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Colonoscopic Diagnosis Questions and Answers
Endoskipie und Biopsie in der Gastroenterologie (Endoscopy and Biopsy in Gastroenterology) By P. Fruehmorgen and M. Classen. Springer-Verlag, BerlinHeidelberg-New York, 220 pages, 1974. Price $8.10.
This is a well-rounded, small reference book with editors, who need no introduction. The content covers all procedures from total enteroscopy, through therapuetic endoscopy, to laparoscopy and biopsy of the pancreas. A thorough section on basic issues such as care of instruments and documentation should be recommended reading for everyone starting out in gastrointestinal endoscopy. The detailed discussion on obtaining intestinal biopsies by Elster and the excellent description of cytology techniques by Widenhiller are commendable. The remaining portion of the book is well organized into sections devoted to each procedure with subdivisions for description of instruments, preparation of the patient, postprocedural care, technique, indications, contraindications, and complications. Almost equal space allotted to each procedure may give a wrong impression about their individual frequency and importance. For example, an excellent section on colonoscopy is most detailed in description of instrument introduction and advance (by Fruehmorgen), while the article on emergency endoscopy by Koch appears somewhat sparse. The up-to-dateness of this little book is emphasized by an article by Fruehmorgen and Classen on therapeutic endoscopy, in particular on foreign body removal and polypectomy of the upper and lower gastrointestinal tract. The sections on the technique of percutaneous liver biopsy by Menghini and on laparoscopy and its adjunctive procedures (visualisation and biopsy of the pancreas, cholecystography, and splenoportography) by Lindner et al. are well written and contain valuable practical hints. It is regrettable that this small and inexpensive book is not available in the English language. It represents a perfect introduction for the novice, a reference guide for the experienced, and should have its place in every gastroenterologist's library. Klaus Anselm, MD Southern Colorado Clinic Pueblo, Colorado
Kolondivertikulitis (Acute Problems of Diagnosis and Therapy)
Edited by M. Reifferscheid. Georg Thieme Verlag Stuttgart, 114 pages, 1974.
This booklet contains reproduction of papers given at a symposium (workshop) in Aachen in 1973. It has excellent contributions by noted internists, pathologists, radiologists and surgeons. Ottenjann's article on the development and pathophysiology of diverticular disease is of particular interest, as is the thorough paper by de Graff on progressive and regressive diverticulosis as well as pseudodiverticulosis. As happens with other editions of conventions and workshops, duplications are apparent and unavoidable. A recent issue of Clinics in Gastroenterology provides equal if not better information, and purchase of this booklet appears unnecessary unless one is primarily interested in colorectal disease. Klaus Anselm, MD Southern Colorado Clinic Pueblo, Colorado. 54
Colonoscopic Diagnosis Questions and Answers The following is an abridged transcript from a panel discussion conducted during the A/S/G/E postgraduate course on colonoscopy held at Los Angeles in January, 1975.
Moderator: Panel:
J. E. Berk, MD Richard Corlin, MD William G. Friend, MD Walter D. Gaisford, MD John F. Morrissey, MD
Dr. Berk: Dr. John Morrissey gave us a long list of indications for colonoscopy. John, will you tell us what the situation is now with respect to the conventional 25 em sigmoidoscope? Is it an archaic instrument? Dr. Morrissey: I would say it still has a very important role. In our own institution we do 10 to 12 standard sigmoidoscopies for every colonoscopy. It is the way we follow most of our inflammatory bowel disease patients. It is the first study we do in anyone with symptoms suggesting the presence of colorectal disease. It is certainly much easier to perform as a standard diagnostic procedure, and it is less expensive in terms of technician time and cost to the patient. We are not doing fewer sigmoidoscopies than we did 10 years ago, and colonoscopy has not replaced the standard sigmoidoscopic examination. Dr. Berk: Let's consider the patient who has a polypoid defect that is discovered by the ordinary sigmoidoscope. Should a total colonoscopic examination then be performed? Dr. Morrissey: If a patient has I polyp, then the chances of that patient's having another polyp are, in my view, high enough to merit an examination of his entire colon. Even if the original polyp was within the range of the standard sigmoidoscope, we would then proceed to examine the entire colon, take out all the polyps we find, and on the way out remove the one that is down low. I prefer to take polyps out with the fiberscope rather than with the standard 'scope, unless the polyp lies very low. Dr. Berk: In patients who have had 1 or more adenomatous polyps removed, how often do you advocate that patient be re-examined by means of total colonoscopy? Dr. Morrissey: We usually advise annual re-examination if there were multiple polyps of any size, or if any polyp is larger than I em, but especially if they have had multiple large polyps. However, if they have just a solitary 5 mm polyp, I do not think that person has to be screened on a regular basis. Dr. Berk: What about the patient who has had a cancer removed? How often would you advocate total colonoscopy? Dr. Morrissey: I have been doing it at 6 months, a year, and then yearly. Dr. Berk: Among the indications for colonoscopy, you included lower bowel bleeding. Can you prepare that bowel so as to see anything if there is profuse, fresh bleeding? Dr. Morrissey: First we do a standard sigmoidoscopic GASTROINTESTINAL ENDOSCOPY
examination to be sure the bleeding is coming from above the sigmoidoscopic level. Establishing that it is above that level, we give the patient a magnesium citrate purge and allow 6 hours to elapse so that there is a gross evacuation of colonic contents. We then examine the colon, preferring to use the 2-channel ACMI 'scope so that we have a large suction channel to evacuate blood clots. However, we have also used the Olympus single-channel 'scope as well. Whether I am using an ACMI or an Olympus 'scope in this situation, I do not use the standard suction system, but I attach an extra suction tube directly on to the external suction (biopsy) channel. I use a tracheal aspirating tip with a hole in it to give me an on/off suction control. With this system you can dislodge a plugged clot by taking the tube off and injecting a syringe of fluid through the biopsy channel. Your technician can always do that for you. In this way you are not going to have your 'scope suddenly inoperative. If the problem is just a little blood on the lens, I use the standard suction and water to clean the lens. When you try to evacuate either stool or blood, you first want to dilute it. So I have my assistant, with a large syringe, inject water directly into the small channel and aspirate through the large channel. It is possible in this fashion to get through the bowel in the face ofgross bleeding; it takes a little time, but it is worthwhile in terms of what we have found. We have found polyps as the cause of major bleeding, we have found localized granulomatous colitis involving only the transverse colon causing bleeding, we have localized the sites of vascular anomalies that have caused bleeding, and we have been able to determine that blood was coming from the small bowel and not