Usefulness of a pediatric colonoscope for routine colonoscopy in women who have undergone hysterectomy

BACKGROUND: Colonoscopy can be difficult in some women who have undergone hysterectomy, which can be associated with a fixed, angulated sigmoid colon caused by postoperative pelvic adhesions. Our goal was to determine whether colonoscopy is easier and more comfortable for women after hysterectomy when performed with a pediatric colonoscope, which is thinner in diameter and more flexible than a standard "adult" colonoscope. METHODS: One hundred women with a history of hysterectomy undergoing outpatient colonoscopy were randomized in unblinded fashion to colonoscopy with a standard colonoscope (CF-100L or CF-Q140L, Olympus) or with a pediatric colonoscope (PCF-100, Olympus). All procedures were performed by a faculty endoscopist and timed. After examination, the endoscopist graded procedure difficulty, and patients were given a questionnaire that assessed their experience. RESULTS: The cecum was intubated more frequently in the pediatric colonoscope group than in the standard colonoscope group (96.1% vs. 71.4%, p < 0.001). Success increased in the standard colonoscope group to 89.8% when the pediatric colonoscope was used to complete the examination. There were no differences in the two groups in terms of mean total procedure times (21.4 minutes vs. 22.6 minutes), mean doses of meperidine administered (57 mg both groups), mean doses of midazolam administered (1.5 mg vs. 1.7 mg), scales of procedure difficulty as graded by the endoscopists, and comfort scales as graded by patients. For the cases in which the cecum was intubated, the mean time to reach the cecum (11.7 minutes for the pediatric colonoscope group vs. 12.7 minutes for the adult) was similar. CONCLUSIONS: The pediatric colonoscope is a reasonable choice for colonoscopy in women who have had a hysterectomy. Alternatively, if the endoscopist elects to start the procedure with a standard colonoscope, it is helpful to have a pediatric colonoscope available for use should a fixed, angulated sigmoid colon be encountered that cannot be easily or safely traversed with the standard colonoscope.     

Colonoscopy: go small for success?

Colonoscopy using standard adult colonoscopes can be difficult in patients with fixed, angulated sigmoid colons. An earlier study from the same center suggested that in women who have had hysterectomy, successful colonoscopy occurred with greater frequency when initiated with a pediatric colonoscope versus an adult colonoscope. This follow-up study was a nonblinded clinical trial comparing the use of a pediatric colonoscope with an adult colonoscope for routine colonoscopy in women with previous hysterectomy. A total of 100 female patients presenting for an outpatient colonoscopy were randomized to use the pediatric (Olympus PCF-100) or adult (Olympus CF-100L or CF-Q140L) colonoscope.
The primary outcome was the comparative rate of cecal intubation. Secondary outcomes included total procedure time, cecal insertion time, sedative administration, procedural difficulty, and patients' experience. Endoscopists encountering difficult insertion had the opportunity to use the alternate scope. The cecum was reached in 49 of 51 (96.1%) women when using the pediatric colonoscope versus 35 of 49 (71.4%) women when using the adult colonoscope. Of the 14 incomplete examinations initiated with an adult colonoscope, the pediatric colonoscope was used 12 times, and the cecum was reached in nine, adjusting the rate of successful colonoscopy to 44 of 49 (89.8%). There was no statistical difference in total procedure time, cecal insertion time, sedative drug dosages, procedural difficulty, or patient comfort using either scope.
When performing routine colonoscopy in women with previous hysterectomy, the authors recommend either starting with a pediatric colonoscope or having one available in the advent of a fixed, angulated sigmoid colon.     

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.     

