Colonoscopy E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 2512

Veröffentlichungsjahr: 2011

Beschreibung

First Edition - Winner of 2004 BMA Medical Book Competition in Gastroenterology

The second edition of this prize winning book is written by some of the world's foremost experts in the field of colonoscopy and colonic imaging. Every chapter has been updated and 5 new chapters have been added to include the latest information and advances in the field of colonoscopy:

• Capsule Colonoscopy
• Narrow Band Imaging
• Confocal Endomicroscopy
• Endoscopic Submucosal Dissection in the Colon
• New Colonoscopes and Assist Devices

Drawing on the vast experience of the authors it covers every area of medicine that impacts on colonoscopy, including virtual colonography, pathology, techniques for pediatric and adult procedures, and legal aspects concerning colonoscopy.

The book is focused on patient care, and provides explanations on how to perform the procedure effectively and make the best outcome for your patients. It serves as a detailed manual of procedures, extensively illustrated with diagrams and photographs.

The book includes a companion website with supplementary material: a lecture on the history of colonoscopy, interviews with famous gastroenterologists, demonstrations of techniques, and typical and unusual cases.

This is an invaluable compendium on all aspects of colonoscopy, suitable for use by every grade of practitioner world-wide and an essential reference book for all establishments with an endoscopy facility.

Please note: This product no longer comes with a DVD. The DVD content is now available online at wiley.mpstechnologies.com/wiley/BOBContent/searchLPBobContent.do

Leseprobe

Contents

List of Video Clips on DVD-ROM

Acknowledgments

Preface to the First Edition

Preface to the Second Edition

List of Contributors

Section 1 General Aspects of Colonoscopy

1 History of Endoscopy in the Rectum and Colon

Introduction-from rigid endoscopes to colonofiberscopes

Rigid endoscopes

Gastrocameras, the “sigmoidocamera” and “colonocamera”

American fiberscope development

Japanese colonofiberscope development

Other early approaches to the proximal colon

Polypectomy

The transition to electronic endoscopes

Videocolonoscopes

Shaft characteristics

Other countries’ and individuals’ involvement in colonoscopy

Summary

2 The Colonoscopy Suite

Step 1/start planning

Assessment and programming

Number of procedure rooms

Recovery space

Scope cleaning and storage

Room size standards and the written program

Arrangement

Preliminary planning solutions

Design development

Equipment arrangement options

Conclusion

Summary of regulatory requirements for ambulatory centers in the US

3 Continuous Quality Improvement in Colonoscopy

Introduction

Background

Definition of quality in colonoscopy

Developing a continuous quality improvement program

Summary

Section 2 Preparation—General

4 The Gastrointestinal Assistant during Colonoscopy

Introduction

Setting up the room

Monitoring and sedation

The gastrointestinal assistant during the procedure

Operation of a snare

Biopsy and cytology

Endoscopic tattoo

Colorectal bleeding

Postprocedure or recovery care

Occupational Safety and Health Administration Regulations

Protective gear

Processing of reusable equipment (see Chapter 5)

Disposable items

Supply order

Odors in the endoscopy suite

Summary

Troubleshooting tips for the gastrointestinal assistant

5 Cleaning and Disinfection

Background

Colonoscope reprocessing

High-level disinfection versus sterilization

Spaulding criteria

Transmission of microorganisms during endoscopy

Viruses

Bacteria

Mycobacteria

Fungi, protozoa, and parasites

Prions

Steps in endoscope reprocessing

Mechanical cleaning

Current standards

Endoscope design

Summary

Section 3 Preparation of the Patient

6 Informed Consent for Colonoscopy

Introduction

Conceptual aspects of informed consent

Practical aspects of informed concept

Special situations and problem areas for informed consent with respect to colonoscopy

Summary

7 Antibiotic Prophylaxis for Colonoscopy

Prevention of infective endocarditis

Vascular grafts

Prosthetic joints and orthopedic prostheses

The patient with cirrhosis

The immunocompromised patient

Summary

8 Management of Anticoagulation and Antiplatelet Agents

Introduction

Scope of the problem

Risk of discontinuing anticoagulants and antiplatelet agents

American Society for Gastrointestinal Endoscopy guideline

Short-term heparin substitution for warfarin (heparin window)

Low-molecular-weight heparin: is it acceptable to use yet?

The aspirin controversy

Nonaspirin antiplatelet agents

Summary

9 Sedation for Colonoscopy

Introduction

Understanding sedation and analgesia

Pharmacology of drugs for sedation and analgesia

Current approaches to sedation for colonoscopy

Standards of practice for colonoscopic sedation

Staffing and colonoscopic sedation

Technical issues specific to sedation for colonoscopy

Impact of sedation on the technical performance of colonoscopy

Colonoscopy, sedation, and risk management

Sedation and the economics of colonoscopy

Conclusions

10 Preparation for Colonoscopy

Impact of proper colon preparation

Goals of preparation

Colon cleansing methods

Special considerations

Contraindications for colonoscopy preparation

Cleansing instructions

Summary

Section 4 Preparation of Endoscopist

11 Training in Colonoscopy

Introduction

Training to competency in colonoscopy

Components of an ideal training program

An ideal fellowship training program for colonoscopy

Assessing training

Maintaining competency

Retraining

12 Teaching Aids in Colonoscopy

Introduction

Role of teaching aids

Text with photographic images

Electronic media

Videotape

Multimedia

Teaching courses

Summary

13 Teaching Colonoscopy

Introduction

Training provision

Basic training equipment

Training units and training lists

Trainees

Practice

Demonstration

Motivation

Instruction and feedback

Trainers

Scaffolding in colonoscopy training

Preparation

Hands-on training

Instruction and feedback

Assessment

Completion of training

Short skills courses for colonoscopy

Summary

Acknowledgments

14 Role of Simulators in Colonoscopy

Introduction

Types of simulators

Summary

Section 5 Indications, Contraindications, and Screening

15 Indications and Contraindications

Introduction

Classification of indications

Specific indications

Contraindications to colonoscopy

Summary

16 Diagnostic Yield of Colonoscopy by Indication

Introduction

Patient characteristics

Family history

Main clinical indications

Screening for colon cancer

Diagnostic reliability of colonoscopy

Summary

17 Screening Colonoscopy: Rationale and Performance

Introduction

Programmatic colorectal cancer screening

Colorectal cancer screening with colonoscopy

Summary

18 Cost-effectiveness of Colonoscopy Screening

Introduction

General principles of cost-effectiveness analyses

Small costs in a great many as opposed to great effects in a small few

Cost-effectiveness of decennial colonoscopy

Cost-effectiveness of alternative screening procedures

Cost-effectiveness analyses comparison of competing screening strategies

Costs of inconclusive tests and colonoscopy as the final arbiter

Other aspects of colon cancer prevention

Surveillance and prevention in ulcerative colitis

Limitations of cost-effectiveness analyses

Summary

Section 6 Reports and Imaging

19 Standardization of the Endoscopic Report

Organization of the endoscopy report

The Minimal Standard Terminology for standardization of the endoscopic report

Standardization and exchange of images in digestive endoscopy

Adaptation of the Minimal Standard Terminology to new technologies and procedures

Summary

20 Reporting and Image Management

Introduction

Text report

The digital revolution

Standardized terminology (see Chapter 19)

Summary

Acknowledgments

Section 7 Instrument and Accessories

21 The Video Colonoscope

Introduction

Insertion tube

Flexibility

Adjustable flexibility

Distal tip

Bending section and angulation system

Air, water, and suction systems

Illumination system

Solid-state image capture

“Reading” the image created on the CCD

Types of charge-coupled device

History of endoscope charge-coupled device development

Image resolution

Zoom (optical and electronic)

Angle of view

Shape of displayed image

Reproduction of color

Narrow-band imaging

Functions of a typical video processor

Factors to consider when evaluating a video image colonoscope

Summary

22 The Colonoscope Insertion Tube

Introduction

Overview of the insertion tube

Various available instruments for cofonoscopy

Chofce of instruments

Summary

23 Capsule Colonoscopy

The case for capsule colonoscopy

The PillCam Colon® capsule endoscope

The bowel preparation regime

Initial pilot studies

Capsule colonoscopy—where are we now and where are we going?

