These webinars feature expert physicians in their field, and I am very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, How to Perform Colonoscopy. My name is Michael DeLutri, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so please feel free to ask questions at any time by clicking on the Q&A feature at the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted to GILeap, ASGE's online learning platform. You will have ongoing access to this recording in GILeap as part of your registration. Now it is my pleasure to introduce our GI fellow moderator, Kasia Pawlak from the University of Toronto in Toronto, Ontario. I will now hand over this presentation to her. Thank you so much, Michael. I have also an unspeakable pleasure to welcome and to share this meeting with Dr. Jerome Wei, who was retired four years ago from active practice as a full-time endoscopist at Mount Sinai Hospital in New York. He began his private practice in 1963, and his professor emeritus was both in medicine and in surgery at the Icahn School of Medicine at Mount Sinai. He developed many techniques in colonoscopy and has been one of the best known teachers of endoscopy, having participated in many life courses throughout the world, even in one in Toronto for many, many years thereafter. Also, while in private practice, he published over 200 papers and authored seven books, including the award-winning classic Colonoscopy Principles and Practice. He's also one of the co-founders of the New York Society for Gastroenterology and Endoscopy, and he has been president of American Society for Gastrointestinal Endoscopy, the president of the American College of Gastroenterology, and the president of the World Endoscopy Organization. What's also super interesting to me, and kudos to you, Jerry, that he's successfully training endoscopists in Uganda by Zoom and inaugurating the first program to teach endoscopy remotely. Okay, I'm going to do my screen sharing now. Welcome everybody to this ASGE seminar. We will be with you for the next hour and a half, and I'm going to try to demonstrate to you how to perform colonoscopy. The topic is how to perform colonoscopy, and it's a topic that's near and dear to my heart. We have to realize one thing, that colonoscopy is nothing like gastroscopy. The first thing is gastroscopy is the scope is a little bit shorter. The only real difference in instrumentation is that the biopsy channel comes out at five o'clock with the colonoscope and seven o'clock with the gastroscope. That's about the big difference between the two. In gastroscopy, you push the scope through the esophagus into the stomach. Then you push first into the end of the stomach, and the scope makes a loop. The scope makes a big loop on the greater curvature aspect, and you keep pushing. You go through the pylorus, down the duodenum. You make a big bend in the duodenum, and then you pull the scope back and it straightens out. That's okay for gastroscopy, but for colonoscopy, pushing is not going to get you where you want to go. Now, that seems peculiar because you have to push to get it in anyway. However, we'll find out shortly that pushing is not going to get you to the end of the colon. The big difference between the stomach and the colon is that there are a lot of curves and bends and twists and bends in the colon, which does not happen in the stomach. The stomach is a fairly straight organ. We can go all the way down. We can look in the large capacious stomach, and when we get to the duodenum, we pull it back. But here in the colon, it's a whole different story. The fact is that the anatomy, and this is a depiction from an old anatomy textbook, Gray's Anatomy, that shows the pelvic colon. These on the side here, this is the pelvic wall, the bones of the pelvis, and you'll see that the sigmoid colon is listed here as the pelvic colon. The interesting part is that that colon is held in place by mesentery, and it's always going to take that configuration. And then the colon goes upward, goes posteriorly up along the descending colon, and the descending colon is a posterior structure. But this portion right here in the sigmoid colon is very anterior. The difficulty is, if you want to put a scope in the rectum and push it around the sigmoid colon, the first bend of the sigmoid, you want the scope to go around the corner and go toward the posterior section of the descending colon. But what often happens is that instead of pushing forward, you're going to be pushing upward toward the diaphragm. And that's a big problem because it's like a bent cane, and you put the scope in, you bend it around the first corner of the sigmoid colon, and you push, and the scope just goes straight up. It doesn't go further forward, but it goes up toward the diaphragm. And you can see it in this cartoon here, where these red areas are the pelvic walls, and you put the scope in like this, you push, it goes further up, and it actually may go way up toward the diaphragm and cause some discomfort. The fact is that this is held in place by the mesentery. And you'll see that the mesentery is hold the scope in this position. Notice, if we take the scope like this, and it's here at the iliopelvic junction, this is, here is the tip of the scope, here at the sacrum and ilium, at the iliac crest. And here, if we push, instead of going forward, notice the tip of the scope is still at the same place, but now we have a big loop here and a loop there. So pushing is not going to get you where you want to go in the colon. And how do we overcome that problem? Well, I think that the important thing is that a loop is forming. And you know that a loop is forming when you push the scope in 10 centimeters and the tip doesn't move, then you know that a loop is forming. If you push the scope in another 10 centimeters and the tip doesn't move, a loop is forming. So the solution is to pull back, get the loop out of there, make the scope straight, and then continue. Kasia, what do you think about that maneuver? I think it's an excellent point because this is our main trouble when we start performing colonoscopy as a newbie, I would say. And then you can repeat this maneuver for many different also curves in the further part of the colon, right? So you always have to like force yourself to pull back whenever it's possible and make scope as much straight as possible. It's difficult to understand at the beginning, but when you will get it that you have to always pull it back and straighten no matter what, then it will put you to the right place at the end of the day. Well, that's a good comment. The fact is that the anatomy is the anatomy and this is the way it is. Remember that I mentioned that this part of the colon is very anterior and let me show you by a sketch here on the right. If this is the anterior wall and this is the back of the patient, this is the stomach, this is the back, the colon takes this sort of configuration. It goes very anteriorly right here. So it's anterior and then it progresses across the abdomen down toward the back and then up toward the descending colon. The descending colon is a posterior structure. Jerry, do you think that like anything else, because it's I think it's maybe difficult also to explain straighten the position of the skull, do you think anything else can help to pass this moment, the most difficult moment in the colon? Any other tip to cross this? Yes, there are a lot of tips to get around this. Let's get to that in a few minutes. Let me show you what the anatomy looks like. So here is the pelvic colon. Remember it's very anterior here. Then the upper part of the sigmoid colon is here. This is all the sigmoid colon and here is the descending colon. So now the fact is that if we take a normal person and look at the anterior posterior patient lying on their side, this is anterior sigmoid colon here. But if we have a really skinny patient, these bends become very compressed and the anterior and posterior walls are close together and these angles are very sharp. So if you have a slender patient, you have to be very careful because these are very tight bends. However, if you have a very obese patient, it's very easy. And these bends are very, very wide. You can easily just pass the scope with obese patients. You push the scope, you push the scope and it looks like it's straight, straight ahead. And all of a sudden you run out of scope because you've used all your scope in going down this very straight area and down here. So you find with obese patients that you often run out of scope because it's so easy to pass the scope around all these bends. Now what's keeping