Proximal Adenoma Detection Rate Research Articles

Colonoscopy quality improvement after initial training: A cross-sectional study of intensive short-term training.

Background and study aims High-quality is crucial for the effectiveness of colonoscopy and can be achieved by high-quality training and verified with assessment of key performance indicators (KPIs) for colonoscopy such as cecum intubation rate (CIR), adenoma detection rate (ADR) and adequate polyp resection. Typically, trainees achieve adequate CIR after 275 procedures, but little is known about learning curves for KPIs after initial training. Methods This cross-sectional study includes work-up colonoscopies after a positive screening test with fecal occult blood testing (FIT) or sigmoidoscopy, performed by either trainees after 300 training colonoscopies or by consultants. Outcome measures were KPIs. We assessed inter-endoscopist variation in trainees and learning curves for trainees as a group. We also compared KPIs for trainees and consultants as a group. Results Data from 6,655 colonoscopies performed by 21 trainees and 921 colonoscopies performed by 17 consultants were included. Most trainees achieved target standards for main KPIs. With time, trainees shortened cecum intubation time and withdrawal time without decreasing their ADR, reduced the proportion of painful colonoscopies, and increased the adequate polyp resection rate (all P < 0.01). Compared to consultants, trainees had higher CIR (97.7 % vs. 96.3 %, P = 0.02), ADR after positive FIT (57.6 % vs. 50.3 %, P < 0.01), and proximal ADR after sigmoidoscopy screening (41.1 % vs. 29.8 %; P < 0.01), higher adequate polyp resection rate (94.9 % vs. 93.1 %, P = 0.01) and fewer serious adverse events (0.65 % vs. 1.41 %, P = 0.02). Conclusions Trainees performed high-quality colonoscopies and achieved international target standards. Several KPIs continuously improved after initial training. Trainees outperformed consultants on several KPIs.

Computer-aided detection, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized controlled trial

Computer-aided detection (CADe) and a mucosal exposure device can improve adenoma detection rate (ADR). Potential benefits of combining the 2 modalities have never been studied. This study aimed to compare ADR differences among CADe alone, endocuff-assisted colonoscopy (EAC) alone, and the combination of CADe and EAC (CADe+EAC) with standard colonoscopy. This prospective randomized controlled study included 1245 participants who underwent screening colonoscopy. Participants were randomized to CADe, EAC, CADe+EAC, and standard colonoscopy as a control. The primary outcome was ADR. Secondary outcomes were proximal ADR (pADR), advanced ADR (AADR), and the number of adenomas per colonoscopy (APCs). ADRs from the control, CADe, EAC, and CADe+EAC groups were 41.9%, 52.2%, 54.0%, and 58.8%, respectively; pADRs were 25.2%, 33.3%, 34.9%, and 37.0%, respectively; AADRs were 7.7%, 8.3%, 8.3%, and 13.6%, respectively; and APCs were .76, 1.11, 1.18, and 1.31, respectively. Significant increases in ADR and pADR were observed between the intervention and control groups (P< .05 in all comparisons). The AADR was significantly higher only in the CADe+EAC group than in the control group (P= .02). The adjusted incidence rate ratios of APCs were significantly higher in the intervention groups versus the control group (P< .01 in all comparisons). CADe+EAC significantly improve ADR and AADR over standard colonoscopy. However, although CADe or EAC alone can substantially increase the detection of adenomas, they do not lead to increased detection of advanced adenomas unless used in combination. (Clinical trial registration number: TCTR20200929003.).

Comparative Efficacy of Endoscopic Assist Devices on Colonic Adenoma Detection: A Systematic Review With Network Meta-analysis.