24 Accessories

Introduction

Polypectomy snares

Retrieval devices

Biopsy forceps

Injection needles

Spray catheters

Endoscopic clips

Detachable loops

Contact and noncontact thermal devices

Transparent cap

Overtubes

Summary

25 Clips, Loops, and Bands: Applications in the Colon

Introduction

Clips

Loops

Bands

Summary

26 Principles of Electrosurgery, Laser, and Argon Plasma Coagulation with Particular Regard to Colonoscopy

Introduction

Relevant thermal effects in biological tissues

Generation of high temperature in thermal tissue

Principles of high-frequency surgical coagulation

Principles of high-frequency surgical cutting

Technical aspects of polypectomy

Safety aspects of high-frequency surgery

Argon plasma coagulation

Laser

Safety aspects of Nd:YAG lasers in flexible endoscopy

Summary

Section 8 Neoplasia

27 Polyp Biology

Introduction

Tumor genetics

Types of mutation

Familial colon cancer

Multistep carcinogenesis and sporadic polyps

Summary

28 Colon Polyps: Prevalence Rates, Incidence Rates, and Growth Rates

Introduction

Prevalence

Incidence

Growth

Summary

29 Pathology of Colorectal Polyps

Introduction

Diagnostic accuracy

Histological artifacts

Polyp orientation and sampling

Clinical-pathologic correlation

Adenomatous polyps

Serrated polyps

Nondysplastic serrated polyps

Dysplastic serrated polyps

Neurogenic polyps

Polyps associated with mucosal prolapse

Summary

30 Management of Malignant Polyps

Introduction

Pathology

Risk factors for malignant polyps

Initial endoscopic evaluation and treatment

Evidence for surgery versus endoscopic follow-up

New concepts and risk parameters

Role of the clinician

Summary

31 Magnifying Colonoscopy, Depressed Colorectal Cancer, and Flat Adenomas

Introduction

Procedure

Gross appearance

Summary

32 Flat and Depressed Colorectal Adenomas in the Western Countries

Introduction

Definitions

Epidemiology

Detection and diagnosis of nonpolypoid colorectal neoplasms

Treatment technique

Biology

Conclusions

33 Hereditary Colorectal Cancer

Introduction

Common familial colon cancer

Inherited syndromes of colon cancer

Summary

34 Colonoscopic Biopsy

Biopsy instruments

Hot biopsy forceps

Suction biopsy

Improving the quality of handling of tissue specimens in the endoscopy unit

Retrieval of biopsy from the forceps and insertion into fixative

Handling polyps and endoscopic resection specimens

Pinch biopsy techniques to improve quality and efficiency

Dialogue with the pathologist

What can the pathologists do?

When and where to biopsy the colon, and special circumstances in diagnosis

Newer imaging modalities

Diarrhea and a normal endoscopy

Diarrhea and an abnormal endoscopy

Biopsies at the outset of, or in, established ulcerative colitis or Crohn’s disease

Lumps and bumps in ulcerative colitis and Crohn’s disease

Summary

35 Colonoscopic Chromoendoscopy

Introduction

Evidence to suggest failure in secondary colorectal cancer prevention using conventional “white-light” colonoscopy: the need to reappraise techniques

Basic principles and practice of chromoendoscopy

Stains used in chromoendoscopy

Chromoscopic techniques and the morphological classification of lesions

Pancolonic chromoendoscopy

Selective or “targeted” chromoendoscopy

In vivo staging of neoplastic colorectal lesions using chromoscopy and morphological analysis: expanding the role of chromoscopy beyond lesion detection alone

Chromoscopy in the detection of intraepithelial neoplasia and colitis-associated cancer

Chromoscopic intraepithelial neoplasia detection and characterization in chronic ulcerative colitis: current evidence-based practice

Conclusion

Acknowledgments

36 Optical Techniques for the Endoscopic Detection of Early Dysplastic Colonic Lesions

Introduction

Basic tissue optics

Tissue autofluorescence

Clinical evaluation of fluorescence endoscopy

Exogenous photosensitizer-induced fluorescence

Raman spectroscopy

Light scattering spectroscopy

Optical coherence tomography

Immunophotodiagnostics

Summary

Acknowledgments

37 Endoscopic Ultrasonography and Colonoscopy

History

Instruments

Patient preparation

Anatomy

Colorectal adenocarcinoma

Benign mucosal and submucosal tumors

Inflammatory bowel disease

Conclusion

38 Narrow-band Imaging

Rationale for narrow-band imaging application

Historical background of narrow-band imaging

The blue light physical principle

Using the narrow-band imaging system at the endoscopy unit

Narrow-band imaging for screening colonoscopy

Narrow-band imaging for non-neoplastic and neoplastic lesions

Meshed capillary vessels by narrow-band imaging

Benefit of in vivo diagnosis of small colorectal polyps

Nonmagnifying narrow-band imaging system

Narrow-band imaging for noninvasive and invasive colorectal cancer

Vessel diameter measured by immunohistochemistry

Rationale for differences in size of meshed capillary vessels in colorectal polyps—the Toppan test

The Sano-Emura narrow-band imaging classification of the capillary pattern

Detection of dysplastic areas in ulcerative colitis

Future perspective

Acknowledgments

39 Confocal Laser Endomicroscopy

Introduction

Principle of confocal microscopy

Endoscopic confocal microscopy

Reflectance confocal imaging

Fluorescence confocal imaging

Components of the confocal laser endoscope

Contrast agents

Endomicroscopy of the normal colon

Confocal imaging of colon pathology

Ulcerative colitis

Consequences of in vivo confocal microscopy

Summary

Section 9 Technique

40 Insertion Technique

Introduction

Choice of instrument—the relevance of sex, symptomatology, and embryology

Preprocedure checks

Instrument handling—single-handed, two-handed, or two-person approach?

Patient position

Inserting into the anorectum

Efficient handling

Intubating and steering—practical tips

Sigmoid colon—endoscopic anatomy

Navigating through the sigmoid

Sigmoid loops

Descending colon

Splenic flexure

Transverse colon

Hepatic flexure

Terminal ileum

41 Missed Neoplasms and Optimal Colonoscopic Withdrawal Technique

Introduction

The impact of colonoscopy on incidence and mortality from colorectal cancer

Medicolegal risk and the impact of missing on surveillance

Mechanisms of interval cancers

Optimal withdrawal time

Examination technique

Technologies to improve detection of flat lesions

Technologies to increase mucosal exposure

Summary

42 Polypectomy: Basic Principles

Introduction

Principles of colonoscopic polypectomy

Coaptive coagulation

Electrosurgical unit

The colonoscope

Snares

Injector needles

Hot biopsy forceps

Types of polyps

Precolonoscopic laboratory testing (see Chapter 8)

Polypectomy technique

Summary

43 Difficult Polypectomy

Introduction

Size

Ambulatory or inpatient polypectomy

The colonoscope

Endoscopic mucosal resection

Endoscopic submucosal dissection (see Chapter 44)

Polypectomy in a narrow diverticular segment

Location of lesion in the colon

The extremely difficult colonoscopy

44 Endoscopic Submucosal Dissection in the Colon

Introduction

Overview of endoscopic submucosal dissection

Indications for colorectal endoscopic submucosal dissection

Preparation and setting up for colorectal endoscopic submucosal dissection

Performing colorectal endoscopic submucosal dissection

Evaluation criteria

Postoperative clinical course and follow-up

Treatment results and complications

Complications and procedure time

Summary

Acknowledgment

45 Retrieval of Colonic Polyps

Introduction

Summary

46 Magnetic Imaging for Colonoscopy

Introduction

The need for imaging

Colonic anatomy

Difficult colonoscopy

Colonoscope imaging

Impact of magnetic imaging on colonoscopy practice

Future developments

Conclusions

Section 10 Clinical Use and Results of Colonoscopy

47 Colonoscopy and Severe Hematochezia

Introduction

Epidemiology

Resuscitation and initial evaluation

Diagnostic evaluation

Bowel preparation

Endoscopes and other equipment

Coagulation probes

Endoscopic hemoclips (see Chapter 25)

