Volume 22 N~mber 7
LETTERS TO THE EDITOR
the recommended Chiu and Spencer "conservative treatment of villous lesions as appropriate when invasive carcinoma is not detected" is risky. The thought that a "conservative procedure for the treatment of villous lesions" may be used in community hospitals in Europe and in the United States by proctologic colleagues, after reading the article of Chiu and Spencer, is alarming. J. WEOELL, M.D. P. MEIER Zv EISSEN, M.D. j. MEIER ZU EISSEN, M.D. H. VAN CALKER, M.D.
Surgical Department arm Pathological Institute of the A cademic Teaching Hospital H erford S chwarzenmoorstrasse 70 Postfach 523 4900 Herford, West Germany
~07
References 1. Bacon HE, Eisenberg SW: Papillary adenoma or villous tumor of the rectum and colon. Ann Surg 174: 1002, 1971 2. McCabe JC, McSherry CK, Sussman EB, et al: Villous tumors of the large bowel. Am J Surg 126: 336, 1973 3. Orringer MB, Eggleston JC: Papillary (villous) adenomas of the colon and rectum. Surgery 72: 378, 1972 4. Parks AG, Stuart AE: The inanagement of villous turnouts of the large bowel. Br .| Surg 60: 688, 1973 5. Quan SH, Castro EB: Papillary adenomas (villous tumors): A review of 215 cases. Dis Colon Rectum 14: 267, 1971 6. Welch JP, Welch CE: Villous adenomas of the colorectum. Am J Surg 131: 185, 1976 7. Wheat NIW Jr, Ackerman LV: Villous adenomas of the large intestine: Clinicopathologic evaluation of 50 cases of villous adenomas with emphasis on treatment. Ann Surg 147: 476, 1958 8. Arnaud JP, Eloy MR, Clendinnen G, et al: The posterior approach for villous tumors of the rectum: Report of 11 cases. Am J Surg 136: 273, 1978 9. Harp RA, Waugh JM, Dockerty MB: Noninfiltrating villous colonic tumors: Partial review of literature and report of 63 cases. Dis Colon Rectum 5: 191, 196_9
Intraoperative Colonoscopy To the Editor:--Although it is appropriate for the medical literature to include reports that may stimulate controversy (i.e., freedom of the press), I am disappointed with the thrust of the article entitled "Intraoperative Colonscopy" by Drs. Martin and Forde [Martin PJ, Forde KA: Intraoperative colonoscopy: Preliminary report. Dis Colon Rectum 22: 234, 1979]. I feel that this article is taking us in the wrong direction and demonstrates possibly a more modest performance than should hopefully be the standard in the community. The indications for intraoperative colonoscopy are exceedingly rare. An experienced colonoscopist should be able to evaluate the entire colon preoperatively. Failure to reach a certain level because of adhesions of previous pelvic surgery or extensive diverticulosis occurs rarely in experienced hands. With regard to the article as published--I am disappointed by example # 1 on page 236, where the author wrote, "The surgeon decided on exploration, but requested intraoperative colonoscopy which disclosed a smooth-surfaced submucosal lesion. This mass was excised without intestinal resection, and pathologic examination showed that it was a submucosal lipoma. This patient was spared ileocolect o m y . " I f this p a t i e n t had been c o l o n o s c o p e d preoperatively, the lipoma may well have been confirmed endoscopically, and this patient could have been spared abdominal surgery of any kind. Although lipomas are fairly common in the right colon,
they are virtually never symptomatic (very rarely they are a source of intussusception), and rarely require excision for tissue confirmation. An experienced endoscopist can almost always recognize a lipoma endoscopically, and conclude that no treatment is necessary. Table 3 on page 236 refers to the intraoperative colonoscopy done in six cases to locate lesions not seen on preoperative barium-enema examination, but diagnosed on preoperative colonoscopy. At the time of the preoperative colonoscopy, a flat film of the a b d o m e n would have located the lesions (with superimposition on a barium enema film), definitively, and allowed the surgeon to proceed without delay and w i t h o u t the need for i n t r a o p e r a t i v e colonoscopy. Example 5, on page 237, refers to a 65-year-old woman undergoing a large ventral hernia repair. Because of a preoperative barium enema showing a possible transverse colon polyp, intraoperative colonoscopy was done. Because i1o polyp was present, a colotomy was avoided. This colonoscopy examination could have more conveniently been done preoperatively, even the day before the scheduled surgery, eliminating unnecessary anesthesia and operating room time. Although intraoperative colonoscopy is appropriate in isolated and rare instances, the indications and need are much more rare than indicated in this article. Intraoperative colonoscopy should not be a sub-
508
LETTERS TO T H E EDITOR
