Position change during colonoscope withdrawal increases polyp and adenoma detection in the right but not in the left side of the colon: results of a randomized controlled trial

doi:10.1016/j.gie.2015.01.035

Gastrointestinal Endoscopy

Volume 82, Issue 3, September 2015, Pages 488-494

https://doi.org/10.1016/j.gie.2015.01.035 Get rights and content

Background

It has been suggested that changing patient position during colonoscope withdrawal increases adenoma detection. The results of previous studies have been conflicting.

Objective

To evaluate whether routine position change during colonoscope withdrawal improves polyp detection.

Design

Randomized, 2-way, crossover study.

Setting

Teaching hospital.

Patients

A total of 130 patients attending for diagnostic colonoscopy.

Interventions

Patients undergoing colonoscopy had each colon segment examined twice: the right side of the colon (cecum to hepatic flexure) in the supine and left lateral position and the left side of the colon (splenic flexure and descending colon) in the supine and right lateral position. The transverse colon was examined twice in the supine position.

Main Outcome Measurements

The primary outcome measure was the polyp detection rate (≥1 polyp) per colon segment. Secondary outcome measures included the number and proportion of patients with ≥1 adenoma in each segment and adequacy of luminal distension (1 = total collapse and 5 = no collapse).

Results

Examination of the right side of the colon in the left lateral position significantly improved polyp detection (26.2% vs 17.7%; P = .01) and luminal distension (mean = 4.0 vs 3.5; P < .0001). Position change did not improve polyp detection in the left side of the colon (5.4% vs 4.6%; P = .99). There was no significant correlation between luminal distension and polyp detection in the right side of the colon (r = .03).

Limitations

Single center and open study design.

Conclusion

Examining the right side of the colon in the left lateral position increased polyp detection compared with examination in the supine position. Polyp detection in the left side of the colon was similar in the right lateral and supine positions. (Clinical trial registration number: NCT01554098.)

Section snippets

Methods

Patients aged 40 to 80 years presenting for a diagnostic colonoscopy at the Northern General Hospital, Sheffield, between March 2012 and February 2014 were invited to participate. Patients with limited mobility, those who had previously undergone colon surgery, or those known to have colitis or a polyposis syndrome were excluded. Patients with a permanent pacemaker also were excluded, because this would preclude the use of the Scopeguide (Olympus, Tokyo, Japan). All patients gave written

Results

A total of 198 patients were screened for study inclusion. A total of 67 were excluded, most commonly because of patient preference and insertion time >20 minutes. One patient was withdrawn because of difficulty with reinsertion in the right side of the colon, leaving 130 patients for analysis (Fig. 2). The procedural characteristics and medication use did not significantly differ between the study groups, although more men and fewer patients referred for investigation of anemia were randomized

Discussion

Modifying a patient’s position is accompanied by the intra-abdominal movement of the colon and the intraluminal movement of fluid and gas. Radiologists have used these changes to optimize views during barium examinations for decades, and it has been suggested that adjusting the patient position, to bring colon segments uppermost within the abdomen, improves luminal distension and therefore lesion detection during colonoscope withdrawal.