Study results

Specific lesions

Summary

48 Endoscopy in Inflammatory Bowel Diseases

Introduction

Characteristic endoscopic findings in inflammatory bowel disease

Endoscopic assessment of extent and severity of inflammatory bowel disease

Surveillance for cancer in chronic colitis

Endoscopic assessment of the small bowel with video capsule and double-balloon techniques (see Chapter 23)

Endoscopic monitoring of therapeutic efficacy and its value in clinical trials

Perioperative endoscopy in Crohn’s disease

Endoscopic features of the ileo-anal pouch and pouchitis

Endoscopic therapy of strictures in Crohn’s disease

Conclusion: indications for endoscopy in inflammatory bowel disease

49 Infections and Other Noninflammatory Bowel Disease Colitides

Introduction

Infectious ileocolitis

Other causes of colitis

The role of colonoscopy and ileoscopy in diagnosis of chronic diarrhea

50 Acute Colonic Pseudo-obstruction

Introduction

Epidemiology and predisposing factors

Pathophysiology

Clinical presentation

Diagnosis

Complications

Management

Prognosis

51 Endoscopic Treatment of Chronic Radiation Proctopathy

General principles

Argon plasma coagulation

Bipolar and monopolar coagulation

Formalin therapy

Nd:YAG laser

Cryotherapy

Recommendations

52 Benign and Malignant Colorectal Strictures

Introduction

Colonoscopy in the diagnosis of colorectal strictures

Endoscopic therapy of colorectal strictures

Conclusions

53 Complications

Introduction

Risk management

The dilemma of teaching

Putting the literature into perspective

Mortality

Complications of bowel preparation

Complications of intubation

Intraluminal bleeding

Complications of therapeutic colonoscopy

Postpolypectomy syndrome

The missed lesion (see Chapter 41)

Summary

Section 11 Surveillance

54 Postpolypectomy Surveillance

Introduction

Colonoscopy is the procedure of choice for postpolypectomy surveillance

Risk of cancer following polypectomy

Concept of the advanced adenoma

Missed synchronous versus metachronous polyps

Frequency of postpolypectomy colonoscopic surveillance

Repeat clearing colonoscopy after polypectomy

Effect of polypectomy on cancer incidence and mortality

Further stratification of postpolypectomy cancer risk

Hyperplastic polyps and the serrated adenoma

Postpolypectomy surveillance recommendations

Quality in the technical performance of colonoscopy

Cost and cost-effectiveness of postpolypectomy surveillance

Summary

55 Colonoscopy after Colorectal Cancer Resection

Introduction

Surveillance strategies

Literature review

Perioperative clearing and postoperative surveillance

Surveillance intervals

Health outcomes and health care utilization

Alternatives to colonoscopy

Evaluation of the anastomosis

Patients with a colostomy

Section 12 Pediatric Colonoscopy

56 Pediatric Colonoscopy

Personnel and facilities

Sedation

Equipment

Indications

Contraindications

Antibiotic prophylaxis

Preparation

Technique

Other colonoscopic techniques in pediatric patients

Complications

Summary

Section 13 Virtual Colonoscopy

57 Virtual Colonoscopy in the Evaluation of Colonic Diseases

Introduction

General principles and technique

Clinical indications

Performance results for lesion detection

Summary

Section 14 The Future

58 New Colonoscopes and Assist Devices

59 The Future of Colonoscopy

Introduction

The future of screening colonoscopy

Beyond screening: the real future of colonoscopy

Summary

Index

This edition first published 2003 © 2009 by Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication Data

Colonoscopy: principles and practice/edited by Jerome D. Waye, Douglas K. Rex, Christopher B. Williams. – 2nd ed.

p.; cm.

Includes bibliographical references and index.

ISBN 978-1-4051-7599-9

1. Colonoscopy. I. Waye, Jerome D., 1932– II. Rex, Douglas K. III. Williams, Christopher B. (Christopher Beverley)

[DNLM: 1. Colonoscopyamethods. WI 520 7179 2009]

RC804.C64C63 2009

616.3′407545–dc22

2008053971

Contents: Video clips on DVD-ROM

This book is accompanied by a DVD-ROM with supplementary video clips on the topics listed here.

The DVD-ROM is fully searchable and is intended to be used independently; however, the chapters in this book which cover these topics are noted in parentheses.

A. Colonoscopy: techniques and training

1 . History of colonoscopy

2 . Bovine colonoscopy simulation model with animal intestine

3 . Olympus colonoscopy simulator being used for training a novice colonoscopist

4 . Simbionix simulator (GI Mentor): A virtual colonoscopy simulator with the capability of polypectomy and skill training

Basic colonoscopy technique :

5 . Sigmoid colon

6 . Descending colon

7 . Splenic flexure

8 . Hepatic flexure

9 . Ileocecal

10 . Entry into terminal ileum: the bow and arrow sign

11 . Why are some colons so long and “difficult” to intubate

Visits to the experts (2002) :

12 . J. D. Waye

13 . C.B. Williams

14 . S. Kudo

15 . Y. Sakai

16 . N. Soehendra

ScopeGuide magnetic imager and examples :

17 . Introduction–how ScopeGuide works

18 . “Classic” insertion technique explained

19 . Short normal colon

20 . Shortening a sigmoid loop

21 . “Alpha” spiral loop

22 . Pushing-through an “N-spiral” loop

23 . Reversed alpha-spiral loop

24 . Deep looping in the transverse

25 . Mobile splenic flexure

26 . Sigmoid loop opposed with hand pressure

27 . Transverse loop opposed with hand pressure

28 . Atypical mobile colon

B. Polyps, cancer, and complications

1 . Retroversion to see and remove a polyp

2 . Readjusting snare position for safe polypectomies

3 . Getting the polyp into position for removal

4 . The value of retroversion during polyp removal

5 . Polyp in melanosis

6 . Endoloop

7 . Clips to close a polypectomy perforation

8 . Immediate postpolypectomy bleeding controlled with clip

9 . Loop on pedunculated polyp

10 . Clips to control immediate postpolypectomy hemorrhage

11 . Endoloop applied after polypectomy

12 . Clip on polyp stalk after resection

13 . Clip for anastomotic bleeding

14 . A benign-appearing flat cancerous polyp

15 . Familial adenomatous polyposis (FAP)

16 . Chromoendoscopy for flat adenoma

17 . NBI to delineate the extent of a flat polyp

18 . Large lipoma

19 . Missed lesion in cecum

20 . Missed lesion in descending colon

21 . A crying polyp

22 . Cold snare for a small polyp

23 . Clamshell sessile polyp

24 . Piecemeal polypectomy

25 . Piecemeal polypectomy in retroversion

26 . A polyp located between two folds

27 . Injection of surgical marker (pure carbon in suspension) into saline bleb

28 . Resection of a pedunculated polyp

29 . A polyp in the appendix

30 . Submucosal injection polypectomy (SIP) or endoscopic mucosal resection (EMR)

31 . Piecemeal polypectomy follow-up submucosal injection polypectomy (SIP)

32 . Giant rectal polyp removed over a five-year interval

33 . Large sessile polyp (a) and (b)

