Colonoscopic Removal of Juvenile Colonic Polyps By Wallace
A. Gleason,
Jr., Paul D. Goldstein,
Burton
A. Shatz,
and Francis J. Tedesco
I
NCREASING EXPERIENCE with fiberoptic colonoscopy and colonoscopic polypectomy has led to its acceptance as a safe method of removing polypoid lesions from the colon in adults. ‘,2 Although some children with juvenile colonic polyps may be candidates for colonoscopic polypectomy, there has been only one report of its use in this group.3 Our experience with five children from whom juvenile colonic polyps were removed via the colonoscope is presented here. PATIENTS
AND
METHODS
Between May. 1972 and June, 1974. five children were referred for colonoscopic polypectomy. Their clinical features are presented in Table I. Four had recurrent hematochezia attributed to colonic polyps. One of these patients (Case 3) had multiple colonic polyps. The only patient who did not have recurrent hematochezia (Case 2) had colocolonic intussusception attributed to a polyp in the midtransverse colon diagnosed during reduction of the intussusception by barium enema. Air-contrast barium enema verified the location and number of polyps in Cases I. 2, and 3. In Cases I through 4. the polyps were beyond the reach of the sigmoidoscope. The fifth patient underwent two attempts at signoidoscopic removal of a large polyp in the sigmold colon. Although the polyp was seen. its size (2 cm) and location (23 cm proximal to the anus) prevented adequate visualization of the stalk. Preparation for colonoscopy included a clear liquid diet for 72 hr, magnesium citrate lhe evening before, and enemas until clear 3 hr before the procedure. Patients were premeditated with atropine sulfate, 0.01 mg/kg. Intravenous ketamine HCI was employed in sedative doses in Cases I and 2. More recently (Cases 3, 4 and 5) intravenous diazepam has been employed. Viscous xylocaine was used to lubricate the instrument as it was advanced. The polyps were removed by snare electrocautery. according to the method of Wolf and Shinya.’ All patients were kept on clear liquid diets for 24 hr after the procedure. Hematocrits were determined at 6 hr and I8 hr after polypectomy. RESULTS Adequate cleansing of the colon was achieved in all cases by the regimen outlined above. Although sedative doses of ketamine HCl (2-3 mg/kg) were used initially, intravenous diazepam was found to produce satisfactory anesthesia in doses of 7-10 mg in our more recent cases. The procedure was well tolerated by all patients. Mild discomfort was noted during air insufflation. One patient developed fever and left lower quadrant tenderness 6 hr after polypectomy. Treatment was limited to intravenous fluids and cessation of oral intake: these findings resolved spontaneously within 12 hr. No patient had rectal bleeding after polypectomy, and postpolypectomy hematocrits were stable in all cases.
From the Department o/Pediatrics. St. Louis University School of Medicine and the Division of Gastroenterology. Departments of Pediatrics and Medicine, Washington University School of Medicine, St. Louis, Mo. .4ddrrw for reprint requests: Wallace A. Gleason. Jr., M.D., Cardinal Glennon Memorral Hospital ji)r Children, 1465 S. Grand Blvd.. St. Louis. MO. 63104 c IV75 hv Grune & Stratton. Inc.. Journal of Pediatric Surgery, Vol. 10, No. 4 (August). 1975
519
GLEASON
520
Table 1. Clinical Faclturer of Patients Undergoing Care No.
Age
1
6
2
2-9/12
Indication Recurrent
Location
bleeding
lntussusception
Splenic Distal
ET
Al.
Colonoscopic Polypectomy
of Polyp
Remarks
flexure transverse
COlOfl
3
6
Multiple
polyps,
Eight
polyps
sigmoid
recurrent
from
for
of descend-
Polyp
bleeding 4
11
Recurrent
Polyps
to cecum
not recovered histologic
examination bleeding
Junction
not recovered
ing and sigmoid
5
6
bleeding,
Recurrent prolapse polyp
Sigmoid
of
colon
Two
unsuccessful
attempts
per rectum
at
rigmoidoscopic removal
Polyps were recovered for histologic examination in three cases. All had the typical histologic appearance of juvenile colonic polyps. DISCUSSION
The majority of polypoid lesions in the colon in children are juvenile colonic polyps. Indications for surgical removal of such lesions have been a matter of controversy. Recommendations that they be removed when discovered in asymptomatic patients in order to prevent future complications4*’ have been tempered by the benign clinical course and excellent prognosis associated with these lesions.6 The operative risk of excision of these polyps has thus been a central consideration. This is particularly true for polyps beyond the reach of the sigmoidoscope, since general anesthesia, laparotomy, and colotomy are required for their excision. Recent advances in fiberoptic gastrointestinal endoscopy have led to the development of a noninvasive technique for removal of polyps from any part of the colon. Our results indicate that application of this procedure in the pediatric age group is a safe and effective method of removing juvenile colonic polyps complicated by recurrent or severe hemorrhage, or intussusception. Limitations of the method include the requirement that considerable experience in colonoscopy and polypectomy are necessary for its safe use.’ Reported complications include bleeding’ and perforation, ’ but these were not encountered in this group of patients. Further experience is necessary to determine the indications for colonoscopic polypectomy in patients with uncomplicated juvenile colonic polyps, although at present, we do not feel that these polyps need to be removed. SUMMARY
Five children have undergone colonoscopic polypectomy in the last 2 yr. Four had recurrent episodes of hematochezia. One of these had multiple colonic polyps. The fifth patient underwent polypectomy after a polyp in the midtransverse colon was demonstrated during hydrostatic reduction of a colocolonic intussusception. Fever and abdominal tenderness occurred in one patient after polypectomy, but resolved spontaneously. Colonoscopic poly-
JUVENILE
COLONIC
521
POLYPS
pectomy is a safe, noninvasive method of removal of juvenile polyps, and is particularly useful in patients with polyps beyond the reach of the sigmoidoscope. ACKNOWLEDGMENT The authors appreciate the assistance of Drs. Jesse Ternberg and James Keating for referring these patients, Drs. J. Eugene Lewis and David H. Alpers who critically reviewed the manuscript. and Mrs. Catherine Camp who assisted in its preparation.
