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11 Fundamentals ofDrain Management
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159
Wound edge
Skin
Subcutaneous
fat
Muscle
Fig. 11.12 (a) Unprotected wound. (b) Wound containing indwelling sponge with overlying lm and “lily pad” con-
nected to V.A.C.
®
(KCI—An Acelity Company, San Antonio, TX) therapy canister
ba
Adhesive
film
“Lily pad”
Suction tubing
Foam
a
de
Fig. 11.13 Wound V.A.C.® application. (a) Sponge cut to
appropriate size. (b) Sponge placed into wound.
(c) Adhesive lm applied over sponge and surrounding
the skin, forming an occlusive dressing. (d) Dime-sized
11.5.2.2 Applying theWound VAC
In applying the wound VAC (Fig.11.13), a piece
of foam is cut to a size that is slightly smaller than
the wound itself and laid within the wound bed.
defect created in the lm directly overlying the foam.
(e) “Lily pad” applied over defect and connected to
®
V.A.C.
machine
An occlusive lm is then applied to cover the
entire wound. A small dime-sized defect is created in the lm directly overlying the foam, and
the tubing is connected to this defect via an occlu-
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sive “lily pad” adapter. The tubing is then hooked
to the vacuum device, and negative pressure is
applied to the desired level of suction ranging
from −25 to −200mmHg. Generally, this dressing is changed every 2–3 days. Theoretically, with
each dressing change, the wound bed heals and
shrinks in size as it is gradually replaced by granulation tissue. The VAC is continued until the
wound can either be left unprotected or skin
grafted depending on size and depth.
11.5.2.3 Precautionary Measures
forApplying theWound VAC
With the traditional VAC, care must be taken to
ensure that the surface of the indwelling sponge
only comes into contact with subepidermal tissue,
as any contact directly onto the epidermis has
potential to cause skin necrosis with the application of suction. In general, the typical foam dressing should not be applied directly onto the nerves,
blood vessels, or viscera (with the exception of
open abdomen VACs—see Chap. 20) [7]. Ideally,
only one single piece of sponge is laid into the
wound to minimize the risk of inadvertently leaving sponge within the wound. If multiple pieces of
sponge are required, they should be counted and
documented with each VAC change. Finally, care
should be taken to avoid placing the lily pad on
weight-bearing areas of the body, as this can lead
to pressure ulcers. In such instances, as in the care
of sacral decubitus ulcers, for example, creation of
a “skin bridge” is generally recommended to
extend a foam bridge away from the wound. Foam
is placed onto the healthy skin that is covered by
occlusive dressing, and the lily pad is placed at the
end of this “bridge” on a non-weight-bearing area.
11.5.2.4 Other Applications
There are many variations in the design and
applications of the original wound VAC.A number of different types of foams exist, with differences in composition, porosity, and antimicrobial
properties. These developments have enabled the
application of negative-pressure wound therapy
to extend far beyond nonhealing or large postoperative wounds. The incisional VAC allows for
atraumatic foam to be applied directly onto incisions. Recent data suggest that incisional VACs
G. S. Chevrollier et al.
Take-Home Points
• The surgical trainee must become familiar with the various types, indications,
and appropriate placement of surgical
drains.
• The French scale is generally used to
measure catheters and tubes and has a
direct relationship to drain size, while
the gauge system is generally used to
measure hypodermic needles and has an
inverse relationship to size.
• The four common classes of drains are
open drains, closed drains, closed drains
with suction, and sump drains with and
without irrigation.
• Chest tube thoracostomy is an essential
skill that must be familiar to all surgical
trainees, and understanding how chest
tube drainage works is critical to proper
management of the chest tube.
• Negative-pressure wound therapy is a
rapidly advancing technology that is
quickly expanding in terms of its application; however, despite its many theoretical advantages over standard wound
therapy, more prospective studies are
needed to truly elucidate its benets in
various patient populations.