34 . Lateral spreading polyp

35 . Large sessile descending colon polyp

36 . Large polyp sent for surgery

37 . Endoscopic mucosal resection of a large hepatic flexure polyp

38 . Endoscopic mucosal resection of a sessile rectal polyp

39 . Endoscopic submucosal dissection (ESD) of a large flat rectal polyp

40 . Endoscopic submucosal dissection (ESD): ascending colon polyp

41 . Accurate localization of bleeding by the water jet

42 . Endoscopic submucosal dissection (ESD): sigmoid colon polyp

43 . Endoscopic submucosal dissection (ESD): perforation

44 . Colon stent descending: self-expanding metal stent (SEMS) for colon cancer

45 . Colon stent: self-expanding metal stent (SEMS) for rectal carcinoma

46 . Late postpolypectomy bleeding

47 . Treatment of immediate postpolypectomy bleeding

48 . Postpolypectomy bleeding

49 . Recurrent malignant polyp

50 . Recurrent polyp

51 . Postpolypectomy bleed

C. Inflammatory conditions

1 . Chromoendoscopy reveals a dysplastic lesion in ulcerative colitis

2 . A pedunculated dysplastic lesion in ulcerative colitis

3 . Cancer in Crohn’s disease

4 . Cancer in a surveillance patient with chronic ulcerative colitis

5 . Ulcerative colitis: removal of flat polyp

6 . Dysplastic lesion in ulcerative colitis

7 . Inflammatory polyps in ulcerative colitis

8 . Chromoendoscopy in two cases of ulcerative colitis

9 . Clostridium difficile infection

10 . Polypoid mucosal lesions in diverticulosis

11 . Diverticular colitis

12 . Granulation tissue at a diverticulum

13 . Red folds in diverticular disease

D. Other conditions and topics

1 . Foreign body

2 . Cap polyposis

3 . Solitary rectal ulcer syndrome

4 . Confocal laser endomicroscopy

5 . Ascaris in the cecum

6 . Pinworms

7 . Red rings in the rectum

8 . Ischemic colitis at two weeks

9 . Ischemic colitis

10 . Ischemic colitis at two days

11 . Radiation proctopathy

12 . Balloon dilation of anastomotic colo-colon anastomotic stricture one year after surgery

13 . Anastomotic stricture and balloon dilation

Acknowledgements

The Editors and other contributors have supplied a range of video clips in the hope that they will be of interest. Particular acknowledgment is made to: Dr. Todd Baron, Dr. M. J. Bourke, Dr. Jonathan Cohen, Dr. Gregory Ginsberg, Dr. Ralf Kiesslich, Dr. S. Kudo, Dr. N. E. Marcon, Dr. J. R. Armengol-Miro, Professor Y. Sakai, Professor N. Soehendra, and Dr. N. Yahagi.

Clips B28, 37, 38, 39, and 40 are from Dr. Marcon’s Therapeutic Endoscopy course, performed at the Annual Therapeutic Endoscopy Workshop in Toronto, Canada, at St. Michael’s Hospital.

Preface to the First Edition

Flexible endoscopy of the colon was introduced in 1963, six years after Basil Hirschowitz developed the fiberoptic gastroscope. Since the first attempts at intubating the entire colon, this procedure has now become a primary diagnostic and therapeutic tool for evaluation and treatment of colonic diseases. Using the ability to inspect, obtain tissue samples and remove colon polyps, colonoscopy has expanded our knowledge of the natural history of colonic neoplasia. Multiple large studies have shown that removal of benign adenomas will prevent colorectal cancer. Because of the increasing awareness of colorectal cancer being a common cause of death from cancer throughout the world, and the possibility to interrupt the adenoma to carcinoma sequence by polypectomy, the volume of colonoscopies around the world continues to be driven upward by widespread acknowledgement of the effectiveness of the procedure.

Colonoscopy is not merely a tool in the hands of a practitioner, but it is a discipline with an infrastructure built upon many areas of medicine, including internal medicine, the general practice of medicine, and gastroenterology in particular, as well as surgery, pathology, radiology, pediatrics, and molecular biology. The expanding horizon of colonoscopy was the stimulus for us to organize a new comprehensive textbook on this field. The chapters in this volume address every aspect of colonoscopy, and its interface with all of the other sections of medicine.

The editors of this book learned and indeed developed many techniques of colonoscopy when imaging was limited to the barium enema and there was no cap ability to visualize the intraluminal topography in the intact patient. This book represents the “state of the art” in colonoscopy. However, colonoscopy is a procedure in evolution and investigators around the world are actively pursuing improvements.

Colonoscopy is a relatively new discipline, and although tremendous strides have been made since its introduction, there are many unanswered questions such as how can we improve training in colonoscopy? Can bowel cleansing be made less toxic and less miserable? Can colonoscopy be made painless? Can we improve the detection of neoplasia? Can we make colonoscopy faster? Can we eliminate complications from both diagnostic and therapeutic procedures? The answers to these questions will determine the future of colonoscopy and its ultimate impact on colorectal disease. We look forward to the continuing pursuit of answers to all questions concerning colonoscopy, and urge future generations of colonoscopists to continue the quest for knowledge and add more information to each of the chapters in this book.

For many colonoscopists and certainly for ourselves, colo-noscopy is not considered as part of a job, but rather as a passion. Every colonoscopy presents an opportunity to improve a patient outcome, to learn, often to reassure, to identify new questions and problems both clinical and scientific, and to enjoy the application of skills both manual and cognitive in nature. Thus, to edit a volume on colonoscopy has been for us a particular pleasure. We extend our most sincere thanks to the authors who contributed to this volume. The list of authors includes the world’s most foremost practitioners from every aspect of medicine. Their expertise, diligence, and friendship are deeply appreciated. On behalf of all the authors, we thank the many, many thousands of patients who have trusted us and been our teachers.

Jerome D. Waye

Douglas K. Rex

Christopher B. Williams

2003

Preface to the Second Edition

The first edition of this book was conceived because there was no overall source of information concerning the current status of colonoscopy. The chapter headings were intended to cover the entire range of colonoscopy. With careful editing, attention to detail in each chapter and drawing on the vast clinical and teaching experience of all three editors, the book won first prize in the 2004 prestigious medical society award for gastroenterology conferred by the British Medical Association.

In one of the reviews of the first edition, it was stated that Colonoscopy was “a masterpiece of its kind. The authors should be complimented for their successful effort to provide such an important and fascinating book”. “Very rarely has the reviewer examined a monograph... which has impressed him so much for its clarity, completeness, attractiveness and its fascination”. This second edition is intended to capture all the changes that have taken place in the field of colonoscopy within the past several years, with six new chapters and 34 new authors, who represent the best minds and practitioners in the field of colonoscopy and colonoscopic imaging. Each chapter has been extensively revised, and many were completely rewritten with a view to bring a focus of current knowledge to this updated second edition. The editors have encouraged all authors to add layers of new information to the data of 5 years ago.

As colonoscopy is such a visual imaging field and since the technique of therapy is so closely associated, a DVD has been added to the book to accompany this edition. The DVD has over 100 video segments covering the entire aspect of colonoscopy from history to teaching, from insertion technique to polypectomy, and it also contains many cases of interesting pathology ranging from parasites to perforation. Several videos demonstrate the most recent developments of narrow-band imaging, confocal laser endomicroscopy, and endoscopic submucosal dissection.

Most of the individual video clips for the DVD were contributed by the editors, many were submitted by the chapter authors themselves, and others represent videos of live cases performed at international teaching courses. Some of the videos have audio commentaries, but most have an accompanying full text description.

We hope this second edition of Colonoscopy: Principles and Practice will enhance the knowledge of everyone interested in the field of colonoscopy and colonic imaging. Although intended to be a source of information for physicians, surgeons, residents and fellows, as well as students and gastrointestinal assistants, our goal is to enhance the care and treatment of patients with colonic problems, who are the ultimate beneficiaries of shared knowledge and improved skills.

We wish to thank the unflagging efforts of our text editors, Rebecca Huxley from Wiley-Blackwell, Helen MacDonald from Prepress Projects Ltd, and the careful overview of Meg Barton, also from Wiley-Blackwell, in organizing the accompanying DVD section.

We would also like to thank William W. Gantt who worked on both the first and second edition of Colonoscopy, rekeying all amendments to the manuscript, in preparation for the publishers.

