0016-5107/91/3702-0152$03.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1991 by the American Society for Gastrointestinal Endoscopy
Total colonoscopy: is it always possible? Jerome D. Waye, MD, Eric Bashkoff, MD New York and Manhasset, New York
One-thousand three hundred fifty-one consecutive colonoscopies were performed in an office setting without fluoroscopy. Three different models of colonoscopes were utilized; all were manufactured by' the Olympus Corporation of America, and included a videoendoscope, a CF-20L immersible OES-type instrument, and an older fiberoptic colonoscope, CFLB-3W. In all colonoscopies, the cecum was reached in 95.9%, even when an obstructing lesion or stenosis was present. Total intubation was performed in 97% of cases with the videoendoscope, 95.5% with the CF-20L, and 95.7% with the CFLB-3W. In a subgroup of 865 colonoscopies, total colonoscopy was performed in 98% of cases when obstructing lesions (carcinoma or stricture) were excluded from analysis. In this subgroup, total colonoscopy could not be performed in 16 patients because of colonic fixation, tortuosity, or for unknown anatomical reasons. Forty-five percent of this subgroup was female, but of the 16 patients in whom total colonoscopy was not possible, 15 were women, 5 of whom had a previous hysterectomy. We conclude that in the absence of any obstructing lesion, an expert can perform complete colonoscopy in 98% of examinations, and in 95% of all patients presenting for colonoscopy. Total colonoscopy may be more difficult in women than men, but a previous hysterectomy does not seem to adversely affect the ability to perform colonoscopy. The type of instrument used for colonoscopy does not impact on the ability to visualize the entire colon. (Gastrointest Endosc 1991;37:152-154)
Total colonoscopy to the cecum should be the goal whenever a colonoscope is introduced into the rectum. In spite of the procedure being performed for over 20 years, the actual number of successful total colonic intubations varies in the recent published literature from 55 to 98%.1-8 It is evident that not all colonoscopies can be completed to the cecum, but there are no guidelines with which to compare adequacy of colonoscopic intubation. A prospective collection of data was designed to ascertain the frequency of total colonoscopy in the hands of an expert. In this study, the ability to reach the cecum was correlated with the type of instrument utilized since there is a general feeling that the stiffness or rigidity of the instrument Received August 29, 1989. For revision November 5, 1989. Accepted October 25, 1990. From the Mount Sinai Medical Center (CUNY), Department of Medicine, Division of Gastroenterology and the Department of Surgery, North Shore University Hospital, Manhasset, New York. Reprint requests: Jerome D. Waye, MD, 650 Park Avenue, New York, New York.
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may playa role in the ease with which colonscopy is performed. There is also a consensus that the female anatomy may predispose to more difficult colonoscopy, especially after pelvic surgery. We evaluated the frequency with which total colonoscopy was achieved in a consecutive series of endoscopic examinations, all performed in an office setting without fluoroscopy. We correlated total colonoscopy with the patient's sex and type of instrument used. MATERIALS AND METHODS
The distance reached with the endoscope tip in 1351 consecutive colonoscopies over a 16-month interval was recorded prospectively. Fluoroscopy was not utilized, nor was it available. The criteria for "total colonoscopy" was achieving either entry into the terminal ileum or visualization of the ileocecal valve. The appendiceal orifice is a useful landmark, but once identified, the ileocecal valve can always be seen upon scope withdrawal. Light in the right lower quadrant is not a reliable indicator of the tip in the cecum, nor is the ability to deeply indent a GASTROINTESTINAL ENDOSCOPY
sfction of distended bowel by finger palpation over the right lower quadrant. The cecum was not considered to have been reached if the endoscope tip was not advanced to the level of the ileocecal valve; although the cecal caput was not entered in every patient, it was intubated in all but three patients when the colonoscope reached the ileocecal valve. Of 1351 consecutive endoscopies, total colonoscopy was achieved in 1296 (95.9%) (Table 1). All colonoscopies have been included in this determination, whether or not an obstruction was present. The Olympus videoendoscope was used 786 times, with a 97% success rate for total intubation. The Olympus CF-20L fiberoptic instrument was used 110 times, with a 95.5% success rate, and the CFLB-3W fiberoptic colonoscope was used 455 times, with a 95.7% success rate. During this interval, 345 polyps were removed with the