stitute for colonoscopy by an experienced colonoscopist preoperatively. An article such as this one serves, in my opinion, only to encourage other colo n o s c o p i s t s o f m e d i o c r e ability to c o n s i d e r intraoperative colonoscopy more frequently. In general, I have always felt that criticism of the work of others should be constructive rather than
Dis. Col. & Rect. October 1979
negative. Because of the potential negative effects of the thrust of this article, I feel obligated to make this response and hope that the criticism can be accepted as a constructive effort, which was intended. JOHN P. CHRISTIE, M.D. 7330 S.W. 62rid Place, Suite 220 South Miami, Florida 33143
The Author Replies To the Editor:--We regret Dr. Christie's interpretation of our report. We hold no special brief for intraoperative colonoscopy and did not at all suggest it as the p r e f e r r e d m e t h o d of examination. Careful reading by Dr. Christie would have obviated much of his criticism. His suggestion that we p e r f o r m intraoperative colonoscopy with u n d u e frequency is not supported by any statement or data in our paper. Like all colonoscopists with significant experience and expertise we prefer preoperative colonoscopy, and the cases reported in our article represent less than 2% of our total experience and even a smaller percentage in recent years. We now have enough experience at our institution however to know that there are indeed some patients in whom total colonoscopy is not feasible, even by experts at other institutions and to recognize that colonoscopists lose their credibility when they claim otherwise. To state that it is possible to overcome all adhesions, all irradiated bowel, and all diverticular problems is not consistent with the honest experience of most workers in this field. Most of his comments may be dismissed if he noted (as we implied) that the reluctance to examine the patient before operation was usually not that of the endoscopist but chiefly the j u d g m e n t of the patient's primary surgeon. This applies to some of the patients in Table 3, example 5, and several others not noted by Dr. Christie. T h a t the surgeons' operative j u d g m e n t was improved by colonoscopy has helped them and us to come to better agreement concerning the indications for preoperative colonoscopy at our own institution and so has been an educational experience. Dr. Christie missed the point in example 1. Every surgeon of significant experience recognizes too well the limitations of attempting to assess a lesion by palpation t h r o u g h the bowel wall. To do a blind resection or to open the colon to verify the nature of a lesion are not desirable surgical alternatives. T h e surgeon in this case (example l) was concerned about the possibility of the lesion being a villous a d e n o m a of the c e c u m for which he would have p e r f o r m e d an ileocolectomy (not unacceptable in surgical circles as is known).
T h e knowledge of the radiographic and endoscopic appearance of typical lipomas is commonplace and needs no restatement, as is the fact that their removal is rarely necessary. With respect to preoperative localization, it is often easier even than Dr. Christie suggested. We have fluoroscopy available in our endoscopic suite for this purpose. T h e use of various dyes injected in the bowel wall may also be an aid to the surgeon and this is of even greater potential benefit when a recent polypectomy site needs to be included in a subsequent resection. Some time ago we visualized, biopsied, and localized fluoroscopically a distal descending colon lesion by preoperative colonoscopy. At celiotomy, a palpable lesion with serosal changes was resected only to find that it was an unsuspected e n d o m e t r i o m a . T h e lesion we were after was several centimeters distal and was not included in the resection. T h e resultant need for additional and separate resection with takedown of the already created anastomosis could have been obviated by intraoperative colonoscopy. We would reiterate that in selected rare instances intraoperative colonoscopy, if properly p e r f o r m e d , need not delay operative or anesthesia time. We purposefully labeled our report "preliminary," anticipating that as colonoscopy gains wider acceptance (a perspective not always possible for those whose experience is largely endoscopic) the indications for intraoperative colonoscopy may change. Nevertheless it is important to know how to do it deftly and expertly if called upon. We are flattered that Dr. Christie feels that our report will stimnlate others "of" mediocre ability" to indulge more frequently in intraoperative colonoscopy, but disappointed in his totally u n f o u n d e d suggestion that we advocate it as a substitute for preoperative colonoscopy. We have, I think, done neither. K E N N E T H A . FORDE, M . D .
