19
Vol. 67, No. 1
Indications For Colonoscopy In Surgical Practice KENNETH A. FORDE, M.D., FA.C.S.,
Assistanit Prokssor ol Surgerv, College o.f PhYsicianls (iidl Surgeons, Collutibia Universitv (1t,( Presbvierian, Hospital Newv Yotk Cdtv
Although the primary emphasis on colonoscopy to date has been its dramatic impact on the management of colonic polyps, there are many areas in which we have found this new technique to have a significant role in the surgical management of colonic disease. COMPLEMENTARY AID TO BARIUM ENEMA
CASE REPORTS Case 1. A 49-year-old woman with documented alcoholic cirrhosis followed in hematology clinic for an anemia that was difficult to characterize, underwent barium enema which revealed a sigmoid colon abnormality which was felt to represent either stool or a polyp (Fig. 1). At colonoscopy a flat ulcerated lesion was noted which on biopsy proved to be adenocarcinoma (Fig. 2). The patient subsequently underwent sigmoid resection for what proved to be a I)ukes A carcinoma.
The colonoscopist is frequently able to resolve the question of whether or not disease
Fig. 1. Caise I. Barium enemat showing equivocal lesion.
Fig. 2 Case I Colonoscopic biopsy showing crcinoma-
is present when the radiologist, despite an excellent study, is unable to do so. This may vary from the patient with signs and symptoms of colonic disease but negative or equivocal barium enema to the finding of additional lesions unsuspected on barium enema. Sometimes lesions having a similar radiologic appearance may be of varying pathology and require different approaches to therapy. We have been able to detect several Dukes A and B colonic carcinomas in situations in which the diagnosis of malignancy was not suspected on barium enema.
Case 2. A 66-year-old mian with a biopsy proven undifferentiated carcinoma of the lung, was felt on barium enema (Fig. 3) to have a serosal Implant on the sigmoid colon. At colonoscopy he was found to have a primary carcinomia at this site (Fig. 4), proven on biopsy and subsequent resection.
Especially in the high risk patient it is helpful in planning the extent of an operative procedure if the surgeon is armed with a definitive
diagnosis.
Case 3. A 71-year-old obese anxious woman was ad 2itted for evaluation of lower abdo sinalcoiplaints. She had undergone mdultiple previous abdominal procedures (appendectomay, hysterectomy, ventral herniorrhaphy). Sigmoidoscopy was negative, but barium enema (Fig. 5) revealed a narrow stenotic seg.ent at the junction of the sigmoid and descending colon. The niucosa
JANUARY, 1975
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
20
appeared destroyed raising the possibility of carcinoma in an area of diverticulitis. Colonoscopy revealed evidence of diverticular disease only and this was confirmed when a limited sigmoid resection was subsequently performed
(Fig. 6)
carcinoma cannot be definitely established with barium enema, it is sometimes possible to solve the problem by direct endoscopic examination, and biopsy, if necessary. 5 a 3 .. B . divertic ..............tis.
:~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ :
...~~~~~~~~~~~~~~~~~~~. .i....
.:.. ..
...
. . :: ~~~~~~~~~~~~~~~.. -.
Fig. 5. Case 3. Barium enema-Carcinoma in
area of
diverticulitis.
Fig. 3. Case 2. Barium
enema
showing "serosal implant"'
FOLLOW-UP ON PREVIOUS COLONIC DISEASE
Suture Line Recurrence. If the anastomotic site is above the level of the sigmoidoscope and suture line recurrence of previously resected
Fig. 4. Case 2. Colnosopiviema-show ing"eosampa nt'
4..}! .o
..
Case 4. A 66-year-old man had previously undergone resection of a perforated sigmoid carcinoma. In preparation for closure of his transverse colostomy, barium enema studies of the distal limb revealed mid-sigmoid obstruction (Fig. 7). Colonscopy per rectum and through the distal stoma disclosed inflammatory narrowing only. His surgeon accepted our findings and after a three month interval he was reoperated upon at which time there was purely inflammatory stricture of his anastomosis which was revised without further resection. One week later his colostomy was closed and he has since done well.