Jerome D. Waye,

Douglas K. Rex

Christopher B. Williams

June 2009

List of Contributors

L. Aabakken, MD, PhDProfessor of Medicine and Chief of GI Endoscopy, Department of Medical Gastroenterology, Rikshospitalet University Hospital, Oslo, Norway

J. Aisenberg, MDAssociate Clinical Professor, Department of Medicine (Gastroenterology), The Mount Sinai School of Medicine, New York, NY, USA

J.T. AndersonGloucestershire Hospital NHS Foundation Trust, Cheltenham, Gloucestershire, UK

S. Banerjee, MDDirectory of Biliary Endoscopy, Stanford University School of Medicine, Stanford, CA, USA

D.E. Barlow, PhDVice PresidentaResearch and Development, Olympus America Inc., Center Valley, PA, USA

T.H. Baron, MD, FACPProfessor of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA

S. Bar-Meir, MDProfessor of Medicine and Director, Department of Gastroenterology and Hepatology, Chaim Sheba Medical Center, Tel Hashomer, and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

J.H. Bond, MDChief, Gastroenterology Section, Minneapolis Veterans Affairs Medical Center, and Professor of Medicine, University of Minnesota, MN, USA

C.R. Boland, MDChief, Division of Gastroenterology, Baylor University Medical Center, Dallas, TX, USA

M.J. Bourke, MB, BS, FRACPDirector of Gastrointestinal Endoscopy, Westmead Hospital, Sydney, Australia

R.D. BrewerPhD Candidate in Mechanical Engineering, Stanford University Department of Engineering, Stanford, CA, USA

R.W. Burt, MDProfessor of Medicine, Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA

J. Cohen, MD, FASGE, FACGClinical Professor of Medicine, New York University School of Medicine, New York, NY , USA

L.B. Cohen, MDAssociate Clinical Professor, Department of Medicine (Gastroenterology), The Mount Sinai School of Medicine, New York, NY, USA

J. Church, MDVictor W. Fazio Professor of Colorectal Surgery, Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH, USA

R.S. DaCosta, PhDAssistant Scientist, Division of Biophysics and Bioimaging, Ontario Cancer Institute, University Health Network, and STARR Innovation Center, Radiation Medicine Program, University of Toronto, Toronto, Ontario, Canada

M.M. Delvaux, MD, PhDDepartment of Internal Medicine and Digestive Pathology, University Hospital of Nancy, Nancy, France

G. D’Haens, MD, PhDGastroenterologist, Imelda General Hospital, Bonheiden, Belgium

J. DevièreErasme Hospital, Brussels, Belgium

J.A. DiPalma, MDDivision of Gastroenterology, University of South Alabama College of Medicine, Mobile, AL, USA

C.A. Dykes, CTR, NNMCSenior Nurse Research Coordinator, Colon Health Initiative, National Naval Medical Center, Bethesda, MD, USA

G.M. Eisen, MD, MPHProfessor of Medicine, Oregon Health & Science University, Portland, OR, USA

F. Emura, MD, PhDMedical Director, Advanced Digestive Endoscopy, Emura Foundation for the Promotion of Cancer Research, Bogotá, and Honorary Professor of Gastrointestinal Endoscopy, School of Medicine, Universidad del Valle, Cali, Colombia

G. FarinEngineer, Center for Medical Research, Experimental Endoscopy, Tübingen, Germany

A.D. Feld, MD, JDClinical Professor of Medicine, University of Washington, Seattle, and Rockwood Clinic, WA, USA

P. Fockens, MD, PhDAssociate Professor of Medicine, Director of Endoscopy, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands

C. Fraser, MB, ChB, MD, MRCPConsultant Gastroenterologist, The Wolfson Unit for Endoscopy, St Mark’s Hospital, London, UK

F. Froehlich, MDAssistant Professor of Gastroenterology, Department of Gastroenterology and Hepatology, University of Basle, Basle, and Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland

G.G. Ginsberg, MDProfessor of Medicine, University of Pennsylvania School of Medicine, Gastroenterology Division, and Director of Endoscopic Services, University of Pennsylvania Health Systems, Philadelphia, PA, USA

A. Goel, PhDInvestigator, Baylor University Medical Center, Dallas, TX, USA

J.-J. Gonvers, MDProfessor of Gastroenterology, Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland

C.J. Gostout, MDProfessor of Medicine, Mayo Graduate School of Medicine, Mayo Foundation, Rochester, MN, USA

D.A. Greenwald, MDAssociate Division Director, Montefiore Medical Center, and Associate Professor of Clinical Medicine, Albert Einstein College of Medicine, New York, NY, USA

K.E. Grund, MDProfessor of Surgery, Surgical and Experimental Endoscopy, University Hospital Tübingen, Germany

D.A. Haggstrom, MD, MASResearch Scientist, HSR&D, Indianapolis Veterans Affairs Medical Center, and Assistant Professor of Medicine, Indiana University, Indianapolis, IN, USA

N. Harpaz, MD, PhDProfessor of Pathology and Medicine, Mount Sinai School of Medicine, and Director, Division of Gastrointestinal Pathology, The Mount Sinai Medical Center, New York , NY, USA

K.M. Hoda, MDGastroenterology Fellow, Oregon Health & Science University, Portland, OR, USA

B. Hofstad, MDSenior Gastroenterologist, Division of Gastroenterology, Ullevaal University Hospital, Oslo, Norway

K.C. Huh, MD, PhDDepartment of Internal Medicine, Konynag University School of Medicine, Daejeon, South Korea

D.P. HurlstoneBarnsley NHS Foundation Trust, Barnsley, UK

H. Ikematsu, MDStaff of Gastrointestinal Oncology and Endoscopy, National Caner Center Hospital East, Chiba, Japan

D.M. Jensen, MDProfessor of Medicine, UCLA School of Medicine, Director of Human Studies Core, CURE: Digestive Disease Research Center, WLA VA Medical Center/CURE, Los Angeles, CA, USA

C.J. Kahi, MD, MSCAssistant Professor of Clinical Medicine, Indiana University School of Medicine, and Director of Endoscopy, Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, In, USA

M. Kay, MDDirector Pediatric Endoscopy, Department of Pediatric Gastroenterology and Nutrition, Children’s Hospital, Cleveland Clinic, Cleveland, OH, USA

M.A. Khashab, MDDepartment of Medicine, Division of Gastroenterology/Hepatology, Indiana University School of Medicine, and Clarian Health Partners, Indianapolis, IN, USA

H. Kashida, MD, PhDAssociate Professor, Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan

R. Kiesslich, MD, PhDProfessor, Head of Endoscopic Unit I. Med. Klinik, Johannes Gutenberg University, Mainz, Germany

M.B. Kimmey, MDTacoma Digestive Disease Center, Tacoma, WA, USA

M.J. Krier, MDFellow, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA

S. Kudo, MD, PhDProfessor, Chairman, Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan

D. Lieberman, MDProfessor of Medicine, Division of Gastroenterology, Oregon Health & Science University, Portland, OR, USA

G.A. Machicado, MDClinical Professor of Medicine, UCLA School of Medicine, Van Nuys, CA, USA

N.E. Marcon, MDSt Michael’s Hospital, Center for Therapeutic Endoscopy and Endoscopic Oncology, Toronto, Ontario, Canada

J.B. Marshall, MDProfessor of Medicine, Division of Gastroenterology, University of Missouri School of Medicine, Columbia, MO, USA

M.F. Neurath, MD, PhDProfessor, Head of the Institute of Molecular Medicine, I. Med. Department, Johannes Gutenberg University, Mainz, Germany

H. Niwa, MD, DMScProfessor of Medicine, St. Marianna University School of Medicine, Kawasaki, Japan

M. O’Brien, MD, MPHProfessor of Pathology and Laboratory Medicine, Boston University School of Medicine, and Chief of Anatomic Pathology, Boston Medical Center, Boston, MA, USA

P.J. Pasricha, MDChief, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, CA, USA

J. Petrini, MDSansum Clinic, Santa Barbara, CA, USA

P.J. Pickhardt, MDAssociate Professor of Radiology, Abdominal Imaging Section, University of Wisconsin, School of Medicine & Public Health, Madison, WI, USA

A. PostgateFellow, St Mark’s Hospital, London, UK

D.K. Rex, MDProfessor of Medicine, Indiana University School of Medicine, and Director of Endoscopy, Indiana University Hospital, IN, USA

M.E. Rich, AIA, LLED APArchitect PC, 2112 Broadway, New York, NY, USA

B.E. Roth, MDProfessor of Medicine and Chief, Clinical Affairs, Division of Digestive Disease, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

P. Rutgeerts, MD, PhDDepartment of Medicine, Division of Gastroenterology, University Hospital Gasthuisberg, Leuven, Belgium

R. Sáenz, MDThe Latin-American WGO and OMED Gastrointestinal Endoscopy Training Center and Vice Chair, Clinica Alemana, Universidad del Desarrollo, Santiago, Chile

