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Endoscopy 2023; 55(04): 324-331
DOI: 10.1055/a-1929-4552
Original article

Minimal water exchange by the air–water valve versus left colon water exchange in unsedated colonoscopy: a randomized controlled trial

Cenqin Liu
1   Department of Gastroenterology, Ningbo Hospital, Zhejiang University, Ningbo, China
3   Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
,
Shuhao Zheng
3   Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
4   School of Medicine, Ningbo University, Ningbo, China
,
Hui Gao
3   Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
4   School of Medicine, Ningbo University, Ningbo, China
,
Xin Yuan
3   Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
4   School of Medicine, Ningbo University, Ningbo, China
,
Zhixin Zhang
3   Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
4   School of Medicine, Ningbo University, Ningbo, China
,
Jiarong Xie
3   Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
,
Chaohui Yu 
2   Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
5   Zhejiang Provincial Clinical Research Center for Digestive Diseases, Hangzhou, China
,
Lei Xu
1   Department of Gastroenterology, Ningbo Hospital, Zhejiang University, Ningbo, China
3   Department of Gastroenterology, Ningbo First Hospital, Ningbo, China
5   Zhejiang Provincial Clinical Research Center for Digestive Diseases, Hangzhou, China
› Author AffiliationsSupported by: Medical Health Science and Technology Project of Zhejiang Provincial Health Commission 2022KY315
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Abstract

Background Water exchange colonoscopy is the least painful method for unsedated colonoscopies. Simplified left colon water exchange (LWE) reduces the cecal intubation time but it is difficult to avoid the use of an additional pump. Minimal water exchange (MWE) is an improved novel method that eliminates the need for pumps, but it is not clear whether MWE has the same efficiency as LWE.

Methods This was a prospective, randomized, controlled, noninferiority trial conducted in a tertiary hospital. Enrolled patients were randomized 1:1 to the LWE group or MWE group. The primary outcome was recalled insertion pain measured by a 4-point verbal rating scale. Secondary outcomes included adenoma detection rate (ADR), cecal intubation time, volume of water used, and patient willingness to repeat unsedated colonoscopy.

Results 226 patients were included (LWE n = 113, MWE n = 113). The MWE method showed noninferior moderate/severe pain rates compared with the LWE method (10.6 % vs. 9.7 %), with a difference of 0.9 percentage points (99 % confidence interval [CI] –9.5 to 11.3; threshold, 15 %). ADR, cecal intubation time, and willingness to repeat unsedated colonoscopy were not significantly different between the two groups, but the mean volume of water used was significantly less with MWE than with LWE (163.7 mL vs. 407.2 mL; 99 %CI –298.28 to –188.69).

Conclusion Compared with LWE, MWE demonstrated a noninferior outcome for insertion pain, and comparable cecal intubation time and ADR, but reduced the volume of water used and eliminated the need for a water pump.