REFERENCES I. Wolff WI, Shinya tiberoptic colonoscope. 329, 1973
H: Polypectomy via the N Engl J Med 288:
2. Berci G, Panish J, Morgenstern agnostic colonoscopy and colonoscopic pectomy. Arch Surg 106:818. 1973
L: Dipoly-
3. King JF, Smith GE: Endoscopic removal of recurrent juvenile polyps in a 6 year old. Gastroenterology 66:815. 1974 4. Jackman RJ, Beahrs OM: Tumors of the large bowel. in Dunphy JE (ed): Major Prob-
lems in Clinical Surgery vol 8 Philadelphia. Saunders 1968 p 118 5. Welch CE: Polypoid lesions of the gastrointestinal tract in Dunphy JE (ed): Major Problems in Clinical Surgery. vol 2 Philadelphra Saunders 1964 p 92 6. Shermeta DW. Morgan WW. Eggleston J et al: Juvenile retention polyps. J Pediatr Surg 4:‘l I, 1969 7. Geenen JE. Schmitt MG. Hogan WJ. Complications of colonoscopy. Gastroenterology 66:812, 197-t
A. Gleason,
Jr., Paul D. Goldstein,
Burton
A. Shatz,
and Francis J. Tedesco
I
NCREASING EXPERIENCE with fiberoptic colonoscopy and colonoscopic polypectomy has led to its acceptance as a safe method of removing polypoid lesions from the colon in adults. ‘,2 Although some children with juvenile colonic polyps may be candidates for colonoscopic polypectomy, there has been only one report of its use in this group.3 Our experience with five children from whom juvenile colonic polyps were removed via the colonoscope is presented here. PATIENTS
AND
METHODS
Between May. 1972 and June, 1974. five children were referred for colonoscopic polypectomy. Their clinical features are presented in Table I. Four had recurrent hematochezia attributed to colonic polyps. One of these patients (Case 3) had multiple colonic polyps. The only patient who did not have recurrent hematochezia (Case 2) had colocolonic intussusception attributed to a polyp in the midtransverse colon diagnosed during reduction of the intussusception by barium enema. Air-contrast barium enema verified the location and number of polyps in Cases I. 2, and 3. In Cases I through 4. the polyps were beyond the reach of the sigmoidoscope. The fifth patient underwent two attempts at signoidoscopic removal of a large polyp in the sigmold colon. Although the polyp was seen. its size (2 cm) and location (23 cm proximal to the anus) prevented adequate visualization of the stalk. Preparation for colonoscopy included a clear liquid diet for 72 hr, magnesium citrate lhe evening before, and enemas until clear 3 hr before the procedure. Patients were premeditated with atropine sulfate, 0.01 mg/kg. Intravenous ketamine HCI was employed in sedative doses in Cases I and 2. More recently (Cases 3, 4 and 5) intravenous diazepam has been employed. Viscous xylocaine was used to lubricate the instrument as it was advanced. The polyps were removed by snare electrocautery. according to the method of Wolf and Shinya.’ All patients were kept on clear liquid diets for 24 hr after the procedure. Hematocrits were determined at 6 hr and I8 hr after polypectomy. RESULTS Adequate cleansing of the colon was achieved in all cases by the regimen outlined above. Although sedative doses of ketamine HCl (2-3 mg/kg) were used initially, intravenous diazepam was found to produce satisfactory anesthesia in doses of 7-10 mg in our more recent cases. The procedure was well tolerated by all patients. Mild discomfort was noted during air insufflation. One patient developed fever and left lower quadrant tenderness 6 hr after polypectomy. Treatment was limited to intravenous fluids and cessation of oral intake: these findings resolved spontaneously within 12 hr. No patient had rectal bleeding after polypectomy, and postpolypectomy hematocrits were stable in all cases.
