Terminal ileum images for verification of colonoscopy completion

Reading the study by Powell et al. [1] on the use of captured images for verification of completion of colonoscopy, we strongly agree with the use of digital images as a quality indicator for endoscopy. Indeed, while on the one hand suspected incompletion can mean unnecessary repetition of colonoscopy, on the other hand, underestimating the possible error in assessment of completion can lead to missed diagnosis.

First, we wondered why patients with previous colonic resection were excluded from the study. While, as determined in the study, intubation of the cecum can be demonstrated in most cases by captured images, it may be difficult to obtain convincing pictures when the cecal landmarks are absent or distorted, after surgery for instance, or in the presence of several factors associated with incomplete examination [2]. In such cases it would be useful to explore the ileal regions in order to ensure the completion of the examination. In our opinion, in cases where the cecal landmarks are unclear, the capture of terminal ileum images, assisted by water instillation, is just as highly advisable as in the cases where such terminal ileum images are clinically required.

It would be interesting to ask the operators to reassess the images, to find whether they also had doubts about images that were evaluated as unconvincing by the independent assessors.

Cherian & Singh [3] reported an ileoscopy rate of 71.5 %; however, other authors have described terminal ileum intubation as a difficult procedure for inexperienced endoscopists and the reality of routine clinical practice may be different [4]. Nevertheless, the process of intubation of the terminal ileum, even though it may be incomplete, usually provides a convincing view of the valve orifice. Moreover, when landmarks are ill-defined, deflation of the lumen or taking a photograph immediately after extubation of the terminal ileum might allow these features to be captured in the image.

In our practice, in all cases, we take one photo of the cecum just distal to the ileocecal valve, a second is taken of the appendiceal orifice and, when it is possible that these images might be unconvincing, we take one more photo of the valve lips (ileocecal valve orifice), as suggested by Rex [5]. Thus, we can rationalize and standardize the number of pictures needed and the need to intubate the terminal ileum in relation to the appearance of the cecal valve it looks. Moreover, the valve lip images are not considered sufficient if the cecal background is not visible, even if the lips can be seen clearly.

This is because even if indisputably convincing photos are obtained when terminal ileum intubation is performed, an accurate view of the cecal background should always be documented to avoid missing cecal lesions. In this regard, it would be helpful to know whether there is a significant difference between the adenoma identification ratings from colonoscopy with or without ileoscopy.

An excellent result can be achieved, in terms of procedure completion, by deep sedation [6] and we agree with Powell et al. that the sedation dose required is no different when ileal intubation is performed. In fact, when the colonoscope is near the cecal valve, there is no longer any traction on the bowel loops and the instrument can be rotated without patient discomfort.

We would like to know whether there is a correlation between bowel preparation, reliability of the pictures, and time for terminal ileal intubation. In our experience, the leakage of fecal material in the cecum is not always a negative factor. In particular, the leakage of fecal material while the ileocecal orifice is being viewed may be helpful in identifying a ”difficult” valve.

In conclusion, completion of the procedure, accuracy, comfort, and safety are of essential importance in achieving high quality colonoscopy. We agree with Powell et al. that ileal images are more convincing than cecal images, and we strongly recommend the ileoscopy procedure during routine endoscopy. In addition, we believe that when, as in their study, attempts are not unduly prolonged, this procedure can have the benefit of improving basic technique during training sessions.

References

• 1 Powell N, Knight H, Dunn J et al. Images of the terminal ileum are more convincing than cecal images for verifying the extent of colonoscopy.  Endoscopy. 2011;  43 196-201
• 2 Shah H A, Paszat L F, Saskin R et al. Factors associated with incomplete colonoscopy: a population-based study.  Gastroenterology. 2007;  132 2297-2303
• 3 Cherian S, Singh P. Is routine ileoscopy useful? An observational study of procedure times, diagnostic yield, and learning curve.  Am J Gastroenterol. 2004;  99 2324-2329
• 4 Radaelli F, Meucci G, Minoli G.. Italian Association of Hospital Gastroenterologists (AIGO) . Colonoscopy practice in Italy: a prospective survey on behalf of the Italian Association of Hospital Gastroenterologists.  Dig Liver Dis. 2008;  40 897-904
• 5 Rex D K. Still photography versus videotaping for documentation of cecal intubation: a prospective study.  Gastrointest Endosc. 2000;  51 51-459
• 6 Cardin F, Minicuci N, Andreotti A et al. Maximizing the general success of cecal intubation during propofol sedation in a multi-endoscopist academic centre.  BMC Gastroenterol. 2010;  10 123