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Fiberoptic colonoscopy
Fiberoptic Colonoscopy A New Look at Old Problems
Paul H. Sugarbaker, MD, Boston, Massachusetts Gordon C. Vineyard, MD, Boston, Massachusetts
Fiberoptic colonoscopy* can increase diagnostic accuracy and sometimes avert major surgery in patients with colorectal disease. Its use in the United States began in 1957 when Hirschowitz, Peters, and Curtiss [I] reported on the possible applications of the long fiberscope for internal medical examinations. In Japan in the same year gastro- and sigmoidocameras were being developed. As polydirectional ends were developed in 1967 and 1968 in the United States and Japan, colonoscopes were reported to be successful in visualization and biopsy of colonic lesions distal to the splenic flexure approximately 80 per cent of the time. As skill in the use of the instrument improved and the length of colonoscopes increased, examination of the terminal ileum was performed more frequently. Wolff and Shinya [2] introduced the snare polypectomy technic. * The basic patent for the fiberbundle used for fiberoptic endoscopy was issued on June 28, 1971 (patent #3,589,793) to Mr Lawrence E. Curtiss. The technology aas worked out between 1954 and 1958 at the Uniuersity of Michigan. Glass fibers are drawn out to 5 to 10 p in diameter and coated with a uniform layer of glass resin of a different refractive index from that of the main fiber. Light falling on one end is bounced along the inner core off the walls of the fibers. If the fibers are in the same orientation at the opposiie ends of the fiberbundle, an image is transmitted. Cold light is piped in one end with separate fiberbundles. Lenses can be attached to either end of the fiberoptic core.
From the Department of Surgery of Harvard University at the Peter Bent Brigham Hospital, Boston, Massachusetts. Reprint requests should be addressed to Dr Vineyard, Peter Bent Brigham Hospital, 721 Huntington Avenue, Boston, Massachusetts 02115. Presented at the Fifty-Third Annual Meeting of the New England Surgical Society, Whitefield. New Hampshire, October 12-14, 1972.
Volume 125. April 1973
This paper reports our experience with diagnostic and therapeutic maneuvers using this instrument. Material and Methods Clinical Material. From October 1971 through September 1972, 105 patients underwent 120 colonoscopies at the Peter Bent Brigham Hospital. Initially, most of these examinations were performed on inpatients; recently, however, most have been carried out in outpatients. Patients requiring polypectomy have been hospitalized routinely. Preparation. The routine for inpatients and outpatients involves a clear fluid diet the day before examination, a cathartic (usually castor oil) the evening before, and two enemas of 1 quart of tap water that morning. Colonic preparation done by the patient at home is usually better than that done in the hospital. Premeditation for inpatients involves the intramuscular administration of 10 mg of morphine and 50 mg of Nembutals. The use of atropine has been discontinued because of abdominal cramps which have occurred one to two hours after the examination. Valium”, 5 mg intravenously, is given to outpatients just prior to the examination. An intravenous needle is inserted in every patient so that if the examination is complicated or prolonged, supplemental analgesics can be given. Technic. The end of the colonoscope is introduced on the forefinger, as in rectal examinations, and advanced under direct vision only, using minimal air insufflation to distend the bowel in front of the tip of the colonoscope. Visualization is accomplished during withdrawal. Biopsy and snare polypectomy can be performed. The major indications for colonoscopy are as follows: (1) differentiation between carcinoma and diverticulitis of the sigmoid; (2) follow-up examination of colonic suture lines; (3) clarification of confusing findings on barium enema;
429
Sugarbaker
TABLE I
and Vineyard
Major Indications and Results of Fiberoptic
Colonoscopy Results
Indications
Total
Differentation of sigmoid carcinoma and diverticulitis Follow-up examination of colonic suture lines Clarification of findings of barium enema Biopsy of polyps to determine therapy Polypectomy ~______
12
Benign
Malignant
7*
5
6
3
3
14
14
0
17
14
3
40
36
4
*Seven patients with sigmoid diverticulitis and one patient with lipomatosis of the ileocecal valve were spared exploratory laparotomy.
