Seeing better - Evidence based recommendations on optimizing colonoscopy adenoma detection rate

Table 1 Techniques that have demonstrated improve adenoma detection rate

	Evidence	Limitations	Comments
Adequate bowel preparation	RCT and meta-analysis		Split-dose may have a positive impact itself on ADR
			No significant differences from fair to excellent bowel preparation
Withdrawal time	Retrospective	Some contradictory data, maybe reflecting that it is an intermediate parameter	Withdrawal time needs to be productively spent
			Likely more impact on low ADR endoscopists
Repeat right colon exploration or retroflexion	Prospective	Unclear if retroflexion preferable to forward view
Additional observers	Prospective	Heterogeneity in the type of observer	Marginal benefit, especially helpful if observers experienced
High definition endoscopy	RCT and one meta-analysis	Discrete effect for ADR, more significant for flat and right colonic lesions. Heterogeneity of the studies	ESGE recommends its use if available in average-risk screening colonoscopies
Position changes	Prospective, randomized	Unclear if the benefit is from seeing the colon segments twice
Water exchange	RCT	Slight impact on ADR	Most helpful to detect right colonic lesions
		Procedure time may confound results

ADR: Adenoma detection rate; ESGE: European Society of Gastrointestinal Endoscopy; RCT: Retrospective cohort study.