Br. J. Surg. 1992, Voi. 79, December, 1376-1 378
E. Brullet, J. M . Montane*, J. Bornbardo*, X. Bonf ill?, M . Nogue? and J. M. Bordasf Endoscopy Unit and Departments of *Surgery and ?Oncology, Hospital de Sabadell and $Hospital Clinic i Provincial de Barcelona, Barcelona, Spain Correspondence to: Dr E. Brullet, Endoscopia Digestiva, Hospital de Sabadell, Parc Tauli s/n, 08208 Sabadell, Barcelona, Spain
lntraoperative colonoscopy in patients w i t h colorectal cancer Sixty-seven patients underwent intraoperative colonoscopy during elective surgery f o r colorectal cancer. Complete examination of the colon was achieved in 65 patients ( 9 7 per cent), albeit with insertion through a colotomy in three ( 4 per cent). A synchronous carcinoma was found in six patients (9per cent), which necessitated a change ofplanned surgical procedure. Synchronous polyps were detected and removed in 24 patients (36 per cent); two had polyps with carcinoma in situ. The mean age of patients with synchronous carcinoma was signijicantly higher than that of those without (74.1 versus 61.2 years, P = 0-02). Intraoperative colonoscopy took a mean of 1Smin surgical time and only two minor complications (serosal lacerations) were encountered. In patients with colorectal cancer, intraoperative colonoscopy allows complete assessment of the colon and identijies synchronous lesions.
The incidence of synchronous lesions in patients with colorectal cancer varies from 2 to 11 per cent for carcinoma and from 27 to 60 per cent for a d e n ~ m a l - ' ~The . whole of the large bowel should therefore be assessed before surgery is performed in patients with colorectal cancer. Failure to detect synchronous carcinoma before operation may produce prognostic and therapeutic mistakes. Early metachronous carcinomas (diagnosed < 3 years after surgery) may be missed synchronous lesions; patients with undetected synchronous carcinoma may undergo inappropriate surgical procedure^^,^,' 2-1 6 , 2 2 . The preoperative diagnosis of synchronous carcinomas is d i f f i c ~ l t ~ 1. .~1 2. ,' 1 6 3 2 1 . Fibreoptic colonoscopy is the most useful method, but it is often not possible to perform complete colonoscopy because of bowel stenosis20.21.24-28. Doublecontrast barium examination detects between only 50 and 70 per cent of synchronous lesions and peroperative manual palpation of the large bowel misses almost half such tumours8.1 1-13.21.26 This study evaluated the efficacy of intraoperative colonoscopy for the detection of synchronous lesions during elective surgery in patients with colorectal cancer, and assessed its effect on the planned surgery.
Patients and methods In 1988, a collaborative protocol for assessment of patients with colorectal cancer was developed. When a tumour of the large bowel was observed at colonoscopy, total colonoscopy was not attempted. A barium enema examination was not performed before surgery and colonoscopy was arranged to be carried out during the elective operation. The bowel was cleansed with polyethylene glycol electrolyte lavage solution .(3000ml) given orally the day before surgery. Antibiotic prophylaxis comprised one dose of metronidazole and gentamicin before surgery and two afterwards. The colonoscope was submerged in 2 per cent glutaraldehyde for 20 min before use. The endoscopist and nurse took similar antiseptic precautions to other personnel in the operating theatre. The patient was placed in the Lloyd-Davies position. After laparotomy and inspection of the abdominal cavity, the primary tumour was located and manual palpation of the entire colon carried out. The terminal ileum was occluded with a non-crushing clamp to avoid intestinal distension from air insufflation during endoscopy. The colonoscope was advanced through the colon under direct control of the surgeon, who facilitated its progression in the event of stenosing lesions or during pull-back manoeuvres. During withdrawal of the
1376
endoscope, air was aspirated while the surgeon examined the serosa to detect possible injury. When stenosing neoplasms blocked the passage of the colonoscope, the instrument was cleaned and reintroduced via a colotomy at the proximal margin of the planned surgical resection. A small colotomy (1.5 c m ) enabled the colonoscope to pass but did not allow air to escape. Antiseptic measures were applied around the colotomy to prevent contamination during intraoperative colonoscopy. Endoscopic polypectomy was performed when polyps were located outside the planned surgical resection limits. A synchronous carcinoma was defined by the criteria of Kaibara et a\.".