Numerous endoscopic assist devices exist, yet data surrounding their comparative efficacy is lacking. We conducted a systematic review with network meta-analysis to determine the comparative efficacy of endoscopic assist devices on colonic adenoma detection. A systematic search was performed using multiple electronic databases through July 2020, to identify all randomized controlled trials and dual-arm observational studies compared with either other endoscopic assist devices and/or standard colonoscopy. The primary outcome was adenoma detection rate (ADR). Secondary outcomes included polyp detection rate (PDR), serrated adenoma detection rate (SADR), right-sided adenoma detection rate (RADR), and proximal adenoma detection rate (PADR). Fifty-seven studies (31,051 patients) met inclusion criteria and were analyzed. Network meta-analysis identified an enhanced ADR among (clear) cap [odds ratio (OR): 2.69, 95% confidence interval (CI): 1.45-4.99], endocuff, (OR: 4.95, 95% CI: 3.15-7.78), and endoring (OR: 3.68, 95% CI: 1.47-9.20)-with no significant difference amongst any particular device. Similar findings for PDR were also seen. Enhanced SADR was identified for endocuff (OR: 9.43) and endoring (OR: 4.06) compared with standard colonoscopy. Enhanced RADR (OR: 5.36) and PADR (OR: 3.78) were only identified for endocuff. Endocuff comparatively demonstrated the greatest ADR, PDR, and SADR, but this was not significant when compared with the other assist devices. Subgroup analysis of randomized controlled trials identified enhanced PDR and ADR for both cap and endocuff. Endoscopic assist devices displayed increased ADR and PDR as compared with standard colonoscopy and thus should be widely adopted. A nonsignificant trend was seen toward higher efficacy for the endocuff device.

Linked color imaging, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized trial

By different mechanisms, image-enhancement techniques (linked color imaging [LCI]) and mucosal exposure devices (Endocuff-assisted colonoscopy [EAC]) can improve the adenoma detection rate (ADR) during screening colonoscopy. The impact of the combination of the 2 techniques has never been studied. This study aimed to compare the ADR between the combination of LCI and EAC (LCI+EAC), LCI alone, EAC alone, and standard high-definition (HD) colonoscopy. This prospective randomized controlled trial included participants who underwent screening colonoscopy. Participants were randomized to LCI+EAC, LCI, EAC, and standard HD colonoscopy. All colonoscopies were performed by endoscopists with a recorded ADR≥35%. The primary outcome was the ADR. Secondary outcomes were proximal ADR (pADR) and the mean number of adenomas per colonoscopy (APC). One thousand participants were included in the study. The LCI+EAC group provided the highest ADR and pADR. The ADRs in the LCI+EAC, LCI, EAC, and standard HD colonoscopy groups were 57.2%, 52.8%, 51.6%, and 47.6%, respectively, with pADRs of 38.4%, 34.8%, 33.6%, and 28.0%, respectively. The mean numbers of APC were 1.28, 1.20, 1.16, and .89, respectively. After a multiple comparison adjustment, a significant difference in pADR was only observed between the LCI+EAC and standard HD colonoscopy groups (difference, 10.3 percentage points; 95% confidence interval, .02%-17.4%; P= .05). The incidence rate ratios of the adenoma numbers were significantly higher in the LCI+EAC (1.43), LCI (1.34), and EAC (1.30) groups relative to the standard HD colonoscopy group (.89) (P< .009 for all comparisons). The combination of LCI and EAC can significantly improve the detection of pADR and APC but not ADR by high-ADR performers. (Clinical trial registration number: TCTR20190319001.).

Educational interventions are associated with improvements in colonoscopy quality indicators: a systematic review and meta-analysis.

