quently solves the problem. If an impossible situationis encountered, early termination is safer for the pa­tient and less stressful for the endoscopist and hisequipment.

For the endoscopist, the reward of a completelysuccessful colonoscopy in a difficult case is an exhil­arating sense of personal and professional pride. Ifone uses all known methods along with fluoroscopiccontrol and still fails, the reward is that sense ofsatisfaction that comes in knowing "it simply cannotbe done" and referral to another colonoscopist wouldbe fruitless. After a failed colonoscopy without fluo­roscopic study, the endoscopist is haunted by theuncertain reason for failure. After a failed colonoscopywhich has been studied fluoroscopically, the endoscop­ist can recommend an alternative method with confi­dence. Last but not least, the endoscopist who uses allavailable techniques will know he has done exactlywhat his patient expected, his very best.

B. H. Gerald Rogers, MDGastrointestinal Laboratory

Ravenswood HospitalChicago, Illinois

University of ChicagoPritzker School of Medicine

Chicago, Illinois

REFERENCES1. Tabibian N, Michaletz PA, Schwartz JT, et al. Use of an

endoscopically placed clip can avoid diagnostic errors in colon­oscopy. Gastrointest Endosc 1988;34:262-4.

2. Bat L, Williams CB. Usefulness of pediatric colonoscopes inadult colonoscopy. Gastrointest Endosc 1989;35:333-5.

Colonoscopy without fluoroscopy

Historically, fluoroscopy was necessary when colon­oscopy was in its infancy, since there were no otheridentifying factors by which endoscopists could locatethe tip of the endoscope in the colon. Since that time,there have been multiple articles and descriptions ofintracolonic landmarks so that, for the most part,endoscopists have a fairly good idea of tip locationduring colonoscopy. No one feels that the intraluminalmarkings are absolute, since there are only two fixedlandmarks in the colon, the cecum and the rectum.However, knowledge of endoscopic anatomy permitsmost colonoscopists to estimate, with a fair degree ofaccuracy, their position in the colon. The relativelystraight and tubular segment reached after a tortuouspassage through a zig zag sigmoid is usually the de­scending colon. The splenic flexure, with its dependentfluid pool as the patient lies in the left lateral position,is located just before entry into the transverse colon,identified by its triangular luminal appearance, andthe hepatic flexure's sharply defined blue hue is a

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valuable identifying landmark. However, it is the flattened fold of the superior labia or the notched lip cthe ileocecal valve that gives an absolute indicatiOlthat the cecum has been reached, and the round hoIof the appendiceal orifice or its crescentic configuration confirms entry into the cecal pole.

That fluoroscopy is not necessary in passage of thlcolonoscope to the cecum is well known. Many of thlphysicians who originally thought that fluoroscop~

was an "absolute must" for colonoscopy have aban·doned its use in routine circumstances. In 1968, aftelthe first four passages of the colonoscope with fluo­roscopy, I realized that x-ray imaging was an unnec­essary burden for colonoscopy, and have developedmethods which permit total cecal intubation in 97%of all cases, without the use of fluoroscopy. Those whouse the fluoroscope state that it serves a dual purpose:location of the instrument tip and an aid in withdrawalof loops. Non-fluoroscopic endoscopists know that anyloop in the colon can be straightened by instrumentwithdrawal. Indeed, whenever several centimeters ofthe shaft are introduced into the rectum, and only asmall amount of forward tip motion occurs (as deter­mined by visualizing passage over the mucosal sur­face), it is immediately known that a loop must beforming. The location of that loop is not important,but whether the twist is clockwise or counterclockwiseis important, since pulling the shaft straight backwhen the scope is looped and twisted will result in lossof tip position, an undesirable occurrence. The loopand twist configuration must be straightened by acombination of shaft withdrawal and torque simulta­neously. The direction of torque required is usuallyclockwise, but when this results in the tip being buriedin the colon wall in spite of maximal control manip­ulation, then counterclockwise torque is needed.

It may be necessary to use fluoroscopy if an overtube"stiffener" is used, but this sleeve has never beenutilized at the Mount Sinai Hospital in New York,where endoscopists teach the technique of non-fluo­roscopic colonoscopy to fellows who rapidly learn themethod, and are able to perform total colonoscopy ina high percentage of cases without stiffening devices.Abdominal pressure is often used during colonoscopy,but its use does not require fluoroscopy.

