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Repeat exam of right colon with retroflexed, forward views achieved comparable adenoma detection
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PHILADELPHIA — Adenoma detection rates in patients undergoing colonoscopy for colorectal cancer screening were similarly improved with a second examination of the right colon in either retroflexed or forward view, according to new data presented at the ACG Annual Scientific Meeting.
“We all know that colonoscopy is the gold standard screening test for colorectal cancer,” Vladimir M. Kushnir, MD, division of gastroenterology at Washington University School of Medicine, said in a presentation. “However, while colonoscopy provides excellent protection against cancers in the distal colon, multiple recent studies have shown [on] the right side of the colon, cancer protection is lacking.”
Vladimir M. Kushnir
According to the researchers, the aim of the study was to directly compare the clinical yield of reexamining the right colon in retroflexion vs. forward view as measured by incremental adenoma detection rates during routine screening and surveillance colonoscopy performed by a relatively diverse group of endoscopists.
Kushnir and colleagues performed a parallel, randomized control trial of 850 patients (mean age 59.1 years, 59% women) undergoing screening or surveillance colonoscopy performed by one of 10 endoscopists at two centers. After initial cecal intubation followed by visualized polyp removal, the patients were randomly assigned to receive a second exam of the proximal colon in either forward view (FV; n=400) or retroflexion view (RV; n=450). Subsequent adenoma detection rates were compared.
Retroflexion was achieved in 93.5% of the RV group, and at least one adenoma was detected in 46% of the FV group compared with 47% of the RV group (P=.69). Mean number of adenomas detected per patient was 0.9 ± 1.4 in the FV group, compared with 1.1 ± 2.1 in the RV group (P=.69). At least one additional adenoma was detected on second exam in 10.5% in the FV group compared with 7.5% in the RV group (P=.13). Factors that were predictive of additional adenoma detection on second withdrawal were older age (OR=1.04; 95% CI, 1.01-1.08), adenomas detected on first withdrawal (OR=2.8; 95% CI, 1.7-4.7) and low confidence in quality of first exam of the right colon as reported by the endoscopist (OR=4.8; 95% CI, 1.9-12.1). No adverse events occurred.
“We found that reexamination of the right colon in retroflexion and forward [views] yield similar incremental adenoma detection [rates] during routine screening and surveillance colonoscopy,” Kushnir concluded. “Moreover, retroflexion is feasible in the right colon in over 90% of patients undergoing screening endoscopy, and is safe.”
For more information:
Kushnir VM. Abstract 8. Presented at: ACG Annual Scientific Meeting, Oct. 20-22, 2014; Philadelphia, PA.
Disclosure: Kushnir reports no relevant financial disclosures.
Perspective
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John Saltzman, MD
This study looks at a very important issue, which is quality of colonoscopy exams and completeness of removal of adenomas. We know it is absolutely important for us to be able to detect and remove all polyps in order to prevent colon cancer, and have a high quality examination. Unfortunately we also know that with current colonoscopy techniques we still do not detect all polyps, particularly on the right side of the colon, and there are a variety of techniques being looked at to see if we can further increase our adenoma detection rates, or polyp detection rates in this area.
This is a really clever trial, in which over 800 patients were assigned to a standard colonoscopy, after which the endoscopist withdrew the instrument back to the hepatic flexure, then did a second look. Patients were randomized to one of two arms, one of which was a forward view second look similar to what was done initially, and the second was a retroflex view, which has been talked about a lot in the right side of the colon. They looked at the additional adenomas detected and, interestingly, in both groups there were additional adenomas, up to 10% or so with the forward view and 7.5% in the retroflex view, but these were similar to one another.
This study shows us that we can detect polyps that we missed during standard colonoscopy by just doing a simple maneuver, which could be as simple as going back and looking again with the scope in a forward viewing manner, or retroflexing; each seems to be acceptable.
This study may change how we do things; it certainly points out that we probably need to slow down on the right side of the colon, and either take much longer than what we are currently using in the right side for inspections — say twice as long — or that we should do as the authors did and do a second examination of the right colon either with the forward view or the retroflex view, to be sure that we discover and remove all polyps, and that we give a quality colonoscopy examination.Click Here to Manage Email Alerts