Practical Gastrointestinal Endoscopy

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CHAPTER 6
may affect management. A cardiac pacemaker contraindicates
use of the 3-D imager or argon plasma coagulation (APC).
PATIENT PREPARATION
Most patients can manage bowel preparation at home, present for
colonoscopy and walk out shortly afterwards. Management routines
depend on national, organizational and individual factors.
Overall management is influenced, among other things, by:
• cost;
• facilities available;
• type of bowel preparation and sedation used;
• age and state of the individual patient;
• potential for major therapeutic procedures;
• availability of adequate facilities and nursing staff for day-care
and recovery.
Experienced colonoscopists in private practice or large units
are motivated to organize streamlined day-case routines, even
for patients with large polyps. Some nationalities (Dutch, Japanese)
do not expect sedation whereas others (British, American)
frequently insist on it. In countries with sufficient anesthesiologists
(France, Italy, Australia) a full general anesthetic can,
regrettably, become the norm. These variables result in an extraordinary
spectrum of performance around the world, from
the many skilled colonoscopists who require patients for less
than an hour on a ‘walk-in, walk-out’ basis in an office or daycare
unit, to others with less experience and a traditional hospital
background who feel that many hours in hospital, or even an
overnight stay, are essential.
Colonoscopy can be made quick and easy for the majority
of patients. This requires both a reasonably planned day-care
facility and an endoscopist with the confidence and skill to work
gently and reasonably fast. Some flexibility of approach is wise.
A very few patients are better admitted before or after the procedure;
the very old, sick and very constipated may need professional
supervision during bowel preparation. Frail patients may
merit overnight observation afterwards if their domestic circumstances
are not supportive or they live far away. We admit a
few patients for polypectomy, especially if the lesion is very large
and sessile or if the patient has a bleeding diathesis or is on anticoagulants
or antiplatelet medications (aspirin, dipyrinamide,
etc.). However, even such patients, providing they live near good
medical support services and have been fully informed about
what to do in a crisis, can often be justifiably managed on an outpatient
basis, since complications are rare—and can be ‘delayed’,
occurring several days after the procedure.