This week a demonstration of some of the challenges posed by a redundant colon in the ASGE SUTEP tip of the week. So here's the patient referred for an incomplete colonoscopy. He's a man in his 60s. The indication for the first colonoscopy was a positive cologuard. That colonoscopy by the referring physician reached the transverse colon after an extensive effort, no polyps removed. The anatomic problem defined by reviewing the previous report is a redundant colon. We elected to perform our repeat attempt with a standard adult VS scope, the standard choice for redundant colon. So we think that this is a loopy and redundant colon. And so the first thing that we are going to do is choose the adult scope because we want a scope that has got more stiffness to it so that we can counter the redundancy. A lot of people will choose a pediatric scope for any incomplete colonoscopy. And choosing a thin scope is of course a good strategy as we've discussed for a colon where there's a very difficult sigmoid. But in the case of a redundant colon, which in our experience is about two-thirds of all the referrals are for redundant colons, then we want to have an adult scope because we're trying to counter looping and redundancy and stiffness is helpful in that regard. So one, we choose the right scope. Two, we are going to fill the colon with water. So our goal here is to, and we have really the gas turned off. Do we have the gas turned off? So we turn the gas off at the source and this is not actually a water exchange method, rather we're simply putting enough water into the colon so we can see the luminal direction. But we are going to remove any gas pockets that we encounter as we're going. So here's a little bit of gas. So we're going to take that gas out and so this would be kind of a water immersion technique. Then the other part of this is that we really want to keep the instrument straight. We want to counter any tendency to form loops early in the process. And so we'll get some abdominal pressure early on. Now this patient is not a huge patient. He's a good sized man but he's not, he doesn't have a really high BMI and actually a really significant percentage of these patients that we see with long redundant colons have a very high BMI and sometimes when we put pressure on them, we find that in order to cover their abdomen, we may have to put pressure on with two or three people getting four hands or even more, six hands on the abdomen. You can see I'm encountering some gas pockets and all the time as I go around loops, I'm trying to get plenty of scope back and so far I haven't reformed loops. I think the best strategy with regard to loop formation and pressure is to use pressure more to prevent loop formation than to counter it once you've already got it. So when you get loop formation, it's usually most helpful to get the loops out and then apply the pressure to try to keep the loops from reforming. But you are seeing that I'm using a lot of scope here, trying to get it back on a regular basis. But at this stage, to try to counter this, I am going to ask the technician, Joy, to put some abdominal pressure on and so she's going to get herself in here and start to push and see if it saves us a little bit. Now at 6 minutes 35 seconds since the start of the procedure, we're going to remove the pressure from a single individual, unwind the scope and start four-handed pressure. So we're going to have Joy take the pressure off, I think it's best to take the pressure off when you're trying to unwind the scope and I'm going to see if I can hook a little bit and try to get some scope back. But I do think that we definitely have a redundant colon because I've got all the scope in here. So now we're going to try. And you'll notice the prep looks like it's not a split prep. I didn't ask him if he took all the prep last night. But Joy, it's time for you to push again and we're actually going to get some additional help. So we're going to ask the nurse in the room to come over also and see if we can get more hands on the abdomen here. Now at 8 minutes 13 seconds, you can hear me calling for transverse colon pressure. It's a pretty good size pedunculated polyp that we're going to have to remove. Maybe the reason for the positive colon guard. And now let's have both you guys, let's have somebody pushing down low, up. So we're pushing a bit on the transverse colon. The best direction to push to get the loop in the transverse to get some counter pressure is to go down low and then go up. At 949 calling for abdominal massage. All right, let's massage a little bit. We're going to try to massage the abdomen and see if that helps us. At 1021 I'm reduced to imploring the nurses and techs to help me get into the cecum. Okay, try pushing up on the cecum also. Yeah. Help me guys, help me. We often delay back rotation because of the deep sedation and the risk of aspiration. But at 1248 we're trying it. At this stage I've decided I'm probably going to have to start over. So I'm going to remove the polyps that we've identified and then come out. Open. Woo! Close those. Cut that. Probably transverse, I hope it's transverse. Okay, take that. Closing. Closing. Closing. I've got it. Okay, now Joy, it's important that we not go very fast, okay? Yes. 225. You've got a pretty good grip. Yeah. Okay, let it burn first. Okay. Alright, I'm going to start coming through. Totally coming through. Okay, that was good. Alright, now we're going to reach out there and grab that. Open. Closing. Okay, now we're going to haul that out. Now we've started over from scratch, using the same scope, going in again underwater. Honestly, this would be a great time to use an overtube like the Pathfinder, but we didn't have it at the time that this video was made. So we're going back in underwater, keeping the insertion tube as straight as possible, close to the seacum. Okay, so we're still underwater at this stage. We appear to be looking into the seacum. We got kind of stuck. We found a place here where the scope... Don't take your hands off. ...where Christina has been pushing down toward the middle. We found a loop there, and that actually moved us from the sort of hepatic flexure region down into the seacum. So this is the seacum. And at this stage, we're going to carefully turn the gas on. As we put the gas on, the colon is going to tend to move out away from us, and it's going to become more difficult to get down there. Now you're going to see us get fully into the seacum some 32 minutes after the initiation of the procedure. On a scale of 1 to 10, I would say this is a 9 in terms of difficulty, a very long insertion for me. We put a bit of gas in, removed the loops, and then we get the pressure figured out and finally get into the seacum. I would try to manipulate this down and in this direction and push it back. Massage it a little bit. Okay, let me see if I can get the scope out. I'm going to let off. Why don't you stay on, Christina? Do you want to get some... I'm just going to let you get a little back here. Okay, so that's good. So we just pulled a lot of scope out, and we didn't fall back. So I'm going to move that back there. Okay, now we are going to try... We took a loop out. Now I want you to push on the place where you felt that loop, okay? I need a loop on the scope, Joy. Push that back. Is there something that you can do other than pushing straight at it? Try to pinch it like... Or you can push it back to the right. Oh, yeah. Hang on to that. Hang on to that. No? No? It buckled. It buckled again. It started to go and it buckled. I feel it buckle right here. Okay, don't let it buckle, guys. You've got to pin it. If you feel it, don't let it buckle. You've got a hold of it. Don't let it buckle. Hang on tight. Hang on tight. Alright. Yay! Girls class! So this is an example of a very difficult colonoscopy, where really I got some expert help with abdominal pressure, where these guys, we were able to determine where the loops were, get the scope straightened out, and then counter those loops from reforming. And that's what has gotten us down into the CECA. So it's a combination of water immersion to about the mid-ascending colon, a stiff scope, and four hands. And you can see one of the nurses is pushing up on a loop that was down here. We could actually, the CECA, the right colon, we're actually pushing the hepatic flexure down. And it took quite a bit of poking around and seeing where the loops were to be able to do it. Next week, demonstration of passage of an angulated sigmoid on the ASGE SUTAC tip of the week.

colonoscopy procedure

redundant colon

adult scope

water filling

abdominal pressure