videoendoscope, and 240 with the fiberoptic instruments. In order to assess whether previous pelvic surgery adversely impacted on the ability to perform total colonoscopy, additional data were obtained in a smaller subset of patients included in this report, relating total colonoscopy to sex of the patient and whether pelvic surgery had been performed. Eight hundred sixty-five patients were included, with 55% being males (Table 2). Twenty percent of the women had a previous hysterectomy. Using a standard castor oil and enema preparation, only one patient (0.1 %) had a poor prep as the reason for an incomplete examination. Ten patients (1.0%) were not totally intubated because of an obstruction due to carcinoma in eight patients, and due to stricture in ulcerative colitis in two patients. One patient was uncooperative in spite of what was considered to be adequate premedication, and total colonoscopy was not possible. In 16 patients, total colonoscopy could not be performed because of colonic fixation, tortuosity, or for unknown anatomical reasons. Of these latter 16 patients, 15 were women, Table 1. One-thousand three hundred fifty-one consecutive colonoscopies Type of colonoscope
Number of patients
Olympus videoendoscope Olympus CF-20L Olympus CFLB-3W Total
Total colonoscopies (%)
786 110
97
455
95.7
1351
95.9
95.5
Table 2. Reason for inability to perform total colonoscopy in 865 patients (55%) Reason Anatomical problem Obstruction (N = 10) Cancer Stricture Other (N = 18) Poor prep Uncooperative Unknown (fixation or tortuosity)
VOLUME 37, NO.2, 1991
M
F
5 1
3 1
Sum
Total (%)
8 2 2
1 1 15
16
and, of these, 5 had a previous hysterectomy (33% hysterectomy in this group was not statistically significantly different than 20% in the overall group of women). In this series of 865 colonoscopies, when an obstructing lesion was eliminated (10 patients), total colonoscopy was possible 98% of the time. DISCUSSION
Total colonoscopy to the cecum was performed in over 95% of all patients presenting for colonoscopy. In the absence of an obstructing lesion, an expert can perform complete colonoscopy in 98% of examinations. In this study, incontrovertible landmarks were used to localize the tip of the endoscope. Ancillary methods may be helpful in corroborating the endoscopist's impression that the scope is in the cecum, but none is as precise as entering the terminal ileum or visualizing the round bulge or flattened upper labia of the ileocecal valve. Transillumination of light in the right lower quadrant can be seen when the tip is in the cecum 90% of the time using a fiberscope and 54% of the time with the less intense light of the videoendoscope. 9 However, a light shining through the tissue in the right lower quadrant is not an absolute criteria that the cecum has been reached, for this finding is possible during intubation of the sigmoid colon or when the mid-transverse colon is pushed deep into the right pelvis during intubation. Tip location can also be confirmed with x-ray or fluoroscope monitoring, but that imaging modality was not used here. In the last few years, a wide range of success in total colonic intubation has been reported, with a spread from 55%/ 75%,2,3 83%,4 to 94 to 98%.5 One series reported a 90%6 incidence of total colonoscopy in inflammatory bowel disease patients, and another reported a 94%7 incidence of total colonoscopy except where a major anatomic problem such as an obstructing lesion prevented total examination. An abstract8 mentions an increased difficulty with total colonoscopy in patients who have had surgery, with a 58% success rate when patients have had previous abdominal or pelvic surgery compared with an 82% success rate in patients who have not had surgery. Our data confirm the impression that colonoscopy is more difficult in women, presumably because of the effect of anatomical variations on configuration of the large bowel. A previous hysterectomy does not seem to further adversely affect the ability to pass the colonoscope to the cecum. The type of instrument does not impact on the performance of total colonoscopy since success occurred in approximately the same percentage of patients regardless of whether the instrument used was an old model fiberendoscope (CFLB-3W), a new model fiberendoscope (OES-CF20L), or a videoendoscope (CFV-IOL). 153
It is evident that total colonoscopy is not possible in every patient, but an attempt should be made at total colonoscopy whenever colonoscopy is to be performed. The endoscopist should aspire to pass the instrument to the cecum in all patients who do not have an obstructing lesion, although the reality is that this goal is not always achievable even in the hands of an expert. These data are presented as a point of reference for the performance of total colonoscopy as related to type of instrument and sex of the patient.
