Comparing adenoma and polyp miss rates for total underwater colonoscopy versus standard CO 2: a randomized controlled trial using a tandem colonoscopy approach

Joseph C. Anderson, Charles J. Kahi, Andrew Sullivan, Margaret MacPhail, Jonathan Garcia, Douglas K. Rex

Research output: Contribution to journalArticle

8 Scopus citations


Background and Aims: Although water exchange may improve adenoma detection compared with CO 2 , it is unclear whether water is a better medium to fill the lumen during withdrawal and visualize the mucosa. Total underwater colonoscopy (TUC) involves the use of water exchange with the air valve off during insertion followed by the inspection of the mucosa under water. Our goal was to compare miss rates for TUC with standard CO 2 for polyps and adenomas using a tandem colonoscopy design. Methods: We randomized participants to undergo tandem colonoscopies using TUC or CO 2 first. In TUC, water exchange was performed during insertion, and withdrawal was performed under water. For the CO 2 colonoscopy, both insertion and withdrawal were performed with CO 2 . The main outcomes were miss rates for polyps and adenomas for the first examination calculated as the number of additional polyps/adenomas detected during the second examination divided by the total number of polyps/adenomas detected for both examinations. Inspection times were calculated by subtracting the time for polypectomy, and care was taken to keep the times equal for both examinations. Results: A total of 121 participants were randomized with 61 having CO 2 first. The overall miss rate for polyps was higher for the TUC-first group (81/237; 34%) compared with the CO 2 -first cohort (57/264; 22%) (P =.002). In addition, the overall miss rate for all adenomas was higher for the TUC-first group (52/146; 36%) compared with the CO 2 group (37/159; 23%) (P =.025). However, 1 of the 3 endoscopists had higher polyp/adenoma miss rates for CO 2 , but these were not statistically significant differences. The insertion time was longer for TUC than for CO 2 . After adjusting for times, participant characteristics, and bowel preparation, the miss rate for polyps was higher for TUC than for CO 2 . Conclusions: We found that TUC had an overall higher polyp and adenoma miss rate than colonoscopy performed with CO 2 , and TUC took longer to perform. However, TUC may benefit some endoscopists, an issue that requires further study. (Clinical trial registration number: NCT03231917.)

Original languageEnglish (US)
Pages (from-to)591-598
Number of pages8
JournalGastrointestinal endoscopy
Issue number3
StatePublished - Mar 2019


ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging
  • Gastroenterology

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