Cap-Assisted Colonoscopy

Amit Rastogi, MD

KEYWORDS
 Cap-assisted colonoscopy  Polyp detection rate  Adenoma detection rate
 Cecal intubate rate  Cecal intubation time

KEY POINTS
 Cap-assisted colonoscopy is a simple, practical, and inexpensive technique that serves
several useful purposes in enhancing the performance of colonoscopy.
 It helps improve polyp detection by its ability to visualize the otherwise blind mucosal
areas on the proximal aspects of folds and flexures, although its effect on adenoma detec-
tion has been inconsistent.
 By helping navigate the colon more efficiently, it facilitates intubation of the cecum faster
and with lesser patient discomfort.
 Cap-assisted colonoscopy can be tried as a salvage procedure in cases of failed cecal
intubation with regular colonoscopy.
 Cap-assisted colonoscopy also is of assistance during polypectomy, especially for polyps
located on the proximal aspects of folds.
 In cases of diverticular bleeding, use of cap helps localize the bleeding diverticulum and in
the treatment of the bleeding stigmata.

INTRODUCTION

Colonoscopy is considered the preferred method for colorectal cancer screening,

especially in the United States.1 With the recent US Multi-Society Task Force guide-
lines2 emphasizing that the goal of screening should be the prevention of colorectal
cancer, the role of colonoscopy has assumed even greater significance. The central
premise by which colonoscopy prevents colon cancer is the detection and removal
of precursor lesions, such as adenomas. Colonoscopy remains an imperfect tool,
however, for the prevention of colorectal cancer. One of the major reasons for this
is that adenomas can be missed during colonoscopy, even when the procedure is
performed by expert endoscopists using meticulous technique.3 Adenoma detection
rate is considered an important quality indicator of colonoscopy performance and its
clinical relevance was highlighted in a recent study showing that the adenoma detec-
tion rate of endoscopists is independently associated with interval colorectal cancer.4

Conflict of Interest: Received research grant support from Olympus America Inc.
Kansas City VA Medical Center, University of Kansas, 4801 Linwood Boulevard, Kansas City, MO
64128, USA
E-mail address: amitr68@hotmail.com

Gastroenterol Clin N Am 42 (2013) 479–489

http://dx.doi.org/10.1016/j.gtc.2013.05.008 gastro.theclinics.com
0889-8553/13/$ – see front matter Published by Elsevier Inc.
480 Rastogi

Therefore, efforts to improve and optimize adenoma detection rates continue to be an

active area of research in the field of colonoscopy.

REASONS FOR MISSING ADENOMAS

Several reasons have been attributed for missing adenomas during colonoscopy.
These include inadequate bowel preparation,5,6 suboptimal technique,7 shorter with-
drawal time,8 presence of flat/depressed/subtle lesions evading detection, and the
inability to visualize the proximal sides of haustral folds, flexures, rectal valves, and
ileocecal valve. Incomplete visualization continues to be a vexing problem for endo-
scopists with a wide range of experience. The haustral folds in the colon are of varying
dimensions and can shield significant amount of mucosal surface area from the view
of the endoscopist. One of the elements of good inspection technique during the with-
drawal phase of colonoscopy is to inspect between folds by torquing the colonoscope
and/or deflecting its tip. But this maneuver is limited by the extent of tip deflection and
angle of view of the lens at the colonoscope tip as well as the loss of visualization when
the colonoscope tip closely approximates the mucosa, leading to a red out. The fact
that lesions located on the proximal aspects of colonic folds are prone to be missed
during colonoscopy was highlighted in a study that used CT colonography as the
reference standard.9 This study showed that majority of clinically significant ade-
nomas that are missed during colonoscopy are located on the proximal sides of folds.
There are 3 methods that aid in inspecting these blind mucosal areas, which include
cap-assisted colonoscopy, third eye colonoscopy,10 and retroflexion of the colono-
scope.11 This review discusses the different aspects of cap-assisted colonoscopy.

