Abstract
Purpose: Case-control reports suggested that colonoscopy failed to reduce incident cancers and cancer mortality in the right colon (Gastro 2004;127:452; AIM 2009;150:1; JNCI 2010;102:89). ADR, but not cecal intubation rate, was an independent predictor of the risk of interval colorectal cancer after screening colonoscopy (NEJM 2010; 362: 1795). The impact of high-definition, wide-angle endoscope (Gastro 2008; 135: 1062), narrow band imaging (Gastro 2009; 136: 410), dye-spray chromoendoscopy (Endoscopy 2006; 38: 444), withdrawal time >6 min (Gastro 2008; 135: 1892) or modifying bowel preparation (AJG doi:10.1038/ajg.2010.160) on ADR was inconclusive. A “colonoscopist-controlled” technique to obviate “missed” right-sided lesions is needed. The water method, albeit awkward, cumbersome and non conventional; but when executed “correctly” increases proximal ADR (GIE 2010; 71: AB248) merits consideration. The purpose of the report is to determine if the water method significantly increases proximal colon ADR in the results of two RCT with non-ADR-related primary outcomes. Methods: The water method was implemented by turning off the air pump prior to insertion of the colonoscope into the rectum. Residual air was suctioned to minimize angulations of flexures. Warm water was infused to assist in identification of the lumen. Residual fecal matter was aspirated before additional clean water was infused. Two RCT were conducted at two VA facilities to determine if the water method increased the proportion of patients who could complete colonoscopy without sedation when the option of scheduled, unsedated (N=82) or on demand sedation (N=100) was used. As part of the protocol overall ADR (proportion of patients with at least one adenoma) and ADR in the proximal colon were tracked in both RCT. Results: Randomization revealed balanced demographic and clinical variables. The water method yielded significantly higher ADR in the proximal colon. Conclusion: The data derived from two RCT revealed that the water method significantly increased ADR in the proximal colon. The results support the hypothesis that the “correct” use of the water method was associated with fewer “missed lesions” in the right colon. Assessment of its impact on interval colorectal cancer after screening colonoscopy deserves to be supported (Supported in part by ACG clinical research award).Table
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