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PubMed1997

Laparoscopic repair of a colonoscopic perforation.

We report a case of laparoscopic repair of a diagnostic colonoscopic perforation. No other such reports were noted in the literature. The management of colonoscopic perforations has become controversial. Operative vs nonoperative treatment is continually debated. The morbidity of operative management is significant. Colostomy is often performed. Laparoscopy should allow early evaluation of operative patients and primary repair of those with minimal contamination and no residual pathology. The benefits of minimally invasive surgery, such as shortened hospitalization and rapid return to full activities, including work, were realized in our patient. Laparoscopy should be considered in the selective management of colonoscopic perforations.

Colon, Sigmoid↗
PubMed2003

Usefulness of flexible colonoscopic microwave coagulation therapy for a colorectal anastomotic stricture.

PURPOSE: Several methods of treatment for benign anastomotic strictures after anterior resection have been described. We describe a simple, safe, effective, and inexpensive method for treating benign colorectal anastomotic stricture by means of microwave coagulation under flexible colonoscopic visualization. METHODS: Eighteen patients with rectal or rectosigmoidal cancer underwent low anterior resection or anterior resection without colonic pouch and colorectal anastomosis by a double-stapling technique with PCEEA. Two of 18 patients (11.1 percent) developed an anastomotic stenosis. A microwave electrode was passed through the biopsy channel of the flexible colonoscope. Under flexible colonoscopic visualization, microwave irradiation was performed at four points (3, 6, 9, and 12 o'clock) in the stricture site because of granulation scar to obtain an adequately coagulated area. No bougies were performed thereafter. RESULTS: The anastomotic strictures could be dilated adequately, the patients could defecate satisfactorily, and their abdominal distentions and bowel symptoms were resolved. No complications occurred. No occurrence of restricture has been observed. CONCLUSION: Flexible endoscopic, microwave coagulation therapy is a useful, simple, effective, and safe method for the treatment of benign colorectal anastomotic strictures.

Anastomosis, Surgical↗
PubMed1993

Colonoscopic surveillance reduces mortality from colorectal cancer in ulcerative colitis.

BACKGROUND: To control the increased risk of colorectal carcinoma in patients with long-standing ulcerative colitis, surveillance colonoscopy is widely recommended. METHODS: To assess the role of colonoscopic surveillance in affecting colorectal carcinoma-related mortality, an outcome analysis was performed. RESULTS: Among the total of 41 patients who developed carcinoma associated with ulcerative colitis, 19 patients were under colonoscopic surveillance and 22 patients were not. Carcinoma was detected at a significantly earlier Dukes' stage in the surveillance group (P = 0.039). Four patients in the surveillance group died, compared with 11 patients in the no-surveillance group. The 5-year survival rate was 77.2% for the surveillance group and 36.3% for the no-surveillance group (P = 0.026). CONCLUSIONS: These results suggest that colonoscopic surveillance reduces colorectal carcinoma-related mortality by allowing the detection of carcinoma at an earlier Dukes' stage.

Adolescent↗
PubMed2005

Colorectal cancer risk after colonoscopic polypectomy: a population-based study and literature search.

Adenoma patients are considered to be at an elevated risk for colorectal cancer, even after their adenomas have been removed. The aim of this study was to estimate the colorectal cancer risk after colonoscopic polypectomy compared with age- and gender-matched general population controls. Colorectal cancer incidence was studied in 553 consecutive patients without cancer whose adenomas were colonoscopically removed in the endoscopy department of a general hospital. The colorectal cancer relative risk in these patients was 0.9 (0.3-2.0). A literature search was performed to identify all published studies on relative colorectal cancer risk after polypectomy. The relative risk estimates in seven other studies ranged from 0.2 (0.1-0.6) to 1.3 (0.6-2.3). The difference can, be explained partially by the inclusion or exclusion of patients with large sessile polyps and other factors. Our review shows that colorectal cancer risk after colonoscopic polypectomy does not exceed the risk in the general population.

Adenoma↗
PubMed2006

Position changes improve visibility during colonoscope withdrawal: a randomized, blinded, crossover trial.

