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Colonoscopic removal of a giant adenoma in a patient with portal hypertension and coagulopathy
COLON A N D R E C T U M 325 V A L U E OF T R A N S R E C T A L U L T R A S O U N D S T A G I N G (TRUS) IN RECTAL CANCER TREATED WITH ENDOCAVITARY RADIATION G,Gaqliardi, I.J.Kodner, R.M. Myerson and J.W.Fleshman Section of Colon and Rectal Surgery and Department of Radiation Oncology. Washington U n i v e r s i t y , St Louis MO. Objective: to d e t e r m i n e factors which predict o u t c o m e of r e c t a l c a n c e r t r e a t e d w i t h e x t e r n a l b e a m (RT) and e n d o c a v i t a r y r a d i a t i o n (EC). M e t h o d s : B e t w e e n 1988 and 1992 44 r e c t a l cancers w e r e t r e a t e d w i t h 4500 c G y RT f o l l o w e d 5 weeks l a t e r by 6000 cGy EC. 19 p a t i e n t s h a d e x c i s i o n a l b i o p s y at d i a g n o s i s . T u m o r o r b i o p s y site were a s s e s s e d by T R U S b e f o r e RT in 42 and a f t e r RT b e f o r e EC in 26. M e a n f o l l o w - u p w a s 55 m o n t h s (range 32-72). Results: In p a t i e n t s w h o d i d not h a v e e x c i s i o n a l biopsy local recurrence was m o r e frequent in t u m o r s that d i d not s h r i n k a f t e r RT (1/17 vs 5/5; p < 0 . 0 1 ) . TRUS, c l i n i c a l a n d h i s t o l o g i c a l staging before RT were not predictive of tumor recurrence. Advanced TRUS T stage and tumor t h i c k n e s s a f t e r RT w e r e c o r r e l a t e d w i t h i n c r e a s e d local recurrence (p=0.02 and p=0.04 respectively). Conclusion: T u m o r s h r i n k a g e and T R U S a s s e s s m e n t of r e s i d u a l d i s e a s e a f t e r RT w e r e p r e d i c t i v e of local c o n t r o l in r e c t a l c a n c e r t r e a t e d w i t h RT a n d EC. TRUS a s s e s s m e n t of r e c t a l c a n c e r a f t e r RT m a y be u s e f u l in d e t e r m i n i n g t r e a t m e n t strategy.
t327 OGILVIE'S SYNDROME: EFFECTIVENESS OF COLONOSCOPIC DECOMPRESSION. A. Geller. B.T. Petersen, C.J. Gostout. Mayo Clinic, Rochester MN. Introduction: Acute colonic pseudo-obstruction (ACPO) is an uncommon syndrome for which no controlled studies exist to guide therapy. We describe the experience of a specialized endoscopy team management of ACPO. Aim: To assess the efficacy, safety and outcome of colonoscopic decompression (CD) in pts with ACPO. Methods: All CD for ACPO in our data base from 1988 to 1994 were reviewed. The extent of endoscopy, decompression tube placement and pathologic findings were assessed. Diagnostic criteria used were abdominal distention, colonic dilatation on x-ray and absence of obstruction. A medical history score was developed to weigh relative clinical patient complexity. Early endoscopic success required a reduced colonic diameter following the procedure on x-ray. The extent of colonic dilatation on x-ray in the following 24-48 hours determined clinical success. Results: ACPO was diagnosed in 50/56 pts (33 M;17 F; mean age 68 13; range 26-91 years). All pts had an initial trial of conservative therapy. Median medical history score was 5 (range 1-8). There were 16 pts with only medical disease, 28 surgical and 6 trauma. Abdominal surgery and orthopedic joint replacement were most common. 10% had nausea, vomiting and abdominal pain. 50% pts had implicated medications. 61 CD were performed with 100% early success. 41 pts (82%) had 1 CD, 40 of these pts had placement of decompression tube (DT). Clinical success was achieved in 39. Nine pts required multiple (24) CD each. The in-hospital mortality was 28%. Endoscopic data: The scope reached the right colon in 84% of procedures all in unpreped colons. DT was placed in the right colon in 62% and in the transverse in 30% of procedures. There was 91% clinical success in the former and 94% in the latter. A DT was not placed in 7 pts of which failure rate was 5/7 (71%). The overall clinical success of CD was 90%. Colitis was noted in 14% of pts. Pathology in 4 pts showed: chronic colitis, ischemia, pseudomemhranous and nondiagnostic. There was one perforation. Summary: Colonoscopic decompression with DT is effective and safe in pts with ACPO who fail conservative therapy. The majority ofpts will respond to one CD with DT, 10% required repeated CD. Decompression tube in the right or transverse colon is sufficient for successful decompression. Conclusions: 1. Complete colonoscopy and cecal tube placement is unnecessary. 2. Immediate decompression (early success) is a poor indicator of clinical success. 3. The overall prognosis of ACPO is poor with an in-hospital mortality of 28% due to the complexity of underlying diseases.
