Flexible Fiberoptic Sigmoidoscopy Research Articles

Lower Gastrointestinal Endoscopy

Since the advent of the first flexible fiberoptic sigmoidoscope in 1967, lower gastrointestinal endoscopy equipment has technologically advanced and is used for a number of diagnostic and therapeutic procedures. This review covers the definition of and indications for lower endoscopy; diagnostic and screening colonoscopy, bowel preparation for colonoscopy, special considerations for patients on anticoagulants and antiplatelet agents; endocarditis prophylaxis; general technique; diagnostic and therapeutic techniques during colonoscopy, sigmoidoscopy, anoscopy, endoscopic ultrasonography, balloon-assisted colonoscopy, and lower endoscopy training; and innovations on the horizon. Figures show room setup and patient positioning for colonoscopy; technique for insertion of a colonoscope and endoluminal view of rectum, descending colon, transverse colon, and cecum; pinch biopsy and hot biopsy forceps; snare polypectomy and endomucosal resection of a polyp using the lift and cut and suction cap techniques; Haggitt classification of tissue invasion in a pedunculated polyp; endoscopic clips and their application; self-expanding uncovered metal stents and their method of deployment; an anoscope; and rigid endorectal probes for endoscopic ultrasonography. Tables list indications for colonoscopy, recommendations for screening for colorectal cancer (average risk) from the US Preventive Services Task Force, recommendations from the US Multi-Society Task Force for surveillance after baseline colonoscopy in average-risk individuals, recommendations from the US Multi-Society Task Force for screening and surveillance in colorectal cancer (high risk), bowel preparation scales, agents for bowel preparation prior to colonoscopy, and Haggitt classification of tumor invasiveness in an adenomatous polyp. This review contains 10 highly rendered figures, 7 tables, and 60 references.

Guidelines for training non-specialists in screening flexible sigmoidoscopy

Guidelines for training non-specialists in screening flexible sigmoidoscopy

6969 Outcome of rescreening patients referred for open access flexible fiberoptic sigmoidoscopy.

Backround: Open access flexible fiberoptic sigmoidoscopy (FFS) has been in place for one year at Brooke Army Medical Center. This service is available for routine colorectal cancer screening and thus performed on average risk asymptomatic patients. To ensure that these patients are appropriate candidates a health care provider must answer a series of questions to ensure that these patients are at average risk. After these screening questions have been answered, the patient is enrolled into the open access FFS clinic. The patients are not interviewed further and a FFS is completed. Methods: Three hundred and thirty seven patients, who were enrolled in the open access FFS program by the primary care providers, were contacted by telephone and rescreened by a member of the gastroenterology clinic for appropriateness of the FFS.Those who did not meet criteria for screening FFS were referred back to the primary care provider to obtain a full gastroenterology appointment. Results: There were two hundred and eighty three or 83.9% who fulfilled the criteria for screening FFS. The remaining 16.1% were either not average risk for colorectal cancer or needed a total colonic exam rather than a screening flexible sigmoidoscopy. Twentyfour (7.1%) patients had a family history of colon cancer, 15 (4.5%) patients had a personnel history of colonic polyps, 12 (3.6%) patients had recent history of hematochezia, and 3 (.9%) patients had a personnel history of colon cancer. Conclusion: Routine screening FFS is an appropriate screening strategy in approximately 3/4 of patients in an open access FFS program. Further questioning will result in a total colonic exam as being a more appropriate test in about 1/4 of patients. Backround: Open access flexible fiberoptic sigmoidoscopy (FFS) has been in place for one year at Brooke Army Medical Center. This service is available for routine colorectal cancer screening and thus performed on average risk asymptomatic patients. To ensure that these patients are appropriate candidates a health care provider must answer a series of questions to ensure that these patients are at average risk. After these screening questions have been answered, the patient is enrolled into the open access FFS clinic. The patients are not interviewed further and a FFS is completed. Methods: Three hundred and thirty seven patients, who were enrolled in the open access FFS program by the primary care providers, were contacted by telephone and rescreened by a member of the gastroenterology clinic for appropriateness of the FFS.Those who did not meet criteria for screening FFS were referred back to the primary care provider to obtain a full gastroenterology appointment. Results: There were two hundred and eighty three or 83.9% who fulfilled the criteria for screening FFS. The remaining 16.1% were either not average risk for colorectal cancer or needed a total colonic exam rather than a screening flexible sigmoidoscopy. Twentyfour (7.1%) patients had a family history of colon cancer, 15 (4.5%) patients had a personnel history of colonic polyps, 12 (3.6%) patients had recent history of hematochezia, and 3 (.9%) patients had a personnel history of colon cancer. Conclusion: Routine screening FFS is an appropriate screening strategy in approximately 3/4 of patients in an open access FFS program. Further questioning will result in a total colonic exam as being a more appropriate test in about 1/4 of patients.