• When postoperative bleeding is suspected on clinical grounds, remember
that drain output can be very unreliable
as drains can clot and fail to evacuate
accumulated blood.
can decrease the rate of wound infections in certain high-risk wounds [8]. Another new development is the open abdomen (OA) VAC to provide
temporary abdominal wall closure. This type of
abdominal wall closure is discussed in further
detail in Chap. 20.
Suggested Reading
Meyerson JM. A brief history of two common surgical
drains. Ann Plast Surg. 2016;77(1):4–5.
11 Fundamentals ofDrain Management
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161
Urbach DR, Kennedy ED, Cohen MM. Colon and rec-
tal anastomoses do not require routine drainage:
a systematic review and meta-analysis. Ann Surg.
1999;229(2):174.
Mowery NT, et al. Practice management guidelines for
management of hemothorax and occult pneumothorax. J Trauma Acute Care Surg. 2011;70(2):510–8.
Dumville JC, etal. Negative pressure wound therapy for
treating surgical wounds healing by secondary intention. Cochrane Database Syst Rev. 2015;6:CD011278.
References
1. Edwards BL, etal. Use of prophylactic postoperative
antibiotics during surgical drain presence following
mastectomy. Ann Surg Oncol. 2014;21(10):3249–55.
2. Meyerson JM.A brief history of two common surgical drains. Ann Plast Surg. 2016;77(1):4–5.
3. Iserson KV. J.-F.-B. Charriere: the man behind the
“French” gauge. J Emerg Med. 1987;5(6):545–8.
4. Ahn W, Bahk J-H, Lim Y-J.The “gauge” system for
the medical use. Anesth Analg. 2002;95(4):1125.
5. Urbach DR, Kennedy ED, Cohen MM. Colon and
rectal anastomoses do not require routine drainage:
a systematic review and meta-analysis. Ann Surg.
1999;229(2):174.
6. Mowery NT, etal. Practice management guidelines
for management of hemothorax and occult pneumothorax. J Trauma Acute Care Surg. 2011;70(2):510–8.
7. Dumville JC, et al. Negative pressure wound therapy for treating surgical wounds healing by secondary intention. Cochrane Database Syst Rev.
2015;6:CD011278.
8. Acelity. KCI.An Acelity company negative pressure
wound therapy technology. 2017.
com/products/tech/vac
9. Acosta S, Björck M, Wanhainen A.Negative-pressure
wound therapy for prevention and treatment of
surgical- site infections after vascular surgery. Br J
Surg. 2016;104(2):e75–84.
10. Kantak NA, Mistry R, Halvorson EG. A review of
negative-pressure wound therapy in the management
of burn wounds. Burns. 2016;42(8):1623–33.
11. Hasan MY, Teo R, Nather A. Negative-pressure
wound therapy for management of diabetic foot
wounds: a review of the mechanism of action, clinical
applications, and recent developments. Diabetic Foot
Ankle. 2015;6(1):27618.
. Accessed 22 June 2017.
http://www.acelity.
Fundamentals ofFlexible
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Endoscopy forGeneral Surgeons
RobertD.Fanelli
12
12.1 Introduction
Modern exible endoscopes are marvels of medical science. Thin, highly exible tubular devices
illuminated with powerful light sources, with
channels for irrigation, suction, and lens clearance, which permit tissue sampling, injection of
substances, and the introduction of adjunctive
devices like clips and stents, have dramatically
altered the landscape of surgical practice since
their widespread introduction. The introduction
of new, less invasive procedures, those done
endoscopically instead of surgically, changed
surgical practice forever. From the time that
Ponsky introduced percutaneous endoscopic gastrostomy (PEG) [1], McCune described endoscopic retrograde cholangiopancreatography
(ERCP) [2], Sugawa used a exible endoscope to
accurately identify the source of upper GI bleeding during laparotomy [3], and Youmans Jr. used
a exible endoscope to treat upper GI bleeding
[4], surgeons without endoscopic skills suddenly
became ill prepared for the future of general
surgery.
