This week, Techniques for Intubation of the Terminal Ilium on the ASGE SUTAB Tip of the Week. So first is TI intubation in routine colonoscopy the standard of care? Opinions vary on the topic. I would argue that it's not. It's screening colonoscopy. There isn't anything that I know of from one of the societies that says you have to go in the terminal ilium on a routine basis. In my opinion, the only really important thing that's found in there in asymptomatic people is neuroendocrine tumors, ileal carcinoids, which do have a high propensity to metastasize even when small. So it's good to find them when they're there. I have found nine in more than 50,000 colonoscopies. So I don't think something that's occurring about one in every five or 6,000 colonoscopies is a requirement from the standpoint of standard of care that you have to do it. It does have impact on the use of distal attachments, because if you believe it's the routine standard of care, then distal attachments in general make it a bit harder to get in there. You're not going to get in there as often, and so it's going to affect your use of those devices. Obviously, there are some clinical situations where you should work very hard to get in the TI. So tools for TI intubation, it goes without saying that a skinnier scope is going to be more effective. So if you have a device on the end of the scope, like the endocuff vision or the amplify, you would need to take that off, switch to a pediatric scope, to an ultrathin, to an enteroscope. I occasionally get referrals for difficulty entering the TI abnormal radiographs of the TI, and switching to a thinner scope is a very important part of the solution. Next, I'll say that for routine cases, I favor just deflation of the cecum so that the valve turns distally toward the anus, and then just intubating it directly, as opposed to the routine use of the bow and arrow sign, which I see many fellows do, and I sort of feel for routine cases, it's kind of a waste of time. I do think the bow and arrow sign is very accurate and is useful in difficult cases, but routinely, I prefer to just deflate and go straight at the valve. Some people advocate the use of the bow and arrow sign, which means that if you're looking in the forward view down into the cecum, you take the curve of the appendiceal orifice and draw an arrow through the middle of it, and it will aim toward the location of the valve orifice underneath the valve, even if you can't see it. Then you go past the valve, deflect in the direction that is signaled to you by the bow and arrow sign, and then pull back. The problem with this on a routine basis is that you spend a lot of time distal to the valve, sort of slowly coming back. This is okay in a difficult situation, but it's not as efficient for routine use as the simple method of just deflating a bit, looking, finding the crevice between the valve lips and driving straight into the TI. That should be tried first in almost every instance. If you don't see the actual space between the valve lips, it's to simply deflate, because deflation will tend to turn the valve up so that it's facing more anally. The key thing is to just see that crack between the valve lips. The proximal or secal side lip is what you want to visualize, and then just drive up and aim the scope into the crevice in between and deflect into the terminal ilium. This is by far the fastest way to get into the terminal ilium on a routine basis. This is what I mean by the direct approach. You just deflate a little bit, visualize the lips of the valve, and then drive the scope tip up there and wedge the scope by deflection between the lips until you pop in. And if you have nothing on the end of the scope, you can do this even with an adult scope and almost everybody who's basically undergoing normal surveillance, screening, diagnostic examinations occasionally. A little bit of abdominal pressure, especially in the right lower quadrant, can help. An underused tool for TI intubation is to go underwater. That is, take the gas out of the cecum and fill it with water. This will cause the valve to relax and turn toward the anus. The orifice turns toward the anus, facilitating intubation. Very useful, especially if there is any device on the tip of the scope that increases the diameter. The very best way to get the valve orifice turned toward you so that you can see it and enter it more easily is to remove the gas from the cecum and ascending colon and fill it with water. This will tend to make the colon collapse and it will really roll the valve up so that it's no longer with the orifice pointing toward the cecal side, but rather toward the anal side. This is a fabulous way to get in when you are struggling and you can't get the valve turned toward you. And it's especially useful if you have a device on to improve visualization like the Endocav Vision or Amplify. I'll demonstrate this underwater technique a couple of times because, again, I think it's underused. So here we have a valve where the orifice is pointed toward the cecum. You can't really see it from the anatomic distal side, from the anal side. So we're taking the gas out and filling it with water. Sometimes you have to do a bit of water exchange if the fluid has a lot of mucus in it. But you can see now the valve is much more directly at us and then we can push our way in underwater. And I think the water often causes the opening to relax a bit. It just allows a bigger diameter to go through. Here's another case of underwater intubation of the TI. And when you're using this technique, it can help to clean up a bit first because if there's a lot of mucus around and you start to infuse water, it can get a bit cloudy. It's possible to lose track of the valve. You can see now with this clear water, we can already see the valve turning out. Everything is relaxing. And we came past the valve. It's turned away from us a little bit, but when we get under there, it actually is quite easy to turn into the valve lips. And again, I think the water technique seems to make the valve orifice a little bit more receptive. It's easier to push through a large scope, an adult scope with a device on the tip. Sometimes you have to deflect a little bit to the right or left to sort of get off the area where you're catching right on the valve orifice in order to get up into the TI. And a little bit of abdominal pressure, as I mentioned, sometimes in the right lower quadrant can help push the bending section into the TI. But the key thing that I want to demonstrate here is how water filling, underwater intubation of the TI, how this approach turns the valve orifice toward you. There you can see it turning toward you, and that's really the key to facilitation of intubation. It's that turning toward you and relaxation of the valve that lets you in. Finally, there's approaching the TI in retroflexion. This will usually get you into the TI, but because you have such a hook in the scope, as you start to straighten, you've got to get some abdominal pressure on right away in order to be able to push deeply into the TI. Another technique you can use if other measures fail is to go into retroflexion in the cecum, look directly at the valve orifice as it's pointed toward the cecal side, and then just pull the scope back in the retroflex position and pull the tip of the scope right up through the ileocecal valve into the terminal ileum. So if I get to the point where I'm resorting on this technique, retroflexion, primarily to get into the TI, often I've switched to a thin scope. If the valve is open, it can be relatively easy to pull the tip of the scope up through the orifice into the TI, but the trick is staying there as you start to pull back and unwind and straighten. So you need to get some abdominal pressure on so you can move forward deeper into the TI. Thanks, and see you next week on the ASGE SuTab tip of the week.

intubation

terminal ilium

colonoscopy

neuroendocrine tumors

ileal carcinoids