Usefulness of a pediatric colonoscope for colonoscopy in adults

BACKGROUND: There are few published data on how different types of colonoscopes affect success in reaching the cecum and patient comfort. We examined the feasibility of using a pediatric colonoscope for routine colonoscopy in adults and investigated whether there were subgroups of patients in whom use of this instrument was preferable. METHODS: One-hundred fifty adults undergoing outpatient colonoscopy were randomized to colonoscopy with a standard colonoscope (Olympus CF-100L) or with a pediatric colonoscope (Olympus PCF-100). All procedures were performed by a faculty endoscopist and timed by an independent observer. After examinations, the endoscopist graded procedure difficulty and patients were given a questionnaire that assessed their experience. RESULTS: The adult (n = 77) and pediatric (n = 73) colonoscope groups were comparable in all outcomes measured, including success in reaching the cecum (91% vs. 93%, p = 0.61), mean time to reach the cecum (11.4 vs. 9.7 min, p = 0.07), mean total procedure time (21.8 vs. 21.9 min, p = 0.95), mean meperidine dose (55 vs. 52 mg, p = 0.17); median midazolam dose (2.0 mg in both groups, p = 0.10), the endoscopists' perception of procedure difficulty, and patient comfort scales. Of the 7 patients in whom colonoscopy with the adult colonoscope was unsuccessful, the cecum was reached in 4 by switching to a pediatric colonoscope (all women, 3 of whom had prior hysterectomy). In the 5 patients in whom colonoscopy with the pediatric colonoscope was unsuccessful, the cecum was reached in 1 by switching to an adult colonoscope. Including the cases in which the cecum was reached by switching to the alternative colonoscope, the overall frequency of cecal intubation was 143 of 150 (95%). Subgroup analysis disclosed no difference between the 2 groups in outcomes when gender, presence of diverticulosis, and patient size were considered. Colonoscopy with the pediatric colonoscope was more successful than with the adult instrument in reaching the cecum in women with prior hysterectomy (11 of 12 [92%] vs. 15 of 21 [71%]); however, the numbers in each group were relatively small and the difference was not significant (p = 0.22). CONCLUSIONS: The pediatric colonoscope is suitable for routine colonoscopy in adults. It is also useful in patients in whom colonoscopy with the adult colonoscope is unsuccessful in reaching the cecum (particularly in women). Additional study is needed to see if the pediatric colonoscope is actually superior to the adult colonoscopy for routine colonoscopy in women with prior hysterectomy.     

Ultrathin colonoscope with a diameter of 9.8 mm for total colonoscopy

BACKGROUND: The pediatric colonoscope is superior to the standard colonoscope in some patients with a fixed, angulated colon. A colonoscope thinner than the pediatric one is thought to outperform even the pediatric colonoscope in such cases. This study was conducted to assess the efficacy of an ultrathin colonoscope, 9.8 mm in diameter, comparing it with pediatric and standard colonoscopes. METHODS: Three types of colonoscopes were used: ultrathin, pediatric, and standard. A total of 287 consecutive patients were assigned to three groups: ultrathin (n=94), pediatric (n=98), and standard (n=95). First assessment was the ratio of cecal intubation and the reasons for unsuccessful colonoscopy. The second was the time to cecal intubation. RESULTS: Cecal intubation rates were not different among three groups (96% in each). The main reasons for failed colonoscopy were looping in the ultrathin group, and angulation or stricture in the pediatric and standard groups. Mean time to the cecum was slightly longer in the ultrathin group (6.5 minutes) than the pediatric group (5.6 minutes) and standard group (6.1 minutes), but there were no significant differences among three groups. CONCLUSION: Colonoscopy with the ultrathin colonoscope was as successful as with the pediatric and standard colonoscopes. The advantage of the ultrathin colonoscope might be notable in cases with stricture or severe angulation.     

Impact of bending section length on insertion and retroflexion properties of pediatric and adult colonoscopes

