Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA, USA; West Los Angeles Veterans Affairs Medical Center, Veterans Affairs Greater Los Angeles Healthcare System, West Los Angeles, CA, USA; University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA; Presidio Ospedaliero CTO, Iglesias, Italy; Fourth Military Medical University, Xian, China; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA; Evergreen General Hospital, Taoyuan, Taiwan; Dalin Tzu Chi Hospital, Chiayi, Taiwan; Sacramento Veterans Affairs Medical Center, Mather, CA, USA
aGastroenterology, Medicine, Sepulveda Ambulatory Care Center, Veterans Affairs Greater Los Angeles Healthcare System, North Hills, CA, USA (Felix W. Leung, Vivek Dixit, Nora Jamgotchian, Hui Jia); bGastroenterology, Medicine, West Los Angeles Veterans Affairs Medical Center, Veterans Affairs Greater Los Angeles Healthcare System, West Los Angeles, CA, USA (Felix W. Leung, Vivek Dixit, Noam Jacob, James Sul); cUniversity of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA (Felix W. Leung, Vivek Dixit, Noam Jacob, Angshuman Saha, Holly Wilhalme); dPresidio Ospedaliero CTO, Iglesias, Italy (Sergio Cadoni, Paolo Gallittu, Donatella Mura); eFourth Military Medical University, Xian, China (Long Chen, Hui Jia, Yanglin Pan, Linhui Zhang); fVeterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA (Yu Chen, Ramsey Cheung, Shai Friedland, Jennifer Yi-Jiun Pan, Susan Y. Quan, Robert J. Wong); gEvergreen General Hospital, Taoyuan, Taiwan (Chi-Liang Cheng, Yen-Lin Kuo, Bai-Ping Lee, Yi-Ning Tsui); hDalin Tzu Chi Hospital, Chiayi, Taiwan (Yu-Hsi Hsieh, Chia Hsin Cheng, Chih-Wei Tseng); iSacramento Veterans Affairs Medical Center, Mather, CA, USA (Joseph W. Leung, Aliya Shaikh, Andrew W. Yen)
We thank Coşkun et al [1] for their opinion about our publication [2] in which we indicated that “The combination of water exchange with these selected caps is new, and the findings should be confirmed in further studies before their use is recommended for performance improvement to increase ADR and APC” [2].
Response to point 1: P-value is at the borderline, and the result is not strong. When the study was planned (around 2016), there were no published data on the efficacy of Endocuff Vision (ECV) with water exchange. Given that our study was one of the first set of trials involving water exchange and ECV, though not necessarily conclusive, the borderline result was worthy of mention. “To generate pilot data for further studies … ECV was included to preserve committed coinvestigators’ participation to ensure adequate recruitment of No cap and SC patients”, when the use of Daisycuff was disapproved by the local institutional review board at 2 sites.
Response to point 2: While we acknowledge that it was not a stated goal, Fuccio et al [3] reported that water exchange significantly increased overall ADR, ADR in screening cases, and in the right side of the colon. Their meta-analysis was published after we completed our study planning and motivated us to report this finding. We may not have been aware of this specific interest at the time of planning the study.
Response to point 3: We are aware that there were differences in withdrawal time between centers. They were consistent with literature data, as we pointed out in the Discussion “All withdrawals exceeded 9 min [4] and were close to 13 min” [5]. The longer time was not deliberate, due to additional inspection or additional steps in searching for adenoma, etc. There was no a priori cause.
1. Coşkuna S, Hoshikab S, Bannob M. Methodological concerns in evaluating water exchange combined with distal attachments for adenoma detection. Ann Gastroenterol 2026;39:378.
2. Leung F, Cadoni S, Chen L, et al, A prospective international multisite randomized controlled trial of water exchange with and without distal cap(s) in adenoma detection. Ann Gastroenterol 2026;39:104-113.
3. Fuccio L, Frazzoni L, Hassan C, et al. Water exchange colonoscopy increases adenoma detection rate:a systematic review with network meta-analysis of randomized controlled studies. Gastrointest Endosc 2018;88:589-597.
4. Zhao S, Yang X, Wang S, et al. Impact of 9-minute withdrawal time on the adenoma detection rate:a multicenter randomized controlled trial. Clin Gastroenterol Hepatol 2022;20:e168-e181.
5. Desai M, Rex DK, Bohm ME, et al. Impact of withdrawal time on adenoma detection rate:results from a prospective multicenter trial. Gastrointest Endosc 2023;97:537-543.