(4) biopsy of polyps to determine therapy; and (5) polypectomy. (Table f.) Less frequent indications for colonoscopy include: (1) relief of sigmoid volvulus; (2) relief of high sigmoid impaction; (3) fiberoptic sigmoidoscopy in patients with rectal stenosis; (4) fiberoptic sigmoidoscopy in patients in orthopedic traction; (5) fiberoptic sigmoidoscopy in patients who refuse to undergo routine sigmoidoscopic examination; (6) regular follow-up study of patients with ulcerative colitis to detect carcinoma at an early stage; (7) biopsy of the terminal ileum; and (8) search for a second lesion in a patient with a known neoplasm of the colon. Results
Extent of Examination. Two different sized instruments, a 90 cm and a 110 cm colonoscope, have been used. From October 1971 through April 1972, the 90 cm colonoscope was used. The diseased segment of colon seen on barium enema was reached in all cases. Eight-four per cent of the examinations were completed on the first attempt; 44 per cent were completed to the splenic flexure on the first attempt. Since May 1972 most examinations were performed with the 110 cm instrument; all but one was completed. Sixty-five per cent of the examinations were complete to the splenic flexure on the first attempt. Fifteen of fifteen attempted examinations of the cecum were completed. The most common reason for an incomplete examination was poor bowel preparation; nine of our patients had examinations terminated because of this. Three patients had polyps measuring 1 cm or less in diameter; although their presence was confirmed by repeated barium enema or surgery, the polyps could not be located even though the bowel was thought to be well visualized.
430
Diagnostic Technics. Twelve patients were examined to differentiate between carcinoma and diverticulitis of the sigmoid. Since the colonoscope allows direct visualization of the colonic mucosa, it was thought that if the sigmoid could be seen in its entirety, the differential diagnosis could be made with great accuracy. Five patients were found to have carcinoma; seven patients had diverticulitis (three of these with severe inflammatory strictures) and were spared exploratory laparotomy. Six patients had examination of the colonic suture line because of persistent narrowing of the anastomosis as seen on follow-up barium enema. In one patient, biopsy was positive for recurrent tumor and in two patients there was narrowing suggesting recurrence. Fourteen patients had barium enema examinations which gave confusing results, and colonoscopy was needed to clarify the radiologic findings. It was especially useful in two situations: (1) lesions of the ileocecal valve; (2) redundant sigmoid colon that could not accurately be visualized radiologicalIy. Seventeen patients underwent biopsy of polyps or polypoid lesions. Three of these biopsies indicated adenocarcinoma although the barium enema had given no evidence of malignancy. Two patients had villous adenoma. One patient with a polypoid lesion at the ileocecal valve was spared laparotomy after biopsy showed lipomatosis of the ileocecal valve. Polypectomy. Forty colonoscopic polypectomies were performed in thirty patients using the snare technic. Twenty-two of these patients had one or more polyps that were greater than 1 cm in diameter, beyond the reach of the straight sigmoidoscope, and not accompanied by other intra-abdominal disease requiring laparotomy. Two other patients had polyps requiring removal. One sessile polyp of 0.9 cm was thought to be carcinomatous on barium enema and would have required exploration. A second 0.8 cm polyp caused repeated gastrointestinal bleeding in a patient required to stay on coumadin. Therefore, we judge that twenty-four laparotomies have been averted ‘by colonoscopic polypectomy technics. Four polyps in three patients contained foci of carcinoma. One of these patients subsequently needed colonic resection; however, no evidence of carcinoma was found in the specimen. In the other two patients no additional surgery was performed. Complications. One major and ten minor complications occurred among 120 colonoscopies. One patient with sigmoid diverticulitis who was maintained on prednisone because of severe asthma had a “blow-out” of a sigmoid diverticulum. This was the only case of free perforation in our series. Other complications -were as follows: submucosal dissection of insufflated air (one); gastrointestinal bleeding one
The American Journal of Surgery
Fiberoptic