Correction of deficiencies in flexible fiberoptic sigmoidoscope cleaning and disinfection technique in family practice and internal medicine offices.

To assess whether deficiencies exist in the processing of contaminated flexible fiberoptic sigmoidoscopes in family practice and internal medicine offices and whether training of office personnel results in a correction of identified deficiencies, we conducted a prospective review of sigmoidoscope processing in family practice and internal medicine offices before and after a training course. Participants were questioned on their current endoscope processing for 17 standards before and 2 months after receiving training. The 19 offices had between 4 and 11 deficiencies per office before training, with an average of 6.8 deficiencies per office. After training, deficiencies ranged from 0 to 8, with an average of 0.9 deficiencies per office (P < or = .001; Student t test). Personnel responsible for processing flexible sigmoidoscopes in family practice and internal medicine offices are insufficiently trained for this function. Endoscopes are not being processed according to current standards. After a 2-hour training period, these persons maintain their equipment close to or according to standards.

The yield of flexible fiberoptic sigmoidoscopy in the detection of asymptomatic colorectal neoplasia.

Recent evidence of a reduction in mortality rates from distal colorectal cancers in populations screened by rigid sigmoidoscopy suggests that further benefits may be achieved by the use of fiberoptic sigmoidoscopy as the screening modality. However, there is limited evidence as to the expected yield of neoplasia using the standard 60-cm instrument. The aim of this study was to determine the yield of neoplasia in an asymptomatic population in the at-risk age group undergoing fiberoptic sigmoidoscopy. Recruitment into the screening program was among State Department personnel. In total, 4,216 asymptomatic subjects (50-65 years) were offered flexible sigmoidoscopic screening performed following a simple enema bowel preparation. Those in whom a neoplastic condition was identified underwent further investigation (colonoscopy or barium enema). Of those offered screening 4,005 (95%) underwent the examination. Eleven carcinomas were detected at flexible sigmoidoscopy and two carcinomas were detected at further investigation in subjects with rectosigmoid polyps. The overall detection rate of carcinomas was 3.2 per 1,000 subjects screened. Histologically proven adenomas were detected in 217 subjects, 5.4% of the population screened. In this cohort of individuals flexible sigmoidoscopy appears to have been an acceptable form of screening. The detection rate of neoplasia, particularly colorectal adenomas, is higher than that reported from studies of fecal occult blood screening.

???Screening for Colorectal Cancer by Nurse Endoscopists???

Background Case-control studies have demonstrated that screening by sigmoidoscopy is effective in reducing mortality from colorectal cancer. If nurses performed screening examinations, more patients could be screened and, at current income levels, at a lower cost. Methods Two registered nurses and two licensed practical nurses learned to perform examinations with the flexible fiberoptic sigmoidoscope in order to screen patients for colorectal tumors. They performed 1881 independent examinations of outpatients more than 45 years of age. During the same period, 730 examinations were performed by two gastroenterologists in similar patients. Results The mean depth of insertion of the sigmoidoscope was slightly but significantly greater in the patients examined by the physicians than in those examined by the nurses (48 vs. 46 cm in men, P = 0.003; 41 vs. 38 cm in women, P = 0.002). Adenomas were found in 14 percent of the men and 8 percent of the women examined (P = 0.001). Nine cancers were found in men and f...