Background and study aims The quality of screening-related colonoscopy depends on several physician- and patient-related factors. Adenoma detection rate (ADR) varies considerably between endoscopists. Educational interventions aim to improve endoscopists’ ADRs, but their overall impact is uncertain. We aimed to assess whether there is an association between educational interventions and colonoscopy quality indicators. Methods A comprehensive search was performed through August 2019 for studies reporting any associations between educational interventions and any colonoscopy quality indicators. Our primary outcome of interest was ADR. Two authors assessed eligibility criteria and extracted data independently. Risk of bias was also assessed for included studies. Pooled rate ratios (RR) with 95 % confidence intervals (CI) were reported using DerSimonian and Laird random effects models. Results From 2,253 initial studies, eight were included in the meta-analysis for ADR, representing 86,008 colonoscopies. Educational interventions were associated with improvements in overall ADR (RR 1.29, 95 % CI 1.25 to 1.42, 95 % prediction interval 1.09 to 1.53) and proximal ADR (RR 1.39, 95 % CI 1.29 to 1.48), with borderline increases in withdrawal time, ([WT], mean difference 0.29 minutes, 95 % CI – 0.12 to 0.70 minutes). Educational interventions did not affect cecal intubation rate ([CIR], RR 1.01, 95 % CI 1.00 to 1.01). Heterogeneity was considerable across many of the analyses. Conclusions Educational interventions are associated with significant improvements in ADR, in particular, proximal ADR, and are not associated with improvements in WT or CIR. Educational interventions should be considered an important option in quality improvement programs aiming to optimize the performance of screening-related colonoscopy.

Endocuff-assisted versus Cap-assisted Colonoscopy in Increasing Adenoma Detection Rate. A Meta-analysis.

Several add-on devices have been developed to increase rates of colon adenoma detection. We aimed to compare the endocuff-assisted colonoscopy with cap-assisted colonoscopy through a pairwise meta-analysis of randomized trials. We searched the PubMed/Medline and Embase database through March 2020 and identified 6 randomized controlled trials (comprising 2,027 patients). The primary outcome was adenoma detection rate; secondary outcomes included sessile serrated adenoma detection rate, mean adenoma per colonoscopy, cecal intubation rate and time to reach cecum. Safety data were also analyzed. We performed pairwise meta-analysis through a random effects model and expressed data as risk ratio and 95% confidence interval. Overall, pooled adenoma detection rate was 48.1% (39.3-56.8%) with endocuff and 40.5% (30.4- 50.6%; risk ratio 1.14, 0.96-1.35) with cap. Proximal adenoma detection rate was 45.7% (36.8-54.7%) and 24% (17-45.1%) with endocuff and cap, respectively (risk ratio 2.04, 0.93-4.49), whereas endocuff outperformed cap-assisted colonoscopy in detecting diminutive (≤ 5 mm) adenomas (risk ratio 2.74, 1.53-4.90) and in terms of mean adenoma per colonoscopy (mean difference 0.31, 0.05 -0.57; p=0.02). Sessile serrated adenoma detection rate (risk ratio 1.36, 0.72-2.59), cecal intubation rate (risk ratio 0.99, 0.98-1.00), and time to reach cecum (6.87 min versus 6.87 min) were similar between the two groups. No serious adverse event was observed. Endocuff-assisted colonoscopy seems to provide a higher adenoma detection rate as compared to cap-assisted colonoscopy, in particular concerning smaller diminutive polyps.

How to increase proximal adenoma detection rate: a meta-analysis comparing water exchange, water immersion and air/CO2 insufflation methods for colonoscopy.

BackgroundRecent meta-analyses have demonstrated a higher adenoma detection rate using the water exchange method (WE), compared to water immersion (WI) and air/CO2 insufflation (ACI). Proximal adenomas have a high miss rate owing to their location and appearance. We performed a systematic review and meta-analysis of studies comparing the WE and WI methods to the ACI method, with a primary focus on proximal adenoma detection rate.MethodsThe following databases were searched for our systematic review: Medline, Embase, Cochrane Library, CINAHL, and Web of Sciences. We included both randomized controlled trials and cohort studies. The primary outcome was proximal adenoma detection rate, and secondary outcomes were right adenoma detection rate and cecal intubation rate.ResultsA total of 12 studies (17 arms) with 5660 patients (2260 ACI, 2281 WE, and 1119 WI) were included. A higher proximal adenoma detection rate (risk ratio [RR] 1.30, 95% confidence interval [CI] 1.11-1.53; P=0.001) and right adenoma detection rate (RR 1.43, 95%CI 1.19-1.71; P≤0.001; I2=0%) were noted for the WE group compared to the ACI group. The WI group did not demonstrate a better detection rate of proximal or right adenomas.ConclusionsThe water exchange method for colonoscopy holds promise and should be encouraged in the clinical setting to increase proximal and right adenoma detection rates. This will in turn decrease the incidence of colorectal cancer.

