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DOI: 10.1055/s-0043-101229
Water exchange for screening colonoscopy increases adenoma detection rate: a multicenter, double-blinded, randomized controlled trial
Publication History
submitted 12 July 2016
accepted after revision 20 December 2016
Publication Date:
10 March 2017 (online)
![](https://www.thieme-connect.de/media/endoscopy/201705/lookinside/thumbnails/14617_10-1055-s-0043-101229-1.jpg)
Abstract
Background and study aims Single-center studies, which were retrospective and/or involved unblinded colonoscopists, have suggested that water exchange, but not water immersion, compared with air insufflation significantly increases the adenoma detection rate (ADR), particularly in the proximal and right colon. Head-to-head comparison of the three techniques with ADR as primary outcome and blinded colonoscopists has not been reported to date. In a randomized controlled trial with blinded colonoscopists, we aimed to evaluate the impact of the three insertion techniques on ADR.
Patients and methods A total of 1224 patients aged 50 – 70 years (672 males) and undergoing screening colonoscopy were randomized 1:1:1 to water exchange, water immersion, or air insufflation. Split-dose bowel preparation was adopted to optimize colon cleansing. After the cecum had been reached, a second colonoscopist who was blinded to the insertion technique performed the withdrawal. The primary outcome was overall ADR according to the three insertion techniques (water exchange, water immersion, and air insufflation). Secondary outcomes were other pertinent overall and right colon procedure-related measures.
Results Baseline characteristics of the three groups were comparable. Compared with air insufflation, water exchange achieved a significantly higher overall ADR (49.3 %, 95 % confidence interval [CI] 44.3 % – 54.2 % vs. 40.4 % 95 %CI 35.6 % – 45.3 %; P = 0.03); water exchange showed comparable overall ADR vs. water immersion (43.4 %, 95 %CI 38.5 % – 48.3 %; P = 0.28). In the right colon, water exchange achieved a higher ADR than air insufflation (24.0 %, 95 %CI 20.0 % – 28.5 % vs. 16.9 %, 95 %CI 13.4 % – 20.9 %; P = 0.04) and a higher advanced ADR (6.1 %, 95 %CI 4.0 % – 9.0 % vs. 2.5 %, 95 %CI 1.2 % – 4.6 %; P = 0.03). Compared with air insufflation, the mean number of adenomas per procedure was significantly higher with water exchange (P = 0.04). Water exchange achieved the highest cleanliness scores (overall and in the right colon). These variables were comparable between water immersion and air insufflation.
Conclusions The design with blinded observers strengthens the validity of the observation that water exchange, but not water immersion, can achieve significantly higher adenoma detection than air insufflation. Based on this evidence, the use of water exchange should be encouraged.
Trial registered at ClinicalTrials.gov (NCT02041507).
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References
- 1 GLOBOCAN. Estimated cancer incidence, mortality and prevalence worldwide in 2012. 2012 Available from: http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx Accessed 1 December 2016
- 2 Corley DA, Levin TR, Doubeni CA. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
- 3 Baxter NN, Goldwasser MA, Paszat LF. et al. Association of colonoscopy and death from colorectal cancer. Ann Intern Med 2009; 150: 1-8
- 4 Brenner H, Hoffmeister M, Arndt V. et al. Protection from right and left-sided colorectal neoplasms after colonoscopy: population-based study. J Natl Cancer Inst 2010; 102: 89-95
- 5 Carethers JM. One colon lumen but two organs. Gastroenterology 2011; 141: 411-412
- 6 Lee TJ, Rees CJ, Blanks RG. et al. Colonoscopic factors associated with adenoma detection in a national colorectal cancer screening program. Endoscopy 2014; 46: 203-211