R. D. Fanelli
Department of Surgery, The Guthrie Clinic,
Sayre, PA, USA
The Geisinger Commonwealth School of Medicine,
Scranton, PA, USA
Albany Medical College, Albany, NY, USA
Once a set of tools improved the diagnostic
yield and target localization for lesions like intestinal tract cancers and sites of GI bleeding, there
has been a continual explosion in endoscopic
practice since the advent of therapeutic endoscopy, and endoscopy has emerged as a mainstay
of clinical practice. During the 1970s and 1980s,
while many general surgeons focused on traditional surgical developments and their busy operative practices, others continued the quest for
increasingly less invasive methods for the diagnosis and treatment of common problems, as
demonstrated in Table12.1. GI bleeding, intestinal polyps, and common bile duct stones became
the targets of these advancements, among other
things, and before long surgeons found that endoscopic methods of treatment had changed the
Table 12.1 The history of endoscopy is an important
part of our rich surgical heritage
Which were developed by surgeons? All of these major
endoscopic innovations were:
Colonoscopy Turell
Endoscopic control of hemorrhage Gaisford,
Polypectomy Shinya, Wolf
Endoscopic retrograde
cholangiopancreatography (ERCP)
Variceal band ligation Steigman
Percutaneous endoscopic
gastrostomy (PEG)
Biliary stenting Sohendra
Sugawa
McCune, Shorb
Ponsky,
Gauderer
© Springer International Publishing AG, part of Springer Nature 2018
F. Palazzo (ed.), Fundamentals of General Surgery, https://doi.org/10.1007/978-3-319-75656-1_12
163
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R. D. Fanelli
landscape of surgical practice. Continued development in the eld of exible endoscopy has
pushed boundaries of treatment beyond the operating room, and other specialists have claimed
this tool and the set of procedures developed
around it as their own, in an attempt to exclude
surgeons from practicing this art for the benet of
their patients. The exible GI endoscope, however, owes its development to surgery and remains
well entrenched in our discipline.
12.2 General Concepts
It isn’t possible to provide anything but an introduction to a broad eld like surgical endoscopy,
which includes numerous primary and adjunctive
procedures, through a chapter in a textbook.
Whole texts have been devoted to each of the exible endoscopy procedures commonly employed
in practice, and the reader interested in more than
the fundamental viewpoints presented herein is
advised to seek additional information from the
recommended reading list, below, and other
sources. Acquisition of endoscopic skills requires
direct clinical exposure, an immersion experience, and use of a validated tool to assess competence after training has been conferred by an
expert endoscopist [5]. This is the role of the
Flexible Endoscopy Curriculum developed by the
American Board of Surgery, Inc. (ABS), to guide
the acquisition of skills in this set of techniques
central to the past, present, and future of surgery.
Assessment requires the measurement of accomplishment against a validated yardstick, and surgeons are fortunate to have access to assessment
through the Fundamentals of Endoscopic Surgery
program and testing modules, produced by the
Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES), the rst such
program ever created for the objective assessment
of endoscopy skills regardless of specialty [6].
This program removes economic bias from
assessment and credentialing determinations and
promotes a patient-rst approach by ensuring that
standards of training and achievement are met [7].
The inclusion of exible GI endoscopy within
surgical practice improves the performance and
outcomes of gastrointestinal surgery. At its very
basic level, the endoscope is a tool that, when
used to provide inspection at the conclusion of an
operation involving GI tract reconstruction or
anastomosis, conrms for patients and surgeons
that the intended goals of surgery have been
safely accomplished. At the very least, all surgeons who operate on the GI tract should have
great facility with the use of endoscopes to leak
test anastomoses, inspect mucosal surfaces for
ischemia, and gauge the appropriateness of
reconstructive procedures, like Nissen fundoplication, or the completeness of dissections important to optimal outcomes, like during esophageal
myotomy for achalasia. Intraoperative endoscopy
has become a critically important part of GI surgery [8]. Without robust experience with these
basic endoscopic approaches, surgeons will not
be positioned to move forward with progressive
therapies, like peroral endoscopic myotomy
(POEM), peroral pyloromyotomy (POP), or
endoscopic mucosal resection (EMR), for example, or other procedures that rely on the exible
endoscopy platform.
