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PubMed2004

Mucocele of the appendix: a report of five cases.

Mucocele of the appendix is an uncommon disorder, characterized by a cystic dilatation of the lumen. It is often diagnosed clinically from signs and symptoms of acute appendicitis or, if it is asymptomatic, as an incidental finding during ultrasonography, computed tomography, and radiographic examinations of the gastrointestinal tract, or laparotomy. The incidence of mucocele ranges from 0.2% to 0.3% of all appendectomy specimens. We report five cases of appendiceal mucocele (all women, aged 19-90 years), who were admitted from January 1993 to January 2003 to our hospital. These cases represent 0.29% of the 1720 appendectomies performed during this period. Three of the patients were symptomatic and had appendectomies. The final diagnosis for mucocele was given at laparotomy. No colon neoplasms were identified during surgery, and subsequent colonoscopic examinations were also negative. The other two patients were asymptomatic of appendiceal tumor. Colonoscopy revealed two colonic malignant tumors in one patient and an adenocarcinoma of the sigmoid colon in the other. Mucocele of the appendix was diagnosed pre-operatively by ultrasound and computed tomography. One of the two patients underwent a right hemicolectomy and sigmoidectomy; the other one underwent an appendectomy, cecostomy and sigmoidectomy. Four of the patients recovered and are doing well today; one patient died on the twenty-fifth postoperative day. The most common symptom of mucocele is abdominal pain, although many patients may be asymptomatic. Mucocele is often associated with concomitant colon cancer, thus patients with this tumor should be systematically checked for other colonic lesions.

Adenocarcinoma↗
PubMed2004

Synchronous polyps in patients with colorectal cancer.

BACKGROUND: The aim of this study is to underscore the incidence of synchronous polyps in patients with colorectal cancer and to emphasise the importance of their perioperative detection and management. PATIENTS AND METHODS: Three hundred and seven patients underwent a potentially curative resection for colorectal cancer during the last ten years. A total of 129 synchronous polyps were detected in 72 of the patients (23.5%). Complete preoperative colonoscopy was performed in 62 of the patients. Forty-three polyps (33.4%) in 37 patients were removed preoperatively, while 69 polyps (53.4%) in 25 patients were included in the surgical specimen. In 10 patients the colon was evaluated postoperatively and 17 polyps (13.1%) were removed via endoscopy. RESULTS: A total of 81 polyps were detected in different surgical segments than the index cancer. Furthermore, 15 polyps were detected in the right colon of 55 patients with left colon cancer. CONCLUSIONS: Synchronous polyps in patients with colorectal cancer are a frequent event. Thus, all patients should undergo a perioperative colonoscopy and endoscopic polypectomy, if feasible. The planned surgical procedure may alter as a consequence of the colonoscopic findings in some of the patients.

Adult↗
PubMed2004

Management of recurrent anastomotic stricture and iatrogenic stenosis by circular stapler.

Anastomotic stricture is an increasingly common clinical finding. It is thought to arise because of ischemia, disruption, or leakage at an anastomosis site. Its management can be difficult and strictures often are resistant to standard dilation therapy. Major corrective surgery is possible; however, it is technically challenging and not without risk. We have used a circular stapler to excise colorectal strictures, introducing the anvil of the stapler via a proximal stoma or colotomy, drawing the anvil through the stricture with a snare via a colonoscope and affixing it to the body of a circular staple gun and excising the stricture. We have with found this to be an effective treatment in appropriately selected patients.

Aged↗
PubMed2004

Hyperplastic polyposis and the risk of colorectal cancer.