it that position? It's the mesentery. So the mesentery is here and it maintains the position of this all the time. That's why if we push the scope in, we just bend it like this. And if you push too hard, you may perforate the patient. But the fact is you stretch the mesentery. If you stretch the mesentery, you have pain. And that's what causes the discomfort during colonoscopy is stretching the mesentery. So when we do this and stretch the mesentery, the patient has pain. The younger the patient, the tighter the mesentery. So the older the patient, the mesentery is sort of lax and you can do a lot of manipulation in older patients with minimal sedation because the mesentery is very relaxed. So between an old patient and obese patient where the mesentery is very loose, it's very easy to do colonoscopy in older obese patients because they really have very little pain and the mesentery is very relaxed. The fact is when you push the scope in, don't just hope the scope is going to go in the right direction because it may not go in the right direction and you may end up out in the peritoneal cavity and that's not to be performed. So we will go into areas that we may help to keep you out of trouble so you don't end up in the peritoneal cavity. So now let's look at the x-ray. If we want to do the radiographic anatomic correlation, here is the anatomy and here is the x-ray. Now you say this looks nothing like that but here let me trace for you the rectum. Here's the rectum. It goes from here to there. The rectum is 12 centimeters long and this is the rectum. Over here is the sigmoid colon. This is all sigmoid colon. So the sigmoid colon is here and this is also a depiction of the sigmoid colon in the anatomy picture and here it is in the x-ray. So here the sigmoid colon goes up, bends down again, comes posteriorly and now it goes up into the descending colon in a posterior fashion. So here is the descending colon. Here's the descending colon posteriorly. So we have to pay attention to the anatomy because it's a very important fact that this configuration will always tend to be there. Every time we push the scope in it's going to tend to make that configuration because that's the way the mesentery keeps the colon in place. The same thing here. The mesentery will keep this sigmoid colon in place and here even though it's lots of bends and loops the mesentery will keep that configuration. Now there are ways of knowing what the colonoscope looks like inside. In some instruments like in the in Olympus instruments they have something called scope guide. There are small electromagnets in the instrument that maintain an electrical discharge from the magnets and it's transmitted to a computer which reconstitutes the shape of the scope. So this is a computerized image made from magnetic impulses that are built into the colonoscope and so you can use this as a guide for using the for seeing the configuration of scope inside and it's always the same. The light part is anterior and the dark part is posterior if you look at the patient lying on their back. So this is the anterior and the sigmoid. This begins to go posterior here and the descending colon is posterior. So do you use scope guide at all Kasia? No I've never had actually a chance because we before when I was starting we didn't have but it's actually very helpful and now we could ask our participants just to think about that why it's useful because seeing that you can decide when or where you should turn your scope to straighten this loop right? Yes actually when we first started colonoscopy back in 1970 we didn't know what what the anatomy was we had no idea everybody used fluoroscopy and so fluoroscopy everybody made their colonoscopy with fluoroscopy. Now when I first did my first colonoscopy I did it in the x-ray department and everybody wanted to see what the colonoscope looked like. So in the room were the director of radiology all the senior radiologists all the the radiology residents and the chief of gastroenterology was there all the attendants in gastroenterology there the room was crowded. Well it took me after an hour the director of radiology left the director of gastroenterology left after the second hour all of the fellows left after the third hour I couldn't even find an x-ray technician so it took forever to do it. So it was me who out of necessity the next day the director of radiology called me in and said Jerry this instrument isn't going to do anything we could have done 10 barium enemas when you were doing your colonoscopy and this is not going to replace barium enema so you can't use my department anymore because you take too too long. So I had to find a way of doing colonoscopy without fluoroscopy and I was the first one to do it and it was just out of necessity that I developed colonic landmarks and that sort of thing and mapped out what the colon should look like internally so that we didn't have to use fluoroscopy. That's why we still use that actually because when we do enteroscopy sometimes right we are looking for some loops and when we do for example double balloony RCP and so on so like fluoroscopy is still used sometimes. Yes okay fluoroscopy is still used sometimes but this scope this scope guide some people swear by it and some people think it's it's not necessary. I personally don't think it's necessary but some groups in the United Kingdom where it was first developed by Chris Williams and Dr. Bladen they swear by it and they use it all the time so it just depends on what you're used to but I think most people now do colonoscopy without fluoroscopy and without the scope guide but if you're learning colonoscopy sometimes this may help to know where you are and where the loops in the colon are forming. So here's what the magnetic imager looks like. These are little magnets electromagnets that are built into the scope and you can see here they're about every five centimeters and they're sent to sensor coils nearby the patient and then the image display is constructed like this so these are constructed computer graphically and so here once again darkest posterior here is the front here the back there but here notice this is very light this is sigmoid colon very anterior descending colon is posterior splenic flexure here's this here's the posterior the descending colon here splenic flexure is here remember the scope now goes from posterior to anterior at the splenic flexure this is now the transverse colon and here it is the transverse colon in the anterior posterior view this is a lateral view so here splenic flexure transverse colon is very anterior as is the sigmoid now these bits of anatomy are very important because here these are close to the anterior abdominal wall so abdominal pressure may be exerted here to help with passage of the instrument because these are very anterior okay so now if we use scope guide it's there and every Olympus colonoscope has scope guide built into it so these are all you need is this coil the and a transducer to be able to collect the images from the magnetic impulses here and do the image construction so now once again let me show you this is the rectum on this x-ray here's the rectum here in scope guide here's the sigmoid colon remember sigmoid colon is here becomes very anterior there right here it becomes very anterior so this is the anterior portion of the sigmoid. And then this is a descending colon. It's posterior. Here it is in the back of the patient. We run the posterior splenic flexure, transverse colon. So remember, the anatomy is the same, everybody. The only patients I've found with the anatomy as altered is in situs inversus, but fortunately, we find very few patients with situs inversus. So have you ever done one, Kesha? No. No, they're very tricky. They're really, it's a fun examination to do situs inversus. Okay. So the fact is that here we are again. The anatomy is the anatomy. And it's fixed anatomy. Remember, if you just push on here, you could push straight ahead. You can go right through the area of this colon. The colon is not very thick, Kesha. What do you think about that? Oh, of course. It's thin like a paper. And so far you're going, it's even thinner. So this might be very tricky because you will push, push, push. And then unfortunately, it can be too late. So the only one point like whenever, what I was found and also what they will tell me about the colon wall is that whenever you will see the wall is getting wider and wider, it's a very bad sign. Don't force because it cause the compression. So it can cause the perforation and actually, especially in this part of colon. So you have