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Leung JW, Yen AW, Jia H, Opada C, Melnik A, Atkins J, Feller C, Wilson MD, Leung FW. A prospective RCT comparing combined chromoendoscopy with water exchange (CWE) vs water exchange (WE) vs air insufflation (AI) in adenoma detection in screening colonoscopy. United European Gastroenterol J 2019; 7:477-487. [PMID: 31065365 DOI: 10.1177/2050640619832196] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Accepted: 01/22/2019] [Indexed: 12/15/2022] Open
Abstract
Background A low adenoma detection rate (ADR) increases risks of interval cancers (ICs). Proximal colon flat polyps, e.g. serrated lesions (SLs), are difficult to find. Missed proximal colon flat lesions likely contribute to IC. Aims We compared chromoendoscopy with water exchange (CWE), water exchange (WE) and air insufflation (AI) in detecting adenomas in screening colonoscopy. Methods After split-dose preparation, 480 veterans were randomized to AI, WE and CWE. Results Primary outcome of proximal ADR (55.6% vs 53.4% vs 52.2%, respectively) were similar in all groups. Adenoma per colonoscopy (APC) and adenoma per positive colonoscopy (APPC) were comparable. Detection rate of proximal colon SLs was significantly higher for CWE and WE than AI (26.3%, 23.6% and 11.3%, respectively, p = 0.002). Limitations: single operator; SLs only surrogate markers of but not IC. Conclusions When an endoscopist achieves high-quality AI examinations with overall ADR twice (61.6%) the recommended standard (30%), use of WE and CWE does not produce further improvement in proximal or overall ADR. Comparable APC and APPC confirm equivalent withdrawal inspection techniques. WE alone is sufficient to significantly improve detection of proximal SLs. The impact of increased detection of proximal SLs by WE on prevention of IC deserves to be studied. This study is registered at ClinicalTrial.gov (NCT#01607255).
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Affiliation(s)
- J W Leung
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA.,Division of Gastroenterology and Hepatology, University of California, Davis School of Medicine, Sacramento, CA, USA
| | - A W Yen
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - H Jia
- Department of Gastroenterology, Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - C Opada
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - A Melnik
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - J Atkins
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - C Feller
- Section of Gastroenterology, Sacramento Veteran Affairs Medical Center, Veteran Affairs Northern California Health Care System (VANCHCS), Mather, CA, USA
| | - M D Wilson
- Clinical and Translational Science Center, Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, Sacramento, CA, USA
| | - F W Leung
- Sepulveda Ambulatory Care Center, Veteran Affairs Greater Los Angeles Healthcare System (VAGLAHS) and David Geffen School of Medicine at UCLA, North Hills, CA, USA
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Khan MY, Dirweesh A, Siddiqui WJ. Impact of Hyoscine Bromide Use on Polyp Detection Rate During Colonoscopy: A Systematic Review and Meta-Analysis. Gastroenterology Res 2018; 11:295-304. [PMID: 30116429 PMCID: PMC6089588 DOI: 10.14740/gr1057w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background Colorectal cancer (CRC) is a leading cause of death worldwide. Polyp detection rate (PDR) and adenoma detection rate (ADR) are key focus in endoscopic research for CRC screening and prevention. Use of anti-spasmodic agents during colonoscopy to help identify adenomas and polyps has remained a controversial topic. Hyoscine butyl bromide (HBB) is the most commonly used anti-spasmodic agent in patients undergoing colonoscopy. Some randomized controlled trials (RCTs) have questioned the clinical efficacy and safety of routine use of HBB for polyp and adenoma detection rates. Methods We conducted a systematic search in PubMed and MEDLINE from inception until February 10, 2018, for studies which compared HBB with placebo. We used RevMan version 5.3 for analysis. Procedural end-points were polyps, adenomas, and advanced adenoma detection rates, mean number of polyps detected and cecal intubation time. Results We included seven RCTs with 2,588 patients in our analysis. A total of 1,301 patients were randomized to HBB arm and 1,287 to the placebo arm. There was no significant difference in the primary outcome of polyp detection rate, 654 in HBB group vs. 616 in the placebo group, (odds ratio (OR) = 1.11, confidence interval (CI) = 0.93 - 1.34, P = 0.25). There was no difference in secondary outcomes of adenoma detection rate, 430 in HBB group vs. 396 in the placebo group, (OR = 1.06, CI = 0.89 - 1.26, P = 0.51), advanced adenoma detection rate, 92 in HBB vs. 95 in placebo group (OR = 0.95, CI = 0.70 - 1.30, P = 0.76), mean number of polyps detected (point estimate = 0.12, CI = 0.00 - 0.23, P = 0.05), adenomatous polyps (OR = 0.84, CI = 0.39 - 1.81, P = 0.65) and cecal intubation time (point estimate = 0.73, CI = -1.98 - 0.52, P = 0.25) between the two groups. Conclusions The use of HBB in patients undergoing colonoscopy does not appear to improve polyp or adenoma detection rates. It showed a non-significant trend of increased mean number of polyps detected with HBB.
