And the ASGE SuTab tip of the week. I'm going to show a case of cecal intubation in a patient referred after failure to pass the sigmoid because of narrowing and angulation. This is the typical case of a luminal narrowing related to severe diverticular disease. And the patient, unfortunately, had a poor prep proximal to the sigmoid. I did go ahead and intubate the cecum to get a look and survey of the colon, but ended up having to tell the patient to come back within a year according to our guidelines about how to manage a patient with an unsatisfactory prep. But I would ask you to focus on the key learning tips here, which are the keys to success, the discussion of scope diameter and the length of the bending section. Secondly, water insertion and its value both for safety and success in the narrow and angulated colon. And then also to note the use of the left-hand scope grip, you'll see the insertion tube being sometimes pushed with the right hand, and then repeatedly exchanging back and forth to the left-hand scope grip or left-hand grip on the insertion tube, which allows then forward pressure on the scope to keep the tip into the turn using pressure from the left forearm, but at the same time, simultaneously allowing exquisite control of the direction of the scope tip because you can operate the up-down and the left-right control at the same time. So here we go. Okay, so the first step in this case is from record review that we know that this patient has a narrowed and angulated sigmoid colon. The referring doctor has already tried to get through with a pediatric scope and sort of indicated that they couldn't even come close. So we're going to already go to a narrower scope, and this is the Olympus Ultra-Thin Scope, the PA. The bending section on this instrument is basically the same length as a standard colonoscope. So if we can't get through this, we won't give up. We'll switch to a scope that is as narrow or narrower, namely the SIF-180 enteroscope, but which has an even tighter turning section because in a very sharp angle, we need both a narrow scope and sometimes we need a very tight turning section to get around this. And the SIF-180 or some upper scopes can actually achieve a narrower turning radius. We also are going to be using water. We're gonna be pumping water in rather than gas to avoid barrel trauma and to keep the sigmoid colon lying down in a straight line. So let's try this approach and see if we can get through. All right, so we're just heading into the distal sigmoid colon here. And unfortunately, we don't have good bowel preparation. So that's an initial thing that we're gonna have to clean up as we're doing. So we'll probably do a little bit of water exchange if we can. The problem with doing water exchange with this scope is that we're pumping the water, not through a water jet, but actually directly into the channel. So if we, under normal circumstances where we're doing water exchange, we would be pumping water and suctioning at the same time. You can't really do that. If we hit the water jet and if we hit suction, we're just gonna suck back the water that we're pumping in. You can see that we've got some angulation here. I don't think we've hit the really bad part of this yet is my guess. And we're trying to stay completely under water. And here's sort of the first area where I'm not quite sure where the lumen is, maybe off to the right, up and right. Man, I may have a little trouble with the water jets. Okay, so it looks like we're starting to hit the areas of the area of pretty severe angulation here. And I'm using the left-hand scalp grip. I've got the insertion tube between my fourth and fifth fingers to help me push the scalp in. Grant, will you hold this for a second? I got a really bad angle here. I'm just gonna, I feel like I'm coming around her butt. All right, so we're searching for the lumen. Again, we're hoping our water is going to keep us a little bit straighter. The other advantage of it is avoiding barotrauma. We don't have to worry about pumping gas ahead of us into the more proximal colon. All right, so the lumen looks like it's down and left. I really like to try to use both directional controls at the same time to find the lumen. But I admit right now, I don't know exactly where the lumen is. That could have been sort of led astray off to the, there we go, there's our lumen. That's what was following the diverticulum. So again, we're pumping water continuously. Now water is going to run back around the scalp and come out the patient's bottom. And it'll tend to take the lubrication off the scope. So now my guess would be that we're through the worst of the narrowing. And so in this particular case, the UltraThin has really enabled us to get through. I think we're going to have some problems, however, with preparation. Let's see if this gets any better here in a minute. But the key thing is that from the standpoint of completing this colonoscopy is that the thing that allowed us to do it was going to the UltraThin scope. Angulated sigmoid, you get a narrow scope. If it works, great. Usually first the pediatric. If it doesn't work, then you get a narrower scope or a narrower scope with a tighter bending section. Oh yeah, you got it, you got it already. Flexible instrument like this, very likely that we're going to have to apply a little bit of pressure for stiffening. So now you can see we're in the CECA, but unfortunately we'll probably still try to take a look at this colon, but we're going to be limited by the prep. Here's the ileocecal valve. Thanks and see you next week on the ASGE SuTab tip of the week.

cecal intubation

narrowed sigmoid colon

angulated sigmoid colon

scope diameter

water insertion