BACKGROUND: Colonoscopes with short bending sections facilitate retroflexion but their effect on other aspects of colonoscope insertion are unknown. We sought to determine the impact of short bending on cecal insertion, terminal ileal intubation, and proximal colon retroflexion. METHODS: Two studies were performed. In study 1, we randomized 104 adult patients with intact colons to undergo colonoscopy with a standard pediatric colonoscope (Olympus PCF-160), a prototype pediatric colonoscope with short bending in four directions (PCF-AYL), or a prototype pediatric colonoscope with short bending in two directions, and normal bending in two directions (PCF-AY3L). In study 2, we randomized 70 patients with intact colons to undergo colonoscopy with a prototype 170 degrees wide angle colonoscope (CFQ160-WL) with a standard bending section length or to a prototype 170 degrees colonoscope with a short bending section (CFQ160-W2L). RESULTS: In study 1, the cecum was reached in all patients. Using the AYL, the cecal intubation time (4.08 min) was significantly longer when compared to both the PCF-160 (2.62 min; p=0.0001) and the AY3L (3.25 min; p=0.02). The AYL required the application of abdominal pressure (79%) and activation of the variable stiffness device (70%) more frequently when compared to both the PCF-160 (32%; p=0.0001 and 41%; p=0.02, respectively) and the AY3L (34%; p=0.0003 and 41%; p=0.02, respectively). Successful cecal retroflexion was possible less often with the PCF-160 (57%) when compared to either the AYL (94%; p=0.005) or AY3L (91%; p=0.001). The ability to intubate the terminal ileum was similar in all three groups (PCF-160 and AY3L 100%; AYL 94%) as was the time needed to intubate (p=0.73). Depth of ti intubation was deeper for the PCF-160 when compared to the AYL (p=0.0002) or AY3L (p=0.02). There was a trend toward deeper ileal intubation with the AY3L compared to AYL (p=0.09). In study 2, no difference was noted in cecal intubation time (p=0.1) or in frequency of application of abdominal pressure (p=0.28), position change (p=0.15), or activation of the stiffening device (p=0.46). Cecal retroflexion was successful more often when using the W2L when compared to the WL (p=0.00001). CONCLUSION: Short bending sections facilitate proximal colon retroflexion for both pediatric and adult colonoscopes, but can negatively impact cecal insertion and terminal ileal intubation in pediatric colonoscopes. A pediatric colonoscope with short bending in only two directions had good function for both cecal insertion and proximal colon retroflexion.     

Use of a push enteroscope improves ability to perform total colonoscopy in previously unsuccessful attempts at colonoscopy in adult patients

Objective: Total colonoscopy with use of a standard adult colonoscope can be difficult in the presence of a redundant or angulated colon. It is often possible to traverse these areas with the use of a thinner, more flexible endoscope. The objective of this study was to evaluate the efficacy of completing total colonoscopy using a push enteroscope when a standard colonoscope was unsuccessful. Methods: A prospective analysis was performed for 721 consecutive colonoscopies attempted by two gastroenterologists. Those patients in whom complete colonoscopy was unsuccessful using the standard colonoscope (Olympus CF-100L) had attempts to complete colonoscopy using the enteroscope (Olympus SIF-100). The extent of each exam was recorded. Additional pathologic findings discovered by the use of the enteroscope and therapeutic interventions performed were additionally noted. Results: Colonoscopy using an enteroscope was performed in 32 patients with successful total colonoscopy in 22 patients (68.7%). Additional pathology was noted in nine patients who had successful complete colonoscopy using the enteroscope; adenomatous polyp (  n = 5  ), adenocarcinoma (  n = 1  ), bleeding source (  n = 2  ), and extent of colitis (  n = 1  ). Total colonoscopy rate using standard adult colonoscope was 93.2% (630 of 676) when cases with poor bowel preparation (  n = 23  ) and obstructing lesions (  n = 14  ) were excluded. When the results of successful colonoscopies with the enteroscope were included, the overall completion rate of total colonoscopy improved to 96.4% (652 of 676). Conclusion: The use of the enteroscope to help evaluate patients who have had incomplete colonoscopies with the standard colonoscope increases the diagnostic yield of colonic examination.     

Use of enteroscope without the overtube in incomplete colonoscopies

Abstract

Objectives: Colonoscopy is the gold standard diagnostic method for colorectal cancer (CRC) screening. Despite the progress in the endoscopy technology field, a small percentage of colonoscopies is still incomplete. The reasons for that are mostly associated with anatomic features, such as fixed, angulated, long and loopy colon, intra-abdominal adherences and female gender. To overcome such difficulties, the usefulness of scopes different from conventional adult colonoscope (CF), such as paediatric colonoscope (PCF), gastroscope (GIF), single and double balloon enteroscope (SBE and DBE, respectively), has been shown in literature. Our retrospective study aims to evaluate the caecal intubation rate using a SBE without the overtube in patients who previously underwent an incomplete procedure with a different scope.