4_.
.
e
Fig. 6. Case 3. Gross pathology specimen shows diver ticulitis.
Polypoid Lesions. Many patients with known colonic polyps have been followed for varying periods of time with repeated barium contrast
Vol. 67, No. 1
CO/Olloscopv
studies, operation being deferred because the risks of laparotomy and colotomy in these often elderly patients with multiple medical problems is felt to outweigh the likelihood of the lesion being carcinoma. It is now possible for the colonoscopist to resolve many of these situations by either: a) proving the lesion to be benign by biopsy, b) eradicating it by polypectomy, or c) the consideration of laparotomy by proving the lesion to be a carcinoma.
21
equivocal lesion seen on barium enema is indeed present, for if it is not, the patient may be spared an unnecessary colotomy. This situation sometimes arises when the patient is being anesthetized for another reason; for example, ventral hernia/repair, cholecystectomy. The colonoscopist may also help at laparotomy to indicate more accurately where the colotomy should be placed or even assist in determining the extent of resection. MANAGEMENT OF COLONIC POLYPS
Fig. 7. Case 4. Lf iBarium enema showing sigmoid obstruction. Right-Colonoscope inserted through distal limb of transverse colostomy down to area of sigmoid obstruction. Case 5.A fragile 72-year-old man who had undergone previous gastrectomy for carcinoma complicated by pulmonary embolism, hepatitis and congestive heart failure had multiple known colonic polyps which were being followed by periodic barium enemas and they
consistently appeared benign. When one study revealed a suspicious cecal mass, colonoscopy was requested. We found that three of the presumed benign polyps were either carcinoma or had definite atypia and this was confirmed by our biopsies. This prompted surgical exploration at which time subtotal colectomy was performed. Three separate carcinomas were found as well as multiple polyps, some with atypia. Prophylactic interruption. of the inferior vena cava was also performed and the patient has since done well. PLANNING FUTURE THERAPY
In the patient with a demonstrated vesicocolic fistula without known diverticulitis or the patient explored for perforated sigmoid disease in whom proximal diversion of the fecal stream with or without local drainage has been performed, the decision concerning early or late re-intervention to treat the primary disease process may be facilitated by colonoscopic evaluation, especially when the barium enema is equivocal or cannot be obtained. LOCALIZATION OF LESIONS AT LAPAROTOMY
There is now an established place for colonoscopy at the time of laparotomy. The endoscopist (inserting the instrument per rectum) may assist the surgeon in determining whether an
The management of colonic polyps is to date the most revolutionary advance of colonoscopy. The advantages to the patient of abbreviated hospital stay, avoidance of general anethesia, obviation of laparotomy and colotomy, the ability of the patient to return to his usual activity almost immediately without a period of convalescence are indeed tremendous attractions to both patients and their internists. The colonoscopist must have the requisite skill in manipulation of the instrument, trained assistance, adequate space and equipment before attempting polypectomy. Controversy does exist concerning the endoscopic removal of broad-based lesions although there are circumstances in which this technique is indicated and possible in very experienced hands. However, as a general rule, lesions must be pedunculated before adequate and safe removal is uniformly possible. If a lesion of significant size is flat or ulcerated, our initial approach is biopsy regardless of what form of therapy is ultimately chosen. The biopsies, although small, have been adequate for our pathologists to interpret at almost every instance. Small, flat, smbooth-surfaced, biopsyproven adenomas may be easily fulgurated through the colonoscope. CONCLUSION
Fiberoptic colonoscopy has added a new diagnostic and therapeutic tool to the surgeon's armamentarium. For the future this technique offers exciting prospects in the study of colon pathophysiology and the natural history of sundry disease processes, as well as presenting a simplified approach to many complicated problems of management. It also offers hope for earlier detection of colonic malignancy.
