Editor's Corner

Introduction to the third issue

Volume 1, Issue 3   July/August/September 2011
Page 96
Authors: Felix W. Leung and Joseph W. Leung

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Abstract:

Welcome to the third issue of the Journal of Interventional Gastroenterology. In this issue, it is exciting to see the work related to the teaching, learning and outcome of water method for colonoscopy unfolding. This is particularly germane to the discussion of present-day colonoscopy training and improving the quality of colorectal cancer screening by optical colonoscopy. We learn from all our professional society guidelines and recommendations authored by leading experts that perhaps colonoscopy training in the past was suboptimal in many training programs. Experts are needed to point out that quality colonoscopy involves comprehensive documentation: pre-procedure risk assessment; depth of insertion of the colonoscope; quality of the bowel preparation; complete description of the polyps found, including the location of each polyp, size, number and gross morphology; and recommendations for follow up. Much less has been said about the actual methodological improvement needed to enhance the quality of the actual performance of colonoscopy. The reports on the water method have highlighted the difference between conventional air insufflation and the innovative water method – not merely as a convenient air-water hybrid, or the literal interpretation of water replacing air to distend the colon as in water immersion. Air insufflation could lengthen the colon and exaggerate angulations at the flexures making colonoscopy difficult. This was why significant emphasis was placed on minimal air insufflation in the past by leading experts. On the other hand, water exchange is an essential part of the water infusion in lieu of air insufflation method which facilitates local viewing with minimal distension to aid scope insertion. Once understood, the water method is easy, simple and inexpensive. However, it does require active learning by novice (or re-learning by experienced colonoscopist) and repeat practice to master the essential skills. Coaching provided by an experienced endoscopist during initial clinical performance may help to shorten the learning process. A number of published randomized controlled studies comparing the water immersion method with usual air insufflation indicated a significant reduction of pain and sedation medication used and an increase in the proportion of patients completing unsedated colonoscopy. The significant difference is even more dramatic when water exchange was employed. There are also data to indicate that water exchange is crucial to the benefits of the water method in improving adenoma detection rate which could be variable or even significantly decreased by water immersion. Whether the water method alters the outcome of colorectal cancer screening (particularly in the right colon) will have to await longer term studies. It behooves the colonoscopy community worldwide to support evaluation of this important clinical research question, especially if there are concerns that optical colonoscopy could lose ground to other novel technologies. The Journal has started a new section on rapid communication which allows investigators to report their findings on novel ideas or techniques that hold promise of impact on clinical management as well as opening up new avenues for investigations.

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