Comparison of colon adenoma detection rates using cap-assisted and Endocuff-assisted colonoscopy: a randomized controlled trial.

Objectives and study aim Colonoscopy prevents colorectal cancer by removing adenomatous polyps, but missed adenomas lead to interval cancers. Different devices have been used to increase adenoma detection rates (ADR). Two such devices of interest are the transparent cap (Olympus) and Endocuff (ARC Medical). Our study aimed to compare differences in ADR between Endocuff-assisted colonoscopy (EAC), cap-assisted colonoscopy (CAC) and standard colonoscopy (SC). Patients and methods A sample size of 126 subjects was calculated to determine an effect size of 30 %. Patients undergoing screening or surveillance colonoscopy between March 2016 and January 2017 were randomized to SC, CAC or EAC groups. Three experienced endoscopists performed all colonoscopies. Patient demographics, procedure indication, Boston Bowel Prep Score (BBPS), withdrawal time, polyp size, location, histopathology, were analyzed. Results There was no difference in ADR (52 %, 40 % and 54 %) in the SC, CAC and EAC groups respectively ( P = 0.4). Similar findings were also observed for proximal ADR (45 %, 35 %, and 50 %, P = 0.4) and SSA detection rate (16 %, 14 %, and 23 %, P = 0.5). EAC detected higher mean ADR per colonoscopy compared to CAC (1.70 vs 0.76, P = 0.01). However, there was no significant difference in mean ADR per positive colonoscopy (2.08, 1.63, and 2.59, P = 0.21). Conclusion In a randomized controlled trial comparing AC to CAC and SC, neither device conferred additional benefits in ADR among high detectors. When comparing each device, EAC may be better than CAC at detecting more total adenomas.

Defining adenoma detection rate benchmarks in average-risk male veterans

Veterans have higher prevalence of colorectal neoplasia than non-veterans; however, it is not known whether specific Veterans Affairs (VA) adenoma detection rate (ADR) benchmarks are required. We compared ADRs of a group of endoscopists for colonoscopies performed at a VA center with their ADRs at a non-VA academic medical center. This was a retrospective review of screening colonoscopies performed by endoscopists who practice at the Indianapolis VA and Indiana University (IU). Patients were average-risk men aged 50 years or older. ADR, proximal ADR, advanced ADR, and adenomas per colonoscopy were compared between IU and the VA groups. Six endoscopists performed screening colonoscopies at both locations during the study period (470 at IU vs 608 at the VA). The overall ADR was not significantly different between IU and the VA (58% vs 61%; P= .21). Advanced neoplasia detection rate (13% vs 17%; P= .46), proximal ADR (46% vs 47%; P= .31), and adenomas per colonoscopy (1.59 vs 1.84; P= .24) were not significantly different. There were no significant differences in cecal intubation rate (100% vs 99%; P= .13) or withdrawal time (10.9 vs 11.1 min; P= .28). In regression analysis, there was significant correlation between the attending-specific ADRs at IU and the VA (P= .041, r2= 0.69). In this study of average-risk men undergoing screening colonoscopies by the same group of endoscopists, the ADRs of VA and non-VA colonoscopies were not significantly different. This suggests that a VA-specific ADR target is not required for endoscopists with high ADRs.

Variable Endoscopist performance in proximal and distal adenoma detection during colonoscopy: a retrospective cohort study