the colon. Dr. Berk: I would like to make a,pitch for the adjunctive use of ultraviolet endoscopy in such situations. We've used this in the upper gastrointestinal tract, and now we have begun to apply it to colonoscopy as well. We had an experience with a vascular defect that we could not see bleeding, but when we injected fluorescein and examined it under the ultraviolet light, the whole cecum lit up. It was obviously oozing some blood at the time that we didn't see with white light. Dr. Gaisford, is it your view that colonoscopy is appropriate as an office procedure? Dr. Gaisford: In a large majority of cases, yes. I don't use fluoroscopy except in unusually difficult cases involving fixed sigmoid segments. In general, routine colonoscopy, not operative colonoscopy but diagnostic examinations, can be done on an outpatient in an office very well. Dr. Berk: You are saying then that fluoroscopy is not mandatory but desirable if available? Dr. Gaisford: Right, and I think only in a very few cases is it really necessary. Dr. Berk: You stated earlier that general anesthesia was contraindicated. Dr. Gaisford: Yes, and for 2 reasons: (f) You do not have the patient as a monitor to tell you when you are doing something wrong. Causing discomfort to the patient is dangerous. You can tear the mesentery, you can injure the bowel or overdistend it, and the patient won't be able to tell you. (2) In many cases, general anesthesia may paralyze the bowel and make it more difficult to pass the colonoscope. Dr. Berk: Would you say that applies as well to the VOLUME 22, NO, 1, 1975
examination of children? Dr, Gai4ord: Yes, I have examined a number of children in my office. I have used intravenous sedation, and they have tolerated it very well. Dr. Berk: I don't believe you mentioned the various drugs that you used. Do you use glucagon at all? Dr. Gaisford: No. There has been a recent evaluation of its use in a double blind study, and the authors did not find any particular advantage in the success of passage of the instrument or the examination. Dr. Berk: Is there anybody on the panel who uses glucagon? Dr. Morrissey: The only time I use it is if( am trying to do a polypectomy in an area of great motor activity and I cannot, by repositioning the patient, find a position where the bowel will hang open. I may use glucagon to try to suppress contractions in order to make the polypectomy a little safer. Dr. Berk: Dr. Gaisford, you mentioned that in the preparation for colonoscopy enemas should be given until the returns are clear. How many enemas should the patient get? Dr. Gaisford: For the fragile or elderly patient, both purgatives and enemas must be given with caution. For the average patient, 2 to 6 enemas usually remove the liquid stool. Dr. Berk: I have been impressed that older patients, after barium enema examination were rather exhausted, and some of them collapsed with hypotension. We'made a study of blood volume in patients over the age of 60 before and after barium enemas. It was amazing what an appreciable increase in total circulating blood volume had occurred because of the absorption of fluid that was in that bowel. I worry whenever I see an order that is written, "Give enemas until returns are clear". We may get clear returns, but I am not sure the patient will be with us all the time. Dr. Gaisford: I think that is a good precaution, but more often than not my concern has been with dehydration and hypovolemia from the purgative and from insufficient clear liquids by mouth. Dr. Berk: Dr. Corlin, how often does your preparation for colonoscopy cause a serious flare-up in patients with inflammatory bowel disease? Dr. CorLin: I haven't seen that. I use magnesium citrate rather than castor oil. It is not an irritative cathartic. It is a saline cathartic, and we have found it to be extremely effective. If there is any stool remaining in the colon, it is almost always thin, liquid stood and no problem to get out through the suction channel. Dr. Berk: Have you any concern that mucosal biopsy in ulcerative colitis might induce perforation? Dr. Corlin: We haven't had that problem occur. The biopsy forceps are exceedingly small, and we haven't used great pressure against the wall and have always biopsied only under direct vision. Whenever possible, both for purposes of safety and ease ofobtaining the biopsy, we will take the biopsy specimen right from the peak of a fold. Dr. Berk: You talked about the importance of doing colonoscopy in patients who showed "pseudopolypoid lesions in association with ulcerative colitis". What is it that you are looking for when you do colonoscopy in such patients? 55
Dr. Carlin Distinguishing pseudopolyps from true polyps or carcinoma. Dr. Berk: Can you do that? Dr. Carlin: Grossly, I don't think so, but the pathologist can when he reviews the biopsy specimens. Dr. Berk: Did you also suggest that it was your objective to try to remove as many of these pseudopolyps as possible? Dr. Carlin: That is the case where there is a limited number of lesions. Dr. Berk: How many is a limited number? Dr. Carlin: I think the most I have ever taken out at one sitting has been about 5 or 6. Dr. Berk: John, why do you feel that pseudopolyposis is an indication for colonoscopy? What is it that you are looking for? Dr. Morrissey: I think whenever there is pseudopolyposis you are dealing with a bowel that has tumor-like growths in it, and you are concerned about malignancy. We have had one ulcerative colitis patient in whom we diagnosed a carcinoma. The thing to remember in a person with ulcerative colitis is that carcinoma frequently does not begin as a polypoid defect but rather as a plaque-like infiltrating defect, similar to a scirrhous carcinoma of the stomach. It is important not to look just at the polypoid defects but to look carefully at the colon wall. We take "big particle" biopsies of suspicious lesions. It is important to try to give the pathologist as wide a piece of tissue as possible. We use a prototype name made by ACMI which has a braided wire with a very small diameter, stiff loop and is quite suited to getting these large particle biopsies. Dr. Berk: What concerns me, and the reason I am pressing this point, is that it is my impression, perhaps erroneous, that this lesion (that has such a terribly inappropriate name, "pseudopolyp") is really an island of intact retained mucosa in a sea of denuded mucosa. It's not a new growth like an adenomatous polyp. Histologic studies suggest that the origin of cancerous growths in colons with ulcerative disease is in denuded areas from their epithelial regrowth and not in the remnant islands that we call pseudopolyps. Therefore, why clean the bowel out of these things? What's the gain and profit from that? Dr. Carlin: Two things: (1) You can't always be sure when you look at the lesion at colonoscopy that is what it is, and (2) you can't be always sure by x-ray of what you are dealing with. I am not, at least not yet, an advocate of routine, repeated colonoscopy. I think it is still more demanding of the patient than a properly, gently done barium enema. Ifbarium enema discloses a lesion, taking a look at it and getting it out will both confirm what it is now and avoid problems of interpretation on the next barium enema. Dr. Berk: In your opinion, Dr. Friend, does a patient with roentgen evidence of a lesion that seems clearly to be a tumor, a cancer of some type, need have colonoscopy before surgery? Dr. Friend: If you are going to operate on a patient regardless of what the colonoscopic findings are, then you might as well not do the colonoscopy. Dr. Berk: If you then operated upon that patient on the strength of that x-ray, without preliminary colonoscopy, would you make any effort at the time of the resection to examine the rest ofthe bowel to see if there are other lesions present? 56