Results Between December 1988 and December 1990, intraoperative colonoscopy was performed in 67 patients with colorectal cancer (49 men and 18 women) with a mean(s.d.) age of 63.5( 12.8) years. None of the patients had a history of ulcerative colitis, familial adenomatous polyposis or previous surgery for colorectal cancer. The location of the primary tumour was the rectum in 37 patients (55 per cent), the sigmoid colon in 21 (31 per cent), the descending colon in seven (10 per cent) and the transverse colon in two ( 3 per cent). The tumour was causing stenosis in 39 patients (58 per cent). Full examination of the colon was achieved without help from the surgeon in 40 patients (60 per cent). Of the other 27 patients, the stenosis was negotiated after manipulation by the surgeon in 22 and the colonoscope could not be advanced in five. Full examination of the colon was achieved in three of these by reintroduction of the endoscope through a colotomy. This procedure was not carried out in two patients who underwent palliative surgery owing to advanced age and multiple peritoneal metastases. Complete colonoscopy was thus accomplished in a total of 65 patients (97 per cent). Intraoperative colonoscopy was normal in 37 patients ( 5 5 per cent ). In 24 (36 per cent ), polyps located outside the planned resection limits were detected and removed. In two patients the polyps contained carcinoma in situ. Synchronous carcinoma was found in six patients (9 per cent) (Table I ). In five the primary tumour was located in the rectum and in four was stenosing. All six had associated adenomatous polyps. Only four synchronous tumours were detected by manual palpation during surgery; two were discovered by intraoperative colonoscopy. The planned surgical approach was modified in all cases. The mean age of patients without synchronous lesions was 61.2 years and for those with synchronous polyps 65.3 years. Patients with synchronous carcinoma were significantly older
0007 1323/Y2/121376 03
I
l Y Y 2 Rutterworth Heinemann Ltd
lntraoperative colonoscopy: E. Brullet et al.
Table 1 Derails
of six
patients with synchronous carcinoma
Synchronous tumour Primary tumour no.
Sex
Location
Stage*
Stenosis
Location
Stage*
Detection by manual palpation
I
F
Rectum
T, N,
Yes
T, N ,
No
Enlarged resection
2
M
Rectum
T, No
Yes
T, N ,
Yes
Enlarged resection
3
M M
Rectum Rectum
T, N, T,No
Yes
4
Splenic flexure Transverse colon Caecum Sigmoid
T, N, T, N,
No Yes
5
M
Rectum
T, No
No
T, N ,
Yes
Enlarged resection Palliative colostomy (peritoneal metastases) Enlarged resection
6
F
Transverse colon
T, N,
Yes
T, N,
Yes
Enlarged resection
Patient
No
colon
Sigmoid colon Caecum
Final surgical procedure?
* Tumour node metastasis classification. ?The planned surgical approach was modified in all six cases than those without (mean age 74.1 uersus 61.2 years; P = 002, analysis of variance). Serosal laceration was noted and repaired in two patients during surgery. In both, intraoperative colonoscopy was technically difficult because of adhesions and needed complex endoscopic manipulation and help from the surgeon. The mean duration of intraoperative colonoscopy was 15 min. If endoscopic polypectomy or surgical help was needed, the mean time was 21 min; it was 9 min when polypectomy or manual help were not required.
Discussion
but preoperative detection of synchronous lesions allows a more appropriate surgical procedure’.’ 1-14,15-17,21,2’.In this study the intraoperative colonoscopy findings allowed the modification of the planned surgical approach in all patients with synchronous carcinoma. Intraoperative colonoscopy is a useful method of achieving full examination of the colon and identifies synchronous lesions, notably in those patients with stenosing turn our^'^*^^. It does not prolong operating time and complications are both minor and rare. Intraoperative colonoscopy allows a ‘clearing’ of the colon, removing polyps and preventing possible early metachronous carcinomas. The impact of intraoperative colonoscopy on survival in patients with colorectal cancer has to be determined.