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Affiliation(s)
- Muhammad Yasir Khan
- Department of Medicine, Capital Health Regional Medical Center, Trenton, NJ, USA
| | - Ahmed Dirweesh
- Department of Medicine, Division of Gastroenterology, University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Waqas Javed Siddiqui
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA, USA.,Department of Medicine, Hahnemann University Hospital, Philadelphia, PA, USA
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Shi X, Tian D, Ye X, Wu Q, Pan Y, Yang Z, Fan D. Is water exchange superior to water immersion in detecting adenomas during colonoscopies? Results from a Bayesian network meta-analysis. Oncotarget 2018; 9:30679-30693. [PMID: 30093978 PMCID: PMC6078142 DOI: 10.18632/oncotarget.25504] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/08/2018] [Indexed: 12/13/2022] Open
Abstract
AIM Water-assisted colonoscopy (water exchange [WE] and water immersion [WI]) has been shown to improve the adenoma detection rate. However, few studies have compared these two methods head-to-head. Thus, we conducted a network meta-analysis to integrate both direct and indirect evidence comparing the effectiveness of these two procedures. METHOD We searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for original papers and abstracts published up to March 2018. Randomized controlled trials (RCTs) reporting data in accordance with the eligibility criteria were included in this study. We performed a Bayesian random effects network meta-analysis with mixed comparisons. RESULTS Twenty-nine studies (n = 11464 patients) including 6 direct and 23 indirect comparisons were included in this network meta-analysis. There was a statistically significant difference in the efficacy of adenoma detection when WE was compared with WI (risk ratio [RR]: 1.2, 95% credible interval [CrI]: 1.1-1.3), air insufflation (AI; RR: 1.3, 95% CrI: 1.1-1.4), and carbon dioxide (CO2) insufflation (RR: 1.2, 95% CrI: 1.1-1.5). The different methods were ranked in order from the most to least effective in adenoma detection as follows: WE, WI, AI, and CO2. Moreover, although there were no significant differences in pain scores, willingness to repeat, caecal intubation rate, or total procedure time between WI and WE colonoscopy, WE required a longer caecal intubation time than WI. CONCLUSION This network meta-analysis supposes that WE may be superior to WI in detecting adenomas during colonoscopies without affecting other technical features or patient acceptance.
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Affiliation(s)
- Xin Shi
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Dan Tian
- Office of Educational Administration, Fourth Military Medical University, Xi’an, China
| | - Xiaofei Ye
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Qiong Wu
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Zhiping Yang
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
| | - Daiming Fan
- State Key Laboratory of Cancer Biology, National Clinical Research Center for Digestive Diseases and Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xi’an, China
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Garborg K, Bretthauer M. Can old dogs learn new tricks? JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2013; 2:126-127. [PMID: 23805392 DOI: 10.4161/jig.23733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2012] [Accepted: 06/27/2012] [Indexed: 11/19/2022]
Affiliation(s)
- Kjetil Garborg
- Department of Medicine, Sorlandet Hospital, Kristiansand (KG, MB), Department of Health Management and Health Economy, University of Oslo, Oslo, (KG, MB), and Dep. of Transplantation Medicine, Section of Gastroenterology, Oslo University Hospital, Oslo (MB), Norway
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Leung FW. Benchmarking and quality-screening colonoscopy. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:100-102. [PMID: 23805385 DOI: 10.4161/jig.23726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2012] [Revised: 05/07/2012] [Accepted: 05/08/2012] [Indexed: 12/17/2022]
Affiliation(s)
- Felix W Leung
- Gastroenterology, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill ; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Leung J, Mann S, Siao-Salera R, Ngo C, McCreery R, Canete W, Leung F. Indigocarmine added to the water exchange method enhances adenoma detection - a RCT. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:106-111. [PMID: 23805387 DOI: 10.4161/jig.23728] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 05/06/2012] [Accepted: 05/09/2012] [Indexed: 02/07/2023]
Abstract
PURPOSE Chromoendoscopy with dye spray and the water method both increase adenoma detection. HYPOTHESIS Adding indigocarmine to the water method will enhance further the effectiveness of the latter in adenoma detection. METHODS Screening colonoscopy was performed with the water method (control) or with 0.008% indigocarmine added (study) by two endoscopists. Randomization was based on computer-generated codes contained in blocks of pre-arranged opaque sealed envelopes. High resolution colonoscopes were used. Upon insertion into the rectum, air was suctioned. With the air pump turned off, water was infused using a blunt needle adaptor connected to the scope channel and a foot pump to facilitate scope insertion until the cecum was reached. Residual stool causing cloudiness was suctioned followed by infusion of clear or colored water (water exchange) to facilitate scope passage with minimal distention of the colonic lumen. Upon seeing the appendix opening under water, water was suctioned and air was insufflated to facilitate inspection on scope withdrawal. STATISTICS Sample size calculation revealed 168 patients (84/group) needed to be randomized. Study was IRB-approved and registered (NCT01383265). RESULTS There were no significant differences in mean age, gender distribution, BMI, and family history of colon cancer. Cecal intubation success rate was 100% in both groups. The overall adenoma detection rate was 44% (water only) versus 62% (water with indigocarmine), respectively (p=0.03). One cancer was detected in each group. CONCLUSION In a RCT, indigocarmine at 0.008% concentration, added to the water method, significantly enhanced further the effectiveness of the latter in detecting adenomas.