REFERENCES 1. Aldridge MC, Sim AJW. Colonoscopy findings in symptomatic patients without x-ray evidence of colonic neoplasms. Lancet 1986;2:833-4. 2. Durdey P, Weston PMT, Williams NS. Colonoscopy or barium enema as initial investigation of colonic disease. Lancet 1987;2:549-51.
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3. Lindsay DC, Freeman JG, Cobden I, Record CO. Should colonoscopy be the first investigation for colonic disease? Br Med J 1988;296:167-9. 4. Irvine EJ, O'Connor J, Frost RA, et al. Prospective comparison of double contrast barium enema plus flexible sigmoidoscopy v colonoscopy in rectal bleeding: barium enema v colonoscopy in rectal bleeding. Gut 1988;29:1188-93. 5. Bat L, Williams CB. Usefulness of pediatric colonoscopes in adult colonoscopy. Gastrointest Endosc 1989;35:329-32. 6. Modigliani R, Mary JY. Reproducibility of colonoscopic findings in Crohn's disease: a prospective multicenter study of interobserver variation. Dig Dis Sci 1987;32:1370-9. 7. Danesh BJZ, Spiliadis C, Williams CB, Zambartas CM. Angiodysplasia-an uncommon cause of colonic bleeding: colonoscopic evaluation of 1,050 patients with rectal bleeding and anemia. Int J Colorect Dis 1987;2:218-22. 8. Ravi J, Brodmerkel GJ Jr, Agrawal RM, Gregory DR, Ashok PS. Does prior abdominal or pelvic surgery affect length of insertion of the colonoscope? Endoscopy 1988;20:43. 9. Waye JD, Atchison MA, Talbott MC, Lewis BS. Transillumination of light in the right lower quadrant during total colonoscopy. Gastrointest Endosc 1988;34:69.
GASTROINTESTINAL ENDOSCOPY
Total colonoscopy: is it always possible? Jerome D. Waye, MD, Eric Bashkoff, MD New York and Manhasset, New York
One-thousand three hundred fifty-one consecutive colonoscopies were performed in an office setting without fluoroscopy. Three different models of colonoscopes were utilized; all were manufactured by' the Olympus Corporation of America, and included a videoendoscope, a CF-20L immersible OES-type instrument, and an older fiberoptic colonoscope, CFLB-3W. In all colonoscopies, the cecum was reached in 95.9%, even when an obstructing lesion or stenosis was present. Total intubation was performed in 97% of cases with the videoendoscope, 95.5% with the CF-20L, and 95.7% with the CFLB-3W. In a subgroup of 865 colonoscopies, total colonoscopy was performed in 98% of cases when obstructing lesions (carcinoma or stricture) were excluded from analysis. In this subgroup, total colonoscopy could not be performed in 16 patients because of colonic fixation, tortuosity, or for unknown anatomical reasons. Forty-five percent of this subgroup was female, but of the 16 patients in whom total colonoscopy was not possible, 15 were women, 5 of whom had a previous hysterectomy. We conclude that in the absence of any obstructing lesion, an expert can perform complete colonoscopy in 98% of examinations, and in 95% of all patients presenting for colonoscopy. Total colonoscopy may be more difficult in women than men, but a previous hysterectomy does not seem to adversely affect the ability to perform colonoscopy. The type of instrument used for colonoscopy does not impact on the ability to visualize the entire colon. (Gastrointest Endosc 1991;37:152-154)
Total colonoscopy to the cecum should be the goal whenever a colonoscope is introduced into the rectum. In spite of the procedure being performed for over 20 years, the actual number of successful total colonic intubations varies in the recent published literature from 55 to 98%.1-8 It is evident that not all colonoscopies can be completed to the cecum, but there are no guidelines with which to compare adequacy of colonoscopic intubation. A prospective collection of data was designed to ascertain the frequency of total colonoscopy in the hands of an expert. In this study, the ability to reach the cecum was correlated with the type of instrument utilized since there is a general feeling that the stiffness or rigidity of the instrument Received August 29, 1989. For revision November 5, 1989. Accepted October 25, 1990. From the Mount Sinai Medical Center (CUNY), Department of Medicine, Division of Gastroenterology and the Department of Surgery, North Shore University Hospital, Manhasset, New York. Reprint requests: Jerome D. Waye, MD, 650 Park Avenue, New York, New York.