Synchronous carcinoma is clinically important because of its incidence, the difficulty of preoperative diagnosis, and Acknowledgements the therapeutic and prognostic implications of missed lesionsl . & 7 . 1 6 . 1 9 . 2 2 . 2 3 . The reported incidencel2-l5 of synThe authors thank Lyn McBride for preparing the manuscript. chronous carcinoma in patients with colorectal cancer ranges from 1.5 to I I per cent; this variation may be due to factors References such as the criteria used t o define synchronous cancer, design of the study, and diagnostic methods employed,. Diagnosis of I . Warren S, Gates 0. Multiple primary malignant tumours: a survey of the literature and a statistical study. Am J Cancer 1932; synchronous lesions may be difficult because in many patients 16: 1358-414. is not possible to perform full preoperative colonoscopy because 2. Moertel CG, Bargen JA, Dockerty MB. Multiple carcinoma of of tumour ~ t e n o s i s ~ ~ - In * ~prospective ~ ~ ~ ~ ~ ’ studies, . examinthe large intestine: a review of the literature and a study of 231 ation of the entire colon was achieved in only 42-60 per cent cases. Gusrroent~,rolog~ 1958; 34: 85--98. of cases and periodic postoperative colonoscopy was recom3 . Rosenthal I . Baronofsky ID. Prognostic and therapeutic mended to detect early metachronous carcinoma19-21~26.2’. implications of polyps in mctachronous colonic carcinoma. This policy can be challenged because the detection of a second J , 4 M A 1960: 172: 37-41. tumour may determine a different resection. 4. Dencker H, Lieddberg G, Tibblin S. Multiple malignant tumours The technique and utility of intraoperative colonoscopy has of the colon and rectum. Acru Chir Si,und 1969; 135: 260-2. 5. Swinton NW, Parshley PF. Multiple cancers of the colon and been d o c ~ m e n t e d for ~ ~localization -~~ of non-palpable colonic rectum. Dis Colon Riwum 1962; 5: 378-80. lesions, investigation of unexplained recurrent gastrointestinal 6. Devitt JE, Roth-Moyo LA, Brown FN. The significance of haemorrhage, assessment of the extent of inflammatory bowel multiple adenocarcinoma of the colon and rectum. Ann Surg disease or when there is an inability to complete colonoscopy 1969; 169: 364-7. before operation. Intraoperative colonoscopy was selectively I . Lasser A. Synchronous primary adenocarcinomas of the colon for the detection of synchronous employed by Kaibara et and rectum. Dis Colon Rivrum 1978; 21: 20-2. lesions and was performed through a colotomy; they found an 8. Heald RJ, Bussey HJR. Clinical experiences at St Mark’s Hospital incidence for synchronous neoplasm of 8.6 per cent. Finan et with multiple synchronous cancers of the colon and rectum. Dis a1.I3 proposed the same strategy. cO/Ot? Ri,
E. Brullet, J. M . Montane*, J. Bornbardo*, X. Bonf ill?, M . Nogue? and J. M. Bordasf Endoscopy Unit and Departments of *Surgery and ?Oncology, Hospital de Sabadell and $Hospital Clinic i Provincial de Barcelona, Barcelona, Spain Correspondence to: Dr E. Brullet, Endoscopia Digestiva, Hospital de Sabadell, Parc Tauli s/n, 08208 Sabadell, Barcelona, Spain
lntraoperative colonoscopy in patients w i t h colorectal cancer Sixty-seven patients underwent intraoperative colonoscopy during elective surgery f o r colorectal cancer. Complete examination of the colon was achieved in 65 patients ( 9 7 per cent), albeit with insertion through a colotomy in three ( 4 per cent). A synchronous carcinoma was found in six patients (9per cent), which necessitated a change ofplanned surgical procedure. Synchronous polyps were detected and removed in 24 patients (36 per cent); two had polyps with carcinoma in situ. The mean age of patients with synchronous carcinoma was signijicantly higher than that of those without (74.1 versus 61.2 years, P = 0-02). Intraoperative colonoscopy took a mean of 1Smin surgical time and only two minor complications (serosal lacerations) were encountered. In patients with colorectal cancer, intraoperative colonoscopy allows complete assessment of the colon and identijies synchronous lesions.
The incidence of synchronous lesions in patients with colorectal cancer varies from 2 to 11 per cent for carcinoma and from 27 to 60 per cent for a d e n ~ m a l - ' ~The . whole of the large bowel should therefore be assessed before surgery is performed in patients with colorectal cancer. Failure to detect synchronous carcinoma before operation may produce prognostic and therapeutic mistakes. Early metachronous carcinomas (diagnosed < 3 years after surgery) may be missed synchronous lesions; patients with undetected synchronous carcinoma may undergo inappropriate surgical procedure^^,^,' 2-1 6 , 2 2 . The preoperative diagnosis of synchronous carcinomas is d i f f i c ~ l t ~ 1. .~1 2. ,' 1 6 3 2 1 . Fibreoptic colonoscopy is the most useful method, but it is often not possible to perform complete colonoscopy because of bowel stenosis20.21.24-28. Doublecontrast barium examination detects between only 50 and 70 per cent of synchronous lesions and peroperative manual palpation of the large bowel misses almost half such tumours8.1 1-13.21.26 This study evaluated the efficacy of intraoperative colonoscopy for the detection of synchronous lesions during elective surgery in patients with colorectal cancer, and assessed its effect on the planned surgery.