BACKGROUND: Adequate distension is essential to maximize neoplasia detection during colonoscope withdrawal. Position changes may improve distension but are often not performed in routine practice. OBJECTIVE: To assess whether routine position changes improve luminal distension during colonoscope withdrawal. DESIGN: Randomized, blinded, crossover trial. SETTING: Single tertiary-referral center, United Kingdom. PATIENTS: Fourteen patients attending for routine colonoscopy. INTERVENTIONS: Videotaped, back-to-back examination of colon proximal to rectosigmoid junction in left lateral position only, then with position changes: left lateral for the cecum to the hepatic flexure, supine for the transverse colon, and right lateral for the splenic flexure and the descending colon, or vice versa. MAIN OUTCOME MEASUREMENTS: Luminal distension as scored by a blinded video reviewer. Luminal distension was scored on a scale of 1 to 5 for each colonic area: 1, complete collapse; 5, widely distended to limit of view. A score of 2 or less was considered inadequate for diagnosis. RESULTS: Scores for the 2 examinations from the blinded video reviewer were significantly higher in the transverse, the splenic flexure, and the descending colon, P = .02, .002, and <.001, respectively. Without position changes, 6 of 14 of patients (43%) would have had a nondiagnostic distension score (1 or 2) in at least 1 colonic area, P = .03. LIMITATIONS: Nonvalidated scoring system for luminal distension, however, good agreement between endoscopist and blinded reviewer, weighted kappa 0.53, 95% confidence interval 0.38-0.69. CONCLUSIONS: Position change, a cost-neutral intervention, during colonoscope withdrawal improved luminal distension between hepatic flexure and sigmoid-descending junction and has the potential to reduce adenoma and early cancer miss rates.

Colon↗
PubMed1999

Colonoscopic polypectomy in chronic colitis: conservative management after endoscopic resection of dysplastic polyps.

BACKGROUND & AIMS: Adenomatous polyps are by definition dysplastic and pathologically indistinguishable from the dysplasia-associated lesion or mass (DALM) described in 1981. Yet, adenomatous polyps in noncolitic colons are usually removed definitively endoscopically, whereas DALMs are regarded as harbingers of colon cancer, mandating colectomy. METHODS: Since 1988, all of our patients with chronic ulcerative or Crohn's colitis and dysplastic polyps and no coexistent dysplasia in flat mucosa underwent colonoscopic polypectomy. Biopsy specimens were obtained also adjacent to polypectomy sites, from strictures, and throughout the colon at 10-cm intervals. Follow-up colonoscopies and biopsies were performed within 6 months after polypectomy and yearly thereafter. RESULTS: Colonoscopy in 48 patients with chronic colitis (mean duration, 25.4 years) resected 70 polyps (60 in colitic and 10 in noncolitic mucosa). Polyps were detected on screening colonoscopies (29%) and on surveillance (71%). Pathology was tubular adenoma in all polyps from noncolitic mucosa and low-grade dysplasia (57), high-grade dysplasia (2), or carcinoma (1) in polyps from colitic mucosa. Subsequent colonoscopies (mean follow-up, 4.1 years) revealed additional polyps in 48% but no carcinomas. Surgical resection (6 patients) for recurrent polyps confirmed colonoscopic findings. No dysplasia or cancers in flat mucosa were found at surgery or on follow-up colonoscopies. CONCLUSIONS: In patients with chronic colitis who have no dysplasia in flat mucosa, colonoscopic resection of dysplastic polyps can be performed effectively, just as in noncolitic colons.

Adenoma↗
PubMed1996

Premedication with intravenous antispasmodic speeds colonoscope insertion.

