American Journal of Gastroenterology ISSN 0002-9270


C 2006 by Am. Coll. of Gastroenterology doi: 10.1111/j.1572-0241.2006.00606.x
Published by Blackwell Publishing

Retroflexion in the Colon: A Useful and Safe Technique in

the Evaluation and Resection of Sessile Polyps During
Colonoscopy
Aline Charabaty Pishvaian, M.D. and Firas H. Al-Kawas, M.D.
Division of Gastroenterology, Georgetown University Hospital, Washington, DC

OBJECTIVE: Endoscopic polypectomy has become the standard management approach for colon polyps. Three
factors can make endoscopic resection of colonic polyps difficult: size, configuration, and location.
We describe the use of retroflexion in the colon as a useful and routine technique using a standard
colonoscope for the resection of difficult sessile polyps.
METHODS: Fifteen patients in whom the retroflexion technique was used for polyp removal were prospectively
identified. Each polyp was visualized and resected using both a forward and retroflexed view.
RESULTS: Nine women and six men were identified between the ages of 49 and 81 years. The 15 polyps were
located in the cecum (3), ascending colon (3), hepatic flexure (3), splenic flexure (2), descending
colon (2), and sigmoid colon (2). All the polyps were sessile and their largest diameter ranged from
20 mm to 50 mm. Retroflexion combined with forward viewing allowed for a better assessment of
the size and extent of all the polyps compared with forward viewing alone. All polyps, except two,
were completely resected during the first session, using both the prograde and retroflexion
approaches. No complications from retroflexion of the colonoscope, including perforation or
bleeding, occurred.
CONCLUSION: Retroflexion complements the conventional prograde inspection of sessile polyps that are only
partially visualized on prograde view alone. Retroflexion allows a complete assessment of the
lesions’ size and extent and aid in their complete removal.
(Am J Gastroenterol 2006;101:1479–1483)

INTRODUCTION in the colon as a useful and routine technique using a standard

Endoscopic polypectomy has become the standard manage-
ment approach for colon polyps. In expert hands, the proce-
dure is effective and safe in the majority of patients. Three
factors can make endoscopic resection of colonic polyps diffi-
cult. These are size, configuration, and location. For instance,
sessile polyps >20 mm in diameter, occupying more than
one-third of the wall circumference, extending over more
than two folds, or wrapped around a fold in a clamshell fash-
ion, can make polypectomy a challenge. In addition, sessile
polyps located behind a fold, within a flexure, or in a tortuous
segment of the colon (such as the sigmoid), present a partic-
ular challenge even to the skilled endoscopist (1–4). Several
techniques and instruments have been described to make en-
doscopic removal of the “difficult” polyp feasible and safe.
These include submucosal injection of saline solution to lift
sessile polyps, piecemeal resection, suction cap EMR, use
of a double-channel endoscope, and even a dual-endoscope
technique (5–8). Retroflexion of the scope is frequently used
by expert endoscopists. However, the use of this maneuver has
not been widely applied. We describe the use of retroflexion
colonoscope for the resection of difficult sessile polyps.
METHODS
Between June 2001 and April 2005, a total of 2,157 colono-
scopies were performed by a single experienced endoscopist
at our institution (FAK). Among those, a total of 580 pa-
tients were found to have sessile polyps of all sizes and lo-
cations. Fifteen cases where the retroflexion technique was
used outside the rectum for polyp removal were prospectively
identified by one of the authors (FAK). This study was ap-
proved by the Georgetown University Hospital Institutional
Review Board (IRB). Of the 15 patients, 12 patients were
referred for resection of a known polyp seen on a previous
colonoscopy, one for evaluation of anemia, and two patients
were undergoing screening colonoscopy. Patients were pre-
medicated with intravenous midazolam and meperidine or
propofol. A standard colonoscope was used (most recently,
Pentax EC3831L, Pentax Precision Instrument Corporation,
Orangeburg, NY). Each polyp was visualized in both for-
ward and retroflexed view. Retroflexion was performed after