152
may playa role in the ease with which colonscopy is performed. There is also a consensus that the female anatomy may predispose to more difficult colonoscopy, especially after pelvic surgery. We evaluated the frequency with which total colonoscopy was achieved in a consecutive series of endoscopic examinations, all performed in an office setting without fluoroscopy. We correlated total colonoscopy with the patient's sex and type of instrument used. MATERIALS AND METHODS
The distance reached with the endoscope tip in 1351 consecutive colonoscopies over a 16-month interval was recorded prospectively. Fluoroscopy was not utilized, nor was it available. The criteria for "total colonoscopy" was achieving either entry into the terminal ileum or visualization of the ileocecal valve. The appendiceal orifice is a useful landmark, but once identified, the ileocecal valve can always be seen upon scope withdrawal. Light in the right lower quadrant is not a reliable indicator of the tip in the cecum, nor is the ability to deeply indent a GASTROINTESTINAL ENDOSCOPY
sfction of distended bowel by finger palpation over the right lower quadrant. The cecum was not considered to have been reached if the endoscope tip was not advanced to the level of the ileocecal valve; although the cecal caput was not entered in every patient, it was intubated in all but three patients when the colonoscope reached the ileocecal valve. Of 1351 consecutive endoscopies, total colonoscopy was achieved in 1296 (95.9%) (Table 1). All colonoscopies have been included in this determination, whether or not an obstruction was present. The Olympus videoendoscope was used 786 times, with a 97% success rate for total intubation. The Olympus CF-20L fiberoptic instrument was used 110 times, with a 95.5% success rate, and the CFLB-3W fiberoptic colonoscope was used 455 times, with a 95.7% success rate. During this interval, 345 polyps were removed with the videoendoscope, and 240 with the fiberoptic instruments. In order to assess whether previous pelvic surgery adversely impacted on the ability to perform total colonoscopy, additional data were obtained in a smaller subset of patients included in this report, relating total colonoscopy to sex of the patient and whether pelvic surgery had been performed. Eight hundred sixty-five patients were included, with 55% being males (Table 2). Twenty percent of the women had a previous hysterectomy. Using a standard castor oil and enema preparation, only one patient (0.1 %) had a poor prep as the reason for an incomplete examination. Ten patients (1.0%) were not totally intubated because of an obstruction due to carcinoma in eight patients, and due to stricture in ulcerative colitis in two patients. One patient was uncooperative in spite of what was considered to be adequate premedication, and total colonoscopy was not possible. In 16 patients, total colonoscopy could not be performed because of colonic fixation, tortuosity, or for unknown anatomical reasons. Of these latter 16 patients, 15 were women, Table 1. One-thousand three hundred fifty-one consecutive colonoscopies Type of colonoscope
Number of patients
Olympus videoendoscope Olympus CF-20L Olympus CFLB-3W Total
Total colonoscopies (%)
786 110
97
455
95.7
1351
95.9
95.5
Table 2. Reason for inability to perform total colonoscopy in 865 patients (55%) Reason Anatomical problem Obstruction (N = 10) Cancer Stricture Other (N = 18) Poor prep Uncooperative Unknown (fixation or tortuosity)
VOLUME 37, NO.2, 1991
M
F
5 1
3 1
Sum
Total (%)
8 2 2
1 1 15
16
and, of these, 5 had a previous hysterectomy (33% hysterectomy in this group was not statistically significantly different than 20% in the overall group of women). In this series of 865 colonoscopies, when an obstructing lesion was eliminated (10 patients), total colonoscopy was possible 98% of the time. DISCUSSION