Y. Sano, MD, PhDDirector and Chief of Gastrointestinal Center, Sano Hospital, Kobe, Japan

B.P. Saunders, MD, FRCPConsultant Gastroenterologist, Wolfson Unit for Endoscopy, St Mark’s Hospital, London, UK

U. Seitz, MDChief, Internal MedicineaGastroenterology, Bergstrass Medical Center, Heppenheim, Germany

S.G. Shah, MD, MRCPConsultant Gastroenterologist, Pinderfields General Hospital, Wakefield, UK

N. Soehendra, MDEndoskopie am Glockengiesserwall, Hamburg, Germany

R. Soetikno, MDStanford University School of Medicine, Palo Alto, CA, USA

A. Sonnenberg, MD, MScProfessor of Medicine, Oregon Health & Science University, and Staff Physician, Portland Veterans Affairs Medical Center, Portland, OR, USA

J.W. Stubbe, MDDepartment of Gastroenterology & Hepatology, AZ Sint-Jan, Ostend-Bruges, Belgium

C. Surawicz, MD, MACGProfessor of Medicine, University of Washington School of Medicine, Seattle, WA, USA

J. Van Dam, MD, PhDStanford University School of Medicine, Stanford, CA , USA

G. Van Assche, MD, PhDDepartment of Gastroenterology, University Hospitals Gaithuisberg, Leuven, Belgium

S. Vermeire, MD, PhDDepartment of Gastroenterology, University Hospitals Gaithuisberg, Leuven, Belgium

J.D. Waye, MDDirector of Endoscopic Education, Mount Sinai Hospital, Clinical Professor of Medicine, Mount Sinai Medical Center, New York, NY, USA

W.M. Weinstein, MDProfessor of Medicine, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

C.B. Williams, BM, FRCP, FRCSConsultant Physician, St Mark’s Hospital and London Clinic, London, UK

S.J. Williams, MB, BS, MD, FRACPSenior Gastroenterologist, Westmead Hospital, Sydney, Australia

B.C. Wilson, PhDDepartment of Medical Biophysics, University of Toronto, Ontario Cancer Institute, Toronto, Ontario, Canada

S.J. Winawer, MDAttending Physician & Member with Tenure, Gastroenterology & Nutrition Service, Paul Sherlock Chair in Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

R. Wyllie, MDCalabrese Chair of Pediatrics, Pediatric Institute, Chair, Department of Pediatric Gastroenterology and Nutrition, and Physician-in-Chief, Children’s Hospital, Cleveland Clinic, Cleveland, OH, USA

N. Yahagi, MD, PhDDirector, Department of Gastroenterology and Endoscopy Unit, Toranomon Hospital, Tokyo, Japan

G. Zuccaro Jr, MD, MSDepartment of Gastroenterology and Hepatology, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA

Section 1

General Aspects of Colonoscopy

1

History of Endoscopy in the Rectum and Colon

Hirohuml Niwa1 & Christopher B. Williams2

1St Marianna University School of Medicine, Kawasaki, Japan

2St Mark’s Hospital, London, UK

Introduction–from rigid endoscopes to colonofiberscopes

Long before it became practicable to examine the proximal colon, a variety of rigid instruments were used to examine the anal canal, the rectum, and the distal half of the sigmoid colon. Even the limited view obtained by rigid “hollow tube” scopes had significant clinical value, as disease of the large bowel is most commonly found in the distal half of the sigmoid colon and rectum. The history of modern colonoscopy therefore begins with such devices, starting with the earliest inventions.

This account is substantially limited to the evolution of colorectal endoscopy, but there are excellent more wide-ranging accounts giving the background of prior developments in cystoscopy, esophagoscopy and gastroscopy [1–3]. Outstanding museum collections of the history of endoscopy can be found in Austria (Nitze-Leiter Endoscopy Museum, Vienna; visitors by arrangement) and America (Dittrick Museum, Cleveland, Ohio), with lesser medico-historical exhibits in Germany (Ingolstadt), France (René Descartes University, Paris), China (First Hospital, Beijing), and elsewhere—though urological exhibits tend to dominate [4].

Rigid endoscopes

Primitive specula

From the time of Hippocrates attempts were made to observe the inside of the human body. A “speculum” was used to examine the rectum and vagina and to cauterize hemorrhoids. Primitive instruments similar to today’s anoscopes and colposcopes were discovered in the ruins of Pompeii, buried under volcanic ash after the eruption of Mount Vesuvius in the first century AD (Figure 1.1). The light source for a speculum was sunlight, so inevitably observation was limited to the openings of the body. After these primitive instruments, no significant progress was made until the nineteenth century.

Figure 1.1 Roman speculum from the ruins of Pompeii (79 AD).

Early endoscopes

Although the first telescopes were developed in Europe in the early seventeenth century, it was Phillipp Bozzini who first tried to observe inside the human body, through a rigid tube without optics. He developed an apparatus called the light conductor (lichtleiter) in 1805, which he used in his attempt to observe rectum, larynx, urethra, and upper esophagus [5]. Bozzini was born in Mainz, Germany, in 1773 and started to study medicine there before moving to Frankfurt in 1803. He was a man with a wide range of cultural accomplishments, including medicine, mathematics, engineering, and the fine arts. Bozzini’s instrument (Figure 1.2) can be seen in replica in the Museum of Medical History in the University of Vienna. It is essentially a lantern with round openings on its front and back walls but separated by a vertical partition into two parts. One side held the light source, a candle with a concave mirror behind it, the position of the candle flame being kept unchanged by a spring mechanism. Observation was from the back opening of the other (unlit) viewing side through a speculum attached to the front. Several different specula were available for observation of different organs. For inspection of the larynx, pharynx, and esophagus, a special lateral-viewing speculum was developed, at the tip of which was both a concave mirror and a flat mirror, the concave mirror giving a magnified close-up view and the flat mirror angling illumination.

Figure 1.2 Bozzini’s “Lichtleiter” or light conductor (1806)-dotted cutaway diagram shows the spring-mounted candle with a mirror behind it.

Using this device, Bozzini conducted experiments on corpses and patients. On December 9, 1806, a public demonstration on corpses using his light conductor was held during a meeting of the Imperial Joseph’s Surgical Academy in Vienna, now the Institute of Medical History, the University of Vienna. The details of this experiment are in the archives in Vienna, describing observation of the rectum, vagina, and uterine cervix of a corpse. In a second gathering of the Academy in 1807, using an improved version, observation was carried out of the rectum and vagina and also through a wound in the abdomen of the corpse. The first attempt to use the device on a living patient was made during the same gathering. Based on these experiments, Bozzini published a book on his light conductor in 1807. However, the Faculty of Medicine of the University of Vienna would not permit further study of the device, which the authorities regarded as no more than a plaything or “lanterna magica in corpore humano,” of no medical value. Use of the light conductor was forbidden, partly because of rivalry between the Surgical Academy and the University, but also because of the conservative attitudes of the Viennese authorities. Bozzini’s death in 1809 stopped any further evolution.

In 1826, Segales in France reported on a new method for examining the human bladder using a funnel-shaped met al tube, with a concave mirror and a candle light source. Fischer in America then developed another cystoscope in 1827, and Avery in England developed a similar instrument for observation of urethra, bladder, vocal cords, and esophagus, lit by reflected candle light using a concave mirror. These achievements in development of cystoscopes and urethro-scopes were the foundation for subsequent development of gastrointestinal endoscopes, notably the open-tube rigid proctosigmoidoscope.

In 1853, Désormeaux (1815–81) in France developed the first instrument of clinical value, primarily for diagnosis and treatment of urological disease, and called it the “endoscope” (Figure 1.3). The endoscope comprised a viewing tube and a light source unit, a “gazogene” lamp lit by a mixture of alcohol and turpentine. The viewing tube, at its junction with the light source, had an angled mirror with a small hole in the center reflecting the light from the flame through the viewing tube into the attached speculum. Observation was through a small hole at the end of the viewing tube, which swiveled at its connection to the light source so that the source stayed vertical. Désormeaux published a book in 1865 to summarize his achievements in observing urethra and bladder with the “endoscope.” In it he mentions that he had succeeded in observing inside the rectum as well, although without details, and predicted that it should prove possible to observe the stomach. Désormeaux’s endoscope was, however, essentially a hollow rigid tube with no lens or optical system.