Supplementary material



Publication History

Received: 27 January 2022

Accepted after revision: 23 August 2022

Accepted Manuscript online:
23 August 2022

Article published online:
14 October 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Durdey P, Weston P, Williams NJL. Colonoscopy or barium enema as initial investigation of colonic disease. Lancet 1987; 2: 549-551
    CrossrefPubMedGoogle Scholar
  • 2 Aljebreen A, Almadi M, Leung FW. Sedated vs unsedated colonoscopy: a prospective study. World J Gastroenterol 2014; 20: 5113-5118
    CrossrefPubMedGoogle Scholar
  • 3 Paggi S, Radaelli F, Amato A. et al. Unsedated colonoscopy: an option for some but not for all. Gastrointest Endosc 2012; 75: 392-398
    CrossrefPubMedGoogle Scholar
  • 4 Leung FW, Harker JO, Jackson G. et al. A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method. Gastrointest Endosc 2010; 72: 693-700
    CrossrefPubMedGoogle Scholar
  • 5 Cadoni S, Falt P, Gallittu P. et al. Water exchange is the least painful colonoscope insertion technique and increases completion of unsedated colonoscopy. Clin Gastroenterol Hepatol 2015; 13: 1972-1980
    CrossrefPubMedGoogle Scholar
  • 6 Hsieh YH, 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
    CrossrefPubMedGoogle Scholar
  • 7 Garborg K, Kaminski MF, Lindenburger W. et al. Water exchange versus carbon dioxide insufflation in unsedated colonoscopy: a multicenter randomized controlled trial. Endoscopy 2015; 47: 192-199
    PubMedGoogle Scholar
  • 8 Cheng CL, Kuo YL, Hsieh YH. et al. Water exchange colonoscopy decreased adenoma miss rates compared with literature data and local data with CO2 insufflation: an observational study. BMC Gastroenterol 2019; 19: 143
    CrossrefPubMedGoogle Scholar
  • 9 Jia H, Pan Y, Guo X. et al. Water exchange method significantly improves adenoma detection rate: a multicenter, randomized controlled trial. Am J Gastroenterol 2017; 112: 568-576
    CrossrefPubMedGoogle Scholar
  • 10 Fuccio L, Frazzoni L, Hassan C. et al. Water exchange colonoscopy increases adenoma detection rate: a systematic review with network meta-analysis of randomized controlled studies. Gastrointest Endosc 2018; 88: 589-597
    CrossrefPubMedGoogle Scholar
  • 11 Cadoni S, Ishaq S, Hassan C. et al. Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations. Gastrointest Endosc 2021; 93: 1411-1420
    CrossrefPubMedGoogle Scholar
  • 12 Wasan SK, Schroy PC. Water-assisted unsedated colonoscopy: does the end justify the means?. Gastrointest Endosc 2009; 69: 551-553
    CrossrefPubMedGoogle Scholar
  • 13 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
    CrossrefPubMedGoogle Scholar
  • 14 Yeh JH, Chien HY. Minimal water exchange colonoscopy. VideoGIE 2019; 4: 56-57
    CrossrefPubMedGoogle Scholar
  • 15 Cadoni S, Ishaq S. How to perform water exchange colonoscopy, with tips and tricks. VideoGIE 2019; 4: 355-357
    CrossrefPubMedGoogle Scholar
  • 16 Kaminski M, Robertson D, Senore C. et al. Optimizing the quality of colorectal cancer screening worldwide. Gastroenterology 2020; 158: 404-417
    CrossrefPubMedGoogle Scholar
  • 17 Moon SY, Kim BC, Sohn DK. et al. Predictors for difficult cecal insertion in colonoscopy: the impact of obesity indices. World J Gastroenterol 2017; 23: 2346-2354
    CrossrefPubMedGoogle Scholar
  • 18 Despott EJ, Murino A, Nakamura M. et al. A prospective randomised study comparing double-balloon colonoscopy and conventional colonoscopy in pre-defined technically difficult cases. Dig Liver Dis 2017; 49: 507-513
    CrossrefPubMedGoogle Scholar
  • 19 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
    CrossrefPubMedGoogle Scholar
  • 20 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
    CrossrefPubMedGoogle Scholar
  • 21 Cadoni S, Hassan C, Frazzoni L. et al. Impact of water exchange colonoscopy on endoscopy room efficiency: a systematic review and meta-analysis. Gastrointest Endosc 2019; 89: 159-167
    CrossrefPubMedGoogle Scholar
  • 22 Asai S, Fujimoto N, Tanoue K. et al. Water immersion colonoscopy facilitates straight passage of the colonoscope through the sigmoid colon without loop formation: randomized controlled trial. Dig Endosc 2015; 27: 345-353
    CrossrefPubMedGoogle Scholar
  • 23 Waye J, Thomas-Gibson S. How I do colonoscopy. Endoscopy 2018; 50: 259-262
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Leung JW, Thai A, Yen A. et al. Magnetic endoscope imaging (ScopeGuide) elucidates the mechanism of action of the pain-alleviating impact of water exchange colonoscopy – attenuation of loop formation. J Interv Gastroenterol 2012; 2: 142-146
    CrossrefPubMedGoogle Scholar
  • 25 Garborg KK, Loberg M, Matre J. et al. Reduced pain during screening colonoscopy with an ultrathin colonoscope: a randomized controlled trial. Endoscopy 2012; 44: 740-746
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Suzuki T, Matsushima M, Tsukune Y. et al. Double-balloon endoscopy versus magnet-imaging enhanced colonoscopy for difficult colonoscopies, a randomized study. Endoscopy 2012; 44: 38-42
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Cadoni S, Leung FW. Water-assisted colonoscopy. Curr Treat Options Gastroenterol 2017; 15: 135-154
    CrossrefPubMedGoogle Scholar
  • 28 May F, Shaukat A. State of the science on quality indicators for colonoscopy and how to achieve them. Am J Gastroenterol 2020; 115: 1183-1190
    CrossrefPubMedGoogle Scholar
  • 29 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
    PubMedGoogle Scholar
  • 30 Lesne A, Rouquette O, Touzet S. et al. Adenoma detection with blue-water infusion colonoscopy: a randomized trial. Endoscopy 2017; 49: 765-775
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Hassan C, East J, Radaelli F. et al. Bowel preparation for colonoscopy: European Society of Gastrointestinal Endoscopy (ESGE) guideline – update 2019. Endoscopy 2019; 51: 775-794
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Calderwood AH, Schroy 3rd PC. et al. Boston Bowel Preparation Scale scores provide a standardized definition of adequate for describing bowel cleanliness. Gastrointest Endosc 2014; 80: 269-276
    CrossrefPubMedGoogle Scholar
  • 33 Singh S, Singh PP, Murad MH. et al. Prevalence, risk factors, and outcomes of interval colorectal cancers: a systematic review and meta-analysis. Am J Gastroenterol 2014; 109: 1375-1389
    CrossrefPubMedGoogle Scholar