From the Department o/Pediatrics. St. Louis University School of Medicine and the Division of Gastroenterology. Departments of Pediatrics and Medicine, Washington University School of Medicine, St. Louis, Mo. .4ddrrw for reprint requests: Wallace A. Gleason. Jr., M.D., Cardinal Glennon Memorral Hospital ji)r Children, 1465 S. Grand Blvd.. St. Louis. MO. 63104 c IV75 hv Grune & Stratton. Inc.. Journal of Pediatric Surgery, Vol. 10, No. 4 (August). 1975
519
GLEASON
520
Table 1. Clinical Faclturer of Patients Undergoing Care No.
Age
1
6
2
2-9/12
Indication Recurrent
Location
bleeding
lntussusception
Splenic Distal
ET
Al.
Colonoscopic Polypectomy
of Polyp
Remarks
flexure transverse
COlOfl
3
6
Multiple
polyps,
Eight
polyps
sigmoid
recurrent
from
for
of descend-
Polyp
bleeding 4
11
Recurrent
Polyps
to cecum
not recovered histologic
examination bleeding
Junction
not recovered
ing and sigmoid
5
6
bleeding,
Recurrent prolapse polyp
Sigmoid
of
colon
Two
unsuccessful
attempts
per rectum
at
rigmoidoscopic removal
Polyps were recovered for histologic examination in three cases. All had the typical histologic appearance of juvenile colonic polyps. DISCUSSION
The majority of polypoid lesions in the colon in children are juvenile colonic polyps. Indications for surgical removal of such lesions have been a matter of controversy. Recommendations that they be removed when discovered in asymptomatic patients in order to prevent future complications4*’ have been tempered by the benign clinical course and excellent prognosis associated with these lesions.6 The operative risk of excision of these polyps has thus been a central consideration. This is particularly true for polyps beyond the reach of the sigmoidoscope, since general anesthesia, laparotomy, and colotomy are required for their excision. Recent advances in fiberoptic gastrointestinal endoscopy have led to the development of a noninvasive technique for removal of polyps from any part of the colon. Our results indicate that application of this procedure in the pediatric age group is a safe and effective method of removing juvenile colonic polyps complicated by recurrent or severe hemorrhage, or intussusception. Limitations of the method include the requirement that considerable experience in colonoscopy and polypectomy are necessary for its safe use.’ Reported complications include bleeding’ and perforation, ’ but these were not encountered in this group of patients. Further experience is necessary to determine the indications for colonoscopic polypectomy in patients with uncomplicated juvenile colonic polyps, although at present, we do not feel that these polyps need to be removed. SUMMARY
Five children have undergone colonoscopic polypectomy in the last 2 yr. Four had recurrent episodes of hematochezia. One of these had multiple colonic polyps. The fifth patient underwent polypectomy after a polyp in the midtransverse colon was demonstrated during hydrostatic reduction of a colocolonic intussusception. Fever and abdominal tenderness occurred in one patient after polypectomy, but resolved spontaneously. Colonoscopic poly-
JUVENILE
COLONIC
521
POLYPS
pectomy is a safe, noninvasive method of removal of juvenile polyps, and is particularly useful in patients with polyps beyond the reach of the sigmoidoscope. ACKNOWLEDGMENT The authors appreciate the assistance of Drs. Jesse Ternberg and James Keating for referring these patients, Drs. J. Eugene Lewis and David H. Alpers who critically reviewed the manuscript. and Mrs. Catherine Camp who assisted in its preparation.
REFERENCES I. Wolff WI, Shinya tiberoptic colonoscope. 329, 1973
H: Polypectomy via the N Engl J Med 288:
2. Berci G, Panish J, Morgenstern agnostic colonoscopy and colonoscopic pectomy. Arch Surg 106:818. 1973
L: Dipoly-
3. King JF, Smith GE: Endoscopic removal of recurrent juvenile polyps in a 6 year old. Gastroenterology 66:815. 1974 4. Jackman RJ, Beahrs OM: Tumors of the large bowel. in Dunphy JE (ed): Major Prob-
lems in Clinical Surgery vol 8 Philadelphia. Saunders 1968 p 118 5. Welch CE: Polypoid lesions of the gastrointestinal tract in Dunphy JE (ed): Major Problems in Clinical Surgery. vol 2 Philadelphra Saunders 1964 p 92 6. Shermeta DW. Morgan WW. Eggleston J et al: Juvenile retention polyps. J Pediatr Surg 4:‘l I, 1969 7. Geenen JE. Schmitt MG. Hogan WJ. Complications of colonoscopy. Gastroenterology 66:812, 197-t
