last year. He's going to be talking about top tips for high-quality colonoscopy. Thank you, Doug. Hi, everybody. So, some tips for a high-quality colonoscopy. So, first of all, high-quality means safety, and at least from an insertion standpoint, we want to be able to go through thousands of procedures without causing harm. So, we have some rules to help, you know, reduce the risk of complications. One of the most reliable ones is don't push against fixed resistance. And I think if you follow that rule, and a lot of times it's not really fixed resistance. It's that somebody's created a big loop, and it's just that you can't push on it anymore. Occasionally, it's true fixed resistance, and you need to switch to a thinner scope to get around it. And very rarely, somebody with a lot of pelvic surgery, radiation, et cetera, it's just too fixed to get through. But I think in general, if we follow this rule of not pushing against fixed resistance, you could probably go through your entire career and not rupture the rectosigmoid colon, rip it out. So, that's an important rule. Another one that I ask all of our fellows, and I follow this rule, is every time you go into a really bad sigmoid colon with a lot of diverticular disease, we switch to water. Because this is the situation where occasionally barotrauma occurs. So, you go through this diverticular sigmoid, you're pumping gas into the colon, and perhaps because of a competent ileocecal valve, you get distention and serosal tears and eventually perforation. And so, you have to anticipate that, because if you don't, by the time you get around to the right colon, the perforation will have already occurred. And these perforations are quite nasty. They can be accompanied by compartment syndrome. Patients can get septic very quickly. So, you want to anticipate that and switch to water in a very bad sigmoid colon. Retroflexion. Some groups have reported that about 10% of their perforations occur from retroflexion in the rectum. It should always assess the space that you're going to retroflex in before you do it. Stay in the lower rectum. Don't let the scope slip up into the rectosigmoid. Never force the removal maneuver. And then finally, always remember the spleen. And we don't have a good rule to prevent splenic injury. We've seen two national database studies in the U.S. that have found rates of 1 in 6,000 to 1 in 9,000. In my own unit, we have had more splenic injuries in the last couple of decades than we have had diagnostic rupture type perforations. So, my recommendation is that whenever you have the scope tip up proximal to the splenic flexure, be thinking about that ligament that connects the spleen and the colon. And don't pull too hard on it and don't twist it too much because that's probably what initiates tears. Second tip, study subtlety. And that means, you know, be very familiar with, for both the adenomas and the serrated lesions. There are a group of lesions that are very subtle in their appearance. And I think especially for the serrated lesions, it's important for fellows, for example, to look at lots of pictures. And you can see as you go from left to right across the top and the bottom, progressively flatter disease that's really only visible from a very slight texture change and some obscuring of the underlying vessels. And here's the SSL with cytological dysplasia. And people often worry that that little dysplastic area that looks like an adenoma will be detected, but that the actual borders out here where the arrows are will be missed. So, here on the left is an ultra-flat adenoma and here an ultra-flat serrated lesion. They're actually both visible on the screen. And so, I think we have to come to the inspection process with an awareness of what this looks like and be constantly looking for the most subtle lesions. There's a serrated lesion right here and an adenoma right here that will be more evident after injection. So, that's important to the approach. Third, master the detection basics. You have to measure the ADR and report it. We've had some difficulty agreeing on a serrated lesion detection target that we think would work prospectively nationally because there's so much inter-observer variation amongst pathologists in interpreting SSLs. But you can do it in your institution where presumably you have more consistency among the pathologists. Split or same-day preparation is important. High definition white light and then meticulous technique. So, the technique is quite straightforward. You've got to look behind all of the folds, clean everything up, and then distend the colon adequately. So, here we are in the right colon. You can see the prep is split. It's very good. But beyond that, we're going to really try to clean everything up. I try to convert all the Boston scores of two to a three. And I think part of that process keeps you in between the folds longer, keeps you looking in those spaces so that you're more likely to detect. And then once you've done that, the time of the procedure is really that process of sticking the tip of the scope in between the haustral folds in a very systematic fashion. That's what takes nine or ten minutes to do it carefully. We've got good evidence now that on average it probably takes nine or ten minutes to evaluate the colon carefully rather than six minutes. In the left colon, the principles are the same. I think distension tends to be more of a problem in the left lateral decubitus position. And we're doing an aggressive exam here following the same principles of getting the tip of the scope in between the haustral folds. If you use CO2, I think you're less worried about post-procedural pain and more willing to distend the colon. You can fill the left colon with water. And you can rotate the patient out of the left lateral decubitus position to get distension. We actually a lot of times just take a hold of the patient's rear end and squeeze it together. We call that the tush-squish or the cracoid pressure. And it just keeps gas in the colon because a lot of times they're just losing gas through the rectum. Tip number four is examining the right colon twice in pretty much every one. So after you do that first exam from the appendiceal orifice back to the hepatic flexor, you go back down to the cecum. You can do the second exam either in retroflexion or in the forward view. Retroflexion is easy when you get used to it. You just go max up in the cecum, then push in a little bit so that the scope is along the lateral wall of the right colon, bowing a little bit. That'll move the tip toward the lumen. And then if you go max left and roll the scope over, you'll go right into retroflexion, unless the right colon has a sharp angle in it or is very narrow. In that case, that may be a little bit more difficult. But this is where we most commonly have our interval cancers or we disproportionately have them, and so we do an extra check. And then the fifth one, I'll say, is to master cold snare resection. Because for most of us, 90% of the polyps that we're removing are under a centimeter in size, and they can be removed with cold snare techniques. So the question becomes then, are you doing cold snaring really well? And I think to the extent that you do, it helps the principles and the correct positioning at the 5 or 6 o'clock position, keeping a good working distance, placing the snare accurately. Those are the same things that are important in the resection of large lesions. Six to 10 millimeters, we've seen some data up to 15 millimeters and probably even up to 20 millimeters, especially if it's relatively flat, we can do this well. And the key is to place the snare accurately. You want to have a rim of normal mucosa that is included in the snare, and so you get this kind of fried egg appearance. You see that normal mucosa that is adjacent to the lesion. You can also do this with pedunculated lesions, certainly up to 10 millimeters in size. It's good to go right down close to the wall at the base of the lesion. If you squeeze it a little bit before you cut it, that reduces the immediate bleeding. But the immediate bleeding is typically quite easy to stop. You can stop it with a water jet or with some pressure from the tip of the scope. So a few tips for a high-quality colonoscopy. Strict safety on insertion. Don't forget that that's key. We want to minimize the harm. No subtlety in both classes of precancerous lesions. Do all of the basics well. Make the measurements. Split our same-day preps. Use a high-definition scope. Master basic technique. That's all you need to get a super high ADR. Examine the right colon twice, and then master snare colonoscopy. If you do all those things, you'll be an excellent general colonoscopist. Thank you. Thank you.

colonoscopy

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barotrauma

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