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Affiliation(s)
- Joseph Leung
- Gastroenterology, Sacramento VA Medical Center, Sacramento ; Gastroenterology, UC Davis Medical Center
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Leung F, Cheung R, Fan R, Fischer L, Friedland S, Ho S, Hsieh Y, Hung I, Li M, Matsui S, McQuaid K, Ohning G, Ojuri A, Sato T, Shergill A, Shoham M, Simons T, Walter M, Yen A. The water exchange method for colonoscopy-effect of coaching. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:122-125. [PMID: 23805391 DOI: 10.4161/jig.23732] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 06/05/2012] [Accepted: 06/07/2012] [Indexed: 02/07/2023]
Abstract
The growing popularity of water immersion is supported by its long history as an adjunct to air insufflation; after facilitating colonoscope passage, the infused water is conveniently removed during withdrawal. Water exchange, a modification of water immersion to minimize discomfort in scheduled unsedated patients in the U.S. is new. Even though it may be superior in reducing pain and increasing adenoma detection, the paradigm shift to complete exclusion of air during insertion necessitates removal of infused water containing residual feces, a step often perceived as laborious and time-consuming. The nuances are the efficient steps to remove infused water predominantly during insertion to maintain minimal distension and deliver salvage cleansing. Mastery of the novel maneuvers with practice returns insertion time towards baseline. In this observational study the impact of direct verbal coaching on the primary outcome of intention-to-treat cecal intubation was assessed. The results showed that 14 of 19 (74%) experienced colonoscopists achieved 100% intention-to-treat cecal intubation. Initiation of the examination with water exchange did not preclude completion when conversion to the more familiar air insufflation method was deemed necessary to achieve cecal intubation (total 98%). The overall intention-to-treat cecal intubation rate was 88%, 90% in male and 87% in female. Only 2.7% of bowel preparation was rated as poor during withdrawal. The mean volume of water infused and cecal intubation time was 1558 ml and 18 min, respectively. Direct coaching appears to facilitate understanding of the nuances of the water exchange method. Studies of individual learning curves are necessary.
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Affiliation(s)
- Fw Leung
- Gastroenterology, Sepulveda ACC, VAGLAHS, North Hills, CA, United States ; Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States
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Ramirez FC. Re-learning colonoscopy: just a matter of time. JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2012; 2:133-134. [PMID: 23805394 DOI: 10.4161/jig.23735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 08/01/2012] [Indexed: 12/14/2022]
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Terruzzi V, Paggi S, Amato A, Radaelli F. Unsedated colonoscopy: A neverending story. World J Gastrointest Endosc 2012; 4:137-41. [PMID: 22523614 PMCID: PMC3329613 DOI: 10.4253/wjge.v4.i4.137] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/18/2011] [Accepted: 03/01/2012] [Indexed: 02/05/2023] Open
Abstract
Although sedation and analgesia for patients undergoing colonoscopy is the standard practice in Western countries, unsedated colonoscopy is still routinely provided in Europe and the Far East. This variation in sedation practice relies on the different cultural attitudes of both patients and endoscopists across these countries. Data from the literature consistently report that, in unsedated patients, the use of alternative techniques, such as warm water irrigation or carbon dioxide insufflation, can allow a high quality and well tolerated examination.
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Affiliation(s)
- Vittorio Terruzzi
- Vittorio Terruzzi, Silvia Paggi, Arnaldo Amato, Franco Radaelli, Division of Gastroenterology, Valduce Hospital, I-22100 Como, Italy
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Leung FW. Prevalence and predictors of interval colorectal cancers - what hypotheses should colonoscopists consider in planning studies to modify the undesirable outcome. Ann Gastroenterol 2012; 25:178-180. [PMID: 24714121 PMCID: PMC3959397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 01/02/2012] [Indexed: 10/27/2022] Open
Affiliation(s)
- Felix W. Leung
- Gastroenterology, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hill and David Geffen School of Medicine at UCLA, Los Angeles, CA, USA,
Correspondence to: Felix W. Leung, MD, 111G, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, 16111 Plummer Street, North Hills, CA 91343, Tel: +818 895 9403, Fax: +818 895 9516, e-mail:
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Bak AW. The water method - untapped potential in extended flexible sigmoidoscopy for colorectal cancer screening? JOURNAL OF INTERVENTIONAL GASTROENTEROLOGY 2011; 1:191-192. [PMID: 22586536 PMCID: PMC3350894 DOI: 10.4161/jig.1.4.19972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 01/18/2012] [Accepted: 01/19/2012] [Indexed: 01/20/2023]
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