title: Evidence to suggest adoption of water exchange deserves broader consideration: Its pain alleviating impact occurs in 90% of investigators.
abstract: OBJECTIVE
  To determine whether observations were reproducible among investigators.
  
  
  METHODS
  From March 2013 through June 2014, 18-85-year-old diagnostic and 50-70-year-old screening patients were enrolled at each center to on-demand sedation colonoscopy with water exchange (WE), water immersion (WI) and insufflation with air or CO2 for insertion and withdrawal [air or carbon dioxide (AICD)]. Data were aggregated for analysis.
  
  
  METHODS
  Variations in real-time maximum insertion pain (0 = none, 1-2 = discomfort, 10 = worst).
  
  
  RESULTS
  One thousand and ninety-one cases analyzed: WE (n = 371); WI (n = 338); AICD (n = 382). Demographics and indications were comparable. The WE group had the lowest real-time maximum insertion pain score, mean (95%CI): WE 2.8 (2.6-3.0), WI 3.8 (3.5-4.1) and AICD 4.4 (4.1-4.7), P < 0.0005. Ninety percent of the colonoscopists were able to use water exchange to significantly decrease maximum insertion pain scores. One investigator had high insertion pain in all groups, nonetheless WE achieved the lowest real-time maximum insertion pain score. WE had the highest proportions of patients with painless unsedated colonoscopy (vs WI, P = 0.013; vs AICD, P < 0.0005); unsedated colonoscopy with only minor discomfort (vs AICD, P < 0.0005), and completion without sedation (vs AICD, P < 0.0005).
  
  
  CONCLUSIONS
  Aggregate data confirm superiority of WE in lowering colonoscopy real-time maximum insertion pain and need for sedation. Ninety percent of investigators were able to use water exchange to significantly decrease maximum insertion pain scores. Our results suggest that the technique deserves consideration in a broader scale.
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Sergio
authors.initials: S
authors.lastname: Cadoni
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Liggi
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Premysl
authors.initials: P
authors.lastname: Falt
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Sanna
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Mariangela
authors.initials: M
authors.lastname: Argiolas
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Viviana
authors.initials: V
authors.lastname: Fanari
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Gallittu
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Donatella
authors.initials: D
authors.lastname: Mura
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Maria L
authors.initials: ML
authors.lastname: Porcedda
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Vit
authors.initials: V
authors.lastname: Smajstrla
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Erriu
authors.affiliation: Sergio Cadoni, Mauro Liggi, Paolo Gallittu, Donatella Mura, Digestive Endoscopy Unit, St. Barbara Hospital, 09016 Iglesias, Italy.
authors.forename: Felix W
authors.initials: FW
authors.lastname: Leung
keywords: Colonoscopy; Colonoscopy pain; Painless colonoscopy; Water exchange; Water immersion
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