to be really careful because you have only a few millimeters just to go through. Be very, absolutely right. Be very careful. So I think that's the word for the entire colonoscopic experience, be very careful. So we're going to show you how to negotiate all these bends and twists and turns without getting in trouble. So here, this is what, this is what that barimenema looks like. Now, this is a terrible minefield to try to intubate. It goes like this. Here's the rectum, sigmoid colon goes up, goes back down again, come down around the pelvis, goes posteriorly here, anterior here. Then transverse colon is anterior, goes back, posterior again to the hepatic flexure, anterior again to the ascending colon and down to the cecum. Now, the fact is that there are so many places that loops can form here that it's just not possible to be able to push an instrument through all of these bends. In fact, let me tell you that when colonoscopy was first beginning, the director of the ACMI, the American cystoscope manufacturers who got into colonoscopy and then they got out of it, but he said that you could never pass an instrument retrograde in the colon. Two Italian doctors, Provenzali and Ravignis, back in 1968, they had the patient swallow a long string with a weight on it. And three days later, three days later, the patient passed the end of the string with the weight, but the other end of the string was in the patient's mouth. So they had a string through the entire intestinal tract. When the weight passed through the rectum, they took the weight off and made a loop in the string at that end and then put another string through that loop so that that other string was very long and was looped through the loop that they made at the end of the long string. Then they pulled from the mouth until the loop and that new string that they put through the loop was at the ileocecal valve. So they pulled it all the way to here. Now, coming out of the rectum were two strings that were in that loop that they made on the long string. So they tied a Hirschowitz gastroscope, which was lateral view, to one of the strings and they pulled the other string and using the loop as a fulcrum, they pulled the gastroscope up into the colon all the way to the ileocecal valve. Wow. And that's the way they thought colonoscopy should be performed. Well, that didn't work so well. Thank God, thank God. Because you sheared up the entire small bowel on the string when you pulled it back through the mouth, it was impossible. So the fact is that we don't want to do that and we will eventually get to this stage where we don't have all these bends. And how do you get rid of all these bends? If you want to put it through this and you push, you're going to run out of instrument. In fact, it's not uncommon for doctors to run out of instrument in the hepatic flexure. I was giving a lecture at some city in United States and they said, the problem with our doctors is we can't get it past the hepatic flexure. The fact is that when they got the scope up here by the hepatic flexure, they've already used up all the scope in going through all these loops. So they couldn't get it any further. So the fact is they'll run out of scope and you will run out of scope. So what can we do? If you look at the anatomy, remember that in the anterior posterior view, this is splenic flexure. The splenic flexure is very long. Actually it goes from posterior to anterior. So the splenic flexure in an obese patient is very long. Splenic flexure in a skinny patient is really very short. So the fact is that the anatomy changes with the patient's configuration and you have to be prepared to go through a large, a much larger length of colon with an obese patient than you do for a skinny patient. But for this patient, it may be very difficult to go through these acute angulations in a skinny patient. So here's the same patient during a colonoscopy. Here is what the anatomy looks like. And let me tell you what colonoscopy looks like. This is when we did the colonoscope with this patient. This is my X-ray view a long time ago of what the colonoscope looked like. Now, how do we go from here to there? Hmm. Now, actually, is it possible that this and this patient is the same? This is in the colon all the way to the cecum? And here's the cecum? What happened to all these loops? Well, that's the trick of doing colonoscopy. And I want to tell you an aphorism that's going to stick with you for your entire colonoscopic career. Every time you put the colonoscope on a patient, you have to remember one thing. You have to remember that you have to straighten the scope. Now, you have to pull back, actually, to go from here to there. And you pleat the scope like an accordion. So you pleat the scope on, you pleat the colon on the scope. So you have to pull back to get it from here to there. And it seems peculiar that you pull back to get further into the colon, but that's the only way you can overcome these loops. Let me show you what that means. Here is a depiction of the scope in the sigmoid colon. You push it and the mesentery stretches and the scope may advance further, but it's going to get a bigger and bigger loop here and stretch the mesentery. And in order to get it straight, you have to pull back so you can actually straighten this segment completely and straighten it out. So you pleat it on the scope. So here you have the scope here, you pull the scope back like this and you straighten the scope and then you can maintain that position when it takes all the pressure off the mesentery. And here it is once again. The fact is you're here in the sigmoid colon for the descending colon. You have a big loop in it. You pull it back a little bit. You may advance the scope. This part may actually advance into the wall while you pull back, but that's okay. You're pulling back to straighten. You straighten the whole scope out and then you can advance it once again. But the important thing is in order to get around that corner, you can't keep pushing because it's just going to make a bigger and bigger loop here. So in order to get further forward, you have to pull back, straighten the scope and then you can advance the instrument. Kasia, what do you think of that? Very important what you were saying about just pulling a little bit forward behind this curve because then you have space to straighten out the scope whenever you will stack before this, then you will still be, whenever you will be pulling back, then you can hit this corner, this tight corner. So you always have to go a little bit behind the angle and then straighten the scope, then pull back. So actually colonoscopy is more about pulling back and rotating than advancing the scope. I think Kasia has hit it right on the head. The important thing is pulling back. And here, I want to show you in our book that we wrote, it's coming out again next year, the third edition, but here is something called the alpha loop. When they were first doing colonoscopy, because this was acute angulation, you could make this angle by turning the scope all the way around counterclockwise, you could flip this around, flip it around on the mesentery. And now instead of an acute angle here, you now had this angle was open up and it'd become, instead of an acute angle, it'd become an obtuse angle. And you can get around this way. But that was called, if you look at it with the x-ray configuration, it was an alpha, called the alpha loop. But now nobody mentions alpha loop anymore because we don't use fluoroscopy. So nobody uses the alpha loop. People talk about alpha loops and all the time, but they don't know what they're doing because nobody uses fluoroscopy. So there is no more alpha loop, but you just have to keep pulling back the scope, straightening it out and getting it straight to go around the corner. So here, once you go with the alpha loop, you make a big loop and then you turn it clockwise and pull back and it's like that. So this is really where we are. I think the important thing is when you make a loop in the colon, you have to undo the loop and straighten it out, pleat the colon on the colonoscope so that it's not anywhere near as long as it was before. You've just pleated it on the colonoscope. Right, Kasia? Absolutely. And then we will find out that we had still a lot of scope to advance. Yes, absolutely. So here, let me show you this. You're pushing the scope in and actually it's coming back because you're making a huge loop. So this is not what we want to do. What we really want to do is to put the scope in the rectosigmoid area and advance the scope so that we can see it