loop, especially when you've used ScopeGuide for a while."
Like wearing goggles
Taking a tip from advanced endoscopists who perform endoscopic
mucosal resection (EMR) and endoscopic submucosal dissection
(ESD), Dr. Gorcey also advocates using cap-fitted colonoscopy with
tougher patients. The cap is a distal attachment that improves both
traction and visualization. "Most people don't know to reach for it," he
says. "If, say, you have to get through the iliocecal valve and it's very
difficult, you put a distal attachment cap on and there's a good chance
you're going to get in right away."
The cap also helps separate the camera from the wall of the colon,
which can be hugely beneficial in patients with narrow or tortuous
colons. "When the camera gets too close to the wall, you can't see
anymore," says Dr. Parikh. The cap is "kind of a bubble at the end of
the scope that lets you see through, like wearing goggles underwater."
Speaking of water, irrigation is an alternative to traditional CO
2
insufflation that can "help you float around tight turns," says Dr.
Gorcey. "As I'm going through the sigmoid and want the colon to open
up, I give water rather than air."
Water distends the lumen and helps you advance the scope, even in
segments with substantial diverticulosis, says Francisco C. Ramirez,
MD, a gastroenterologist at the Mayo Clinic in Scottsdale, Ariz. By
weighing down the left colon and straightening the sigmoid, "water
reduces angulation at the flexures."
Just make sure the volume of water coming through is large enough,
says Dr. Parikh. Dr. Gorcey agrees: "You want to make sure have a
water pump with a foot pedal, not some poor guy with a syringe push-
ing it thru a biopsy channel adaptor. That's not irrigation, that's flush-
ing the channel."
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