- 7 Rex DK, Schoenfeld PS, Cohen J. et al. Quality indicators for colonoscopy. ASGE/ACG Taskforce on Quality in Endoscopy. Gastrointest Endosc 2015; 81: 31-53
- 8 Gupta S, Balasubramanian BA, Fu T. et al. Polyps with advanced neoplasia are smaller in the right than in the left colon: implications for colorectal cancer screening. Clin Gastroenterol Hepatol 2012; 10: 1395-1401
- 9 Xiang L, Zhan Q, Zhao XH. et al. Risk factors associated with missed colorectal flat adenoma: a multicenter retrospective tandem colonoscopy study. World J Gastroenterol 2014; 20: 10927-10937
- 10 Leung FW. Water-aided colonoscopy. Gastroenterol Clin N Am 2013; 42: 507-519
- 11 Leung FW, Amato A, Ell C. et al. Water-aided colonoscopy: a systematic review. Gastrointest Endosc 2012; 76: 657-666
- 12 Radaelli F, Paggi S, Amato A. et al. Warm water infusion versus air insufflation for unsedated colonoscopy: a randomized, controlled trial. Gastrointest Endosc 2010; 72: 701-709
- 13 Pohl J, Messer I, Behrens A. et al. Water infusion for cecal intubation increases patient tolerance, but does not improve intubation of unsedated colonoscopies. Clin Gastroenterol Hepatol 2011; 9: 1039-1043
- 14 Leung FW, Harker JO, Leung JW. et al. Removal of infused water predominantly during insertion (water exchange) is consistently associated with an increase in adenoma detection rate – review of data in randomized controlled trials (RCTs) of water-related methods. J Interv Gastroenterol 2011; 1: 121-126
- 15 Ramirez FC, Leung FW. A head-to-head comparison of the water vs. air method in patients undergoing screening colonoscopy. J Interv Gastroenterol 2011; 1: 130-135
- 16 Cadoni S, Gallittu P, Sanna S. et al. A two center randomized controlled trial of water-aided colonoscopy versus air insufflation colonoscopy. Endoscopy 2014; 46: 212-218
- 17 Leung FW, Leung JW, Siao-Salera RM. et al. The water method significantly enhances proximal diminutive adenoma detection rate in unsedated patients. J Interv Gastroenterol 2011; 1: 8-13
- 18 Cadoni S, Falt P, Sanna S. et al. Impact of colonoscopy insertion techniques on adenoma detection. Dig Dis Sci 2016; 61: 2068-2075
- 19 Lai EJ, Calderwood AH, Doros G. et al. The Boston bowel preparation scale: a valid and reliable instrument for colonoscopy-oriented research. Gastrointest Endosc 2009; 69: 620-625
- 20 Leung CW, Kaltenbach T, Soetikno R. et al. Water immersion versus standard colonoscopy insertion technique: randomized trial shows promise for minimal sedation. Endoscopy 2010; 42: 557-563
- 21 Hsieh Y-H, Koo M, Leung FW. A patient-blinded randomized, controlled trial comparing air insufflation, water immersion, and water exchange during minimally sedated colonoscopy. Am J Gastroenterol 2014; 109: 1390-1400
- 22 Brenner H, Chang-Claude J, Seiler CM. et al. Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med 2011; 154: 22-30
- 23 Nishihara R, Wu K, Lochhead P. et al. Long-term colorectal-cancer incidence and mortality after lower endoscopy. N Engl J Med 2013; 369: 1095-1105
- 24 Cooper GS, Xu F, Barnholtz Sloan JS. et al. Prevalence and predictors of interval colorectal cancers in medicare beneficiaries. Cancer 2012; 118: 3044-3052
- 25 le Clercq CM, Bouwens MW, Rondagh EJ. et al. Post-colonoscopy colorectal cancers are preventable: a population-based study. Gut 2014; 63: 957-963
- 26 Rondagh EJA, Bouwens MWE, Riedl RG. et al. Endoscopic appearance of proximal colorectal neoplasms and potential implications for colonoscopy in cancer prevention. Gastrointest Endosc 2012; 75: 1218-1225
- 27 Lee TJ, Rutter MD, Blanks RG. et al. Colonoscopy quality measures: experience from the NHS Bowel Cancer Screening Programme. Gut 2012; 61: 1050-1057
