Retroflexion in the rectum is performed routinely during colonoscopy in an attempt to detect lesions that could be missed by forward viewing alone. Case reports of rectal perforation caused by this procedure have been published, but the frequency of this serious complication in large series is unknown. In addition, there are few reports regarding the management of colonoscopic rectal perforations.

To determine the colonic perforation rate of rectal retroflexion and the management of this complication at 3 affiliated academic hospitals from July 1, 2001, to June 30, 2008.

Multicenter case series.

A university hospital, a Department of Veterans Affairs hospital, and an urban safety-net hospital.

A diverse population of patients who underwent colonoscopy for various indications.

Four cases of rectal perforation occurred during rectal retroflexion in a total of 39,054 consecutive colonoscopies (0.10 per 1000). One of these complications occurred in a colonoscopy performed by a supervised trainee; the other 3 occurred during colonoscopy performed by experienced faculty endoscopists alone. Three of the 4 perforations were managed successfully without surgical intervention.

The complication rate relies on physician self-reporting.

Rectal retroflexion during colonoscopy is associated with a low rate of perforation, yet this serious complication can occur even in the hands of experienced endoscopists. Most cases of rectal perforation during retroflexion can be managed nonoperatively.