Screening for Colorectal Cancer by Nurse Endoscopists

Case-control studies have demonstrated that screening by sigmoidoscopy is effective in reducing mortality from colorectal cancer. If nurses performed screening examinations, more patients could be screened and, at current income levels, at a lower cost. Two registered nurses and two licensed practical nurses learned to perform examinations with the flexible fiberoptic sigmoidoscope in order to screen patients for colorectal tumors. They performed 1881 independent examinations of outpatients more than 45 years of age. During the same period, 730 examinations were performed by two gastroenterologists in similar patients. The mean depth of insertion of the sigmoidoscope was slightly but significantly greater in the patients examined by the physicians than in those examined by the nurses (48 vs. 46 cm in men, P = 0.003; 41 vs. 38 cm in women, P = 0.002). Adenomas were found in 14 percent of the men and 8 percent of the women examined (P = 0.001). Nine cancers were found in men and four in women. There were no significant differences between the nurses and the physicians in the proportion of examinations that were positive for adenomas or cancer. No complications occurred during the initial examinations or during 894 follow-up sigmoidoscopic procedures. Among the patients whose initial examination results were normal, more of those examined by nurses returned for follow-up sigmoidoscopy after 12 months or more (45 percent, vs. 30 percent of those examined by physicians; P = 0.001). Nurses can carry out screening by flexible sigmoidoscopy as accurately and safely as experienced gastroenterologists.

Flexible fiberoptic sigmoidoscopy training for primary care physicians: results of a 5-year experience

The first 5 years of a flexible fiberoptic sigmoidoscopy (FFS) training program for primary care physicians was analyzed in an attempt to assess clinical competence and develop a procedure learning curve. A total of 47 primary care physicians (26 third-year family practice residents, 15 family practitioners, and 6 internists) were successfully trained in 60-cm FFS by five gastroenterologists. Didactic teaching methods included 5 hours of videotapes, slides, endoscopic models, and the use of a photo atlas. Following a patient demonstration, each trainee completed 25 examinations supervised with a teaching attachment. Criteria used to assess trainee competence included unassisted length of scope insertion and examination duration. Mean depth of scope insertion was 35.9 cm for the first five examinations, increasing to a mean of 51.7 cm for the final five examinations. Average examination duration decreased from 19.1 min for examinations 1 through 5 to 17.0 min for examinations 21 through 25. Out of 1236 examinations, one or more polyps were found in 222 patients (18.0%). Carcinoma was found in 15 of 1236 examinations (1.4%). In summary, experienced endoscopists can teach primary care physicians to perform 60-cm FFS. Completion of 25 supervised cases appears to be adequate for achieving technical competence in flexible fiberoptic sigmoidoscopy.

Argon laser treatment of radiation proctitis.

Radiation therapy for malignant gynecologic disease and prostatic cancer has resulted in increased survival and cure rates. This modality has unfortunately produced debilitating radiation proctitis. Recently, five patients were seen with continuous rectal bleeding secondary to radiation disease of the rectum. Four of these patients were women who were being treated for cervical carcinoma and one was a man with prostatic cancer. These patients were refractory to steroid retention enemas, iron therapy, and benproperine enema therapy. Treatment was accomplished using the argon laser with a 300-micron fiber passed via flexible fiberoptic sigmoidoscope. The most proximal areas were treated first. One and a half watts at 0.5 pulses was used. Up to 50 pulses were delivered per therapy session. The fiber was placed in contact with the lesion and circumferentially for 0.5 cm surrounding each suspected area. Bleeding stopped in the four women after two sessions and in the man after four sessions.

Complications of flexible fiberoptic sigmoidoscopy. A conceptual approach.

This paper presents an overview of the potential risks associated with the use of the flexible fiberoptic sigmoidoscope. A reasonable review of the literature on endoscopy reveals few instances of admitted complications. We draw upon a decade of personal observations and experience with over 10,000 examinations to substantiate the actual and potential hazards of flexible fiberoptic sigmoidoscopy. A conceptual approach to recognizing and avoiding the consequences of complications is presented.

