Intest Res.  2015 Oct;13(4):326-331. 10.5217/ir.2015.13.4.326.

Is Retroflexion Helpful in Detecting Adenomas in the Right Colon?: A Single Center Interim Analysis

• Lee HS
• Jeon SW

• KMID: 2070748
• DOI: http://doi.org/10.5217/ir.2015.13.4.326

Abstract

BACKGROUND/AIMS
Colonoscopy is less effective at screening for colorectal cancer in the right side of the colon. Retroflexion during colonoscopy is expected to improve the detection rate of colorectal adenomas. The aim of the present study was to evaluate the usefulness of retroflexion in the right-sided colon.
METHODS
From April to November 2013, a total of 398 patients were enrolled in this study. For each patient, a cap-assisted colonoscopic examination was performed. After cecal intubation, a forward view examination from the cecum up to the hepatic flexure was performed and all identified polyps were removed. The colonoscope was reinserted to the cecum, and a careful second forward view examination of the cecum to the hepatic flexure was performed, with removal of additionally identified polyps. The colonoscope was then reinserted to the cecum and retroflexed; a third colonoscopic examination was then performed to the hepatic flexure in retroflexion with removal of additional polyps. Total polyp numbers and characteristics were compared between the two forward view examinations and the retroflexion examination.
RESULTS
A successful retroflexion was performed in 90.2% of patients. A total of 213 polyps and 143 adenomas were detected in the right-sided colon using the routine method of examining the right colon twice in forward view. An additional 35 polyps and 24 adenomas were detected on retroflexion. Of these 35 polyps, 27 (77.1%) were small-sized polyps (< or =5 mm) and 24 (71.4%) were adenomas. Finding additional adenomas using the retroflexion technique was associated with older age.
CONCLUSIONS
Colonoscopic retroflexion is helpful in the detection of cecum and ascending colon adenomas, especially small-sized adenomas (< or =5 mm). It is particularly useful in older patients.

Keyword

Retroflexion; Colonoscopy; Adenoma

MeSH Terms

Adenoma*
Cecum
Colon*
Colon, Ascending
Colonoscopes
Colonoscopy
Colorectal Neoplasms
Humans
Intubation
Mass Screening
Polyps

Reference

1. Rex DK, Johnson DA, Lieberman DA, Burt RW, Sonnenberg A. Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. American College of Gastroenterology. Am J Gastroenterol. 2000; 95:868–877. PMID: 10763931.

2. Manser CN, Bachmann LM, Brunner J, Hunold F, Bauerfeind P, Marbet UA. Colonoscopy screening markedly reduces the occurrence of colon carcinomas and carcinoma-related death: a closed cohort study. Gastrointest Endosc. 2012; 76:110–117. PMID: 22498179.

3. Chun CG, Kim HG, Jeon SR, Ko BM, Lee BH, Kim JO. Analysis of colonoscopy quality in clinical practices of Korea: cohort study of patients referred to tertiary hospital after colonoscopy examinations. Intest Res. 2013; 11:198–203.

4. Deenadayalu VP, Chadalawada V, Rex DK. 170 degrees wide-angle colonoscope: effect on efficiency and miss rates. Am J Gastroenterol. 2004; 99:2138–2142. PMID: 15554993.

5. van Rijn JC, Reitsma JB, Stoker J, Bossuyt PM, van Deventer SJ, Dekker E. Polyp miss rate determined by tandem colonoscopy: a systematic review. Am J Gastroenterol. 2006; 101:343–350. PMID: 16454841.

6. Rex DK. Maximizing detection of adenomas and cancers during colonoscopy. Am J Gastroenterol. 2006; 101:2866–2877. PMID: 17227527.

7. Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. N Engl J Med. 2006; 355:2533–2541. PMID: 17167136.

8. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rates. Gastrointest Endosc. 2000; 51:33–36. PMID: 10625792.

9. Hanson JM, Atkin WS, Cunliffe WJ, et al. Rectal retroflexion: an essential part of lower gastrointestinal endoscopic examination. Dis Colon Rectum. 2001; 44:1706–1708. PMID: 11711746.

