Difficult colonoscopy: air, carbon dioxide, or water insufflation?

Retrograde colon imaging through colonic transendoscopic enteral tubing helps to confirm the cause of difficult colonoscopy: a case report

Numerous factors can contribute to a difficult colonoscopy, potentially leading to an incomplete procedure and overlooked lesions. Alternative strategies for handling difficult and incomplete colonoscopies should be considered. We present the case of an 85-year-old male who underwent a difficult colonoscopy, during which two expert endoscopists spent 1.5 h attempting various techniques but failed to intubate the cecum. Subsequently, colonic transendoscopic enteral tubing (TET) was performed. Abdominal plain film revealed tortuosity of the TET tube in the left abdomen corresponding to the distribution of the descending colon. Retrograde colon imaging was conducted by injecting a mixture of contrast medium and air into the colon via the TET tube. X-ray demonstrated well-developed visualization of the entire colon and terminal ileum. And evident elongation and tortuosity of the descending colon resembled an N-type folding pattern. The final diagnosis was determined as descending colon redundancy. Colonic TET combined with retrograde colon imaging through the TET tube may serve as an effective supplementary approach for identifying causes of difficult colonoscopy and improving diagnostic accuracy for bowel diseases when complete visualization is not achieved.

Causes of intraprocedural discomfort in colonoscopy: a review and practical tips

Colonoscopy is a commonly performed procedure in the United Kingdom and the gold standard for diagnosis and therapy in the gastrointestinal tract. Increased levels of pain during colonoscopy have been associated with reduced completion rates and difficulties in maintaining attendance for repeat procedures. Multiple factors play a role in causing discomfort intra-procedurally: patient factors, such as gender, anatomy and pre-procedure anxiety; operator factors, such as patient position and level of experience and other factors, such as bowel preparation and total procedure time. A literature search was performed to identify papers that explained how patient, operator and endoscopy factors influenced pain and discomfort in endoscopy. A further search then also identified papers describing solutions to pain and discomfort that have been explored. After review of the literature, key methods are selected and discussed in this paper. Solutions and aids that can resolve and improve pain and discomfort include endoscopic methods such as variable stiffness and ultrathin scopes. Operator improvements in techniques and ergonomics alongside the use of newer technologies such as propelled endoscopy, computer-assisted endoscopy and task distraction. To improve patient experience and outcomes, the investigation and research into improving techniques to reduce pain is crucial. This review aims to identify the modifiable and non-modifiable factors associated with intra-procedural discomfort during colonoscopy. We discuss established methods of improving pain during colonoscopy, in addition to newer technologies to mitigate associated discomfort.

Magnetic endoscopic imaging as a rational investment for specific colonoscopies: a systematic review and meta-analysis

BACKGROUND

Magnetic endoscopic imaging (MEI) was regarded as an adjuvant device to improve procedural efficacy and patients' comfort during colonoscopy.

METHODS

Several electronic databases were searched to identify eligible studies. Based on the heterogeneity of included studies, random-effects or fixed-effects models were used to calculate pooled risk ratios (RR), risk difference (RD) or mean difference (MD) along with 95% confidence intervals (CIs).

RESULTS

Twenty-one randomized controlled trials (RCTs) were selected for meta-analysis, with a total of 7,060 patients. Although there is a slightly lower risk of cecal intubation failure with the adjuvant of MEI (RD 3%; P < 0.00001) compared to the control group, the updated studies show no significant benefits. Similarly, the cecal intubation time, pain scores, and loop formation with the adjuvant of MEI did not show any advantages. However, considerable significant benefits were found in the subgroup of technically difficult colonoscopy and inexperienced colonoscopists. Moreover, MEI was associated with lower loop intubation time, lower abdominal compression times, and better lesion localization.

CONCLUSION

The clinical benefits of MEI could be exaggerated. However, MEI has considerable advantages in technically difficult colonoscopies, the assistance for inexperienced colonoscopists, loop resolving, and lesion localization.

Screening colonoscopy: The present and the future

In the United States, colorectal cancer (CRC) is the second leading cause of mortality in men and women. We are now seeing an increasing number of patients with advanced-stage diagnosis and mortality from colorectal cancer before 50 years of age, which requires earlier screening. With the increasing need for CRC screening through colonoscopy, and thus endoscopists, easier and simpler techniques are needed to train proficient endoscopists. The most widely used approach by endoscopists is air insufflation colonoscopy, where air distends the colon to allow visualization of the colonic mucosa. This technique is un-comfortable for patients and requires an anesthetist to administer sedation. In addition, patients commonly complain about discomfort post-op as air escapes into the small bowel and cannot be adequately removed. Current research into the use of water insufflation colonoscopies has proved promising in reducing the need for sedation, decreasing discomfort, and increasing the visibility of the colonic mucosa. Future direction into water insufflation colonoscopies which have shown to be simpler and easier to teach may increase the number of proficient endoscopists in training to serve our aging population.