Spiraling your insertion: a glimpse into the future of colonoscopyReferring to Beyna T et al. p. 518–523
25 April 2018 (online)
It may appear reductive, but it is hard to deny that the most convincing advance in colonoscopy has been the mere recognition that this technique – somewhat similarly to ultrasound – is heavily operator-dependent . This has been mainly because different degrees of operator competence in detecting small, subtle neoplastic lesions have been strictly related to the risk of interval cancer . As detection is confined to the withdrawal phase, most technical innovations have been limited to this phase. Optimizing the withdrawal time and mucosal cleansing, meticulous exploration of the proximal side of the folds, cognitive improvement, and the use of high definition have become the new standard of diagnostic colonoscopy .
“Technological advances such as motorized spiral colonoscopy may give us a glimpse into the future of colonoscopy...”
On the other hand, the importance of the insertion phase has been somewhat downplayed, if not marginalized. Once it was realized that most community endoscopists were able to intubate the cecum in over 90 % of cases , the issue of insertion no longer appeared to be of especial interest. Some attention has been paid sporadically to the possible educational assistance of magnetic imaging  and to the possible contribution of variable-stiffness technologies , but nothing more.
Are we really confident that the current standard of insertion is acceptable? Any expert colonoscopist is well aware that if colonoscopy is operator-dependent, such dependence affects the technique of insertion at least as much as that of withdrawal. The fact that most endoscopists intubate the cecum most of the time does not necessarily indicate that they are all equivalent in colonoscopy technique. The ability of referral centers to successfully complete what were considered to be “difficult” colonoscopies at community centers gives us a first clue about the possible variability among endoscopists regarding insertion techniques . An overview of the literature also reveals substantial variability in insertion times and, notably, such variation has recently been related to detection rates .
Is there a plausible explanation for excessive variability in the insertion technique? When delivering the retraining courses for the organized screening program at our institution, we quickly realized that endoscopists may be broadly divided in two groups. The first group approaches colonoscopy as a continuous exercise of clockwise and anticlockwise rotations in order to gently pleat the colon over the scope, preventing the formation of complex loops. On the other hand, the technique of the second group may be simply described as something that looks like a “push colonoscopy,” and it is characterized by a prolonged battle between the scope that is vigorously pushed against the colon, and the colon that prevents the progression of the scope by generating complex loops. Disappointingly, most endoscopists seem to prefer the second approach.
To pleat or to push, is it really so irrelevant? When patient experience was assessed in a real-life screening program, an unexpectedly large variation among endoscopists was observed with regard to the intra- and post-procedural pain reported by patients . Notably, use of variable-stiffness scopes and of propofol, well known to minimize pain during insertion, were strong predictors of a better patient experience . As patient experience is now considered to be a key quality indicator for colonoscopy , adequate insertion technique should be incorporated into the new standard of modern colonoscopy.
Can we exploit technology to improve the insertion phase of colonoscopy? In this issue of Endoscopy, Beyna et al. describe an innovative approach that extends spiral-assistance technology to colonoscopy, that is, motorized spiral colonoscopy (MSC) . Spiral-assisted endoscopy, as widely described for enteroscopy, is not a new technique. However, it has recently been optimized. The manually rotatable overtube has been abandoned; the spiral has been directly incorporated into the endoscope and coupled with a motorized system able to rotate the spiral. While this prototype was under evaluation for enteroscopy [11, 12], it was tested by Beyna et al. for diagnostic colonoscopy .
In this pilot study on 30 consecutive colonoscopies, we learn that MSC is highly feasible as it was successfully conducted in all patients except one who was affected by an unexpected post-inflammatory stricture. Second, MSC allowed intubation of the cecum in all patients, except the single individual where the procedure was unfeasible. Third, the time to intubate the cecum was only 7 minutes, confirming that pleating rather than pushing represents the quickest way to get to the cecum. Fourth, MSC was scored as extremely easy by the operators in most procedures, and this is noteworthy as insertion technique is not generally perceived as being so simple. Fifth, all the data concerning detection and resection appeared compatible with a standard screening setting, suggesting that no compromise between insertion and withdrawal is required by MSC. This is well explained by the incorporation of MSC into high definition and wide-angle scopes of the highest standard.
Of course, there is a need for more information. For instance, patients were not under conscious sedation, as propofol was used in all cases. Thus, we do not know whether these would have been genuinely painless colonoscopies. Second, no information was provided on the formation of loops; concomitant use of the new device with magnetic imaging may provide an answer. Third, we do not know whether this is a better approach, compared for instance with expert colonoscopy, for difficult procedures such as those in patients with gynecological adhesions or who are post radiotherapy. Fourth, safety is a major issue in screening colonoscopy, and a lack of severe adverse events in a series of only 30 cases is not sufficiently reassuring; larger studies are required. Fifth, we cannot exclude the possibility that MSC may have additional benefits for detection rates. The spiral, in fact, may be useful to flatten the colonic folds, exposing mucosal portions normally hidden by the folds, during withdrawal. Finally, it should also be clarified whether the spiral overtube may play a role in stabilizing the position of the endoscope during withdrawal and, more importantly, during therapeutic procedures.
In conclusion, an unacceptably high variability in patient experience during colonoscopy is related to a large variability among operators in insertion technique. Technological advances such as that presented by Beyna et al.  may give us a glimpse into the future of colonoscopy, where automated systems, such as MSC, will provide a more uniform, and hopefully better standard for screening colonoscopy.
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