- Email: [email protected]
High volume screening for colorectal neoplasia using a disposable sheath flexible sigmoidoscopy (FS) system
COLON AND RI~CI UM "~361
363
THE NON-LIFTING SIGN AND LYMPH NODE METAsTAsIs OF COLORECTAL CANCER ~ A. Munakata, Y. Sasaki, H. Nakajima, Y Yoshida, First Department of internal Medicine, Hirosaki University School of Medicine, Hirosaki, Japan CotorectaJ cancer with protffecated fibers in the submucosa is not alevated by submucosal injection ot methylene blue, although the normal mucesa arojed the lesion is lifted, Eedoscop~cally, a blue bled is seen outside the lesion. We have named this phenomenon the non-lifting sign (NLS). The NLS is useful for deterrn~ the d e ~ of cobresla/carcinoma (Gasl~ntest Eedesc1994;40:485489): it is not noted in cases of intramucosal neop(asrn and submucosal cancer with minute invasDn, because these teSions have little with few fibrosis of the submucosa. However, early invasive carcinoma carries a nsk of lymph node metastaSis (LNM). This study was undertaken to ident~ the relationship between LNM and NLS. Methods: Forty-three colorectal cancers from 40 patients were investigated for the NLS before resection. Five of the lesions were resected along with lymph nodes by laparoscopic co~ectomy, and 38 lesions were resected by traditional colectomy. After histbl~ic diagnosis from the lymph nodes of each resected specimen, the sensitivity, specificity, and accuracy of the NLS ~or LNM were assessed. Results: The NLS was noted in 37 of the 43 cancers; 3 of T1No, 2 of T2No, 12 of TzNt 10 of "131'41,and 9 of T3NZ Six cancers without NLS were associated with minute submnoosal invasion and no lymph node metastaSis. The specificity (45'/0) of NLS for LNM was low, but sensitivity (t00%) and accuracy (88"} were h~h.
USE OF HEPARIN TO INDUCE POSITIVE RED BLOOD
LNM (+)
LNM (-)
Total
NLS (+)
32
5
37
NLS (-)
0
6
6
Total
3~
11
43
Conclusion: These results s u ~ { t h a i the NLS in cokxec'tal cancer is useful fer assessing not only the depth of invasion but also lymph node metastasis, patients with~ t a l canoer without the NLS may be curable by eedoscopic pdypectomy alone. Patients with cancer showing the NLS slmutd he selected for treatment colectOmy with lym~ r ~ excis~n.
CELL SCINTISCAN IN PATIENTS WITH CHRONIC GASTROINTESTINALHEMORRHAGE J. Marienhagen*. Ch. Eilles*, J Schrlmerich, A, Holstege; Department of Internal Medic~e I, *Department of Nuclear Medicine, University of Regensburg, 93042 Regansburg, Germany
Introduction: Diagnostic evaluation of chronic GI hemorrhage often leads to repeated invasive diagnostic procedures without successful identification of the source of hemorrhage. We describe our experience with heparin provocation to induce a positive red blood cell (RBC) scintiscan. Methods: In cases of unsuccessful identification of the source of hemorrhage by endoscopic and radiological procedures, a r inf'asion of heparin was stoned. The heparin dose was adjusted to maintain a partial thromboplastin time in the range of 60-80 s. A monitoring of vital signs and several btood counts were doneA Tc-labeled RBC scintiscan was performed obtaining several image sequences during a penod of 24 h. Results: 4 patients ( 3 men; age 22, 53, 65 yrs; 1 woman, age 75 yrs) with a history of recurrent G1 bleeding were examined. In all eases RBC scintiscan under hepafin provocation was positive. The induced hemorrhage had no hemodynamie relevance. No transf~ions were required.The source of bleeding was confirmed by laparotomy in one patient ( Meckel's diverticulum ) and by endoscopy in two patients (angiodysplasia in the caecum in a patient with aortic valve stenosis 0teyde syndrome); erosive mucosal lesion at the site of anastomosis after ileotransversostomy in another patient), In one patient no further evaluation was done because there were no signs of recurrent bleeding in the follow-up atter heparin infusion was stopped. Conclusions: When endoscopic and radiological evaluation of patients fails to indantify the source of chronic GI hemorrhage the RBC scintiscan under heparin provocation appears to be a highly sensitive and safe "tiagaostic procedure to identiOr the source of hemorrhage
362
~364
HIGH VOLUME SCREENING FOR COLORECTAL NEOPLASIA USING A DISPOSABLE SHEATH FLEXIBLE SIGMOIDOSCOPY (FS) SYSTEM. R. Vasudeva, J. Sheley, B: Woods, J. Greenhalgh, C.W. Howden. Division of Digestive Diseases and Nutrition, University of South Carolina, Columbia, SC.