BACKGROUND: Use of antispasmodic medication prior to colonoscopy is controversial but may improve visualization of colonic mucosa and ease colonoscope insertion. METHOD: The effects on the performance of colonoscopy by premedication with the antispasmodic hyoscine n-butyl bromide were studied in a prospective, double-blind, placebo-controlled trial. Fifty-six consecutive patients were randomly assigned to receive intravenous hyoscine 20 mg (n = 29) or placebo (n = 27) in conjunction with our standard initial medications (meperidine 0.7 mg/kg and midazolam 0.03 mg/kg). Insertion and withdrawal of the colonoscope were timed, and 100 mm visual analogue scales were used to assess procedure difficulty, colonic motility, and the degree of discomfort experienced by the patients. RESULTS: In those patients receiving hyoscine, intubation time was quicker (median hyoscine, 13 minutes; median placebo, 17.5 minutes, p = 0.045) and colonic spasm less (median hyoscine, 19 mm; median placebo, 53.5 mm, p = 0.01). The procedure was considered significantly less difficult in the hyoscine group (median, 23.5 mm) compared to the placebo group (median, 50), p <0.05. No significant differences in withdrawal time or patient pain scores were found. CONCLUSIONS: Premedication with intravenous hyoscine n-butyl bromide reduces colonic spasm and in this study made colonoscope insertion significantly quicker and easier.

Adult↗
PubMed1997

Management of colonoscopic perforations.

OBJECTIVE: To document our evolving surgical management of colonoscopic perforation and examine factors crucial to the improvement of patient care. DESIGN: We conducted a computer-based retrospective analysis of medical records (1980 through 1995). MATERIAL AND METHODS: Among 57,028 colonoscopic procedures performed, 43 patients (0.075%, or 1 perforation in 1,333 procedures) had a colonic perforation. Two additional patients were treated after colonoscopy performed elsewhere. The outcomes analyzed included surgical morbidity and mortality. RESULTS: Twenty-six women and 19 men who ranged in age from 28 to 85 years (median, 69) were treated for colonic perforation. More than 80% of perforations occurred during the latter half of the study period because of the increased volume of colonoscopic procedures (8 perforations among 12,581 examinations from 1980 through 1987 versus 35 perforations among 44,447 colonoscopies from 1988 through 1995). Emergency laparotomy was performed in 42 patients (93%). Perforations occurred throughout the colon: right side = 10; transverse = 9; and left side = 23. Three patients without evidence of peritoneal irritation fared well with nonoperative management. Most patients underwent primary repair or limited resection in conjunction with end-to-end anastomosis. In 14 patients (33%), an ostomy was created. One patient underwent laparotomy without further treatment. Intra-abdominal contamination ranged from none (31%) to local soiling (48%) to diffusely feculent (21%). Postoperative complications occurred in 12 patients and were associated with older age (P = 0.01), large perforations (P = 0.03), and prior hospitalization (P = 0.04). No postoperative deaths occurred. CONCLUSION: Despite a consistently low risk of colonic perforation, the increasing use of colonoscopy in our practice has resulted in an increased number of iatrogenic colonic perforations. In order to minimize morbidity and mortality, prompt operative intervention is the best strategy in most patients. Non-operative management is warranted in carefully selected patients without peritoneal irritation.

Adult↗
PubMed1999

Staging of rectosigmoid neoplasia with colonoscopic endoluminal ultrasonography.

BACKGROUND: The accurate staging of colorectal neoplasia may aid the stratification of patients for adjuvant treatment. At present the mural extent of neoplasia proximal to the mid rectum is difficult to determine. Prediction of mural invasion could help identify patients suitable for radical resection, minimal access surgery or endoscopic treatment. Colonoscopic endoluminal ultrasonography (EUS) was used in a prospective study to determine the stage of rectosigmoid neoplasia in 121 patients. METHODS: Mural tumour (T) stage was designated by EUS as uT0/1-uT4 in 121 patients. Nodal (N) staging was performed in 39 cases. EUS staging was compared with histological stage (pT and pN) in 93 patients who underwent resection. RESULTS: Mural staging of disease using colonoscopic EUS showed good correlation with histo-pathological stage (kappa = 0.85 (95 per cent confidence interval 0.76-0.95)). Overall pT and pN stage accuracy of EUS was 92 and 65 per cent respectively. CONCLUSION: EUS accurately assessed tumour stage although node staging remained suboptimal. Colonoscopic EUS may aid the selection of treatment in patients with rectosigmoid neoplasia.

Adult↗
PubMed2005

Colorectal cancer in patients under close colonoscopic surveillance.

