Additional Polyp Detection Rate Using Colonoscopic Retroflexion in Right Colon

Heung Up Kim; Sun-Jin Boo; Soo-Young Na; Hyun Joo Song

doi:10.4166/kjg.2015.65.2.90

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Kim, Boo, Na, and Song: Additional Polyp Detection Rate Using Colonoscopic Retroflexion in Right Colon

Original Article

Korean J Gastroenterol 2015;65(2):90-98.

Published online: 4 October 2015

DOI: https://doi.org/10.4166/kjg.2015.65.2.90

Additional Polyp Detection Rate Using Colonoscopic Retroflexion in Right Colon

Heung Up Kim, Sun-Jin Boo, Soo-Young Na, Hyun Joo Song

Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea

Correspondence to: Heung Up Kim, Department of Internal Medicine, Jeju National University Hospital, 15 Aran 13-gil, Jeju 690-767, Korea. Tel: +82-64-717-1130, Fax: +82-64-717-1131, E-mail: Kimhup@jejunu.ac.kr

Received 2 November 201415 December 2014 Accepted 16 December 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims

There have been several studies showing that retroflexion (RF) in the right colon (RC) could reduce the polyp miss rate of proximal colon during colonoscopy. This study was conducted to evaluate the additional benefit of RF technique in the RC.

Methods

Patients who underwent colonoscopy from May 2008 to April 2011 were enrolled in the study. Data were obtained by retrospectively reviewing the medical records. RF was attempted in every patients undergoing colonoscopy since May 2008 except in cases of small RC vault, co-morbidity, severe diverticulosis, failed RF despite two trials, complaints of severe abdominal pain, or time burden. At first, RC was examined under direct vision. It was then examined by RF to detect missed polyps during the initial observation. Finally, the RC was re-examined with direct view.

Results

The cumulative RF success rate in the RC was 78.84% (1,805 of 2,319). The RF success rate increased with the number of cases (50% at 160 cases, 70% at 400 cases, and reached near 90% over 1,000 cases). Few polyps (4.88%) were detected only with RF and the additional adenoma detection rate was 3.32%. The additional polyp/adenoma detection rates were higher in the old age group (p<0.01). There were no RF associated perforation or severe complication.

Conclusions

Using RF examination, additional 4.88% of polyps could be detected in the RC. This technique could be a useful and safe method to detect hidden polyp during colonoscopy.

Keywords: Ascending colon, Colonic polyps, Colorectal neoplasms, Diagnostic errors, Retroflexion

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Fig. 1.

The fluoroscopic X-ray shows retroflexed tip of colonoscope in the right colon.

Fig. 2.

The grade of retroflexion in the right colon. (A) Grade 1, less than two haustral folds are seen. (B) Grade 2, 3–4 haustral folds are seen.(C) Grade 3, more than five haustral folds are seen as full circumference and straight lumen.

Fig. 3.

The learning curve of retroflexion (RF) of colonoscope in right colon. The RF success rates improved with increasing number of cases. The RF success rate was 50% at the point of 160 cases. At 400 cases, the rate improved to 70%, and then reached 90% after 1,000 cases.

Fig. 4.

A case of advanced colon cancer detected by retroflexion of colonoscope in the proximal portion of remnant colon. The patient was 69-year-old female who underwent right hemicolectomy for colon cancer one year ago. (A) The lesion could not be detected by direct vision. (B) During retroflexion, about 1 cm sized IIa+IIc lesion was clearly detected. After rescue surgery, the lesion confirmed to be well differentiated adenocarcinoma with proper muscle invasion.

Table 1.

Comparison of Retroflexion (RF) ^a Success and Failure Group

	RF success	RF failure	Total	p-value
Patient	1,805 (78.84)	514 (21.16)	2,319
Age (yr)	57.03±12.67	60.68±13.06	57.84±12.84	<0.01
Sex				0.58
Male	1,124 (77.46)	327 (22.54)	1,451 (62.57)
Female	681 (78.46)	187 (21.54)	868 (37.43)
Insertion time ^b,c (min)	4.86±2.93	6.84±5.19	5.16±3.44	<0.01

Values are presented as n (%) or mean±SD.

^a RF of colonoscope in the right colon;

^b cecal intubation time.

^c RF success: n=1,457, RF failure: n=258, total: n=1,715.

Table 2.

