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PubMed2000

Laparoscopic management of colonoscopic perforations.

Colonic perforation is a dangerous complication of colonoscopy, both diagnostic and therapeutic, and its management has become controversial. The question of conservative vs operative treatment is still under debate. Despite the recent expansion and wide acceptance of laparoscopy by surgeons, the feasibility of this technique as a means of treating abdominal emergencies has also been questioned. Of 575 patients admitted to our institution for abdominal emergencies between 1993 and 1998, 365 were treated via a laparoscopic approach. Two of these patients were treated for colonoscopic perforations, one after a diagnostic procedure and one after an operative procedure. Our technique employs an open umbilical approach with two other trocars introduced in the right iliac fossa and left flank. In the first case, a diverticular perforation of the subperitoneal rectum was suspected. The abdomen was copiously irrigated with saline solution and a drain was left in the pelvis. In the second patient, localized peritonitis was found in the left iliac fossa due to a microperforation of the sigmoid colon. It was repaired with a single absorbable suture. The postoperative course was unremarkable in both cases. In patients with an emergency abdomen due to a postcolonoscopy perforation, we consider the laparoscopic approach feasible and safe in experienced hands. It allowed us to avoid an unnecessary laparotomy and other time-consuming and expensive diagnostic investigations. This approach represents an excellent means of managing this type of emergency abdominal situation.

Abdomen, Acute↗
PubMed2001

Colonoscopic management of lower gastrointestinal hemorrhage.

Lower gastrointestinal bleeding is a common reason for hospitalization, especially among the elderly. Unlike that of upper gastrointestinal bleeding, the diagnostic and therapeutic approach to individuals with lower gastrointestinal bleeding is not well standardized. Recent reports indicate that early colonoscopy may be the best strategy to improve outcomes and reduce costs. However, good prospective, controlled data on the role of colonoscopy in the management of lower gastrointestinal bleeding are still required. Colonoscopy can establish a definite or probable diagnosis in greater than 80% of individuals with lower gastrointestinal bleeding. Based on the best available evidence, it appears that clinical and colonoscopic data may be combined in an effort to predict outcome and suggest optimal length of stay. It also appears that therapeutic colonoscopy can arrest or prevent bleeding in certain high-risk patients, offering the opportunity to change the natural history of the bleed.

Algorithms↗
PubMed2006

Colonoscopic polypectomy: a critical review of recent literature.

Colonoscopic polypectomy continues to be a major activity of gastrointestinal endoscopists, based upon the belief that ridding the colon of polyps prevents colon cancer. We review recent literature bearing on this assumption, emphasizing the benefits and limitations of colonoscopy for screening and surveillance of polyps. CT colonography has developed as an alternative or adjunct to colonoscopy but has not surpassed it in accuracy or therapeutic potential. Other recent technologic developments, such as magnification and chromoendoscopy, are reviewed, and an attempt is made to put them in perspective.

Colonic Neoplasms↗
PubMed1988

Colonoscopic screening of persons with suspected risk factors for colon cancer. I. Family history.

A family history of colorectal cancer is believed to place persons at increased risk for development of the disease. It is unclear, however, how "strong" a family history must be to increase this risk or to make colonoscopic screening appropriate. We performed initial colonoscopy in 154 asymptomatic subjects whose only suspected risk factor was one or two first-degree relatives with colorectal cancer; 48 of these subjects also had affected second- and third-degree relatives. We found 45 adenomas in 28 subjects (18%). One subject had a 3-cm villous adenoma. In 6 subjects, the most advanced findings were tubular adenomas 5-9 mm in diameter; in 21 subjects, we found only tubular adenomas that were 2-4 mm in diameter. The prevalence of adenomas increased significantly with age of subjects (p less than 0.01). Although the overall prevalence of colorectal neoplasms in our group was no greater than might be expected in the general population, subjects with two first-degree relatives tended to have more diminutive adenomas than those with one such relative. Our findings suggest that colonoscopy is not an appropriate first step in screening persons with one affected first-degree relative. For those with more complex family histories, more data are needed--particularly on the prevalence of advanced neoplasms--to determine whether a screening technique that is less costly and less invasive than colonoscopy may be adequate.

Adenoma↗
PubMed1989

Colonoscopic screening of persons with suspected risk factors for colon cancer: II. Past history of colorectal neoplasms.