Whether or not fluoroscopy is used, there is noalteration of the basic colonoscopic axioms in thepatient under conscious sedation: (1) If pushing onthe instrument causes the tip to advance and thepatient is not uncomfortable, even though a loop maybe forming, keep pushing. (2) Pain during colonoscopyis caused by formation of a loop, not by insufflationof air. (3) If the scope does not advance, pull back theshaft and straighten the instrument. Sometimes, toaid in tip advancement when straightening does nothelp, it is necessary to create a loop and then to "push

GASTROINTESTINAL ENDOSCOPY

through the loop" to continue advancing the instru­ment. However, this maneuver is helpful whether fluo­roscopy is or is not used during colonoscopic passage.

The instrument should only be advanced with thelumen in view, and one should not use the fluoroscopeto blindly point the instrument in the direction of thelumen and then push.

With or without fluoroscopy, 80 to 120 cm of scopemay easily be inserted into the sigmoid colon, withouthaving reached the cecum or even the transverse co­lon. It is well known that the measurements on theinstrument cannot be utilized for any purpose of lo­calization, since the splenic flexure may be reached at120 cm upon instrument introduction, and 40 cm uponwithdrawal in the same patient after all of the loopshave been removed. The endoscopist that reports dis­tance reached or lesion location by cm is using nu­merology to obfuscate ignorance, since a lesion at the50-cm level could be in the hepatic flexure, splenicflexure, or sigmoid colon. Some colons are easy tointubate, and some are difficult, but everyone mustbeware of the rapid examination where a tumor thatwill require surgery is located at 60 cm on intubationin 4 min: the tendency is to consider that it is in thedescending colon or splenic flexure, while it may ac­tually be located in the hepatic flexure, a difference ofconsiderable importance for the surgeon. In a similarmanner, a lesion found after 45 min of difficult colon­oscopy requiring all out effort in a long, long colonmay be considered to be in the right colon, but mayactually be in the splenic flexure. In the absence ofcecal identification, if there is doubt as to the site ofa lesion, its precise location can be obtained by Indiaink marking. The use of clips for identification iscumbersome and requires a large-channel instrument.

Old methods die hard. Reliance on fluoroscopymakes colonoscopy more difficult and increases theamount of time and risk to both patient andendoscopist.

Jerome D. Waye, MDMt. Sinai Medical Center (CUNY)Gastrointestinal Endoscopy Unit

Mt. Sinai HospitalNew York, New York

VOLUME 36, NO.1, 1990

From the Rostrum

Privileges to perform endoscopy

The American Society for Gastrointestinal Endoscopyreceives many requests for assistance in matters that relateto gastrointestinal endoscopy. The most common type ofinquiry by a wide margin is that which concerns the grantingof privileges to perform endoscopic procedures.

Questions about the process of conferring endoscopicprivileges come from organizations that provide health careas well as individual members of the Society. Some requestsare for general information on the principles and process forgranting privileges. These present no difficulty since theSociety offers a number of specific guidelines that are per­tinent to the issue ofprivileges. 1

-5 However, another category

of inquiry is that of the specific dispute. These inquiriesusually outline the details of a particular controversy, andoften include a plaintive appeal to the Society to intercedein some fashion in the conflict. In this regard, it is importantto note that the legal responsibility for confering privilegesrests with the individual organization that proposes to pro­vide health care. Hospitals have a duty to society to ensurethat the care they offer meets reasonable standards of qual­ity and that patients may avail themselves of these serviceswith reasonable safety. The trustees and all medical staff ofany hospital are held accountable for all procedures per­formed within their institution. In view of this mandate, theSociety has no prerogative to intercede in the affairs of aspecific organization.

Although the responsibility for actual privileges to per­form endoscopy is clearly that of the organizations whichprovide care, the A/S/G/E nevertheless has a vital interestin this process. As a professional society, our stated missionis to promote the highest possible standards of endoscopicpractice. Training, the establishment of credentials, and thegranting of privileges are integral to the provision of highquality services. The Society therefore provides severalguidelines that are of assistance in the process of grantingprivileges. Foremost of these is the statement on "Methodsof granting hospital privileges to perform gastrointestinal

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