Evaluating colonoscopy retroflexion in practice

A colonoscopy maneuver to better detect polyps in the right colon is often poorly preformed in practice, according to a Northwestern Medicine study published in BMC Gastroenterology. This finding and other recommendations were discussed in a clinical practice update published in Gastroenterology.

If clinicians are uncomfortable deploying this maneuver, called a retroflexed view, they should instead perform a second pass through the right colon to ensure any hidden polyps are detected, according to Rajesh Keswani, MD, associate professor of Medicine in the Division of Gastroenterology and Hepatology and lead author of both publications.

"Retroflexed view is more difficult, so it may be easier to perform two forward views instead—they are basically equivalent, but the important thing is that you spend time looking," said Keswani, who is also a member of the Digestive Health Center and the Robert H. Lurie Comprehensive Cancer Center of Northwestern University.

Screening colonoscopy is the best way to identify polyps in the colon that may turn into cancer, but detection efficacy varies from clinician to clinician, according to previous research. This especially impacts detection of polyps in the right side of the colon, where they are often flatter and hidden behind folds of the colon.

"When clinicians miss polyps, they tend to be in the right side of the colon," Keswani said.

A retroflexed view—turning the endoscopy camera 180 degrees while moving through the right colon—has been shown to help detect these polyps in clinical studies, but Keswani and his collaborators wanted to measure the effectiveness of this maneuver in real-world practice.

Investigators recorded 119 colonoscopies performed by 17 endoscopists, randomly analyzing seven videos per endoscopist. They found retroflexion was often performed inadequately, either too briefly or without examining all of the right colon.

This can create a false sense of security, falsely reassuring endoscopists that they've fully examined the right colon while still missing polyps, so Keswani and his collaborators recommended that clinicians could instead perform two forward view passes if high-quality retroflexion is not possible.

These findings and other recommendations were detailed in an American Gastroenterological Association clinical practice update authored by Keswani and published in Gastroenterology.

Aside from guidance on retroflexion, the investigators advised on the use of benchmarks, video coaching and mandated minimum standards of practice. The efficacy of these practices were previously studied by Keswani, and can help improve colonoscopy procedures practice wide, he said.

"When you give feedback, some people get better—but when you mandate a minimum standard of performance and provide additional training, everybody rises to the occasion," Keswani said.