LETTERS TO THE EDITOR Should rectal retroflexion be included as a quality indicator for colonoscopy? To the Editor: I 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. In my opinion, a photograph of this area is compulsory and would also constitute a quality indicator for colonoscopy to avoid legal cases concerning postcolonoscopy cancers. The anorectal junction is a blind spot, which is not easily visualized on straight insertion and withdrawal of the endoscope. Rectal retroflexion improves the view of the lower rectum, where up to 50% of lesions, including tumors,3 can be detected only by this maneuver.4 Several published references support the importance of rectal retroflexion. Hanson et al5 reported an increase of 1% in adenoma detection rate with this maneuver. Varadarajulu and Ramsey4 found that more than 50% of all lesions and 66% of adenomatous polyps in the distal rectum were identified only on retroflexion. In my own experience, the most striking case on this topic is shown in Figure 1. This tiny lesion, which was visible only on rectal

retroflexion, turned out to be a malignant polyp. The anorectal junction must be explored on retroflexion, and we encourage all endoscopists to take a photograph of this area to reduce medical and legal risk. We suggest that the rate of rectal retroflexion with a picture be included as a quality indicator for colonoscopy. María Lourdes Ruiz-Rebollo, MD, PhD Department of Digestive Diseases Hospital Clínico Universitario Valladolid, Spain REFERENCES 1. Rex DK, Schoenfeld PS, Cohen J, et al. Quality indicators for colonoscopy. Gastrointest Endosc 2015;81:31-53. 2. Rex DK, Petrini JL, Baron TH, et al. Quality indicators for colonoscopy. Gastrointest Endosc 2006;63:S16-28. 3. Rex DK. Development of distal rectal cancer 5 years after a normal photograph of the distal rectum. Gastrointest Endosc 2011;74:728-9. 4. Varadarajulu S, Ramsey WH. Utility of retroflexion in lower gastrointestinal endoscopy. J Clin Gastroenterol 2001;32:235-7. 5. Hanson JM, Atkin WS, Cunliffe WJ, et al. Rectal retroflexion; an essential part of lower gastrointestinal endoscopic examination. Dis Colon Rectum 2001;44:1706-8. http://dx.doi.org/10.1016/j.gie.2015.02.022

Response:

Figure 1. Retroflexed view of the rectum. Black lines show a small sessile polyp. Examination of biopsy specimens revealed well-differentiated adenocarcinoma.

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.1,2 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.3 Although this is not proven, the perforation risk from retroflexion seems greater when the rectum is narrow

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Volume 82, No. 2 : 2015 GASTROINTESTINAL ENDOSCOPY 421