仿真结肠镜训练模式的优化研究

仿真结肠镜可用于结肠镜初学者的培训,但不同训练模式的优劣仍存在争议。目的：研究不同仿真结肠镜训练模式对建立结肠镜技能的作用,以发现最优化训练模式。方法：学员分为整体训练法（A组）、分段训练法（B组）、整体训练与关键阶段相结合法（C组）三组进行训练。训练结束后根据评分判断最适合结肠镜受训学员的训练模式。结果：三种训练模式在安全性和准确度方面无明显差异,C组在残气量、肠袢形成和操作时间方面具有明显优势。结论：整体训练与关键阶段相结合法是仿真结肠镜最优化的训练模式。     

结肠镜技能训练、能力与质量评估的研究进展

结肠镜检查操作复杂,且操作与镜身运动之间联系微妙,这为教学工作带来很大障碍。对于操作能力和操作质量的评价,缺乏精细、有针对性和指导意义的评价指标和评价方法。在当前结肠镜检查需求激增的背景下,对更先进的结肠镜操作教学法、技能评估和质量控制方法的需求愈发迫切,因此,近年来在该领域涌现出了很多研究成果。本文将从评价的指标、场景和方法3个维度对这一领域研究的现有成果进行综述。     

结肠镜技能训练、能力与质量评估的研究进展

结肠镜检查操作复杂, 且操作与镜身运动之间联系微妙, 这为教学工作带来很大障碍。对于操作能力和操作质量的评价, 缺乏精细、有针对性和指导意义的评价指标和评价方法。在当前结肠镜检查需求激增的背景下, 对更先进的结肠镜操作教学法、技能评估和质量控制方法的需求愈发迫切, 因此, 近年来在该领域涌现出了很多研究成果。本文将从评价的指标、场景和方法3个维度对这一领域研究的现有成果进行综述。     

提高结肠镜腺瘤检出率的技术进展

结直肠癌一直属于世界范围内主要的癌症死因之一，如何提高其癌前病变，即腺瘤检出率，一直是内镜医生的努力方向。结肠镜腺瘤总体漏诊率高达20％～25％，除受内镜医生诊断经验、操作水平、退镜检查时间和患者肠道清洁度影响以外，肠道解剖结构、结肠镜的肠腔盲区均是病变漏诊的重要原因。本文即综述了近年来，对上述问题进行的内镜器械及技术方面的改进。     

结肠镜操作技能培训及评价体系的探讨

随着医学事业的迅猛发展，消化内镜检查术迅速普及，越来越多的医生掌握了消化内镜检查及操作技术，显著提高了消化系统疾病的诊断水平，也使内镜治疗技术迅速普及。结肠镜检查作为一项基本的消化内镜技术，是结肠癌筛查的重要手段，目前我国已有越来越多的基层医院开展了结肠镜检查项目。但是，结肠镜检查操作相对复杂，需要理论知识与实践操作技能的有机结合。目前我国尚未确立完善的结肠镜诊疗技术培训体制，难以适应大肠疾病发病率逐年增高和结肠镜操作医生迅速增加的现状。     

异丙酚静脉麻醉辅助结肠镜检查的应用研究

目的 探讨应用异丙酚作镇静麻醉辅助结肠镜检查的可行性，评价其效果和安全性。方法 将2210例结肠镜检查患者随机分为2组：麻醉组（2000例）静脉注射异丙酚至患者进入4级镇静状态后进行结肠镜检查。对照组（210例）按常规进行结肠镜检查。观察2组检查前，检查开始后1，5，20min和检查结束后的血压，脉搏，血氧饱和度以及检查反应和入镜时间。结果 检查过程中，麻醉组的平均收缩压各时段无明显变化（P＞0．05），对照组变化明显（P＜0．01）。2组的平均舒张压，脉搏和血氧饱和度在相应各时段的变化均无显著性差异（P＞0．05）。麻醉组的入镜时间和检查反应明显优于对照组（P＜0．01）。结论 异丙酚辅助结肠镜检查是安全有效，其入镜时间和检查反应优于普通检查。     

无症状肠结核的结肠镜诊断

目的探讨无症状肠结核的结肠镜检诊断。方法回顾性分析本院1997年1月至2004年12月结肠镜检查诊断的无症状肠结核14例资料。结果结肠镜下表现:病变部位:11例位于回盲部或回肠末端,3例位于结肠;分型:炎症型3例,溃疡型4例,增殖型2例,混合型5例。病检:9例活检病理诊断肠结核,1次阳性5例,2次或以上阳性4例。结论结肠镜检重点观察肠结核好发部位及病变特征,结合活检是诊断无症状肠结核的重要手段。     