However, practice among endoscopists varies, with some

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Repositioning the patient from the left lateral decubitus position to the supine or right lateral position may be useful when encountering difficulty with navigation, tight corners, or when looping occurs. Additionally, systematic position change during withdrawal has been shown to be a simple and cost-neutral intervention to improve adenoma detection rate that does not significantly increase procedure time.31-37 Position change facilitates adequate distension at different colonic segments as gas rises to the least dependent areas and fluid moves to the more dependent areas.
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Hyoscine butyl bromide, peppermint oil, and glucagon have all either shown no efficacy at increasing the ADR or have such limited data that they cannot be routinely recommended for use in screening colonoscopy.35 There are some promising data from randomized controlled trials that indicate that patient position change to the left lateral side on withdrawal increases ADR, especially in the right colon and if the baseline ADR of the physician is low.36,37 However, a recent systematic review called these results into question because there is also high-quality evidence from other studies that suggests that position change does not affect the ADR.38
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The mechanism of improved detection is optimized distention [43]. Results from randomized controlled trials have been mixed [1,43–46]. The most positive studies have been from the United Kingdom, where the use of light and moderate sedation for colonoscopy is common.
The adenoma detection rate (ADR) has emerged as the most important quality measure in colonoscopy, as it predicts the risk of interval cancer after colonoscopy. Measuring and improving ADR is the central focus of the current quality movement in colonoscopy. High ADRs can be achieved by a colonoscopist with a thorough understanding of the wide range of endoscopic appearances of precancerous lesions in the colorectum, effective bowel preparation, and meticulous technique using high definition colonoscopes. The knowledgeable and effective examiner needs no adjunctive devices or techniques to achieve master level ADRs. However, measurement reveals that many colonoscopists have ADRs that are below recommended minimum thresholds or below master levels. These colonoscopists, and even master level performers, can choose from a variety of adjunctive tools to improve ADR. This review describes these tools according to whether they are non-device methods (e.g. double right colon examination, patient position change, water exchange), mucosal exposure devices (wide angle colonoscopy, fold flattening devices), and lesion highlighting techniques (e.g. chromoendoscopy, electronic chromoendoscopy).
Diagnostic yield of scope retroflexion in the right colon: A prospective cohort study
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Patients underwent bowel cleansing with 4 L of polyethylene glycol solution in split doses. Colonoscopies were performed under conscious sedation with incremental doses of midazolam and pethidine, on demand; therefore frequent patient position change was facilitated, maximizing optimal view of the colon mucosa [12–14]. Olympus CF-Q145L standard-definition white-light (SDWL) (Olympus Corporation, Tokyo, Japan) adult colonoscopes were used.
Techniques have been implemented to improve colonoscopy adenoma detection rate (ADR) in the right colon.
We prospectively examined the additional diagnostic yield of right colon examination with colonoscope retroflexion in consecutive, symptomatic and screening–surveillance patients. Right colon was examined in forward-view first and thereafter, retroflexion was performed to re-inspect it.
Right colon examination in retroflexion was achieved in 620 (92%) patients. Increased inserted scope length to the cecum (OR: 0.48 [95%CI: 0.27–0.84]) and elderly status (OR: 0.53 [95%CI: 0.430–0.94]) predicted retrofexion failure. Forward-view colonoscopy detected 134 polyps and 112 adenomas in 105 and 85 patients, respectively. Scope retroflexion revealed 7 missed (6 adenomas – 2 advanced) polyps in 7 patients; indicating 4.96 (95%CI: 1.37–8.55)% and 5.1 (95%CI: 1.12–9.05)% per-polyp and per-adenoma miss rates, respectively. In ITT analysis, per-patient polyp and adenoma miss rates were 1.041% and 0.89%, respectively. Among screening–surveillance patients, retroflexion detected 3 missed adenomas (2 advanced) in 3 patients, resulting in changed surveillance schedule in 2 of them (5.12 per 1000 screening–surveillance patients). Early study termination was favored by low right colon ADR improvement and lacking substantial surveillance interval change.
The additional diagnostic yield of scope retroflexion in the right colon is questionable.
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: DISCLOSURE: All authors disclosed no financial relationships relevant to this article.

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Original articleClinical endoscopyPosition change during colonoscope withdrawal increases polyp and adenoma detection in the right but not in the left side of the colon: results of a randomized controlled trial

Background

Objective

Design

Setting

Patients

Interventions

Main Outcome Measurements

Results

Limitations

Conclusion

Section snippets

Methods

Results

Discussion

Gastroenterology

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Protection from colorectal cancer after colonoscopy: a population-based, case-control study

Ann Intern Med

Association of colonoscopy and death from colorectal cancer

Ann Intern Med

The miss rate for colorectal adenoma determined by quality-adjusted, back-to-back colonoscopies

Gut Liver

Original article
Clinical endoscopy
Position change during colonoscope withdrawal increases polyp and adenoma detection in the right but not in the left side of the colon: results of a randomized controlled trial