Water exchange for screening colonoscopy increases adenoma detection rate: a multicenter, double-blinded, randomized controlled trial

Sergio Cadoni; Přemysl Falt; Emanuele Rondonotti; Franco Radaelli; Petr Fojtik; Paolo Gallittu; Mauro Liggi; Arnaldo Amato; Silvia Paggi; Vit Smajstrla; Ondřej Urban; Matteo Erriu; Malcolm Koo; Felix W. Leung

doi:10.1055/s-0043-101229

Endoscopy, Table of Contents

Endoscopy 2017; 49(05): 456-467
DOI: 10.1055/s-0043-101229

Original article

Water exchange for screening colonoscopy increases adenoma detection rate: a multicenter, double-blinded, randomized controlled trial

Sergio Cadoni

¹Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias, Italy

,

Přemysl Falt

²Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic

,

Emanuele Rondonotti

³Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy

,

Franco Radaelli

³Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy

,

Petr Fojtik

²Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic

,

Paolo Gallittu

¹Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias, Italy

,

Mauro Liggi

¹Digestive Endoscopy Unit, St. Barbara Hospital, Iglesias, Italy

,

Arnaldo Amato

³Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy

,

Silvia Paggi

³Division of Digestive Endoscopy and Gastroenterology, Valduce Hospital, Como, Italy

,

Vit Smajstrla

²Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic

,

Ondřej Urban

²Digestive Diseases Center, Vitkovice Hospital, Ostrava, Czech Republic

,

Matteo Erriu

⁴Department of Surgical Sciences, University of Cagliari, Cagliari, Italy

,

Malcolm Koo

⁵Department of Medical Research, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan

⁶Dalla Lana School of Public Health, University of Toronto, Ontario, Canada

,

Felix W. Leung

⁷Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California, United States

⁸David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, California, United States

› Author Affiliations

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).

Full Text

References

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