Retroflexion at the cecal level
1. Screening colonoscopy – general comments
For the screening colonoscopy, as for any colonoscopic examination, the following aspects are essential: a proper preparation of the colon, evaluated according to the Boston scale, the visualization of the check (in 95% of cases) and a very careful retraction examination with the thorough evaluation of each space. behind the folds, with a withdrawal time of at least 6 minutes (recently discussed even 9 minutes).
Regarding the preparation, there are some important aspects to mention: the fiber-free diet 3-4 days before the colonoscopy, the water diet starting at 12 o’clock the day before, the administration of the preparation solution in 2 doses (in the evening and early in the morning, if the colonoscopy is performed in the first part of the day), the patient’s interest explaining in the pictures the need for a good preparation so as not to lose lesions and possibly the encouragement to send an image with the appearance of the last stool.
Related to intubation to the check, the frequent retraction movement of the colonoscope, its torsion at the level of the curves, the minimal insufflation, the aspiration at the level of the right colon to get closer to the check, the instillation of water in the colon, the change of the patient’s position. external pressure allow a good advance to the check. Viewing the check twice is indicated so as not to lose any injuries.
Retreat exploration is essential: sufficient insufflation and exhalation, aspiration of liquid lakes, systematic exploration after folds, retroversion in the rectum, sufficiently long withdrawal time. All these simple maneuvers allow a good detection of the lesions, respectively the assurance of the quality of the procedure.
2. Retroflexion at the cecal level
REASONS
Complete endoscopic examination of the right colon proved to be one of the “weak points” of screening colonoscopy, the lesions of the check and ascendant being difficult to detect.
The current recommendations suggest a detailed examination of the right colon – either twice by normal vision (forward) as previously presented, or by a forward view and one by retroflexion. Although in clinical trials these strategies appear to be equivalent, retroflexion is increasingly recommended in current practice.
At this time there is relatively little data on how cecal retroflexion is performed in clinical practice, but it seems that in many cases colonoscopists do not perform it, or if they do, they do not do it correctly using the “short, abbreviated version” of the maneuver. with visualization of the ileo-cecal valve, without performing the retraction in the colonic lumen with circumferential retroflex visualization of the valves of the right colon up to the level of the hepatic angle.
WORKING TECHNIQUE (Douglas Rex)
a. the decision to carry out:
– after the forward view of the right colon, it is decided whether the second examination will be retroflexed or not. This decision depends on how short the colonoscope is. If the insertion tube is straight, the retroflex is technically feasible.
b. practical way:
– the colonoscope is at the cecal level then the tip is oriented in a direction where there is enough space to make a U-turn. The maneuver is performed by maximum rotation upwards (big wheel) and to the left (small wheel), and the colonoscope is rotated counterclockwise (without being pushed), until it becomes visible. If you do not have a perfect image, you can gently push the colonoscope or continue rotating it to remove the tip from the adjacent mucosa.
– after retroflexing and visualization of the ileo-cecal valve, the colonoscope is slowly retracted to the hepatic flexure, using gentle twisting maneuvers to perform a circumferential examination behind the folds.
– retroflexion is completed once the splenic flexure is visualized
– to get out of retroflexion, the endoscopist will look for an open section of the right colon in which to reduce the colonoscope to a normal position. The maneuver is performed by releasing directional commands and slowly retracting the colonoscope.
– to make sure that the appliance is not stuck, you can advance the lumen by about 10-15 cm before resuming the retraction to the forward position
c. warning
– the risk of perforation that may occur during this maneuver should not be omitted, so it is not recommended to perform it without a prior period of supervised learning.
CONCLUSIONS
Retroflexion in the right colon is a safe maneuver, relatively easy to perform after a short period of learning and offers the chance to improve quality parameters in screening colonoscopy.
This maneuver could even become the standard procedure in screening colonoscopy.