10. Cutler AF, Pop A. Fifteen years later: colonoscopic retroflexion revisited. Am J Gastroenterol. 1999; 94:1537–1538. PMID: 10364021.

11. Harrison M, Singh N, Rex DK. Impact of proximal colon retroflexion on adenoma miss rates. Am J Gastroenterol. 2004; 99:519–522. PMID: 15056095.

12. Kwon SC, Choi SW, Choi SH, et al. The effect of indigocarmine on improvement of the polyp detection rate during colonoscopic examination with hood cap. Intest Res. 2014; 12:60–65. PMID: 25349565.

13. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Am J Gastroenterol. 2006; 101:873–885. PMID: 16635231.

14. Winawer SJ, Zauber AG, Ho MN, et al. Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med. 1993; 329:1977–1981. PMID: 8247072.

15. Lakoff J, Paszat LF, Saskin R, Rabeneck L. Risk of developing proximal versus distal colorectal cancer after a negative colonoscopy: a population-based study. Clin Gastroenterol Hepatol. 2008; 6:1117–1121. PMID: 18691942.

16. Singh H, Nugent Z, Demers AA, Kliewer EV, Mahmud SM, Bernstein CN. The reduction in colorectal cancer mortality after colonoscopy varies by site of the cancer. Gastroenterology. 2010; 139:1128–1137. PMID: 20600026.

17. Singh H, Nugent Z, Mahmud SM, Demers AA, Bernstein CN. Predictors of colorectal cancer after negative colonoscopy: a population-based study. Am J Gastroenterol. 2010; 105:663–673. PMID: 19904239.

18. Hetzel JT, Huang CS, Coukos JA, et al. Variation in the detection of serrated polyps in an average risk colorectal cancer screening cohort. Am J Gastroenterol. 2010; 105:2656–2664. PMID: 20717107.

19. Soetikno RM, Kaltenbach T, Rouse RV, et al. Prevalence of nonpolypoid (flat and depressed) colorectal neoplasms in asymptomatic and symptomatic adults. JAMA. 2008; 299:1027–1035. PMID: 18319413.

20. Westwood DA, Alexakis N, Connor SJ. Transparent cap-assisted colonoscopy versus standard adult colonoscopy: a systematic review and meta-analysis. Dis Colon Rectum. 2012; 55:218–225. PMID: 22228167.

21. Ng SC, Tsoi KK, Hirai HW, et al. The efficacy of cap-assisted colonoscopy in polyp detection and cecal intubation: a meta-analysis of randomized controlled trials. Am J Gastroenterol. 2012; 107:1165–1173. PMID: 22664471.

22. Hurlstone DP, Cross SS, Slater R, Sanders DS, Brown S. Detecting diminutive colorectal lesions at colonoscopy: a randomised controlled trial of pan-colonic versus targeted chromoscopy. Gut. 2004; 53:376–380. PMID: 14960519.

23. Pohl J, Schneider A, Vogell H, Mayer G, Kaiser G, Ell C. Pancolonic chromoendoscopy with indigo carmine versus standard colonoscopy for detection of neoplastic lesions: a randomised two-centre trial. Gut. 2011; 60:485–490. PMID: 21159889.

24. Hirata M, Tanaka S, Oka S, et al. Magnifying endoscopy with narrow band imaging for diagnosis of colorectal tumors. Gastrointest Endosc. 2007; 65:988–995. PMID: 17324407.

25. Inoue T, Murano M, Murano N, et al. Comparative study of conventional colonoscopy and pan-colonic narrow-band imaging system in the detection of neoplastic colonic polyps: a randomized, controlled trial. J Gastroenterol. 2008; 43:45–50. PMID: 18297435.

26. Hewett DG, Rex DK. Miss rate of right-sided colon examination during colonoscopy defined by retroflexion: an observational study. Gastrointest Endosc. 2011; 74:246–252. PMID: 21679946.