week after polypectomy (one); gaseous distention at surgery from colonoscopy performed just prior to operation (two); abdominal cramps secondary to gaseous distention (four); pain on examination requiring cessation of examination (two). Comments The fiberoptic colonoscope was helpful in the diagnosis and treatment of patients suspected of having colonic disease. One hundred twenty colonoscopies were performed in 105 patients with a single major complication, a “blow-out” of a sigmoid diverticulum. Lesions seen on barium enema were reached in all but one patient; in three patients polyps 1 cm or less could be reached but not found. Several patients required repeated examinations. The indications for examination were variable but the results were helpful in almost all situations. Differentiation of sigmoid carcinoma and diverticulitis can be made accurately and easily. Evaluation of colonic anastomoses for possible recurrent tumor is more difficult because one must be concerned with extrinsic lesions as well as mucosal lesions. Two patients with recurrence at colonic suture lines had no mucosal lesions that could be biopsied, although recurrence was found surrounding the bowel at exploration. The colonoscope was used successfully to clarify the findings on barium enema examination. Fifty-seven polyps were either biopsied or removed. Three of seventeen polyps biopsied and four of forty polyps removed were malignant. Neither size, shape, nor the presence or absence of a stalk seemed to predict malignancy or benignity of a polyp. Thus, every polyp, no matter what its size, must be considered potentially malignant. Since the colonoscope now offers a low risk, low morbidity method of biopsy and removal, we believe that every
Volume 125, April 1973
Colonoscopy
colonic polyp should be visualized, biopsied, and, when possible,_removed. We judge that the colonoscope averted thirty-three laparotomies: twenty-five in inpatients with polyps, one in a patient with lipomatosis of the ileocecal valve, and seven in patients in whom the differential diagnosis of sigmoid carcinoma and diverticulitis could not be made radiologically. Twelve patients who might have required observation were subjected to surgery immediately: three with malignant polyps biopsied, one with a removed malignant polyp, five with carcinoma within sigmoid diverticulitis, and one with a positive biopsy of a coionic suture line. Two patients with small foci of invasive carcinoma in polyps with adequate margins of resection were believed to have had definitive surgery by colonoscopic polypectomy only. Summary One hundred twenty colonoscopies were performed in 105 patients for a variety of indications. Only one major complication occurred. With the colonoscope, difficulties in differential diagnosis can be resolved conclusively. Polyps can be biopsied and often removed. We estimate that laparotomy was averted in thirty-two patients. Twelve patients who might have been followed without surgery received definitive surgery immediately. The colonoscope is a very helpful, technologic advance in the diagnosis and treatment of many forms of colorectal disease.
References 1. Hirschowitz
BI, Peters Cw’, Curtiss LE: Preliminary report on a long fiberscope for examination of stomach and duodenum. Univ Mich Med Bull 23: 178,1957. 2. Wolff WI, Shinya H: Colonfiberoscopy. JAMA 217: 1509, 1971.
431
Paul H. Sugarbaker, MD, Boston, Massachusetts Gordon C. Vineyard, MD, Boston, Massachusetts
Fiberoptic colonoscopy* can increase diagnostic accuracy and sometimes avert major surgery in patients with colorectal disease. Its use in the United States began in 1957 when Hirschowitz, Peters, and Curtiss [I] reported on the possible applications of the long fiberscope for internal medical examinations. In Japan in the same year gastro- and sigmoidocameras were being developed. As polydirectional ends were developed in 1967 and 1968 in the United States and Japan, colonoscopes were reported to be successful in visualization and biopsy of colonic lesions distal to the splenic flexure approximately 80 per cent of the time. As skill in the use of the instrument improved and the length of colonoscopes increased, examination of the terminal ileum was performed more frequently. Wolff and Shinya [2] introduced the snare polypectomy technic. * The basic patent for the fiberbundle used for fiberoptic endoscopy was issued on June 28, 1971 (patent #3,589,793) to Mr Lawrence E. Curtiss. The technology aas worked out between 1954 and 1958 at the Uniuersity of Michigan. Glass fibers are drawn out to 5 to 10 p in diameter and coated with a uniform layer of glass resin of a different refractive index from that of the main fiber. Light falling on one end is bounced along the inner core off the walls of the fibers. If the fibers are in the same orientation at the opposiie ends of the fiberbundle, an image is transmitted. Cold light is piped in one end with separate fiberbundles. Lenses can be attached to either end of the fiberoptic core.
From the Department of Surgery of Harvard University at the Peter Bent Brigham Hospital, Boston, Massachusetts. Reprint requests should be addressed to Dr Vineyard, Peter Bent Brigham Hospital, 721 Huntington Avenue, Boston, Massachusetts 02115. Presented at the Fifty-Third Annual Meeting of the New England Surgical Society, Whitefield. New Hampshire, October 12-14, 1972.