BackgroundAdenoma Detection Rate (ADR) is a validated colonoscopy quality indicator. In addition to overall ADR, Distal and Proximal Adenoma Detection Rates may provide important colonoscopy quality information. The goal of this study is to determine the association between distal and proximal adenoma detection (AD) and to identify factors contributing to overall, distal, and proximal AD.MethodsThis is a retrospective cohort study of patients with a noted family history of CRC or positive fecal occult blood test who underwent a screening colonoscopy at a regional colorectal cancer (CRC) screening center between May 2009 and December 2011. Data regarding patient demographics, procedure details, endoscopist characteristics and polyp histology were captured. The main outcomes measured were overall, distal, and proximal AD.Results1907 patients were included. The median age was 60 years and 42% were male. Endoscopist median overall ADR was 25% (30% male, 21% female). Endoscopist distal ADR was only modestly associated with their proximal ADR (Spearman Rank: 0.51 p = 0.11). Highest overall ADR (29 to 45%) was found for endoscopists whose distal and proximal ADRs were above the group median. In multivariate analysis, factors associated with overall, distal, and proximal AD included age, sex, and endoscopist practicing experience.ConclusionInclusion of distal and proximal ADRs, in addition to overall ADR, in colonoscopy quality assessment provides the more accurate feedback on endoscopist performance.

Efficacy of segmental re-examination of proximal colon for adenoma detection during colonoscopy: a randomized controlled trial.

ClinicalTrials.gov (NCT02581475).

Adenoma and Polyp Detection Rates in Colonoscopy according to Indication.

Background Adenoma detection rate (ADR) is a validated quality measure for screening colonoscopy, but there are little data for other indications. The distribution of adenomas is not well described for these indications. Aim To describe ADR and the adenoma distribution in the proximal and distal colon based on colonoscopy indication. Methods Outpatient colonoscopies are subdivided by indication. PDR and ADR for the entire colon and for proximal and distal colon. Data were compared using generalized estimating equations to adjust for clustering amongst endoscopists while controlling for patient age and gender. Results 3436 colonoscopies were reviewed (51.2%: men (n = 1759)). Indications are screening 49.2%, surveillance 29.3%, change in bowel habit 8.4%, bleeding 5.8%, colitides 3.0%, pain 2.8%, and miscellaneous 1.5%. Overall ADR was 37% proximal ADR 28%, and distal ADR 17%. PDR and ADR were significantly higher in surveillance than in screening (PDR: 69% versus 51%; ADR: 50% versus 33%; p = 0.0001). Adenomas were more often detected in the proximal than in the distal colon, for all indications. Conclusions Prevalence of polyps and adenomas differs based on colonoscopy indication. Adenoma detection is highest in surveillance and more commonly detected in the proximal colon. For quality assurance, distinct ADR and PDR targets may need to be established for different colonoscopy indications.

Endoscopist characteristics that influence the quality of colonoscopy.

Several factors have been shown to be related to colonoscopy quality; however, little is known about the effects of endoscopist factors. This study analyzed the influence of endoscopist-related characteristics on quality indicators for colonoscopy. The study included 48 endoscopists who each performed at least 20 colonoscopies in the colonoscopy arm of a randomized controlled trial comparing fecal immunochemical test vs. colonoscopy in colorectal cancer screening. These endoscopists performed a total of 3838 procedures in the trial. The following were calculated for each endoscopist: adenoma detection rate (ADR), advanced ADR, proximal ADR, distal ADR, and adenoma per colonoscopy rate (APCR). The characteristics of endoscopists were assessed with regard to colonoscopy quality using multivariate regression analysis. Endoscopist characteristics included age, sex, exclusive endoscopy practice, years as a physician, years as a specialist, specialty, total (life-long) number of colonoscopies performed, annual colonoscopy volume, number of hours/week dedicated to endoscopy and number of educational activities in the previous year. Factors associated with ADR were age of the endoscopist (odds ratio [OR] 1.11, 95 % confidence interval [CI] 1.01 - 1.21; P = 0.01) and life-long number of colonoscopies (OR 1.06, 95 %CI 1.01 - 1.11; P = 0.01). Only exclusive dedication to endoscopy practice was found to be independently related to proximal ADR (OR 1.71, 95 %CI 1.15 - 2.74; P = 0.001). Life-long number of colonoscopies was independently related to detection of distal adenomas (OR 1.07, 95 %CI 1.01 - 1.13; P = 0.01). None of the analyzed endoscopist characteristics was associated with advanced ADR or APCR. This study found that the experience of the endoscopist and exclusive dedication to endoscopy practice, but not annual colonoscopy volume, were associated with better colonoscopy quality.