Gastrointestinal Kaposi's sarcoma in patients with acquired immunodeficiency syndrome: Endoscopic and autopsy findings

Homosexual men with acquired immunodeficiency syndrome and Kaposi's sarcoma (KS) have been studied to define the extent of gastrointestinal KS. In 50 patients examined by both upper endoscopy and flexible fiberoptic sigmoidoscopy, 20 (40%) had visible lesions consistent with KS. Ten patients (20%) had upper and lower tract involvement, 6 (12%) patients had upper tract involvement alone, and 4 (8%) had lower tract disease alone. Only 23% of endoscopic biopsies of KS lesions were positive for KS. Gastrointestinal KS was not more frequent in patients with nodal KS (41%) than in patients with skin KS (50%). No clinical sequelae of gastrointestinal KS lesions were seen. Mortality was significantly greater in those patients with endoscopic evidence of gastrointestinal KS. Postmortem examination of 13 men with KS and acquired immunodeficiency syndrome revealed abdominal visceral involvement in 10 patients (77%). Antemortem endoscopic findings correlated with subsequent autopsy data in 5 patients. Our findings suggest that visceral involvement, though rarely symptomatic, may be associated with a poorer prognosis.

The Benefits of Systematic Fiberoptic Flexible Sigmoidoscopy

We used the flexible fiberoptic sigmoidoscope (FFS) on 656 subjects who were receiving their yearly physical examinations. Neoplastic disease was disclosed by the FFS in 138 subjects (21%), including 26 adenocarcinomas, 19 of which were out of reach of a rigid sigmoidoscope. Nineteen of the subjects whose adenocarcinomas were found by the FFS had barium enemas, which detected the carcinomas in only 11. Routine FFS in asymptomatic persons is helpful in detecting both premalignant and malignant lesions, it should be seriously considered as a part of regular preventive physical examinations.

Diagnostic Value of Fiberoptic Sigmoidoscopy: Evaluation of the Anatomical Extent

The anatomical level reached by the fully inserted flexible sigmoidoscope (60 cm) determines the effective potential of the instrument in the detection of left colon diseases. We performed flexible fiberoptic sigmoidoscopy (FFS) in 50 patients, without the help of fluoroscopy and without trying to reduce the bendings of the sigmoid colon. After having inserted the instrument, the endoscopist would define the section reached: sigma, sigmoid-descending colon junction, descending colon, splenic flexure. Barium sulphate was then injected through the fiberoptic sigmoidoscope in order to verify the level: the exact anatomical localization of the tip of the instrument was therefore determined by means of fluoroscopy. 90% of the investigations visualized the whole sigmoid colon, and in 52% more than 50% of the descending colon was studied; the splenic flexure was reached in only 22% of cases. Worse results, i.e. the visualization of only the sigmoid colon, were achieved in old and overweight patients, who had previously undergone abdominal or pelvic surgery. The paper concludes underlining the great diagnostic potential of FFS in the screening and early diagnosis of left colon diseases. FFS should become the surgeon’s first instrumental investigation even in his own surgery, as the technique is easy to perform, fairly inexpensive and requires simple preparation.

Flexible fiberoptic sigmoidoscopy in the emergency department

Endoscopic examination of the large bowel is an historically old procedure. It has become an important element in the initial evaluation of colorectal disorders. Recently the flexible fiberoptic sigmoidoscope (FFS) has displaced the rigid scope because of increased patient comfort and compliance and markedly improved accuracy in diagnosing left colon lesions. The FFS is a valuable adjunct to the routine investigation of acute and chronic colorectal complaints seen in the emergency department. It has been endorsed by the American Cancer Society and is an easily learned and safe procedure when taught properly.

The advantages of the 30-cm flexible sigmoidoscope over the 60-cm flexible sigmoidoscope

To determine the optimal length of the flexible fiberoptic sigmoidoscope we performed a randomized, blinded comparison study of the standard 60-cm instrument with a prototype 30-cm instrument with identical design features. Ninety-six male patients referred for symptom evaluation underwent examination with both instruments in random order by different examiners; positive examinations were followed by colonoscopy or surgery. Performance of the 30-cm sigmoidoscope compared with the 60-cm instrument revealed that the former was significantly more likely to yield a complete examination (74 vs. 32 examinations, p less than 0.002), took less time to perform (6.4 vs. 9.8 min, p less than 0.0001), and was more acceptable to patients and physicians. The 30-cm instrument was not significantly less effective than the 60-cm instrument in detecting polyps (21 vs. 25), adenocarcinoma (six for each), and inflammatory lesions. For these reasons, we conclude that the 30-cm flexible sigmoidoscope has a role in the evaluation of colorectal complaints.