1479
1480 Pishvaian and Al-Kawas
advancing the scope beyond the index polyp. All loops were
reduced. The tip of the colonoscope was then fully bent up-
ward and the scope was gently advanced until the polyp was
seen. Scope rotation was sometimes needed to “free” it from
any folds. After completing polyp inspection, the base of the
polyp was injected and lifted with 5–10 cc of normal saline.
In the last 3 yr, methylene blue was added. The solution was
injected either at the center of the lesion or starting with
the proximal edge of the polyp. Both forward and retrograde
approaches were used. Most polyps were resected in a piece-
meal fashion using a snare and monopolar cautery. Again,
both prograde and retroflexed views to maximize tissue re-
section were used. Polyps were resected using mini, standard,
or large polypectomy snares (Boston Scientific, Natick, MA
and Wilson-Cook, Winston-Salem, NC). Any residual polyp
tissue was ablated using argon plasma coagulation (APC)
(ERBE, Marietta, GA). Forward and retrograde approaches
were alternated as needed to accomplish the task. All polyps
were retrieved and sent to pathology. If the polyp was not in
the cecum, Spot (GI Supply, Camphill, PA) was used to tattoo
the colonic wall near the polypectomy site to facilitate future
identification. All patients were scheduled for a follow-up
endoscopy in 4–24 wk to confirm complete removal or to
remove any residual polyp. As done routinely in our unit, im-
mediate and delayed endoscopic complications were entered
prospectively in our endoscopy database.
RESULTS
Nine women and six men were identified; their age ranged be-
tween 49 and 81 yr (with a mean age of 67.5 yr). The location
of the 16 polyps was as follows: cecum (3), ascending colon
(3), hepatic flexure (3), splenic flexure (2), descending colon
(2), and sigmoid colon (2). All the polyps were sessile and
their largest diameter ranged from 20 to 50 mm. Nine polyps
wrapped around a fold in a clamshell fashion. Polyps located
in the sigmoid colon and at flexures were partially hidden
to forward view. One cecal polyp extended into the lip of
the ileocecal valve. Two other cecal polyps were localized on
the medial wall, proximal to the ileocecal valve. Retroflexion
combined with forward viewing allowed for a better assess-
ment of the size and extent of all the polyps compared to
forward viewing alone (Figs. 1 and 2). All polyps, except
two, were completely resected during the first session: a 50-
mm sigmoid polyp (later found to be malignant) and a cecal
polyp were only partially removed with a plan to complete the
resection on follow-up colonoscopy. Pathology examination
of the retrieved specimen revealed a tubular adenoma or a
tubulovillous adenoma (12 cases), a tubulovillous adenoma
with a focus of high-grade dysplasia (1 case), a tubulovillous
adenoma with a focus of moderate dysplasia (1 case), and an
adenocarcinoma (1 case). No complications from retroflex-
ion of the colonoscope, including perforation or bleeding,
occurred. Mild bleeding at the polypectomy site was seen
in three cases and hemostasis was immediately achieved by
placing endoclips. No delayed complications related to the
procedure occurred. Follow-up colonoscopy was performed
in all but three patients. One patient was lost to follow-up
and two patients are scheduled for a follow-up colonoscopy
in 3–6 months. Four patients had no residual polyp tissue on
further follow-up colonoscopy. In six cases, residual adeno-
matous tissue at the site of the previous polypectomy was
seen and removed. Residual polyp tissue was less than 10
mm in size in two cases and 10 mm or more in four cases.
Residual tissue was resected and the site was further ablated
by APC, using both the prograde and the retroflexed approach
as needed. Two patients had an initial partial resection of their
polyp: one underwent completion of the resection at a later
date, and the other had surgical resection of a sigmoid ade-
nocarcinoma (the surgical specimen did not demonstrate any
residual cancer tissue).
DISCUSSION
We present 15 patients where retroflexion was essential for
the complete visualization and endoscopic resection of sessile
colon polyps outside the rectum. These polyps were deemed
to be difficult to resect by keeping the colonoscope solely in
forward view for reasons pertaining to their size, their loca-
tion, and/or configuration. In these patients, prograde view
alone allowed a limited and partial examination of the polyp,
while retroflexion gave a more complete view of the area in-
spected and frequently helped fully visualize the proximal
“under the fold” aspect of the polyp and the extent of the area
involved in the adenomatous process. This was especially
relevant in the cases of clamshell polyps and polyps close
to or involving the ileocecal valve, where forward inspection
alone can be misleading as to the real size and extent of the
lesion. After examination of the sessile polyp in both pro-
grade and retrograde view, the endoscopist can then estimate
the feasibility of a complete resection of a large sessile polyp
and anticipate the degree of technical difficulty that will be
encountered in order to achieve this goal, allowing the endo-
scopist to devise a strategy to ensure complete resection of
the polyp. For instance, as previously described (1, 4), we find
it very useful to first lift the proximal edge of the polyp with
submucosal injection of saline while in retroflexed position
and then proceed with lifting the edge of the polyp near the
scope while in prograde view. This sequence of injections
allows for the entire polyp to become more visible in a pro-
grade view and facilitate the snaring and resection of a large
portion of the lesion. Reversing the sequence of injection,
i.e., injecting and raising the near edge of the lesion first, can
result in the near edge of the polyp flipping backward, away
from the endoscopist’s view, while burying the farther edge
between two folds, making it difficult to visualize this edge at
that time even with a retroflexed endoscope. After success-
ful lifting, the polyp is snared and resected in a piecemeal
fashion as needed, using both the forward and retroflexed ap-
proach. The polypectomy site is then reexamined in forward
and retroflexed view with ablation of all residual tissue by
 Retroflexion in the Colon 1481