It was Kussmaul who further developed Désormeaux’s methodology, succeeding in making the first functional gastroscope in 1868. Kussmaul had first tried observing the rectum and then the esophagus with Désormeaux’s endoscope, observing cancer of the upper esophagus [5]. Kussmaul then developed a new version with a longer insertion tube, inspired by the performance of a sword-swallower who could insert a straight met al bar from his mouth into the esophagus, and was persuaded to come to the university to experiment. Kussmaul’s gastroscopes were brass hollow tubes of 47 cm in length and 1.3 cm in diameter, either round or oval in cross-section. No lens was used in the optical system, so, although he succeeded in inserting the tube into the stomach, the candle light source of the device was totally inadequate for gastric illumination, and attempts to use it were short-lived.

Figure 1.3 Désormeaux’s “endoscope” (1853)–with (inset) cross-section showing the lens-less view through a perforated mirror, reflecting light from the source.

Electric light–rigid rectoscopes and proctosigmoidoscopes

Before the invention of the electric incandescent light bulb, it was known that bright light could be obtained by passing electrical current through a platinum wire, with water-cooling. This water-cooled electrical lighting system was applied to observation of the larynx in the 1860s and subsequently to other endoscopes, such as that of a German dentist in 1867, described as a “stomatoscope” and used to illuminate the mouth–but apparently also tried up the rectum (Figure 1.4). Nitze and Leiter made a cystoscope in 1879, and subsequently an esophagoscope and a gastroscope. Leiter, a Viennese optical instrument maker, also developed a recto-scope with a similar light source, although whether it was clinically useful is not recorded.

With the introduction of Edison’s electric incandescent bulb in 1879 the size of bulbs reduced, while the brightness increased greatly. In 1886, Nitze and Leiter succeeded in developing a cystoscope with a miniature electric incandescent bulb at the tip, which became the basis for the development of subsequent gastrointestinal endoscopes (principally esophagoscopes and gastroscopes), as described in Edmondson’s excellent 1991 account [1]. Nevertheless, this technology was not used in the lower gastrointestinal (GI) tract until 1895, when Kelly in the US produced the first proctoscope of practical value, a met al hollow tube produced in various lengths [6]. It had an obturator for insertion, and illumination was by a concave reflector, as used by otorhino-laryngologists. The rectum was well seen but, even with longer versions, there was difficulty observing the proximal sigmoid colon because of poor illumination. In 1899, Pennington [7] sealed the eyepiece of the tube with a glass window, supplied air from a rubber ball to distend the sigmoid colon and inserted a small light bulb at the distal end for better illumination. The same year, Laws used a thin met al rod tipped by a miniature light bulb and inserted it through the proctosig-moidoscope for maximal illumination.

Figure 1.4 “Stomatoscope” (1867, Breslau, Germany)—designed for oral illumination but used up the rectum. Note the water-cooled electric lighting system.

In 1903, Strauss, in Germany, following Laws’ approach, developed a proctosigmoidoscope that distended the sigmoid colon with a rubber hand pump and safety bellows. This became the basis of commercially available Strauss-type proctosigmoidoscopes, which were widely used until the arrival of fibersigmoidoscopes. Strauss proctosigmoidoscopes consisted of met al tubes, 2 cm in diameter and of various lengths, inserted into the rectum or distal colon with an obturator in position. For observation the obturator was removed and a thin met al tube with a miniature light bulb inserted to the tip (Figure 1.5). A magnifying apparatus was available that could provide six times magnified images, showing early interest in the possibility of magnification in endoscopy. In 1910, Foges described a proctoscope with a miniature light bulb installed at the eyepiece window, while another proctosigmoidoscope with a light source at the eyepiece end was developed by Yeomans in 1912. Proctosigmoidoscopes from an outside light source with a fiberoptic light guide are still widely used.

There are several lengths of rigid endoscopes for use in the rectum and sigmoid colon. Officially shorter ones, for use in the rectum, are called anoscopes, rectoscopes, or proctoscopes. Longer ones, for use in the distal sigmoid colon, have been called sigmoidoscopes or proctosigmoidoscopes. However, the terms anoscope, rectoscope, proctoscope, sigmoidos-cope, and proctosigmoidoscope are effectively synonymous.

Sigmoidoscopy has been performed in various positions, in lithotomy, lateral decubitus, or “chest–knee” position. It seems that Kelly was the first to use, and emphasize the significance of, the chest–knee or “knee–elbow” position in order to air distend the sigmoid colon and optimize the view [6].

Figure 1.5 Strauss-type proctosigmoidoscope—still widely used in clinical practice.

Rigid scope photography and special proctosigmoidoscopes

Sigmoidoscopic photography was attempted using the Strauss sigmoidoscope with special apparatus. However, it proved difficult to take good pictures through sigmoidoscopes until the early 1960s. This was due to the low sensitivity of the available reversal color film used for slides (in 1960 Kodak film was only ASA 10) and the difficulty of achieving sufficient illumination with available built-in sigmoidoscope bulbs. In 1960, Sakita and Niwa and their coworkers developed a different type of picture-taking sigmoidoscope in order to obtain better pictures using a conventional Strauss-type sigmoidoscope equipped with a separate distal xenon lamp for photography. With the introduction of fiberoptic light guides, sigmoidoscopic photography transiently became popular but was supplanted first by colonofiberscopes and then by videoscopes as the means of taking pictures.

Other specialized proctosigmoidoscopes which allowed magnified three-dimensional observation of the rectal and colonic mucosa were used by Niwa in 1965 [8], the proctoscope being coupled to a surgical stereomicroscope. Staining with pontamine sky blue or toluidine blue was described by Yamagata and Miura in 1961 for intraluminal microscopic observation of rectal mucosa, using a conventional sigmoido-scope with insertion of an “intraluminal microscope” to observe the pit openings with up to ×l30 magnification. The first published report of similar dye-spraying methodology in the upper GI tract was not until 1966 [9].

Figure 1.6 Regenbogen’s sigmoidoscope. (a) Slotted end of tube, (b) Wire “extender” mechanism, closed and open, (c) Sigmoidoscope insertion stretches and angulates sigmoid colon, (d) Expanded “extender” grips and straightens colon on withdrawal.

A subsequent example of innovation was a special sigmo-idoscope made by Regenbogen in Germany in 1966, attempting to visualize more proximal parts of the sigmoid colon (“high colonic endoscopy”) [10]. His sigmoidoscope had a rounded tip to help insertion through the bends of the sigmoid colon and an ingenious mechanism to assist insertion (Figure 1.6). Two slits in the body of the sigmoidoscope and a rubber covering allowed the atraumatic arms of an “extender” to open out through the slits, fixing the bowel wall so that it could be pulled back over the sigmoidoscope—rather as a glove is pulled over the fingers. Regenbogen claimed that he could observe at least 15 cm deeper than with an ordinary sigmoidoscope. His approach anticipates the basis for current colonoscopic technique and even “double-balloon” endoscopy.

Gastrocameras, the “sigmoidocamera” and “colonocamera”

Recent literature studies have revealed a number of surprisingly advanced experiments in the late nineteenth century in the US and Germany, attempting to capture photographic images of the stomach over 50 years before Japanese descriptions of functional gastrocameras. Edison’s description of the filament light bulb in 1879 was the breakthrough that was needed, although it was several years before miniaturized bulbs became available. In 1889, Einhorn, in the US (described by Bockus as a “gadgeteer”), tried what he called “gastrodiaphany”—illuminating the water-distended stomach with a light bulb on the end of a rubber tube, and viewing the glow through the abdominal wall [11]. He reported having inserted the device into the colon but failed to achieve his suggestion of incorporating a miniaturized camera. Schaaf, also in the US, in 1898 evolved the concept with a flexible rubber tube device “for intragastric photography” (Figure 1.7) [12]. It had a filament light bulb and miniaturized camera, but could take only a single picture and was therefore impractical. By 1897, Kelling, in Germany, had a relatively sophisticated forward-viewing rigid esophageal tube, tipped by a curved filament lamp surrounding a lens through which multiple photographs could be taken by advancing a (black and white) film strip. A year later, Lange and Meltzing, in Germany, reported a similar but superior device (Figure 1.8), side-viewing but able to take 50 photographs on a cable-controlled film strip after bellows inflation of the stomach [13]. This sophisticated instrument largely anticipated later Japanese gastro-camera developments, failing only because of the limitations of the photographic films then available, which were grainy and had poor sensitivity.

