Achieving cecal intubation in the very difficult colon.

Cecal intubation is defined as insertion of the colonoscope tip into the cecal caput so that the medial wall of the cecum proximal to the ileocecal valve can be fully inspected. Although colonoscopists outside the United States sometimes undertake colonoscopy without intending to intubate the cecum, the intent to achieve full cecal intubation or reaching an ileocolonic anastomosis is the norm in the United States. The U.S. Multisociety Task Force on Colorectal Cancer and a combined task force of the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology have made recommendations on quality indicators for the technical performance of colonoscopy. Targets for successful cecal intubation rates are 90% for all colonoscopies and 95% for screening colonoscopies. Patients with procedures aborted for poor preparation, severe colitis, or when the intention of the procedure is to treat a known lesion distal to the cecum (and the cecum has been previously intubated) need not be counted in the denominator when cecal intubation rates are calculated. The recommended rates for cecal intubation are based on published experience from both academic and community colonoscopists. That the recommended rates are not 100% obviously reflects that complete colonoscopy either is not or may not be possible in every patient. However, maximizing cecal intubation rates results in positive outcomes. Patients with incomplete colonoscopy incur the cost, risk, and inconvenience of other procedures, usually barium enema or CT colonography, to complete the colorectal examination. If radiographic studies show lesions proximal to the extent of incomplete colonoscopy, another attempt at colonoscopy may be needed. Such patients may severely test the skills of even the most experienced colonoscopists. This review discusses an approach to patients with technically difficult colons, with a goal of guiding experienced colonoscopists to techniques and equipment that allow successful intubation in even the most difficult cases.