Impact of Retroflexion Vs. Second Forward View Examination of the Right Colon on Adenoma Detection: A Comparison Study

Abstract

OBJECTIVES Although screening colonoscopy is effective in preventing distal colon cancers, effectiveness in preventing right-sided colon cancers is less clear. Previous studies have reported that retroflexion in the right colon improves adenoma detection. We aimed to determine whether a second withdrawal from the right colon in retroflexion vs. forward view alone leads to the detection of additional adenomas. METHODS Patients undergoing screening or surveillance colonoscopy were invited to participate in a parallel, randomized, controlled trial at two centers. After cecal intubation, the colonoscope was withdrawn to the hepatic flexure, all visualized polyps removed, and endoscopist confidence recorded on a 5-point Likert scale. Patients were randomized to a second exam of the proximal colon in forward (FV) or retroflexion view (RV), and adenoma detection rates (ADRs) compared. Logistic regression analysis was used to evaluate predictors of identifying adenomas on the second withdrawal from the proximal colon. RESULTS A total of 850 patients (mean age 59.1±8.3 years, 59% female) were randomly assigned to FV (N=400) or RV (N=450). Retroflexion was successful in 93.5%. The ADR (46% FV and 47% RV) and numbers of adenomas per patient (0.9±1.4 FV and 1.1±2.1 RV) were similar (P=0.75 for both). At least one additional adenoma was detected on second withdrawal in similar proportions (10.5% FV and 7.5% RV, P=0.13). Predictors of identifying adenomas on the second withdrawal included older age (odds ratio (OR)=1.04, 95% confidence interval (CI)=1.01–1.08), adenomas seen on initial withdrawal (OR=2.8, 95% CI=1.7–4.7), and low endoscopist confidence in quality of first examination of the right colon (OR=4.8, 95% CI=1.9–12.1). There were no adverse events. CONCLUSIONS Retroflexion in the right colon can be safely achieved in the majority of patients undergoing colonoscopy for colorectal cancer screening. Reexamination of the right colon in either retroflexed or forward view yielded similar, incremental ADRs. A second exam of the right colon should be strongly considered in patients who have adenomas discovered in the right colon, particularly when endoscopist confidence in the quality of initial examination is low.

Can Technology Improve the Quality of Colonoscopy?

“…Rather than performing a retroflexion, simply doing a second examination of the right colon in forward view can be beneficial. There was a similar gain in adenoma detection whether a second forward view or a second retroflexed view was performed [45]. In a recent prospective study, a second forward view exam increased the overall ADR by 3.2 % and the right colon ADR by 6.7 % [46•].…”

Endoscopic Improvement of the Adenoma Detection Rate during Colonoscopy - Where Do We Stand in 2015?

“…Thus, the value of retroflexion in terms of ADR and higher risk for perforation is limited. Kushnir et al [86] performed a randomized, controlled, 2-center trial in which patients undergoing screening or surveillance colonoscopy were randomized to a second exam of the proximal colon in forward or retroflexion view, and ADRs were compared. The ADR was similar in both groups (p = 0.75) with no significant benefit in favor of retroflexion of the proximal colon.…”

Endocuff assisted colonoscopy significantly increases sessile serrated adenoma detection in veterans

“…Some of these include: high-resolution endoscopic imaging, narrowband endoscopic imaging, wide-angle colonoscopes, high definition colonoscopes, third eye retroscopes, Full Spectrum Endoscopy, balloon assisted colonoscopy (G-Eye), second forward view of the right colon and cecal retroflexion (19,(21)(22)(23)(24). The latest accessory devices in this field are the transparent cap colonoscopy (Endocap) and EC.…”