Rural surgeons have long found that surgical
endoscopy is an important part of their practices
as they often provide patients with screening,
diagnostic, and therapeutic services that otherwise would not be available in their communities.
A 2005 publication revealed that rural surgeons
were observed to have performed more endoscopic procedures than operative procedures,
important to their communities and practices, and
that these skills in exible GI endoscopy are an
essential component to general surgery practice
in rural regions of the United States [9]. The
results of this same publication, summarized in
Table 12.2, demonstrated also that while rural
surgeons performed more endoscopy than their
urban colleagues, the number of exible GI
endoscopy procedures performed by urban surgeons was substantial as well and concluded that
endoscopy remains an important tool for surgical
patient care in all situations. Regardless of
practice setting, surgeons are encouraged to
maintain their endoscopy skills and incorporate
these skills into practice for the benet of their
patients and communities.
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165
Table 12.2 Comparison of cases reported by urban and
rural general surgeons applying for ABS recertication
Rural Urban p Value
General 211 305 <0.0001
Endoscopy 220 77 <0.0001
Gynecology 18 5 <0.0001
Obstetrics 6 1 0.0003
Laparoscopic 94 119 0.016
n=421 n=114
Adapted from Heneghan etal. [
9]
At the time of this writing, great uncertainty
exists about future policies that will be central to
the American healthcare system. Regardless of
which plan emerges as the framework that will
guide how we care for patients in this country
going forward, putting exible GI endoscopes in
the hands of surgeons makes sense economically.
Evaluations of the healthcare labor force suggest
that combining the capabilities of specialists, and
tearing down traditional silos of care, may be
more efcient and may improve the quality and
expedience of care [10]. Surgeons who combine
their extensive knowledge and experience in the
treatment of conditions and symptoms like gastroesophageal reux disease, gastrointestinal
hemorrhage, GI malignancy, and dysphagia and
abdominal pain, as some examples, are likely to
provide a more economically efcient approach
to the care of these patients when involved early,
as they have the broadest array of diagnostic and
therapeutic capability available to be deployed
for the benet of the patient. By eliminating
delays and costly but not always additive consultations with other specialists, the surgeon is able
to swiftly assemble an evaluation that benets the
patient in a cost-efcient manner.
While there is no question that incorporating
exible GI endoscopy into surgical practice
serves the needs of our patients today, it will be
an increasingly important set of skills for future
generations of surgeons. Numerous surgical procedures that already have been replaced by endoscopic approaches are listed in Table 12.3. The
exible endoscope has emerged as an exciting
platform upon which future minimally invasive
surgical procedures will be based. Consider the
positive impact of effective colonoscopic screen-
Table 12.3
endoscopic approaches (partial list)
Esophagus Foreign body removal
Stomach Hemorrhage management
Pancreaticobiliary Management of
Colon Polypectomy
Surgical procedures already replaced by
Stricture management
Palliation of malignancy
Variceal hemorrhage management
Achalasia
GERD (early)
Barrett esophagus
Pyloric obstruction
Gastroparesis
Foreign body management
Enteral feeding access
Obesity (early)
choledocholithiasis
Biliary stricture management
Periampullary neoplasm (benign)
Complicated pancreatitis,
walled-off pancreatic necrosis
Pseudocyst drainage
Intestinal hemorrhage
Colonic stricture
Acute colonic obstruction
Management of hemorrhoid
disease
ing and endoscopic ablation for patients with
Barrett esophagus, for example, and the use of
EMR or endoscopic submucosal dissection
(ESD) for those with early rectal or esophageal
cancer. Traditional surgical approaches will continue to be less commonly necessary, and less
invasive therapies based on the exible GI endoscopy platform will emerge as new standards in
our approach to many patients. Surgeons who do
not develop and maintain their skills in surgical
endoscopy will miss the opportunity to participate in the next epoch of our specialty.
