Original articleClinical endoscopyImpact of water filling on terminal ileum intubation with a distal-tip mucosal exposure device
Introduction
Endocuff (Arc Medical Design, Ltd, Leeds, UK) is a distal colonoscope attachment designed to improve mucosal exposure and adenoma detection. In meta-analyses, the adenoma detection rate increases by an average of 7% with use of Endocuff.1 Endocuff has been replaced by Endocuff Vision (EV) (Fig. 1), a similar device to the original Endocuff but with a single row of fingers that are longer than in the original device.2 Endocuff and EV have been shown to speed up colonoscope insertion to the cecum3, 4, 5 and allow faster withdrawal without a reduction in detection.5, 6, 7, 8
Despite the advantages, use of Endocuff or EV also has disadvantages. The device increases the diameter of the colonoscope tip, so that patients with narrowed sigmoid colons, usually from diverticular disease, may require removal of the device to pass the sigmoid.9 Some data, as well as a widespread anecdotal impression, indicate that the devices slow down terminal ileal (TI) intubation and in some cases prevent it.10,11 In patients with a clear indication for TI intubation, such as Crohn’s disease, or a patient with unexplained abdominal pain and diarrhea,12 the use of EV could be considered contraindicated.
In patients undergoing routine screening and surveillance examinations, the advantages of EV arguably outweigh the disadvantages. Nevertheless, some endoscopists prefer to routinely intubate the TI.
In an exploratory quality assessment, we assessed the success rate of TI intubation in ≤1 minute using adult and pediatric Olympus colonoscopes with and without use of EV. We varied the use of filling of the cecum and right colon segment with gas versus water. Water filling of the right colon segment relaxes the ileocecal valve and often allows the orifice of the valve to turn distally to give a more en face approach compared with gas filling of the right colon segment.
Section snippets
Methods
From May 24, 2019, to July 24, 2019, we recorded TI intubation information for consecutive patients who underwent either a standard colonoscopy or colonoscopy with EV using either an adult or pediatric colonoscope. Patients were excluded if they had a specific indication to intubate the TI (eg, Crohn’s disease or unexplained abdominal pain and diarrhea). Patients with right hemicolectomy were also excluded. More than 98% of the procedures were performed using Olympus 190 series colonoscopes.
Patients and procedures
A total of 204 eligible patients underwent colonoscopy during the study period. Women comprised 54% of the study population, and the average age was 63.1 (±11.2) years. An adult colonoscope was used in 106 (52%) patients. Most patients underwent colonoscopy for a surveillance indication (70%) followed by screening (19%), and then diagnostic and therapeutic indications. The EV group was younger (mean, 62 years vs 67 years, P = .006), had a trend toward more males (50% vs 34%, P = .054), and use
Discussion
In this study, we report a prospective nonrandomized assessment of several approaches to intubation of the TI during routine screening and surveillance examinations. Our results show that use of EV does decrease the success rate of TI intubation in ≤1 minute, and that this effect is more marked when using adult colonoscopes with EV in place compared with pediatric colonoscopes. The obvious explanation for this difference would be the difference in the diameter of the distal colonoscope tips and
Acknowledgments
This work was supported by a gift from Scott Schurz of Bloomington, Indiana, and his children to the Indiana University Foundation in the name of Douglas K. Rex, MD.
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Disclosure: Dr Rex has consulted for Olympus Corporation, Boston Scientific, Medtronic, Aries Pharmaceutical, Lumendi Corporation, and Braintree Laboratories, received research support from EndoAid, Olympus Corporation, and Medivators, and has ownership in Satisfai Health. All other authors disclosed no financial relationships.