PURPOSE: Hyperplastic polyps are usually considered to be an innocent finding with little or no potential to progress to colorectal cancer. However, recent literature suggests that some of these polyps may be morphologically and genetically distinct and lead to microsatellite unstable colorectal cancers. The purpose of this study was to define the cancer risk associated with hyperplastic polyposis. METHODS: All patients with hyperplastic polyposis diagnosed by a single colorectal surgeon at a university hospital were followed prospectively. The diagnosis of hyperplastic polyposis was made by the presence of more than 20 hyperplastic polyps distributed throughout the colon and/or a hyperplastic polyp at least 1 cm in size in diameter in the right colon. Patient demographics, family history, size, location, and distribution of polyps and the development of colorectal cancer were noted. RESULTS: Thirteen patients who met the criteria for hyperplastic polyposis were identified and followed prospectively. All of these patients had at least 30 polyps distributed throughout the colon, often > 100. Nine of 13 also had a hyperplastic polyp at least 1 cm in size, usually in the right colon. Of particular note, 7 of 13 patients (54 percent) were diagnosed with colorectal cancer during the study period. Four had cancer on initial diagnosis and three patients developed cancer despite frequent colonoscopic surveillance. Five of seven colorectal cancers were located in the right colon. CONCLUSIONS: Patients with hyperplastic polyposis are at high risk for colorectal cancer. Failure to identify this subset of patients could have dire consequences.

Adenoma↗
PubMed2005

Assessment of JC polyoma virus in colon neoplasms.

PURPOSE: Research data have recently emphasized an intriguing association of JC polyoma virus with colon carcinogenesis. Tumorigenicity of JC virus is attributed to the T-antigen of its Mad-1 variant. Controversy arose when another research group did not confirm this association. The purpose of this study was to detect JC virus in a series of colon neoplasms from Greek patients. METHODS: A nested polymerase chain reaction assay was used to detect JC virus in 80 cancerous, 25 adenomatous specimens of large bowel, and 20 colonoscopic biopsy samples from normal patients without colorectal neoplasia. Quantitation of JC virus DNA was performed by real-time polymerase chain reaction. RESULTS: JC polyoma virus nucleotide sequence was detected in 61 percent of colon adenocarcinomas and in 60 percent of adenomas, at a viral load of 9 x 10(3) to 20 x 10(3) copies/microg DNA. Adjacent normal mucosa in 35 positive colon adenocarcinoma specimens, and normal mucosa from six patients of the control group, had low viral loads (50-450 copies/microg DNA). CONCLUSIONS: JC polyoma virus genome is present in colon neoplasms. JC virus detection in adenomas at comparable viral loads to malignant tumors suggests its implication at early steps of colonic carcinogenesis. Taking into consideration other published data, infection of colonic epithelium with JC virus might be a prime candidate for a role in chromosomal and genomic instability.

Adenocarcinoma↗
PubMed2005

Preoperative colonoscopy decreases the need for laparoscopic management of colonic polyps.

PURPOSE: Patients are commonly referred to surgeons for surgical resection of polyps that cannot be excised colonoscopically. Repeating the colonoscopy may be met with resistance by both the patient and the referring endoscopist. However, there are two distinct benefits. First, if the lesion was not marked, tattooing facilitates laparoscopic resection. Second, and more importantly, many of these polyps can be removed endoscopically by an experienced colorectal surgeon, avoiding unnecessary colon resection. Over a period of five years, we have reviewed preoperative colonoscopy in patients who were referred for surgical treatment of benign polyps. METHODS: From January 1999 through September 2003 all patients referred for surgical resection of a benign polyp were consecutively entered into a database by a single group of colorectal surgeons. All patients underwent preoperative colonoscopy on the day before the planned colon resection. Patient charts were reviewed, and demographics were recorded. The referral and preoperative colonoscopy reports and all pathology results were reviewed to record the polyp size, location, histology, and subsequent treatment. RESULTS: Altogether, 71 patients were included in this study. The average size of the polyps was 24 mm (range, 10-60 mm). The location of the polyp as determined by preoperative colonoscopy differed from the location noted on referral colonoscopy in nine patients (13 percent). Surgery was canceled in 23 patients (32 percent), primarily because of complete polypectomy at preoperative colonoscopy. Of the 48 who underwent surgery, 23 (47 percent) had a colonic tattoo placed, at the discretion of the surgeon. Lesions clearly located in the cecum were not tattooed routinely. Of the 48 patients who underwent surgery, 45 (94 percent) underwent laparoscopic colon resection. CONCLUSIONS: We concluded that patients referred for surgical resection of a polyp should undergo repeat colonoscopy preoperatively, given that in our study one-third of patients were spared unnecessary colectomy. In addition, repeat endoscopy by the operating surgeon offers an opportunity to confirm the location of the lesion and place a colonic tattoo to facilitate laparoscopic resection.