- 28 Denis B, Sauleau EA, Gendre I. et al. The mean number of adenomas per procedure should become the gold standard to measure the neoplasia yield of colonoscopy: a population-based cohort study. Dig Liver Dis 2014; 46: 176-181
- 29 Cohen LB. Split dosing of bowel preparations for colonoscopy: an analysis of its efficacy, safety, and tolerability. Gastrointest Endosc 2010; 72: 406-412
- 30 Chokshi RV, Hovis CE, Hollander T. et al. Prevalence of missed adenomas in patients with inadequate bowel preparation on screening colonoscopy. Gastrointest Endosc 2012; 75: 1197-1203
- 31 Oh CH, Lee CK, Kim JW. et al. Suboptimal bowel preparation significantly impairs colonoscopic detection of non-polypoid colorectal neoplasms. Dig Dis Sci 2015; 60: 2294-2303
- 32 Clark BT, Protiva P, Nagar A. et al. Quantification of adequate bowel preparation for screening or surveillance colonoscopy in men. Gastroenterology 2016; 150: 396-405
- 33 Radaelli F, Paggi S, Hassan C. et al. Split-dose preparation for colonoscopy increases adenoma detection rate: a randomised controlled trial in an organised screening programme. Gut 2017; 66: 270-277
- 34 Zavoral M, Suchanek S, Majek O. et al. Colorectal cancer screening: 20 years of development and recent progress. World J Gastroenterol 2014; 20: 3825-3834
- 35 Sanaka MR, Rai T, Navaneethan U. et al. Adenoma detection rate in high-risk patients differs from that in average-risk patients. Gastrointest Endosc 2016; 83: 172-178
- 36 Luo H, Zhang L, Liu X. et al. Water exchange enhanced cecal intubation in potentially difficult colonoscopy. Unsedated patients with prior abdominal or pelvic surgery: a prospective, randomized, controlled trial. Gastrointest Endosc 2013; 77: 767-773
- 37 Wang X, Luo H, Xiang Y. et al. Left-colon water exchange preserves the benefits of whole colon water exchange at reduced cecal intubation time conferring significant advantage in diagnostic colonoscopy – a prospective, randomized controlled trial. Scand J Gastroenterol 2015; 50: 916-923
- 38 Cadoni S, Sanna S, Gallittu P. et al. A randomized controlled trial comparing real-time insertion pain during colonoscopy confirmed water exchange to be superior to water immersion in enhancing patient comfort. Gastrointest Endosc 2015; 81: 557-566
- 39 Cadoni S, Falt P, Gallittu P. et al. Water exchange is the least-painful colonoscope insertion technique, increasing completion of unsedated colonoscopy. Clin Gastroenterol Hepatol 2015; 13: 1972-1980
- 40 Cadoni S, Falt P, Gallittu P. et al. Impact of carbon dioxide insufflation and water exchange on post-colonoscopy outcomes in patients receiving on-demand sedation: a randomized controlled trial. Gastrointest Endosc 2017; 85: 210-218.e1
- 41 MacPhail ME, Hardacker KA, Tiwari A. et al. Intraprocedural cleansing work during colonoscopy and achievable rates of adequate preparation in an open-access endoscopy unit. Gastrointest Endosc 2015; 81: 525-530
- 42 Aviation Instructors’ Handbook, FAA-H-8083-9A. Washington: U.S Department of Transportation, Federal Aviation Administration, Flights Standards Service; 2008: 2-24 3–3
- 43 Douglas HE, Raban MZ, Walter SR. et al. Improving our understanding of multi-tasking in healthcare: drawing together the cognitive psychology and healthcare literature. Appl Ergon 2017; 59: 45-55
- 44 Yen AW, Yung VY, Leung JW. et al. Insertion water exchange minimizes endoscopist multitasking during withdrawal inspection – a plausible explanation for enhanced polyp detection in the right colon. J Interv Gastroenterol 2015; 5: 3-9
- 45 Ramirez FC, Leung FW. The water method for aiding colonoscope insertion: the learning curve of an experienced colonoscopist. J Interv Gastroenterol 2011; 1: 97-101
- 46 Cadoni S, Liggi M, Falt P. et al. Evidence to suggest adoption of water exchange deserves broader consideration: Its pain alleviating impact occurs in 90% of investigators. World J Gastrointest Endosc 2016; 8: 113-121