Colonoscopy: A Few Simple Rules

Transcription

1 Colonoscopy: A Few Simple Rules Jerome D. Waye, MD Center for Advanced Colonoscopy and Therapeutic Endoscopy-Sinai (CACTES) Mount Sinai Medical Center NYSGE GI Fellows 2018

2 Technique of Colonoscopy Completely different from gastroscopy Push scope into cricopharynx Push scope into esophagus Push scope into stomach Push scope into duodenum When you are finished, and only then, pull back the scope Colonoscopy is a different mind set

3 Effect of Pushing vs. Ideal

4 The Anatomy

5 Radiographic/Anatomic Correlation

6 Effect of Pushing Diaphragm

7 Stretching the Mesentery Pushing the scope in stretches the restosigmoid like a rigid sigmoidoscope In young patients, the mesentery resists stretch, and causes pain Perforation may result

8 Cope with the Curves

9 Only One Rule STRAIGHTEN THE SCOPE

10 Straighten the Scope

11 How to Do The Rule

12 Pull Back to Go from THIS TO THIS

13 The Most Important Maneuver During Colonoscopy Keep the Scope Straight The way to do this is: PULL BACK THE SCOPE NOT ONCE, NOT TWICE: DO IT OFTEN Usually with clockwise torque or twisting

14 Magnetic Imager For position in the colon AP View Lateral Dark is Posterior

15 Magnetic Imager For position in the colon AP View Lateral Dark is Posterior

16 Not all loops are the same configuration

17 STRAIGHT SCOPE After every advance, pull back After passing a curve, pull back After rounding the splenic flexure, pull back When approaching the cecum, pull back Pull back, pull back, pull back until you reach the cecum

18 Abdominal Pressure Remove Loop Before Giving Pressure Suprapubic Pressure Force Vector = blue arrow

19 BLACK: AWAY FROM YOU: POSTERIOR LIGHT GRAY: CLOSE TO YOU: ANTERIOR Normal Anatomy Of Colon In Rectosigmoid Scope Guide View PATIENT IN SUPINE POSITION

20 The Anatomy The colon has a clockwise spiral twist. It is kept in that configuration by the mesentery Anterior structure Sigmoid colon

21 The Second Most Important Maneuver During Colonoscopy Abdominal Pressure Tends to keep the scope straight Keeps the scope from making big loops Moves tip forward May move bowel over the scope tip An aid to increase speed of the examination BUT: Limit the use of pressure by assistant

22 Abdominal Pressure: Non- Specific to Prevent a Loop Suprapubic pressure Anterior Posterior At cm, use suprapubic pressure After pulling back to reduce the loop

23 Abdominal Pressure: Non- Specific Posterior At cm, or when the tip is in TVC, left mid abdominal pressure may help to prevent anterior bowing of scope

24 Abdominal Pressure: Specific Endoscopist must find the proper place Prevent bowing Useful for any location proximal to splenic flexure This upper mid abdomen pressure often helps to reach AC and cecum-prevent bowing

25 Abdominal Pressure From: Practical Colonoscopy. Waye, Aisenberg, Rubin 2013 Wiley

26 For you, for me, for everyone: Shaft: Air: Dials: Options are Limited push in/pull out torque clockwise/counterclockwise (stiffen/soften) insufflate/aspirate up-down/right-left Patient: change position external pressure on abdomen

27 The Most Important Maneuver During Colonoscopy Keep The Scope Straight

28 Right Hand Does the Work Practical Colonoscopy: Waye, Aisenberg, Rubin PULL BACK TO STRAIGHTEN

29 Why pull with clockwise torque The colon has a clockwise spiral twist. The clockwise torque locks the tip in position. Counterclockwise torque would remove scope Anterior structure Sigmoid colon

30 The Third Most Important Maneuver During Colonoscopy Aspirate air Decreases the length of the colon Decreases the width (circumference) of the colon Helps to advance the scope Can be of great help in getting around a corner Does little to add to patient discomfort

31 Shortens the colon Decreases the circumference Remove Air Balloon deflated 11 inches Balloon inflated 40 inches

32 The Bare Bones of Colonoscopy There are only 3 things to remember: 1. Keep the scope straight 2. Abdominal pressure 3. Aspirate air

33 The Actual Technique The colon has to be clean, clean, clean. Start with patient in left lateral I rarely change patient s position Others use a lot of position shifting (sedation) The right hand does almost all of the work along with the left thumb on the large wheel The left thumb NEVER leaves the left wheel

34 Key Maneuvers Torque often and a lot Frequent reduction of loops Remove both internal and external loops Abdominal pressure may help tip advance Perhaps position change may be of some help Amount of gas?minimize or use freely? Do not push if you don t know where tip is going

35 Basic Colonoscopy Always Know Location of Lumen Light/dark relationship Lumen is behind a blind fold Surface light reflections from circular muscle layer Don t push if you don t know where you are going

36 Signposts for the Lumen In a different place, you may not be able to read the signs But they are there You must learn how to read them

37 Signposts in the Colon LUMEN IS BEHIND A BLIND FOLD LUMEN IS TOWARD THE DARK AREA SEE THE LUMEN READ HIGHLIGHTS

38 Signposts in the Colon

39 Signposts in the Colon

40 Signposts in the Colon

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42 Water Colonoscopy A LOT: Turn off air Fill colon with water Careful of your shoes A LITTLE: ml. use at rectosigmoid: may straighten it out Still be careful of your shoes

43 Water Intubation: turn off air

44 Anatomy Affects Colonoscopy Sometimes colonoscopy is difficult: Tall men Big fat people Slender women

45 Different scopes for different folks Nose or Radius Bending Section Starts Standard colonoscope Pediatric colonoscope Gastroscope

46 When Tip is on Mucosa When free, tip moves well, but if on mucosa the action changes Another reason to pull back on scope

47 Always Remember Rule #1 KEEP THE SCOPE STRAIGHT

48 Endoscopy Mar;50(3): How I do colonoscopy. Waye JD #1, Thomas-Gibson S #2.

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