Help wanted on technique of colonoscopy - Forum

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A Doctor

Help wanted on technique of colonoscopy - Ärzteforum

Post#1 »

I did about 300 flexible sigmoid fiberoscopies before starting with the usual and less rigid colonoscope, which I have used a similar number of times. These days I don't do many because of the way the work comes along, and I am finding that my ability to get round the loops is getting worse and worse.

I went off to see an expert colonoscopist for a couple of days, used image intensifiers a few times [which is not very practical in my situation], spent a lot of time talking with skilful colleagues, and still have a problem avoiding a sigmoid loop.

Any tips from the experts and teachers of colonoscopy? Can you put into words just what the expert does to avoid or undo the loop? I think I've heard much of the standard advice.


John Dissector

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#2 »

A group of experts published colonscopy videos in about 1990--these were extremely helpful, unfortunately, I can't find my copies today so can't tell you where I got them . I have also rented gastroenterology tapes from the American Gastroenterology Society (once again I don't remember exact name of the society).

Here are some tips which work for me and some I have been told work by experts like Sandy Nivatvongs at Mayo Clinic:
1. Whenever you get lost, pull back on the scope to straighten out the loops and visualize the lumen
2. Use tip deflection of course as needed
3. When you have trouble negotiating the sigmoid, rotate the scope (not just the tip, instead the whole scope) until you see the lumen
4. Have an assistant push the sigmoid into the left lower quadrant to reduce kinking
5. I occasionally have an assistant push upward on the transverse colon to negotiate the hepatic flexure
6. More often, if I get hung up in the transverse colon, I flip the patient onto their right side--this lets gravity advance the scope
7. In the right colon, use suction to advance the scope. You of course, need a little insufflated air to see the lumen, but the scope often advances better if the ascending colon is less distended.
8. This one I have not used much but is one expert's technique: Air feed as you are suctioning stool and fluid--apparently saves time for him
9. Also don't use much because Anesthesia protests: Sometimes flipping patient prone helps, because of direct pressure on the abdomen (from the position). This is not a good idea if your patient is heavily sedated and may stop breathing.
10. Sedation is critical. I still use Anesthesia for these (apparently insurers here still pay), but notice a big difference with different Anesthesia providers (our rules and regs or bylaws or something prevent us from scheduling only with the Anesthesia providers we prefer, so get stuck with the less desirable too often). Almost everyone uses a benzodiazepine and narcotic (usually Versed/Fentanyl) but some supplement with Ketamine (where I worked in Illinois they used Ketamine quite successfully), Propofol or sodium pentothal. I think it is also a matter of how much---our current Anesthesiologist uses only Versed and Fentanyl and is chintzy with her meds in general and colonoscopy with her is a struggle. The others who add one of the Anesthetic agents are much easier to work with--I can get to the cecum in 10-20 minutes and may even have a small snare polypectomy done in this time.
11. Run the scope yourself as much as possible at least while you are learning. Run the scope controls with your left hand. Advance and pull back on the scope with your right hand. At the moment, I have 2 expert scope helpers who can advance the scope for me watching the video monitor, so I let them do this (actually these are the bossy type techs and it would be difficult to keep them from advancing the scope). These 2 are usually also pushing on the abdomen to help advance the scope, pulling back at the right time, etc.--this is definitely a luxury. I have 5 others who aren't so good so I revert back to doing it all myself.
12. Know how the scope works and how to trouble shoot all problems. If necessary, read the manual, and go to an Olympus scope care course or get their video. This saves tons of frustration and saves time. Specifically, learn all the tricks for unclogging the suction and for fixing a scope that is not air feeding correctly. (Even worse, I had one scope that air fed continuously and could not be stopped and of course, the people working with me insisted it was fine--this was a dangerous problem that could easily have overinflated the colon and perforated the cecum.)
13. When the scope gets hung up, it sometimes helps to put more lubricant on the scope just as it enters the anus--I usually squirt a couple inches of lubricant onto the scope at this point.
14. Some people you just cannot do a complete colonoscopy on--this is a rule that I should remember better more often---I tend to struggle on much longer than I should with the truly difficult colonoscopies. I did, though, a few days ago get to the cecum in under 20 minutes in a patient that a good colonoscopist could not get past the mid-transverse colon on (so I was proud of myself).

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Surgeon

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#3 »

I don't have anything significant to add to very complete note. I am, however, interested that she (and others?) use anesthesia for these procedures. I never have, except with an occasional patient who is very nervous, or has anal stenosis, or something of the sort. I have been using Versed and Morphine for several years and have been very happy.

Avicenna

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#4 »

Very little to add. For the difficult sigmoid loop I usually start all colonoscopies with the patient on the left side, progress to the supine which works best for your assistant to apply pressure and only on the most difficult cases switch to the prone position as a last resort. Versed and Demerol work well for me without any other anesthesia. Your most important tool is an experienced endoscopy nurse that knows all the abdominal pushing tricks. I find better "feel" if I do all the pushing, pulling and applying torque to the scope myself. The more you do the easier it will get.

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A Doctor

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#5 »

Thank you for your useful tips on colonoscopies. I recall that companies selling the colonoscopes often used to put in an "overcoat" in the set that was designed to stop the sigmoid colon forming a loop. One would put it over the scope once in the tip was in the transverse colon and would help with passage through the transverse and right colon by preventing the sigmoid from looping. Any experience with this?

Paranoid

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#6 »

I've used overtubes on both colonoscopies and gastroscopies. They CAN be useful on occasion, but are very rarely needed. It is unusual that one can't pass the scope by the time one has used all of the tricks mentioned.