Adenoma and sessile serrated polyp detection rates: variation by patient sex and colonic segment but not specialty of the endoscopist.

Adenoma detection rate is an important quality indicator. High adenoma detection rate is related to fewer interval cancers. Interval cancers arise from sessile serrated polyps, often in the proximal colon. The detection of adenomas and sessile serrated polyps by location may enhance colonoscopy efficacy. The aim of this study was to determine entire colon and segmental adenoma and sessile serrated polyp detection rates and to assess the impact of endoscopist specialty on polyp detection. Colonoscopies performed by 65 multispecialty endoscopists were studied. This study was conducted at an academic medical center. Average-risk outpatients undergoing screening colonoscopy were selected. Polyp detection rates were determined by sex, colon segment, and each endoscopist. Included were 2167 patients. Adenoma and sessile serrated polyp detection rates were 25% and 2% and not significantly different by specialty of the endoscopist. The adenoma detection rate was higher in men (31%) than in women (20%), including each segment in the colon. It was higher proximally (20%) than distally (16%) (p = 0.027) in men, but no different in proximal (11%) and distal colon (11%) (p = 0.66) in women. Sessile serrated polyp detection was the same in men and women at 2% (p = 0.84) and 3-fold higher in the proximal than in the distal colon (1.4% vs 0.5%), but only significantly so in women (p = 0.041). We found a poor correlation between adenoma and sessile serrated polyp detection rates (r = 0.35). This study was limited by its retrospective nature. Prevalent adenomas are detected more often in men than in women, including overall and by colon segment. The proximal adenoma detection rate is significantly higher than the distal adenoma detection rate in men, but segmental rates are similar in women. Sessile serrated polyp detection rates are low, albeit 3-fold higher in the proximal colon, and are found as frequently in men and women. High-quality colonoscopy, as evidenced by adenoma detection rate, varies by endoscopist but is independent of colonoscopist subspecialty.

Impact of fair bowel preparation quality on adenoma and serrated polyp detection: data from the New Hampshire Colonoscopy Registry by using a standardized preparation-quality rating

The effect of colon preparation quality on adenoma detection rates (ADRs) is unclear, partly because of lack of uniform colon preparation ratings in prior studies. The New Hampshire Colonoscopy Registry collects detailed data from colonoscopies statewide, by using a uniform preparation quality scale after the endoscopist has cleaned the mucosa. To compare the overall and proximal ADR and serrated polyp detection rates (SDR) in colonoscopies with differing levels of colon preparation quality. Cross-sectional. New Hampshire statewide registry. Patients undergoing colonoscopy. We examined colon preparation quality for 13,022 colonoscopies, graded by using specific descriptions provided to endoscopists. ADR and SDR are the number of colonoscopies with at least 1 adenoma or serrated polyp (excluding those in the rectum and/or sigmoid colon) detected divided by the total number of colonoscopies, for the preparation categories: optimal (excellent and/or good), fair, and poor. Overall/proximal ADR/SDR. The overall detection rates in examinations with fair colon preparation quality (SDR 8.9%; 95% confidence interval [CI], 7.4-10.7, ADR 27.1%; 95% CI, 24.6-30.0) were similar to rates observed in colonoscopies with optimal preparation quality (SDR 8.8%; 95% CI, 8.3-9.4, ADR 26.3%; 95% CI, 25.6-27.2). This finding also was observed for rates in the proximal colon. A logistic regression model (including withdrawal time) found that proximal ADR was statistically lower in the poor preparation category (odds ratio 0.45; 95% CI, 0.24-0.84; P< .01) than in adequately prepared colons. Homogeneous population. In our sample, there was no significant difference in overall or proximal ADR or SDR between colonoscopies with fair versus optimal colon preparation quality. Poor colon preparation quality may reduce the proximal ADR.