Methods: Patients with a previous incomplete colonoscopy with CF, PCF or GIF were retrospectively enrolled through the analysis of a dedicated database. The enteroscope used was the Olympus Enteropro Single Balloon SiF-Q180 with no overtube. Complete colonoscopy was defined as successful caecal intubation.

Results: SBE was used to scope 47 adult patients, mostly female, and it led to a complete procedure in 91% of them. The most frequent reason for an incomplete procedure even with the use of SBE was a fixed and angulated colon.

Conclusions: Colonoscopy performed with SBE was safe and no adverse events during and/or after the procedure occurred. Our results suggest that SBE with no overtube is a useful and valid alternative to other type of scopes in difficult cases, especially those related to fixed/angulated colon and in female gender.     

Usefulness of pediatric colonoscopes in adult colonoscopy

Use of small diameter, extraflexible pediatric colonoscopes has proved to be valuable in adult endoscopy practice, not only for passing strictures and stomas but also where either fixation due to diverticular disease or postoperative adhesions, or unavoidably painful looping made passage of adult colonoscopes impossible. In 70 of 78 (92%) of the cases where the adult colonoscope could not be passed through the sigmoid colon by an expert endoscopist, the pediatric colonoscope passed through, often very easily. Fifteen of these patients were considered to have been saved surgery by successful passage. The "failure" rate for all colonoscopy examinations was only 2%; this low failure rate was attributable to the use of pediatric instruments whenever passage through the sigmoid colon proved to be impossible with standard colonoscopes. In our opinion every unit performing frequent colonoscopies should have a pediatric colonoscope available for selected adult patients as well as for use in children.     

Incomplete colonoscopy: Maximizing completion rates of gastroenterologists

BACKGROUND

Cecal intubation is one of the goals of a quality colonoscopy; however, many factors increasing the risk of incomplete colonoscopy have been implicated. The implications of missed pathology and the demand on health care resources for return colonoscopies pose a conundrum to many physicians. The optimal course of action after incomplete colonoscopy is unclear.

OBJECTIVES:

To assess endoscopic completion rates of previously incomplete colonoscopies, the methods used to complete them and the factors that led to the previous incomplete procedure.

METHODS:

All patients who previously underwent incomplete colonoscopy (2005 to 2010) and were referred to St Paul’s Hospital (Vancouver, British Columbia) were evaluated. Colonoscopies were re-attempted by a single endoscopist. Patient charts were reviewed retrospectively.

RESULTS:

A total of 90 patients (29 males) with a mean (± SD) age of 58±13.2 years were included in the analysis. Thirty patients (33%) had their initial colonoscopy performed by a gastroenterologist. Indications for initial colonoscopy included surveillance or screening (23%), abdominal pain (15%), gastrointestinal bleeding (29%), change in bowel habits or constitutional symptoms (18%), anemia (7%) and chronic diarrhea (8%). Reasons for incomplete colonoscopy included poor preparation (11%), pain or inadequate sedation (16%), tortuous colon (30%), diverticular disease (6%), obstructing mass (6%) and stricturing disease (10%). Reasons for incomplete procedures in the remaining 21% of patients were not reported by the referring physician. Eighty-seven (97%) colonoscopies were subsequently completed in a single attempt at the institution. Seventy-six (84%) colonoscopies were performed using routine manoeuvres, patient positioning and a variable-stiffness colonoscope (either standard or pediatric). A standard 160 or 180 series Olympus gastroscope (Olympus, Japan) was used in five patients (6%) to navigate through sigmoid diverticular disease; a pediatric colonoscope was used in six patients (7%) for similar reasons. Repeat colonoscopy on the remaining three patients (3%) failed: all three required surgery for strictures (two had obstructing malignant masses and one had a severe benign obstructing sigmoid diverticular stricture).

CONCLUSION:

Most patients with previous incomplete colonoscopy can undergo a successful repeat colonoscopy at a tertiary care centre with instruments that are readily available to most gastroenterologists. Other modalities for evaluation of the colon should be deferred until a second attempt is made at an expert centre.     