Aged↗
PubMed2002

Depressed-type submucosal colon cancer: report of a case.

PURPOSE: The article presents one of very few Korean reports on the detection of depressed early colorectal cancers, which have been cited by some Japanese doctors as another pathway for the development of colon cancers. Depressed-type early colorectal cancers have mainly been reported in Japan, and recently a few have also been reported in Western countries. Depressed early colorectal cancers are still rarely detected in Korea, where most colorectal surgeons, endoscopists, and radiologists refer to Western guidelines. METHODS: Recently, the authors experienced a typical 12-mm depressed-type early colon cancer in the ascending colon of a 55-year-old Korean male patient. It was detected by a colonoscopic examination. RESULTS: The lesion was flexible on insufflation and deflation with air and was considered an early colon cancer. Because of the large size, a surgical resection was performed. The final pathologic result was a minimally invasive submucosal cancer without lymph node metastasis. CONCLUSION: This Korean case is one of very few reported abroad, so we think that it might make an important contribution to research on depressed-type early colorectal cancer.

Adenocarcinoma↗
PubMed2002

The application of percutaneous endoscopic colostomy to the management of obstructed defecation.

PURPOSE: We describe the case of a 52-year woman with a 17-year history of obstructed defecation in whom all other standard treatments had failed and the patient had refused a colostomy. Her symptoms were controlled by percutaneous endoscopic colostomy with antegrade colonic irrigation. METHOD: A percutaneous endoscopic colostomy tube was placed in the sigmoid colon endoscopically using a colonoscope and the patient irrigated two liters of water through the percutaneous endoscopic colostomy twice each day and was able to successfully evacuate her rectum without excess straining or discomfort. CONCLUSION: Percutaneous endoscopic colostomy is an alternative option to colostomy in the management of obstructed defecation.

Colostomy↗
PubMed2002

Effect of sulindac treatment for attenuated familial adenomatous polyposis with a new germline APC mutation at codon 161: report of a case.

INTRODUCTION: Patients with familial adenomatous polyposis develop colorectal cancers if left untreated. As indicated in patients with familial adenomatous polyposis, prophylactic colectomy has been recommended even in a milder colonic phenotype referred to as attenuated familial adenomatous polyposis. However, therapeutic strategies in attenuated familial adenomatous polyposis are still controversial. METHODS: We report a patient with attenuated familial adenomatous polyposis who has been treated with sulindac for five years. During the period of observation, she has been carefully followed up by chromoscopic and radiographic surveillance. Immunohistochemical study for cyclooxygenase-2 and genetic analysis in the adenomatous polyposis coli gene was also performed. RESULTS: Continuous administration of sulindac resulted in obvious regression of both colorectal adenomatous polyps and gastric fundic gland polyps, and no cancers developed during the observation period. Immunohistochemical study showed the decrease of cyclooxygenase-2-positive epithelial cells in colorectal polyps by the treatment. The genetic analysis revealed a C to A substitution at nucleotide 481 of her germline adenomatous polyposis coli gene, which resulted in a nonsense mutation at codon 161. CONCLUSIONS: Our case suggests that treatment with sulindac accompanied by intensive colonoscopic surveillance may be a choice of management for attenuated familial adenomatous polyposis.

Adenomatous Polyposis Coli↗
PubMed2003

Internal hernia as a complication of colonoscopy: report of a case.

After screening colonoscopy, a 65-year-old female developed small-bowel obstruction as demonstrated on abdominal CT scan. The obstruction was caused by a large herniation of the small intestine seemingly caused by the colonoscopic procedure. This is only the second report in the literature of incarcerated intestinal hernia as a complication of colonoscopy.

Aged↗
PubMed2003

Vertebral venous air embolism: an unusual complication following colonoscopy: report of a case.

