterologists (or offer a competitive threat?).

Another contentious area is – who is qualified to provide the sedation that most patients expect? Some gastroenterologists say that sedation is so safe that they can provide, or at least supervise it, while they do the colonoscopy. Anesthesiologists would argue the contrary. (Disclaimer: I am one – an anesthesiologist).

Outside the United States, colonoscopy is often done without sedation. This may even be the norm, as discussed in an American Medical News article which reports on a center in California which has been doing these on a routine basis, in volunteers, with some success (78% completed the study without drugs).

It’s clear from this article that colonoscopy without sedation is possible in America. But that is hardly a surprise. What’s missing in this analysis, and all the controversy, is outcomes. Not the number of colonoscopies completed, which is what is reported in these studies, but how many lesions were picked up (or missed) during the colonoscopy. That’s a much more difficult study to do, but isn’t finding (or ruling out) cancer the reason for undergoing this rather unpleasant test?

Intuitively, an endoscopist who does not have the additional responsibility of sedation, or the time pressure of completing the study as quickly as possible in an unsedated patient, has better conditions to fulfill his primary role – to find cancerous or pre-cancerous lesions in the colon and rectum. But that’s just my suspicion – let’s hope the outcome studies get done.