Dr. Friend: I don't do that as a routine, and I would probably find it technically awkward at the time. I either do colonoscopy or surgery, but I don't like doing them both at the same time. I'm a surgeon; I can't be at both ends at once, you see. Dr. Gai5ford: Dr. Berk, I would like to offer another opinion. I am also a surgeon, and I have had a number of patients with it diagnosis of a filling defect, most likely carcinoma, seen on barium enema x-ray when they have been referred to me for evaluation. I have done total cononoscopy, and I have found at least 2 patients with other lesions, patients who not only have the carcinoma, but other polyps in the colon. I may be in the minority, but I think that a patient who has a known malignant lesion in one part of the colon deserves total colonoscopy before surgery. The only question in my mind is whether there is any risk of spreading the carcinoma by rubbing the 'scope against the lesion in completing the total colonoscopy. I doubt very much that the risk of that would be as great as the risk of missing other lesions in the colon. As any surgeon knows, it is very difficult to feel through the colon at the time of surgery to pick up other secondary lesions, so I feel strongly that the patient should have total colonoscopy before surgery. Dr. Berk: According to the "no-touch" technique, you are not allowed to touch the lesion at the time you want to resect it. Do you think it is safe to put a 'scope up and down the colon beforehand? Dr. Gaisford: Do it very gently. Dr. Friend: The no-touch technique is a concept, it's not a physical reality. It isn't that we actually must not touch the carcinoma. For example a carcinoma low in the rectum or low in the sigmoid colon cannot be removed without touching the colon. The concept of no-touch dictates first the high ligation of the veins and then the proper isolation of the tumor. I would probably not deliberately pass the 'scope through an annular lesion, not just because offear of spreading tumor emboli, but also for fear of causing a perforation. Dr. Berk: How do the surgeons feel about concomitant colonoscopy done peroperatively, with the surgeon helping advance the instrument introduced through the rectum, guiding it through the abdomen? Does that add anything? Dr. Gaisford: I agree with Dr. Friend that colonoscopy with the abdomen open, with the surgeon in the abdomen, is much more difficult than doing it in the normal way. It may be of value in a situation where a polyp removed by conventional colonoscopy turns out to contain invasive carcinoma. Such a patient deserves to have a colon resection. Occasionally, I have found difficulty at the operating table finding the site where that polyp was removed. A colonoscope, placed in the colon either preoperatively as Dr. Friend has suggested or intraoperatively, would be very helpful in exactly pinpointing for the surgeon where that malignant polyp had been removed. Another instance in which it has been helpful is that wherein a known lesion requires open surgery and there are some associated polyps which the surgeon wishes to include in his resection. He wants to make sure that he hasn't missed them, because he can't feel them well in the colon. Dr. Friend: Intra-operative colonoscopy has a place, but I would say that in my own personal experience this is something that I do less than once a year. GASTROINTESTINAL ENDOSCOPY
Dr. Morrissey: Our experience is similar. We have had a number of situations where we've found malignant polyps and have gone in the same way to localize them for the surgeon. We have had I complication doing this which emphasizes the hazard of this procedure. I think it is definitely more dangerous to be passing a 'scope under these circumstances. While the surgeon was watching, we were advancing a 'scope up within the sigmoid, and there was a pelvic adhesion holding the loop of sigmoid down, and as we put a little stress on it, we got a serosal split. It was about 10 em long, just a split right through the serosa and the muscularis, leaving only the mucosa intact. It was fortunate that the surgeon was there, because he just put in a few sutures. Having seen this happen, we wonder how often it happens when we don't know about it, and I suspect that this is one accident that may happen more frequently than we suspect. There is another situation that we encountered. A patient had a 4 em x 5 em villous adenoma in the left colon in addition to a carcinoma of the cecum. The surgeon planned to remove the carcinoma ofthe cecum as a resection, but we went in and took out the villous adenoma through the colonoscope while he watched us to be sure we didn't perforate when we did it. So we removed the villous adenoma by means of the colonoscope and saved the surgeon from making an extra incision in the colon. Dr. Berk: Let's return to inflammatory bowel disease again and see if we can zero in on some things that are not entirely clear to all of us. Is moderately severe or severe ulcerative colitis a contraindication to colonoscopy? The chief reason, I think, for not doing colonoscopy in a patient who is acutely ill is that you don't have to. It would be an unusual circumstance in which it would provide you with vitally needed information upon which you would make a "go" or "no go" decision with respect to any significant therapy. In almost all cases, the indications or contraindications that apply to doing a barium enema will apply also to colonoscopy. Dr. Morrissey: In 95% of ulcerative colitis patients you will see an abnormal rectum on standard sigmoidoscopy so your diagnosis is made by sigmoidoscopy, and you don't need colonoscopy. There are only 2 circumstances that I can think of where you will need colonoscopy. The first is in patients who have had active disease for 5 years or longer and you are starting to worry about malignancy. Usually these people have smoldering disease, often relatively asymptomatic. The other group are people who have quite active proctitis, and you are interested in determining the extent of disease in patients who are not doing very well. You are starting to wonder about whether this should be treated surgically. An example is the patient with an abnormal proctoscopy and an apparently normal barium enema who has continuing symptoms for an inappropriate length of time. The Milwaukee group has about 20 such patients in whom they have not just proctitis; the reason they were doing poorly was that they actually had a pancolitis. Dr. Corlin: These people are not really what we would call acutely ill. Dr. Morrissey: That's right, they're not. These are people that you have followed for months on medical therapy; they are not in the early stages of their treatment. The only people in the early stages of inflammatory bowel disease that VOLUME 22, NO.1, 1975