here. And then instead of advancing it like this and coming actually back further than where you are, we really want to go forward with the scope like this, go around this first bend. And instead of pushing here, don't push, you have to pull back. And you actually, it's very important that you pull way back with torque and then you can advance it again through the next loop. But the fact is that this first loop is always going to make it again because the anatomy of the mesentery makes it that this is going to re-loop again. So although you're going further forward here, that's going to make another loop. So remember that the important thing is to pull back, pleat the scope, pleat the colon onto the scope so you can continue to advance. So you get the scope straight by pulling back. Pulling back is the key to doing colonoscopy. Absolutely fantastic video. I wish to have it when I was starting because it's so clear, like just getting beyond this corner and pulling back and then straightening out the scope. So fantastic. I'm just amazed by this. Okay, so here, let me show you this schematic. If the scope tip is here and this is 30 centimeters, say this is the descending colon in 30 centimeters. The scope tip is here, it's at 15 centimeters. Okay, but it has a loop. So you pull back and now the tip is at eight centimeters. You pull back again until it's at five centimeters. Now it's straight. So now you can push it forward and you may go up to 20 centimeters, but this loop is going to form again. It's always gonna form because the mesentery. So the mesentery is always gonna make this loop reform. So once you get up here, now you're at 20 centimeters instead of 15 centimeters, and then you have to pull back again to do the same maneuver here. Pull back, straighten the scope, and then you can keep going up the descending colon. But the important thing is that this loop is going to continue to reform even though you've straightened it out, you go further forward. Now you can advance it a little bit further, but the loop forms again because of the mesentery. Jerry, we have one question from the chat. So how do you know what direction to apply torque when you're reducing the scope? Ah, you always bring it back clockwise. It's always clockwise when you bring it back because that's the configuration of the mesentery. The mesentery always, this loop right here is a clockwise spiral. So once you get up there, in order to, because your scope is in this configuration, it's sort of in a big clockwise spiral. So you turn the scope clockwise, pull it back, and that's the only way you can maintain the position of your scope while you take the loop out. Yeah, whenever you will try to do this anticlockwise, then you will have more and more resistance because then you will form more and more loop. Yes. Okay. Hold on, we have another one. I will just give you another one and we will go forward. So how to know when to stop pulling back, how to stop pulling back? Is there a way to know that the loop has resolved or just keep pulling back till you see that it's moving backwards and then advance again? Yes, I think so. What do you think, Aisha? Yeah, so you will see that whenever you will be pushing the scope and the scope will be coming back, it means that you still have a loop. So you cannot then push forward. At some point, there are some situations that you can push, but whenever you will see that you're stacking in the same position and you're coming back once you're advancing, it means that you didn't straighten out the scope. Yes, that's for sure. Okay, so now the important thing is the right hand does the work of colonoscopy. Now, what does that mean? The hand that's on the shaft of the instrument is the one that advances the scope. It torques it, it pulls it back. The hand that's on the shaft is the one that does the colonoscopy. The person that's holding the head, the left hand that's holding the head of the scope does air and water and moves the tip controls up, down, or right, left. But the fact is that it's the right hand that really does the work. That's the one that does the torquing and that sort of thing. In fact, when I first start colonoscopy with a student, I take the shaft and the student takes the head. If the student turns the scope to the left and I want it to go to the right, all I have to do is twist the shaft 180 degrees and it'll go the other direction. So I can manipulate the scope any way I want by holding onto the shaft of the scope. He thinks he's doing colonoscopy, but I'm doing the colonoscopy. And all that the one that's holding the head of the instrument is doing is putting in air and water and moving the tip. So it's the right hand that does the work of colonoscopy. So here, here's the sigmoid loop. Here it again to take the loop out, clockwise torque, always clockwise torque, because that's the way the mesentery makes the configuration fixed. So when you pull back, use clockwise torque, pull back and straighten out the instrument so the tip can advance. So we have to keep doing that. Remember that this loop is always going to form again. Every time you push it in, it's going to form again, but you pull back to straighten the scope. Make sure you pull back. If there's nothing else to get out of tonight's session, it's you have to pull back the instrument and you can't just push it forward. The trick of doing colonoscopy is to pull back to straighten out the scope and shear the colon onto the instrument. Somebody's asking Jerry if it's possible to torque you too much when you reduce the scope. No, you really can't over torque it because the scope itself is fixed pretty well. Once you torque it to the right, you'll feel the tension in the scope and you just can't torque it much more. So you have to pull back to go from here to there. You have to pull back. And what does that mean? Well, what that means is that if this is, if you go over the rectum, sigmoid colon, this is 15 centimeters. This is 25 centimeters. This is 30 centimeters. Now, these are relatively fixed numbers and this is measured on the x-ray itself. So these are 15 centimeters, 25 centimeters, 30 centimeters. What does that mean as far as we're concerned? What that means is when we pull back the instrument, this is what happens. That 15 centimeters is now here. The 25 centimeters is now here. The 30 centimeters remains where it was. So the fact is that what we've done is by pulling back, like that cartoon showed you, we pull this back to here. We pull this back. See this loop? We pull this back to here. So all this, this air you see here in the colon, is coal that's been bunched up and accordion pleated onto the scope. So this is all the colon is all bunched up here and pleated. The descending colon has not changed, but this is all changed. So the only way you can make this configuration is to pull back the instrument to straighten it out. Yeah, that's perfect because then sometimes we see, we look at our scope and we see the measurements. And then if you will see that you're still in sigmoid and you have 60 centimeters advanced then that means that you definitely have to pull back. Yes and oftentimes when we advance the scope through a cone like this we're at the splenic flexure at say 80 centimeters or 90 centimeters. But with the scope straight the splenic flexure is somewhere around 40 centimeters. So when we're at 40 centimeters with a straight scope with the splenic flexure. But the fact is that in order to get there we have to push the scope in and then pull it back. Push the scope in and pull it back. So we have to have the length of scope that we can use to get around this, pull it back, keep going, pulling it back all the time to shear the colon onto the instrument. So we need a longer instrument. We can't just use this sort of instrument. We have to get a instrument around the corner here, pull it back. It has to go around the next corner, pull it back. So in order to get up there we may need 60 or 80 centimeters scope to get there. But when we're there and straight it's between 40 and 45 centimeters. Jerry, somebody's asking if there are any specific situation in the sigmoid cone like for example after surgical abdomen that they have to just consider anti-clockwise torque instead of conventional clockwise torque. Not, it'd be rare. Maybe with sinus inverses but it'd be rare. You always have to use the same configuration. Okay, so now you have to pull back to go from this to this but here once again let me show you this sketch here. This is the rectum. Here's the rectum when the scope is straight. Sigmoid colon, sigmoid colon. Note how