A prospective trial of variable stiffness pediatric vs. standard instrument colonoscopy

BACKGROUND: The pediatric variable stiffness colonoscope is believed to have theoretical advantages over the standard colonoscope, however a systematic evaluation of this instrument in routine clinical practice involving adult patients is lacking. METHODS: Consecutive patients (blinded) undergoing colonoscopy in an outpatient endoscopy center by one of 4 experienced colonoscopists had the procedure performed with a standard colonoscope (n=384) or pediatric variable stiffness colonoscope (n=413). Failure to negotiate the sigmoid colon within 10 minutes was regarded as a failure and, if suitable, the patient was crossed over to colonoscopy with the alternative instrument. RESULTS: Median (95% CI) time to the cecum was significantly faster in the pediatric variable stiffness colonoscope group (odds ratio 5.0: 95% CI[4.7,5.3] minutes) compared with the standard colonoscope group (odds ratio 5.5: 95% CI[5.2,5.8] minutes, p=0.01). There were 22 failures overall (2.8%), 14 in the standard colonoscope group (3.6%) and 8 in the pediatric variable stiffness colonoscope group (1.9%; p=0.1). With regard to the 14 failures in the standard colonoscope group, colonoscopy was attempted with the pediatric variable stiffness colonoscope in 13 and completed successfully in 12 (92%). The pediatric variable stiffness colonoscope was superior in cases of severe stenosing diverticular disease; two of 27 examinations with the pediatric variable stiffness colonoscope were rated as failed vs. 12 of 18 with the standard colonoscope (p<0.001). CONCLUSIONS: Intubation time was faster with the pediatric variable stiffness colonoscope, but use of this instrument was not associated with a superior cecal intubation rate compared with the standard colonoscope. However, in patients with severe stenosing diverticular disease, the intubation rate with the pediatric variable stiffness colonoscope was superior.     

Accessing proximal aspects of folds and flexures during colonoscopy: impact of a pediatric colonoscope with a short bending section

OBJECTIVE: Accessing the proximal sides of colorectal folds, flexures, and valves can be difficult endoscopically and can contribute to missed lesions and failed therapeutic procedures. The aim of this study was to determine whether a prototype colonoscope with a short bending section could facilitate accessing difficult to reach areas proximal to folds, flexures, and valves. METHODS: In a nonrandomized study, the prototype colonoscope, a standard pediatric colonoscope, and a standard adult colonoscope were used to attempt retroflexion in the cecum and, if unsuccessful, in the right colon. RESULTS: The prototype colonoscope allowed cecal retroflexion, including clear visualization of the ileocecal valve and the cecal mucosa medial to the valve, in 95% of attempts. A standard pediatric colonoscope was successful in 50% and a standard adult colonoscope in 24.5%. The prototype was more successful than both the standard pediatric (p < 0.001) and the standard adult instrument (p < 0.001). The standard pediatric colonoscope was successful more often than the standard adult colonoscope (p = 0.02). CONCLUSIONS: Using the ability to retroflex in the cecum as a surrogate marker, a prototype pediatric colonoscope with a short bending section seems to facilitate retroflexion and visualization of the proximal aspects of difficult to see regions in the proximal colon.     

The variable stiffness colonoscope: assessment of efficacy by magnetic endoscope imaging