I colonoscope are those who have normal proctosigmoidoscopic examinations. I want to see if they have disease proximally in the colon. Dr. Berk: Then both of you are emphasizing that the usual precautions still hold true. We should be most concerned with the individual who comes in with diarrhea, cramps, passing bloody stools, with all of the clinical signs and symptoms of acute ulcerative colitis. We had better stay out of their bowel with any type of instrument for the time being if they are very sick, is that what you are saying? Dr. Morrisey: Not any type of instrument other than a proctosigmoidoscope. Dr. Berk: Dr. Gaisford, in reference to technique, what is a "mucosal slide"? Sounds like something in baseball. Dr. Gaisford: Or skiing. "Mucosal slide" refers to passing the end of the colonoscope freely past the mucosa where the lumen of the bowel is not visible. It's almost mandatory or required in certain parts of the colon. I use it most commonly at the junction of the sigmoid colon and the descending colon. The examiner should know the general direction of the lumen. Ifhe doesn't know, maybe he ought to use fluoroscopy. I don't think you can slide blindly. You have to know the direction of the lumen and make sure that the tip of the' scope is sliding freely and that it isn't blanching the mucosa and that there isn't undue pressure with passing and sliding on the mucosa. Dr. Friend: The mucosal slide is something that I taught myself to do back in 1970, necessitated by the limited deflection of the orginal Olmypus equipment. Now that the tips of the newer' scopes can be turned a full 180 degrees, I find I don't have to use "slide-by" any more, and I like being able to see the lumen at all times before I proceed. Dr. Morrissey: The mucosal slide is not the way to get through the sigmoid segment. I would like to emphasize that if you start doing that you are going to end up with a very large, dilated sigmoid that is stretched almost up to the diaphragm, and then you are going to have a lot of trouble negotiating the junction between the sigmoid and descending colon. The only time I like to use mucosal slide is to get from the sigmoid into the descending colon. If you start sliding just after you get out of the rectum, it frequently happens that you suddenly see lumen ahead, and you start going up the lumen, and it disappears, and you say, "Well, I know that lumen was there, I was looking at it just a minute ago." Then there is a temptation to try that slide, and that's when you are going to drag that bowel up into the left upper quadrant and be in serious difficulty. Dr. Gaisford: The technique is to know how much to slide. If you slide all the way into third base, you are going to do exactly what John says. But if you keep the 'scope squarely in the center of the lumen when you go through the sigmoid colon, and you have to inflate quite a bit of air to do that, you are going to end up with a great big sigmoid loop. I am not disagreeing with what John is saying, but I am saying that you have to slide a little bit. You see the lumen, and then you go past it and avoid making the sigmoid loop, keeping the sigmoid as straight as possible. If you look at a barium enema evacuation film, and compare the difference between the sigmoid colon under those circumstances, and again after the radiologist has it filled with barium, you see that the sigmoid is up to the diaphragm, and that's the difference. I 57
think if you avoid the air and keep that sigmoid in a relatively straight line when you are going through it, then you will avoid the problem, and that requires a certain amount of mucosal slide. Dr. Berk: I can just picture the late Dizzy Dean giving a blow-by-blow radio account of a colonoscopy and saying he just slid into the sigmoid. I want to ask all the members of the panel if they will, in turn, comment about their views on the use of stiffeners, internal and extrernal. Is there value to them, should they be used, do you use them? Dr. Morrissey: Well, the 'scope that I presently use is a 2-channel ACMI F9 'scope which is quite stiff, so that for many examinations I probably can get by without using any stiffening device at all. I find that although I don't absolutely need the internal stiffener, frequently I can go a little faster with the stiffener in getting across the transverse colon because it does maintain some rigidity in the sigmoid. It is not as stiff as an external stiffener for maintaining a straight sigmoid, but it does help. A stiffer 'scope has a tendency to elevate the transverse colon, and elevation is what you want in a transverse colon. Dr. Berk: How often do you use it? Dr. Morrissey: I use it pretty routinely. If I'm using a small diameter 'scope, either ACMI or Olympus, and since I almost always want to go the whole way and not knowing whether I am going to need the stiffener or not, I always have it in place. The external stiffener must always be applied in anticipation of its use. Once in a great while you will have a situation where, because of adhesions, the sigmoid is bound down in such a way that you have to leave an alpha curve in there, and you can't derotate it; the stiffener may get in the way, but that is very unusual. Under those circimstances, if you have the external stiffener on, you have to take the 'scope out, take the stiffener off, and go back in without it. The external stiffener is not that difficult to use, so that I tend to use it routinely with the long instrument. Dr. Gaisford: I've had no experience with the internal stiffener, so I can't comment on that. The external stiffener requires fluoroscopy, I think, in order to use it safely. Because I don't use fluoroscopy, I don't use the external stiffener. The stiffener is used almost exclusively with the medium-length 'scope. So I don't use either type of stiffener.
58
Dr. Carlin: I have no experience with the internal stiffener, but I really like to use the external stiffener in getting around to the cecum. We put it on almost all the time. Sometimes we find that we get around to the cecum before we get to the point of having to use it. In effect, it shortens the amount of 'scope we have available without the use of the stiffener. We almost never have to do any sort of alpha maneuver, because we can usually easily get up toward the splenic flexure, then rotate a little bit clockwise to get any loop out. Often we will then have some redundancy in the sigmoid, so we will hook the 'scope into the splenic flexure and gently pull back until we see that we've straightened out the colonoscope. Then under fluoroscopic guidance, gently and with rotation, slowly push the stiffener up. We wind up getting the stiffener up almost to the splenic flexure. Since we have pleated the whole sigmoid over it, we can quickly and easily get around to the cecum with far less patient discomfort. I might point out that everybody is always very careful to lubricate the outside of the stiffener very well, but you also must remember that you need a lot of lubrication between the colonoscope and the stiffener, otherwise the stiffener binds against the colonoscope. Dr. Friend: I have seldom used the stiffener. One way of avoiding difficulty when going through that sigmoid colon is to keep a clockwise torque on the 'scope, making short movements in and out, with a little bit of deflection on the tip. Most of the time you can get through the sigmoid colon without any fancy loops. Once you are up to the splenic flexure area, the clockwise torque will keep that sigmoid colon relatively straight. Dr. Berk: Last question, rapidly down the line, yes or no: do you do the alpha maneuver? Dr. Morrissey: I use it very rarely. Dr. Gaisford: Very rarely. Dr. Carlin: The same. Dr. Friend: I use it deliberately, exactly the way Dr. Christopher Williams taught me how to use it. The only time I make a counterclockwise rotation for torquing is with the alpha maneuver. The other method to hold a sigmoid straight, while advancing to the splenic flexure and hepatic flexure, is to perform a clockwise torquing maneuver. As a rule of thumb, if you are not sure which way to go, it's a clockwise torque that holds everything in place, not the alpha loop.