BACKGROUND & AIMS: Colonoscopic polypectomy is considered effective for preventing colorectal cancer (CRC), but the incidence of cancer in patients under colonoscopic surveillance has rarely been investigated. We determined the incidence of CRC in patients under colonoscopic surveillance and examined the circumstances and risk factors for CRC and adenoma with high-grade dysplasia. METHODS: Patients were drawn from 3 adenoma chemoprevention trials. All underwent baseline colonoscopy with removal of at least one adenoma and were deemed free of remaining lesions. We identified patients subsequently diagnosed with invasive cancer or adenoma with high-grade dysplasia. The timing, location, and outcome of all cases of cancer and high-grade dysplasia identified are described and risks associated with their development explored. RESULTS: CRC was diagnosed in 19 of the 2915 patients over a mean follow-up of 3.7 years (incidence, 1.74 cancers/1000 person-years). The cancers were located in all regions of the colon; 10 were at or proximal to the hepatic flexure. Although most of the cancers (84%) were of early stage, 2 participants died of CRC. Seven patients were diagnosed with adenoma with high-grade dysplasia during follow-up. Older patients and those with a history of more adenomas were at higher risk of being diagnosed with invasive cancer or adenoma with high-grade dysplasia. CONCLUSIONS: CRC is diagnosed in a clinically important proportion of patients following complete colonoscopy and polypectomy. More precise and representative estimates of CRC incidence and death among patients undergoing surveillance examinations are needed.

Adenoma↗
PubMed1977

A new technique for insertion of the colonoscope through the ileocaecal valve.

At colonoscopy it is important to examine the distal part of ileum in inflammatory diseases particularly. Different techniques for insertion of the colonoscope into the ileum have been described. In our experience these methods require considerable skill and practice. We have therefore worked out a technique for easier access to the ileum with a colonoscope. A closed biopsy forceps is used for identification of the ileocaecal valve by dislodging the upper lip. The forceps is manoeuvred through the ostium and then the colonoscope can be inserted into the ileum with the forceps as a guide.

Biopsy↗
PubMed2003

[Laparoscopic-assisted colonoscopic polypectomy--indications and results].

OBJECTIVE: Endoscopic treatment of large, sessile or awkward localized polyps, especially in the colon sigmoideum or the coecum holds the risk of colonic perforation. For these cases the combined colonoscopic-laparoscopic approach is described in this publication as an alternative procedure. PATIENTS AND METHODS: Since 1995 23 patients (male 11, female 12, age 70.7 +/- 12.0 years) were treated by laparoscopic-assisted colonoscopic polypectomy. Thirteen polyps were localized in the colon descendens or sigmoideum, seven in the cecum and one in the right respectively the left colonic flecture. Under general anesthesia and modified lithotomy position laparoscopy with occlusion of the colon or terminal ileum was followed by colonoscopy. After endoscopic localization the polyp was removed under laparoscopic visualization. During this procedure the colonic wall was stabilized, interfering adhesions were cut and coagulation- induced lesions of the wall were laparoscopically sutured if needed. RESULTS: In 17 patients the endoscopic polypectomy could be performed laparoscopically-assisted. In two patients the polypectomy was done by colotomy and in two others by segmental colonic resection due to the volume of the polyp. In two patients with histologically verified carcinoma laparoscopic-assisted left hemicolectomy was performed secondarily. Intra- or perioperative complications did not occur. CONCLUSION: Laparoscopic-assisted colonoscopic polypectomy is a new minimal-invasive therapeutical approach in selected cases with large, sessile or arkward localized polyps. The endoscopic procedure is possible also in polyps which should be treated by colotomy or segmental resection in the past. The additional discomfort for the patients due to laparoscopy is minimal.

Adult↗
PubMed2005

Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital.