The feasibility of total water colonoscopy

Traditional colonoscopy is done using minimal air insufflations to distend the colon upon scope insertion until the cecum is reached. Residual stool in the colon is removed with water irrigation and suction. Biopsy and removal of lesions is usually performed on scope withdrawal. Water (exchange) colonoscopy utilizing water infusion in lieu of air insufflations on scope insertion compared favorably to air colonoscopy in screening colonoscopy. Upon reaching the cecum, the residual water is suctioned and air insufflated to distend the colon to facilitate inspection and removal of lesions on scope withdrawal. In randomized controlled trials (RCTs), it has been reported that the water method improves overall success rate of cecal intubation with unsedated colonoscopy, reduces medications requirement in sedated colonoscopy, and increases the proportion of patients completing colonoscopy without sedation medications when given the option of on-demand sedation compared with the conventional air method. Further analysis of RCTs indicated that the water exchange method (with suction removal of dirty water before infusing clean water on scope insertion) is associated with an increase in overall as well as proximal adenoma detection rate (ADR) when compared with the air method. While removal of lesions including biopsies and polypectomy are done normally on scope withdrawal under air insufflations, we examine the possibility of performing total water colonoscopy and polypectomy without using air insufflations.

A two-center randomized controlled trial of water-aided colonoscopy versus air insufflation colonoscopy

Water-aided colonoscopy includes water immersion and water exchange. Several small single-center studies have suggested that the use of water rather than air insufflation during colonoscopy reduces pain on insertion. The aim of this study was to investigate whether water-aided colonoscopy is less painful than air insufflation in a large cohort of patients. This was a two-center, randomized controlled trial. Consecutive patients who agreed to start colonoscopy without premedication were included. Sedation was administered on demand. Water-aided colonoscopy was performed using water immersion in the early phase of the study, and subsequently water exchange was used. The primary endpoint was cecal intubation with pain scores of ≤ 2 and sedation with no or ≤ 2 mg midazolam. Secondary outcomes were pain score at discharge, cecal intubation rate and time, and adenoma detection rate (ADR). A total of 672 patients were randomized to water exchange (n = 338) or air insufflation (n = 334). The primary endpoint was achieved in more patients in the water exchange group (83.8 % vs. 62 %; P < 0.0005). On-demand sedation was also required less (11.5 % vs. 26.0 %; P < 0.0005) and mean pain score was lower (1.3 vs. 2.3; P < 0.0005) in the water exchange group. The cecal intubation rates were comparable. Water exchange had a significantly higher overall ADR (25.8 % vs. 19.1 %; P = 0.041), proximal ADR (10.1 % vs. 4.8 %; P = 0.014), and proximal < 10 mm ADR (7.7 % vs. 3.9 %; P = 0.046); proximal ADR was also higher in screening-only patients in the water exchange group (18.9 % vs. 7.4 %; P = 0.015). No detailed analysis was possible for the air insufflation vs. water immersion comparison. The current results confirmed that water exchange minimized the requirement for sedation and increased the ADR.

Increase in proximal adenoma detection rate after transition from air to water method for screening colonoscopy in a community-based setting in the United States

Background: The water method of colonoscopy has been shown to increase adenoma detection rate in the United states veteran population, but this has not yet been demonstrated in a non-veteran community setting in the United states. Aims: Our aim is to perform a retrospective study to compare adenoma detection rate between the air and the water colonoscopy methods for screening colonoscopies at a non-veteran community site. Methods: We performed a retrospective review of 100 patients from before and after a single community endoscopist transitioned from air colonoscopy to water colonoscopy. The patients selected were the 50 most recent patients who presented for air colonoscopy and the first 50 patients who underwent water colonoscopy after the transition. patients who presented for indications other than colon cancer screening or surveillance were excluded. The primary end point was overall adenoma detection rate; secondary end points included cecal intubation time, procedure time, polyp detection rate, proximal colon adenoma detection rate, and sedation requirement. Results: There was no significant difference between the two methods in total adenoma detection rate, polyp detection rate, cecal intubation time, total procedure time, or sedation requirement. however, there was a significantly higher proximal adenoma detection rate (34%) with the water method compared to the air method (18%), p=0.015. Conclusion: In a non-veteran community setting, screening colonoscopy done with the water method resulted in a significantly higher proximal colon adenoma detection rate without significantly adding to total procedure time or sedation requirement.