Patients and methods In 1988, a collaborative protocol for assessment of patients with colorectal cancer was developed. When a tumour of the large bowel was observed at colonoscopy, total colonoscopy was not attempted. A barium enema examination was not performed before surgery and colonoscopy was arranged to be carried out during the elective operation. The bowel was cleansed with polyethylene glycol electrolyte lavage solution .(3000ml) given orally the day before surgery. Antibiotic prophylaxis comprised one dose of metronidazole and gentamicin before surgery and two afterwards. The colonoscope was submerged in 2 per cent glutaraldehyde for 20 min before use. The endoscopist and nurse took similar antiseptic precautions to other personnel in the operating theatre. The patient was placed in the Lloyd-Davies position. After laparotomy and inspection of the abdominal cavity, the primary tumour was located and manual palpation of the entire colon carried out. The terminal ileum was occluded with a non-crushing clamp to avoid intestinal distension from air insufflation during endoscopy. The colonoscope was advanced through the colon under direct control of the surgeon, who facilitated its progression in the event of stenosing lesions or during pull-back manoeuvres. During withdrawal of the
1376
endoscope, air was aspirated while the surgeon examined the serosa to detect possible injury. When stenosing neoplasms blocked the passage of the colonoscope, the instrument was cleaned and reintroduced via a colotomy at the proximal margin of the planned surgical resection. A small colotomy (1.5 c m ) enabled the colonoscope to pass but did not allow air to escape. Antiseptic measures were applied around the colotomy to prevent contamination during intraoperative colonoscopy. Endoscopic polypectomy was performed when polyps were located outside the planned surgical resection limits. A synchronous carcinoma was defined by the criteria of Kaibara et a\.".
Results Between December 1988 and December 1990, intraoperative colonoscopy was performed in 67 patients with colorectal cancer (49 men and 18 women) with a mean(s.d.) age of 63.5( 12.8) years. None of the patients had a history of ulcerative colitis, familial adenomatous polyposis or previous surgery for colorectal cancer. The location of the primary tumour was the rectum in 37 patients (55 per cent), the sigmoid colon in 21 (31 per cent), the descending colon in seven (10 per cent) and the transverse colon in two ( 3 per cent). The tumour was causing stenosis in 39 patients (58 per cent). Full examination of the colon was achieved without help from the surgeon in 40 patients (60 per cent). Of the other 27 patients, the stenosis was negotiated after manipulation by the surgeon in 22 and the colonoscope could not be advanced in five. Full examination of the colon was achieved in three of these by reintroduction of the endoscope through a colotomy. This procedure was not carried out in two patients who underwent palliative surgery owing to advanced age and multiple peritoneal metastases. Complete colonoscopy was thus accomplished in a total of 65 patients (97 per cent). Intraoperative colonoscopy was normal in 37 patients ( 5 5 per cent ). In 24 (36 per cent ), polyps located outside the planned resection limits were detected and removed. In two patients the polyps contained carcinoma in situ. Synchronous carcinoma was found in six patients (9 per cent) (Table I ). In five the primary tumour was located in the rectum and in four was stenosing. All six had associated adenomatous polyps. Only four synchronous tumours were detected by manual palpation during surgery; two were discovered by intraoperative colonoscopy. The planned surgical approach was modified in all cases. The mean age of patients without synchronous lesions was 61.2 years and for those with synchronous polyps 65.3 years. Patients with synchronous carcinoma were significantly older
0007 1323/Y2/121376 03
I
l Y Y 2 Rutterworth Heinemann Ltd
lntraoperative colonoscopy: E. Brullet et al.
Table 1 Derails
of six
patients with synchronous carcinoma
Synchronous tumour Primary tumour no.
Sex
Location
Stage*
Stenosis
Location
Stage*
Detection by manual palpation
I
F
Rectum
T, N,
Yes
T, N ,
No
Enlarged resection
2
M
Rectum
T, No
Yes
T, N ,
Yes
Enlarged resection
3
M M
Rectum Rectum
T, N, T,No
Yes
4
Splenic flexure Transverse colon Caecum Sigmoid
T, N, T, N,
No Yes
5
M
Rectum
T, No
No
T, N ,
Yes
Enlarged resection Palliative colostomy (peritoneal metastases) Enlarged resection
6
F
Transverse colon
T, N,
Yes
T, N,
Yes
Enlarged resection
Patient
No
colon
Sigmoid colon Caecum
Final surgical procedure?