GASTROINTESTINAL ENDOSCOPY
This is a well-rounded, small reference book with editors, who need no introduction. The content covers all procedures from total enteroscopy, through therapuetic endoscopy, to laparoscopy and biopsy of the pancreas. A thorough section on basic issues such as care of instruments and documentation should be recommended reading for everyone starting out in gastrointestinal endoscopy. The detailed discussion on obtaining intestinal biopsies by Elster and the excellent description of cytology techniques by Widenhiller are commendable. The remaining portion of the book is well organized into sections devoted to each procedure with subdivisions for description of instruments, preparation of the patient, postprocedural care, technique, indications, contraindications, and complications. Almost equal space allotted to each procedure may give a wrong impression about their individual frequency and importance. For example, an excellent section on colonoscopy is most detailed in description of instrument introduction and advance (by Fruehmorgen), while the article on emergency endoscopy by Koch appears somewhat sparse. The up-to-dateness of this little book is emphasized by an article by Fruehmorgen and Classen on therapeutic endoscopy, in particular on foreign body removal and polypectomy of the upper and lower gastrointestinal tract. The sections on the technique of percutaneous liver biopsy by Menghini and on laparoscopy and its adjunctive procedures (visualisation and biopsy of the pancreas, cholecystography, and splenoportography) by Lindner et al. are well written and contain valuable practical hints. It is regrettable that this small and inexpensive book is not available in the English language. It represents a perfect introduction for the novice, a reference guide for the experienced, and should have its place in every gastroenterologist's library. Klaus Anselm, MD Southern Colorado Clinic Pueblo, Colorado
Kolondivertikulitis (Acute Problems of Diagnosis and Therapy)
Edited by M. Reifferscheid. Georg Thieme Verlag Stuttgart, 114 pages, 1974.
This booklet contains reproduction of papers given at a symposium (workshop) in Aachen in 1973. It has excellent contributions by noted internists, pathologists, radiologists and surgeons. Ottenjann's article on the development and pathophysiology of diverticular disease is of particular interest, as is the thorough paper by de Graff on progressive and regressive diverticulosis as well as pseudodiverticulosis. As happens with other editions of conventions and workshops, duplications are apparent and unavoidable. A recent issue of Clinics in Gastroenterology provides equal if not better information, and purchase of this booklet appears unnecessary unless one is primarily interested in colorectal disease. Klaus Anselm, MD Southern Colorado Clinic Pueblo, Colorado. 54
Colonoscopic Diagnosis Questions and Answers The following is an abridged transcript from a panel discussion conducted during the A/S/G/E postgraduate course on colonoscopy held at Los Angeles in January, 1975.
Moderator: Panel:
J. E. Berk, MD Richard Corlin, MD William G. Friend, MD Walter D. Gaisford, MD John F. Morrissey, MD
Dr. Berk: Dr. John Morrissey gave us a long list of indications for colonoscopy. John, will you tell us what the situation is now with respect to the conventional 25 em sigmoidoscope? Is it an archaic instrument? Dr. Morrissey: I would say it still has a very important role. In our own institution we do 10 to 12 standard sigmoidoscopies for every colonoscopy. It is the way we follow most of our inflammatory bowel disease patients. It is the first study we do in anyone with symptoms suggesting the presence of colorectal disease. It is certainly much easier to perform as a standard diagnostic procedure, and it is less expensive in terms of technician time and cost to the patient. We are not doing fewer sigmoidoscopies than we did 10 years ago, and colonoscopy has not replaced the standard sigmoidoscopic examination. Dr. Berk: Let's consider the patient who has a polypoid defect that is discovered by the ordinary sigmoidoscope. Should a total colonoscopic examination then be performed? Dr. Morrissey: If a patient has I polyp, then the chances of that patient's having another polyp are, in my view, high enough to merit an examination of his entire colon. Even if the original polyp was within the range of the standard sigmoidoscope, we would then proceed to examine the entire colon, take out all the polyps we find, and on the way out remove the one that is down low. I prefer to take polyps out with the fiberscope rather than with the standard 'scope, unless the polyp lies very low. Dr. Berk: In patients who have had 1 or more adenomatous polyps removed, how often do you advocate that patient be re-examined by means of total colonoscopy? Dr. Morrissey: We usually advise annual re-examination if there were multiple polyps of any size, or if any polyp is larger than I em, but especially if they have had multiple large polyps. However, if they have just a solitary 5 mm polyp, I do not think that person has to be screened on a regular basis. Dr. Berk: What about the patient who has had a cancer removed? How often would you advocate total colonoscopy? Dr. Morrissey: I have been doing it at 6 months, a year, and then yearly. Dr. Berk: Among the indications for colonoscopy, you included lower bowel bleeding. Can you prepare that bowel so as to see anything if there is profuse, fresh bleeding? Dr. Morrissey: First we do a standard sigmoidoscopic GASTROINTESTINAL ENDOSCOPY
examination to be sure the bleeding is coming from above the sigmoidoscopic level. Establishing that it is above that level, we give the patient a magnesium citrate purge and allow 6 hours to elapse so that there is a gross evacuation of colonic contents. We then examine the colon, preferring to use the 2-channel ACMI 'scope so that we have a large suction channel to evacuate blood clots. However, we have also used the Olympus single-channel 'scope as well. Whether I am using an ACMI or an Olympus 'scope in this situation, I do not use the standard suction system, but I attach an extra suction tube directly on to the external suction (biopsy) channel. I use a tracheal aspirating tip with a hole in it to give me an on/off suction control. With this system you can dislodge a plugged clot by taking the tube off and injecting a syringe of fluid through the biopsy channel. Your technician can always do that for you. In this way you are not going to have your 'scope suddenly inoperative. If the problem is just a little blood on the lens, I use the standard suction and water to clean the lens. When you try to evacuate either stool or blood, you first want to dilute it. So I have my assistant, with a large syringe, inject water directly into the small channel and aspirate through the large channel. It is possible in this fashion to get through the bowel in the face ofgross bleeding; it takes a little time, but it is worthwhile in terms of what we have found. We have found polyps as the cause of major bleeding, we have found localized granulomatous colitis involving only the transverse colon causing bleeding, we have localized the sites of vascular anomalies that have caused bleeding, and we have been able to determine that blood was coming from the small bowel and not the colon. Dr. Berk: I would like to make a,pitch for the adjunctive use of ultraviolet endoscopy in such situations. We've used this in the upper gastrointestinal tract, and now we have begun to apply it to colonoscopy as well. We