Routine rectal retroflexion during colonoscopy has a low yield for neoplasia

Abstract

AIM:To investigate the value of retroflexion in detecting neoplasia in the distal rectum. METHODS:This was a prospective observational study performed in an academic endoscopy unit. Consecutive patients undergoing colonoscopy had careful forward viewing of the distal rectum by retroflexion. Of 1502 procedures, 1076 (72%) procedures were performed with a 140° angle of view colonoscope and 426 (28%) were performed with a 170° angle of view colonoscope. The outcome measurement was the yield of neoplasia in the distal rectum detected by forward viewing vs retroflexion. RESULTS:A total of 1502 patients, including 767 (51%) females and 735 (49%) males, with mean age of 58.8 ± 12.5 years were enrolled. Retroflexion was successful in 1411 (93.9%) patients, unsuccessful or not performed because the rectum appeared narrow in 91 (6.1%). Forty patients had a polyp detected in the distal rectal mucosa. Thirty-three were visible in both the forward and retroflexed view (25 hyperplastic, 8 adenomatous). Seven polyps were visualized only by retroflexion (6 hyperplastic sessile polyps, one 4 mm sessile tubular adenoma). There was no significant difference in information added by retroflexion with 140° vs 170° angle of view instrument. CONCLUSION:To o u r k n o w l e d g e , t h i s i s t h e largest reported evaluation of retroflexion in the rectum. Routine rectal retroflexion did not detect clinically important neoplasia after a careful forward examination of the rectum to the dentate line. Since retroflexion has risks and may cause discomfort, the use of routine retroflexion should be at the discretion of the endoscopist.

UK key performance indicators and quality assurance standards for colonoscopy

“…An increase in yield of 8% was demonstrated in one study,33 with others demonstrating a yield of around 2–2.5% 34–37. Manoeuvre success rates between 94%36 and 100%38 have been reported. Retroversion may rarely cause rectal injury39 40 with the estimated the risk 0.01% 41.…”

Rectal Retroflexion during Colonoscopy: A Bridge over Troubled Water

“…It showed how easily an early-stage cancer in a diminutive colonic polyp can be missed when in difficult areas of straight view 3. However, there stands a controversy that RR has a low yield for adenoma detection, causing the risks to surpass the benefits 7,8. For instance, Quallick and Brown9 reported four cases of rectal perforation in the rectum during RR.…”

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

“…It is commonly believed that the visualization of the hemorrhoids and the distal rectum might be enhanced by rectal retroflexion [81]. However, in the prospective study by Saad and Rex [82], the authors concluded that routine performance of retroflexion has a very low yield for neoplasia and is not routinely required to achieve a highly effective colonoscopy. In that study with 1,052 patients, 7 polyps were visualized only by retroflexion (6 hyperplastic sessile polyps, one 4-mm sessile tubular adenoma) without any clinical impact.…”