Today, maintaining colonic distension during withdrawal on the ASGE SUTAB tip of the week. Here's a left colon examination during withdrawal in a patient of the left lateral cubitus position. You notice we've got excellent bowel preparation. We're using the endocuff vision. We are also doing a very active examination. We're going back and forth in and out multiple times, multiple passes basically also helps to improve detection. But the basics are also being achieved. We're looking behind all of the hostile folds. We're cleaning up and we're achieving distension and that's the subject of this video tip is how do you achieve distension, especially in the left colon when the patient's in the left lateral decubitus position. The problem is that the sigmoid colon in the left lateral decubitus position is dependent. So gas tends to escape into the proximal colon or come out of the anus. One thing we can do is rotate the patient so that it's no longer dependent. We've got in the U.S. where we're using propofol and we rotate the patient. We're a little bit more concerned about aspiration. Many of our patients have very high BMIs. They're harder to move. So how can we stay in the left lateral decubitus position and get good distension of the colon? I think the use of CO2 helps because when you're using gas, some people are worried about abdominal distension and abdominal pain in the recovery area after the procedure. They'll actually suck the gas out. But with CO2, you can be much more aggressive in insufflation because you don't have to worry about pain in the recovery area. So maintaining good distension is actually really important to high level detection. There are times when you under distend where a polyp behind a fold will come into view because of decreased distension, but you've got to at some point achieve adequate distension of all sections of the colon. There are several ways to do it. We mentioned CO2 and then patient rotation groups in the U.K. have shown the importance of this. They tend to use very light levels of sedation in the U.K. and so they can have the patient rotate more easily and they've shown that best distension is achieved for the right colon in the left lateral decubitus position, for the transverse colon as you'd expect because it's anterior in the supine position, and for the left colon actually best distension is achieved in the patient is in the right lateral decubitus position. But as I mentioned, because of high BMIs and concerns about aspiration in patients sedated with propofol, we're more reluctant to do that. So I'm going to focus on three methods that will allow us to stay in the left lateral decubitus position during withdrawal through the left colon and still achieve adequate distension. And those are filling the left colon with water using cracoid pressure, and then the GI scope, which is a new scope that has been shown to improve detection and the specific mechanism that it works is at least partly by achieving better distension. We've discussed many uses of water during colonoscopy and yet another one is achieving left colon distension in the left lateral decubitus position. When gas is escaping out the anus, you can just convert to water filling using the water jet and get good distension. One of the tools that I rely on the most to get good left colon distension during withdrawal is the gluteal squeeze maneuver, or what we humorously refer to as cracoid pressure. We talk about cracoid pressure and use that during upper endoscopy if the patient is burping and trying to get good gastric distension. During left colon withdrawal, if the patient is passing gas through the anus, then you're going to have a hard time achieving good distension. So we counter that by applying the gluteal squeeze maneuver or cracoid pressure, and you can see the technician who's to my left has her hands on the gluteal muscles. She's just squeezing them together to prevent gas from coming out the anus. Usually we have the technician over on the right, we just have her over on the left here so you can see where the hands are placed. I think the need for this is greater with the use of propofol because the patient is very relaxed, including their anal sphincter, but the need for it also is dependent on just the natural strength of their anal sphincter. So if you're having a hard time in a left lateral cubitus position, descending the left colon, you can rely on cracoid pressure. This is the GI scope from Smart Medical, recently FDA approved, has a balloon on it that is mounted on the scope back from the tip a couple of centimeters. So insert the scope to the cecum in the deflated position, of course, and unlike devices like Endocav Vision or Amplify, it doesn't increase the diameter of the device effectively. So it's not going to occasionally restrict you from passing through a narrowed sigmoid colon. Once you get to the cecum and clean up, then the balloon is inflated and it grips the walls of the colon and as you're withdrawing, it kind of pulls the colon into more of a straight tube and it's also difficult for gas to escape back around the balloon, especially in the left colon. So it helps to maintain a distension of the colon. Here's the GI in action and I've got the room lights too low here. It makes the endoscopic image look very washed out, but I hope you can see how well the colon is distended here in the left colon with the balloon up. You can feel a little bit of resistance as you're pulling back and we're pumping CO2 into the colon. You can sort of see how it's pulling the colon into a straight line, a little bit of fluid escaping back around, but gas has a very hard time escaping around the balloon. So one of the ways that this balloon works to improve detection is by achieving great distension. In summary, we've talked about several ways to maintain distension during colonoscope withdrawal. So important for detection and one of these is to rotate the patient, but for those of us in the U.S. who are using propofol or may have a very large patient, there are several ways, especially in the left colon where we have the most problems with distension when we're in the left lateral decubitus position, to keep that distension without rotating the patient. And those are to use CO2, fill the colon with left water or use cracoid pressure. And then there's the GI scope, which you may not have experience with yet, but works at least partly by maintaining excellent distension. That concludes the ASGE SUTAB series. They'll continue to be available on the website and I hope you enjoyed them.

colonoscopy withdrawal

colon distension

left lateral decubitus position

CO2 insufflation

abdominal pain