title: Water Exchange Method Significantly Improves Adenoma Detection Rate: A Multicenter, Randomized Controlled Trial.
abstract: Adenoma detection rate (ADR) is a key colonoscopy quality indicator in Western clinical literature. Our low ADR prompted us to assess novel methods to improve performance. Western retrospective reports suggested that water exchange (WE) could increase ADR. However, most of these studies used pain score or intubation rate as the primary outcome. Here we test the hypothesis that WE significantly increases ADR among Chinese colonoscopists and design a prospective randomized controlled trial using ADR as our primary outcome.
  
  
  
  This prospective, randomized controlled trial was performed at six centers in China. Screening, surveillance, and diagnostic cases were randomized to be examined by WE or traditional air insufflation (AI) method. The primary outcome was ADR.
  
  
  
  From April 2014 to July 2015, 3,303 patients were randomized to WE (n=1,653) and AI (n=1,650). The baseline characteristics were comparable. Overall ADR was 18.3% (WE) and 13.4% (AI) (relative risk 1.45, 95% confidential interval: 1.20-1.75, P<0.001). ADR in screening patients using AI was 25.8% (male) and 15.7% (female). ADR in screening patients aged >50 years old was 29.4% (WE) and 22.9% (AI) (relative risk 1.09, 95% confidential interval: 1.00-1.19, P=0.040). The increase by WE was reproducibly observed in all indication categories, and significant in screening and diagnostic cases. The limitation imposed by the unblinded investigators was mitigated by comparable inspection times in cases without polyps, similar adenoma per positive colonoscopy, and reproducible enhancement of ADR and adenoma per colonoscopy by WE across all eight investigators.
  
  
  
  This prospective study confirms Western retrospective data that WE significantly improves ADR among Chinese colonoscopists. WE may be superior to AI for screening colonoscopy in China. Colonoscopists elsewhere with low ADR might consider evaluating WE for performance improvement.
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.|Department of Gastroenterology, Weinan Central Hospital, Weinan, China.
authors.forename: Hui
authors.initials: H
authors.lastname: Jia
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Yanglin
authors.initials: Y
authors.lastname: Pan
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Xuegang
authors.initials: X
authors.lastname: Guo
authors.affiliation: Department of Radiotherapy, Xijing Hospital, Fourth Military Medical University, Xian, China.
authors.forename: Lina
authors.initials: L
authors.lastname: Zhao
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Xiangping
authors.initials: X
authors.lastname: Wang
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Linhui
authors.initials: L
authors.lastname: Zhang
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Tao
authors.initials: T
authors.lastname: Dong
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Hui
authors.initials: H
authors.lastname: Luo
authors.affiliation: Division of Gastroenterology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
authors.forename: Zhizheng
authors.initials: Z
authors.lastname: Ge
authors.affiliation: Department of Gastroenterology, Tongji Medical Union Hospital, Huazhong Science Technology University, Wuhan, China.
authors.forename: Jun
authors.initials: J
authors.lastname: Liu
authors.affiliation: Department of Gastroenterology, Beijing Chao Yang Hospital, Capital Medical University, Beijing, China.
authors.forename: Jianyu
authors.initials: J
authors.lastname: Hao
authors.affiliation: Department of Gastroenterology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
authors.forename: Ping
authors.initials: P
authors.lastname: Yao
authors.affiliation: Division of Gastroenterology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
authors.forename: Yao
authors.initials: Y
authors.lastname: Zhang
authors.affiliation: Department of Gastroenterology, Tongji Medical Union Hospital, Huazhong Science Technology University, Wuhan, China.
authors.forename: Hongyu
authors.initials: H
authors.lastname: Ren
authors.affiliation: Department of Gastroenterology, Beijing Chao Yang Hospital, Capital Medical University, Beijing, China.
authors.forename: Weizhen
authors.initials: W
authors.lastname: Zhou
authors.affiliation: Department of Gastroenterology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China.
authors.forename: Yujie
authors.initials: Y
authors.lastname: Guo
authors.affiliation: Division of Gastroenterology, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
authors.forename: Wei
authors.initials: W
authors.lastname: Zhang
authors.affiliation: Department of Gastroenterology, Tongji Medical Union Hospital, Huazhong Science Technology University, Wuhan, China.
authors.forename: Xiaolin
authors.initials: X
authors.lastname: Chen
authors.affiliation: Department of Gastroenterology, Guangzhou General Hospital of Guangzhou Military Command of the People's Liberation Army, Guangzhou, China.
authors.forename: Dayong
authors.initials: D
authors.lastname: Sun
authors.affiliation: Department of Gastroenterology, Guangzhou General Hospital of Guangzhou Military Command of the People's Liberation Army, Guangzhou, China.
authors.forename: Xiaoqiang
authors.initials: X
authors.lastname: Yang
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Xiaoyu
authors.initials: X
authors.lastname: Kang
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Na
authors.initials: N
authors.lastname: Liu
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Zhiguo
authors.initials: Z
authors.lastname: Liu
authors.affiliation: Division of Gastroenterology, Department of Medicine, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, California, USA.|David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
authors.forename: Felix
authors.initials: F
authors.lastname: Leung
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Kaichun
authors.initials: K
authors.lastname: Wu
authors.affiliation: Xijing Hospital of Digestive Diseases, Fourth Military Medical University, Xian, China.
authors.forename: Daiming
authors.initials: D
authors.lastname: Fan
mesh_terms: D000236:Adenoma / Q000175:diagnosis*; D000328:Adult; D002681:China; D003111:Colonic Polyps / Q000175:diagnosis*; D003113:Colonoscopy / Q000009:adverse effects / Q000379:methods*; D015179:Colorectal Neoplasms / Q000175:diagnosis*; D055088:Early Detection of Cancer; D005260:Female; D006801:Humans; D007327:Insufflation; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000209:etiology; D016016:Proportional Hazards Models; D014867:Water
chemical_list: D014867:Water