had an experience with a vascular defect that we could not see bleeding, but when we injected fluorescein and examined it under the ultraviolet light, the whole cecum lit up. It was obviously oozing some blood at the time that we didn't see with white light. Dr. Gaisford, is it your view that colonoscopy is appropriate as an office procedure? Dr. Gaisford: In a large majority of cases, yes. I don't use fluoroscopy except in unusually difficult cases involving fixed sigmoid segments. In general, routine colonoscopy, not operative colonoscopy but diagnostic examinations, can be done on an outpatient in an office very well. Dr. Berk: You are saying then that fluoroscopy is not mandatory but desirable if available? Dr. Gaisford: Right, and I think only in a very few cases is it really necessary. Dr. Berk: You stated earlier that general anesthesia was contraindicated. Dr. Gaisford: Yes, and for 2 reasons: (f) You do not have the patient as a monitor to tell you when you are doing something wrong. Causing discomfort to the patient is dangerous. You can tear the mesentery, you can injure the bowel or overdistend it, and the patient won't be able to tell you. (2) In many cases, general anesthesia may paralyze the bowel and make it more difficult to pass the colonoscope. Dr. Berk: Would you say that applies as well to the VOLUME 22, NO, 1, 1975
examination of children? Dr, Gai4ord: Yes, I have examined a number of children in my office. I have used intravenous sedation, and they have tolerated it very well. Dr. Berk: I don't believe you mentioned the various drugs that you used. Do you use glucagon at all? Dr. Gaisford: No. There has been a recent evaluation of its use in a double blind study, and the authors did not find any particular advantage in the success of passage of the instrument or the examination. Dr. Berk: Is there anybody on the panel who uses glucagon? Dr. Morrissey: The only time I use it is if( am trying to do a polypectomy in an area of great motor activity and I cannot, by repositioning the patient, find a position where the bowel will hang open. I may use glucagon to try to suppress contractions in order to make the polypectomy a little safer. Dr. Berk: Dr. Gaisford, you mentioned that in the preparation for colonoscopy enemas should be given until the returns are clear. How many enemas should the patient get? Dr. Gaisford: For the fragile or elderly patient, both purgatives and enemas must be given with caution. For the average patient, 2 to 6 enemas usually remove the liquid stool. Dr. Berk: I have been impressed that older patients, after barium enema examination were rather exhausted, and some of them collapsed with hypotension. We'made a study of blood volume in patients over the age of 60 before and after barium enemas. It was amazing what an appreciable increase in total circulating blood volume had occurred because of the absorption of fluid that was in that bowel. I worry whenever I see an order that is written, "Give enemas until returns are clear". We may get clear returns, but I am not sure the patient will be with us all the time. Dr. Gaisford: I think that is a good precaution, but more often than not my concern has been with dehydration and hypovolemia from the purgative and from insufficient clear liquids by mouth. Dr. Berk: Dr. Corlin, how often does your preparation for colonoscopy cause a serious flare-up in patients with inflammatory bowel disease? Dr. CorLin: I haven't seen that. I use magnesium citrate rather than castor oil. It is not an irritative cathartic. It is a saline cathartic, and we have found it to be extremely effective. If there is any stool remaining in the colon, it is almost always thin, liquid stood and no problem to get out through the suction channel. Dr. Berk: Have you any concern that mucosal biopsy in ulcerative colitis might induce perforation? Dr. Corlin: We haven't had that problem occur. The biopsy forceps are exceedingly small, and we haven't used great pressure against the wall and have always biopsied only under direct vision. Whenever possible, both for purposes of safety and ease ofobtaining the biopsy, we will take the biopsy specimen right from the peak of a fold. Dr. Berk: You talked about the importance of doing colonoscopy in patients who showed "pseudopolypoid lesions in association with ulcerative colitis". What is it that you are looking for when you do colonoscopy in such patients? 55
Dr. Carlin Distinguishing pseudopolyps from true polyps or carcinoma. Dr. Berk: Can you do that? Dr. Carlin: Grossly, I don't think so, but the pathologist can when he reviews the biopsy specimens. Dr. Berk: Did you also suggest that it was your objective to try to remove as many of these pseudopolyps as possible? Dr. Carlin: That is the case where there is a limited number of lesions. Dr. Berk: How many is a limited number? Dr. Carlin: I think the most I have ever taken out at one sitting has been about 5 or 6. Dr. Berk: John, why do you feel that pseudopolyposis is an indication for colonoscopy? What is it that you are looking for? Dr. Morrissey: I think whenever there is pseudopolyposis you are dealing with a bowel that has tumor-like growths in it, and you are concerned about malignancy. We have had one ulcerative colitis patient in whom we diagnosed a carcinoma. The thing to remember in a person with ulcerative colitis is that carcinoma frequently does not begin as a polypoid defect but rather as a plaque-like infiltrating defect, similar to a scirrhous carcinoma of the stomach. It is important not to look just at the polypoid defects but to look carefully at the colon wall. We take "big particle" biopsies of suspicious lesions. It is important to try to give the pathologist as wide a piece of tissue as possible. We use a prototype name made by ACMI which has a braided wire with a very small diameter, stiff loop and is quite suited to getting these large particle biopsies. Dr. Berk: What concerns me, and the reason I am pressing this point, is that it is my impression, perhaps erroneous, that this lesion (that has such a terribly inappropriate name, "pseudopolyp") is really an island of intact retained mucosa in a sea of denuded mucosa. It's not a new growth like an adenomatous polyp. Histologic studies suggest that the origin of cancerous growths in colons with ulcerative disease is in denuded areas from their epithelial regrowth and not in the remnant islands that we call pseudopolyps. Therefore, why clean the bowel out of these things? What's the gain and profit from that? Dr. Carlin: Two things: (1) You can't always be sure when you look at the lesion at colonoscopy that is what it is, and (2) you can't be always sure by x-ray of what you are dealing with. I am not, at least not yet, an advocate of routine, repeated colonoscopy. I think it is still more demanding of the patient than a properly, gently done barium enema. Ifbarium enema discloses a lesion, taking a look at it and getting it out will both confirm what it is now and avoid problems of interpretation on the next barium enema. Dr. Berk: In your opinion, Dr. Friend, does a patient with roentgen evidence of a lesion that seems clearly to be a tumor, a cancer of some type, need have colonoscopy before surgery? Dr. Friend: If you are going to operate on a patient regardless of what the colonoscopic findings are, then you might as well not do the colonoscopy. Dr. Berk: If you then operated upon that patient on the strength of that x-ray, without preliminary colonoscopy, would you make any effort at the time of the resection to examine the rest ofthe bowel to see if there are other lesions present? 56