Volume 125. April 1973
This paper reports our experience with diagnostic and therapeutic maneuvers using this instrument. Material and Methods Clinical Material. From October 1971 through September 1972, 105 patients underwent 120 colonoscopies at the Peter Bent Brigham Hospital. Initially, most of these examinations were performed on inpatients; recently, however, most have been carried out in outpatients. Patients requiring polypectomy have been hospitalized routinely. Preparation. The routine for inpatients and outpatients involves a clear fluid diet the day before examination, a cathartic (usually castor oil) the evening before, and two enemas of 1 quart of tap water that morning. Colonic preparation done by the patient at home is usually better than that done in the hospital. Premeditation for inpatients involves the intramuscular administration of 10 mg of morphine and 50 mg of Nembutals. The use of atropine has been discontinued because of abdominal cramps which have occurred one to two hours after the examination. Valium”, 5 mg intravenously, is given to outpatients just prior to the examination. An intravenous needle is inserted in every patient so that if the examination is complicated or prolonged, supplemental analgesics can be given. Technic. The end of the colonoscope is introduced on the forefinger, as in rectal examinations, and advanced under direct vision only, using minimal air insufflation to distend the bowel in front of the tip of the colonoscope. Visualization is accomplished during withdrawal. Biopsy and snare polypectomy can be performed. The major indications for colonoscopy are as follows: (1) differentiation between carcinoma and diverticulitis of the sigmoid; (2) follow-up examination of colonic suture lines; (3) clarification of confusing findings on barium enema;
429
Sugarbaker
TABLE I
and Vineyard
Major Indications and Results of Fiberoptic
Colonoscopy Results
Indications
Total
Differentation of sigmoid carcinoma and diverticulitis Follow-up examination of colonic suture lines Clarification of findings of barium enema Biopsy of polyps to determine therapy Polypectomy ~______
12
Benign
Malignant
7*
5
6
3
3
14
14
0
17
14
3
40
36
4
*Seven patients with sigmoid diverticulitis and one patient with lipomatosis of the ileocecal valve were spared exploratory laparotomy.
(4) biopsy of polyps to determine therapy; and (5) polypectomy. (Table f.) Less frequent indications for colonoscopy include: (1) relief of sigmoid volvulus; (2) relief of high sigmoid impaction; (3) fiberoptic sigmoidoscopy in patients with rectal stenosis; (4) fiberoptic sigmoidoscopy in patients in orthopedic traction; (5) fiberoptic sigmoidoscopy in patients who refuse to undergo routine sigmoidoscopic examination; (6) regular follow-up study of patients with ulcerative colitis to detect carcinoma at an early stage; (7) biopsy of the terminal ileum; and (8) search for a second lesion in a patient with a known neoplasm of the colon. Results
Extent of Examination. Two different sized instruments, a 90 cm and a 110 cm colonoscope, have been used. From October 1971 through April 1972, the 90 cm colonoscope was used. The diseased segment of colon seen on barium enema was reached in all cases. Eight-four per cent of the examinations were completed on the first attempt; 44 per cent were completed to the splenic flexure on the first attempt. Since May 1972 most examinations were performed with the 110 cm instrument; all but one was completed. Sixty-five per cent of the examinations were complete to the splenic flexure on the first attempt. Fifteen of fifteen attempted examinations of the cecum were completed. The most common reason for an incomplete examination was poor bowel preparation; nine of our patients had examinations terminated because of this. Three patients had polyps measuring 1 cm or less in diameter; although their presence was confirmed by repeated barium enema or surgery, the polyps could not be located even though the bowel was thought to be well visualized.