Total colonoscopy to the cecum was performed in over 95% of all patients presenting for colonoscopy. In the absence of an obstructing lesion, an expert can perform complete colonoscopy in 98% of examinations. In this study, incontrovertible landmarks were used to localize the tip of the endoscope. Ancillary methods may be helpful in corroborating the endoscopist's impression that the scope is in the cecum, but none is as precise as entering the terminal ileum or visualizing the round bulge or flattened upper labia of the ileocecal valve. Transillumination of light in the right lower quadrant can be seen when the tip is in the cecum 90% of the time using a fiberscope and 54% of the time with the less intense light of the videoendoscope. 9 However, a light shining through the tissue in the right lower quadrant is not an absolute criteria that the cecum has been reached, for this finding is possible during intubation of the sigmoid colon or when the mid-transverse colon is pushed deep into the right pelvis during intubation. Tip location can also be confirmed with x-ray or fluoroscope monitoring, but that imaging modality was not used here. In the last few years, a wide range of success in total colonic intubation has been reported, with a spread from 55%/ 75%,2,3 83%,4 to 94 to 98%.5 One series reported a 90%6 incidence of total colonoscopy in inflammatory bowel disease patients, and another reported a 94%7 incidence of total colonoscopy except where a major anatomic problem such as an obstructing lesion prevented total examination. An abstract8 mentions an increased difficulty with total colonoscopy in patients who have had surgery, with a 58% success rate when patients have had previous abdominal or pelvic surgery compared with an 82% success rate in patients who have not had surgery. Our data confirm the impression that colonoscopy is more difficult in women, presumably because of the effect of anatomical variations on configuration of the large bowel. A previous hysterectomy does not seem to further adversely affect the ability to pass the colonoscope to the cecum. The type of instrument does not impact on the performance of total colonoscopy since success occurred in approximately the same percentage of patients regardless of whether the instrument used was an old model fiberendoscope (CFLB-3W), a new model fiberendoscope (OES-CF20L), or a videoendoscope (CFV-IOL). 153
It is evident that total colonoscopy is not possible in every patient, but an attempt should be made at total colonoscopy whenever colonoscopy is to be performed. The endoscopist should aspire to pass the instrument to the cecum in all patients who do not have an obstructing lesion, although the reality is that this goal is not always achievable even in the hands of an expert. These data are presented as a point of reference for the performance of total colonoscopy as related to type of instrument and sex of the patient.
REFERENCES 1. Aldridge MC, Sim AJW. Colonoscopy findings in symptomatic patients without x-ray evidence of colonic neoplasms. Lancet 1986;2:833-4. 2. Durdey P, Weston PMT, Williams NS. Colonoscopy or barium enema as initial investigation of colonic disease. Lancet 1987;2:549-51.
154
3. Lindsay DC, Freeman JG, Cobden I, Record CO. Should colonoscopy be the first investigation for colonic disease? Br Med J 1988;296:167-9. 4. Irvine EJ, O'Connor J, Frost RA, et al. Prospective comparison of double contrast barium enema plus flexible sigmoidoscopy v colonoscopy in rectal bleeding: barium enema v colonoscopy in rectal bleeding. Gut 1988;29:1188-93. 5. Bat L, Williams CB. Usefulness of pediatric colonoscopes in adult colonoscopy. Gastrointest Endosc 1989;35:329-32. 6. Modigliani R, Mary JY. Reproducibility of colonoscopic findings in Crohn's disease: a prospective multicenter study of interobserver variation. Dig Dis Sci 1987;32:1370-9. 7. Danesh BJZ, Spiliadis C, Williams CB, Zambartas CM. Angiodysplasia-an uncommon cause of colonic bleeding: colonoscopic evaluation of 1,050 patients with rectal bleeding and anemia. Int J Colorect Dis 1987;2:218-22. 8. Ravi J, Brodmerkel GJ Jr, Agrawal RM, Gregory DR, Ashok PS. Does prior abdominal or pelvic surgery affect length of insertion of the colonoscope? Endoscopy 1988;20:43. 9. Waye JD, Atchison MA, Talbott MC, Lewis BS. Transillumination of light in the right lower quadrant during total colonoscopy. Gastrointest Endosc 1988;34:69.
GASTROINTESTINAL ENDOSCOPY