变焦结肠镜的临床应用

在电子内镜广泛应用的基础上,最近各大内镜公司又相继推出了变焦结肠镜,并开始向全国普及。迄今有关变焦结肠镜的文献报道还不多,本文旨在总结介绍一些使用变焦结肠镜的基本知识和临床经验。     

水交换结肠镜结合二氧化碳注气行结肠镜检查的临床分析

目的探讨水交换肠镜加二氧化碳气泵用于结肠镜诊疗中的效果和安全性。 方法随机选取进行结肠镜检查的患者600例,随机分为2组,即注气组（对照组）、水交换肠镜加二氧化碳气泵组（观察组）,每组300例;观察两组患者的镇痛效果、进镜时间、不良反应发生情况。 结果观察组镇痛效果、进镜时间优于对照组,差异有统计学意义（P<0.05）;术中HR、BP、SpO₂与对照组比较,差异无统计学意义（P>0.05）。 结论水交换结肠镜检查诊疗可以缩短肠镜检查时间,减少患者痛苦,有镇痛作用,安全有效且操作简便,联合二氧化碳气泵使用效果更好。     

老年人进展期结肠癌彩色多普勒超声与电子结肠镜检查的对比研究

目的 探讨彩色多普勒超声榆查在老年人进展期结肠癌诊断中的价值及其与电子结肠镜检查的比较. 方法经彩色多普勒超声对69例老年结肠癌患者进行诊断,并将诊断结果与电子结肠镜检查及手术病理检查结果进行对比研究. 结果与手术病理诊断及定位诊断比较,彩色多普勒超声对老年人结肠癌定性诊断符合率为95.6%(66/69),电子结肠镜为91.3%(63/69),2种检查定性诊断符合率的差异无统计学意义(精确概率P>0.05);彩色多普勒超声对老年人结肠癌定位诊断符合率为91.3%(63/69),电子结肠镜为94.2%(65/69),2种检查定位诊断符合率的差异无统计学意义(χ~2=0.431,P>0.05).彩色多普勒超卢对患者瘤体内部小同程度的血流信号均可探出,其检出率为100%,对腹腔淋巴结转移、肝转移、周围组织侵犯及远端结肠转移诊断的符合率分别为87.5%、100%、84.6%及100%. 结论彩色多普勒超声对老年人结肠癌的诊断具有较高的应用价值,可作为老年人进展期结肠癌诊断的一项无创性检查方法.彩色多普勒超声与电子结肠镜检查相互结合,对老年人结肠癌的诊治可提供更可靠的依据.     

Mechanical analysis of insertion problems and pain during colonoscopy: Why highly skill-dependent colonoscopy routines are necessary in the first place... and how they may be avoided

BACKGROUND:

Colonoscopy requires highly skill-dependent manoeuvres that demand a significant amount of training, and can cause considerable discomfort to patients, which increases the use of sedatives. Understanding the underlying fundamental mechanics behind insertion difficulties and pain during colonoscopy may help to simplify colonoscopy and reduce the required extent of training and reliance on sedatives.

METHODS:

A literature search, anatomical studies, models of the colon and colonoscope, and bench tests were used to qualitatively analyze the fundamental mechanical causes of insertion difficulties and pain. A categorized review resulted in an overview of potential alternatives to current colonoscopes.

RESULTS:

To advance a colonoscope through the colon, the colon wall, ligaments and peritoneum must be stretched, thus creating tension in the colon wall, which resists further wall deformation. This resistance forces the colonoscope to bend and follow the curves of the colon. The deformations that cause insertion difficulties and pain (necessitating the use of complex conventional manoeuvres) are the stretching of ligaments, and stretching of colon wall in the transverse and longitudinal directions, and the peritoneum.

CONCLUSIONS:

Four fundamental mechanical solutions to prevent these deformations were extracted from the analysis. The current results may help in the development of new colonoscopy devices that reduce – or eliminate – the necessity of using highly skill-dependent manoeuvres, facilitate training and reduce the use of sedatives.     

