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Am Fam Physician. 1999;60(8):2237-2238

to the editor: In addition to my editorial1 on “Flexible Sigmoidoscopy: The Unkept Promise of Cancer Prevention,” which accompanied the recent review article on this subject, 2 I would like to offer several clarifications and comments on the techniques and equipment as described by the author.

  1. Reflecting the advance to longer scopes, manufacture of the 35-cm flexible sigmoidoscope was discontinued more than five years ago. Short colonoscopes (65 cm) remain on the market. As prices of the longer colonoscopes decrease, the 65-cm scope will also probably be discontinued.

  2. Scope diameters vary slightly and have no significant impact on technique or clinical outcome.

  3. The descending colon may have a gun-barrel appearance, with concentric ridges separating the pouches (haustrae). In the transverse colon, triangular folds are observed 50 to 60 percent of the time. Clues to anatomic depth can be helpful, but these clues are not constant, particularly in patients 70 years of age or older.

  4. Diagnostically, anoscopy is no match for fiberoptic retroflexion, although slotted anoscopes remain helpful for therapeutic surgeries. Otherwise, I have not used an anoscope in 10 years.

  5. Physician involvement with cleaning and disinfection is essential, but soapy water is not. At postendoscopy, immediate rinsing and suctioning with tap water works fine.

  6. Using clinical judgment to avoid varices, physicians should biopsy lesions that appear abnormal. Too many lesions are missed at a second examination. The physician should perform a biopsy while the lesion is “in your sights.” The physician should be careful not to snap the wrist as part of the biopsy technique—these are avulsion, not cutting biopsy forceps.

  7. The terms “dithering” and “jiggling” are jargon and describe several mildly effective loop-reduction maneuvers. Formation of a sigmoid loop impedes advancement. Physicians can maneuver the scope right and left, up and down, in and out, and twist right and twist left for advancement of the endoscope. Air insufflation and suction are additional functions. Using all of these maneuvers in an effective manner defines the art of endoscopic insertion.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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