BACKGROUND: Variable-stiffness colonoscopes combine the flexibility of pediatric instruments for negotiation of the sigmoid colon with the ability to stiffen the insertion tube to prevent or control looping after straightening. Previous studies have found wide variation in the efficacy of the stiffening mechanism. Thus, two studies were conducted to assess the potential benefit of the stiffening device and its optimal use. METHODS: In study 1, the effect of routinely stiffening the straightened variable-stiffness colonoscopes in the mid-descending colon was determined in 82 patients. Two insertions were performed (mid-descending colon to cecum) in each patient with and without application of the stiffening device (randomized). The time to negotiate the proximal colon (mid-descending to cecum), time to pass the variable-stiffness colonoscopes across the splenic flexure into the transverse colon, time to pass the right colon, and ancillary maneuvers used were recorded for each insertion. In study 2, consecutive patients, excluding any with previous colonic resection, were examined by using standard adult variable-stiffness colonoscopes. Real-time views of the procedure with magnetic endoscope imaging were recorded for all examinations, but procedures were randomized to be done either with (n = 88), or without (n = 87) the endoscopist viewing the magnetic endoscope imaging display. Whenever stiffening was applied, the anatomic location of the colonoscope tip and stiffness efficacy were recorded. RESULTS: In study 1, time taken to negotiate the proximal colon (p = 0.0041) and time to negotiate the splenic flexure (p = 0.006) were significantly shorter and ancillary maneuvers performed were fewer (p = 0.0014) with the stiffening device activated. In study 2, stiffening was used with similar frequency in patients examined with and without the magnetic endoscope imaging view, most commonly for passing the splenic flexure (71%), but also in the transverse colon (12%), right colon (9%), and sigmoid/descending colon (8%). Stiffening was significantly more effective when used in combination with magnetic endoscope imaging (69% with imager vs. 45% without imager; p = 0.0102). CONCLUSIONS: Overall, the variable-stiffness device used was effective in controlling looping 57% of the time. Activating maximum stiffness appears to be effective once the sigmoid colon has been negotiated and the colonoscope straightened with the tip in the proximal colon, reducing the number of ancillary maneuvers and shortening the insertion time through the proximal colon. Routine magnetic endoscope imaging further enhances the efficacy of the variable-stiffness colonoscopes by helping to identify the optimal time for stiffening.     

A randomized controlled trial in a training institution comparing a pediatric variable stiffness colonoscope, a pediatric colonoscope, and an adult colonoscope

BACKGROUND: There are few comparative data on the efficacy of different colonoscopes. This study compared the efficacy of a new pediatric variable stiffness colonoscope with that of standard pediatric and adult colonoscopes in the performance of routine colonoscopy. METHODS: Three hundred sixty-three consecutive patients were randomized to undergo colonoscopy with a pediatric variable stiffness (n = 122), pediatric (n = 114), or adult colonoscope (n = 127). Primary outcomes recorded were minutes to the cecum and completeness of the examination. Secondary outcomes included patient tolerance, use of abdominal compression, and endoscopists' assessment of the difficulty of the procedure. RESULTS: Cecal intubation rates were not statistically different between the groups: variable stiffness (94.3%), pediatric (96.5%), and adult (89.8%) (p = 0.099). There was no significant difference in mean insertion time, patient tolerance, use of abdominal compression, or endoscopists' global assessment or examination difficulty between groups. Overall, the initial completion rate of 93% increased to 97% on switching to a different colonoscope. Colonoscopy was unsuccessful more often and was more time consuming in women who had undergone hysterectomy. CONCLUSION: The variable stiffness colonoscope performs well, but does not appear to offer any distinct advantage over standard pediatric or adult colonoscopes for routine colonoscopy. Further study may identify subgroups of patients that benefit from this new technology.     

Usefulness of a small-caliber, variable-stiffness colonoscope as a backup in patients with difficult or incomplete colonoscopy

OBJECTIVES: Although variable-stiffness colonoscopes have been developed, difficult or incomplete colonoscopies occasionally occur. The aim of this study was to evaluate the usefulness of a small-caliber, variable-stiffness colonoscope (scVSC) as a backup in patients with difficult or incomplete colonoscopies. METHODS: First, we retrospectively reviewed the cecal intubation rate of colonoscopies in which an adult standard colonoscope (AC) was immediately switched to an scVSC in all patients in whom a colonoscopy with an AC was incomplete. Second, 374 consecutive patients were randomized to undergo colonoscopy with a pediatric variable-stiffness colonoscope (PVSC, n = 123), AC (n = 125), or scVSC (n = 126). The scVSC was used by the same endoscopist to reattempt colonoscopy immediately after colonoscopy with a PVSC or an AC had been assessed as difficult or incomplete. The cecal intubation rate and time and the ancillary maneuvers used were evaluated. RESULTS: Fifty-two (2.5%) of the 2,056 attempted colonoscopies with an AC did not reach the cecum. Fifty-one of the 52 patients (98.1%) had complete colonoscopies after the switch from the AC to the scVSC. The initial intubation rate and time were not statistically different among the groups: PVSC, 95% and 6.8 min; AC, 91% and 7.5 min; and scVSC, 98% and 8.2 min. Cecal intubation was achieved in all five patients (100%) and in 10 out of 11 (91%) patients, respectively, after the PVSC or AC was switched to the scVSC. CONCLUSIONS: The completion rate markedly improved after switching from an AC or PVSC to an scVSC in difficult or incomplete colonoscopies, although the scVSC does not appear to offer any distinct advantage over the AC or PVSC for routine colonoscopies.     

