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— for what might be any number of reasons. That redundant colon, for example, is going to have a lot of twists and turns, and require a lot of maneuvering to get through. Steven Gorcey, MD, AGAF, chief of gastroenterology at Monmouth Medical Center in Long Branch, N.J., and an assistant clinical profes- sor at Drexel University Medical Center in Philadelphia, is wary of 2 scenarios. "One is where you're in the middle of a colonoscopy and all of the sudden you go, Wow, this is getting hard, or I can't go any- more. The other is where someone else failed, or you remember from the previous time that this was a brutal colonoscopy," says Dr. Gorcey. Given the choice, he'd rather know in advance about a difficult case. That way, he can modify his approach beforehand. For example, says Dr. Parikh, if you're dealing with an elderly patient who's had multiple bouts of diverticulitis, that patient may require a smaller or thinner scope. "Choosing the right scope to start with is the first thing," he says. "For the proverbial shorter, thinner elderly woman with divertic- ulitis, we may want to use a pediatric colonoscope or even a gastro- scope." If you need something thinner than a colonoscope, Dr. Gorcey prefers the gastroscope, because it's less likely than a pediatric scope to loop, he says. "You're only talking about a couple of millimeters' difference in width, but there's a significant performance difference in terms of stiffness." Loops, after all, are one of the biggest challenges you face. Everyone who does scopes learns basic tricks and techniques to get through them, but when internal structures twist and turn like a roller coaster, and scopes loop back on themselves more than once, there's bound to be trouble. "Every colon is like a lock with its own combination, and you have to figure out the code to get through," says Dr. Gorcey. "Do I torque here or push here? Do I pull here or do I turn here? One loop, you can push through. Two loops is going to get really, really tough. 8 9 M A Y 2 0 1 5 | O U T P A T I E N TS U R G E R Y. N E T