Another important example an evolution that
surgeons must participate in is the burgeoning
eld of bariatric endoscopy. While there are few
at present who would argue that any of the currently available endoscopic therapies for obesity
compare with the effectiveness of gastric bypass
and sleeve gastrectomy, new technical developments, combinations of pharmacologic and
endoscopic approaches, and therapeutic
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R. D. Fanelli
improvements will develop, and there is great
likelihood that an endoscopic treatment model
will emerge that serves the needs of many
patients well [11]. In order for surgeons to
remain relevant to their patients in all areas of
our specialty, we must embrace the exible
endoscopy platform and apply its principles liberally in preparation for a future that incorporates these techniques in ways we might not even
imagine presently.
12.3 Practical Considerations
Unless a surgeon in training sets out to master
exible GI endoscopy, and pursues specialized
training opportunities, it is unlikely that she is
going to acquire the skills necessary to offer full
spectrum diagnostic and therapeutic endoscopy
to her community of patients. However, the
incorporation of exible GI endoscopy into surgical practice should not be seen as an all or none
proposition. It is completely reasonable that a
foregut surgeon or bariatric surgeon will develop
expertise in upper endoscopy, as the minimum,
and offer those services to patients to address
preoperative, intraoperative, and postoperative
concerns and forego the dedicated additional
training that would be required to add ERCP to
their practice. Similarly, a colorectal surgeon
would be expected to develop and maintain
expertise in colonoscopy as a minimum, although
given the signicant plasticity seen in specialty
practices, maintaining skills in upper GI endoscopy may be warranted [12]. Although I support
the notion that surgical endoscopists develop a
broad range of skills and recognized expertise in
as many endoscopic procedures as possible, we
all tailor our skill sets to the needs of our communities, to our clinical interests, and to the particular circumstances of our careers. Surgeons
are encouraged to begin broadly and acquire the
wide-ranging set of endoscopic skills that will
support them in offering patients an optimal
choice of procedures and superb clinical outcomes, but if that is not possible, or not feasible
given one’s area of subspecialization, then maintaining expertise in the endoscopic procedures
central to their eld of practice is what will serve
patients best.
There is no question that the best time for surgeons to learn to perform exible GI endoscopy
procedures is within the structured learning environment of their residency and fellowship training. This is why SAGES and the ABS have taken
such measures as developing FEC and FES programs that seek to increase the endoscopic competence of our surgical workforce going forward
in order to maximally benet patients. Surgeons
who did not learn endoscopy during their training
must make special efforts to attain this knowledge and skill and gain clinical experience. The
pursuit of fellowship opportunities is available to
surgeons able to take time away from their practice, and individualized programs of instruction
and assessment are possible as well but vary from
locale to locale. Mentorship is a hallmark of the
surgical community, and surgeons interested in
further training and ongoing education aimed at
achieving mastery of new skills are advised to
seek out mentorship arrangements that will work
best in their individual environments.
12.4 Specic Procedures
Although it would be an impossible task to discuss in detail each of the basic and advanced
endoscopic techniques that are incorporated into
a full spectrum surgical endoscopy practice that
might include expertise in EGD, enteroscopy,
ERCP, EUS, and colonoscopy and their adjuncts
as its mainstays, for most surgeons, the fundamental procedures that will be employed are
EGD and colonoscopy. These will be detailed
below.
12.4.1 Esophagogastroduodenoscopy
(EGD)
EGD provides for detailed inspection of the
mucosal surfaces of the esophagus, stomach, and
early duodenum. This study is indicated for the
evaluation of symptoms that persist despite
conservative treatment, alarm symptoms such as
12 Fundamentals ofFlexible Endoscopy forGeneral Surgeons
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dysphagia and odynophagia, and surveillance of
treated malignancy or premalignant conditions or
in lieu of radiographic or other evaluation where
the therapeutic advantage of endoscopy adds
value [13].
