Ten tips for better, safer insertion.

AJG December 2012

2:

Acute recto-sigmoid angle:

Young women.

Elderly with stenosing Div dis.

Previous pelvic surgery(lower abd

or pelvic as H/O abd hysterectomy).

To overcome:

Not push forcibly.

Keep short scope, use torque & rotation( clockwise).

1. Anticipate altered sigmoid anatomy.

2. Never push against fixed resistance.

Force does not work in endoscopy.

Sp in IBD or radiation colitis.

Hold the scope like pencil not like tennis racket.

3. Maximize sensory feedback from the IT.

2/3 of insertion time. Reduce any loop before bypassing splenic flexture.The most difficult segment during insertion.Sigmoid colon accordion-like &its mesentry length is quite variable.Can be short 25–30 cm with a straight scope in the cecum (at 65–70 cm of insertion). Or stretched to 70–80 cm.Precise localization, by outside body scope length, is difficult when looped, so mark polyps for finding it on withdrawal.80% conventional alpha loop occurs because of the shape of the pelvis& curved sacrum.

4. Master the left colon.

If this is not obvious, it can be approximated by assessing the amount ofscope inserted and the tension in the IT& applying knowledgeof the colonic anatomy to that point. A resistance-free insertion through featureless colon to 80 cm with few angulations suggests the formation of a large sigmoid loop. This will need to beresolved before you attempt to advance to the right colon. In contrast,a straight 50-cm scope at the splenic flexure with non-progressionon insertion suggests a mobile sigmoid or “high” splenic.Use of the stiffener or specific pressure will control the problem.

Try not> 2 attempts, but go to the next strategy.

Change to ped colonoscope or gastroscope.

Try to enter ascending colon with only 70–90 cm.Often rotate clockwise into the ascending with gentle advancement & by aspirating & gentle backward/ forward movements, proceed to the cecum.Brisk/forceful movements when is in the right colon will result in looping of the relatively unfixed left colon.

Loss of one-to-one progress, means that redundant length of inserted endoscope requires withdrawal after the next corner&at the hepatic flexure this can be simply completed by clockwise torque, aspiration& withdrawal into the ascending colon or put the patient in half back or total supine.

The site of flat lesions responsible for interval cancers. It is inferior to ileocecal valve.If difficulty is encountered, aspiration of air & counterclockwisetorque, hugging the medial wall of the ascending colon& workinggently backward & forward with 2-cm movements to insertthe tip of the colonoscope beyond the ileocecal valve. Should touch the appendicular orifice for deep cecal intubation.

Cecum not reached within 20 mins or not half way in 10 mins:

Call the supervisor for discussion or take over.

Consider benefit-risk ratio for continuing attempt.

Quit & consider alternative imagings.

At least half given on the morning of the examination.No increase risk of aspiration pneumonia.No increase in hesitancy..

Now FOR ALL.

Co2+ Propofol= Truly painless colonoscopy.

Decreases postprodeural distention pain.

Used specially when risk of pneumatic injury as in:Colonoscopic decompression for acute colonic pseudoobstructionColonic stricture dilationStent placementSevere colonic diverticular disease.

During insertion & aspirate water on withdrawal to see details.

Useful for:

Unsedated colonoscopy

Redundant colon.

Allows simultaneous movement of the up/down control with left hand & the right/left control with the right hand.Can perform detailed therapeutic work.Can be useful in passing complex turns in the sigmoid colon.

Major: bleeding, perforation.

Don’t forget: Aspiration( if hiccough be aware), splenic injury (sedation increase looping & pull the spleno-colic ligament) .

Both increase by: sedation, supine & RL positioning.

For most diminutive & 1-2 cms polyps, cold snare can be used.No need for tenting or deflation & some of normal mucosa can be reoved with the polyp.

50% of precan lesions is of the above lesions.

Needs:Adequate luminal distentionAdequate cleanup of stool, mucus& bubblesAdequate time“Working the folds.” Mucus cap on serrated polyps.

Screening colonoscopy is less preventive of CRC in right colon BZ Flat,depressed & serrated lesions are more.

So examine right colon twice sp if few or no lesions are detected.

Use retroflexion or cap for folds inspection.

New snare for flat & difficult to access polyps.

Spiral stents ( for flat ).

Ultrathin stents.

[Presented by]

Prophylactic cliping of large polypectomy defects. Specially for:On anticoagulation or antiplatelet agent such as clopidogrel.When a polyp in the ascending colon particularly hard to reachWhen there is any question about a deeper injury during polypectomyWhen the patient has been referred from a remote area where there is less endoscopic Expertise.Postpolypectomy bleed or other complication might not be well tolerated.

ANY QUESTIONS

THANKS