INCOMPLETE COLONOSCOPY: INCIDENCE, CAUSES, AND FURTHER EVALUATION. JL Watkins, KP Etzkorn, I Alam, KP Block, JL Goldstein. Univ of Illinois, Westside VA Chicago.
Conventional FS for colorectal neoplasia screening is underutilized. FS using current systems requiring disinfection is time consuming and may not be suitable for mass screening. We studied the use of a disposable sheath FS syslem as a high volume screening tool. Stool testing and FS was offered free of charge to 425 employees (M:F 1:6) aged >50y at a local tertiary care hospital. The program was advertised through newsletters, TV and the Employee Clinic. A personalized letter along with educational materials underscoring the importance of screening was sent to each subject. This was followed by a phone call as a reminder and a chance to participate in an educational workshop prior to a fixed date for FS. Of the 425 subjects, 31 (7%) were excluded since they had FS or eolonoscopy within the past 5 years. Of the remaining 394, 21 (5%) signed up for the workshop and 5 attended. 20 subjects, all female, were scheduled for FS; 15 (4%) with a mean age of 56.6 y (range 50-63) underwent the procedure on a weekend morning by experienced endoscopists utilizing the 60 cm. disposable sheath system (Vision-Sciences Inc., Natick, MA) in three separate rooms. Mean total room utilization and turnaround time was 15 min. per procedure, including mean procedure time of 10.5 rain (range 4-16), accomplishing 4 procedures/hour/room. Findings included rectal polyp (n=l), hemorrhoids and]or sigmoid diverticula (n=10) and normal appearance (n=4). Lack of interest in screening was the reason for non-participation in 99% of subjects declining the invitatiom CONCLUSIONS : High volume FS screening with a disposable system is feasible and offers the advantage of a short turnaround time. Eenlales appear more receptive to screening than males. The dismal response rate to the invitation despite being offered free suggests poor patient acceptability. Increased public education efforts arc needed to overcome the lackadaisical attitude and may improve the acceptance of this modality.
386
GASTROINTESTINAL ENDOSCOPY
Experienced endoseopists exceed a 90% rate of Intuhatlon of the cecum. Purpose:To determine the rate and reason for incomplete colonoscopy(IC), and to assess the yield of subsequent radiographic/endoscopic evaluation of these patients. Methods__~The Endoscopy Database(TM) was used to retrieve all lowe~ endoscopy procedures at two teaching hospitals from L988~ - 1 9 9 4 These were classified by depth of insertion, reason for failure, medication dosage, sex, and presence of diverticulosis. Patients with IC were classified aceogdlng to reason for failure to reach the cecum; dlscomfort(DIS), poor prep(PREP), technical difficulty(TECH), and unknown (UNKN). Subsequent data for barium enema (LGl)/repeat colonoseopy was obtained for pts with IC. R e s u l t s : O f 7597 procedures, 3618 were sigmoidoscopies, 231 were infrared coagulations of hemorrhoids, leaving 3979 attempted eolonoscopies(AC). Of all AC, 3647 were completed(92%), equal for male and female patients. Dosage of Demerol (55 mg) and Versed (1.37 mg) were similar in the complete (CC) and IC groups. Diverticulosis was present in 17% of the IC and 22% of the CC patients. Of the 332 failures, 34% were DIS, 31% PREP, 29% TECH, and 6% UNKN. Of 324 IC with data available, 123(38%) had a subsequent LGI. Of these, 18(14% 7 had poor prep for the LGI, 45(37%) had divertieulosis, and 28(23%) had redundant colons. Of note, only 9(7%) had new findings (polyps or carcinoma). Conclusions: i) cecal intubaclon was aceomplishe~ in 92% of patients, with success being independent of sex, medication dosage, and presence of diverticulosis; 2) reasons for failure were equally distributed between discomfort, poor prep and technical difficulty; 3) LGI offered little additional information after an incomplete eslonoscopy.