Vol. 67, No. 1
Indications For Colonoscopy In Surgical Practice KENNETH A. FORDE, M.D., FA.C.S.,
Assistanit Prokssor ol Surgerv, College o.f PhYsicianls (iidl Surgeons, Collutibia Universitv (1t,( Presbvierian, Hospital Newv Yotk Cdtv
Although the primary emphasis on colonoscopy to date has been its dramatic impact on the management of colonic polyps, there are many areas in which we have found this new technique to have a significant role in the surgical management of colonic disease. COMPLEMENTARY AID TO BARIUM ENEMA
CASE REPORTS Case 1. A 49-year-old woman with documented alcoholic cirrhosis followed in hematology clinic for an anemia that was difficult to characterize, underwent barium enema which revealed a sigmoid colon abnormality which was felt to represent either stool or a polyp (Fig. 1). At colonoscopy a flat ulcerated lesion was noted which on biopsy proved to be adenocarcinoma (Fig. 2). The patient subsequently underwent sigmoid resection for what proved to be a I)ukes A carcinoma.
The colonoscopist is frequently able to resolve the question of whether or not disease
Fig. 1. Caise I. Barium enemat showing equivocal lesion.
Fig. 2 Case I Colonoscopic biopsy showing crcinoma-
is present when the radiologist, despite an excellent study, is unable to do so. This may vary from the patient with signs and symptoms of colonic disease but negative or equivocal barium enema to the finding of additional lesions unsuspected on barium enema. Sometimes lesions having a similar radiologic appearance may be of varying pathology and require different approaches to therapy. We have been able to detect several Dukes A and B colonic carcinomas in situations in which the diagnosis of malignancy was not suspected on barium enema.
Case 2. A 66-year-old mian with a biopsy proven undifferentiated carcinoma of the lung, was felt on barium enema (Fig. 3) to have a serosal Implant on the sigmoid colon. At colonoscopy he was found to have a primary carcinomia at this site (Fig. 4), proven on biopsy and subsequent resection.
Especially in the high risk patient it is helpful in planning the extent of an operative procedure if the surgeon is armed with a definitive
diagnosis.
Case 3. A 71-year-old obese anxious woman was ad 2itted for evaluation of lower abdo sinalcoiplaints. She had undergone mdultiple previous abdominal procedures (appendectomay, hysterectomy, ventral herniorrhaphy). Sigmoidoscopy was negative, but barium enema (Fig. 5) revealed a narrow stenotic seg.ent at the junction of the sigmoid and descending colon. The niucosa
JANUARY, 1975
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION
20
appeared destroyed raising the possibility of carcinoma in an area of diverticulitis. Colonoscopy revealed evidence of diverticular disease only and this was confirmed when a limited sigmoid resection was subsequently performed
(Fig. 6)
carcinoma cannot be definitely established with barium enema, it is sometimes possible to solve the problem by direct endoscopic examination, and biopsy, if necessary. 5 a 3 .. B . divertic ..............tis.
:~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ :
...~~~~~~~~~~~~~~~~~~~. .i....
.:.. ..
...
. . :: ~~~~~~~~~~~~~~~.. -.
Fig. 5. Case 3. Barium enema-Carcinoma in
area of
diverticulitis.
Fig. 3. Case 2. Barium
enema
showing "serosal implant"'
FOLLOW-UP ON PREVIOUS COLONIC DISEASE
Suture Line Recurrence. If the anastomotic site is above the level of the sigmoidoscope and suture line recurrence of previously resected
Fig. 4. Case 2. Colnosopiviema-show ing"eosampa nt'
4..}! .o
..
Case 4. A 66-year-old man had previously undergone resection of a perforated sigmoid carcinoma. In preparation for closure of his transverse colostomy, barium enema studies of the distal limb revealed mid-sigmoid obstruction (Fig. 7). Colonscopy per rectum and through the distal stoma disclosed inflammatory narrowing only. His surgeon accepted our findings and after a three month interval he was reoperated upon at which time there was purely inflammatory stricture of his anastomosis which was revised without further resection. One week later his colostomy was closed and he has since done well.