Consent for EGD is based on a discussion of
the potential risks associated with the procedures,
the potential benets to be gained, and the alternatives for investigation or treatment that might
be used instead. Patients are selected according
to local standards of the unit where EGD will be
performed, but general health and airway assessments are important to the appropriate selection
and treatment of patients. Nasal oxygen, complete cardiac, oximetry, and, increasingly, capnographic monitoring are utilized, and intravenous
access is established for the administration of
both uids and sedative agents and rescue medications when needed.
Equipment is selected and tested prior to any
endoscopic procedure, and in particular, the
planned procedure is central to these selections.
Each endoscope has at least one working channel
through which endoscopic tools are deployed,
and it is important that the endoscopist ensures
Fig. 12.1 The head of the endoscope is held in the left
hand, index nger poised to insufate, suction, or cleanse
the lens. Proper balance is important to ergonomic
function
that the selected endoscope will accept the tools
necessary for the planned procedure (Fig.12.1).
Once the equipment has been selected and tested,
an appropriate pre-procedure safety check completed, and the patient sedated either by the
endoscopist or an anesthesiologist, the procedure
may begin.
The endoscope is advanced under direct vision
at all times, and carbon dioxide insufation, preferred over room air insufation because of its
with advancement into the distal stomach, but
this can be accomplished more easily if the
endoscopist rotates themselves slightly toward
their right to face toward the head of the patient,
so that the endoscope advances along the greater
curvature of the stomach. This maneuver aligns
the scope with the pylorus, and after inspection,
the pylorus then is intubated to examine the
duodenum.
more rapid absorption that results in improved
patient comfort, is used to distend the lumen of
the organ being inspected in order to provide the
best view possible and aid in complete inspection
of the mucosal surfaces. As the endoscope is
advanced over the base of the tongue, it is passed
into the proximal esophagus and directed into the
center of the lumen as it is advanced distally
(Fig.12.2). Mucosal surfaces are inspected along
the way, noting pathology and securing samples
for biopsy as needed. The endoscope is then
advanced into the stomach and advanced toward
the pylorus. Novice endoscopists often struggle
torque on the shaft of the endoscope is effective
in exposing mucosal surfaces to the left and right
of center, for inspection. As the endoscope is
advanced through the duodenal bulb, the direc-
tional wheels of the endoscope become more
important. As the endoscope advances toward the
second portion of the duodenum, the endoscopist
once again takes an oblique step forward with the
left foot, rotates her body toward her right, and
rotates the large directional wheel counterclock-
wise and the small directional wheel clockwise,
delivering the tip of the endoscope into the
167
Throughout most of an upper endoscopy,
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abc
de f
ghi
R. D. Fanelli
Fig. 12.2 (a) The vocal cords are seen superior to the
esophageal introitus (red arrow), where the endoscope
will be introduced. (b) The esophageal introitus yields to
gentle insertion and insufation as the gastroscope is
advanced. (c) The body of the esophagus is inspected and
observed, noting mucosal abnormalities, altered peristalsis, and other abnormalities. Note that the gastroscope
remains centered in the lumen. (d) The esophagogastric
junction is inspected for erosions, metaplasia, gaping, and
other abnormalities using white light. (e) The esophagogastric junction is inspected for metaplasia and other
descending duodenum. This is the deepest extent
of insertion in the average procedure, and the
careful observation of mucosal surfaces continues during slow withdrawal of the endoscope,
and samples for biopsy are obtained as needed
using a biopsy forceps designed for the endoscope in use. Care should be taken to inspect for
pathology, obtain tissue samples that will be
helpful in diagnosis, and observe all important
anatomic structures, like the major papilla, seen
more easily on the medial duodenal wall if the
abnormalities using narrow bandwidth illumination. (f)
After advancement along the greater curvature, the pylo-
rus is inspected from the antrum. (g) The duodenal bulb is
evaluated after gentle advancement of the gastroscope
through the pylorus. (h) The descending duodenum is
inspected after advancement of the gastroscope. Note the
biliary ampulla on the medial wall (red arrow). (i)
Retroexed view of the esophagogastric junction demon-
strates the gastroscope entering the stomach in the region
of the hiatus. Note the small hiatus hernia (red arrow)
shaft of the endoscope is slightly rotated clock-
wise during withdrawal. Great care should be
taken to avoid taking biopsies from the medial
wall in order to avoid inadvertent biopsy of the
major or minor papillae.
