BACKGROUND AND AIMS: Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR. METHODS: Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements. RESULTS: In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11). CONCLUSIONS: The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.

ASSL Carbonia Sirai Hospital Digestive Endoscopy Unit Carbonia Italy

Bezmialem Vakif University Medicine Faculty Department of Medicine Istanbul Turkey

Birmingham City University Birmingham United Kingdom

California Pacific Medical Center Interventional Endoscopy Services San Francisco California United States

Chiba University Gastroenterology Department Chiba Japan

Cochin Hospital Gastroenterology Department Paris France

CTO Hospital Digestive Endoscopy Unit Iglesias Italy

Dalin Tzu Chi Hospital Buddhist Tzu Chi Medical Foundation Dalin Township Taiwan

David Geffen School of Medicine at UCLA Department of Medicine Los Angeles California United States

Department of Gastroenterology New Tokyo Hospital Gastroenterology Matsudo Chiba Japan

Department of Medicine VA Greater Los Angeles Health Care System Los Angeles United States

Division of Gastroenterology and Hepatology Department of Internal Medicine Keio University School of Medicine Tokyo Japan

Division of Gastroenterology and Hepatology Internal Medicine Department Faculty of Medicine Gadjah Mada University Sardjito General Hospital Yogyakarta Indonesia

Division of Gastroenterology and Hepatology Sacramento VA Medical Center and University of California Davis School of Medicine Sacramento California USA

Division of Gastroenterology and Hepatology Stanford University School of Medicine VA Palo Alto California United States

Division of Gastroenterology and Hepatology University of Virginia Charlottesville Virginia United States

Division of Population Medicine School of Medicine Cardiff University Cardiff United Kingdom

Endoscopy Department Hereford County Hospital Hereford United Kingdom

Endoscopy Unit Hospital Universitario 12 de Octubre Madrid Spain

Endoscopy Unit University Hospital La Fe Valencia Spain

Faculty of Medicine Charles University Hradec Králové Czech Republic

Gastroenterology Department Endoscopy Unit Complejo Hospitalario de Navarra Pamplona Spain

Gloucestershire Hospitals NHS Foundation Trust Gloucestershire United Kingdom

Hospital Germans Triasi i Pujol Teknon Medical Center Gastroenterology Barcelona Spain

JAG Clinical Fellow JAG Royal College of Physicians London United Kingdom

King's College Hospital NHS foundation Trust Gastroenterology Department London United Kingdom

Lund University Surgery Department of Gastrointestinal Surgery Malmö Sweden

Mayo Clinic Scottsdale Arizona United States

Newcastle Upon Tyne NHS Foundation Trust Gastroenterology Department Newcastle Upon Tyne United Kingdom

NHO Kure Medical Center and Chugoku Cancer Center Gastroenterology Department Kure Japan

NHO Kurihama Medical and Addiction Center Endoscopy Center Yokosuka Japan

NIHR Nottingham Biomedical Research Centre Department of Gastroenterology Nottingham University Hospitals NHS Trust and University of Nottingham Nottingham United Kingdom

Nuovo Regina Margherita Hospital Digestive Endoscopy Unit Rome Italy

Osaka International Cancer Institute Department of Gastrointestinal Oncology Osaka Japan

Ospedale Valduce Gastroenterology Unit Como Italy

Population Health Sciences Institute Faculty of Medical Sciences Newcastle University Newcastle United Kingdom

Portsmouth University Hospital Dept of Gastroenterology Portsmouth United Kingdom

Russell Hall Dept of Gastroenterology Birmingham United Kingdom

S Orsola Malpighi University Hospital Department of Medical and Surgical Sciences Bologna Italy

Sheffield Teaching Hospitals Gastroenterology Department Sheffield United Kingdom

Telemark Hospital Gastroenterology Department Skien Norway

University Hospital and Faculty of Medicine Palacky University Olomouc Czech Republic

University Hospital North Tees NHS Department of Gastroenterology Stockton on Tees United Kingdom

University Medical Center Interventional Endoscopy Center Medizinische Klinik und Poliklinik Mainz Germany

University of British Columbia Department of Medicine Kelowna Canada

University of Florida Gainesville Florida United States

University of Minnesota Division of Gastroenterology Minneapolis Minnesota United States

University of Roehampton London United Kingdom

VU University Medical Center Department of Gastroenterology Amsterdam The Netherlands

Wolfson Unit for Endoscopy St Mark's Hospital London United Kingdom

Xijing Hospital Department of Gastroenterology Xian Republic of China

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$a BACKGROUND AND AIMS: Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR. METHODS: Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements. RESULTS: In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11). CONCLUSIONS: The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.

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$a Ishaq, Sauid $u Russell Hall, Dept. of Gastroenterology, Birmingham, United Kingdom; Birmingham City University, Birmingham, United Kingdom

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$a Falt, Přemysl $u University Hospital and Faculty of Medicine, Palacky University, Olomouc, Czech Republic; Faculty of Medicine, Charles University, Hradec Králové, Czech Republic

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$a Fuccio, Lorenzo $u S. Orsola-Malpighi University Hospital, Department of Medical and Surgical Sciences, Bologna, Italy

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$a Siau, Keith $u JAG Clinical Fellow, JAG, Royal College of Physicians, London, United Kingdom

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$a Leung, Joseph W $u Division of Gastroenterology and Hepatology, Sacramento VA Medical Center and University of California Davis School of Medicine, Sacramento, California, USA

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$a Anderson, John $u Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, United Kingdom

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$a Binmoeller, Kenneth F $u California Pacific Medical Center, Interventional Endoscopy Services, San Francisco, California, United States

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$a Radaelli, Franco $u Ospedale Valduce, Gastroenterology Unit, Como, Italy

