Susan E. McCormick

Spiral overtube–assisted colonoscopy after incomplete colonoscopy in the redundant colon

BACKGROUND A redundant colon can lead to incomplete colonoscopy. A variety of tools and techniques are available to complete colonoscopy but have limitations. OBJECTIVE To determine the feasibility and safety of using a spiral overtube to complete a difficult colonoscopy. DESIGN Retrospective review of a prospectively collected database. SETTING Single tertiary institution. PATIENTS Twenty-four patients with incomplete colonoscopy because of redundant colons underwent 26 procedures. The median age was 68 years, and 58% were men. INTERVENTIONS All patients underwent colonoscopy performed with a 90-cm flexible threaded overtube and a variable-stiffness pediatric colonoscope. Four individuals (18%) required exchanging the colonoscope for an enteroscope. MAIN OUTCOME MEASUREMENTS Successful cecal intubation, polyp identification and removal, time to reach the cecum, sedation needed, and complications. RESULTS Cecal intubation was achieved in 22 patients (92%). Failures occurred in 2 patients with large hernias. The median time from insertion of the colonoscope to reaching the cecum was 14.5 minutes. All procedures were performed by using conscious sedation with midazolam (median dose 7 mg) and fentanyl (median dose 150 μg). Significant findings were encountered in 17 of 22 patients (77%) including 1 cancer and 2 advanced polyps. A median of 3 polyps was removed from each patient who had polyps. All noncancerous polyps were removed during the procedure. There were no complications. LIMITATIONS Retrospective design, no control group, single center. CONCLUSION Spiral overtube-assisted colonoscopy can enable cecal intubation in the majority of patients in whom standard colonoscopy fails because of a redundant colon.

One year experience with computer-assisted propofol sedation for colonoscopy

AIM To report our one-year experience with computer assisted propofol sedation (CAPS) for colonoscopy as the first United States Medical Center to adopt CAPS technology for routine clinical use. METHODS Between September 2014 and August 2015, 2677 patients underwent elective outpatient colonoscopy with CAPS at our center. All colonoscopies were performed by 1 of 17 gastroenterologists certified in the use of the CAPS system, with the assistance of a specially trained nurse. Procedural success rates, polyp detection rates, procedure times and recovery times were recorded and compared against corresponding historical measures from 2286 colonoscopies done with midazolam and fentanyl from September 2013 to August 2014. Adverse events in the CAPS group were recorded. RESULTS The mean age of the CAPS cohort was 59.9 years (48.7% male); 31.3% were ASA I, 67.3% ASA II and 1.4% ASA III. 45.1% of the colonoscopies were for screening, 31.5% for surveillance, and 23.4% for symptoms. The mean propofol dose administered was 250.7 mg (range 16-1470 mg), with a mean fentanyl dose of 34.1 mcg (0-100 mcg). The colonoscopy completion and polyp detection rates were similar to that of historical measures. Recovery times were markedly shorter (31 min vs 45.6 min, P < 0.001). In CAPS patients, there were 20 (0.7%) cases of mild desaturation (< 90%) treated with a chin lift and reduction or temporary discontinuation of the propofol infusion, 21 (0.8%) cases of asymptomatic hypotension (< 90 systolic blood pressure) treated with a reduction in the propofol rate, 4 (0.1%) cases of marked agitation or discomfort due to undersedation, and 2 cases of pronounced transient desaturation requiring brief (< 1 min) mask ventilation. There were no sedation-related serious adverse events such as emergent intubation, unanticipated hospitalization or permanent injury. CONCLUSION CAPS appears to be a safe, effective and efficient means of providing moderate sedation for colonoscopy in relatively healthy patients. Recovery times were much shorter than historical measures. There were few adverse events, and no serious adverse events, related to CAPS.

A pilot study on crystalline lactulose for colonoscopy bowel preparation.

METHODS Patients scheduled to undergo routine screening or diagnostic colonoscopy were prospectively enrolled after informed consent. Each patient consumed nine 20 g doses of crystalline lactulose (Kristalose; Cumberland Pharmaceuticals, Nashville, TN), with 1 dose taken every 30 minutes for 4 hours the evening before the colonoscopy, starting at 5 PM. Each 20 g dose was dissolved in 4 ounces of water, and subjects were instructed to drink a further 64 ounces of water over the course of the evening. To rule out the risk of explosion during colonoscopic cautery, each subject underwent a baseline breath analysis [BreathTracker Digital MicroLyzer (Quintron, Milwaukee, WI)] the day before the colonoscopy (before the start of the bowel preparation) and a follow-up breath analysis done after the preparation was completed but 30 to 180 minutes before the colonoscopy. The following were the study endpoints: (1) safety and side effects; (2) efficacy: during colonoscopy, the preparation quality was evaluated by the unblinded endoscopist using the validated Boston Bowel Preparation Scale (BBPS), which uses a number from 0 to 3 to rate each of 3 sections of the colon/rectum.1 The number of patients considered bowel preparation “failures,” defined as those with an overall BBPS of <5 and/or any colon segment score of 0, was recorded; and (3) tolerability: after the procedure, patients completed a short mail-back questionnaire within 7 days asking whether crystalline lactulose was preferred compared with previous bowel preparation regimens experienced by the patient (if any).

7171 Pesky findings on endoscopy or ct scan: endoscopic ultrasound can help.

Endoscopists often encounter submucosal lesions of unknown significance during endoscopy or are asked to evaluate thickened esophageal, stomach or bowel wall noted on CT scan. Endoscopic ultrasound (EUS) has proved useful in defining submucosal and extraluminal structures. The purpose of this study is to determine whether these often incidentally noted abnormalities represent clinically significant entities and to determine whether the addition of EUS changes management or avoids further evaluation. Methods All charts from patients undergoing EUS at Virginia Mason Medical Center between December 1998 and November 1999 were evaluated retrospectively. Patients were included if the procedure was performed because of a nonspecific abnormality seen on endoscopy (thick folds, submucosal nodules or extrinsic compression) or CT scan (thickened gut wall). Patients whose abnormalities were highly suspicious for malignant neoplasm were excluded. Charts were evaluated for patients age, sex and symptoms which initiated the evaluation. EUS findings and subsequent treatment were noted. Results Of 292 EUS procedures, 33 (11%) were performed because of an ambiguous finding on endoscopy or CT scan. Of these, 10 patients (30%) had clinically significant findings, 4 (12%) of whom had malignant neoplasms (61 y/o female with gastric cancer, 45 y/o female with periappendiceal carcinoid tumor, 45 y/o male and 61 y/o male with gastric leiomyosarcomas). One patient was completely asymptomatic. Other clinically significant findings included small leiomyomas which will require follow up, adenopathy, a prolapsing pancreatic rest and a lymphangiectatic cyst. In all other patients, EUS was able to determine that the abnormality represented a benign process requiring no further evaluation. Findings included lipomas, pancreatic rests, large adjacent vessels causing compression and thicked mucosa due to inflammation without underlying abnormality. Conclusion EUS is useful in evaluating “incidental” abnormalities found on endoscopy and CT scan. All of the patients could be diagnosed with confidence. Clinically significant findings were seen in 30%, including 12% with malgnant neoplasms. Age, sex and symptoms did not distinguish benign from malignant processes.