326
328
ILEOSTOMY POUCH POLYPOSIS IN A PATIENT WITH FAMILIAL ADENOMATOUS POLYPOSIS. A Geller. KK Wang. Mayo Clinic, Rochester, MN.
COLONOSCOPIC REMOVAL OF A GIANT ADENOMA IN A PATIENT WITH PORTAL HYPERTENSION AND COAGULOPATHY; Scott M. Gioe. M.D., Fredric Regenstein, M.D. Ochaner Medical Foundation, New Orleans, Louisiana The removal of large colonic polyps in cirrhotic patients with coexisting portal hypertension and coagulopathy represents a very challenging and difficult problem. This is particularly problematic in patients being evaluated for hepatic transplantation. Since up to 16% of large (-> 3 cm), endoscopically benign appearing polyps may be malignant, these polyps must be completely removed prior to being considered for transplantation and laparotomy in these patients is very risky. Here we report a case of a patient with end-stage liver disease who underwent successful endoscopic removal of a 5 cm sessile polyp from the right colon. A 45 yo wm with cirrhosis due to alpha-l-antitrypsin deficiency was being evaluated for hepatic transplantation. Due to a family history of colon cancer and Hemoccult positive stools, he underwent a colonoscopy. The examination revealed a 5 cm sessile polyp in the right colon. Since the patient had severe portal hypertension and a coagulopathy (PT 20.1 sec, INR 3.1, PLT count of 41,000/mm3), it was decided to attempt removal at a later date. At the time of repeat colonoscopy, 4 units of FFP were infused. A sclerotherapy catheter containing dilute (1:20,000) epinephrine (Epi) was used and multiple submucosal injections to the base of the polyp were performed. Once the entire polyp base was raised and the surrounding mucosa blanched, piecemeal snare resection was performed with approximately 70% of the polyp removed. Mild oozing from the base of the resected tissue was controlled with additional Epi injections. The remainder of the polyp was removed in a similar fashion seven weeks later. The patient tolerated both procedures well and had no evidence of overt bleeding. Histologic examination of all specimens was consistent with a tubulovillous adenoma. The base of the polyp was injected with dilute Epi because it has been proven safe and theoretically it may reduce bleeding. Epi injection works by tamponading and constricting blood vessels supplying the polyp, reducing blood flow and hopefully decreasing bleeding. We feel that endoscopic removal of large polyps in patients with portal hypertension and a coagulopathy can be performed safely with the technique used in this case. These patients have a high surgical morbidity and mortality for colectomy; therefore, the endoscopic approach may be safer.