BACKGROUND AND STUDY AIMS: Colonic tuberculosis is not uncommon in developing countries. As emigration to the West increases, it is worthwhile to recall the clinical, colonoscopic, and histopathological features of this condition. PATIENTS AND METHODS: The clinical, colonoscopic and histopathological findings were evaluated in 43 patients with colonic tuberculosis. RESULTS: Abdominal pain, weight loss, diarrhea, fever, and a lump in the abdomen were the commonest symptoms. Extraintestinal tuberculosis was present in 11 patients (26 %). Colonoscopy revealed ulcers in 30 patients (70 %), nodules in 24 (56 %), a deformed cecum and ileocecal valve in 17 (40 %), strictures in 10 (23 %), polypoid lesions in six (14 %), and fibrous bands forming mucosal bridges in three (7 %). The cecum and ascending colon were the commonest sites involved. Segmental tuberculosis was seen in six of the 32 patients (19 %) in whom full-length colonoscopy could be performed. Two or more sites were involved in 19 patients (44 %). Histopathology revealed well-formed granulomas in 23 patients (54 %). Fourteen of the above patients (61 %) had caseation and 11 (48 %) had confluence of the granulomas. Acid-fast bacilli were present in the biopsies from two patients (5 %). Ill-formed granulomas were seen in seven patients (16 %) and chronic inflammatory changes in 13 (30 %). Despite the various histopathological findings, all of the patients responded to antitubercular treatment and continued to remain asymptomatic during the follow-up period. CONCLUSIONS: Colonoscopy with biopsy is a useful method for diagnosing colonic tuberculosis. Even in the absence of the classic histopathological features, a therapeutic trial may be indicated in a given clinical and colonoscopic setting. Follow-up is essential.

Abdominal Pain↗
PubMed2006

Analysis of colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn's disease.

BACKGROUND AND STUDY AIMS: Intestinal tuberculosis and Crohn's disease are chronic inflammatory bowel disorders that are difficult to differentiate from one another. This study aimed to evaluate the diagnostic value of various colonoscopic findings in the differential diagnosis between intestinal tuberculosis and Crohn's disease. PATIENTS AND METHODS: Colonoscopic findings on initial work-up were prospectively recorded in patients with an initial diagnosis of either intestinal tuberculosis or Crohn's disease. These findings were analyzed after a final diagnosis of intestinal tuberculosis (n = 44) or Crohn's disease (n = 44) had been made after follow-up. RESULTS: Four parameters (anorectal lesions, longitudinal ulcers, aphthous ulcers, and cobblestone appearance) were significantly more common in patients with Crohn's disease than in patients with intestinal tuberculosis. Four other parameters (involvement of fewer than four segments, a patulous ileocecal valve, transverse ulcers, and scars or pseudopolyps) were observed more frequently in patients with intestinal tuberculosis than in patients with Crohn's disease. We hypothesized that a diagnosis of Crohn's disease could be made when the number of parameters characteristic of Crohn's disease was higher than the number of parameters characteristic of intestinal tuberculosis, and vice versa. Making these assumptions, we calculated that the diagnosis of either intestinal tuberculosis or Crohn's disease would have been made made correctly in 77 of our 88 patients (87.5 %), incorrectly in seven patients (8.0 %), and would not have been made in four patients (4.5 %). CONCLUSIONS: A systematic analysis of colonoscopic findings is very useful in the differential diagnosis between intestinal tuberculosis and Crohn's disease.

Adolescent↗
PubMed1990

The colon in shigellosis: serial colonoscopic appearances in Shigella dysenteriae I.

Twenty-five patients (16 males and 9 females; mean age 24.7 +/- 8.4 years) with acute colitis caused by Shigella dysenteriae I were studied, a total of 115 colonoscopic examinations being performed. Twenty-two patients had weekly colonoscopic examinations until the last procedure revealed normal colonic mucosa. Six abnormal colonoscopic appearances were documented, namely mucosal edema, ulcers, friability, punctate spots, erythematous areas and luminal exudate. Mucosal edema was the dominant finding in the first week of the disease. Star-shaped mucosal ulcers and friability were observed in the 2nd and 3rd weeks of the disease. Punctate hemorrhagic spots with normal intervening mucosa in patients with minimal constitutional and colonic symptoms were the hallmark of the disease from the 4th week onwards. None of the patients revealed granularity, cobblestoning, linear fissures, pseudopolyps, pseudomembrane or anal lesions. The colonic involvement was subtotal in 20 patients and total in 5 patients. The mucosal disease was continuous in the initial stage and became patchy during the later stage of recovery. The mucosal disease lasted for 38.8 +/- 12.1 (10-65 days). All the patients followed-up by serial colonoscopy examinations eventually had normal colonic mucosa.