Figure 1.7 Schaaf’s “device for intragastric photography” (1898) took only a single pinhole photograph—so was impractical [12].

Figure 1.8 Lange and Meltzing’s surprisingly sophisticated film strip gastroscope (1898)—it failed only because of insensitive film.

In 1929, Porges and Heilpern reported their “Gastrophotor” (Figure 1.9), for use in the stomach and rectum [14]. This had an eight-pinhole stereoscopic camera, allowing simultaneous pictures to be taken of a wide area of stomach or rectum. The Gastrophotor set, as supplied commercially, contained two instruments—one for the stomach (black shaft) and one for the rectum (red shaft)—but there are no published reports of its clinical use in the rectum.

Uji’s (1950) Japanese side-viewing and angulating film strip gastrocamera (Figure 1.10) proved able to take multiple pictures, but was soon abandoned due to frequent malfunctions and poor-quality photographs. However, Sakita, of the University of Tokyo, made a number of technical improvements and also established the standardized routine for taking gastrocamera pictures, with later review of the images, so making the device practical for clinical use.

Figure 1.9 Gastrophotor (1929)—a flexible multi-pinhole photographic tube. A rectal version was available.

Figure 1.10 Uji’s gastrocamera mechanism (1953)—note the 30° angulation capability (and similarity to Figure 1.8).

The “sigmoidocamera” was trialed by Matsunaga and Tsushima in 1958 after modifying the commercialized Olympus type II gastrocamera [15]. A conventional sig-moidoscope was first inserted into the sigmoid colon and the sigmoidocamera passed through it to take pictures. In 1960, Niwa developed the prototype of a new colonocamera (Figure 1.11a) [16], a modification of the mass survey gastrocamera (later called the type V gastrocamera) but with a much longer shaft. The visual angle of the lens was 80° and the film used was 5 mm in width. With this prototype, photography up to the left (splenic) flexure was successful, the first time that observation of the proximal colon had been possible. Figure 1.11b shows an example of the pictures obtained with this instrument. Further improvements were then made and its length extended, which allowed insertion into the proximal colon under fluoroscopic guidance. By 1964, the Olympus gastrocamera with fiberscope (GTF) had been developed, the film-strip facility being retained as the images were much superior to those possible through the fiberoptic viewing bundle. The colonocamera concept was, however, impractical due to the poor pictures obtainable in the narrow colon lumen, very few of which were satisfactory. Nonetheless, the development of sophisticated insertion tubes and tip angulation mechanisms in these instruments formed the basis for the superior handling and angulating characteristics of later Japanese fiberscopes.

Figure 1.11 Niwa’s (a) “Colonocamera” (1960) and (b) image of sigmoid colon.

American fiberscope development

While gastrocamera and colocamera development proceeded in Japan, Hopkins and Kapany in the UK, in 1954, had demonstrated crude image transmission down a short fiberoptic bundle (Figure 1.12) and speculated on its potential use for gastroscopy [17]. Hirschowitz, Peters, and Curtiss, at the University of Michigan, developed a fiberoptic viewing bundle by 1957 and used it to perform the first flexible gastroduodenoscopy [18]. They then worked with American Cystoscope Makers Inc. (ACMI) to produce prototype endoscopes, and by 1961 the ACMI “Hirschowitz fibergastroscope” was commercially available, creating excitement in Japan and around the world (Figure 1.13).

Figure 1.12 The image quality of Hopkins’ original fiberoptic bundle.

Figure 1.13 Commercialized Hirschowitzfibergastroscope (American Cystoscope Makers Inc., ACMI, 1964), also used in the colon. Side-viewing, no angulation controls (focusing lever only), with transformer for distal tip light bulb.

Local academic disagreement at the University of Michigan, however, caused a delay in progress to the colon. Overholt, starting in 1961, obtained US government funding to start work on developing fiberscopes for sigmoidoscopy. By 1963, three different US teams had produced prototype short instruments and Overholt was able to perform the first flexible sigmoidoscopy with a relatively crude but four-way angling instrument (Figures 1.14 and 1.15). ACMI, a small company, had been preoccupied with gastroscope development and was unwilling to accept governmental conditions for colo-noscope development. ACMI did, however, supply both passive viewing bundles and prototype side-viewing fiber-gastroscopes, which were used in 1966–68 by pioneer colon enthusiasts in the US [19], the UK [20], and Italy, but it was not until 1967, 10 years after Hirschowitz’s first gastroscopy, that Overholt could report a series of 40 successful flexible sigmoidoscopies [21]. The US colorectal establishment showed little enthusiasm for the opportunities of fiberendoscopy, except as a superior light source for conventional procto-sigmoidoscopes [22]. A fourth company, American Optical, was able to produce fiberoptic bundles [3] and sold some to Japan for use in prototype development.

Figure 1.14 Prototype fibersigmoidoscope: Illinois Institute of Research (Overholt, 1963).

Figure 1.15 The first functional fibersigmoidoscope—four-way angling: Eder Instrument Co. (Overholt, 1963).

ACMI, partly because of the small and very flexible fibers produced by its development of the Hirschowitz and Curtiss two-glass drawn-fiber method of production (Figure 1.16), was able, by 1971 onwards, to produce highly robust colonoscopes. These were capable of acute tip angulation without damage to the fibers (a problem with contemporaneous Japanese fiber bundles), and had an innovative “flag-handle” method of controlling four-way angulation (Figure 1.17), although their mechanical construction and torque stability characteristics were somewhat inferior to those of Japanese instruments of the same period. The images obtained by later ACMI instruments were of superior size and without visible breakages, although they were often criticized as being “fuzzy” (Figure 1.18).

The US medical endoscope companies (ACMI and, later on, Welch–Allyn) were too small to sustain the costs of long-term quality improvement, while larger corporations proved uninterested in the medical market, so, by the late 1980s, American colonoscope production ceased. ACMI at least had the satisfaction, on behalf of Hirschowitz and Curtiss, of winning the battle to establish their patent rights on the critical underlying principles for fiberoptic manufacture.

Figure 1.16 The original patent diagram (Curtissand Hirschowitz, filed 1957; registered 1971)—drawing a “two-glass” fiber through an electric furnace.

Figure 1.17 ACMI F9A “flag handle coloscope” (1974) with single lever giving four-way angulation control.

Japanese colonofiberscope development

After introduction of the Olympus GTF gastroscope in 1964, attempts were made to utilize it for colonic examination. However, insertion into the proximal half of the sigmoid colon proved extremely difficult because of the shaft characteristics of the scope and the very limited field of view due to the side-viewing optical system. To adapt to the narrow and tortuous lumen of the colon, modifications were necessary to make the shaft of the colonofiberscope more flexible and to alter the direction of optical view.

Figure 1.18 ACMI colonoscopic view–no visible fiber breakages with the small fibers, but fuzzy.

A prototype forward-viewing “colonofiberscope” was first made by Olympus for Niwa in 1965 [8] (Figure 1.19a and b). Its angle of view was 35°, with fiberoptic illumination, but it was a passive bundle 2 m in length, with no angulation mechanism. Partly because the shaft was too stiff, insertion into the descending colon was very difficult and, when inserting into the proximal sigmoid colon, the tip tended to press into the colonic wall, losing the view. Observation during withdrawal was also difficult because of poor distance illumination. This passive prototype, inserted under fluoroscopic control, therefore proved impractical, although Niwa tried to avoid impaction by attaching a centering balloon at the tip end. The next prototype was a forward-or side-viewing colonofiberscope (Figure 1.20a) which could be made forward- or side-viewing by changing the lens at its tip [23]. However, the image was not good, either in forward view (Figure 1.20b—because of poor illumination) or in side view (Figure 1.20c—due to an inner reflection at the cover glass of the lens). A “rotating prism” colonofiberscope was developed next (