Prophylactic total proctocolectomy with ileostomy has been widely accepted for patients with familial adenomatous polyposis since 1951. We report a case of a 56 year old male who developed multiple adenomatous polyposis in an ileostomy pouch. The patient was diagnosed with familial adenomatous polyposis at age 26 and underwent a partial colectomy and ileoproctostomy. Seventeen years after the initial surgery, he developed a carcinoma in the rectal stump and underwent a proctectomy with a permanent ileostomy. Thirteen years after this, he presented with upper abdominal discomfort and bright red blood in the ileostomy output. Gastroscopy revealed multiple gastric polyps which were fundic gland polyps on histology. Small flat duodenal polyps were found which were shown to be tubulovillous adenomas. A small bowel x-ray showed no jejunal polyposis but numerous polyps in the ileal pouch. An ileoscopy demonstrated multiple large polyps in the ileal pouch but none in the afferent ileal limb. The ileal polyps were confirmed to be tubular adenomas on histology. The ileal mucosa in the pouch appeared to have undergone colonic metaplasia. The mucosa in the ascending ileum showed chronic inflammation. The patient did not have a prior history of ileal poIyposis. This represents a case of polyps developing in an ileostomy pouch after colectomy for familial adenomatous polyposis. It is unclear if colonic metaplasia is a predisposing factor for development of ileal polyposis or whether the ileal pouch polyposis is an extracolonic manifestation of familial polyposis. Currently no s t a n d a r d recommendations exist to periodically evaluate the ileostomy pouch in patients with familial adenomatous polyposis after total proctocolectomy with ileostomy or ileoanal anastomosis. In addition, the prevalence of ileostomy pouch polyposis and cancer is unknown. A prospective study with endoscopy and biopsies is needed to determine the prevalence of colonic metaplasia, ileostomy polyposis and carcinoma to clarify the need for periodic endoscopy.
V O L U M E 41, NO. 4, 1995
GASTROINTESTINAL
ENDOSCOPY
377
t327 OGILVIE'S SYNDROME: EFFECTIVENESS OF COLONOSCOPIC DECOMPRESSION. A. Geller. B.T. Petersen, C.J. Gostout. Mayo Clinic, Rochester MN. Introduction: Acute colonic pseudo-obstruction (ACPO) is an uncommon syndrome for which no controlled studies exist to guide therapy. We describe the experience of a specialized endoscopy team management of ACPO. Aim: To assess the efficacy, safety and outcome of colonoscopic decompression (CD) in pts with ACPO. Methods: All CD for ACPO in our data base from 1988 to 1994 were reviewed. The extent of endoscopy, decompression tube placement and pathologic findings were assessed. Diagnostic criteria used were abdominal distention, colonic dilatation on x-ray and absence of obstruction. A medical history score was developed to weigh relative clinical patient complexity. Early endoscopic success required a reduced colonic diameter following the procedure on x-ray. The extent of colonic dilatation on x-ray in the following 24-48 hours determined clinical success. Results: ACPO was diagnosed in 50/56 pts (33 M;17 F; mean age 68 13; range 26-91 years). All pts had an initial trial of conservative therapy. Median medical history score was 5 (range 1-8). There were 16 pts with only medical disease, 28 surgical and 6 trauma. Abdominal surgery and orthopedic joint replacement were most common. 10% had nausea, vomiting and abdominal pain. 50% pts had implicated medications. 61 CD were performed with 100% early success. 41 pts (82%) had 1 CD, 40 of these pts had placement of decompression tube (DT). Clinical success was achieved in 39. Nine pts required multiple (24) CD each. The in-hospital mortality was 28%. Endoscopic data: The scope reached the right colon in 84% of procedures all in unpreped colons. DT was placed in the right colon in 62% and in the transverse in 30% of procedures. There was 91% clinical success in the former and 94% in the latter. A DT was not placed in 7 pts of which failure rate was 5/7 (71%). The overall clinical success of CD was 90%. Colitis was noted in 14% of pts. Pathology in 4 pts showed: chronic colitis, ischemia, pseudomemhranous and nondiagnostic. There was one perforation. Summary: Colonoscopic decompression with DT is effective and safe in pts with ACPO who fail conservative therapy. The majority ofpts will respond to one CD with DT, 10% required repeated CD. Decompression tube in the right or transverse colon is sufficient for successful decompression. Conclusions: 1. Complete colonoscopy and cecal tube placement is unnecessary. 2. Immediate decompression (early success) is a poor indicator of clinical success. 3. The overall prognosis of ACPO is poor with an in-hospital mortality of 28% due to the complexity of underlying diseases.
326
328
ILEOSTOMY POUCH POLYPOSIS IN A PATIENT WITH FAMILIAL ADENOMATOUS POLYPOSIS. A Geller. KK Wang. Mayo Clinic, Rochester, MN.
