The water exchange method for colonoscopy-effect of coaching

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 timeconsuming. 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 intentionto-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.

A survey of colonoscopists with and without in‐depth knowledge of water‐aided colonoscopy

“…Most of the learning of WAC was based on coaching, which was an effective approach adopted by the WAC core group to expand the use of the emerging techniques. [14][15][16][17][18][19][20][21] In line with published commentaries, shorter colonoscopy time slots favored the use of WI, and longer ones increased the use of WE. 22,23 Together with data summarized in the MDCR, the current findings confirmed that the use of WAC was evolving and incorporated into research, routine practice, and teaching since the singular description of WI in 1984.…”

Increase your adenoma detection rate without using fancy adjunct tools

“…A learning curve with >90% successful cecal intubation is easily achievable after 50–100 cases [ 68 76 ]. Direct coaching by a knowledgeable trainer appears to facilitate understanding of the nuances of the WE method [ 77 ]. One approach for those who have a set number of procedures to perform on a very tight schedule is to set aside a fixed amount of time, for example, 5 min, to the per-patient allotted time to learn and practice the WE technique and then turn on the air pump when time elapses [ 69 ].…”

Minimal water exchange colonoscopy

“…Compared with the water immersion method, which only infuses water without deflating the lumen,3, 4 elimination of air pockets in MWE further reduces lumen distension and loop formation. On the left side of the colon, MWE is similar to the conventional water exchange method without the need of a water pump, and faster intubation is achieved because limited air can be used from the transverse colon.…”