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Routine intubation is performed. After cecal intubation, the cecum and ascending colon is examined with colonoscope tip in forward direction for the first time. Re-intubation is performed after the first examination of the cecum and ascending colon, and then this region of the large bowel is re-examined in the same fashion. After that, the rest of the colon is examined in routine method.

Routine intubation is performed. After cecal intubation, the cecum and ascending colon is examined with colonoscope tip in forward direction for the first time. Re-intubation is performed after the first examination of the cecum and ascending colon, and then this region of the large bowel is re-examined with the colonoscope tip in reverse direction (retroflexion fashion). After that, the rest of the colon is examined in routine method.

Retroflexion technique in colonoscopy means turning the colonoscope tip 180 degree in order to look backward in the colon and rectum.

Retroflexion

Re-examination in colonoscopy means examining the cecum and ascending colon twice in the routine fashion.

Re-examination

En-Da YU, MBBS

Zi-Ye ZHAO, MD

Chu-Jun LI, MBBS

Ping-Hong ZHOU, MD

Wen LI

The primary aim of this study is

- to explore the usefulness of re-examination and retroflexion on adenoma miss rate (AMR) in the proximal colon.

Other aims include to explore the data below when re-examination or retroflexion is used.

* Adenoma detection rate, ADR
* Polyp miss rate, PMR
* Polyp detection rate, PDR
* Withdrawal time, WT

AMR = number of adenomas missing during the first examination/ total number of adenomas in both examinations = number of adenomas detected only in the second examination/(number of adenomas detected during the first examination + number of adenomas detected only in the second examination)

Examining Techniques on Adenoma Miss Rate in Proximal Colon

Efficacy of Segmental Re-examination and Retroflexion of Proximal Colon for Adenoma Miss Rate During Colonoscopy

AMR refers to the rate of adenoma missing, calculated as the proportion of adenomas which are missing in the first examination. AMR in the proximal colon is calculated with only the proximal colon concerned.

ADR refers to the rate of adenoma detection, calculated as the proportion of subjects with at least one adenoma. ADR in the proximal colon is calculated with only the proximal colon concerned.

Changhai Hospital

Director of Department of Colorectal Surgery and Vice Director of GI Endoscopy

Inclusion criteria were as follows: Patients older than 18 years, with a complete colonoscopy, for CRC screening or post-polypectomy surveillance or diagnostic assessment. Exclusion criteria precluded patients with previous colectomy or an abdominal surgery in the last 6 months, patients with polyposis syndromes or inflammatory bowel diseases and if they were unfit for polypectomy or the polyp specimen was not retrieved for histology.

Prospective evaluation of an every day technique (retroflexion) used in our department for many years. The protocol of ascending colon examination encompassed 2 phases: A first phase (1) divided in Forward view (1a) videlicet insertion from the right flexure to the caecum followed by a second forward view (1b) namely withdrawal till the right flexure and reinsertion to the caecum maintaining the endoscope straight and a second phase (2, Retroflexion) with U-turn of the colonoscope in the caecum till the right flexure and then redressing to the forward view and reinsertion to the caecum.

Retroflexion in the Right Colon

Missing polyps during colonoscopy is considered an important factor for interval cancer appearance especially in the ascending colon (AC). Aim of the study: To evaluate the contribution of retroflexion to adenoma detection in the AC. Patients-Methods: Prospective observational study included consecutive patients with complete colonoscopy between June 2017 and June 2018. The AC was examined in two phases. The first phase included two forward views from the hepatic flexure to the cecum and the second phase a retroflexion in the cecum, inspection till the hepatic flexure then redressing to forward view and reinsertion to the cecum.

We prospectively evaluated for polyp detection in the ascending colon a cohort of consecutive patients addressed (intended) for complete colonoscopy in Alexandra University Hospital, Athens, Greece for a predetermined period (June 2017-June 2018). All colonoscopies were performed under conscious sedation by using midazolam and/or propofol and continuous monitoring for vital signs. The type of endoscopes used were adult high definition, with variable stiffness, colonoscopes Olympus Evis Exera CF-H185 and 190. Insufflation was performed by means of a CO2 insufflator (OLYMPUS - UCR). An irrigation pump (OLYMPUS - OFP2) was used if needed, either for washing or for water exchange technique according to the endoscopist judgement. Oral sodium and potassium sulphate in combination (Eziclen®) or PEG solutions (Klean Prep® or Fortrans®) were used for bowel preparation which was measured by means of the Segmental Boston Bowel Preparation Scale. Inclusion criteria were as follows: Patients older than 18 years, with a complete colonoscopy, for CRC screening or post-polypectomy surveillance or diagnostic assessment. Exclusion criteria precluded patients with previous colectomy or an abdominal surgery in the last 6 months, patients with polyposis syndromes or inflammatory bowel diseases and if they were unfit for polypectomy or the polyp specimen was not retrieved for histology. The protocol of ascending colon examination encompassed 2 phases: A first phase (1) divided in Forward view (1a) videlicet insertion from the right flexure to the caecum followed by a second forward view (1b) namely withdrawal till the right flexure and reinsertion to the caecum maintaining the endoscope straight and a second phase (2, Retroflexion) with U-turn of the colonoscope in the caecum till the right flexure and then redressing to the forward view and reinsertion to the caecum.

Concerning endoscopy 2 seniors and 4 trainees participated in the study. All colonoscopies were performed with at least 2 operators, one senior and one trainee. The main investigator, the most experienced endoscopist in the department was present during all the procedures for the ascending colon examination (SM). Only 3 attempts were permitted for retroflexion achievement, performed by the main investigator if a younger trainee or senior gastroenterologist could not perform it. Polyps were mapped during both phases and were not removed until the end of the inspection. Polypectomy followed according to the previous mapping and all polyps were collected and sent for histological examination. The protocol of this non-interventional study as well as the informed consent for the patients were submitted and approved by the local ethical committee.

Adenoma detection rate (ADR) was defined as the number of colonoscopies in which one or more adenomas were detected, divided by the total number of colonoscopies. ADR in the ascending colon as the number of colonoscopies with at least one adenoma in the ascending colon divided by the total number of colonoscopies. Adenoma miss rate (AMR) of the ascending colon was defined as the number of additional adenomas in ascending colon detected by retroflexed view divided by the total adenomas in ascending colon detected with two forward and retroflexion views. The per-patient miss rate was calculated as the number of patients with additional adenomas detected on retroflexion divided by the total number of patients who underwent the examination.

Finally we evaluated two additional quality parameters in order to assess the contribution of retroflexion in adenoma detection: adenomas per colonoscopy (APC) calculated by dividing the number of detected adenomas by the total number of colonoscopies and adenomas per positive participant (APP) calculated by dividing the number of detected adenomas by the number of colonoscopies in which at least 1 adenoma was detected.

Retroflexion In The Ascending Colon Is A Costless Endoscopic Maneuver Increasing Adenoma Detection Rate

adenoma miss rate by performing systematically a retroflexion after a second forward view in the ascending colon and evaluate the additional gain in adenoma detection

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization	Link
Examining Techniques on Adenoma Miss Rate in Proximal Colon	NCT03355443	Colorectal Aden... Colorectal Poly...	Retroflexion Re-examination	45 Years - 80 Years	Changhai Hospital
Retroflexion In The Ascending Colon Is A Costless Endoscopic Maneuver Increasing Adenoma Detection Rate	NCT04086706	Colonoscopy Adenoma Detecti... Adenoma Miss Ra... Retroflexion	Retroflexion in...	18 Years -	Alexandra Hospital, Athens, Greece

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