Sessile serrated adenoma/polyp detection rate of water exchange, Endocuff, and cap colonoscopy: A network meta-analysis

J Gastroenterol Hepatol. 2021 Dec;36(12):3268-3277. doi: 10.1111/jgh.15702. Epub 2021 Oct 25.


Background and aim: Sessile serrated adenoma/polyp (SSA/P) may contribute to interval cancer. In a recent meta-analysis, water exchange (WE) was shown to be superior to Endocuff and cap colonoscopy at adenoma and advanced adenoma detection. The strong positive correlation between adenoma detection rate (ADR), advanced adenoma detection rate (AADR), and sessile serrated adenoma/polyp detection rate (SSA/PDR) prompted us to hypothesize that WE could significantly improve SSA/PDR compared with Endocuff and cap colonoscopy.

Methods: The literature was searched for all randomized controlled trials (RCTs) that reported SSA/PDR as an outcome and included the keywords colonoscopy, and water exchange, Endocuff, or cap. We performed traditional network meta-analyses with random effect models comparing SSA/PDR of each method using air insufflation as the control and reported the odds ratios (ORs) with 95% confidence interval (CI). Performances were ranked based on P-score.

Results: A total of 531 articles resulted from initial keywords search. Eleven RCTs were included in the analysis. A total of 7856 patients underwent air insufflation, WE, Endocuff, or cap colonoscopy. WE significantly increased SSA/PDR (OR 2.04; 95% CI 1.33-3.13). Endocuff (OR 1.15; 95% CI 0.94-1.41) and cap (OR 1.08; 95% CI 0.42-2.74) did not significantly impact SSA/P detection. P-scores for WE (0.96), Endocuff (0.49), cap (0.37), and air insufflation (0.17) suggested that WE had the highest SSA/PDR. The results did not change after adjusting for mean withdrawal time and indication for colonoscopy.

Conclusion: Water exchange significantly increases SSA/PDR and is superior to Endocuff and cap colonoscopy at detecting SSA/P.

Keywords: Endocuff; air insufflation; cap colonoscopy; sessile serrated adenoma, sessile serrated polyp, sessile serrated adenoma/polyp detection rate (SSA/PDR); water exchange (WE).

Publication types

  • Meta-Analysis

MeSH terms

  • Adenoma* / diagnosis
  • Adenoma* / pathology
  • Colonic Polyps* / diagnosis
  • Colonic Polyps* / pathology
  • Colonoscopy / instrumentation
  • Colonoscopy / methods*
  • Humans
  • Network Meta-Analysis
  • Precancerous Conditions / diagnosis
  • Precancerous Conditions / pathology
  • Water


  • Water