Dr. Friend: I don't do that as a routine, and I would probably find it technically awkward at the time. I either do colonoscopy or surgery, but I don't like doing them both at the same time. I'm a surgeon; I can't be at both ends at once, you see. Dr. Gai5ford: Dr. Berk, I would like to offer another opinion. I am also a surgeon, and I have had a number of patients with it diagnosis of a filling defect, most likely carcinoma, seen on barium enema x-ray when they have been referred to me for evaluation. I have done total cononoscopy, and I have found at least 2 patients with other lesions, patients who not only have the carcinoma, but other polyps in the colon. I may be in the minority, but I think that a patient who has a known malignant lesion in one part of the colon deserves total colonoscopy before surgery. The only question in my mind is whether there is any risk of spreading the carcinoma by rubbing the 'scope against the lesion in completing the total colonoscopy. I doubt very much that the risk of that would be as great as the risk of missing other lesions in the colon. As any surgeon knows, it is very difficult to feel through the colon at the time of surgery to pick up other secondary lesions, so I feel strongly that the patient should have total colonoscopy before surgery. Dr. Berk: According to the "no-touch" technique, you are not allowed to touch the lesion at the time you want to resect it. Do you think it is safe to put a 'scope up and down the colon beforehand? Dr. Gaisford: Do it very gently. Dr. Friend: The no-touch technique is a concept, it's not a physical reality. It isn't that we actually must not touch the carcinoma. For example a carcinoma low in the rectum or low in the sigmoid colon cannot be removed without touching the colon. The concept of no-touch dictates first the high ligation of the veins and then the proper isolation of the tumor. I would probably not deliberately pass the 'scope through an annular lesion, not just because offear of spreading tumor emboli, but also for fear of causing a perforation. Dr. Berk: How do the surgeons feel about concomitant colonoscopy done peroperatively, with the surgeon helping advance the instrument introduced through the rectum, guiding it through the abdomen? Does that add anything? Dr. Gaisford: I agree with Dr. Friend that colonoscopy with the abdomen open, with the surgeon in the abdomen, is much more difficult than doing it in the normal way. It may be of value in a situation where a polyp removed by conventional colonoscopy turns out to contain invasive carcinoma. Such a patient deserves to have a colon resection. Occasionally, I have found difficulty at the operating table finding the site where that polyp was removed. A colonoscope, placed in the colon either preoperatively as Dr. Friend has suggested or intraoperatively, would be very helpful in exactly pinpointing for the surgeon where that malignant polyp had been removed. Another instance in which it has been helpful is that wherein a known lesion requires open surgery and there are some associated polyps which the surgeon wishes to include in his resection. He wants to make sure that he hasn't missed them, because he can't feel them well in the colon. Dr. Friend: Intra-operative colonoscopy has a place, but I would say that in my own personal experience this is something that I do less than once a year. GASTROINTESTINAL ENDOSCOPY
Dr. Morrissey: Our experience is similar. We have had a number of situations where we've found malignant polyps and have gone in the same way to localize them for the surgeon. We have had I complication doing this which emphasizes the hazard of this procedure. I think it is definitely more dangerous to be passing a 'scope under these circumstances. While the surgeon was watching, we were advancing a 'scope up within the sigmoid, and there was a pelvic adhesion holding the loop of sigmoid down, and as we put a little stress on it, we got a serosal split. It was about 10 em long, just a split right through the serosa and the muscularis, leaving only the mucosa intact. It was fortunate that the surgeon was there, because he just put in a few sutures. Having seen this happen, we wonder how often it happens when we don't know about it, and I suspect that this is one accident that may happen more frequently than we suspect. There is another situation that we encountered. A patient had a 4 em x 5 em villous adenoma in the left colon in addition to a carcinoma of the cecum. The surgeon planned to remove the carcinoma ofthe cecum as a resection, but we went in and took out the villous adenoma through the colonoscope while he watched us to be sure we didn't perforate when we did it. So we removed the villous adenoma by means of the colonoscope and saved the surgeon from making an extra incision in the colon. Dr. Berk: Let's return to inflammatory bowel disease again and see if we can zero in on some things that are not entirely clear to all of us. Is moderately severe or severe ulcerative colitis a contraindication to colonoscopy? The chief reason, I think, for not doing colonoscopy in a patient who is acutely ill is that you don't have to. It would be an unusual circumstance in which it would provide you with vitally needed information upon which you would make a "go" or "no go" decision with respect to any significant therapy. In almost all cases, the indications or contraindications that apply to doing a barium enema will apply also to colonoscopy. Dr. Morrissey: In 95% of ulcerative colitis patients you will see an abnormal rectum on standard sigmoidoscopy so your diagnosis is made by sigmoidoscopy, and you don't need colonoscopy. There are only 2 circumstances that I can think of where you will need colonoscopy. The first is in patients who have had active disease for 5 years or longer and you are starting to worry about malignancy. Usually these people have smoldering disease, often relatively asymptomatic. The other group are people who have quite active proctitis, and you are interested in determining the extent of disease in patients who are not doing very well. You are starting to wonder about whether this should be treated surgically. An example is the patient with an abnormal proctoscopy and an apparently normal barium enema who has continuing symptoms for an inappropriate length of time. The Milwaukee group has about 20 such patients in whom they have not just proctitis; the reason they were doing poorly was that they actually had a pancolitis. Dr. Corlin: These people are not really what we would call acutely ill. Dr. Morrissey: That's right, they're not. These are people that you have followed for months on medical therapy; they are not in the early stages of their treatment. The only people in the early stages of inflammatory bowel disease that VOLUME 22, NO.1, 1975