Figure 2. Sessile polyp at the ICV, involving one lip of the valve
Figure 1. Sessile polyp in the ascending colon (A) with a clamshell as seen on retroflexion (A). Resection of the polyp with a snare
configuration as seen on retroflexion (B). Complete resection of the with the colonoscope in retroflexed position (B). ICV after complete
polyp as seen in retroflexed view (C). resection of the polyp (C).
1482 Pishvaian and Al-Kawas
using APC, to decrease the risk of recurrence of the adenoma
(9). In our series, residual polyps needed one–three additional
sessions to be completely eradicated, highlighting the need for
close colonoscopy follow-up, even after presumed complete
resection of large sessile polyps.
Although retroflexion of the tip of the colonoscope in the
rectal vault is an integral part of colonoscopy, retroflexion is
not routinely performed in other areas of the colon because
of questions pertaining to benefits, risks, and feasibility of
this maneuver outside the rectal vault. Retroflexion in the
rectum has been shown to increase the detection rate of ade-
nomas by 1% when it was added to a flexible sigmoidoscopy
examination (10). However, similar benefit in adenoma de-
tection rate from retroflexion in other parts of the colon has
not been evaluated. Harrison et al. (11) performed a second
look of the proximal colon of a total of 98 patients looking
for small polyps that were missed at the initial examination
of the colon performed in forward view. The patients were
randomized to a second look in either forward view or in
retrograde view. Although, there was no difference in the
rate of missed small polyps whether the second examination
was performed in the forward view or the retroflexed view,
the authors commented on the advantage of retroflexion over
prograde view in fully exposing polyps that involved the prox-
imal edge of a fold. In our patients, retroflexion was required
for a complete evaluation and resection of all polyps. Other
anecdotal reports by expert endoscopists mention the use of
retroflexion to fully visualize and resect difficult polyps (4,
12). However, most authors limit the use of retroflexion out-
side the rectum to the right colon, describing retroflexion of
a standard colonoscope in other parts of the colon as difficult
(1, 11).
The degree of difficulty linked to retroflexion of an adult
colonoscope depends on several factors: the experience of
the endoscopist and their comfort level in manipulating the
colonoscope in retroflexed position, the anatomical character-
istics of the colonic segment where retroflexion is attempted,
and the properties intrinsic to the colonoscope. The endo-
scopist might be reluctant to perform retroflexion in the colon
because of potential technical difficulty and unfamiliarity as-
sociated with this maneuver. The colonoscope needs to be
straightened, i.e., the endoscopist needs to reduce any loop
before attempting retroflexion, since retroflexion is less likely
to be successful when a loop is present (4). Once the tip of
the instrument is retroflexed, shaft response to the to and fro
movements is opposite to that expected during the conven-
tional forward viewing method. Endoscopists have to become
familiar with the instrument’s response to their manipulations
in order to proceed safely with the planned therapeutic inter-
ventions (1). Another factor that determines the success of
retroflexion is colon anatomy: the wide lumen of the cecum,
ascending colon, and transverse colon allows for an easier
retroflexion in these segments compared to retroflexion in
the narrow lumen of a sigmoid colon (1, 11). The standard
colonoscope has a wide insertion tube diameter, a limited
tip deflection, and a long bending section, all characteristics
that make it difficult to retroflex in narrowed segments of the
colon. Knowing the characteristics of the instrument used
will help the endoscopist choose the endoscope that is best
suited to a particular situation. The insertion tube diameters of
standard upper endoscopes range from 9.5 to 9.8 mm depend-
ing on the manufacturer; that of the standard colonoscopes
range between 12.3 and 12.8 mm. Pediatric instruments have
a smaller diameter of insertion tube, whereas therapeutic up-
per endoscopes have a larger one. As for the tip deflection
capability of the bending section, upper endoscopes have a
maximal upward angulation of 210◦ , whereas adult and pe-
diatric colonoscopes have a maximal upward angulation of
180◦ . Finally, colonoscopes have a longer bending section
when compared to upper endoscopes, with a length of 11–
11.4 cm and 10.2–11.5 cm for adult and pediatric colono-
scopes, respectively, versus a length of 7.5 and 6 cm for adult
and pediatric upper endoscopes, respectively. Whereas the in-
strument characteristics of a standard colonoscope can limit
the feasibility to perform a tight turn in some patients, a scope
with a smaller insertion tube diameter, a greater tip deflec-
tion capability, and a shorter bending portion can facilitate
retroflexion in narrowed segments. Such an instrument, when
fully retroflexed, would have a smaller cross distance between
the bending section and the straight portion of the scope than
a standard colonoscope would have. Hence, if needed, a pedi-
atric colonoscope or a standard adult upper endoscope can be
used to retroflex in the left colon (1, 4). Recently, several stud-
ies have been published looking at the influence of instrument
characteristics on the ability to retroflex in the cecum and/or
the right colon (4, 11, 13). A prototype pediatric colono-
scope with a short bending section allowed cecal retroflex-
ion in 95% of the cases, whereas the pediatric and standard
adult colonoscopes were successful in only 50% and 24.5%
of the cases, respectively. In our series, a standard colono-
scope was successfully used to retroflex in the descending
and sigmoid colon as well as in the right colon. However,
one of the limitations of this study is that it did not assess
the success rate of retroflexion in different segments of the
colon in all the patients where it was needed and attempted.
This study also relied on the experience of a single skilled
endoscopist in one institution and his opinion on the ease of
the retroflexion maneuver. A larger prospective study looking
at the retroflexion in all segments of the colon as performed
by different endoscopists can better define the success rate of
retroflexion in each particular segment and assess the influ-
ence of the endoscopist experience on the success rate of the
maneuver.
Finally, a concern over safety and risk of bowel perforation
is another factor that deters endoscopists from retroflexing the
colonoscope outside the rectum. The risk of causing bowel
perforation is of particular concern in thin-walled areas such
as the cecum or in narrow segments such as the sigmoid colon
(with or without diverticulosis) where the pressure of the tip
or the bend of the endoscope against the bowel wall can cause
mucosal injury and potential perforation. However, several
studies looking at retroflexion in the cecum and proximal

