Questions over anesthesia during colonoscopies

When it comes to colonoscopies, most patients agree comfort during the procedure is key.

But how much comfort? And at what cost?

With more patients receiving anesthesia during colonoscopies - rather than light or moderate conscious sedation - the expense of using the drug propofol by a credentialed anesthetist or anesthesiologist has come into question.

In the spring, Highmark Blue Cross and Blue Shield, the dominant insurer in western Pennsylvania, announced it would no longer pay benefits for monitored anesthesia for average-risk patients receiving endoscopic procedures. But then the insurer reconsidered, spurred by fierce objections from doctors, patients, and legislators.

No one doubts the value of colonoscopies. Colon cancer - the nation's second-deadliest cancer - often begins as precancerous polyps, which can be detected and removed during a colonoscopy.

The test enables doctors to look at the entire six-foot length of the colon. They insert a flexible tube with a light source and a small computer chip on the end that operates as a camera, and remove polyps before they become dangerous.

While many regard the prep as unpleasant, the test saves 25,000 lives a year.

Full anesthesia adds $1.1 billion a year in costs, a 2012 study concluded.

Questioning the cost of anesthesia is not new. In 2008 Aetna considered withdrawing benefits for anesthesia in colonoscopies for normal-risk patients. But it rejected the idea after weighing the benefits of colonoscopies against the chance that without propofol, far more subscribers would forgo the lifesaving procedure.

A spokesperson for Independence Blue Cross took a similar tack, noting that anesthesia greatly raises the costs of a colonoscopy, but "we are very sensitive to concerns that an uncomfortable patient experience will result in less colorectal cancer screening by our members."

Recent developments have enhanced the imaging so that doctors can magnify and examine patterns on the lining of the colon, not just the cells on the lining.

Other, less-invasive methods for colon screening include fecal occult blood samples, flexible sigmoidoscopy, CT colonography, and a small capsule that can be swallowed that snaps pictures as it moves through the colon, approved only for patients who properly prepared themselves and had an incomplete colonoscopy. But if any of these screenings detect problems, patients still must have a traditional colonoscopy.

"There are physicians, myself included, who will do a colonoscopy without any sedation," said Michael Kochman, director of the Center for Endoscopic Innovation, Research, and Training at the University of Pennsylvania. "But most patients do opt for some sedation."

Without sedation, says Kochman, patients may have a little bit of bloating and discomfort, but doctors can minimize that, partly by using carbon dioxide in place of room air to inflate the colon; the carbon dioxide is quickly absorbed, which decreases the amount of air that can cause bloating and cramping.

Kochman points out that the colon doesn't feel pain on the inside. Discomfort comes from distending the colon with air or carbon dioxide or pushing on it from the outside.

"It can be uncomfortable," said Gregory Ginsberg, director of Endoscopic Services at Penn Medicine. "In most patients, we need some level of sedation to complete the procedure."

"At Penn we try to have a hybrid system," Ginsberg said. "We . . . try to arrange to have propofol for patients who need it, and moderate sedation for those who need that."

There are some benefits to anesthesia, Ginsberg said. Patients have no discomfort or memory of the procedure, and when the procedure is completed and the drip turned off, the patient wakes at once, without any grogginess.

He also notes that there can be problems with a small subset of patients who find the procedure unpleasant with lighter sedation, and that in some cases, discomfort can lead to an incomplete exam.

The trend toward higher levels of sedation and anesthesia can also be attributed to more sophisticated exams. Ginsberg says that a few years back, studies in Canada and Germany showed patients were developing cancers in the intervals between colonoscopies. Research revealed "polyps had migrated from the left to the right side of the colon."

Doctors may have missed polyps on the right side due to the poor quality of the prep or because doctors were skipping over these more subtle polyps that occur most commonly on the right side. The result was more training to improve the quality and completeness of the exam but also a need to reexamine sedation as the intensity of the colonoscopy procedure increased.

"We saw that deep sedation may help us do a more complete exam," Ginsberg said.

Ginsberg had one more thought: "While talking to a gentleman who had visited Gettysburg, I was thinking how not long ago, we were taking off limbs with a shot of whiskey while biting on a bullet." He laughed: "We're not as tough as we used to be."