VOLUME 41, NO. 4, 1995
363
THE NON-LIFTING SIGN AND LYMPH NODE METAsTAsIs OF COLORECTAL CANCER ~ A. Munakata, Y. Sasaki, H. Nakajima, Y Yoshida, First Department of internal Medicine, Hirosaki University School of Medicine, Hirosaki, Japan CotorectaJ cancer with protffecated fibers in the submucosa is not alevated by submucosal injection ot methylene blue, although the normal mucesa arojed the lesion is lifted, Eedoscop~cally, a blue bled is seen outside the lesion. We have named this phenomenon the non-lifting sign (NLS). The NLS is useful for deterrn~ the d e ~ of cobresla/carcinoma (Gasl~ntest Eedesc1994;40:485489): it is not noted in cases of intramucosal neop(asrn and submucosal cancer with minute invasDn, because these teSions have little with few fibrosis of the submucosa. However, early invasive carcinoma carries a nsk of lymph node metastaSis (LNM). This study was undertaken to ident~ the relationship between LNM and NLS. Methods: Forty-three colorectal cancers from 40 patients were investigated for the NLS before resection. Five of the lesions were resected along with lymph nodes by laparoscopic co~ectomy, and 38 lesions were resected by traditional colectomy. After histbl~ic diagnosis from the lymph nodes of each resected specimen, the sensitivity, specificity, and accuracy of the NLS ~or LNM were assessed. Results: The NLS was noted in 37 of the 43 cancers; 3 of T1No, 2 of T2No, 12 of TzNt 10 of "131'41,and 9 of T3NZ Six cancers without NLS were associated with minute submnoosal invasion and no lymph node metastaSis. The specificity (45'/0) of NLS for LNM was low, but sensitivity (t00%) and accuracy (88"} were h~h.
USE OF HEPARIN TO INDUCE POSITIVE RED BLOOD
LNM (+)
LNM (-)
Total
NLS (+)
32
5
37
NLS (-)
0
6
6
Total
3~
11
43
Conclusion: These results s u ~ { t h a i the NLS in cokxec'tal cancer is useful fer assessing not only the depth of invasion but also lymph node metastasis, patients with~ t a l canoer without the NLS may be curable by eedoscopic pdypectomy alone. Patients with cancer showing the NLS slmutd he selected for treatment colectOmy with lym~ r ~ excis~n.
CELL SCINTISCAN IN PATIENTS WITH CHRONIC GASTROINTESTINALHEMORRHAGE J. Marienhagen*. Ch. Eilles*, J Schrlmerich, A, Holstege; Department of Internal Medic~e I, *Department of Nuclear Medicine, University of Regensburg, 93042 Regansburg, Germany
Introduction: Diagnostic evaluation of chronic GI hemorrhage often leads to repeated invasive diagnostic procedures without successful identification of the source of hemorrhage. We describe our experience with heparin provocation to induce a positive red blood cell (RBC) scintiscan. Methods: In cases of unsuccessful identification of the source of hemorrhage by endoscopic and radiological procedures, a r inf'asion of heparin was stoned. The heparin dose was adjusted to maintain a partial thromboplastin time in the range of 60-80 s. A monitoring of vital signs and several btood counts were doneA Tc-labeled RBC scintiscan was performed obtaining several image sequences during a penod of 24 h. Results: 4 patients ( 3 men; age 22, 53, 65 yrs; 1 woman, age 75 yrs) with a history of recurrent G1 bleeding were examined. In all eases RBC scintiscan under hepafin provocation was positive. The induced hemorrhage had no hemodynamie relevance. No transf~ions were required.The source of bleeding was confirmed by laparotomy in one patient ( Meckel's diverticulum ) and by endoscopy in two patients (angiodysplasia in the caecum in a patient with aortic valve stenosis 0teyde syndrome); erosive mucosal lesion at the site of anastomosis after ileotransversostomy in another patient), In one patient no further evaluation was done because there were no signs of recurrent bleeding in the follow-up atter heparin infusion was stopped. Conclusions: When endoscopic and radiological evaluation of patients fails to indantify the source of chronic GI hemorrhage the RBC scintiscan under heparin provocation appears to be a highly sensitive and safe "tiagaostic procedure to identiOr the source of hemorrhage
362
~364
HIGH VOLUME SCREENING FOR COLORECTAL NEOPLASIA USING A DISPOSABLE SHEATH FLEXIBLE SIGMOIDOSCOPY (FS) SYSTEM. R. Vasudeva, J. Sheley, B: Woods, J. Greenhalgh, C.W. Howden. Division of Digestive Diseases and Nutrition, University of South Carolina, Columbia, SC.