I colonoscope are those who have normal proctosigmoidoscopic examinations. I want to see if they have disease proximally in the colon. Dr. Berk: Then both of you are emphasizing that the usual precautions still hold true. We should be most concerned with the individual who comes in with diarrhea, cramps, passing bloody stools, with all of the clinical signs and symptoms of acute ulcerative colitis. We had better stay out of their bowel with any type of instrument for the time being if they are very sick, is that what you are saying? Dr. Morrisey: Not any type of instrument other than a proctosigmoidoscope. Dr. Berk: Dr. Gaisford, in reference to technique, what is a "mucosal slide"? Sounds like something in baseball. Dr. Gaisford: Or skiing. "Mucosal slide" refers to passing the end of the colonoscope freely past the mucosa where the lumen of the bowel is not visible. It's almost mandatory or required in certain parts of the colon. I use it most commonly at the junction of the sigmoid colon and the descending colon. The examiner should know the general direction of the lumen. Ifhe doesn't know, maybe he ought to use fluoroscopy. I don't think you can slide blindly. You have to know the direction of the lumen and make sure that the tip of the' scope is sliding freely and that it isn't blanching the mucosa and that there isn't undue pressure with passing and sliding on the mucosa. Dr. Friend: The mucosal slide is something that I taught myself to do back in 1970, necessitated by the limited deflection of the orginal Olmypus equipment. Now that the tips of the newer' scopes can be turned a full 180 degrees, I find I don't have to use "slide-by" any more, and I like being able to see the lumen at all times before I proceed. Dr. Morrissey: The mucosal slide is not the way to get through the sigmoid segment. I would like to emphasize that if you start doing that you are going to end up with a very large, dilated sigmoid that is stretched almost up to the diaphragm, and then you are going to have a lot of trouble negotiating the junction between the sigmoid and descending colon. The only time I like to use mucosal slide is to get from the sigmoid into the descending colon. If you start sliding just after you get out of the rectum, it frequently happens that you suddenly see lumen ahead, and you start going up the lumen, and it disappears, and you say, "Well, I know that lumen was there, I was looking at it just a minute ago." Then there is a temptation to try that slide, and that's when you are going to drag that bowel up into the left upper quadrant and be in serious difficulty. Dr. Gaisford: The technique is to know how much to slide. If you slide all the way into third base, you are going to do exactly what John says. But if you keep the 'scope squarely in the center of the lumen when you go through the sigmoid colon, and you have to inflate quite a bit of air to do that, you are going to end up with a great big sigmoid loop. I am not disagreeing with what John is saying, but I am saying that you have to slide a little bit. You see the lumen, and then you go past it and avoid making the sigmoid loop, keeping the sigmoid as straight as possible. If you look at a barium enema evacuation film, and compare the difference between the sigmoid colon under those circumstances, and again after the radiologist has it filled with barium, you see that the sigmoid is up to the diaphragm, and that's the difference. I 57
think if you avoid the air and keep that sigmoid in a relatively straight line when you are going through it, then you will avoid the problem, and that requires a certain amount of mucosal slide. Dr. Berk: I can just picture the late Dizzy Dean giving a blow-by-blow radio account of a colonoscopy and saying he just slid into the sigmoid. I want to ask all the members of the panel if they will, in turn, comment about their views on the use of stiffeners, internal and extrernal. Is there value to them, should they be used, do you use them? Dr. Morrissey: Well, the 'scope that I presently use is a 2-channel ACMI F9 'scope which is quite stiff, so that for many examinations I probably can get by without using any stiffening device at all. I find that although I don't absolutely need the internal stiffener, frequently I can go a little faster with the stiffener in getting across the transverse colon because it does maintain some rigidity in the sigmoid. It is not as stiff as an external stiffener for maintaining a straight sigmoid, but it does help. A stiffer 'scope has a tendency to elevate the transverse colon, and elevation is what you want in a transverse colon. Dr. Berk: How often do you use it? Dr. Morrissey: I use it pretty routinely. If I'm using a small diameter 'scope, either ACMI or Olympus, and since I almost always want to go the whole way and not knowing whether I am going to need the stiffener or not, I always have it in place. The external stiffener must always be applied in anticipation of its use. Once in a great while you will have a situation where, because of adhesions, the sigmoid is bound down in such a way that you have to leave an alpha curve in there, and you can't derotate it; the stiffener may get in the way, but that is very unusual. Under those circimstances, if you have the external stiffener on, you have to take the 'scope out, take the stiffener off, and go back in without it. The external stiffener is not that difficult to use, so that I tend to use it routinely with the long instrument. Dr. Gaisford: I've had no experience with the internal stiffener, so I can't comment on that. The external stiffener requires fluoroscopy, I think, in order to use it safely. Because I don't use fluoroscopy, I don't use the external stiffener. The stiffener is used almost exclusively with the medium-length 'scope. So I don't use either type of stiffener.
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Dr. Carlin: I have no experience with the internal stiffener, but I really like to use the external stiffener in getting around to the cecum. We put it on almost all the time. Sometimes we find that we get around to the cecum before we get to the point of having to use it. In effect, it shortens the amount of 'scope we have available without the use of the stiffener. We almost never have to do any sort of alpha maneuver, because we can usually easily get up toward the splenic flexure, then rotate a little bit clockwise to get any loop out. Often we will then have some redundancy in the sigmoid, so we will hook the 'scope into the splenic flexure and gently pull back until we see that we've straightened out the colonoscope. Then under fluoroscopic guidance, gently and with rotation, slowly push the stiffener up. We wind up getting the stiffener up almost to the splenic flexure. Since we have pleated the whole sigmoid over it, we can quickly and easily get around to the cecum with far less patient discomfort. I might point out that everybody is always very careful to lubricate the outside of the stiffener very well, but you also must remember that you need a lot of lubrication between the colonoscope and the stiffener, otherwise the stiffener binds against the colonoscope. Dr. Friend: I have seldom used the stiffener. One way of avoiding difficulty when going through that sigmoid colon is to keep a clockwise torque on the 'scope, making short movements in and out, with a little bit of deflection on the tip. Most of the time you can get through the sigmoid colon without any fancy loops. Once you are up to the splenic flexure area, the clockwise torque will keep that sigmoid colon relatively straight. Dr. Berk: Last question, rapidly down the line, yes or no: do you do the alpha maneuver? Dr. Morrissey: I use it very rarely. Dr. Gaisford: Very rarely. Dr. Carlin: The same. Dr. Friend: I use it deliberately, exactly the way Dr. Christopher Williams taught me how to use it. The only time I make a counterclockwise rotation for torquing is with the alpha maneuver. The other method to hold a sigmoid straight, while advancing to the splenic flexure and hepatic flexure, is to perform a clockwise torquing maneuver. As a rule of thumb, if you are not sure which way to go, it's a clockwise torque that holds everything in place, not the alpha loop.
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