Letters to the Editor
Mark Rabiner, MD Department of Medicine, Division of General Internal Medicine Icahn School of Medicine at The Mount Sinai Hospital New York, New York
REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10-29. 2. Chau S, Chin M, Chang J, et al. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev 2002;11:431-8. 3. Gawron AJ, Yadlapati R. Disparities in endoscopy use for colorectal cancer screening in the United States. Dig Dis Sci 2014;59:530-7. 4. Brawarsky P, Brooks DR, Mucci LA, et al. Effect of physician recommendation and patient adherence on rates of colorectal cancer testing. Cancer Detect Prev 2004;28:260-8. http://dx.doi.org/10.1016/j.gie.2014.05.309
Colonoscopy in the tilt-down position To the Editor: Changing a patient’s body position during colonoscopy from left lateral to supine is often a helpful maneuver to advance the colonoscope.1 We previously reported our clinical experience with placement of the patient in the Trendelenburg position as a maneuver to help negotiate a tortuous sigmoid colon.2 A steep (60 ) Trendelenburg position during surgery has 2 reported risks: increased intraocular pressure and reduced arterial oxygen pressure.3,4 Regurgitation of gastric contents is an additional concern for the sedated colonoscopy patient, especially those with a history of acid reflux. To study this technique further, 3 studies were attempted to address the safety and efficacy of tilting a patient downward during colonoscopy. A pilot study of colonoscopy performed with patients in the 15 Trendelenburg position throughout cecal insertion for nonobese men and women showed that there was less oxygen desaturation in the Trendelenburg position compared with the level position.5 There was a 1-minute decrease in cecal insertion time in the 20 patients in the 15 Trendelenburg position compared with the 20 patients in the left lateral horizontal position. A second study randomized 173 female patients to the left lateral 15 tilt-down position versus the left lateral horizontal position. It allowed enrollment of obese patients (body mass index 30-34.9). All tilt-down position patients were kept in this position until the cecum was reached.6 A 10% reduction in cecal insertion time by using tiltdown positioning was found by 3 of 5 physicians ( 10%, 23% [P Z .04], 32%). When severe diverticulosis was present, a trend toward reducing cecal insertion time by 1.3 minutes less in the tilt-down position group
746 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 4 : 2014
was seen. Furthermore, in the left lateral position group, 9% required a change to the tilt-down position to negotiate past a difficult sigmoid. Bradycardia occurred in none of the patients in the tilt-down position compared with 2 (2.3%) of the patients in the left lateral position. Transient oxygen desaturation occurred in 9 of 85 (10.6%) tilt-down position and 2 of 88 (2.3%) left lateral position patients (P Z .02), and this event was associated with obesity (P Z .02). No subject required mask-assisted ventilation or had clinical sequelae including aspiration. Finally, a third study included 92 nonobese women and men placed in the 15 tilt-down position during advancement through the sigmoid colon. After passing the sigmoid, the stretcher was leveled out. Application of abdominal pressure was prohibited while the subject was in this position. In these patients, there were no cardiopulmonary adverse events. A sex difference was noted for cecal insertion time: 3.3 1.4 minutes in men compared with 4.9 1.8 minutes in women (P ! .001).6 From these studies and additional clinical experience, the tilt-down position technique is a helpful method to assist colonoscope passage through a difficult sigmoid colon. Based on these published data, we recommend that the tilt-down position be used only during advancement through the sigmoid colon, be limited to nonobese patients, and be avoided in patients at risk of regurgitation, and abdominal pressure should not be applied with patients in this position. Leonard B. Weinstock, MD, FACG Specialists in Gastroenterology, LLC Washington University School of Medicine St. Louis, Missouri, USA Dayna S. Early, MD, FASGE Washington University School of Medicine St. Louis, Missouri, USA
REFERENCES 1. Rex DK. Achieving cecal intubation in the very difficult colon. Gastrointest Endosc 2008;67:938-44. 2. Weinstock LB. Body positions for colonoscopy: value of Trendelenburg. Gastrointest Endosc 2009;69:1409-10. 3. Ozcan MS, Praetel C, Bhatti MT, et al. The effect of body inclination during prone positioning on intraocular pressure in awake volunteers: a comparison of two operating tables. Anesth Analg 2004;99:1152-8. 4. Meinninger D, Zwissler B, Byhahn C, et al. Impact of overweight and pneumoperitoneum on hemodynamics and oxygenation during prolonged laparoscopic surgery. World J Surg 2006;30:520-6. 5. Saad AM, Winn J, Chennamaneni V, et al. The value of the Trendelenburg position during routine colonoscopy: a pilot study [Abstract]. Gastroenterology 2012;A142S1:S229. 6. Weinstock LB, Early DS, Saad AM. Tilt down method for colonoscopy: novel safe and effective scope insertion technique [Abstract]. Am J Gastroenterol 2013;A1693:108(Sl). http://dx.doi.org/10.1016/j.gie.2014.05.328
www.giejournal.org