CAP-ASSISTED COLONOSCOPY
Mechanism of Action of Cap
Cap-assisted colonoscopy is a simple technique using a small transparent cap
attached to the tip of the colonoscope (Figs. 1–3). The cap is shaped like a hollow cyl-
inder and, depending on its length, a portion of it protrudes for a variable distance
beyond the tip of the colonoscope. This portion of the cap helps depress the colonic
folds while keeping an appropriate distance between the mucosa and the lens at the
tip of colonoscope, thus preventing loss of visualization and facilitating the inspection
of the mucosal areas on the proximal aspects of folds, flexures, and valves

Fig. 1. Cap with a side hole.

 Cap-Assisted Colonoscopy 481

Fig. 2. Cap being fitted to the tip of colonoscope.

Fig. 3. Cap fitted to the colonoscope and extending for 4 mm beyond the tip.

Fig. 4. Colonoscopic view of the cap.

482 Rastogi

(Fig. 4).12–15 Furthermore, the cap can improve mucosal inspection by stretching or
splaying colonic mucosa that might have otherwise folded over and obscured small
lesions from the view of the endoscopist.13 The cap can also be of assistance during
insertion of the colonoscope by pushing away folds and helping with luminal orienta-
tion and better visualization at bends.12,16,17 This helps the endoscopist insert the
colonoscope with less air insufflation. Finally, the cap can be used to hook colonic
folds at acute bends and help reduce loops in the colonoscope.18

Type of Caps
Caps are of varying lengths, ranging from 2 mm to 10 mm. The most commonly used
one protrudes for approximately 4 mm beyond the tip of colonoscope after being
tightly secured (see Fig. 4). Caps come in different diameters that fit snugly on colo-
noscopes of various sizes (adult colonoscope, pediatric colonoscope, and magnifica-
tion colonoscope). The distal end of the cap is horizontal and the edges are rounded to
minimize mucosal trauma. The newer version of the cap has a side hole for drainage of
fluid and fecal material that might get entrapped within the interior confines of the cap
and can, therefore, obscure the view. Another variation of the cap used in one study19
is the retractable cap (Fig. 5). This cap extends to the desired length beyond the tip of
colonoscope by the injection of air with a 10-mL syringe and retracts by aspiration of
the air. The maximum extension possible is 7 mm. Various synonyms used for cap in

Fig. 5. Transparent retractable cap. Cap retracted (upper panel) Cap extended (lower panel).
(From Horiuchi A, Nakayama Y. Improved colorectal adenoma detection with a transparent
retractable extension device. Am J Gastroenterol 2008;103:341–5; with permission.)
 Cap-Assisted Colonoscopy 483

the literature include hood, transparent hood, transparent extension device, and distal
attachment.
Cap-assisted colonoscopy has been studied for a variety of endpoints that include
adenoma or polyp detection rates, cecal intubation rates, cecal intubation time,
patient discomfort during colonoscopy, and efficiency in colonoscopy. The literature
pertinent to each of these endpoints is reviewed.