short the sigmoid colon is here because we've really crunched it together and we pleated it onto the scope. So this long sigmoid colon is now here. So all of this that you see in the air contrast around it, this is the sheared up and accordion pleated sigmoid colon and then the descending colon is not affected. So here I think the important thing is that we have to take this loop out. If we just push on this we're going to make a huge loop, big big loopy here and what that means is we have to keep pulling back, straighten the scope out and get the scope, get the colon to be pleated onto the instrument so that we can advance further. So it can only happen by pulling back the scope. So remember once again pull back the scope. You have to remember that if you're going to get anything out of this session, you have to remember you have to pull back the scope. Now a lot of people don't believe in pulling back the scope and they just push, push, push and they run out of scope. So be very careful when you're pulling out of scope. So be very careful to straighten the scope by pulling it back. Once again remember that this is what's going to happen if you just push. You push you're going to get a make a big loop here in the sigmoid and it's not going to get where you want it to be. You have to really pull back the instrument in order to straighten it out to get these bends out of the colon so that you can straighten it out and progress further up the intestinal tract. Sherry, also somebody's asking what do you think about unstable scope position when when it comes to loop reduction. Oftentimes when I want to reduce a sigmoid loop I find myself falling, I find myself falling back considerably. Is that still within the realms of one step forward to step back? Do you at times only reduce loops when in a more stable position in the transverse ascending colon? No, when you push in and the scope comes back it just means you have a big loop in it. So if you push and the tip comes back you're making a huge loop and you're just pulling your part of what you're having is you're pushing in here and the scope comes back with just like this configuration. Let's go back to here if I can do that. Here, so this is what happens. You're pushing and the scope actually comes back from its position. Here's the scope here. Look, you push and it comes back. It goes further back in the colon and that happens because you're making a big loop. So it just pulls the scope backward because you're making this huge loop and you have to pull back the scope in order to rectify that loop that you're making. So whenever the loop, the colon you're pushing, the scope tip comes back it means you're making a loop you have to pull back. So there's only one rule that you have to remember. Remember nothing else from this seminar you have to remember is straighten the scope. That's the holy grail of colonoscopy is straighten the scope. So I think that the thing is that if you took the scope in, you push the scope in and you get a red out. That is you can't see. You don't see anymore. You see red. Do not push. The fact is that you're against the wall of the colon and if you push, you might just push right through the wall. So when you see red, do not push. The fact is that what happens is when you see red and you use your dial controls back, up, down, right, left and you can't and you still see red all the time and you don't know where the lumen is. The fact is don't push to try to get it. You have to pull it back because when you touch the mucosa even lightly you will see from this cartoon that when we're changing the dials and we're away from mucosa the tip will go back and forth. Watch this. That's the way we expect it to happen, right? That's what we expect is when you do dial controls the tip is going to move. But when we touch, when we fix the tip of the scope, everything changes. The mechanical action is no longer bending here. It's fixed now at the tip. So watch what happens here. We do what we think we're doing but as soon as it tits mucosa, watch this. It's a whole different area. You see this? It's not going to move from the mucosa. So it just bends here back and forth. So when you see a red out and you're using the tip control up, down, back, forth, you can't get rid of the red. It's because you're not, you fixed the tip and it's bending here but it's not using the usual tip controls when the tip is free. So what you have to do is pull back to get it off the mucosa and then once again you'll restore the ability to move back to use your dial controls. So once again as always pull back to straighten and get that off the wall. Don't push to get it off the wall because you're not going to get it off the wall. You're just going to impact it further on the wall. So even if you have light touch with the tip against the mucosa, you've changed the mechanical action of the control mechanism so that it no longer bends here. It fixes the tip and it just bends back and forth at the knuckle and doesn't move the tip at all. Okay so for everybody, for you, for me, for Kasia, for all of us, this is all you can do with the colonoscope. You can't do anything else. You can push it in and pull it out. You can twist it right or twist it left. So on some scopes you can stiffen and soften it. You can put air in, take air out. Your dials can go up, down, or right, left. You can change the direction of the right, left. You can change the position of the patient or use pressure on the abdomen. Whether you're a very fast colonoscopist or you're a first-year fellow trying for the first day, this is all you can do. You can't do anything different. So what's the difference between a fast colonoscopist and a slow colonoscopist? It's how you do these. You can do all these at once or you can do it one at a time. You can push it a little bit. Then you can put a little bit of air in. Then you can use the dials up, down, right, left. You can change the position. You can put pressure. You can pull it out a little bit. So you can do one at a time or you can do them all together. And by now, Kasia is an excellent colonoscopist. She can do all these things together. She can use the dial controls while she's giving air at the same time, while she's twisting the scope and pulling it back. So all these things happen at the same time. And I think that you just have to get used to doing things together, but that takes a while to get all of your coordination together so that you can do multiple maneuvers with the instrument at the same time. But remember, the one who handles the shaft is the one who does the colonoscopy. So here, your hand on the shaft of the scope is the important hand. And that's the one that you have to pay most attention to. And that's the one that's going to advance, but mainly it's going to be pulling out and allowing you to see where the lube is. Okay, so straight scope. That fact is that after every advance, you have to pull back. And why do you pull back after an advance? You pull back after every advance because you're always going to make that sigmoid loop. The mesentery makes you continue to make that configuration. So the mesentery will always keep that sigmoid loop in. So after every advance, you have to pull back, get rid of that sigmoid loop. Even if you're further up the colon, you have to get rid of the sigmoid loop. After passing a curve, you have to pull back. And that's to straighten the curve, so you can straighten, so you can have a straight scope. When you round the splenic flexure, pull back once again, so you can get the sigmoid loop out and straighten the scope. When approaching the cecum, you have to pull back because in order to get to the cecum, you had to put a lot of scope in. Sometimes when we're in the right colon, you have to put a lot of scope in to go a little bit further. And that's okay because now you've done your straightening maneuvers, and now that sigmoid loop is going to form, and you may not be able to, when you're at the tip of the cecum, to completely pull back the sigmoid loop. So you may have to put a lot of scope in. But then when you get to the right colon, you really have to pull back. And oftentimes, when you're in at 140 centimeters, and you're in the ascending colon, then you want to go a little bit further. You just can't make it. It just won't go. Well, the important thing is you have to pull back. Pull back. Right, Kasia? Yeah, absolutely. Because sometimes we are too fast, and then we are so excited that the scope is going without any resistance, and then you're getting exactly to hepatic flexure, and you cannot go forward because you