BACKGROUND: Low adenoma detection rate (ADR) predicts development of interval cancers, found mainly in the right (cecum-ascending) colon, where poor bowel preparation is an associated factor. Single-site studies reported increased detection of adenomas in the proximal colon segments by water exchange (WE). Data about colon cleansing revealed that WE had the greatest impact in the right colon. AIMS: To test the hypothesis that WE had the greatest impact on ADR in colon segments with the most favorable bowel cleanliness scores, namely the right colon. METHODS: We pooled right colon and overall ADR data of three similarly designed colonoscopy trials that compared WE, water immersion (WI) and insufflation of air or carbon dioxide (AICD) in a mixed gender European population. RESULTS: In this study, 1200 (704 males) subjects and were included. 288 were screening cases. Demographic and procedural data were comparable. Water exchange achieved significantly higher right colon <10 mm ADR (11.9 %, vs WI 6.9 %, p = 0.016; vs AICD 7.2 %, p = 0.025). Water exchange achieved the lowest proportions of poor bowel preparation and the highest right colon and overall Boston bowel preparation scale scores (p range 0.003, <0.0005). In patients with right colon excellent bowel cleanliness, water exchange was the only method significantly associated with right colon adenoma detection. One of the limitations is unblinded colonoscopists. CONCLUSIONS: In a mixed gender European population, water exchange is confirmed to be a superior insertion technique showing a significant increase in <10 mm right colon adenoma detection, achieving the cleanest colon and lowest proportions of poor bowel preparation requiring repeat procedures. CLINICALTRIALS. GOV NO: NCT01781650, 01954862, 01780818.

Department of Surgical Sciences University of Cagliari 09121 Cagliari Italy

Digestive Diseases Center Vìtkovice Hospital Zálužanského 1192 15 703 84 Ostrava Czech Republic

Digestive Endoscopy Unit N S di Bonaria Hospital 09037 San Gavino Monreale VS Italy

Digestive Endoscopy Unit St Barbara Hospital Via S Leonardo 1 09016 Iglesias CI Italy

Sepulveda Ambulatory Care Center Veterans Affairs Greater Los Angeles Healthcare System North Hills CA 91343 USA David Geffen School of Medicine University of California at Los Angeles Los Angeles CA 90024 USA

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$a Cadoni, Sergio $u Digestive Endoscopy Unit, St. Barbara Hospital, Via S. Leonardo, 1, 09016, Iglesias, CI, Italy. cadonisergio@gmail.com.

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$a Impact of Colonoscopy Insertion Techniques on Adenoma Detection / $c S. Cadoni, P. Falt, S. Sanna, M. Argiolas, V. Fanari, P. Gallittu, M. Liggi, D. Mura, ML. Porcedda, V. Smajstrla, M. Erriu, FW. Leung,

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$a BACKGROUND: Low adenoma detection rate (ADR) predicts development of interval cancers, found mainly in the right (cecum-ascending) colon, where poor bowel preparation is an associated factor. Single-site studies reported increased detection of adenomas in the proximal colon segments by water exchange (WE). Data about colon cleansing revealed that WE had the greatest impact in the right colon. AIMS: To test the hypothesis that WE had the greatest impact on ADR in colon segments with the most favorable bowel cleanliness scores, namely the right colon. METHODS: We pooled right colon and overall ADR data of three similarly designed colonoscopy trials that compared WE, water immersion (WI) and insufflation of air or carbon dioxide (AICD) in a mixed gender European population. RESULTS: In this study, 1200 (704 males) subjects and were included. 288 were screening cases. Demographic and procedural data were comparable. Water exchange achieved significantly higher right colon <10 mm ADR (11.9 %, vs WI 6.9 %, p = 0.016; vs AICD 7.2 %, p = 0.025). Water exchange achieved the lowest proportions of poor bowel preparation and the highest right colon and overall Boston bowel preparation scale scores (p range 0.003, <0.0005). In patients with right colon excellent bowel cleanliness, water exchange was the only method significantly associated with right colon adenoma detection. One of the limitations is unblinded colonoscopists. CONCLUSIONS: In a mixed gender European population, water exchange is confirmed to be a superior insertion technique showing a significant increase in <10 mm right colon adenoma detection, achieving the cleanest colon and lowest proportions of poor bowel preparation requiring repeat procedures. CLINICALTRIALS. GOV NO: NCT01781650, 01954862, 01780818.

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$a Sanna, Stefano $u Digestive Endoscopy Unit, N. S. di Bonaria Hospital, 09037, San Gavino Monreale, VS, Italy.

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$a Liggi, Mauro $u Digestive Endoscopy Unit, St. Barbara Hospital, Via S. Leonardo, 1, 09016, Iglesias, CI, Italy.

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$a Leung, Felix W $u Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA, 91343, USA. David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, 90024, USA.

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