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Colonic endoscopy in perspective.

Sigmoidoscopy is an easy procedure and should be utilized more frequently. Barium enema examination is incomplete without sigmoidoscopy. Flexible fiberoptic sigmoidoscopy may have a role in the detection of disease of the descending, sigmoid, and rectosigmoid colon. The necessity for its routine usage remains to be determined. The control of colonic polyps by colonoscopy has been the greatest contribution to date by the fiberoptic instrument. Colonoscopy has improved the accuracy of diagnosis of colonic disease and, in certain instances, is helpful in the early detection of cancer of the colon. Colonoscopy complements the use of barium enema examination. Colonoscopy only for the purpose of confirmation of clinical or radiological diagnosis is often unnecessary. While the benefits of endoscopy are obvious, there are definite practical and technological limitations to its use. Complications, although infrequent, are major. Indications for colonoscopy must be clear and findings interpreted with knowledge of the limitations.

Colonic Diseases↗

Flexible rectosigmoidoscopy in the detection of tumoral colonic lesions.

The fibrorectosigmoidocope Olympus TCF I S, has been systematically applied to the exploration of the distal colon (rectum and sigmoid) in patients with intestinal or digestive extra intestinal symptoms. In the first 300 patients the technical parameters of the method were tested: the fleet enema preparation was found excellent or satisfactory in 95% of examinations. The tolerance was good in 96% of examinations--the mean length of operation was 5.15 min--the mean length of colon examined was 48.5 cm, the distance of 50 cm being surpassed in 50% of patients. The efficacy in the detection of the lesions was tested in 476 patients. Tumoral colonic lesions were detected in 105 patients with a total of 125 adenomas and 31 cancers. In the area that could have been explored by a rigid rectosigmoidoscope (0-19 cm) we found 71 lesions (50 adenoma and 10 carcinoma), whereas beyond this limit (25-60 cm) 85 lesions (50 adenoma and 10 carcinoma).

Adenoma↗

Evaluation of a new fibre colonoscope the Olympus TCF-2L.

Experience with the new Olympus twin channel TCF-2L colonoscope is presented. Based on 60 examinations including 25 polypectomies it is concluded that the instrument when compared with other colonoscopes is easier to handle and its advancement within the colon is faster, smoother and therefore less disagreeable to the patient. The proximal colon is easier to reach than previously experienced. Polypectomy and retrieving of polyps can efficiently be undertaken. This instrument will undoubtedly further enhance the usefulness and therapeutic value of fibre colonoscopy.

Carcinoma↗

A new self-twisting polypectomy snare.

In contrast to the hitherto available polypectomy snares the newly designed snare for endoscopic polypectomy offers the following advantages: when the tip of the endoscope is directed towards the polyp the snare turns automatically into a position parallel to the polyp-bearing bowel wall. "Combusting ulcers" are avoided, a homogenous circular flow of electric current is guaranteed.

Electrosurgery↗

A new technique for insertion of the colonoscope through the ileocaecal valve.

At colonoscopy it is important to examine the distal part of ileum in inflammatory diseases particularly. Different techniques for insertion of the colonoscope into the ileum have been described. In our experience these methods require considerable skill and practice. We have therefore worked out a technique for easier access to the ileum with a colonoscope. A closed biopsy forceps is used for identification of the ileocaecal valve by dislodging the upper lip. The forceps is manoeuvred through the ostium and then the colonoscope can be inserted into the ileum with the forceps as a guide.

Biopsy↗

Sigmoid stiffener for decompression tube placement in colonic pseudo-obstruction.

BACKGROUND AND STUDY AIMS: Decompression tube placement improves outcome in colonic pseudo-obstruction (CP) which is refractory to conservative measures, especially if the decompression tube is placed proximal to the hepatic flexure. We evaluate the ability of a sigmoid stiffener to facilitate more proximal colonoscopy and decompression tube placement. PATIENTS AND METHODS: A sigmoid stiffener is used in the standard fashion during colonoscopic decompression for pseudo-obstruction. After cecal wire placement, the colonoscope is withdrawn, leaving the stiffener and wire in place. By passing through the stiffener, an over-wire decompression tube can avoid sigmoid looping. We compared proximal extent of colonoscopy, tube position, endoscopy time, and patient outcomes using a sigmoid stiffener, with a control group of patients treated previously. Patients with colonic ischemia were excluded. RESULTS: Using this technique, nine consecutive colonoscopies and decompression tube placements reached the right colon. Significantly, only three of seven control colonoscopies and two control decompression tubes did so. However, improvements in procedural time and patient outcome did not reach statistical significance. No complications occurred. CONCLUSION: The use of a sigmoid stiffener during colonic decompression allows more proximal colonoscopy and decompression tube placement, with possible clinical benefit. We do not use this technique in the setting of left colon ischemia.