Clinical impact of endoscopy position detecting unit(UPD-3) for a non-sedated colonoscopy

AIM:To evaluate whether an endoscopy position detecting unit(UPD-3) can improve cecal intubation rates, cecal intubation times and visual analog scale(VAS) pain scores, regardless of the colonoscopist's level of experience.METHODS:A total of 260 patients(170 men and 90women)who underwent a colonoscopy were divided into the UPD-3-guided group or the conventional group(no UPD-3 guidance).Colonoscopies were performed by experts(experience of more than 1000colonoscopies)or trainees(experience of less than 100colonoscopies).Cecal intubation rates,cecal intubation times,insertion methods(straight insertion:shortening the colonic fold through the bending technique;roping insertion:right turn shortening technique)and patient discomfort were assessed.Patient discomfort during the endoscope insertion was scored by the VAS that was divided into 6 degrees of pain.RESULTS:The cecum intubation rates,cecal intubation times,number of cecal intubations that were performed in15 min and insertion methods were not significantly different between the conventional group and the UPD-3-guided group.The number of patients who experienced pain during the insertion was markedly less in the UPD-3-guided group than in the conventional group.Univariate and multivariate analysis showed that the following factors were associated with lower VAS pain scores during endoscope insertion:insertion method(straight insertion)and UPD-3guidance in the trainee group.For the experts group,univariate analysis showed that only the insertion method(straight insertion)was associated with lower VAS pain scores.CONCLUSION:Although UPD-3 guidance did not shorten intubation times,it resulted in less patient painduring endoscope insertion compared with conventional endoscopy for the procedures performed by trainees.     

Repeat colonoscopy after endoscopic polypectomy

The records of all patients undergoing endoscopic polypectomy between December 1979 and December 1982 were reviewed. One hundred seventy-two patients underwent colonoscopic polypectomy in the absence of carcinoma or inflammatory bowel disease. Of these, the polyp could not be retrieved in 4, and 19 were lost to follow-up. One hundred forty-nine patients underwent subsequent endoscopy from one to four years after the initial polypectomy. Seventy-five (50.3 percent) of the patients developed new polyps. Although 61 of the 75 patients with new polyps were identified in the first two years, new polyps were noted throughout all four years. The presence of multiple polyps on the initial examination was statistically significant in predicting new polyps. The age and sex of the patients, size of the polyps, and the presence of atypia did not identify patients at higher risk for new polyps. The data indicate that new polyps are more likely to develop in patients who had a previous, polyp. It would appear that annual examinations should be performed until two successive examinations are negative. Following a second negative examination, reexamination at two- or three-year intervals, unless symptomatic, would appear to be adequate. Read at the meeting of the American Society of Colon and Rectal Surgeons, Houston, Texas, May 11 to 15, 1986.     

Management of perforation due to colonoscopy

Six patients who underwent emergency laparotomy for perforations secondary to colonoscopy or polypectomy are described. Three patients had the laceration closed primary, two required colostomy, and one needed resection. When contamination is minimal and the colon is mechanically prepared, primary closure without diversion is the treatment of choice. Colostomy is rarely indicated and may lead to increased morbidity, in view of the need for closure. However, resection should be considered if suspicion of carcinoma is great. Factors that contribute to perforation include sedation, forceful introduction of the colonoscope, inadequate equipment for hemorrhage control, and prolonged application of electrocoagulation to the colonic wall. The opinions or assertions contained herein are the private ones of the authors and are not to be construed as official or reflecting the view of the Navy Department or the Naval service at large.     

Appropriateness of colonoscopy： Diagnostic yield and safety in guidelines

AIM: To evaluate if the guidelines for the appro-priateness of performing colonoscopy by American Society for Gastrointestinal Endoscopy (AGSE) and Italian Society of Digestive Endoscopy (SIED) yield a good diagnostic efficacy and do not present risks of missing important colonic pathologies in an Italian population sample.METHODS: A total of 1017 consecutive patients (560 men and 457 women; mean age 64.4 ± 16 years) referred to an open-access endoscopy unit for colonoscopy from July 2004 to May 2006 were evaluated according to ASGE and SIED guidelines for appropriateness of performing the procedure. Diagnostic yield was defined as the percentage of relevant colonic pathologies of the total number of colonoscopies performed.RESULTS: About 85.2% patients underwent colono-scopy that was considered appropriate based on at least one ASGE or SIED criterion, while it was considered inappropriate for 14.8% of patients. The diagnostic yield of colonoscopy was significantly higher for appropriate colonoscopies (26.94% vs 10.6%, P < 0.001) than for inappropriate colonoscopies (5.3%). There was no missed colorectal cancer following the ASGE/SIED criteria.CONCLUSION: ASGE/SIED guidelines have shown a good diagnostic yield and the rate of missing relevant colonic pathologies seems very low. Unfortunately, the percentage of inappropriate referrals for colonoscopy in an open-access endoscopy system is still high, despite the number of papers published on the issue and the definition of international guidelines. Further steps are required to update and standardize the guidelines to increase their diffusion and to promote educational programs for general practitioners.     

