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Abstract

Thanks to Dr Rebollo for her comments regarding retroflexion in the rectum during colonoscopy. We agree that rectal retroflexion is an important maneuver that should be performed in nearly all patients and should be photodocumented when it is performed. However, contrary to the reports cited by Rebollo, recent reports have found the yield of rectal retroflexion for neoplasia to be extremely low.1Cutler A.F. Pop A. Fifteen years later: colonoscopic retroflexion revisited.Am J Gastroenterol. 1999; 94: 1537-1538Crossref PubMed Scopus (33) Google Scholar, 2Saad A. Rex D.K. Routine rectal retroflexion during colonoscopy has a low yield for neoplasia.World J Gastroenterol. 2008; 14: 6503-6505Crossref PubMed Scopus (32) Google Scholar The difference in results of recent studies from those of older studies may reside in the performance in recent studies of a systematic forward-viewing examination to the dentate line before retroflexion is initiated. By use of this approach, almost all neoplasia in the distal rectum can be visualized in the forward view, although in some cases it undoubtedly can most easily be characterized, undergo biopsy, resected in retroflexion, or some combination of these. In addition, certainly rectal retroflexion can provide important information about benign anorectal disorders and the cause of symptoms such as hematochezia. The other aspect of rectal retroflexion that needs wider acknowledgement is the perforation risk, which in 1 series accounted for 10% of all colonoscopic perforations.3Quallick M.R. Brown W.R. Rectal perforation during colonoscopic retroflexion: a large, prospective experience in an academic center.Gastrointest Endosc. 2009; 69: 960-963Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Although this is not proven, the perforation risk from retroflexion seems greater when the rectum is narrow from surgery or diseases like chronic ulcerative colitis or radiation injury. Given the low yield of retroflexion for neoplasia in recent studies and reports of perforation, we recommend that a forward view be routinely performed all the way to the dentate line. At that point the size of the rectum should be assessed, and retroflexion performance considered based on visibility of the distal rectum in the forward view, rectal size, the size of the instrument (standard vs pediatric), and the clinical indication for the examination. In the overwhelming majority of cases, retroflexion will be appropriate and safe and should be photodocumented, but in some cases a narrow rectum can be completely photographed in the forward view from the dentate line, and risk can be averted by avoidance of retroflexion. When performed, the retroflexion maneuver requires attention to detail in its technical performance. If rectal size is reduced or resistance to retroflexion is encountered, it seems wise to recheck the rectum in the forward view for evidence of injury before withdrawal of the instrument. Given the low yield of rectal retroflexion for neoplasia and the small risk of perforation, we do not agree that rectal retroflexion is mandatory in every case. However, we acknowledge that if the caveats noted here are taken into account, rectal retroflexion should be performed and photodocumented in the overwhelming majority of colonoscopies. There is currently insufficient evidence for establishing a threshold for rectal retroflexion performance as a quality indicator. If retroflexion is not performed, we recommend a photograph of the rectum in the forward view from the dentate line. Should rectal retroflexion be included as a quality indicator for colonoscopy?Gastrointestinal EndoscopyVol. 82Issue 2PreviewI read with great interest the recently published article by Rex et al1 addressing the topic of quality indicators for colonoscopy. Undoubtedly, it will help us to improve our clinical practice. The authors consider that cecal intubation and its photography must be performed in 90% to 95% of the procedures. However, our attention was drawn to the fact that in neither this issue nor in their first publication about this topic2 is there a reference to rectal retroflexion. Rectal retroflexion is a final maneuver to complete the examination of the colon performed by most colonoscopists. Full-Text PDF