NO SURE THING The patient you'd expect to be as routine as they come may turn out to be just the opposite.

Can you tell just by looking at a patient that the colonoscopy you're about to start isn't going to be run-of-the-mill? True, you know that patients who are particularly thin, particularly heavy and particularly old are likely to be more challenging, but does that mean every patient who's none of the above is going to be a cinch?

"Anybody can be turn out to be difficult," says Samir Parikh, MD, FACS, FASCRS, of the Riddle Surgical Center in Media, Pa. "Sometimes you see the most average-looking person, someone who should have the easiest colonoscopy in the world, and it turns out they have a redundant colon."

Dr. Parikh, who estimates that he's performed close to 15,000 colonoscopies, breaks the population down this way: 50% to 60% are easy, 30% are in the middle, and the remaining 10% or more are tough — for what might be any number of reasons. That redundant colon, for example, is going to have a lot of twists and turns, and require a lot of maneuvering to get through.

Steven Gorcey, MD, AGAF, chief of gastroenterology at Monmouth Medical Center in Long Branch, N.J., and an assistant clinical professor at Drexel University Medical Center in Philadelphia, is wary of 2 scenarios. "One is where you're in the middle of a colonoscopy and all of the sudden you go, Wow, this is getting hard, or I can't go anymore. The other is where someone else failed, or you remember from the previous time that this was a brutal colonoscopy," says Dr. Gorcey.

Given the choice, he'd rather know in advance about a difficult case. That way, he can modify his approach beforehand. For example, says Dr. Parikh, if you're dealing with an elderly patient who's had multiple bouts of diverticulitis, that patient may require a smaller or thinner scope. "Choosing the right scope to start with is the first thing," he says. "For the proverbial shorter, thinner elderly woman with diverticulitis, we may want to use a pediatric colonoscope or even a gastroscope."

If you need something thinner than a colonoscope, Dr. Gorcey prefers the gastroscope, because it's less likely than a pediatric scope to loop, he says. "You're only talking about a couple of millimeters' difference in width, but there's a significant performance difference in terms of stiffness."

VOLUME CONTROL If you use an irrigation system to help "float around tight turns," make sure you have a water pump with a foot pedal.

Loops, after all, are one of the biggest challenges you face. Everyone who does scopes learns basic tricks and techniques to get through them, but when internal structures twist and turn like a roller coaster, and scopes loop back on themselves more than once, there's bound to be trouble. "Every colon is like a lock with its own combination, and you have to figure out the code to get through," says Dr. Gorcey. "Do I torque here or push here? Do I pull here or do I turn here? One loop, you can push through. Two loops is going to get really, really tough. With 3 loops, you get a lock and you're done. You can't go any further."

The ability to actually see those inevitable loops can make things dramatically easier. Enter the Olympus ScopeGuide, which displays a 3D image of the colonoscope during the procedure, eliminating the guesswork as to why a scope has stalled, or what you need to do to get it moving again. It can be a huge help navigating through difficult colonoscopies, says Dr. Parikh. "Is the scope folded on itself? Is it looped up? It's like taking an X-ray while the scope is in there," he says.

Dr. Gorcey, who does consultancy work for Olympus, says after a while you can start to think like the ScopeGuide, even when you're not using one. That's helpful, he says, if you work in both ASCs and hospitals. "In an ASC when you use a piece of equipment, you don't get reimbursed by the insurance company, you eat the price," he says. "There are things I use regularly at the hospital that I don't use regularly at my surgery center. For example, the ScopeGuide." But, he says, even if he's not using one, he wonders, What would the Scope-Guide show? "Often, you can figure out the 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 CO2 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 pushing it thru a biopsy channel adaptor. That's not irrigation, that's flushing the channel."

Other tools
The Endocuff endoscopic overtube, which helps flatten folds and improve visualization, can also help with tight passages. "There's lot more to Endocuff than just adenoma detection," says Dr. Gorcey. "It helps a lot when you're trying to get through a twistier colon, because it gives you ability to anchor anywhere." When reimbursement isn't a concern, "I'll usually go in with ScopeGuide and Endocuff. I might as well use the highest level of technology I have."

The more tools you have, the more you can do, says Dr. Parikh, even if you're talking about tools that may not be needed for every patient. Narrow-band imaging can also improve outcomes with difficult patients, he says. "Certain flat and sessile polyps are easier to see. You can demarcate what's normal colon and what's polyp. Sometimes they're so flat, it's hard to tell the difference."

For those rare patients whose anatomies are so challenging that traditional colonoscopies are essentially impossible, the virtual colonoscopy is an emerging technique, as is the PillCam, a small camera that patients actually swallow. The virtual scope, which scans the abdomen in thin layers and creates a 3D reproduction, is likely to reveal larger polyps — those of at least 1 cm — but may not find smaller ones. "I've also seen some false readings," says Dr. Parikh. "You go in and it turns out there's nothing there. My assumption is that that happens because the colon loops up, back and forth, so you have multiple parts of the colon right next to each other."