430
Diagnostic Technics. Twelve patients were examined to differentiate between carcinoma and diverticulitis of the sigmoid. Since the colonoscope allows direct visualization of the colonic mucosa, it was thought that if the sigmoid could be seen in its entirety, the differential diagnosis could be made with great accuracy. Five patients were found to have carcinoma; seven patients had diverticulitis (three of these with severe inflammatory strictures) and were spared exploratory laparotomy. Six patients had examination of the colonic suture line because of persistent narrowing of the anastomosis as seen on follow-up barium enema. In one patient, biopsy was positive for recurrent tumor and in two patients there was narrowing suggesting recurrence. Fourteen patients had barium enema examinations which gave confusing results, and colonoscopy was needed to clarify the radiologic findings. It was especially useful in two situations: (1) lesions of the ileocecal valve; (2) redundant sigmoid colon that could not accurately be visualized radiologicalIy. Seventeen patients underwent biopsy of polyps or polypoid lesions. Three of these biopsies indicated adenocarcinoma although the barium enema had given no evidence of malignancy. Two patients had villous adenoma. One patient with a polypoid lesion at the ileocecal valve was spared laparotomy after biopsy showed lipomatosis of the ileocecal valve. Polypectomy. Forty colonoscopic polypectomies were performed in thirty patients using the snare technic. Twenty-two of these patients had one or more polyps that were greater than 1 cm in diameter, beyond the reach of the straight sigmoidoscope, and not accompanied by other intra-abdominal disease requiring laparotomy. Two other patients had polyps requiring removal. One sessile polyp of 0.9 cm was thought to be carcinomatous on barium enema and would have required exploration. A second 0.8 cm polyp caused repeated gastrointestinal bleeding in a patient required to stay on coumadin. Therefore, we judge that twenty-four laparotomies have been averted ‘by colonoscopic polypectomy technics. Four polyps in three patients contained foci of carcinoma. One of these patients subsequently needed colonic resection; however, no evidence of carcinoma was found in the specimen. In the other two patients no additional surgery was performed. Complications. One major and ten minor complications occurred among 120 colonoscopies. One patient with sigmoid diverticulitis who was maintained on prednisone because of severe asthma had a “blow-out” of a sigmoid diverticulum. This was the only case of free perforation in our series. Other complications -were as follows: submucosal dissection of insufflated air (one); gastrointestinal bleeding one
The American Journal of Surgery
Fiberoptic
week after polypectomy (one); gaseous distention at surgery from colonoscopy performed just prior to operation (two); abdominal cramps secondary to gaseous distention (four); pain on examination requiring cessation of examination (two). Comments The fiberoptic colonoscope was helpful in the diagnosis and treatment of patients suspected of having colonic disease. One hundred twenty colonoscopies were performed in 105 patients with a single major complication, a “blow-out” of a sigmoid diverticulum. Lesions seen on barium enema were reached in all but one patient; in three patients polyps 1 cm or less could be reached but not found. Several patients required repeated examinations. The indications for examination were variable but the results were helpful in almost all situations. Differentiation of sigmoid carcinoma and diverticulitis can be made accurately and easily. Evaluation of colonic anastomoses for possible recurrent tumor is more difficult because one must be concerned with extrinsic lesions as well as mucosal lesions. Two patients with recurrence at colonic suture lines had no mucosal lesions that could be biopsied, although recurrence was found surrounding the bowel at exploration. The colonoscope was used successfully to clarify the findings on barium enema examination. Fifty-seven polyps were either biopsied or removed. Three of seventeen polyps biopsied and four of forty polyps removed were malignant. Neither size, shape, nor the presence or absence of a stalk seemed to predict malignancy or benignity of a polyp. Thus, every polyp, no matter what its size, must be considered potentially malignant. Since the colonoscope now offers a low risk, low morbidity method of biopsy and removal, we believe that every
Volume 125, April 1973
Colonoscopy
colonic polyp should be visualized, biopsied, and, when possible,_removed. We judge that the colonoscope averted thirty-three laparotomies: twenty-five in inpatients with polyps, one in a patient with lipomatosis of the ileocecal valve, and seven in patients in whom the differential diagnosis of sigmoid carcinoma and diverticulitis could not be made radiologically. Twelve patients who might have required observation were subjected to surgery immediately: three with malignant polyps biopsied, one with a removed malignant polyp, five with carcinoma within sigmoid diverticulitis, and one with a positive biopsy of a coionic suture line. Two patients with small foci of invasive carcinoma in polyps with adequate margins of resection were believed to have had definitive surgery by colonoscopic polypectomy only. Summary One hundred twenty colonoscopies were performed in 105 patients for a variety of indications. Only one major complication occurred. With the colonoscope, difficulties in differential diagnosis can be resolved conclusively. Polyps can be biopsied and often removed. We estimate that laparotomy was averted in thirty-two patients. Twelve patients who might have been followed without surgery received definitive surgery immediately. The colonoscope is a very helpful, technologic advance in the diagnosis and treatment of many forms of colorectal disease.
References 1. Hirschowitz
BI, Peters Cw’, Curtiss LE: Preliminary report on a long fiberscope for examination of stomach and duodenum. Univ Mich Med Bull 23: 178,1957. 2. Wolff WI, Shinya H: Colonfiberoscopy. JAMA 217: 1509, 1971.
431