Although fiberoptic colonoscopy has gained wide popularity as a diagnostic and therapeutic tool, there remains an inherent complication rate following colonoscopic evaluation. Endoscopically induced bowel perforation and uncontrolled bleeding often necessitate immediate surgical intervention. Another often-unrecognized complication is the introduction of air into the vertebral venous system. A case of vertebral venous air embolism after routine diagnostic colonoscopy is reported with a review of current literature.

Colonoscopy↗
PubMed2005

Colorectal polyps in carriers of the APC I1307K polymorphism.

PURPOSE: The probability of colorectal cancer is moderately increased among carriers of the APC I1307K polymorphism. However, it is not known if endoscopic surveillance of this high-risk group is warranted. The prevalence of polyps and adenomas in specimens of colorectal cancer who are carriers and noncarriers of the APC I1307K polymorphism is compared. METHOD: Prevalence of adenomatous polyps in the pathology specimens of the study participants, stratified by their APC I1307K polymorphism status, was studied in 900 consecutive cases of colorectal cancer diagnosed in northern Israel between 1998 and 2002, within the framework of a population-based, case-controlled study (MECC Study). RESULTS: The APC I1307K mutation was detected in 78 colorectal cancer cases (8.7 percent) of the study population. Prevalence was higher among Ashkenazi Jews (11.2 percent) than among non-Ashkenazi Jews (2.7 percent) or Arabs (3.1 percent). After adjustment for age, APC I1307K carriers were significantly more likely than noncarriers to have polyps in their surgical specimen (51.3 percent vs. 32.6 percent, P = 0.002). Adenomas with a tubular component (either tubular adenomas or tubulovillous adenomas), but not villous adenomas, were significantly more frequent among carriers (37.2 percent vs. 23.6 percent, P = 0.005). CONCLUSION: Together with former evidence of I1307K being a risk factor for colorectal cancer, these data suggest that colonoscopic surveillance for colorectal adenomas and cancer may be warranted in I1307K carriers, even in the absence of other identifiable risk factors.

Adenoma↗
PubMed2006

Twelve years of endoscopic surveillance in a family carrying biallelic Y165C MYH defect: report of a case.

PURPOSE: We report the case of two siblings, clinically andendoscopically followed for 12 years, who displayed anattenuated adenomatous polyposis coli phenotype. METHODS: On workup for rectal bleeding with colonoscopy, we found multiple adenomas mainly right-sided in a 21-year-old female and the same colonic phenotype was observed in her 27-year-old brother. We made a clinical diagnosis of attenuated adenomatous polyposis coli and performed APC gene testing. Because they had refused the proposed ileorectal anastomosis surgical option, we planned a periodic, endoscopic follow-up. RESULTS: Gene testing did not confirm the clinical suspicion of attenuated adenomatous polyposis coli. Actually, we did not find anypathogenic mutation in APC gene and we recently identified a biallelic Y125C MYH defect. During the endoscopic follow-up, a progressive reduction of adenomas was seen. CONCLUSIONS: New insight colorectal cancer genetics have allowed definition of a new class of polyposis that applies to some patients with attenuated adenomatous polyposis coli phenotype as in the siblings we have described. To prevent colorectal cancer without recurring to surgery, colonoscopic polypectomy may be a suitable tool in controlling MYH polyposis.

Adenomatous Polyposis Coli↗
PubMed2006

Colonoscopy in the elderly: low risk, low yield in asymptomatic patients.