have still this loop in sigmoid. So whenever even you feel that you're going straight, then pull back scope a little bit, because you will save your time. Otherwise, you will have to come back to the sigmoid, and then unloop it again, and then come back again. Well, that's an important point that Kasia makes. The fact is that once I was in Belgium doing some demonstrations, and the head of endoscopy at the hospital was doing a colonoscopy, and he was stuck at the hepatic flexure. And he was sweating, and he said, Jerry, can you help me with this? So I said, sure. So I took the scope, and I pulled it all the way back to sigmoid colon, because that's where he was stuck. And so then I went back to sigmoid colon, and when I passed the sigmoid colon, I pulled back so that I could keep the sigmoid straight all the way as I advanced more proximally. Then I had to keep picking the sigmoid colon, the sigmoid loop out, so then I could get the cecum fairly easily. But let me tell you one thing, that once you've gotten to the cecum, getting there a second time is easy, because now the mesentery is relaxed, you've stretched the colon, you've taken out the air, and if you want to impress your family, first put the scope in the cecum, then take the scope out, now do it again, and you'll fly to the cecum, because the scope goes easily to the cecum. Okay, so always pull back. So insert the scope in the rectum, and pull back until you reach the cecum. I think that's the secret to doing colonoscopy, and I can't impress upon you enough that you really have to pull back. But let me tell you that the actual technique is, the colon has to be clean. And Kasia, can you tell us about cleanliness? What do you do to prep the patient? Yeah, so you always have to think about a few main key aspects. First of all, about using a proper dose, using a proper like laxatives, and of course informing the patient about the diet, and about the timing of taking the prep, right? So what we do, what we can think about, we can think about different types of solutions. So we have all these which includes PEC, all these which includes high volume or low volume PEC, and then you will have one which are non-PEC. But then you have to explain to your patient the main rule that they always have to divide dose. If they will not divide dose, they will not be fully prepared to the colonoscopy, no matter what time the colonoscopy is performed. If the patient will have the colonoscopy the next day, you have to divide for the one day, and the next dose day. But when the patient will be done the next day in the morning or early afternoon, whenever the patient will be done, then the next day, the late afternoon or evening, then they still have to divide the dose, but then the dose will be taken in the morning and in the afternoon. Whenever it comes to the diet, there's many different studies. Of course, they should take the low residue diet because nothing else will help. A fluid diet is not so helpful. The high residue diet is not so helpful, but the low residue diet. But you also have to tell them that no matter how much they will drink the laxative, the PEC, they have to drink a lot of water. And that's, I think, the secret to encourage the patients to drink as much as possible to be really nicely prepared. Kasia, does a patient only have a clear liquid for two days? No, like the studies showed actually that the day before is fine and not even clear liquids, the low residue diet, even with meat, with something which not includes seeds or brown bread or brown rice and so on. But sometimes I've noticed that these are the recommendations for societies. But I found that some patients which have the diverticulosis or constipation, they might require extra dose of PEC or drinking much more fluids or having a little bit of liquid diet before, but longer, not only the day before, but even the second day before. It depends on the patient. Okay. So I start with the patient, almost everybody starts with the patient in the left lateral position. Personally, I rarely change the patient position, but others use a lot of position shifting. And I'd like to refer you to a paper that I wrote. I was invited to write a paper on how I do colonoscopy. This was in Gastrointestinal Endoscopy in 2018. This topic was so important that actually it was published simultaneously in the American Gastrointestinal Endoscopy and in the European Journal, the same issue, the same year, so that it was published simultaneously in two different journals, how to do colonoscopy. So I always use the left lateral position. Dr. Thomas Gibson in London often changes the patient position. She changes it from left lateral to supine to the back and back and forth. And I can tell you that if you use no sedation, it's easy for the patient to move around. If you use conscious sedation, it's a little bit difficult because you have to prod the patient to move. But if you use propofol anesthesia, like is used by everybody in the United States, it's almost impossible to move the patient from one side to the other side, back and forth. So I just use a left lateral position for the entire procedure, but some people use a lot of position changes. So this is the article on how to do colonoscopy from both sides of the Atlantic Ocean. There are some people also asking if you recommend to do lateral position or supine in pediatric patients. I think it doesn't matter, right? No, I always use the left lateral position. Okay, so it has to be clean. The right hand does almost all the work. And I think the left thumb never leaves the big dial. I never take the thumb off the big dial because that's the counter pressure. And it allows these fingers, here's the thumb on the big dial. And this finger goes back and forth. This is not where you want to put the thumb all the time. This is doing you no good at all. It's giving counter pressure to the fingers, but it's not doing anything. It's just holding the scope. You have to really have it onto that control all the time. And here you can use the counter pressure for this and also be able to move the tip controls back and forth. The other thing is that the umbilicus of the instrument should be tucked inside your forearm. And here it's tucked inside. Here's tucked inside. Let me show you. If it's outside, it makes it very difficult to hold the scope. It gets it very unstable. So it's easier if this umbilicus is towards your body on the inside of the forearm. And here I want to show you a Dr. Canterboy, one of the real heavy duty therapeutic endoscopists in the world. Here his umbilicus you see is on the inside next to his body and it doesn't extend outside the forearm. So be careful of how you scope. Now I just want to show you one other thing. The scope is flat on the table. It may make it very difficult to torque the scope. Because look, if you torque the scope, see how it's very difficult, it's almost impossible to torque the scope very much. So it's very difficult when the scope is lying on the table. So try not to have the scope lying on the table. And let me show you one other thing. This is the way it used to be a long time ago. Here is the endoscopy room. This is what we used to do with fiber optic scopes. These were two lecture scopes that were added on to the tip of the scope. The doctor holds it right up to his eye. This is a fellow. That's me looking at one lecture scope, another attending looking at another lecture scope. Look who can't see anything. One of the most important people in the room. And she's giving abdominal pressure here. And notice this. No glove. Yeah, those were the days. So now I'd like to turn you over to Kasia. Because Kasia has some very important aspects. But I'd like to talk to you a little bit about the simulators. And how we can use simulators to teach colonoscopy. So maybe I will show you like the Jerry said. So we have many different options. Because I also feel as a trainer now that these all simulators are very, very helpful. Before you will start just to understand how to maneuver with the scope. Because like if you will take the scope normally. Of course you can see what is responsible for what. Like big wheel, small wheel. How to maneuver with the scope. How to handle the scope. But then when you start advancing the scope the ride starts. So there's many different simulators. Which were built up many years ago and more recently. Which will help you to understand how to unloop. What means pulling back the scope. And what means straightening out the scope. And that one is actually very simple. But it's very helpful. Because as you can see. You have many