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$a Rutter, Matt D $u University Hospital North Tees NHS, Department of Gastroenterology, Stockton-on-Tees, United Kingdom; Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, United Kingdom

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$a Sugimoto, Shinya $u Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan

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$a Muhammad, Humayun $u University of Roehampton, London, United Kingdom

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$a Bhandari, Pradeep $u Portsmouth University Hospital, Dept. of Gastroenterology, Portsmouth, United Kingdom

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$a Draganov, Peter V $u University of Florida, Gainesville, Florida, United States

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$a de Groen, Piet $u University of Minnesota, Division of Gastroenterology, Minneapolis, Minnesota, United States

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$a Wang, Andrew Y $u Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, United States

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$a Yen, Andrew W $u Division of Gastroenterology and Hepatology, Sacramento VA Medical Center and University of California Davis School of Medicine, Sacramento, California, USA

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$a Hamerski, Chris $u California Pacific Medical Center, Interventional Endoscopy Services, San Francisco, California, United States

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$a Thorlacius, Henrik $u Lund University Surgery, Department of Gastrointestinal Surgery, Malmö, Sweden

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$a Neumann, Helmut $u University Medical Center, Interventional Endoscopy Center, Medizinische Klinik und Poliklinik, Mainz, Germany

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$a Ramirez, Francisco $u Mayo Clinic, Scottsdale, Arizona, United States

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$a Mulder, Chris J J $u VU University Medical Center, Department of Gastroenterology, Amsterdam, The Netherlands

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$a Albéniz, Eduardo $u Gastroenterology Department, Endoscopy Unit, Complejo Hospitalario de Navarra, Pamplona, Spain

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$a Amato, Arnaldo $u Ospedale Valduce, Gastroenterology Unit, Como, Italy

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$a Arai, Makoto $u Chiba University, Gastroenterology Department, Chiba, Japan

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$a Bak, Adrian $u University of British Columbia, Department of Medicine, Kelowna, Canada

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$a Barret, Maximilien $u Cochin Hospital, Gastroenterology Department, Paris, France

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$a Bayupurnama, Putut $u Division of Gastroenterology and Hepatology, Internal Medicine Department, Faculty of Medicine, Gadjah Mada University, Sardjito General Hospital, Yogyakarta, Indonesia

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$a Cheung, Ramsey $u Division of Gastroenterology and Hepatology, Stanford University School of Medicine, VA Palo Alto, California, United States

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$a Ching, Hey-Long $u Sheffield Teaching Hospitals, Gastroenterology Department, Sheffield, United Kingdom

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$a Cohen, Hartley $u Department of Medicine, VA Greater Los Angeles Health Care System, Los Angeles, United States; David Geffen School of Medicine at UCLA, Department of Medicine, Los Angeles, California, United States

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$a Dolwani, Sunil $u Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, United Kingdom

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$a Friedland, Shai $u Division of Gastroenterology and Hepatology, Stanford University School of Medicine, VA Palo Alto, California, United States

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$a Harada, Hideaki $u Department of Gastroenterology, New Tokyo Hospital, Gastroenterology, Matsudo, Chiba, Japan

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$a Hsieh, Yu-Hsi $u Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin Township, Taiwan

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$a Hayee, Bu $u King's College Hospital NHS foundation Trust, Gastroenterology Department, London, United Kingdom

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$a Kuwai, Toshio $u NHO Kure Medical Center and Chugoku Cancer Center, Gastroenterology Department, Kure, Japan

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$a Lorenzo-Zúñiga, Vicente $u Endoscopy Unit, University Hospital La Fe, Valencia, Spain

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$a Liggi, Mauro $u ASSL Carbonia, Sirai Hospital, Digestive Endoscopy Unit, Carbonia, Italy

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$a Mizukami, Takeshi $u NHO Kurihama Medical and Addiction Center, Endoscopy Center, Yokosuka, Japan

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$a Mura, Donatella $u ASSL Carbonia, Sirai Hospital, Digestive Endoscopy Unit, Carbonia, Italy

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$a Nylander, David $u Newcastle Upon Tyne NHS Foundation Trust, Gastroenterology Department, Newcastle Upon Tyne, United Kingdom

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$a Olafsson, Snorri $u Telemark Hospital, Gastroenterology Department, Skien, Norway

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$a Paggi, Silvia $u Ospedale Valduce, Gastroenterology Unit, Como, Italy

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$a Pan, Yanglin $u Xijing Hospital, Department of Gastroenterology, Xian, Republic of China

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$a Parra-Blanco, Adolfo $u NIHR Nottingham Biomedical Research Centre, Department of Gastroenterology, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom

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$a Ransford, Rupert $u Endoscopy Department Hereford County Hospital, Hereford, United Kingdom

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$a Rodriguez-Sanchez, Joaquìn $u Endoscopy Unit, Hospital Universitario 12 de Octubre, Madrid, Spain

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$a Senturk, Hakan $u Bezmialem Vakif University Medicine Faculty, Department of Medicine, Istanbul, Turkey

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$a Suzuki, Noriko $u Wolfson Unit for Endoscopy, St Mark's Hospital, London, United Kingdom

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$a Tseng, Chih-Wei $u Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Dalin Township, Taiwan

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$a Uchima, Hugo $u Hospital Germans Triasi i Pujol, Teknon Medical Center, Gastroenterology, Barcelona, Spain

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$a Uedo, Noriya $u Osaka International Cancer Institute, Department of Gastrointestinal Oncology, Osaka, Japan

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$a Leung, Felix W $u Department of Medicine, VA Greater Los Angeles Health Care System, Los Angeles, United States; David Geffen School of Medicine at UCLA, Department of Medicine, Los Angeles, California, United States

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