* Tumour node metastasis classification. ?The planned surgical approach was modified in all six cases than those without (mean age 74.1 uersus 61.2 years; P = 002, analysis of variance). Serosal laceration was noted and repaired in two patients during surgery. In both, intraoperative colonoscopy was technically difficult because of adhesions and needed complex endoscopic manipulation and help from the surgeon. The mean duration of intraoperative colonoscopy was 15 min. If endoscopic polypectomy or surgical help was needed, the mean time was 21 min; it was 9 min when polypectomy or manual help were not required.
Discussion
but preoperative detection of synchronous lesions allows a more appropriate surgical procedure’.’ 1-14,15-17,21,2’.In this study the intraoperative colonoscopy findings allowed the modification of the planned surgical approach in all patients with synchronous carcinoma. Intraoperative colonoscopy is a useful method of achieving full examination of the colon and identifies synchronous lesions, notably in those patients with stenosing turn our^'^*^^. It does not prolong operating time and complications are both minor and rare. Intraoperative colonoscopy allows a ‘clearing’ of the colon, removing polyps and preventing possible early metachronous carcinomas. The impact of intraoperative colonoscopy on survival in patients with colorectal cancer has to be determined.
Synchronous carcinoma is clinically important because of its incidence, the difficulty of preoperative diagnosis, and Acknowledgements the therapeutic and prognostic implications of missed lesionsl . & 7 . 1 6 . 1 9 . 2 2 . 2 3 . The reported incidencel2-l5 of synThe authors thank Lyn McBride for preparing the manuscript. chronous carcinoma in patients with colorectal cancer ranges from 1.5 to I I per cent; this variation may be due to factors References such as the criteria used t o define synchronous cancer, design of the study, and diagnostic methods employed,. Diagnosis of I . Warren S, Gates 0. Multiple primary malignant tumours: a survey of the literature and a statistical study. Am J Cancer 1932; synchronous lesions may be difficult because in many patients 16: 1358-414. is not possible to perform full preoperative colonoscopy because 2. Moertel CG, Bargen JA, Dockerty MB. Multiple carcinoma of of tumour ~ t e n o s i s ~ ~ - In * ~prospective ~ ~ ~ ~ ~ ’ studies, . examinthe large intestine: a review of the literature and a study of 231 ation of the entire colon was achieved in only 42-60 per cent cases. Gusrroent~,rolog~ 1958; 34: 85--98. of cases and periodic postoperative colonoscopy was recom3 . Rosenthal I . Baronofsky ID. Prognostic and therapeutic mended to detect early metachronous carcinoma19-21~26.2’. implications of polyps in mctachronous colonic carcinoma. This policy can be challenged because the detection of a second J , 4 M A 1960: 172: 37-41. tumour may determine a different resection. 4. Dencker H, Lieddberg G, Tibblin S. Multiple malignant tumours The technique and utility of intraoperative colonoscopy has of the colon and rectum. Acru Chir Si,und 1969; 135: 260-2. 5. Swinton NW, Parshley PF. Multiple cancers of the colon and been d o c ~ m e n t e d for ~ ~localization -~~ of non-palpable colonic rectum. Dis Colon Riwum 1962; 5: 378-80. lesions, investigation of unexplained recurrent gastrointestinal 6. Devitt JE, Roth-Moyo LA, Brown FN. The significance of haemorrhage, assessment of the extent of inflammatory bowel multiple adenocarcinoma of the colon and rectum. Ann Surg disease or when there is an inability to complete colonoscopy 1969; 169: 364-7. before operation. Intraoperative colonoscopy was selectively I . Lasser A. Synchronous primary adenocarcinomas of the colon for the detection of synchronous employed by Kaibara et and rectum. Dis Colon Rivrum 1978; 21: 20-2. lesions and was performed through a colotomy; they found an 8. Heald RJ, Bussey HJR. Clinical experiences at St Mark’s Hospital incidence for synchronous neoplasm of 8.6 per cent. Finan et with multiple synchronous cancers of the colon and rectum. Dis a1.I3 proposed the same strategy. cO/Ot? Ri,