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Doctor Green

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#7 »

I don't have much to add except that pulling back and suctioning will get you a lot farther in the sigmoid. If you are stuck in a redundant transverse colon, pull the scope back to the rectum and start again...it often becomes surprisingly easier with a fresh approach. The one time I've found the prone position definitely advantageous is when you are stuck in the upper caecum and trying to get to the bottom or into the terminal ileum to cevalluate Crohn's etc. This maneovre will often get you that extra 4 or 5 cm you need. DO make a point of entering the terminal ileum IN EVERY CASE for 2 reasons...There will be occasions (SBFT+BA enema NORMAL) when a look inside the T.I. will reveal a low grade ileitis with a few apthous ulcers that will religiously CONVINCE you and your witness, the LORD ALMIGHTY, unless you have it on tape..... that this pt. is a CROHN'S...also it will force you to look at the ileo-ceacal valve HEAD-ON, and occasionally,...?every year or two..you will discover a carcinoma of the inferior lip of the ileo-caecal valve, when you retroflex the scope in the base of the caecum.

John Dissector

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#8 »

How do you get into the ileum routinely?

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Doctor Green

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#9 »

"Routinely" means about 95% of the time. If you don't make the effort to try and get in routinely, occasions when a look inside the ileum is the main reason for doing the endoscopy, will be a real effort, and frustrating if you don't. Most of the time, positioning the tip of the scope at the orifice will allow you to suck yourself in, with tip deflection. With the pt. in the prone position, direct advancement is often successful. Retroflexion is occasionally useful in slit-like valves that enter the caecum at an acute angle. In my experience, ulcerative colitis colons tend to admit the scope reasonable easily, and it is like being in the eye of a hurricane, with everything quiet all of a sudden in the ileum. Occasionally, multiple "blind" biopsies into the terminal ileum will provide positive histology for Crohn's even if you can't get in. Often the endoscopist is the only one who knows whether the pt has Crohn's or not, however, since the histology might be negative, although endoscopically apthous or serpiginous ulcers have been seen in the ileum, and this will make a significant difference in your treatment (higher doses and more proximally released 5-aASA cpds) , and more steroid dependence with Crohns.

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Turkish surgeon

Re: Help wanted on technique of colonoscopy - Ärzteforum

Post#10 »

I have been following this topic with interest. I have been doing colonoscopies over last 15 yrs. I don't do as many as my esteemed colleagues, average being 130-170 per yr.

One of my colleagues here, used the overtube for the first time, & unfortunately his patient suffered a sigmoid perforation.I personally have never used it.

BTW, what is the generic name of Versed ? Is that Sublimaze/Fentanyl ?

We generally use Propofol +/- Midazolam +/- Fentanyl. Caecum is reached in ~12-15 min. & in quite a few occasions, one is lucky to see the 'Mercedes sign' ( the tri-radiate fold at caecal pole ) in around 6-7 min. if sigmoid &/or hepatic flexure falls easily in line. { that's when the scope goes like a ferret on meth.!!. :))) }. Since using Oral Phosphate soln. & surgeon's pressure saline wash trick, the colons are uniformly clean.

Some of the tricks/lessons I learnt:

I always try & think/imagine where the tip of the scope is & what it is doing, where & how the colon is lying. I haven't used the Image Intensifier in yonks, but it provided valuable help yrs ago, in this.

Starting in lt.lateral,the assistant presses in Lt.iliac fossa as soon as I am in upper rectum/sigmoid. I keep the lumen in view centrally. I try not to blow too much air in sigmoid to avoid overdistended-long-balloon situation. If sigmoid is a bit difficult, I turn the patient on the back, early. I get the assistant to push at the umbilicus with the back of the open palm, trying to get the colon to lie reasonably.
The single most important technique I learnt was the twisting/torquing the scope (usually clockwise by supinating the hand holding the scope) to bring lumen in view & keep it in view all the time. I generally only use that movement + up/down movement of the tip by left hand control wheel. I avoid pushing scope in forcibly. Withdrawing 5-10 cm & restarting is usually quicker in the long run.
Many a times sigmoid loops, & one can sense or feel this. Change of pos.from lt.lateral to supine & back again, usually allows the colon to fall in place, but, many a times very little or no pressure of hand on abdo./ or turning is required. As I have very little help, the anaesthetist,the trim slim nurse assistant or the theatre sisters declare that if the patient is >85kg in wt. I will have to do a uni-positional scopy. :((.
I change the position of assistants' pressure by feeling the abdomen. Above the umbilicus; just under the spleen; in hypogastrium; over the hepatic flexure.. etc.This is what II taught me...by watching the tip of the long artery forceps placed on the abdo wall one sees where the apex of the loop lies, & where to push to straighten it while pulling the scope back.
If the scope is more than 40-50 cm. in & I can't see transverse colon, there must be a loop. Similarly, if the caecum is not identified at 60 to 80 cms. the sigmoid is not straightened as in 95% or more of cases, caecum is reached at 60-90 cms.& anything more than this means a loop needs straightening. This is done by withdrawing the scope & seeing that the view of the lumen is not changing.
At the hepatic flexure, turning the handle of the scope 90 degrees to rt. +/- rolling the pt. in Lt.lateral if he is supine,helps bring the rt.colon in view. Sucking in allows advancement as others have mentioned.

I haven't put the patient in prone position..for fear that the native denizens of theatre may get uptight..but will try that to get into ileum. I haven't been doing that routinely..It has happened fortuitiously at times. I would be grateful for any hints others may have for slipping into that something smaller...(Ileum)

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