Experience with water-aided colonoscopy in a Canadian community population

Purpose: Water-aided colonoscopy, immersion (WI) or exchange (We), minimizes insertion pain and reduces sedation. We improves adenoma detection rates (ADR). In a performance improvement program, we assessed water-aided methods in a busy community GI practice in c anada. Methods: Over a 13 month period patients were offered water-aided colonoscopy with an option to complete the examination with on-demand sedation. WI was used in the first 1-2 months and replaced exclusively with W e thereafter. procedural outcomes were compared to a continuous retrospective cohort of standard sedated air insufflation (AI) colonoscopy. Results: 200 (106M/94F) water-aided colonoscopies were completed. cecal intubation without air insufflation was achieved in 93%. sedation was not required in 95% of patients accepting on-demand sedation. Average insertion time was 15 min with an average withdrawal time of 6 min. 145 (87M/58F) water-aided colonoscopies, completed for screening or surveillance were compared to a cohort of 145 (77M/68F) AI colonoscopies in the immediate prior period. The overall ADR of water-aided colonoscopy was 30% (43/145) with a proximal ADR of 21%. Using AI the overall ADR was 27.6% (40/145) with a proximal ADR of 14.5% (21/145). In males, the proximal colon ADR was 25% in water-aided colonoscopies and 14.3% using AI (p=0.0397). Conclusions: Water-aided colonoscopy is feasible in a busy community practice with respectable cecal intubation rates. A large percentage of patients consenting to on-demand sedation completed without sedation. ADR in male subjects is consistent with similar prior reports of a significantly higher ADR in the proximal colon using W e when compared to AI.

Feasibility of Water Colonoscopy in a Canadian Community Population

Purpose: Water-aided methods, either by immersion or exchange, minimize pain during colonoscopy, thereby reducing or eliminating sedation requirements. Water exchange, in particular, also enhances adenoma detection rates (ADR) when compared to air insufflation. Previous descriptions of the technique in North America involved predominantly male VA populations. In the context of a performance improvement program, to establish the feasibility of using water-aided methods in one busy GI community practice in Canada. Methods: At the Kelowna General Hospital, over a 13 month period patients presenting for colonoscopy, for all indications, were offered a colonoscopy using the water-aided methods and an option to attempt the procedure without sedation. The method of water immersion was performed in the first 1-2 months and replaced exclusively with water exchange thereafter. Communication with a knowledgeable trainer via email facilitated learning and conversion to the water exchange method. Colonoscopy was performed by two endoscopists. Standard colonoscopes were used. Water was infused with a paddle pump. Clean water was infused to facilitate insertion while suctioning cloudy water. Once cecal intubation was achieved air insufflation allowed examination and polyp removal on withdrawal. Procedural outcomes were recorded. Results: 200 (106M/94F) water-aided colonoscopies were completed, 81 for screening, 64 for surveillance and 55 were diagnostic. The intent-to-treat cecal intubation rate was 93%. 97 patients (62M/35F) of 102 (64M/38F), 95% who consented to the procedure without sedation successfully completed it without on demand sedation. Average insertion time was 15 min with an average withdrawal time of 6 min (excluding polypectomy) for an overall average procedure time of 21 min for all indications. The overall ADR for patients with a screening/surveillance indication was 30% (43/145), 36% (31/87) in males and 21% (12/58) in females with an overall proximal ADR of 21% (31/145), 25% (22/87) in males and 16% (9/58) in females and an overall sessile serrated polyp detection rate of 4% (5/145). Two advanced adenomas and one cancer were identified in 2% of patients (3/145). Conclusion: Water-aided methods are feasible and can be integrated into a busy community practice. Rates of cecal intubation are similar to published results. ADR are higher than recommended quality standards (male 25%, female 15%). These results are instrumental in generating funding support provided by the Canadian Association of Gastroenterology and the Canadian Digestive Health Foundation to conduct a prospective RCT to evaluate the approach of extended, unsedated flexible sigmoidoscopy using water exchange as a universal screening examination.