Colorectal cancer screening by nurse practitioner using 60-cm flexible fiberoptic sigmoidoscope.

In a routine sigmoidoscopy clinic a specially trained nurse practitioner examined 825 patients between the ages of 23 and 88 with a mean age of 59. Seventy-two patients were found to have polyps; only eight of these patients had a history of rectal bleeding. Seventy-nine percent of these polyps were above 25 cm or beyond the reach of the rigid scope. Three patients with polyps were found to have cancer in the polyp. None of these patients had noted rectal bleeding. Significantly, there was a 10.6% yield of positive pathology among patients 50 and over. The training of the nurse practitioner is described in the article.

Flexible fiberoptic sigmoidoscopy in the practice of a surgeon

The extent to which surgeons participate in surveillance programs depends on their clinical interests, referral patterns, and the needs of the community. The design of surveillance programs, including designation of normal and high risk individuals, and the type and frequency of screening examinations has been studied. The patient's history guides the surgeon in deciding whether and how to implement a surveillance program for a given patient. Sixty-centimeter FFS is clearly superior to 25-cm rigid sigmoidoscopy in screening for rectosigmoid and sigmoid neoplasia. 1-4. 6 The average viewing distance of the rigid sigmoidoscope is less than 20 cm/ whereas in FFS it consistently reaches 40 to 50 cm. The reported diagnostic yield of asymptomatic polyps and cancers is 1.7 to 3 times as great. 4 FFS in sigmoid diverticular disease is very accurate in confirming or ruling out questionable sigmoid lesions noted on barium enema. Some of the logistic and practical deficiencies of FFS include the increased initial expense and maintenance costs, the longer examination and cleaning time, the greater degree of endoscopic skill necessary to use it effectively, and the inadequate cost-effectiveness in small practice settings. Two compelling arguments for FFS screening not often acknowledged are the more dignified examination position, left lateral decubitus rather than knee-chest or jack-knife, and the greater degree of comfort. The value of FFS for neoplasia surveillance is limited. FFS is not a substitute for complete visualization of the colon by colonoscopy or barium contrast enema. The depth of insertion of the FFS is a function of several variables, including endoscopic skill, instrument design, bowel preparation, and the patient's anatomy and cooperation. At what depth another 5cm tube insertion will yield an important increase in percent of lesions detected, or obviate the need for total colonoscopy or barium enema has not been determined. The point of diminishing returns in cancer screening with FFS has yet to be determined. At that point, patient enthusiam or compliance with follow-up examinations may fall off, and the long term effectiveness of a surveillance program is threatened.

Clinical accuracy in the diagnosis of small polyps using the flexible fiberoptic sigmoidoscope.

Seventy-eight patients referred to a specialist clinic for investigation of large-bowel symptoms were examined with the flexible fiberoptic sigmoidoscope. One hundred twenty polyps were treated, including 84 adenomatous and 32 hyperplastic polyps. Sixty-nine per cent of polyps were situated beyond 18 cm from the anal verge. Endoscopic diagnosis was correct in 82 per cent of cases. The size of the polyp assessed endoscopically strongly influenced the clinical diagnosis but proved unreliable as a means of making an accurate diagnosis. Results indicate that whenever possible all polyps of all sizes should be removed for microscopic examination.

A new technique of hand reversal using a harness-type endoscope holder for twin-knob colonoscopy and flexible fiberoptic sigmoidoscopy.

A new technique of hand reversal using a harness-type endoscope holder for twin-knob colonoscopy and flexible fiberoptic sigmoidoscopy.

Screening for colorectal neoplasia in asymptomatic patients using flexible fiberoptic sigmoidoscopy

Four hundred seventeen asymptomatic patients with an average age of 52 years underwent screening flexible fiberoptic sigmoidoscopy. Seventy-three polyps were detected in 52 patients with a 17.5 per cent detection rate. Half were above 25 cm and one-third were greater than 1.0 cm in size. Biannual follow-up of these patients is planned to determine the efficacy of this screening procedure combined with removal of all polyps in preventing the development of colorectal cancer.