4_.
.
e
Fig. 6. Case 3. Gross pathology specimen shows diver ticulitis.
Polypoid Lesions. Many patients with known colonic polyps have been followed for varying periods of time with repeated barium contrast
Vol. 67, No. 1
CO/Olloscopv
studies, operation being deferred because the risks of laparotomy and colotomy in these often elderly patients with multiple medical problems is felt to outweigh the likelihood of the lesion being carcinoma. It is now possible for the colonoscopist to resolve many of these situations by either: a) proving the lesion to be benign by biopsy, b) eradicating it by polypectomy, or c) the consideration of laparotomy by proving the lesion to be a carcinoma.
21
equivocal lesion seen on barium enema is indeed present, for if it is not, the patient may be spared an unnecessary colotomy. This situation sometimes arises when the patient is being anesthetized for another reason; for example, ventral hernia/repair, cholecystectomy. The colonoscopist may also help at laparotomy to indicate more accurately where the colotomy should be placed or even assist in determining the extent of resection. MANAGEMENT OF COLONIC POLYPS
Fig. 7. Case 4. Lf iBarium enema showing sigmoid obstruction. Right-Colonoscope inserted through distal limb of transverse colostomy down to area of sigmoid obstruction. Case 5.A fragile 72-year-old man who had undergone previous gastrectomy for carcinoma complicated by pulmonary embolism, hepatitis and congestive heart failure had multiple known colonic polyps which were being followed by periodic barium enemas and they
consistently appeared benign. When one study revealed a suspicious cecal mass, colonoscopy was requested. We found that three of the presumed benign polyps were either carcinoma or had definite atypia and this was confirmed by our biopsies. This prompted surgical exploration at which time subtotal colectomy was performed. Three separate carcinomas were found as well as multiple polyps, some with atypia. Prophylactic interruption. of the inferior vena cava was also performed and the patient has since done well. PLANNING FUTURE THERAPY
In the patient with a demonstrated vesicocolic fistula without known diverticulitis or the patient explored for perforated sigmoid disease in whom proximal diversion of the fecal stream with or without local drainage has been performed, the decision concerning early or late re-intervention to treat the primary disease process may be facilitated by colonoscopic evaluation, especially when the barium enema is equivocal or cannot be obtained. LOCALIZATION OF LESIONS AT LAPAROTOMY
There is now an established place for colonoscopy at the time of laparotomy. The endoscopist (inserting the instrument per rectum) may assist the surgeon in determining whether an
The management of colonic polyps is to date the most revolutionary advance of colonoscopy. The advantages to the patient of abbreviated hospital stay, avoidance of general anethesia, obviation of laparotomy and colotomy, the ability of the patient to return to his usual activity almost immediately without a period of convalescence are indeed tremendous attractions to both patients and their internists. The colonoscopist must have the requisite skill in manipulation of the instrument, trained assistance, adequate space and equipment before attempting polypectomy. Controversy does exist concerning the endoscopic removal of broad-based lesions although there are circumstances in which this technique is indicated and possible in very experienced hands. However, as a general rule, lesions must be pedunculated before adequate and safe removal is uniformly possible. If a lesion of significant size is flat or ulcerated, our initial approach is biopsy regardless of what form of therapy is ultimately chosen. The biopsies, although small, have been adequate for our pathologists to interpret at almost every instance. Small, flat, smbooth-surfaced, biopsyproven adenomas may be easily fulgurated through the colonoscope. CONCLUSION
Fiberoptic colonoscopy has added a new diagnostic and therapeutic tool to the surgeon's armamentarium. For the future this technique offers exciting prospects in the study of colon pathophysiology and the natural history of sundry disease processes, as well as presenting a simplified approach to many complicated problems of management. It also offers hope for earlier detection of colonic malignancy.