INCOMPLETE COLONOSCOPY: INCIDENCE, CAUSES, AND FURTHER EVALUATION. JL Watkins, KP Etzkorn, I Alam, KP Block, JL Goldstein. Univ of Illinois, Westside VA Chicago.
Conventional FS for colorectal neoplasia screening is underutilized. FS using current systems requiring disinfection is time consuming and may not be suitable for mass screening. We studied the use of a disposable sheath FS syslem as a high volume screening tool. Stool testing and FS was offered free of charge to 425 employees (M:F 1:6) aged >50y at a local tertiary care hospital. The program was advertised through newsletters, TV and the Employee Clinic. A personalized letter along with educational materials underscoring the importance of screening was sent to each subject. This was followed by a phone call as a reminder and a chance to participate in an educational workshop prior to a fixed date for FS. Of the 425 subjects, 31 (7%) were excluded since they had FS or eolonoscopy within the past 5 years. Of the remaining 394, 21 (5%) signed up for the workshop and 5 attended. 20 subjects, all female, were scheduled for FS; 15 (4%) with a mean age of 56.6 y (range 50-63) underwent the procedure on a weekend morning by experienced endoscopists utilizing the 60 cm. disposable sheath system (Vision-Sciences Inc., Natick, MA) in three separate rooms. Mean total room utilization and turnaround time was 15 min. per procedure, including mean procedure time of 10.5 rain (range 4-16), accomplishing 4 procedures/hour/room. Findings included rectal polyp (n=l), hemorrhoids and]or sigmoid diverticula (n=10) and normal appearance (n=4). Lack of interest in screening was the reason for non-participation in 99% of subjects declining the invitatiom CONCLUSIONS : High volume FS screening with a disposable system is feasible and offers the advantage of a short turnaround time. Eenlales appear more receptive to screening than males. The dismal response rate to the invitation despite being offered free suggests poor patient acceptability. Increased public education efforts arc needed to overcome the lackadaisical attitude and may improve the acceptance of this modality.
386
GASTROINTESTINAL ENDOSCOPY
Experienced endoseopists exceed a 90% rate of Intuhatlon of the cecum. Purpose:To determine the rate and reason for incomplete colonoscopy(IC), and to assess the yield of subsequent radiographic/endoscopic evaluation of these patients. Methods__~The Endoscopy Database(TM) was used to retrieve all lowe~ endoscopy procedures at two teaching hospitals from L988~ - 1 9 9 4 These were classified by depth of insertion, reason for failure, medication dosage, sex, and presence of diverticulosis. Patients with IC were classified aceogdlng to reason for failure to reach the cecum; dlscomfort(DIS), poor prep(PREP), technical difficulty(TECH), and unknown (UNKN). Subsequent data for barium enema (LGl)/repeat colonoseopy was obtained for pts with IC. R e s u l t s : O f 7597 procedures, 3618 were sigmoidoscopies, 231 were infrared coagulations of hemorrhoids, leaving 3979 attempted eolonoscopies(AC). Of all AC, 3647 were completed(92%), equal for male and female patients. Dosage of Demerol (55 mg) and Versed (1.37 mg) were similar in the complete (CC) and IC groups. Diverticulosis was present in 17% of the IC and 22% of the CC patients. Of the 332 failures, 34% were DIS, 31% PREP, 29% TECH, and 6% UNKN. Of 324 IC with data available, 123(38%) had a subsequent LGI. Of these, 18(14% 7 had poor prep for the LGI, 45(37%) had divertieulosis, and 28(23%) had redundant colons. Of note, only 9(7%) had new findings (polyps or carcinoma). Conclusions: i) cecal intubaclon was aceomplishe~ in 92% of patients, with success being independent of sex, medication dosage, and presence of diverticulosis; 2) reasons for failure were equally distributed between discomfort, poor prep and technical difficulty; 3) LGI offered little additional information after an incomplete eslonoscopy.
VOLUME 41, NO. 4, 1995