different options to form the loops. Even tighten these loops. And then you can learn how to unloop the scope. And how to straighten. Even you can keep it open. And see what's going on with your scope. When you're pushing. And how much you're forcing the lumen and the wall of the colon. So these are very helpful actually. Not only to get to CECUM. But actually how to understand. And how to overcome the different loops in the colon. With different anatomy. To that one you will have different forms and sets. To set up the loop. And how to overcome them. And another one is more electronic. And that one also maybe will not help you. To understand how to overcome the loop. But more what you're doing with the scope. And what's happening with the patient. Because that one actually can give the sound of the patient. Whenever you're pushing. And you're pushing into the wall of the colon. And of course you can by the way. Also do the polypectomy with that one. It's helpful. But I feel the mechanical one is more real. To understand what you're doing with a scope. However this one is the brand new one. And this is from Japan Mikoto. And it's very interesting. Because you also still can form the loops. So you can see what's going on. But on the other hand. You can see different parameters. How you're handling the scope. How you're advancing the scope. And where you're struggling. And how to overcome that. And also it's giving different sounds. To see what you're doing with your patient. So it's absolutely interesting. Even my boss was performing colonoscopy on that one. Recently at these G-Days. And she was also fascinated. Because for her super experienced endoscopist. Was not so easy to sometimes overcome this. So very helpful to train. And at the end of the day. You have animal model. And this is endosym from United States. Like also figure out by. And developed by the physician. Actually Kai. Who is promoting for different purposes. That one is actually for colonoscopy. And I think it's very helpful. Maybe you don't have loops. But it's very helpful to understand. What's going on with the tip of the scope. Whenever you're advancing. And also you can see. Where your scope is going. When you're pushing or rotating the wheel. Or rotating only with the hand. And aside of that. You can perform as well colonoscopy. Do you want me to Jerry. To talk a little bit about the training? Yes, yes. This is from ASG guidelines. And curriculum about colonoscopy. And what's important. When you start performing colonoscopy. Before you will actually start. Performing colonoscopy. To understand that this is not. Only motoric skills. But this is also cognitive skills. And all these skills should be assessed. And keep in mind. Not only in the mind of trainers. But also as trainees. Or further supervisors. That you can see. You have many different skills. Regarding the motors motor part. And this you can remember. And you can keep in your mind. Till the end of your life. Especially at the beginning. What you should always do. When you start performing colonoscopy. Aside of this initial hands-on experience. As I mentioned before. Then you have key steps. You should perform. Aside of pulling back the scope. I found that many GA doctors. Or endoscopists forget to do that. It's a rectal digital rectal examination. It's really important. Not only to provide lubricate. But present foremost. Just to feel the anatomy. Especially patients. Sometimes have a different anatomy. And you're forcing the scope. Advancing at the beginning. And it's very uncomfortable. Uncomfortable for the patient. Especially when you do this. In conscious sedation. Or without a sedation. So it's very very important. And might be helpful. But also when you have some abnormalities. And pathologies like a tumor. You don't want to force. Because this can cause further problem. Aside of that. Of course you have different colonoscopies. Advancement techniques. Like Jeremy mentioned before. Pulling back the scope. Which is super important. In prevention of the loop. But aside of that. You have different. different ways of actually providing trans-abdominal pressure, which is extremely important and helpful sometimes, especially when you have patients with difficult colon. By this I mean patients after radiation, patients after multiple surgery, especially in pelvis, patients which are very tall and then they can have redundant colon, patients with constipation, or maybe also patients with diverticulosis. So this is very important to provide trans-abdominal pressure whenever you feel if it's important. Change body position, as Jerry mentioned. Sometimes Jerry doesn't use that, but some people use that and it's helpful and it might be helpful in particular situations. But also to provide mucosal visualization, you don't want to advance the scope blindly. You always have to try to visualize, to force, to visualize the lumen, where you're going, because actually you will understand where are you by the watching on the lumen of the colon, because the transverse head have a different shape, the sigmoid have a different shape. So this might be very difficult and of course prevent for adverse events. And at the end of the day, at the end of the exam, actually, you always have to provide retroflexion because sometimes you can miss some abnormalities in the rectum and of course we don't want to do that. Things are different for different people. So sometimes colonoscopies are difficult in tall men. You run out of scope because they're very long. Here you run out of scope in very obese patients. You may use a different instrument and in very slender patients, you may want to something different. So the fact is that for these patients, you may want to use an adult scope that's stiffer and this one you may want to use a pediatric scope, one of these that has a more acute angle. But if you have a really severe diverticular disease and a very narrow lumen, I switch right away to a gastroscope because a gastroscope has a very short nose. Look how long this is. A gastroscope has a very short nose and a very tight bending radius. So I can always get through a difficult diverticular laden sigmoid colon with a gastroscope. Parenthetically, we'll use a gastroscope, although it's much shorter, the rigid sigmoid colon that has a lot of diverticular disease and is difficult to get through acts like a stent. So once you get through it, it keeps that area very rigid and now you can use the gastroscope to get all the way to the cecum. So I could not use a gastroscope to get to the cecum with a normal patient because that sigmoid loop keeps getting bigger and bigger and I just can't get it all the way out with a gastroscope because it's shorter. But the fact is, though, for severe diverticular disease, we can almost always reach the cecum with the gastroscope. So what about water colonoscopy? I'm sure you're all concerned about water colonoscopy. It can be done. You can actually put some water and some air in and that's water exchange colonoscopy. Then there's water immersion colonoscopy where you turn off the air and you only use water. Most people don't use this, although some do. And that's one of the options that you have of actually using only water and turn off the air. And it may actually keep the colon from making big loops, requires a very clean colon. Some people love it. Some people don't want to do it. What do you think, Kasia? What's your experience with water colonoscopy? I'm the fully water person. I found it very, very helpful, especially at the beginning when I was starting. And even now I do almost full water immersion. But air CO2 actually is very also helpful sometimes because you have different anatomy and lumen sometimes can collapse. But I found that when you use water, you will cause less problem to the patient, so less pain, especially when you don't have CO2. However, this is not the standard now when patient and people mainly have CO2 in the units. But also you will, I think, faster get to cecum. And some even studies show that you have a better visualization. But when it comes to scope advancing, I feel water is very, very helpful. Okay, very good. So here's the other considerations that we really didn't talk too much about. Infection, the adenoma detection rate, polyps. But I think the important thing is that when we come down to the rule, no matter if your first year fellowship has been out for 50 years, or if you use peripheral concentration, whether you turn patients, you don't turn patients, always keep in mind one rule, keep the scope straight. That's the one rule that you have to remember