2: Ten tips for better, safer insertion. AJG December 2012
1. Anticipate altered sigmoid anatomy.Acute recto-sigmoid angle:Young women.Elderly with stenosing Div dis.Previous pelvic surgery(lowerabdor pelvic as H/O abdhysterectomy).To overcome:Not push forcibly.Keep short scope, use torque& rotation( clockwise).
2. Never push against fixed resistance.Force does not work in endoscopy.Sp in IBD or radiation colitis.
3. Maximize sensory feedback from the IT. Hold the scope like pencil not like tennis racket.
4. Master the left colon.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 65–70cm of insertion). Or stretched to 70–80 cm.Precise localization, by outside body scope length, is difficult whenlooped, so mark polyps for finding it on withdrawal.80% conventional alpha loop occurs because of the shape of thepelvis& curved sacrum.
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 fewangulations 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 orspecific pressure will control the problem.
Try not> 2 attempts, but go to thenext strategy.Change to ped colonoscope orgastroscope.
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 movementsLoss of one-to-one progress, means when is in the right colonthat redundant length of inserted will result in looping of theendoscope requires withdrawal after relatively unfixed left colon.the next corner&at the hepatic flexurethis can be simply completed byclockwise torque, aspiration&withdrawal into the ascending colon orput the patient in half back or totalsupine.
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 within20 mins or not half way in10 mins:Call the supervisor fordiscussion or take over.Consider benefit-risk ratiofor continuing attempt.Quit & consider alternativeimagings.
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 onwithdrawal to see details.Useful for:Unsedated colonoscopyRedundant 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, coldsnare can be used.No need for tenting or deflation & some ofnormal mucosa can be reoved with thepolyp.
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 inright colon BZ Flat,depressed & serrated lesions aremore.So examine right colon twice sp if few or no lesionsare 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 duringpolypectomyWhen the patient has been referred from a remote area where thereis less endoscopic Expertise.Postpolypectomy bleed or other complication might not be welltolerated.