Colonoscopic screening has been recommended for all persons who have had a colorectal adenoma or carcinoma. Such persons have been assumed to be at increased risk of having additional, asymptomatic colorectal neoplasms, the removal of which would reduce morbidity and mortality from colorectal cancer. In this prospective study, initial colonoscopy was performed on 544 asymptomatic subjects with past histories of colorectal index lesions ranging from small tubular adenomas to invasive cancers. In 402 subjects whose worst index lesion was an adenoma, the prevalence of neoplasms detected at colonoscopy, above the reach of the rigid sigmoidoscope, increased with age, male sex, black race, and the number and size of their index adenomas. In 142 subjects whose worst index lesion was invasive cancer, colonoscopy findings were marginally related to age and white race. A subgroup of 133 subjects whose worst index lesion was a single, small (less than 10 mm) tubular adenoma and who had no first-degree relatives with colorectal cancer had only a 3% prevalence of advanced colonic neoplasms (tubular adenomas greater than or equal to 10 mm in diameter; tubulovillous, villous, or severely dysplastic adenomas; or invasive cancers) found on colonoscopy--no greater than would be expected in the general population. Subgroups of the remaining 411 subjects, who had advanced or multiple index lesions, had prevalences of advanced neoplasms ranging from 8% to 18%. These findings indicate that for persons whose only risk factor is a single small tubular adenoma, current screening guidelines could be modified to recommend techniques less costly and less invasive than colonoscopy.

Adenoma↗
PubMed1990

Colonoscopic surveillance in long-standing total ulcerative colitis--a 15-year follow-up study.

In a 15-year surveillance program composed of 72 patients with total ulcerative colitis, 12 patients developed definite dysplasia. At endoscopy, low-grade dysplasia was detected in seven patients, high-grade in four, and a carcinoma (Dukes' stage A at operation) in one. One of the patients with high-grade dysplasia and macroscopical lesions at colonoscopy had a carcinoma (Dukes' A) detected at operation. A sequential development of dysplasia was found in seven patients. The cumulative risk of developing at least low-grade dysplasia was 14% after 25 years of disease duration. Using flow cytometric analyses, abnormal, aneuploid DNA content was detected in biopsies of 12 of 59 patients (20.3%); this correlated significantly with low-grade and high-grade dysplasia. Aneuploidy preceded dysplasia in two patients and was also detected in two dysplasia-free patients. The long-term use of colonoscopic surveillance in ulcerative colitis is a reliable way to select patients, in whom dysplasia is developing, for prophylactic surgery. Additionally, flow cytometric DNA analyses may help in the selection. The risk of missing a carcinoma until it becomes incurable appears to be low.

Adolescent↗
PubMed1990

Increased expression of a putative adenoma-associated antigen in pre-colonoscopic effluent of patients with colorectal cancer.

A monoclonal antibody Adnab-9, was raised against antigens derived from benign polyps of the colon. Adnab-9 was tested against pre-colonoscopic effluent material obtained from groups of patients with a macroscopically normal colonscopic examination, histologically confirmed adenomatous polyps and patients with colorectal cancer (CRC). The resultant binding levels displayed little overlap between the CRC group and the normal, and the difference was statistically significant. Since this putative early neoplasia associated antigen is essentially not expressed in CRC extracts, it may originate from a region of the colon predisposed to neoplasia, increasing in expression as the tendency to malignancy progresses, useful in the diagnosis of early stage malignancy.

Adenoma↗
PubMedDate not supplied

Is colonoscopic cancer surveillance in ulcerative colitis essential for every patient?

Surveillance aims to diagnose precancer or cancer at a surgically curable stage. Cancer complicating ulcerative colitis affects only 1-2 per million of the general population annually. The risk is low within 10 years of disease onset, and in proctitis or left-sided colitis. It is approximately one in 120 per year for those with extensive disease after 10 years from onset. Results of surveillance programmes from regional hospitals among 423 patients led to surgery for precancer or cancer once every 123 colonoscopies; there were no cancer deaths during surveillance and all 4 cancers were Dukes' stage A or B. At referral centres, many patients have dysplasia at the first colonoscopy. Two-thirds of cancers in colitis develop in the recto-sigmoid; flexible sigmoidoscopy has a role in surveillance which is untested. Colonoscopic surveillance is not appropriate for most patients with colitis; it is worthwhile but not essential for those with long-standing extensive disease.

Colitis, Ulcerative↗
PubMed2005

Colonoscopic perforations: a retrospective review.