Adult↗
PubMed1988

Colonoscopic diagnosis and medical treatment of ten patients with colonic tuberculosis.

Ten patients with tuberculous enterocolitis were diagnosed colonoscopically. In four, the diagnosis was confirmed by positive acid fast stain or the presence of caseating granuloma in colonic biopsy material or ileal washings. In one other patient a cervical lymph gland revealed acid-fast bacilli. He was the only patient with extraintestinal disease, indicating that primary tuberculous colitis is probably more common than secondary in Saudi Arabia. In the other five patients the colonoscopic diagnosis was confirmed by a complete response to antituberculous triple therapy. Six patients had hypertrophic, two ulcerohypertrophic and two widespread ulcerative lesions. Colonoscopy with biopsies has definite advantages over barium enema in diagnosis. After thus excluding malignancy, Crohn's disease remains the most important differential diagnosis. A ten-week therapeutic trial of antituberculous treatment is recommended in patients from high-risk populations with a typical history and colonoscopic picture to avoid the morbidity and mortality of diagnostic laparotomy.

Adult↗
PubMed2003

Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy.

BACKGROUND: The most common major complication of colonoscopic polypectomy is postpolypectomy hemorrhage. Although several factors have been implicated in the occurrence of hemorrhage, accurate prediction of delayed bleeding remains difficult. This randomized controlled trial evaluated the efficacy of prophylactic clip application for prevention of delayed postpolypectomy bleeding. METHODS: Postpolypectomy ulcers created by colonoscopic removal of polyps (mean size 7.8 [4.0] mm) with the endoscopic mucosal resection technique were randomly assigned to prophylactic clip placement (n = 205) or no clip (n = 208). Baseline characteristics of the patients and polyps excised were comparable between the groups. Delayed bleeding was defined as the postprocedure passage of bloody stool or massive hematochezia. The site of delayed bleeding was identified at emergent colonoscopy. RESULTS: Delayed bleeding was identified from 2 ulcers in each group from 1 to 4 days after resection (mean 2.3 days). Delayed bleeding occurred from 0.98% of ulcers in the clip group and 0.96% in the non-clip group (p > 0.9999). No patient with delayed bleeding required transfusion or surgery. CONCLUSIONS: Prophylactic clip placement did not decrease the occurrence of delayed bleeding after colonoscopic polypectomy.

Adenocarcinoma↗
PubMed2002

Clinical and colonoscopic investigation of skipped periappendiceal lesions in ulcerative colitis.

BACKGROUND: Ulcerative colitis (UC) is typically a continuous and diffuse inflammation extending proximally from the rectum. However, skipped lesion in the appendiceal region has been reported recently. Although appendectomy has been shown to reduce the risk of UC, the clinical significance of skipped periappendiceal lesion remains unclear. The present study examined the relationship between the continuous distal lesion of UC and the skipped periappendiceal lesion by observing colonoscopic changes in both lesions. METHODS: Among 279 patients with UC who underwent total colonoscopy from January 1994 to December 2000, 54 patients (19.4%) had skipped periappendiceal lesions. Serial colonoscopic examinations were performed in 35 of the 54 patients to determine the activities in the distal UC lesion and skipped periappendiceal lesion during the course of disease. RESULTS: Patients with skipped periappendiceal lesions were younger and had a longer history of UC than those without them, but no differences in sex ratio and treatment modality were observed between the two groups. In 28 of 35 patients (80%), the activity in the distal lesion correlated well with that in the skipped periappendiceal lesion. Both lesions were improved in 17 patients, unchanged in 5 patients and worsened in 6 patients. Linear regression analysis showed a significant correlation between the changes in colonoscopic activity index in the two lesions. CONCLUSION: A close association is found between disease activity in the skipped periappendiceal lesion and that in the distal lesion of UC.

Adult↗