Mark Rabiner, MD Department of Medicine, Division of General Internal Medicine Icahn School of Medicine at The Mount Sinai Hospital New York, New York
REFERENCES 1. Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10-29. 2. Chau S, Chin M, Chang J, et al. Cancer risk behaviors and screening rates among homeless adults in Los Angeles County. Cancer Epidemiol Biomarkers Prev 2002;11:431-8. 3. Gawron AJ, Yadlapati R. Disparities in endoscopy use for colorectal cancer screening in the United States. Dig Dis Sci 2014;59:530-7. 4. Brawarsky P, Brooks DR, Mucci LA, et al. Effect of physician recommendation and patient adherence on rates of colorectal cancer testing. Cancer Detect Prev 2004;28:260-8. http://dx.doi.org/10.1016/j.gie.2014.05.309
Colonoscopy in the tilt-down position To the Editor: Changing a patient’s body position during colonoscopy from left lateral to supine is often a helpful maneuver to advance the colonoscope.1 We previously reported our clinical experience with placement of the patient in the Trendelenburg position as a maneuver to help negotiate a tortuous sigmoid colon.2 A steep (60 ) Trendelenburg position during surgery has 2 reported risks: increased intraocular pressure and reduced arterial oxygen pressure.3,4 Regurgitation of gastric contents is an additional concern for the sedated colonoscopy patient, especially those with a history of acid reflux. To study this technique further, 3 studies were attempted to address the safety and efficacy of tilting a patient downward during colonoscopy. A pilot study of colonoscopy performed with patients in the 15 Trendelenburg position throughout cecal insertion for nonobese men and women showed that there was less oxygen desaturation in the Trendelenburg position compared with the level position.5 There was a 1-minute decrease in cecal insertion time in the 20 patients in the 15 Trendelenburg position compared with the 20 patients in the left lateral horizontal position. A second study randomized 173 female patients to the left lateral 15 tilt-down position versus the left lateral horizontal position. It allowed enrollment of obese patients (body mass index 30-34.9). All tilt-down position patients were kept in this position until the cecum was reached.6 A 10% reduction in cecal insertion time by using tiltdown positioning was found by 3 of 5 physicians ( 10%, 23% [P Z .04], 32%). When severe diverticulosis was present, a trend toward reducing cecal insertion time by 1.3 minutes less in the tilt-down position group
746 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 4 : 2014
was seen. Furthermore, in the left lateral position group, 9% required a change to the tilt-down position to negotiate past a difficult sigmoid. Bradycardia occurred in none of the patients in the tilt-down position compared with 2 (2.3%) of the patients in the left lateral position. Transient oxygen desaturation occurred in 9 of 85 (10.6%) tilt-down position and 2 of 88 (2.3%) left lateral position patients (P Z .02), and this event was associated with obesity (P Z .02). No subject required mask-assisted ventilation or had clinical sequelae including aspiration. Finally, a third study included 92 nonobese women and men placed in the 15 tilt-down position during advancement through the sigmoid colon. After passing the sigmoid, the stretcher was leveled out. Application of abdominal pressure was prohibited while the subject was in this position. In these patients, there were no cardiopulmonary adverse events. A sex difference was noted for cecal insertion time: 3.3 1.4 minutes in men compared with 4.9 1.8 minutes in women (P ! .001).6 From these studies and additional clinical experience, the tilt-down position technique is a helpful method to assist colonoscope passage through a difficult sigmoid colon. Based on these published data, we recommend that the tilt-down position be used only during advancement through the sigmoid colon, be limited to nonobese patients, and be avoided in patients at risk of regurgitation, and abdominal pressure should not be applied with patients in this position. Leonard B. Weinstock, MD, FACG Specialists in Gastroenterology, LLC Washington University School of Medicine St. Louis, Missouri, USA Dayna S. Early, MD, FASGE Washington University School of Medicine St. Louis, Missouri, USA
REFERENCES 1. Rex DK. Achieving cecal intubation in the very difficult colon. Gastrointest Endosc 2008;67:938-44. 2. Weinstock LB. Body positions for colonoscopy: value of Trendelenburg. Gastrointest Endosc 2009;69:1409-10. 3. Ozcan MS, Praetel C, Bhatti MT, et al. The effect of body inclination during prone positioning on intraocular pressure in awake volunteers: a comparison of two operating tables. Anesth Analg 2004;99:1152-8. 4. Meinninger D, Zwissler B, Byhahn C, et al. Impact of overweight and pneumoperitoneum on hemodynamics and oxygenation during prolonged laparoscopic surgery. World J Surg 2006;30:520-6. 5. Saad AM, Winn J, Chennamaneni V, et al. The value of the Trendelenburg position during routine colonoscopy: a pilot study [Abstract]. Gastroenterology 2012;A142S1:S229. 6. Weinstock LB, Early DS, Saad AM. Tilt down method for colonoscopy: novel safe and effective scope insertion technique [Abstract]. Am J Gastroenterol 2013;A1693:108(Sl). http://dx.doi.org/10.1016/j.gie.2014.05.328
www.giejournal.org