colon did not report any complication from this maneuver
(4, 11, 13). In our report, a standard colonoscope with an
insertion tube diameter of 12.8 mm was used and retroflexion
was safely performed in the cecum and ascending colon as
well as in the left colon. As recommended by other authors,
retroflexion attempt should be stopped if the endoscopist feels
resistance when bending the tip or when trying to advance the
scope after bending the tip, in order to avoid a complication.
As discussed above, the use of an upper endoscope may be a
good alternative in the left colon.
In conclusion, we consider that retroflexion of the tip of
the colonoscope is a valuable maneuver for the examina-
tion and removal of some difficult sessile polyps, especially
those that are only partially visualized on prograde inspec-
tion. Retroflexion complements the conventional prograde
inspection of these polyps by allowing a complete assessment
of the lesions’ size and extent and by aiding in their complete
removal. As demonstrated by our data, frequent follow-up
is mandatory in this population, because of the high inci-
dence of residual adenomatous tissue. A larger prospective
study looking at the success rate of retroflexion in differ-
ent segments of the colon in all cases where it is attempted
and in the hands of gastroenterologists with different endo-
scopic skill levels is needed. However, our data suggest that
retroflexion during colonoscopy outside the rectum is feasi-
ble, safe, and a valuable maneuver to complete polypectomy
in a select population when performed by an experienced
endoscopist.
STUDY HIGHLIGHTS
What Is Current Knowledge
r Sessile polyps can be difficult to fully visualize and
resect using the standard prograde view alone.
r Retroflexion is a safe and feasible maneuver in the rec-
tum and allows better visualization of rectal polyps, but
is rarely performed outside the rectum.
r A simple and safe endoscopic technique is needed for
removal of difficult polyps.
What Is New Here
r Retroflexion in the colon allows for better visualization
of clamshell polyps and polyps hidden behind folds and
flexures.
r Retroflexion facilitate resection of the proximal end of
large sessile polyps.
Retroflexion in the Colon 1483
r Retroflexion in the colon outside the rectum using a
standard colonoscope is a feasible and safe maneuver.
Reprint requests and correspondence: Firas Al-Kawas, M.D., Di-
vision of Gastroenterology, Georgetown University Hospital, 3800
Reservoir Road, NW, M2408, Washington DC 20007.
Received 4 November 2005; accepted 16 January 2006.
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The authors declared no conflicts of interest.