CAP-ASSISTED COLONOSCOPY FOR ADENOMA/POLYP DETECTION

Cap-assisted colonoscopy has been tested for improving adenoma/polyp detection

since the late 1990s. The majority of earlier studies, including randomized controlled
trials (RCTs) comparing cap-assisted colonoscopy to standard colonoscopy, were
conducted in Asia12,14,16,17,19–23 and have shown mixed results. More recently, this
technique has been evaluated in Western countries. The first RCT on cap-assisted
colonoscopy conducted in United States was by Hewett and Rex.15 This was a tan-
dem design study with 100 subjects, of whom 52 were randomized to undergo
cap-assisted colonoscopy and 48 to regular high-definition colonoscopy as the first
procedure, followed by a second colonoscopy by the alternate method. Patients un-
dergoing cap-assisted colonoscopy first had a significantly lower adenoma miss rate
compared with those who underwent a regular colonoscopy as the first procedure
(21% vs 33%; P 5 .039). The difference in the miss rate was, however, seen only
for diminutive (5 mm) adenomas (22% vs 35%; P 5 .037). In another RCT by
Rastogi and colleagues,13 conducted at a tertiary-care veterans hospital, 420 sub-
jects were randomized to either cap-assisted colonoscopy or regular high-
definition colonoscopy. The proportion of subjects with at least 1 adenoma was
higher with cap-assisted colonoscopy (69% vs 56%; P 5 .009). Cap-assisted colo-
noscopy also detected a significantly higher number of adenomas per subject
compared with regular colonoscopy (2.3 vs 1.4; P<.001). Therefore, cap-assisted
colonoscopy detected a 13% higher number of subjects with at 1 one adenoma
and 59% higher adenomas per subject. A higher number of subjects with right-
sided adenomas and total number of right-sided adenomas were also detected by
the cap-assisted procedures. A majority of the subjects enrolled in this study were
male veterans and more than 90% had an excellent or good bowel preparation,
thereby limiting the generalizability of the results. Contrary to the results of these 2
studies, an RCT from the Netherlands24 did not find an increment in adenoma detec-
tion with cap-assisted colonoscopy. This study was conducted at 2 centers by 5
endoscopists, and randomly allocated 1380 participants to cap-assisted colonos-
copy or regular colonoscopy. The proportion of subjects with at least 1 adenoma
was similar in the 2 groups (28% vs 28%; relative risk [RR] 0.98; 95% CI, 0.82–
1.16). The mean number of adenomas per subject was also similar (0.50 vs 0.49;
P 5 .91). A large RCT from Hong Kong16 involving 1000 subjects showed lower ad-
enoma detection rates with cap-assisted colonoscopy. The adenoma detection rate
was 30.5% in the cap-assisted group compared with 37.5% in the regular colonos-
copy group (P 5 .018). Similarly, the number of adenomas per subject was also lower
in the cap-assisted group (0.63 vs 0.96; P 5 .023). This study, however, had limita-
tions because there was less satisfactory bowel preparation and shorter withdrawal
time in the cap-assisted group, factors that could have had a negative impact on the
adenoma detection rates. The type of cap used in all these studies had a length of
4 mm protruding beyond the tip of colonoscope. Horiuchi and Nakayama19 used a
specially designed cap, called a retractable transparent hood, and found that
although the proportion of patients with adenomas was similar compared with
484 Rastogi

colonoscopy without the device (29% vs 24%; P 5 .11), the total number of ade-
nomas detected was significantly higher (205 vs 150; P 5 .04).
Other RCTs have compared cap-assisted colonoscopy with regular colonoscopy
but have reported polyp detection rates without information on polyp histopathology.
Kondo and colleagues12 found that the polyp detection rate was significantly higher
with the cap (49% versus 39%; P 5 .04). In another study by Harada and colleagues,17
the detection rates of polyps was similar with and without the cap (43% vs 42%;
P 5 .86). Similarly, Tee and colleagues23 reported no difference in the polyp detection
rates between colonoscopies performed with and without the cap (33% vs 31%;
P 5 .75).
An exhaustive meta-analysis of the RCTs comparing cap-assisted colonoscopy
with regular colonoscopy was recently published.25 A total of 16 RCTs were included
with 8991 subjects, of whom 4501 underwent cap-assisted colonoscopy and 4490
standard colonoscopy. Twelve trials were identified for comparison of polyp detection
rates. Cap-assisted colonoscopy detected a significantly higher proportion of sub-
jects with polyps compared with regular colonoscopy (52.5% vs 47.5%, RR 1.08;
95% CI, 1.00–1.17). Number-needed-to-treat analysis showed that 27 patients would
need to undergo cap-assisted colonoscopy for 1 additional patient detected with
polyps. For adenoma detection rates, 6 trials were identified and no significant differ-
ence was seen between cap-assisted colonoscopy and regular colonoscopy (46.8%
vs 45.3%; RR 1.04; 95% CI, 0.90–1.19).

