THE FELLOWS CORNER
Colonoscopic tips and tricksdadvice from 3 master
endoscopists
Achieving mastery of endoscopy is one of the most re-
warding experiences in the life of a gastroenterologist.
Yet, as with many things in life, it is accompanied by a signif-
icant amount of frustration. In this months Fellows Corner,
Dr Tyler Berzin, a gastroenterology fellow at Beth Israel Dea-
coness Medical Center, has asked an international panel of
expert endoscopists to offer advice on colonoscopic tech-
nique to the newest group of gastroenterology fellows, in
an effort to ease the pain and maximize the gratification
of learning endoscopy.
Juan Carlos Bucobo, MD
Fellows Corner Editor
Intervention Endoscopy Fellow
Cedars-Sinai Medical Center
Los Angeles, California USA
In his recent book Outliers, Malcom Gladwell makes the
case that, across many fields, world-class performers, ath-
letes, and experts require 10,000 hours of practice in or-
der to achieve success at the highest level. Not genius, not
necessarily natural inclination, but rather diligent repeti-
tion, stemming from an unwavering drive for personal im-
provement, is the key factor leading to the possibility of
virtuosic performance in any given field. The Beatles,
long before achieving international fame, labored away in
obscurity in West Germany, playing multiple extended live
sessions, totaling well over 10,000 hours of practice. Bill
Gates happened to have a computer in his Seattle high
school and spent over 10,000 hours programming before
most other teenagers had even encountered a computer.
The 10,000 hours concept might seem intimidating for
a gastroenterology fellow at the start of fellowship. Becom-
ing proficient in endoscopic procedures is just one of the
many challengesdintellectual, technical, and physicald
faced by new trainees in the field. However, every fellow
on the cusp of countless of hours of endoscopic practice
must begin in the same place: learning and mastering the
basics. As we welcomed a new group of gastroenterology
trainees, we took the opportunity to turn to 3 internation-
ally recognized experts in colonoscopic practice: Drs Mi-
chael Bourke, Dougas Rex, and Christopher Williams, and
posed the following question: What is the single most
Copyright 2009 by the American Society for Gastrointestinal Endoscopy
0016-5107/$36.00
doi:10.1016/j.gie.2009.05.030
370 GASTROINTESTINAL ENDOSCOPY Volume 70, No. 2 : 2009
useful piece of advice on colonoscopic technique you
would give to a gastroenterology trainee?
Michael Bourke, MBBS, FRACP, Director of Gastroin-
testinal Endoscopy, Department of Gastroenterology and
Hepatology, Westmead Hospital, Sydney, Australia
Master the left colon.
Approximately two thirds of your total insertion time
should be spent in the left colon. All loops should be re-
duced and the colonoscope straightened before you
move on. We instruct our fellows that time spent in the
Key Points
d Master the left colondtime spent in the left
colon saves twice as much time again be-
yond the splenic flexure
d Work the folds and aim small, miss small
d Take it gently!
left colon saves twice as much time again beyond the splenic
flexure, and that all people are created equal in length
between the anus and the splenic flexure as, at this point,
insertion length should be between 45 and 50 cm.
Negotiate the left colon by torque steering and minimiz-
ing air insufflation. Torque steering implies that the right
hand remains on the insertion tube (IT) of the instrument,
with your fingers and wrist in coordination with your left
thumb on the large wheel or up/down control. Most changes
of direction in colonoscopy are a coordinated movement
between the right wrist and the left thumb. Hold the IT
within your fingers as if it were a pencil (not like a tennis rac-
quet). This will maximize sensory feedback, thereby provid-
ing information on the amount of tension within the IT. For
major corners, rotate the ITso that the axis of the corner is in
the 6 to 12 oclock orientation, which is the most powerful
bending direction of the instrument (especially upward).
Resist the temptation of pushing into a difficult/refrac-
tory angulation that cannot be easily overcome with tor-
que steering. Instead, enter the corner and rotate the IT
slowly, up to 180 degrees, while gently insufflating and
pulling back very slightly. If a straight segment of lumen
www.giejournal.org
Berzin
comes into view, beyond this corner, try not to push into
it but rather aspirate air and, with small forward and
backward movements, inch your way forward into this
segment.
Use suction liberally during insertion to encourage the
colon to concertina (accordion) onto the colonoscope, es-
pecially when advancing easily through straight segments.
Use pressure for short periods of time and try to be specific
and algorithmic in its application. In best-practice colono-
scopy, cecal intubation is achieved expeditiously with
a short, straight colonoscope, limited use of the insertion
length of the instrument, and minimal patient discomfort.
Insertion length at the cecal pole is ideally between 65
and 90 cm.
Douglas K. Rex, MD, Professor of Medicine, Division of
Gastroenterology and Hepatology, Indiana University
School of Medicine, Director of Endoscopy, Indiana
University Hospital, Indianapolis, Indiana, USA
My advice to fellows regarding the insertion phase of
colonoscopy is (1) keep the instrument shaft straight, and
(2) never push against fixed resistance. Also, dont try to
be a herodif you are struggling in an angulated sigmoid
or if you are forming loops and not advancing, get help.
Watch how your teachers reduce loops, and use abdominal
pressure and position change to get moving again.
For withdrawal I have 2 mantras: work the folds and
aim small, miss small. To work the folds well you need
to think in 3 dimensions as you withdraw, sensing with
the spatial map in your head when mucosa is hidden by
folds, and then aggressively probing the spaces between
folds to expose hidden mucosa. Aim small, miss small
means that you study the mucosa for very minor aberrations
in color, vascular pattern, and texture that could signal the
presence of a small or flat lesion. The idea is that if you
look for even the smallest lesions, you will be less likely to
miss the larger, more important lesions.
Christopher B. Williams. MA, BM, BCh, FRCP,
Honorary Consultant in Gastrointestinal Endoscopy at
St. Marks Hospital, London, United Kingdom
www.giejournal.org
Colonoscopic tips and tricks
If reflow moves this to the next column, keep a line space
between St. Marks. and line beginning Take it gently!.
Take it gently! Minimizing loops and avoiding force is best
both for the patient and the instrument. Slow down and
things will go better. Hold the shaft in the fingers for feel
dnot in a clenched fist, not too close to the anus. Pull back
frequently and deflate whenever possible to keep the colon
pleated and adaptable.
Steering movements should be precise. Do not guessd
pull back if things are uncertain for more than a few sec-
onds. Angulate principally with the up/down control and
shaft twist. Lateral-control angulation should be added
when needed, preferably by using the fingers of the left
hand. Practice accurate steering and targeting when suc-
tioning any fluid pool; polypectomy or ileo-cecal valve ac-
cess will then become easier.
CONCLUSION
Bad habits begin early, and achieving proficiency in colo-
noscopic technique should start with a focus on mastering
basic maneuvers. Several common themes emerge in the
advice of these expert endoscopists: the primary use of tor-
que and up/down controls is emphasized, as are ap-
proaches to keeping the colonoscope straight throughout
the procedure. For gastroenterology fellows, these princi-
ples can serve as an appropriate starting point for the next
10,000 hours of endoscopic practice.
DISCLOSURE
All authors disclosed no financial relationships
relevant to this publication.
Tyler M. Berzin, MD
Gastroenterology Fellow
Beth Israel Deaconess Medical Center
Boston, Massachusetts, USA
Abbreviation: IT, insertion tube.
Volume 70, No. 2 : 2009 GASTROINTESTINAL ENDOSCOPY 371