Adult↗

Palliation of large-bowel obstruction due to recurrent rectosigmoid tumor using self-expandable endoprostheses.

When large-bowel obstruction supervenes in patients with rectal tumor recurrence and extensive nonresectable disease, a proximal diverting colostomy may be indicated. In this study, nonsurgical palliation of the obstruction was attempted by inserting self-expandable endoprostheses to bridge the stenotic lesion. The endoprostheses were positioned in two patients with large-bowel obstruction due to recurrent stenotic tumor, and extensive disease excluding palliative resection. Self-expandable endoprostheses with inner diameters of 18 mm and 22 mm were successfully inserted under endoscopic and radiographic control. Proper expansion of the endoprostheses was achieved in both patients, resulting in immediate decompression of the bowel and lasting relief of the obstruction.

Aged↗

Lithotripsy of urinary concrement in the sigmoid after ureterosigmoidostomy.

A urinary concrement which appeared in the sigmoid of a 63-year-old man after ureterosigmoidostomy was extracted by endoscopy. The stone was situated proximal to a radiogenic stenosis. Because of the disproportion between the stone and the sigmoidal stenosis, mechanical lithotripsy had to be done before the concrement could be completely extracted.

Colon, Sigmoid↗

The utilization of flexible sigmoidoscopy by family practitioners after residency training.

BACKGROUND: Flexible sigmoidoscopy is routinely performed by family practice physicians, most of whom receive training in postgraduate education programs. The aim of this study was to assess the utilization of flexible sigmoidoscopy by family practitioners who received training during residency. METHODS: Family practitioners who underwent training in flexible sigmoidoscopy during their residency were contacted by phone or mail and polled regarding their current use of flexible sigmoidoscopy and assessment of their previous training. RESULTS: Forty-two graduates were contacted; 76% were certified (according to our predefined criteria) during training and 74% were currently performing flexible sigmoidoscopy. Of those who were certified, 87% were currently using flexible sigmoidoscopy compared with 45% of those who did not receive certification (p = 0.02). Training during the last year of residency was more likely to be associated with current use of flexible sigmoidoscopy than earlier training (69% vs. 30%, p = 0.03). Certification was associated with more procedures during training (24.3 +/- 1.7 vs. 16.6 +/- 3.1, p < 0.05). Current users performed a mean of 4.3 +/- 0.75 procedures/month; most reached 40 cm in depth of insertion and completed the procedure in 17.2 +/- 1.2 minutes. Of patients undergoing flexible sigmoidoscopy, 13% were ultimately referred for colonoscopy. Most practitioners considered their training useful and only 9.6% had obtained additional training outside residency. CONCLUSIONS: Most family practitioners certified in flexible sigmoidoscopy during residency performed the procedure in their practices. Depth of insertion and time for completion of the procedure seem to be adequate.

Adult↗

Prospective, randomized, single-blind comparison of two preparations for screening flexible sigmoidoscopy.

BACKGROUND: The best and most cost-effective bowel cleansing regimen for patients undergoing flexible sigmoidoscopy is not known. The aim of this study was to compare patient tolerance, quality of preparation, and cost of 2 bowel cleansing regimens for flexible sigmoidoscopy. METHODS: Two hundred fifty consecutive patients referred for screening flexible sigmoidoscopy were randomized to receive an oral preparation (45 mL oral sodium phosphate and 10 mg bisacodyl) or an enema preparation (2 Fleet enemas and 10 mg bisacodyl). Tolerance of the preparation was graded as easy, tolerable, slightly difficult, extremely difficult, or intolerable. The endoscopist was blinded to which preparation the patient received and graded the quality of the preparation as poor, fair, good, or excellent. Cost was calculated by adding the cost of the medications and the cost for the nursing time required to prepare the patient for endoscopy. RESULTS: Patients in the oral preparation group were more likely to grade the preparation as easy or tolerable when compared with the enema group (96.8% vs. 56.4%, p < 0.001). The endoscopist graded the quality of the preparation as good or excellent in 86.5% of the patients in the oral preparation group compared with 57.3% in the enema group (p < 0.001). In the oral preparation group, the mean nursing time (34.6 vs. 65.3 minutes, p < 0.001) and cost ($16.39 vs. $31.13, p < 0.001) were significantly less than in the enema group. CONCLUSIONS: An oral sodium phosphate preparation results in a superior quality endoscopic examination that is better tolerated and more cost-effective than enemas in patients undergoing screening flexible sigmoidoscopy.

Administration, Oral↗