Analysis of the Success Cases of Retroflexion (RF) in the Right Colon and RF Polyps according to Sex and Age Group

Variable	Total	Sex			Age group (yr)
Variable	Total	Male	Female	p-value	<60	≥60	p-value
Patient	1,805	1,124 (62.27)	681 (37.72)		942 (52.19)	862 (47.76)
Age (yr)	57.03±12.67	57.25±12.43	56.67±13.06	0.35	47.37±9.02	67.59±5.78
Grade of RF ^a
Grade 1	192 (10.64)	114 (10.14)	78 (11.45)	0.02	93 (9.87)	99 (11.48)	<0.01
Grade 2	919 (50.91)	549 (48.84)	370 (54.33)		452 (47.98)	467 (54.18)
Grade 3	694 (38.45)	461 (41.01)	223 (32.75)		397 (42.14)	297 (34.45)
RF PDR ^b	88 (4.88)	57 (5.07)	31 (4.55)	0.73	26 (2.76)	62 (7.19)	<0.01
RF PDR by grade ^c
Grade 1	9 (0.50)	6 (0.53)	3 (0.44)	0.423	5 (0.53)	4 (0.46)	0.046
Grade 2	43 (2.38)	25 (2.22)	18 (2.64)		8 (0.85)	35 (4.06)
Grade 3	36 (1.99)	26 (2.31)	10 (1.47)		13 (1.38)	23 (2.67)
Number of RF polyp ^d
1	83 (4.60)	55 (4.89)	28 (4.11)	0.18	26 (2.76)	57 (6.61)	0.33
2	4 (0.22)	1 (0.09)	3 (0.44)		0	4 (0.46)
3	1 (0.06)	1 (0.09)	0		0	1 (0.12)
RF ADR ^b	60 (3.32)	39 (3.47)	21 (3.08)	0.64	17 (1.80)	43 (4.99)	<0.01
RF ADR by grade ^c
Grade 1	7 (0.39)	4 (0.36)	3 (0.44)	0.41	4 (0.42)	3 (0.35)	0.07
Grade 2	26 (1.44)	15 (1.33)	11 (1.62)		4 (0.42)	22 (2.55)
Grade 3	27 (1.50)	20 (1.78)	7 (1.03)		9 (0.96)	18 (2.09)
Size of RF polyp ^e	4.5±2.4	4.8±2.5	4.3±2.2	0.36	4.5±2.4	4.6±2.3	0.9
Distal	32 (1.77)	23 (2.05)	9 (1.32)	0.54	11 (1.17)	21 (2.44)	0.25
Mid	53 (2.94)	32 (2.85)	21 (3.08)		11 (1.17)	42 (4.87)
Proximal	10 (0.55)	6 (0.53)	4 (0.59)		4 (0.42)	6 (0.70)
Total	95 (5.26)	61 (5.43)	34 (4.99)		26 (2.76)	69 (8.00)
Histology of RF polyp ^e
HPP	31 (1.72)	20 (1.78)	11 (1.62)	0.11	9 (0.96)	22 (2.25)	0.81
LGD	53 (2.94)	33 (2.94)	20 (2.94)		14 (1.49)	39 (4.52)
HGD	9 (0.50)	8 (0.71)	1 (0.15)		3 (0.32)	6 (0.70)
Cancer	2 (0.11)	0	2 (0.29)		0	2 (0.23)

Values are presented as n (%) or mean±SD.

RF polyp/adenoma, the polyp or adenoma only detected by retroflexion of colonoscope in the right colon; ADR, adenoma detection rate; PDR, polyp detection rate; HPP, hyperplastic polyp; LGD, tubular adenoma with low grade dysplasia (including sessile serrated adenoma); HGD, tubular adenoma with high grade dysplasia; Cancer, all case of adenocarcinoma.

^a Grade 1, less than 2 folds are seen; Grade 2, 3–4 haustral folds are seen as full circumference; Grade 3, more than 5 haustral folds are seen as full circumference and straight lumen.

^b Additional adenoma or polyp detection rate in right colon by retroflexion of colonoscope.

^c The number of RF polyp or adenoma detected in each grade of retroflexion.

^d The number of RF polyp detected in single person.

^e The number in the blank is calculated as a percentage of the number of polyps in each group.

Table 3.

Characteristics of the Retroflexion (RF) Polyps according to Site in the Right Colon

	Total	Distal	Mid	Proximal	p-value
Number of RF polyp	95	32	53	10
Size of RF polyp (mm)	4.5±2.6	5.2±2.4	4.2±2.1	4.7±2.9	0.15
Histology of RF polyp
HPP	31 (32.63)	11 (34.38)	19 (35.85)	1 (10.00)	0.09
LGD	53 (55.79)	14 (43.75)	30 (56.60)	9 (90.00)
HGD	9 (9.47)	5 (15.63)	4 (7.55)	0
Cancer	2 (2.11)	2 (6.25)	0	0

Values are presented as n only, mean±SD, or n (%).

RF polyp/adenoma, the polyp or adenoma only detected by retroflexion of colonoscope in the right colon; HPP, hyperplastic polyp; LGD, tubular adenoma with low grade dysplasia (including sessile serrated adenoma); HGD, tubular adenoma with high grade dysplasia; Cancer, all case of adenocarcinoma.

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