COLONOSCOPIC REMOVAL OF A GIANT ADENOMA IN A PATIENT WITH PORTAL HYPERTENSION AND COAGULOPATHY; Scott M. Gioe. M.D., Fredric Regenstein, M.D. Ochaner Medical Foundation, New Orleans, Louisiana The removal of large colonic polyps in cirrhotic patients with coexisting portal hypertension and coagulopathy represents a very challenging and difficult problem. This is particularly problematic in patients being evaluated for hepatic transplantation. Since up to 16% of large (-> 3 cm), endoscopically benign appearing polyps may be malignant, these polyps must be completely removed prior to being considered for transplantation and laparotomy in these patients is very risky. Here we report a case of a patient with end-stage liver disease who underwent successful endoscopic removal of a 5 cm sessile polyp from the right colon. A 45 yo wm with cirrhosis due to alpha-l-antitrypsin deficiency was being evaluated for hepatic transplantation. Due to a family history of colon cancer and Hemoccult positive stools, he underwent a colonoscopy. The examination revealed a 5 cm sessile polyp in the right colon. Since the patient had severe portal hypertension and a coagulopathy (PT 20.1 sec, INR 3.1, PLT count of 41,000/mm3), it was decided to attempt removal at a later date. At the time of repeat colonoscopy, 4 units of FFP were infused. A sclerotherapy catheter containing dilute (1:20,000) epinephrine (Epi) was used and multiple submucosal injections to the base of the polyp were performed. Once the entire polyp base was raised and the surrounding mucosa blanched, piecemeal snare resection was performed with approximately 70% of the polyp removed. Mild oozing from the base of the resected tissue was controlled with additional Epi injections. The remainder of the polyp was removed in a similar fashion seven weeks later. The patient tolerated both procedures well and had no evidence of overt bleeding. Histologic examination of all specimens was consistent with a tubulovillous adenoma. The base of the polyp was injected with dilute Epi because it has been proven safe and theoretically it may reduce bleeding. Epi injection works by tamponading and constricting blood vessels supplying the polyp, reducing blood flow and hopefully decreasing bleeding. We feel that endoscopic removal of large polyps in patients with portal hypertension and a coagulopathy can be performed safely with the technique used in this case. These patients have a high surgical morbidity and mortality for colectomy; therefore, the endoscopic approach may be safer.
Prophylactic total proctocolectomy with ileostomy has been widely accepted for patients with familial adenomatous polyposis since 1951. We report a case of a 56 year old male who developed multiple adenomatous polyposis in an ileostomy pouch. The patient was diagnosed with familial adenomatous polyposis at age 26 and underwent a partial colectomy and ileoproctostomy. Seventeen years after the initial surgery, he developed a carcinoma in the rectal stump and underwent a proctectomy with a permanent ileostomy. Thirteen years after this, he presented with upper abdominal discomfort and bright red blood in the ileostomy output. Gastroscopy revealed multiple gastric polyps which were fundic gland polyps on histology. Small flat duodenal polyps were found which were shown to be tubulovillous adenomas. A small bowel x-ray showed no jejunal polyposis but numerous polyps in the ileal pouch. An ileoscopy demonstrated multiple large polyps in the ileal pouch but none in the afferent ileal limb. The ileal polyps were confirmed to be tubular adenomas on histology. The ileal mucosa in the pouch appeared to have undergone colonic metaplasia. The mucosa in the ascending ileum showed chronic inflammation. The patient did not have a prior history of ileal poIyposis. This represents a case of polyps developing in an ileostomy pouch after colectomy for familial adenomatous polyposis. It is unclear if colonic metaplasia is a predisposing factor for development of ileal polyposis or whether the ileal pouch polyposis is an extracolonic manifestation of familial polyposis. Currently no s t a n d a r d recommendations exist to periodically evaluate the ileostomy pouch in patients with familial adenomatous polyposis after total proctocolectomy with ileostomy or ileoanal anastomosis. In addition, the prevalence of ileostomy pouch polyposis and cancer is unknown. A prospective study with endoscopy and biopsies is needed to determine the prevalence of colonic metaplasia, ileostomy polyposis and carcinoma to clarify the need for periodic endoscopy.
V O L U M E 41, NO. 4, 1995
GASTROINTESTINAL
ENDOSCOPY
377