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Intraoperative Esophagoscopy, Gastroscopy, Colonoscopy, and Endoscopy of the Small Bowel
Symposium on New Skills in Surgery
Intraoperative Esophagoscopy, Gastroscopy, Colonoscopy, and Endoscopy of the Small Bowel
C. Thomas Bombeck, MD.
*
Since the advent of fiberoptic instrumentation in the field of gastroenterology in the mid-1960's, great strides have been made in diagnostic endoscopy of lesions of both the upper gastrointestinal tract, extending down to the third portion of the duodenum, and the entire colon. Recently, the addition of more sophisticated instrumentation has allowed therapeutic intervention in many diseases of the gastrointestinal and biliary tract in these areas. One application of fiberoptic endoscopy, however, has been largely overlooked. This is the intraoperative use of these long, pliable endoscopes to allow visualization of the interior of the entire gastrointestinal tract without the necessity of opening the bowel at the operating table. Incision into the gastrointestinal tract in any of its portions is associated with a definite incidence of leakage from the suture line and is almost always associated with gross contamination of the operative field resulting in what has been termed the "clean contaminated wound." The incidence of wound infection in clean contaminated wounds is much greater than that in noncontaminated wounds. Various methods have been used to reduce this increased infection rate such as antibiotic irrigation, but a definite risk persists. If the necessity for opening the gastrointestinal tract is avoided, none of these risks are incurred. The fiberoptic endoscope, either the side- or end-viewing upper gastrointestinal endoscope or the end-viewing colonoscope, has a number of definite advantages which lend themselves readily to intraoperative use. These are: 1. The endoscopes are pliable tubes ranging from 44 to 50 French in diame-
ter which can readily be manipulated around any curve in the gastrointestinal tract by the operating surgeon through the operative field. 2. The tip of the endoscope can be "steered" in almost all models currently "Associate Professor of Surgery and Chief, Section of Surgical Gastroenterology, The Abraham Lincoln School of Medicine, University of Illinois at the Medical Center, Chicago Supported in part by USPHS grant AM 11835, the West Side Veterans Administration Hospital and by the Ray and Joan Kroc Endowment Fund.
Surgical Clinics of North America- VoL 55, No.1, February 1975
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c.
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3.
4.
5.
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THOMAS BOMBECK
available to allow localization of any lesions encountered by simply pressing the tip of the endoscope against the side of the inflated bowel at the site of the lesion. The lesion then becomes localized as a spot of light on the bowel which is readily visible to the surgeon at the operating table. All of the current endoscopes are equipped with "cold light" sources which allow transillumination of the bowel wall. This is useful both for the localization of lesions and for various mucosal staining techniques which will be described below. Because the average size of the endoscopes ranges from 44 to 50 French, the instrument itself may be used to calibrate various sphincters or narrowed areas in the gastrointestinal tract. In many instances it may serve as a dilator. Almost all endoscopes are equipped with external cameras so that the existence and location of any lesion encountered may be photographically recorded, both for teaching purposes and for documentation of the existence of such lesions in the patient's record. Although insertion and manipulation of the endoscope at the operating table by a trained endoscopist, either gastroenterologist or surgeon, is highly desirable, it is not entirely necessary. Most endoscopy, when used for diagnostic purposes in the awake patient, requires a highly trained individual who, above all, must be sufficiently thorough that he can be certain that he has seen the entirety of that portion of the gastrointestinal tract mucosa which he is examining. This primary requirement is very easily satisfied at the operating table since the surgeon may steer the tip of the endoscope by simply manipulating it through the viscus. The surgeon can then observe the area at which the endoscope is pointed without the geographic confusion which frequently occurs during standard endoscopy. Once the endoscope is inserted, the surgeon may simply look through the eyepiece which is being held by a nonsterile person in the operating room and thereby visualize whatever he is pointing at within the gastrointestinal tract. Using techniques such as these, the surgeon may examine the entirety of the gastrointestinal tract from within its lumen by simply pleating the large and small bowel on one of the longer instruments inserted either from above or from below.
Our Surgical Gastroenterology Clinic has either acquired possession of, or has access to, almost every known make of gastrointestinal endoscope. Because of this, we have had the opportunity to make innovative applications of these endoscopes in many areas of intraoperative endoscopy. It is the purpose of this article to report several of these instances.