CAP-ASSISTED COLONOSCOPY FOR CECAL INTUBATION RATE AND CECAL

INTUBATION TIME

Several studies have compared cap-assisted colonoscopy with regular colonoscopy

for cecal intubation rate and cecal intubation time. A recent meta-analysis of RCTs
on cap-assisted colonoscopy25 included 10 studies that included cecal intubation
rates and found no significant difference between cap-assisted colonoscopy and
regular colonoscopy (96.4% vs 95.6%; RR 1.00; 95% CI, 0.90–1.02). There was,
however, statistical heterogeneity among these trials. Although it seems that cap-
assisted colonoscopy does not confer any significant benefit over regular colonos-
copy for cecal intubation, there is evidence to suggest that it may be useful in difficult
cases. Lee and colleagues16 compared cap-assisted with regular colonoscopy for
success as rescue procedures. In their study, patients in whom the cecum could
not be reached during the initial procedure by cap or the regular method underwent
a second colonoscopy by the alternate method. Cap-assisted colonoscopy achieved
a higher rescue rate in cecal intubation compared with regular colonoscopy (67% vs
21%; P 5 .003). An earlier study by the same group18 had evaluated cap-assisted
colonoscopy for consecutive patients with difficult regular colonoscopy defined as
failure to pass through the sigmoid colon after 20 minutes of examination or failure
to reach the cecum at the end of the procedure. For these patients, the procedure
was repeated with the cap. Of the 100 patients in whom the cecum could not be
reached by regular colonoscopy, success was achieved with the cap in 94 patients.
Therefore, cap-assisted colonoscopy can be considered a rescue method when reg-
ular colonoscopy fails to intubate the cecum. My personal experience has been that
cap-assisted colonoscopy is effective as a back-up procedure in difficult cases. The
potential benefit of using the cap is that it helps in luminal orientation at bends by
keeping the colonic mucosa away from the lens at the colonoscope tip. This assists
in negotiating sharp turns by better anticipation of the direction17 and also allows for
insertion of the colonoscope with less air insufflation. As a result, there is less chance
 Cap-Assisted Colonoscopy 485

of looping of the colonoscope during insertion, with greater likelihood of reaching the
cecum. Another potential mechanism for improved cecal intubation is the ability to
hook the folds, especially at turns, with the tip of the colonoscope augmented by
the cap. This helps reduce loops, thereby straightening the colonoscope and facili-
tating insertion.
As far as time to insert to the cecum is concerned, cap-assisted colonoscopy has
been shown superior to regular colonoscopy in multiple trials.12,13,16,17,19,21,24 Harada
and colleagues17 conducted a prospective randomized study with the primary aim of
comparing the cecal intubation time between cap-assisted colonoscopy and regular
colonoscopy. The mean cecal intubation time with the cap was 10.2  12.5 minutes,
which was significantly shorter than that with regular colonoscopy (13.4  15.8 min;
P 5 .024). The impact of cap on cecal intubation time was more prominent in
the expert endoscopist (5000 colonoscopies) group compared with those with
moderate experience (3000 colonoscopies). In the randomized trial by Lee and col-
leagues,16 the mean cecal intubation time was 1.2 minutes shorter in the cap-assisted
procedures. In the study by Rastogi and colleagues,13 the mean time to reach the
cecum was 3.29 minutes with the cap-assisted method compared with 3.98 minutes
with regular colonoscopy (P<.001). In another recently published large RCT by de
Wijkerslooth and colleagues,24 the cecal intubation time was also significantly lower
with cap-assisted colonoscopy compared with regular colonoscopy (7.7  5.0 min
vs 8.9  6.2 min; P<.001). Kondo and colleagues12 showed that cap-assisted colonos-
copy shortened the cecal intubation time and, in a stratified subanalysis, the effect
was strongest in the subgroups of women and older patients. Ten RCTs comparing
cecal intubation times between cap-assisted colonoscopy and regular colonoscopy
were included in the meta-analysis by Ng and colleagues.25 Of these, 7 showed lower
cecal intubation time with cap-assisted colonoscopy. Although there was significant
statistical heterogeneity, the mean cecal intubation time in the cap-assisted group
was significantly lower compared with regular colonoscopy (mean difference 5
0.64 min; 95% CI, 1.19 to 0.10). No RCT has shown a longer cecal intubation
time with the cap method.

