1 A linear sigmoid colon passage method in colonoscopy

2
3 Satoshi Awazu, Risa Araki, Toshihiko Awazu
4
5 Awazu Hospital, Nagasaki, Japan
6
7 Address correspondence to Satoshi Awazu, Awazu Hospital, Nagasaki 851-0251, Japan. Phone:
8 +81-95-826-9088. E-mail: planeaaaaaa@yahoo.co.jp.
9
10
11 ABSTRACT
12
PrePrints

13 A previous study revealed loop formation of the colonoscope in the sigmoid colon in
14 79% of patients. Colonoscope looping in the sigmoid colon is considered to cause
15 abdominal pain and intestinal perforation. We discovered a phenomenon whereby the
16 rectosigmoid junction becomes linear when the patient is moved from a left lateral to left
17 semiprone position and the colonoscope tip can be readily inserted into the sigmoid colon.
18 Therefore, this phenomenon was applied to our conventional insertion method to determine
19 whether the colonoscope looping rate in the sigmoid colon can be reduced. Thus our new
20 insertion method could reduce the colonoscope looping rate in the sigmoid colon. Our new
21 insertion method may allow safer colonoscope insertion than our conventional insertion
22 method.
23
24
25 INTRODUCTION
26
27 A previous study revealed loop formation of the colonoscope in the sigmoid colon in
28 79% of patients (Shah et al., 2000). Colonoscope looping in the sigmoid colon is
29 considered to cause abdominal pain and intestinal perforation (Lning et al., 2007).
30 We previously reported that the colonoscope can be readily inserted through the
31 sigmoid-descending colon junction in a left semiprone position (Awazu, Araki & Awazu,
32 2012). Therefore, we considered that the colonoscope can be readily inserted through the
33 rectosigmoid junction in a left semiprone position.
34 In fact, we discovered a phenomenon (Fig. 1) whereby the rectosigmoid junction
35 becomes linear when the patient is moved from a left lateral to left semiprone position and
36 the colonoscope tip can be readily inserted into the sigmoid colon by pushing. Therefore,
37 this phenomenon was applied to our conventional insertion method to determine whether
38 the colonoscope looping rate in the sigmoid colon can be reduced.
39
40
41
42
43
44

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1
2 Figure 1. The phenomenon we discovered. The colonoscope tip reached the rectosigmoid junction. When the
3 endoscopist moved the patient from a left lateral to left semiprone position with the colonoscope slightly
4 pushed with twisting to the left, the visual field broadened, both the rectosigmoid junction and colonoscope
5 simultaneously became linear, and the colonoscope tip was readily inserted into the sigmoid colon.
6 Rectosigmoid junction ().
7
8
9 MATERIALS & METHODS
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11 The Pentax EC-3830MK (HOYA, Akishima, Tokyo) was used, and the neutral position
12 of the colonoscope was determined as shown in Fig. 2. Our new insertion method is shown
13 in Fig. 3, and our conventional insertion method is shown in Fig. 4.

14
15 Figure 2. The neutral position of the colonoscope in our new insertion method. The patient is placed in a left
16 semiprone position, and the colonoscope is unbent with its tip directed toward the sigmoid-descending colon
17 junction.
18
19

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PrePrints

1
2 Figure 3. Our new insertion method. The shape of the colonoscope and movements of its tip are observed
3 using fluoroscopy. Step 1. The patient is placed in a left lateral position, the colonoscope tip reaches the
4 rectosigmoid junction, and the colonoscope is slightly pushed with twisting to the left. Step 2. The assistant
5 moves the patient from a left lateral to left semiprone position. Step 3. In some cases, the visual field broadens,
6 and the colonoscope tip is readily inserted into the sigmoid colon by pushing. If this does not occur (colon
7 bending is considered to be present), in the same body position, the colonoscope is pushed with twisting to the
8 left, beyond 1-2 fold, which results in advancement of the colonoscope tip into the sigmoid colon. The
9 colonoscope is unbent with its tip directed toward the sigmoid-descending colon junction. Step 4. When the
10 lumen of the sigmoid colon is observed in the left or front direction, the colonoscope is pushed with twisting
11 to the left (Step 4a). When the lumen of the sigmoid colon is observed in the right direction, the colonoscope
12 is pushed with twisting to the right (Step 4b, left), which causes colonoscope bending. To correct bending, the
13 colonoscope is returned to the neutral position by twisting to the left (Step 4b, right). Excessively advancing
14 the colonoscope with twisting to the right should be avoided. However, when such advancement is
15 unavoidable, the colonoscope is pulled while being returned to the neutral position by twisting to the left with
16 caution not to displace the colonoscope tip. Step 5. Step 4 is repeated. Step 6. The colonoscope tip is inserted
17 into the descending colon. Rectosigmoid junction (), splenic flexure (), colonoscope manipulation and
18 movements of colonoscope tip (brown arrows and point).
19

20
21 Figure 4. Our conventional insertion method. The shape of the colonoscope and movements of its tip were
22 observed using fluoroscopy. The patient was placed in a left lateral position, and the colonoscope tip reached
23 the rectosigmoid junction. The colonoscope was pushed with twisting to the right or left, which results in
24 colonoscope looping in the sigmoid colon. After arrival of the colonoscope tip at the descending colon, the
25 colonoscope loop was resolved, and the sigmoid colon and colonoscope were straightened together.
26 Rectosigmoid junction (), splenic flexure (), colonoscope manipulation and movements of colonoscope
27 tip (brown arrows and point).

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 1 RESULTS
2
3 The colonoscope looping rate in the sigmoid colon was 59% (267 of the 452 patients)
4 using our conventional insertion method but 14% (34 of the 238 patients) using our new
5 insertion method. Thus, our new insertion method could reduce the colonoscope looping
6 rate in the sigmoid colon. And no major complications were associated with our new
7 insertion method.
8 Our new insertion method may allow safer colonoscope insertion than our conventional
9 insertion method.
10
11
12 DISCUSSION
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14 We consider that all physicians who read this manuscript can confirm the reproducibility
15 of this phenomenon irrespective of their skill level. We have confirmed this phenomenon by
16 using fluoroscopy. However, for confirmation of its reproducibility, the use of magnetic
17 endoscope imaging (Shah et al., 2002) is recommended to avoid x-ray exposure.
18 We also consider that this phenomenon is applicable to all insertion methods (Anderson
19 et al., 2007; Leung et al., 2009; Morgan et al., 2011). With the use of any insertion method,
20 it is rational to insert the colonoscope with the patient in a position that brings the
21 colonoscope tip to the highest position when it passes the rectosigmoid junction.
22
23
24 REFERENCES
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PeerJ PrePrints | http://dx.doi.org/10.7287/peerj.preprints.535v1 | CC-BY 4.0 Open Access | rec: 13 Oct 2014, publ: 13 Oct42014