Colonic perforation is no longer a rare complication of colonoscopy. Our previous report identified 45 such iatrogenic injuries from 1980 through 1994 (3082 colonoscopies per year). This follow-up of the ensuing 7 years examines changing trends of endoscopic usage in addition to management and prognosis of patients with colonoscopic perforations. Retrospective analysis of 78,702 colonoscopies (1994 through 2000, 11,243 colonoscopies per year) allowed assessment of medical records in all patients treated at our institution for colonic perforation. Sixty-six patients from our institution (perforation rate, 0.084%; 1 per 1192 procedures) and six patients from outside institutions were treated for colonic perforation following colonoscopy (41 women, 31 men; ages, 30-92 years; median, 73 years). Sixty-two patients underwent laparotomy, while 10 were managed nonoperatively. All 10 patients managed nonoperatively were void of peritoneal irritation by physical examination; eight patients did well (median hospital stay, 5.5 days; range, 0-12), but one death (family declined operative intervention) and one pelvic abscess requiring percutaneous drainage were noted. Peritoneal irritation by physical examination was evident in 57 of 62 patients undergoing laparotomy. Perforations occurred throughout the colon: right, 22 (31%); transverse, 5 (7%); left, 44 (61%); and unknown, 1 (1%). Thirty-eight patients (61%) underwent primary repair or resection with anastomosis. Fecal diversion was used in 100% of patients with extensive peritoneal contamination (n = 12) and 40% of patients with moderate contamination (12 of 30). Perioperative morbidity (39%) and mortality (8%) were significant. Factors predicting a poor outcome included delayed diagnosis, extensive peritoneal contamination, and patients using anticoagulants (P < .05). Compared with our prior study, the present review highlights a higher prevalence of injury based on more frequent use of colonoscopy. Perforation rates remain around 0.08%. While nonoperative management is viable in patients void of peritonitis, expedient surgical intervention seems to facilitate patient recovery.

Adult↗
PubMed2005

Colonoscopic diagnosis of mucocele of the appendix.

BACKGROUND: Appendiceal mucoceles are uncommon cystic neoplasms characterized by distension of the appendiceal lumen with mucus. There have been no reported series of colonoscopically diagnosed mucoceles with clinicopathologic correlation. METHODS: A retrospective review of colonoscopies performed at our institution over the past 14 years was undertaken with patient demographics, clinical data, surgical outcomes, and histopathology obtained from hospital records. OBSERVATIONS: Seven patients (6 women) with mucocele of the appendix were identified at colonoscopy. Three had complained of right lower quadrant pain. All 7 patients underwent surgical resection. Histopathology demonstrated mucinous cystadenoma in all. No cases revealed carcinoma, and there have been no deaths related to the mucocele. CONCLUSIONS: Appendiceal mucoceles may be recognized at colonoscopy as a smooth bulbous submucosal lesion of the cecum with an impression formed by the appendiceal orifice. Recognition at colonoscopy is important because it enables accurate diagnosis and directs management. Surgery is recommended in all cases given the risk of malignancy or perforation with resultant pseudomyxoma peritonei.

Adult↗
PubMed2006

Blood supply of colorectal polyps correlates with risk of bleeding after colonoscopic polypectomy.

BACKGROUND: The most common complication of endoscopic polypectomy is hemorrhage. Several factors have been reported to increase the risk of hemorrhage after polypectomy, but controversies still exist. Additionally, the pathomechanism of this complication is not well understood. OBJECTIVE: To investigate the risk factors of colonoscopic postpolypectomy bleeding in patients without bleeding disorders and the blood supply of resected polyps. PATIENTS: Two hundred forty-five patients (147 men, 98 women; median age, 62.8 +/- 9.5 years [SD]) with 283 colorectal polyps, measuring > or =1 cm in diameter, were included in this prospective study. INTERVENTIONS: The polypectomies were performed using the conventional endoscopic method. Data on the patients' age and sex, as well as polyp location, size, shape, and pathology findings were recorded. The patients were observed for bleeding complications. Microscopic examination of the vascular supply of the removed polyps was performed. RESULTS: Twenty-nine postpolypectomy hemorrhages (10.2%) occurred. The bleeding rate correlated with the size, shape, and pathology results of resected polyps. The microscopic analysis revealed that sessile and thick-stalked pedunculated polyps are supplied with more vessels than other polyps. CONCLUSIONS: Patients with polyps larger than 17 mm, pedunculated polyps with a stalk diameter >5 mm, sessile polyps, and malignant lesions of the colorectal region are at high risk of hemorrhage after endoscopic excision. Moreover, on the basis of microscopic study, broad-based polyps are supplied with a considerable number of blood vessels.