CAP-ASSISTED COLONOSCOPY AND PATIENT DISCOMFORT

Cap-assisted colonoscopy has been compared with regular colonoscopy for patient
discomfort and pain during the procedure. Two studies showed no significant differ-
ences.16,20 Harada and colleagues,17 however, showed that the level of patient
discomfort was significantly lower with the cap. In this study, all procedures were
started without sedation, and intravenous midazolam was given only when a patient
requested it or complained of intolerable pain. The frequency of use of sedative was
similar in the 2 groups. The patients who did not get sedation were asked to complete
a questionnaire regarding the level of discomfort experienced by using a visual analog
scale graded into 3 categories: comfortable, acceptable, and intolerable. The propor-
tion of subjects who were comfortable was significantly higher in the cap-assisted
group (36% vs 28%; P 5 .04) and those who answered intolerable were significantly
lower compared with the regular colonoscopy group (18% vs 25%; P 5 .04). In
another study,26 assessment of pain experienced by patients was assessed postpro-
cedure on a modified 100-mm visual analog scale, on which 0 was defined as pain-
free and 100 as extremely painful. Patients undergoing cap-assisted colonoscopy
reported lower levels of procedural pain—visual analog scale of pain 29 versus 43
for regular colonoscopy (P 5 .01). In the more recent study by the Amsterdam group,24
discomfort during colonoscopy was scored using the 5-point Gloucester Comfort
486 Rastogi

Score, which ranges from no discomfort to extreme discomfort. The overall score was
lower in the cap-assisted group compared with the regular colonoscopy group (2.0 vs
2.2; P 5 .03). There is no study showing a higher level of patient discomfort with cap-
assisted colonoscopy compared with regular colonoscopy.

CAP-ASSISTED COLONOSCOPY AND POLYPECTOMY

Caps have been used to assist in removal of lesions in the gastrointestinal tract for the
past 2 decades, since the report by Inoue and colleagues.27 Most often this involves
sucking the lesion into the compartment between the edge of the cap and the tip of
colonoscope, followed by snaring the lesion or applying a band around it, followed
by snaring. In the colon, however, this technique has not been embraced routinely.
The cap affords, however, a mechanical advantage for endoscopic mucosal resection
of polyps, especially those located on the proximal aspects of folds. Because the cap
depresses the folds to expose their proximal aspects, it helps in better visualization of
the entire polyp located in these areas. The cap also helps stabilize the tip of colono-
scope and, therefore, keeps the polyp relatively stationary at an appropriate distance
for its removal. These factors help achieve a more complete and efficient polypectomy
for polyps in these locations. Park and colleagues28 conducted a prospective
controlled trial in which 329 patients undergoing endoscopic mucosal resection of co-
lon polyps were randomized to either cap-assisted colonoscopy or regular colonos-
copy. The mean size of polyps detected was similar in the 2 groups (11.65 mm vs
12.16 mm). The mean time (SD) required for endoscopic mucosal resection of 1
polyp, however, was shorter in the cap-assisted group compared with the regular co-
lonoscopy group (3.5  4.5 min vs 4.2  5.1 min; P 5 .01). Subgroup analysis showed
that although there was no difference in the time taken to resect pedunculated polyps,
there was a significant difference in the resection of nonpedunculated polyps (cap: 3.4
 5.0 min vs regular: 3.9  4.7 min; P 5 .018).