Department of Surgery College of Physicians and Surgeons 630 West 168th Street New York, New York, 10032
LETTERS TO THE EDITOR
the recommended Chiu and Spencer "conservative treatment of villous lesions as appropriate when invasive carcinoma is not detected" is risky. The thought that a "conservative procedure for the treatment of villous lesions" may be used in community hospitals in Europe and in the United States by proctologic colleagues, after reading the article of Chiu and Spencer, is alarming. J. WEOELL, M.D. P. MEIER Zv EISSEN, M.D. j. MEIER ZU EISSEN, M.D. H. VAN CALKER, M.D.
Surgical Department arm Pathological Institute of the A cademic Teaching Hospital H erford S chwarzenmoorstrasse 70 Postfach 523 4900 Herford, West Germany
~07
References 1. Bacon HE, Eisenberg SW: Papillary adenoma or villous tumor of the rectum and colon. Ann Surg 174: 1002, 1971 2. McCabe JC, McSherry CK, Sussman EB, et al: Villous tumors of the large bowel. Am J Surg 126: 336, 1973 3. Orringer MB, Eggleston JC: Papillary (villous) adenomas of the colon and rectum. Surgery 72: 378, 1972 4. Parks AG, Stuart AE: The inanagement of villous turnouts of the large bowel. Br .| Surg 60: 688, 1973 5. Quan SH, Castro EB: Papillary adenomas (villous tumors): A review of 215 cases. Dis Colon Rectum 14: 267, 1971 6. Welch JP, Welch CE: Villous adenomas of the colorectum. Am J Surg 131: 185, 1976 7. Wheat NIW Jr, Ackerman LV: Villous adenomas of the large intestine: Clinicopathologic evaluation of 50 cases of villous adenomas with emphasis on treatment. Ann Surg 147: 476, 1958 8. Arnaud JP, Eloy MR, Clendinnen G, et al: The posterior approach for villous tumors of the rectum: Report of 11 cases. Am J Surg 136: 273, 1978 9. Harp RA, Waugh JM, Dockerty MB: Noninfiltrating villous colonic tumors: Partial review of literature and report of 63 cases. Dis Colon Rectum 5: 191, 196_9
Intraoperative Colonoscopy To the Editor:--Although it is appropriate for the medical literature to include reports that may stimulate controversy (i.e., freedom of the press), I am disappointed with the thrust of the article entitled "Intraoperative Colonscopy" by Drs. Martin and Forde [Martin PJ, Forde KA: Intraoperative colonoscopy: Preliminary report. Dis Colon Rectum 22: 234, 1979]. I feel that this article is taking us in the wrong direction and demonstrates possibly a more modest performance than should hopefully be the standard in the community. The indications for intraoperative colonoscopy are exceedingly rare. An experienced colonoscopist should be able to evaluate the entire colon preoperatively. Failure to reach a certain level because of adhesions of previous pelvic surgery or extensive diverticulosis occurs rarely in experienced hands. With regard to the article as published--I am disappointed by example # 1 on page 236, where the author wrote, "The surgeon decided on exploration, but requested intraoperative colonoscopy which disclosed a smooth-surfaced submucosal lesion. This mass was excised without intestinal resection, and pathologic examination showed that it was a submucosal lipoma. This patient was spared ileocolect o m y . " I f this p a t i e n t had been c o l o n o s c o p e d preoperatively, the lipoma may well have been confirmed endoscopically, and this patient could have been spared abdominal surgery of any kind. Although lipomas are fairly common in the right colon,
they are virtually never symptomatic (very rarely they are a source of intussusception), and rarely require excision for tissue confirmation. An experienced endoscopist can almost always recognize a lipoma endoscopically, and conclude that no treatment is necessary. Table 3 on page 236 refers to the intraoperative colonoscopy done in six cases to locate lesions not seen on preoperative barium-enema examination, but diagnosed on preoperative colonoscopy. At the time of the preoperative colonoscopy, a flat film of the a b d o m e n would have located the lesions (with superimposition on a barium enema film), definitively, and allowed the surgeon to proceed without delay and w i t h o u t the need for i n t r a o p e r a t i v e colonoscopy. Example 5, on page 237, refers to a 65-year-old woman undergoing a large ventral hernia repair. Because of a preoperative barium enema showing a possible transverse colon polyp, intraoperative colonoscopy was done. Because i1o polyp was present, a colotomy was avoided. This colonoscopy examination could have more conveniently been done preoperatively, even the day before the scheduled surgery, eliminating unnecessary anesthesia and operating room time. Although intraoperative colonoscopy is appropriate in isolated and rare instances, the indications and need are much more rare than indicated in this article. Intraoperative colonoscopy should not be a sub-
508
LETTERS TO T H E EDITOR