Adult↗
PubMed1990

Through the colonoscope--a radiologist's view.

A series of 1578 consecutive colonoscopies performed by radiologists in training is reviewed, with specific reference to patients with colorectal neoplasms. The contribution of the radiologist to the practice of colonoscopy is discussed. This input to the colonoscopy service of a hospital carries several benefits, including the following: a link is established between radiologists and gastroenterologists which improves the standard of both barium enema and colonoscopic examinations; informed discussion is made possible about the suitability of a barium enema lesion for endoscopic removal; the endoscoping radiologist acquires an impartial view of each examination and is able to choose the more appropriate investigation; direct visualisation of the colonic mucosa and its abnormalities may facilitate the interpretation of barium radiographs and enhance the quality of the radiological training that can be offered. In our experience, participation in a weekly colonoscopy session has had no adverse effect on the routine work of the radiology department.

Adenoma↗
PubMed2004

Risk of colonoscopic polypectomy bleeding with anticoagulants and antiplatelet agents: analysis of 1657 cases.

BACKGROUND: Anticoagulants and antiplatelet agents commonly are used to treat patients with cardiovascular and cerebrovascular diseases. Data on the safety of the use of these drugs before colonoscopic polypectomy are scanty. METHODS: An audit was conducted for a 2-year period of consecutive patients undergoing colonoscopy and polypectomy. Patient demographics, site and size of polyps, and the use of anticoagulants and antiplatelet agents were documented from a hospital on-line database. Bleeding episodes were classified as immediate or delayed and were graded as mild, moderate, or severe. Risk factors associated with postendoscopy bleeding were analyzed by multivariate logistic regression analysis. RESULTS: A total of 5593 cases were reviewed. Polypectomy was performed in 1657 patients. There were 37 cases of polypectomy-associated bleeding (2.2%); bleeding was immediate in 32 and delayed in 5. Multivariate analysis showed that warfarin use, after adjustment for the effects of each of the other factors, was an independent risk factor for bleeding, with an odds ratio 13.37: 95% CI[4.10, 43.65]. Age; the location and size of polyp; and the use of aspirin, non-steroidal anti-inflammatory drugs, and other antiplatelet agents were not associated with a higher risk of polypectomy-associated bleeding. CONCLUSIONS: The use of antiplatelet agents during polypectomy was not associated with an increase in post-polypectomy bleeding. In contrast, treatment with warfarin should be discontinued, because this was associated with a significant increase in post-polypectomy bleeding.

Aged↗
PubMed1980

Diagnostic implications of the spatial distribution of colonic mass lesions (polyps and cancers). A prospective colonoscopic study.

A prospective colonoscopic study of 642 consecutive patients demonstrated that 156 (66%) mass lesions including 131 polyps and 25 cancers were located within 60 cm of the anus and 82 (34%) mass lesions including 68 polyps and 14 cancers were located beyond 60 cm, the working length of the rigid sigmoidoscope. One hundred twenty-one (61%) polyps and 14 (36%) cancers were located above 25 cm but less than 60 cm from the anus, the working length of the flexible sigmoidoscope. Sixty-eight (34%) polyps and 14 (36%) cancers were located beyond the reach of the flexible sigmoidoscope. Although the flexible sigmoidoscope detects more lesions than the rigid sigmoidoscope, 50% of colon cancers located beyond detection by the rigid sigmoidoscope would not have been detected with the flexible sigmoidoscope. Of all mass lesions located beyond 25 cm, 38% would not have been detected with the use of the flexible sigmoidoscope. It appears that total colonoscopy rather than flexible sigmoidoscopy must play an increasingly prominent role in the evaluation of patients with suspected colonic mass lesions.

Colonic Neoplasms↗
PubMedDate not supplied

Colonic concentrations of hydrogen and methane following colonoscopic preparation with an oral lavage solution.