Patient comfort and quality in colonoscopy

AIM: To explore the relationship of patient comfort and experience to commonly used performance indicators for colonoscopy. METHODS: All colonoscopies performed in our four endoscopy centres are recorded in two reporting systems that log key performance indicators. From 2008 to 2011, all procedures performed by qualified endoscopists were evaluated; procedures performed by trainees were excluded. The following variables were measured: Caecal intubation rate (CIR), nurse-reported comfort levels (NRCL) on a scale from 1 to 5, polyp detection rate (PDR), patient experience of the procedure (worse than expected, as expected, better than expected), and use of sedation and analgesia. Pearson’ s correlation coefficient was used to identify relationships between performance indicators.RESULTS: A total of 17027 colonoscopies were performed by 23 independent endoscopists between 2008 and 2011. Caecal intubation rate varied from 79.0% to 97.8%, with 18 out of 23 endoscopists achieving a CIR of > 90%. The percentage of patients experiencing significant discomfort during their procedure (defined as NRCL of 4 or 5) ranged from 3.9% to 19.2% with an average of 7.7%. CIR was negatively correlated with NRCL-45 (r=-0.61, P < 0.005), and with poor patient experience (r=-0.54, P < 0.01). The average dose of midazolam (mean 1.9 mg, with a range of 1.1 to 3.5 mg) given by the endoscopist was negatively correlated with CIR (r=-0.59, P < 0.01). CIR was positively correlated with PDR (r=0.44, P < 0.05), and with the numbers of procedures performed by the endoscopists (r=0.64, P < 0.01). CONCLUSION: The best colonoscopists have a higher CIR, use less sedation, cause less discomfort and find more polyps. Measuring patient comfort is valuable in monitoring performance.     

Small caliber overtube-assisted colonoscopy

AIM： To combine the benefits of a new thin flexible scope with elimination of excessive looping through the use of an overtube. METHODS： Three separate retrospective series. Series 1：25 consecutive male patients undergoing unsedated colonoscopy using the new device at a Veteran＇s hospital in the United States. Series 2：75 male patients undergoing routine colonoscopy using an adult colonoscope, pediatric colonoscope, or the new device. Series 3：35 patients who had incomplete colonoscopies using standard instruments.
RESULTS： Complete colonoscopy was achieved in all 25 patients in the unsedated series with a median cecal intubation time of 6 min and a median maximal pain score of 3 on a 0-10 scale. In the 75 routine cases, there was significantly less pain with the thin scope compared to standard adult and pediatric colonoscopes. Of the 35 patients in the previously incomplete colonoscopy series, 33 were completed with the new system.
CONCLUSION： Small caliber overtube-assisted colonoscopy is less painful than colonoscopy with standard adult and pediatric colonoscopes. Male patients could undergo unsedated colonoscopy with the new system with relatively little pain. The new device is also useful for most patients in whom colonoscopy cannot be completed with standard instruments.     

Is the variable-stiffness paediatric colonoscope more effective than a standard adult colonoscope for outpatient adult colonoscopy?: A randomised controlled trial

BACKGROUND: Trials with variable-stiffness colonoscopes have yielded conflicting results regarding efficacy and patient tolerance. AIM: We compared a variable-stiffness paediatric colonoscope with a standard adult colonoscope. METHODS: Two hundred and forty consecutive adult outpatients presenting for colonoscopy were randomised to either a variable-stiffness paediatric colonoscope or an adult colonoscope. If there was difficulty in performing colonoscopy with the assigned scope, the endoscopist was given the option of switching to the alternative instrument. In the condition of a severely fixed, angulated sigmoid colon, a final 'salvage' (backup) option was that of switching to an even thinner diameter paediatric colonoscope. RESULTS: The initial frequency of total colonoscopy was similar with the variable-stiffness paediatric colonoscope and adult colonoscope (95.8% versus 96.6%, p=1.0). Factoring in scope changes, the final frequency was 98.3% versus 99.2% (p=1.0). There was no statistical difference between the two groups in terms of insertion time, doses of sedative medications, scales of procedure difficulty, or patient satisfaction. CONCLUSIONS: Adult colonoscope and variable-stiffness paediatric colonoscope are both effective instruments for routine colonoscopy. In cases when the use of the initial scope is unsuccessful, switching to the alternative scope may permit passage to the caecum. There are occasional patients with fixed, angulated sigmoid colons in whom use of an even thinner diameter paediatric colonoscope can be helpful.