all the time. So Kasia and I wish you good luck. And we will take a few questions. Kasia will let us know what the questions are and see if we can give a few answers before we wrap it up. Thank you, Jerry. So the question to you is that if you have some tips for the ileal intubation. The what? How to get to terminal ileum. Ah, the terminal ileum. I always get to the terminal ileum when I'm there. I don't have to, but it's sort of a fun thing to do to get into the current terminal ileum. I think the terminal ileum is difficult. You just can't explain it in a few words, but you have to do it blind. You have to get into the cecum, know where the ileal valve is located, and there's multiple ways of finding that out. But then you have to pull the scope back. You have to bend it toward the ileocecal valve and then pull the scope back until it falls in. You can't drive into the ileocecal valve straight. You have to pull back to get in the terminal ileum. What's your experience with that, Kasia? Absolutely the same. And sometimes I also use water just to get into less CO2, but pulling back is the main maneuver. Okay. Okay, then another one. Somebody's writing that. Today I had a big alpha loop which scooped all in just before the cecum. I tried changing positions and along with pressure, then I pulled as much as I can, but this didn't work. So is there any limit of pulling so that you can go again? I think you have to pull back until it gets to be tight. And the problem is that sometimes you have two loops. You pull back one and the other one just won't come back easily, and then it's very difficult. You just have to pull back even further to get it out. So if you pull back and you think you're straight and you're somewhere in the splenic flexure, you can't get it out. If you have a splenic flexure or transverse colon and you have a stool, you have a lot of scope in, you can tell how much scope you have in. If you have a lot of scope in, you have to pull back further. I think the important thing is notice how much scope is actually in the patient. And when I'm doing long distance training, like from New York to Uganda, where I'm training people in that I see how much scope is outside the patient. And if they're all the way in and they're having a difficult time, it's obvious they have to pull back more. So they pull back a little bit and you would really have to pull back a lot to get the scope really straight. And sometimes, as we mentioned before, you have to pull back all the way to the sigmoid colon and start all over again. And then mind your pulling back to keep that sigmoid colon straight so you can get all the way to the end. Excellent. Then also somebody is asking why you cannot just reduce multiple loops together when you run out of the scope by pulling back and why it has to be done after every curve individually? Because in order to get around a corner, you have to push to get around the corner. When you push, you always, you're obligated to make that sigmoid loop all the time. So you have to pull back to get rid of that sigmoid loop. So all the time when you get around the corner, because you have to push to get around the corner. Once you push, you've made that sigmoid loop. You've not only gone around the corner, but you've made that sigmoid loop again. So you have to pull back to get rid of the sigmoid loop. Excellent. Then another one about positioning the scope on the bed. So how do you position your colonoscope if you are not keeping it on the bed of the patient? And then it's the same question. Yeah, how exactly you keep the scope straight on the table because there is less torque. How do you circumvent this? So about positioning the scope, actually. Okay, let me tell you how I do it. But let me preface that by saying when colonoscopy first started, there were no guidelines. Nobody knew how to pass an instrument. It was a jungle. Everybody did it differently because nobody learned from anybody else because there were no teachers. So everybody has developed their own technique. Some of them are very good and some of them are terrible. Even now, those that are bad continue to teach the bad techniques. And I go places and I'm appalled at some of the ways people do colonoscopy. It's like they do colonoscopy with their feet. So the fact is that what I do is I drape the scope down by the table and hold the scope by my thigh against the examining table so that keeps it from falling on the floor. There are some other people that put the scope in like a big U in the air, like a trombone, and have the big U outside the patient and have that in the air. So the scope goes from the patient around a big loop outside in the air and then goes in the patient. So that's all to keep it from laying on the table. If you lie on the table, it's very difficult to use torque. So I drape it down, hold my thigh, and by draping it down, I can use torque as much as I want. I can do 360 degrees of torque with the scope lying, with the scope draped down beside the table, and I hold it with my leg against the table when I let go of it so that it won't fall out. Excellent. Jerry, people have so many questions to you. Another one is, so when do you use abdominal pressure and how? We missed a few slides on abdominal pressure. There's a nice paper on abdominal pressure. Look up colonoscopy and abdominal pressure and you'll find the first paper on abdominal pressure was one I wrote. So the fact is that when you're in the sigmoid area, remember that that first loop is very anterior. So you may push on the scope, push on the lower abdomen, just above the symphysis pubis, and that's where the colonoscope is going to be very anterior. Then by pushing there, you can actually turn, you can actually keep the scope from pushing up toward the diaphragm by pushing on the suprapubic area, and now the scope will hit your hand and will bend toward the proximal sigmoid rather than bend up toward the diaphragm. So that's a good place to push. There are two different kinds of pressure you can use. You can use non-specific pressure or very specific pressure. Pressure right above the symphysis pubis or pressure at a certain point, but most of us use non-specific pressure because we don't know where the scope is at the time because we're not using fluoroscopy. But if you use scope guide or fluoroscopy, that helps a lot to direct your pressure. Do you feel, Jerry, that there are any other spots for pressure sometimes? I found that when we get to, for example, CECUM, my nurses are hooking up the area of the spleen or pressing on the transverse colon. Yes, very good. Transverse colon is anterior, so sometimes you push in the mid-abdomen. It'll help to lift the scope up and make it go across the transverse colon. So I think, Kasia, I think we're about finished. Many, many questions, but unfortunately we have to finish. Okay, so Kasia, it's been a pleasure to work with you on this presentation and I hope that we've been able to give some pointers to the group that tuned into the session. Absolutely. Thank you, everyone, for joining. We hope that that was very helpful, especially learning from the legends by itself. Okay. Good luck, everybody. Thank you very much to our GI fellow moderator, Dr. Katarzyna Pawlak, and our content expert, Jerry Wei, for tonight's amazing presentation. It was an absolute pleasure sitting here. Before we close out, I want to let the audience know to check out our upcoming ASGE educational events and to register. Visit the ASGE website for the complete lineup of 2024 ASGE events. The next Endo Hangouts session, Lower Motility for Practicing Gastroenterologists, will take place on Thursday, August 8th from 7 o'clock to 8.30 p.m. Central Time, and registration is open. At the conclusion of this webinar, you will receive a short survey, and we would appreciate your feedback. Your experience with these learning events is important to ASGE, and we want to make sure we offer interactive sessions that fit your educational needs. As a reminder, ASGE trainee membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to our website to sign up. In closing, thank you again to our presenters for this excellent webinar, and thank you to our audience for making this session interactive. We hope this information has been useful to you, and with that, I conclude our presentation. So, all of you, please have a wonderful night.

colonoscopy

scope straightening

abdominal pressure

challenging scenarios

patient preparation

water immersion colonoscopy

anatomy

torque direction

complications prevention

Dr. Wei

Dr. Pawlak

Q&A segment

execution enhancement