Safety and Effectiveness of Cecal Retroflexion in Evaluating Proximal Colon: A Case Series
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BACKGROUND: Cecal retroflexion is a maneuver used by colonoscopists to evaluate the proximal sides of the colonic folds in the right-sided colon. Knowledge is limited regarding cecal retroflexion-associated risk and its effectiveness for increasing neoplasia detection rates in proximal colon. Recently, we encountered a contained perforation caused by cecal retroflexion. To our knowledge, there has been no report on cecal retroflexion-associated complications in the existing literature. OBJECTIVE: We aim to 1) report the case in detail, and characterize cecal retroflexion-related complication rates, and 2) assess whether there is improved neoplasia detection with cecal retroflexion. METHODS: We performed retrospective cohort study of all patients age 18 to 85 years who received colonoscopy by one endoscopist at UT Southwestern Medical Center from 9/1/2006 to 7/31/2012.We excluded patients who received colonoscopies prior to the initiation of cecal retroflexion, had missing colonoscopy reports, or were not found in the electronic medical record system. Our primary outcome is cecal-retroflexion-associated complication rates within 30 days after the procedure; the secondary outcome is cecal-retroflexion-associated neoplasia detection rates. RESULTS: A total of 1,247 patients were included in final analysis. Mean patient age was 57 years; 58.6% of patients were women. Among these patients, 624 (50.0%) received cecal retroflexion during colonoscopy. 1(Case) out of the 624 patients had a cecal retroflexion-related complication, with a complication rate of 1.6 per 1000 cecal retroflexion (95% Cl: 0 to 4.7 per 1000 cecal retroflexion). Of 459 patients underwent screening colonoscopy, 261 (56.9%) had cecal retroflexion. No cecal retroflexion-associated complications were observed with screening colonoscopy. We observed no statistically significant improvement in neoplasia detection rates among individuals who underwent colonoscopy with vs. without documented cecal retroflexion (P>0.05 for all comparisons). CONCLUSION: Cecal retroflexion may be associated with rare but significant complications. Further, the practice does not clearly increase neoplasia detection rates. We postulate that routine implementation of this practice is unlikely to increase neoplasia detection rates substantially, and further, given the small non-significant differences observed in our study, that randomized trials of the practice are unlikely to show clinically significant superiority. We recommend future research explore alternate strategies to improve proximal neoplasia detection.