CAP-ASSISTED COLONOSCOPY FOR DIVERTICULAR BLEEDING

Cap-assisted colonoscopy also is a useful accessory in the management of divertic-

ular bleeding. It helps in examining diverticuli present between folds that may evade
detection and complete visualization during regular colonoscopy. Once the bleeding
stigmata within a diverticulum is found, the cap then helps align the target for therapy
(ie, a visible vessel or clot within the diverticulum) with the axis of the colonoscope29
and also stabilizes the colonoscope in relation to the diverticulum for precise applica-
tion of hemostatic therapy, such as clips or thermal cautery. If the bleeding stigmata
within the diverticulum is not visible, then the cap can be used to evert the diverticulum
and allow for inspection of the entire mucosal lining of the diverticulum dome.30 The
rim of the cap also provides some tamponade effect prior to hemostatic therapy by
pressure at the neck or slight suction of the dome of the diverticulum.30 Although these
are practical observations made by connoisseurs of cap-assisted colonoscopy, there
as yet is no RCT comparing the cap method with regular colonoscopy in patients with
suspected diverticular bleeding.

CAP-ASSISTED COLONOSCOPY FOR TRAINEES AND LESS-EXPERIENCED

ENDOSCOPISTS

Studies have also evaluated the performance of trainees and less-experienced endo-
scopists with cap-assisted colonoscopy. In one study,31 6 trainees, with experience of
fewer than 10 colonoscopies each, were randomly assigned to perform the procedure
 Cap-Assisted Colonoscopy 487

with or without the cap under the supervision of an attending colonoscopist. Success-
ful cecal intubation was defined as reaching the cecum within 20 minutes without the
assistance of the supervising attending. There were 300 procedures performed in
each group. The cecal intubation rate was significantly higher in the cap-assisted
group (81% vs 63%; P<.001) and the average cecal intubation time was significantly
shorter in the cap-assisted group (13.7 min vs 18.7 min; P<.001). In another study,22
one experienced (>5 years experience) and one inexperienced (<1 year experience)
endoscopist performed both cap-assisted and regular colonoscopy. The time taken
to reach the cecum for the experienced endoscopist was similar with or without the
cap. In contrast, for the inexperienced endoscopist, the time taken to reach the cecum
was significantly shorter with the cap (9.5 min vs 12.5 min; P<.05). The visual analog
scale scores of abdominal pain and distension felt by the subjects were also signifi-
cantly lower in the cap-assisted group for the inexperienced endoscopist. Caps
can, therefore, serve as a useful accessory in assisting novice endoscopists in the
performance of more efficient colonoscopy.

COMPLICATIONS

There have been no major complications reported due to the use of cap during colo-
noscopy. In one study,19 the investigators reported mild local submucosal petechial
lesions in the rectal mucosa in 9% of subjects undergoing colonoscopy with the trans-
parent retractable device that extends for a maximum of 7 mm beyond the tip of co-
lonoscope. Retroflexion in the rectum or intubation of the terminal ileum is not
hampered by the cap. The potential drawback of cap-assisted colonoscopy is the
additional cost burden associated with the cap (approximately $30).

SUMMARY

Cap-assisted colonoscopy is a simple, practical, and inexpensive technique that

serves several useful purposes in enhancing the performance of colonoscopy. It helps
improve polyp detection by its ability to visualize the otherwise blind mucosal areas on
the proximal aspects of folds and flexures, although its effect on adenoma detection
has been inconsistent. By helping navigate the colon more efficiently, it facilitates intu-
bation of the cecum faster and with lesser patient discomfort. Cap-assisted colonos-
copy can be tried as a salvage procedure in cases of failed cecal intubation with
regular colonoscopy. Cap can also be of assistance during polypectomy, especially
for polyps located on the proximal aspects of folds. Finally, in cases of diverticular
bleeding, use of the cap can help in localizing the bleeding diverticulum and in the
treatment of the bleeding stigmata.

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