Question Colonoscopy without Anesthesia?

[Akimbo]

I have to get a colonoscopy late this year and have read that a few people refuse anesthesia. This will my 4th colonoscopy. It would be nice not to have driving restrictions after the procedure since I live hours away and will be 75 years old. I recently read that some people have the procedure without anesthesia and it's not "that" uncomfortable. I have had a two bone marrow and two prostate biopsies without anesthesia and was fine with them so seem to be reasonably pain tolerant.

Comments and suggestions?

Ping: @rsingler and @Compressor

 

[kinoons]

It would be pretty hard to do placebo controlled randomized studies on colonoscopies. I suppose you could sedate all patients in both groups and not do the colonoscopy in the "placebo" group, but there may be some serious ethics problems getting the study approved. There is also the problem of people in the placebo group developing advanced cancer — sounds like a trial lawyer's wet dream.

Some people, like my wife, remember the whole procedure in detail so would have to be take off study.

You don’t need a placebo control - instead randomize to colo vs no Colo and see the results.

Additionally sham procedure randomized studies are absolutely performed for things like heart catheterization for stable chest pain and for knee surgery.

This (screening Colo vs presenting with symptoms) was recently done in Northern Europe. Much to the surprise of many it was an essentially negative study. The reduction in colon cancer related death was quite small (and arguably smaller than reported based on which method of interpretation is used) and the all cause mortality was dead even.

https://www.nejm.org/doi/full/10.1056/NEJMoa2208375

 

[Jim Lapenta]

My PCP is not pushing one for me. I turned 65 in Feb this year and had the Cologuard last year, and had it twice before with fecal occult in between. Cologuard is every 3 years for me. No history in the family of it and no issues on the non-invasive tests.
I was having some GI issues earlier this year and that was a possibility. But, I changed my diet and they went away. Turns out the issue was I have developed an intolerance for milk products. I had to switch to almon milk and take a lactaid or two if we have food with cheese.
I have known two people that had complications. My barber had to have surgery to fix his after being perforated and my therapists husband had the same thing happen to him.
I know from breaking my hip socket in 2022 that if I have to have one, knock me the f out!

 

[JuLe]

I did mine with no anesthesia, no sedation, no cath.

Not that bad really. Uncomfortable occasionally going around bends but tolerable.

Drove myself there and back.

All told, the prep was worse.

Same with me. Can't say I enjoyed it, but been thru (much) worse pain when being patched up for various things over the years.
The prep was definately the worst part of it.

 

[diverdoug1]

How fast acting is the sedation? Could it be administered after the procedure began if it became intolerable?

I had sedation during my previous procedures but can't remember a thing. Odd as it may sound, I would like to watch the video and hear the conversation without my memory being erased before my lights come back on.

Anesthesiologist here. To answer your question, intravenous propofol acts in seconds, intravenous Versed, a minute or so. The case would have to be postponed in many cases to get an anesthesia provider and to do a pre-anesthetic evaluation. If you GI Doc usually does his patients colonoscopies under anesthesia, you might have an increased risk of bowel perforation with an awake patient.

 

[Tigerpaw]

Nope, I take the sedation each and every time.
If you're concerned about the drive, why not get a hotel nearby and then drive home the next day.

 

[Dan]

Or get Uber.

 

[Tigerpaw]

Or get Uber.

Most medical places don't want you to take Uber, Lyft, taxi,..etc.

 

[Akimbo]

If you GI Doc usually does his patients colonoscopies under anesthesia, you might have an increased risk of bowel perforation with an awake patient.

I was awake during all my colonoscopies, but can't remember anything. I understood that was so I could provide feedback to the GI doc. My next one will be with a new doc because the old one retired.

 

[diverdoug1]

Consider skipping it altogether and do a FIT or Cologaurd test instead. Bowel perforations are high mortality complications and there's a lack of quality evidence demonstrating the superiority of colonoscopy compared to other screening methods. Every other country I am aware of conducts a colonoscopy only in the presence of a positive fecal test result.

Cologuard is certainly a good option for some patients. One thing you should be aware of is that if your health insurance pays for the Cologuard test, and the results indicate you need to have a colonoscopy, some insurance companies will not then pay for the colonoscopy. I think this policy is pretty crappy (pun intended).

 

[kinoons]

I would argue that cologuard does not have strong enough evidence to support its use.

To quote Drs. Vinay Prasad and John Mandrola

“Before NordICC, colorectal cancer screening was among the preventive interventions with the surest footing. Fecal occult blood testing (FOBT) had consistently shown a reduction in death from colon cancer–though it consistently failed to show any reduction in death from all causes. Flexible sigmoidoscopy had shown both a reduction in colorectal cancer death and death from any cause. Fecal immunochemical testing (FIT) leveraged the principles of FOBT, but did not have direct evidence. Fecal DNA leveraged FIT testing. Blood-based screening had weak data, and colonoscopy– the mainstay of US practice– had no randomized data at all.”

Screening Colonoscopy Misses the Mark in its First Real Test

In today's Study of the Week, Vinay and I offer commentary on one of the most important trials of the year--the NordICC trial of screening colonoscopy.

www.sensible-med.com

It would seem that the only tests with strong evidence is FOBT and flexible sigmoidoscopy.

One reason I bring this up is access and resource limits. Where I practice in New Mexico the current waitlist for a diagnostic colonoscopy (someone has signs or symptoms that make us worry, so we want to do the test to see what may be wrong) is 9 months. I’ll repeat that to let it sink in; if we believe you may have a problem you’re waiting 9 months to get the test.

None the less there are 10+ screening colonoscopies on the docket every weekday. The hospital built an entire freestanding building to support the number of colonoscopies (a vast majority screening studies) to meet the need and demand, with zero randomized evidence that those screening exams were saving any lives.

I cannot reconcile how anyone justifies the 9 month wait for a diagnostic study when even one screening study is being performed. Actually, I can, and it’s all about the money.

If you can find a GI doc who will do a flex sig, that is a good option. Otherwise the improved FOBT testing currently used is the next best test supported by evidence, if you want to test at all.