Efficacy and safety of endoscopic balloon dilation of symptomatic upper and lower gastrointestinal Crohn's disease strictures

GOALS: To evaluate efficacy and safety of endoscopic balloon dilation with or without intralesional steroid injection, of symptomatic upper gastrointestinal (UGI) and lower gastrointestinal (LGI) Crohn's disease (CD) strictures. BACKGROUND: Patients with CD commonly develop obstructive symptoms secondary to gastrointestinal strictures. When these do not resolve with medical management, surgery is usually the only alternative. Limited data are available on the safety and efficacy of endoscopic through-the-scope (TTS) balloon dilation of CD strictures. STUDY: We performed a retrospective review of TTS balloon dilations done on CD-related UGI and LGI strictures. Postdilation intralesional steroid injections were done at the discretion of the endoscopist. Stricture was defined as luminal stenosis <10 mm in diameter, through which a scope could not be passed. Technical success was defined as the ability of the scope to traverse the stricture postdilation. Long-term success rate was claimed if a patient remained asymptomatic and did not require surgery or further endoscopic dilation. RESULTS: Over 4 years, we performed 29 stricture dilations on 17 patients (10 female, 7 male) with 20 strictures. The mean follow-up period was 18.8 months (range, 5-50 months). Stricture locations were as follows: rectal, 5; sigmoid colon, 2; colo-colonic anastomosis, 3; ileocolonic anastomosis, 4; ileum, 1; descending colon, 1; cecum, 1; and distal duodenal bulb, 3 patients. Technical success was achieved in 28 of 29 stricture dilations (96.5%). Ten strictures (34.5%) were dilated to <15 mm and 19 (65.5%) to > or = 15 mm diameter. Long-term success rate in the <15 mm group was 70%, and in > or = 15 mm group was 68.4%. Four quadrant steroid injections were done on 11 strictures. The recurrence rate in this group was 10% and that in the nonsteroid group was 31.3%. The overall long-term success rate was 76.5% by intent-to-treat analysis. Three perforations occurred (all colonic) during 29 stricture dilations, a complication rate of 10% with no mortalities. CONCLUSION: We report the first series of TTS balloon dilations with or without intralesional steroid injection, of both primary and anastomotic UGI and LGI strictures in CD patients. Long-term success was achieved in 76.5% patients with a complication rate of 10%. This mode of therapy appears safe and effective and can be considered as an alternative to surgery in selected patients with medically refractory CD-associated GI strictures. Success rates were better in patients who received four quadrant steroid injections. No difference was seen in stricture recurrence rate or complications based on diameter of TTS balloon used.     

Method of colonoscopy in 42 consecutive patients presenting after prior incomplete colonoscopy

OBJECTIVES: Cecal intubation is one of the goals of colonoscopy. We sought to describe the methodology used by a single experienced examiner to perform colonoscopy in a consecutive group of patients with challenging colons. METHODS: Records of 42 consecutive patients with one or more prior unsuccessful attempts at colonoscopy by a gastroenterologist or surgeon and referred for a repeat attempt at colonoscopy were reviewed. RESULTS: Colonoscopy was complete to the cecum in 40 of the 42 patients (95%). An array of methods was employed, including propofol sedation (n = 2), pediatric colonoscope (n = 8), an external straightener (n = 9), external straightener with pediatric colonoscope (n = 2), upper endoscope (n = 8), guidewire exchange (n = 3), and enteroscope with a colon straightener (n = 1) or an enteroscope straightener (n = 1). CONCLUSIONS: A variety of methods and instruments were employed to achieve a high cecal intubation rate during colonoscopy in a group of patients with prior incomplete colonoscopies. Others may find one or more of these methods useful in patients with challenging colons.     