PURPOSE: Current colonoscopy guidelines do not address the issue of when to stop performing screening and surveillance colonoscopy in the elderly. We reviewed our experience and results of colonoscopy in patients aged 80 years and older to assess the risks and diagnostic yield in this population. METHODS: We reviewed retrospectively the endoscopic and pathologic reports from consecutive colonoscopies performed on patients aged 80 years and older at a single, high-volume endoscopy center between August 1999 and May 2003. Patient characteristics, indications for examination, findings at colonoscopy, and complications were recorded and analyzed. RESULTS: A total of1,199 colonoscopic examinations were performed on 1,112 patients. Average age was 83.1 (range, 80-100) years. Male:female distribution was 1:1.7. Leading exclusive indications for colonoscopy included: polyp surveillance, 227 (19 percent); altered bowel habits, 168 (14 percent); iron-deficiency anemia, 132 (11 percent); and cancer follow-up, 108 (9 percent). Eighty-six examinations (7 percent) were performed solely for an indication of colorectal cancer screening. Twenty-two percent of patients had more than one indication for colonoscopy. Forty-five malignancies were found (3.7 percent). No cancers were found in the screening group, and two malignancies (0.7 percent) were detected in patients undergoing colonoscopy for polyp surveillance. There were eight (0.6 percent) reported major complications. CONCLUSIONS: Colonoscopy can be performed safely in patients aged 80 years and older. However, the diagnostic yield is low, particularly in patients undergoing routine screening or surveillance examinations. Colonoscopy should for the most part be limited to elderly patients with symptoms or specific clinical findings.

Adenoma↗
PubMed2006

Laparoscopic colon resection for polyps: a good novice case?

PURPOSE: Laparoscopic colon resection of the endoscopically unresectable polyp has been considered an ideal case for the surgeon with moderate laparoscopic colectomy experience because tissues are not inflamed and the lymphadenectomy may not need to be as extensive compared with that required for cancer. To assess the appropriateness of this approach, we evaluated the incidence of invasive cancer in a series of laparoscopic colon resections for polyps. METHODS: A retrospective review was performed of 55 consecutive patients undergoing laparoscopic colon resection for endoscopically unresectable polyps during a 35-month period. Colonoscopy data, polyp characteristics, and final colon pathology were reviewed. RESULTS: On final pathologic examination, 18.2 percent of patients had invasive adenocarcinoma. Patient age, gender, indication for colonoscopy, polyp size, polyp location, polyp characteristics, and colonoscopic biopsy pathology were not predictive of adenocarcinoma on final pathology. CONCLUSIONS: A significant number of endoscopically unresectable polyps harbor adenocarcinoma, thereby requiring a formal lymphadenectomy at resection. Caution should be exercised when considering the laparoscopic resection of an endoscopically unresectable polyp as a "learning" case.

Adenocarcinoma↗
PubMed2006

Crohn's colitis: the incidence of dysplasia and adenocarcinoma in surgical patients.

PURPOSE: Data supporting an increased risk of colorectal cancer in patients with Crohn's colitis are inconsistent. Despite this, clinical recommendations regarding colonoscopic screening and surveillance for patients with Crohn's colitis are extrapolated from chronic ulcerative colitis protocols. The primary aim of our study was to determine the incidence of dysplasia and carcinoma in pathology specimens of patients undergoing segmental or total colectomy for Crohn's disease of the large bowel. In addition, we sought to identify risk factors associated with the development of dysplasia and carcinoma. METHODS: We performed a retrospective review of all patients operated on at our institution for Crohn's colitis between January 1992 and May 2004. Data were retrieved from patient charts, operative notes, and pathology reports. Logistic regression was used to model the probability of having dysplasia or adenocarcinoma. RESULTS: Two hundred twenty-two patients (138 females) who underwent surgical resection for the treatment of Crohn's colitis were included in the study. Mean age at surgery was 41 (range, 15-82) years and the mean duration of disease was 10 (range, 0-53) years. There were five cases of dysplasia (2.3 percent) and six cases of adenocarcinoma (2.7 percent). Three patients with dysplasia and one with adenocarcinoma were diagnosed on preoperative colonoscopy; while the other cases were discovered incidentally on pathologic examination of resected specimens. Factors associated with the presence of dysplasia or adenocarcinoma included older age at diagnosis (38.2 vs. 30.3 years, P = 0.02), longer disease duration (16.0 vs. 10.1 years, P = 0.05), and disease extent (90 percent extensive vs. 59 percent limited, P = 0.05). CONCLUSIONS: Patients with severe Crohn's colitis requiring surgery are at significant risk for developing dysplasia and adenocarcinoma, particularly when diagnosed at an older age, after longer disease duration, and with more extensive colon involvement.

Adenocarcinoma↗
PubMed2006

Comparison of glucagon and scopolamine butylbromide as premedication for colonoscopy in unsedated patients.

