How to increase proximal adenoma detection rate: a meta-analysis comparing water exchange, water immersion and air/CO2 insufflation methods for colonoscopy

Background: Recent meta-analyses have demonstrated a higher adenoma detection rate using the water exchange method (WE), compared to water immersion (WI) and air/CO2 insufflation (ACI). Proximal adenomas have a high miss rate owing to their location and appearance. We performed a systematic review and meta-analysis of studies comparing the WE and WI methods to the ACI method, with a primary focus on proximal adenoma detection rate. Methods: The following databases were searched for our systematic review: Medline, Embase, Cochrane Library, CINAHL, and Web of Sciences. We included both randomized controlled trials and cohort studies. The primary outcome was proximal adenoma detection rate, and secondary outcomes were right adenoma detection rate and cecal intubation rate. Results: A total of 12 studies (17 arms) with 5660 patients (2260 ACI, 2281 WE, and 1119 WI) were included. A higher proximal adenoma detection rate (risk ratio [RR] 1.30, 95% confidence interval [CI] 1.11-1.53; P=0.001) and right adenoma detection rate (RR 1.43, 95%CI 1.19-1.71; P