The endoscopist should develop a systematic
approach to mucosal inspection, so that there is
great consistency in the quality of examination.
Once the duodenal inspection has been completed, retroexion is accomplished by rotating
the large directional wheel counterclockwise
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169
while laying the head of the endoscope over
toward the left and withdrawing the endoscope
shaft back toward the hiatus. This position permits inspection for and measurement of a hiatus
hernia, and careful inspection will most often
permit delineation between sliding and paraesophageal hernias.
Once anteexed, the now forward facing
endoscope is used to decompress the stomach of
excess insufation, and the esophagogastric junction is inspected once again. Narrow bandwidth
illumination, present in high-denition endoscopes, shifts the spectrum of light emitted and is
useful in identifying mucosal changes associated
with Barrett esophagus. The esophagus is thoroughly inspected, and as the endoscope is withdrawn, once the pharynx is cleared, the suction
button on the endoscope should be kept depressed
until some uid is suctioned through the channel
and the gastroscope safely laid on a back table for
reprocessing. This simple maneuver keeps uids
from dripping on the patient and staff, and onto
the shoes of the endoscopist, while the endoscope
is transitioned from bedside to back table.
Photo documentation is an important part of
each endoscopic procedure, and it is generally
accepted that capturing images of (1) the esophagogastric junction using white light and narrow
bandwidth illumination, if available, (2) the retroexed view of the gastric cardia and hiatus, (3)
the forward view facing the pylorus, and (4) the
duodenal bulb and (5) descending duodenum are
a reasonable standard to achieve in most, if not
all, upper endoscopy procedures.
12.4.2 Colonoscopy
Colonoscopy provides for detailed inspection of
the mucosal surfaces of the colon, and as often as
technically feasible, the terminal ileum. This
study is indicated for the evaluation of symptoms
that persist despite conservative treatment, alarm
symptoms such as bleeding, and surveillance of
treated malignancy or premalignant conditions
and, most commonly, for screening for polyps
and colorectal cancer where the combined diagnostic and therapeutic capabilities of colonos-
copy hold advantage over other screening
methods.
One measure necessary to perform colonoscopy that is not required for EGD is bowel preparation. Although there are numerous commercial
bowel preparations available, they can be sorted
into two general categories; high-volume lavage
preparations and split-dose preparations. The latter are generally better tolerated and are more
effective in cleansing the colon, but the former
are less expensive and more likely to have lower
patient copay levels. It is recommended that surgeons performing colonoscopy emphasize to
patients the critical importance of a complete
bowel preparation. Without adequate preparation
in advance of colonoscopy, achieving near complete mucosal inspection will not be possible, and
the risk of a missed lesion is increased.
Consent for colonoscopy is based on a discussion of the potential risks associated with the procedure and its adjunctive measures, the potential
benets to be gained, and the alternatives for
investigation or treatment that might be used
instead. Patients are selected according to local
standards of the unit where colonoscopy will be
performed, but general health and airway assessments are important to the appropriate selection
and treatment of patients. Nasal oxygen, complete cardiac, oximetry, and, increasingly, capnographic monitoring are utilized, and intravenous
access is established for the administration of
both uids and sedative agents and rescue medications when needed.
Equipment is selected and tested prior to any
endoscopic procedure, and in particular, the
planned procedure is central to these selections.
Each colonoscope has one working channel
through which endoscopic tools are deployed,
and it is important that the endoscopist ensure
that the selected colonoscope will accept the
tools necessary for the planned procedure, and
that the tools that might be needed are of a length
sufcient to match that required for use through a
colonoscope. Once the equipment has been
selected and tested, an appropriate pre-procedure
safety check completed and all monitoring
devices have been attached and baseline measurements recorded, the patient then is asked to
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