Explosions are a rare complication of electrocautery in the colon. The cause of these explosions is ignition of gas containing hydrogen (greater than 4%) or methane (greater than 5%), and oxygen. Hydrogen and methane are products of colonic bacterial metabolism. Oral solutions used for colonoscopy preparation are designed to cleanse the colonic lumen but provide no substrate for fermentation reactions. In 52 patients undergoing colonoscopy, gas samples were collected from the right, transverse, and left colon and analyzed for hydrogen, methane, oxygen, and carbon dioxide. The highest hydrogen and methane concentrations were 0.6% and 0.7%, respectively, less than 16% of the explosive level. Oxygen and carbon dioxide concentrations were close to those of air, suggesting that the bulk of colonic gas was air infused during the procedure. We conclude that the concentrations of explosive gases are well below the hazardous levels when oral colonic cleansing solutions and standard colonoscopic procedures are employed.

Administration, Oral↗
PubMed1996

Prospective assessment of colonoscopic intubation skills in trainees.

INTRODUCTION: The American Society for Gastrointestinal Endoscopy recommends a minimum of 100 supervised colonoscopies prior to assessment of technical competence. To establish a measurable standard for competence and to assess this recommendation, performance of colonoscopies at a university hospital was studied. METHODS: Colonoscopic preparation, surgical history, medication usage, technical maneuvers, extent of colon intubated, success rate, and cecal intubation time were prospectively monitored for first-year trainees, second-year trainees, and attendings. RESULTS: Excluding patients with poor preparations or colonic resections, 496 colonoscopies were studied. First-year trainees (n = 5) required attending assistance in 73 of 79 (92%) procedures. Second-year trainees (n = 7), who had performed a mean of 123 colonoscopies prior to the study, required attending assistance in 37 of 102 (36.3%) procedures. Attendings (n = 7) successfully intubated the cecum in 297 of 315 (94.3%) colonoscopies in a median time of 10.5 minutes. Second-year trainees were less successful than attendings in cecal intubation (success rate = 84%, p < 0.05), and required more time (median = 14.5 minutes, p < 0.01). More technical maneuvers were performed, and a lesser extent of colon was intubated, during trainee colonoscopies. CONCLUSIONS: We propose a 90% success rate and a median cecal intubation time of less than 15 minutes as reasonable standards for measuring technical competence. Trainees do not achieve this standard after the performance of 100 supervised colonoscopies.

Cecum↗
PubMed1999

Serrated adenoma of the colorectum: colonoscopic and histologic features.

BACKGROUND: Serrated adenoma is a recently recognized epithelial neoplasm of the colorectum. The aim of this study is to clarify the colonoscopic features of serrated adenomas. METHODS: The endoscopic findings for 52 serrated adenomas of the colorectum were investigated; these were then divided into three groups according to surface features. The histologic type (tubular, tubulovillous or villous) and the incidence of high-grade dysplasia were compared among the three groups. RESULTS: The surface under chromoscopy showed a hyperplastic pattern in 17 lesions, a cerebriform pattern in 18 lesions and a combined pattern in 17 lesions. The tubular type of serrated adenoma was predominant in the hyperplastic pattern group (94%), whereas the tubulovillous or villous histologic types were frequent in the cerebriform pattern (89%) and combined pattern (82%) groups. High-grade dysplasia was found in 18% of the combined pattern adenomas; the incidence was lower in hyperplastic (6%) or cerebriform pattern (0%) adenomas. CONCLUSIONS: Surface features of serrated adenomas have a close correlation with their histologic type. A combined hyperplastic-cerebriform surface pattern under chromoscopy was seen only in serrated adenomas.

Adenoma↗
PubMed1982

Colonoscopic diagnosis and management of rectal bleeding.

The use of the colonoscope to evaluate the cause of rectal bleeding in a series of 2200 patients has been reviewed. The most common cause of bleeding in this series was found to be neoplastic polyps, which were present in 723 patients (32 per cent). Colonic carcinoma was detected as the source of the bleeding in 425 cases (19 per cent). Although a large number of barium enema films were false negatives, the patients reviewed are a highly select group. It is still believed that barium enema studies and colonoscopy are complementary rather than competitive procedures. Their continued combined use greatly enhances diagnostic accuracy. Various other causes of colonic bleeding, including inflammatory bowel disease, arteriovenous malformations, endometriosis, ovarian carcinoma, ischemic colitis, and radiation colitis, have been discussed and their endoscopic appearance described. Of particular significance is the coexistence of internal hemorrhoids or diverticular disease and neoplastic colonic lesions. Barium enema films and sigmoidoscopy have been frequently described as the twin pillars of diagnosis in the detection of colonic pathology. Colonoscopy, as the third pillar of diagnosis, should be an integral part of the evaluation of patients with rectal bleeding.

Colitis↗