PURPOSE: Premedication with glucagon or hyoscyamine is reported to be effective in reducing colonic spasm. However, these drugs can be associated with unfavorable events. This prospective study was designed to compare the effects of premedication with glucagon with those of scopolamine butylbromide on cardiopulmonary parameters, intubation time, and patient discomfort in unsedated patients undergoing diagnostic colonoscopy. METHODS: One hundred consecutive adult patients (65 males) undergoing colonoscopy without sedation were randomized to receive 1 mg of glucagon (n = 50) or 20 mg of scopolamine butylbromide (n = 50), intramuscularly. Physiologic changes, including systolic blood pressure, heart rate, and oxygen saturation, were monitored before colonoscope insertion and at three-minute intervals during colonoscopy. The percentages of completed procedure and time to cecal intubation were recorded. Patients were asked to rate pain by using a five-point pain score (0 = no pain; 4 = severe pain). RESULTS: The percentages of completed procedure (96 vs. 98 percent), time to cecal intubation (16.3 vs. 14.5 minutes), and pain score (1.7 vs. 1.5) did not differ significantly between two groups. An increase in heart rate of more than ten beats per minute from baseline during colonoscopy occurred significantly more often in scopolamine group (44 percent of 50 patients) than in the glucagon group (12 percent of 50 patients; P = 0.0004). There were no significant differences between the two study groups with regard to changes in systolic blood pressure and decrease in oxygen saturation during colonoscopy. CONCLUSIONS: Premedication with 1 mg of glucagon facilitates favorable examination with respect to physiologic changes compared with 20 mg of scopolamine. These features favor glucagon as the preferred premedication for patients undergoing colonoscopy.

Aged↗
PubMed2006

Anti-Saccharomyces cerevisiae antibody in intestinal Behçet's disease patients: relation to clinical course.

PURPOSE: This study was designed to assess anti-Saccharomyces cerevisiae antibody positive rate in Behçet's disease and intestinal Behçet's disease and to evaluate whether anti-Saccharomyces cerevisiae antibody expression is associated with clinical findings at diagnosis and clinical course of intestinal Behçet's disease. METHODS: One hundred six patients with intestinal Behçet's disease, 30 patients with Behçet's disease, and 45 healthy control subjects were included. Anti-Saccharomyces cerevisiae antibody was detected by indirect immunofluorescence assay. According to anti-Saccharomyces cerevisiae antibody expression, the various parameters at diagnosis, cumulative relapse rates, and cumulative probabilities of operation were analyzed. RESULTS: Anti-Saccharomyces cerevisiae antibody positive rate was 44.3 percent in intestinal Behçet's disease, 3.3 percent in Behçet's disease, and 8.8 percent in healthy control subjects. In patients with intestinal Behçet's disease, age, gender, distribution of Behçet's disease subtype, symptoms, laboratory tests, and colonoscopic findings at diagnosis were not different according to anti-Saccharomyces cerevisiae antibody expression. Cumulative probability of a first operation was significantly higher in anti-Saccharomyces cerevisiae antibody (+) intestinal Behçet's disease than in anti-Saccharomyces cerevisiae antibody (-) intestinal Behçet's disease: 44.8 and 17.2 percent at one year, and 53 and 24.3 percent at two years after diagnosis, respectively (P=0.006). The number of patients who underwent two or more operations was higher in anti-Saccharomyces cerevisiae antibody (+) intestinal Behçet's disease than in anti-Saccharomyces cerevisiae antibody (-) intestinal Behçet's disease (21.3 vs. 8.5 percent). The cumulative relapse rates were not different between the two groups. CONCLUSIONS: Anti-Saccharomyces cerevisiae antibody positive rate was 44.3 percent in intestinal Behçet's disease. Clinical findings at diagnosis and cumulative relapse rates of intestinal Behçet's disease were not found to be associated with anti-Saccharomyces cerevisiae antibody expression. However, patients with anti-Saccharomyces cerevisiae antibody (+) intestinal Behçet's disease were more likely to receive surgical treatment.

Adolescent↗