Case 1 - Live Training in Colonoscopy: Focus on Through Water Immersion, Splenic Flexure Negotiation, and Cold Snare Polypectomy
Colonoscopy performed by a trainee. Covers water immersion, splenic flexure negotiation, distal and proximal transverse progression and peri-appendiceal cold snare polypectomy. With Educational Contract and Feedback session.

In brief

The video emphasized the importance of patient positioning and managing fluid shifts during colonoscopy. Documenting visualization relevance, especially in areas like the caecum. It also underscored the significance of managing colon spasms using medication such as Buscopan. A critical focus was on identifying lesions and making informed intervention decisions, as illustrated by a case involving the appendiceal orifice. Lastly, the video demonstrated that strategies may need to adapt to specific patient circumstances, like previous fibrosis, by possibly shifting from snare resection to CAST.

Detailed Summary

Here is a list of key learning points from the video:
  • Patient Positioning: Correct positioning of the patient is crucial. 
  • Fluid Shifts: Fluid shifts within the patient's body during procedures could be significant and need to be monitored and managed properly.
  • Photographing Important Views: it's important to document views, particularly when visualizing important areas such as the caecum.
  • Managing Spasms: Managing colon contractions and spasms is crucial during an inspection. It's usefull to administer medication, like Buscopan, to ensure a smooth procedure.
  • Identifying Lesions & Deciding Intervention: In this scenario, a potentially problematic area was identified around the appendiceal orifice. Discussions about the nature of the lesion and how best to approach it were conducted. Initially, it was injected to assess its nature, and based on the findings, the decision was taken to resect it using a cold snare polypectomy. A key takeaway here is that proper characterization, injection, and decision making for intervention are pivotal steps in managing such cases.
  • Adaptation Based on Specific Scenarios: Depending on the patient's specific situation, such as fibrosis from previous attempts, the strategy may need to be adapted, such as shifting from snare resection to CAST.
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Anatomy
Distal TransverseSigmoidSplenic FlexureTransverse
Colonoscope Handling
Anticlockwise TorqueClockwise TorqueLeft HandTip ControlTorque steering
Deconstructed Polypectomy Technique
Snare placement
Difficult Polypectomy Locations
Appendiceal orifice
Equipment
Colonoscope Stiffner
Global Endoscopic Techniques
Underwater Imaging
Insertion
Transverse CantileverWater
Patient Management
Turning to Right LateralTurning to Supine
Polypectomy
Cold Snare
Scope Guide Appearances
Medial lying caecum
Techniques to improve visualisation
Buscopan
Training
Colonic SpasmDeconstruction of current situationDynamic feedbackProactive ApproachToo fast / slow down
Unconventional Loops
Anterior Sigmoid
Video Type
Endoscopic Video and Room Video with Audio Plus Trainee
Visualisation
Caecum (landmarks)Patient Position
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References

1 - Nutalapati V, Desai M, Rastogi A. Effect of dynamic position changes on adenoma detection rate during colonoscope withdrawal: systematic review and meta-analysis. Endoscopy international open, 2020 vol. 8(12) pp. E1842-E1849. Visualisation / Patient Position

2 - Hafner S, Zolk K, Zolk O. Water infusion versus air insufflation for colonoscopy. The Cochrane database of systematic reviews, 2015 vol. (5) pp. CD009863. Insertion / Water

3 - Tate DJ, Desomer L, Bourke MJ. EMR of laterally spreading lesions around or involving the appendiceal orifice: technique, risk factors for failure, and outcomes of a tertiary referral cohort (with video). Gastrointestinal endoscopy, 2018 vol. 87(5) pp. 1279-1288.e2. 10.1016/j.gie.2017.12.018.Difficult Polypectomy Locations / Appendiceal orifice