stitute for colonoscopy by an experienced colonoscopist preoperatively. An article such as this one serves, in my opinion, only to encourage other colo n o s c o p i s t s o f m e d i o c r e ability to c o n s i d e r intraoperative colonoscopy more frequently. In general, I have always felt that criticism of the work of others should be constructive rather than
Dis. Col. & Rect. October 1979
negative. Because of the potential negative effects of the thrust of this article, I feel obligated to make this response and hope that the criticism can be accepted as a constructive effort, which was intended. JOHN P. CHRISTIE, M.D. 7330 S.W. 62rid Place, Suite 220 South Miami, Florida 33143
The Author Replies To the Editor:--We regret Dr. Christie's interpretation of our report. We hold no special brief for intraoperative colonoscopy and did not at all suggest it as the p r e f e r r e d m e t h o d of examination. Careful reading by Dr. Christie would have obviated much of his criticism. His suggestion that we p e r f o r m intraoperative colonoscopy with u n d u e frequency is not supported by any statement or data in our paper. Like all colonoscopists with significant experience and expertise we prefer preoperative colonoscopy, and the cases reported in our article represent less than 2% of our total experience and even a smaller percentage in recent years. We now have enough experience at our institution however to know that there are indeed some patients in whom total colonoscopy is not feasible, even by experts at other institutions and to recognize that colonoscopists lose their credibility when they claim otherwise. To state that it is possible to overcome all adhesions, all irradiated bowel, and all diverticular problems is not consistent with the honest experience of most workers in this field. Most of his comments may be dismissed if he noted (as we implied) that the reluctance to examine the patient before operation was usually not that of the endoscopist but chiefly the j u d g m e n t of the patient's primary surgeon. This applies to some of the patients in Table 3, example 5, and several others not noted by Dr. Christie. T h a t the surgeons' operative j u d g m e n t was improved by colonoscopy has helped them and us to come to better agreement concerning the indications for preoperative colonoscopy at our own institution and so has been an educational experience. Dr. Christie missed the point in example 1. Every surgeon of significant experience recognizes too well the limitations of attempting to assess a lesion by palpation t h r o u g h the bowel wall. To do a blind resection or to open the colon to verify the nature of a lesion are not desirable surgical alternatives. T h e surgeon in this case (example l) was concerned about the possibility of the lesion being a villous a d e n o m a of the c e c u m for which he would have p e r f o r m e d an ileocolectomy (not unacceptable in surgical circles as is known).
T h e knowledge of the radiographic and endoscopic appearance of typical lipomas is commonplace and needs no restatement, as is the fact that their removal is rarely necessary. With respect to preoperative localization, it is often easier even than Dr. Christie suggested. We have fluoroscopy available in our endoscopic suite for this purpose. T h e use of various dyes injected in the bowel wall may also be an aid to the surgeon and this is of even greater potential benefit when a recent polypectomy site needs to be included in a subsequent resection. Some time ago we visualized, biopsied, and localized fluoroscopically a distal descending colon lesion by preoperative colonoscopy. At celiotomy, a palpable lesion with serosal changes was resected only to find that it was an unsuspected e n d o m e t r i o m a . T h e lesion we were after was several centimeters distal and was not included in the resection. T h e resultant need for additional and separate resection with takedown of the already created anastomosis could have been obviated by intraoperative colonoscopy. We would reiterate that in selected rare instances intraoperative colonoscopy, if properly p e r f o r m e d , need not delay operative or anesthesia time. We purposefully labeled our report "preliminary," anticipating that as colonoscopy gains wider acceptance (a perspective not always possible for those whose experience is largely endoscopic) the indications for intraoperative colonoscopy may change. Nevertheless it is important to know how to do it deftly and expertly if called upon. We are flattered that Dr. Christie feels that our report will stimnlate others "of" mediocre ability" to indulge more frequently in intraoperative colonoscopy, but disappointed in his totally u n f o u n d e d suggestion that we advocate it as a substitute for preoperative colonoscopy. We have, I think, done neither. K E N N E T H A . FORDE, M . D .
Department of Surgery College of Physicians and Surgeons 630 West 168th Street New York, New York, 10032