Sigmoid stricture at colonoscopy — an indication for surgery

Strictures of the sigmoid colon continue to pose a diagnostic dilemma. They commonly appear to be due to diverticular disease but carcinoma must always be excluded. In some cases diverticula may be present but in others there is no obvious cause for the stricture. In a series of 1039 consecutive colonoscopies performed between 1984 and 1986, 19 cases of sigmoid stricture that could not be negotiated with the colonoscope were encountered. In each case the cause of the stricture could not be demonstrated. Fifteen patients (79%) underwent laparotomy primarily on clinical grounds or with barium enema findings suggestive of carcinoma. A final diagnosis of diverticular disease was made in nine cases and adenocarcinoma is six cases. Barium enema was a poor predictor of malignancy in a stricture. Four patients were treated conservatively and two of these patients continued to have significant symptoms due to diverticular disease. This experience suggests that sigmoid strictures that prevent the passage of a colonoscope should be resected when the cause of the stricture is not apparent.     

"Passive-bending colonoscope" significantly improves cecal intubation in difficult cases

Colonoscopy sometimes causes pain during insertion, especially in difficult cases. Over-insufflation of air causes elongation or acute angulations of the colon, making passage of the scope difficult and causing pain. We previously reported a sedative-risk-free colonoscopy insertion technique, namely, "Water Navigation Colonoscopy". Complete air suction after water infusion not only improves the vision, but also makes water flow down to the descending colon, while the sigmoid colon collapses and shortens. While non-sedative colonoscopy can be carried out without pain in most cases, some patients do complain of pain. Most of these patients have abnormal colon morphology, and the pain is caused while negotiating the "hairpin" bends of the colon. The "hairpin" bends of the colon should be negotiated by gently pushing the full-angled colonoscope. The proximal 10-20 cm from the angulated part of the conventional colonoscope is stiff, with a wide turning radius, therefore, a conventional colonoscope cannot be negotiated through the "hairpin" bends of the colon without stretching them and causing pain. The "passive-bending colonoscope" has a flexible tip with a narrow turning radius, so that the scope can be negotiated through the "hairpin" bends of the colon with a minimum turning radius and minimal discomfort. Therefore, the intubation and pain-reducing performance of the "passive-bending colonoscope" was assessed in difficult cases.     

A new variable stiffness colonoscope makes colonoscopy easier: a randomised controlled trial

BACKGROUND: Colonoscopy remains technically difficult in 10-20% of procedures due to variable colonic anatomy and fixation. The ability to vary endoscope shaft flexibility may help insertion to the caecum. METHODS: Consecutive patients attending for day case colonoscopy were randomised to examination with either the conventional Olympus CF200HL (200HL) or a new variable stiffness (VS) colonoscope. Intubation time, use of stiffening function, and patient pain scores were compared. RESULTS: Of 100 cases, 43 were performed with the 200HL and 57 with the VS. Four incomplete examinations occurred with the 200HL (two sigmoid fixations, two benign strictures) and two with the VS (one obstructing cancer, one fixed sigmoid). Changing to the paediatric scope was successful in all but one patient from each group (obstructive lesions). Stiff mode was applied 23 times in 18 patients and was effective in 15 of these. Intubation time was quicker with the VS (median 6 minutes 32 seconds) than with the 200HL (median 10 minutes 35 seconds) (p = 0.0005). Pain scores were less with the VS (median 7) than with the 200HL (median 24) (p = 0.0081). CONCLUSIONS: The variable stiffness colonoscope combines paediatric shaft characteristics with the ability to stiffen when needed. This instrument significantly reduces intubation time and patient discomfort. Further comparisons should be made with the newest colonoscopes which are less stiff.