Retrograde inspection vs standard forward view for the detection of colorectal adenomas during colonoscopy: A back-to-back randomized clinical trial

BACKGROUND: The adenoma detection rate (ADR) is inversely associated with the incidence of interval colorectal cancer and serves as a benchmark quality criterion during screening colonoscopy. However, adenoma miss rates reach up to 26% and studies have shown that a second inspection of the right colon in retroflected view (RFV) can increase ADR. AIM: To assess whether inspection of the whole colon in RFV compared to standard forward view (SFV) can increase ADR. METHODS: Patients presenting for screening or surveillance colonoscopy were invited to participate in this randomized controlled trial and randomized into two arms. In RFV arm colonoscopy was initially performed with SFV, followed by a second inspection of the whole colon in RFV. In the SFV arm first withdrawal was performed with SFV, followed by a second inspection of the whole colon again with SFV. Number, size and morphology of polyps found during first and second inspection in each colonic segment were recorded and all polyps were removed and sent for histopathology in separate containers. RESULTS: Two hundred and five patients were randomly assigned to the RFV (n = 101) and SFV (n = 104) arm. In the RFV arm, both polyp detection rate (PDR) and ADR were increased under second inspection in RFV (PDR 1(st) SFV: 39.8%, PDR 2(nd) RFV: 46.6%; ADR 1(st) SFV: 35.2%, ADR 2(nd) RFV: 42%). Likewise, in the SFV arm, PDR and ADR were increased under second inspection (PDR 1(st) SFV: 37.5%, PDR 2(nd) SFV: 46.6%; ADR 1(st) SFV: 34.1%, ADR 2(nd) SFV: 44.3%) with no significant differences in ADR and PDR between the SFV and RFV arm. Mean number of adenomas per patient (APP) was increased in the RFV and SFV (APP RFV arm: 1(st) SFV: 1.71; 2(nd) RFV: 2.38; APP SFV arm: 1(st) SFV: 1.83, 2(nd) SFV:2.2). The majority of adenomas additionally found during second inspection in RFV or in SFV were located in the transverse and left-sided colon and were > 5 mm in size. CONCLUSION: Second inspection of the whole colon leads to increased adenoma detection with no differences between SFV and RFV. Hence, increased detection is most likely a feature of the second inspection itself but not of the inspection mode.