INTRAOPERATIVE ESOPHAGOSCOPY Intraoperative endoscopy of the esophagus has several applications. In this area the endoscope may be inserted and may be used to define the upper limits of esophageal narrowing when a benign esophageal stricture is the object of the operative procedure. Previously appli~d methods have included the passage of various size dilators from both above and below, but these have all depended upon the "feel" of the operating surgeon. The upper extent of the stricture may now be directly visualized, and indeed the size of the stricture may be calibrated by attempted passage of the endQscope through it. Once the stricture has been opened, such as for application of a serosal patch, the endoscope itself may be used as a large stent so that an adequate esophageal lumen is thereby insured. Since passage of the endoscope is always
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carried out under direct vision through the endoscope eyepiece, there is little danger of perforation of the esophagus with this method. These perforations, although readily recognizable and remediable at the time of operation when using a rigid endoscope and various size dilators, do represent a nuisance and may occur at an area other than that of the intended incision into the esophageal wall. They therefore represent a source of dangerous potential postoperative leakage. In patients with previous operative procedures in the area of the gastroesophageal junction, when there are multiple adhesions and much scar tissue obscuring the area, the endoscope may be used to define the true gastroesophageal junction. This junction is often not readily apparent at the operating table. Finally, since most of the endoscopes have metal tips or at least a metal tip protected by a disposable rubber ring, the surgeon may use the tip of the endoscope as a rigid object upon which he may cut down in order to open the esophagus or stricture. This does not injure the endoscope if care is taken to avoid incising the pliable covering above the metal tip and avoids the difficult situation of the oblique incision made through a thickened esophageal wall. This maneuver is also especially useful in patients with achalasia. The esophagus may be distended with air allowing the surgeon to easily define the circular muscle fibers of the lower esophagus. These fibers may be cut without incising the esophageal mucosa during the performance of a standard Heller myotomy. Once this incision is accomplished, the endoscope is simply inserted next to a 20 French nasogastric tube which has already been inserted and both are used as stents for the performance of a large, loose Nissen fundoplication. The technique of fundoplication prevents the subsequent reflux which might be expected as a complication of this operation.
INTRAOPERATIVE GASTROSCOPY Intraoperative endoscopy of the stomach has several diagnostic and therapeutic uses. In the gastrointestinal bleeder it is a common occurrence for the patient to stop bleeding upon induction of anesthesia. When this occurs, it is extremely difficult to examine the entire interior of the stomach for the possible source of bleeding without virtually incising the anterior gastric wall from one end to the other. Before the advent of intraoperative endoscopy, it was our practice to insert a large, sterile operating proctoscope into the stomach to visualize the gastroesophageal junction and those more inaccessible portions of the fundus of the stomach. This method, although better than attempting to evert the gastric mucosa around the fundus to visualize it, gave very poor visualization of the dome of the gastric fundus. This difficult area is now readily accessible to the end-viewing gastroscope. This instrument is inserted after washing of the interior of the stomach, and simply retroflexed by the operating surgeon to view the gastroesophageal junction for possible Mallory-Weiss tears or other possible sources of bleeding such as gastric varices.
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Gastric polyps are frequently difficult to palpate through the wall of the stomach, and when these are too large to remove endoscopically, they may require laparotomy for their excision. The endoscope may simply be inserted, the polyp visualized, and the base of the polyp pressed outward toward the surgeon by the tip of the examining endoscope. This allows the surgeon to simply make a small incision in that area and to wedge the polyp out without a large gastrotomy. We have previously reported a method for determination of completeness of vagotomy 2 by the use of transendoscopic staining of the gastric mucosa. The normal pH of the gastric mucosa, even the completely vagally denervated gastric mucosa, is approximately 1.5. This is exclusive of the ability of the mucosa to secrete liquid hydrochloric acid into the lumen of the stomach. When the mucosa is neutralized by washing with sodium bicarbonate solution, the vagally denervated mucosa will require in excess of 1 hour to return to a pH of less than 3, while vagally innervated mucosa will return to a pH of less than 3, usually within 15 minutes. If atropinization of the patient is avoided, this method may be used during operation to determine whether or not a vagotomy is complete. In many cases it may locate the intact branch of the vagus nerve in cases of partial vagotomy, since the area of the stomach supplied by that particular nerve will change the color of an indicator dye such as Congo red much more quickly than will the remainder of the stomach to which vagal innervation has been severed. We have repeatedly applied this method in the human. The results obtained by endoscopic testing agree closely with those obtained by more standard means such as the Hollander test. The above cited method may, of course, be used to define the upper limit of the gastric antrum when antrectomy is carried out. In this situation, endoscopy is really not necessary since all that need be done is to wash out the stomach with sodium bicarbonate solution, spray the mucosa of the inflated stomach with Congo red solution, and then insert a fiberoptic light source of any sort. The transilluminated parietal cellbearing area will appear black, while the antrum of the stomach will appear its normal red-orange color. Since we have begun a study of highly selective or parietal cell vagotomy in the treatment of duodenal ulcer, we prefer not to apply this operation in patients with pyloric stenosis. The normal caliber of the pyloric channel is approximately 1.5 cm. This is equivalent to 47 to 48 French, the size of most endoscopes. If the endoscope can be inserted through the pyloric channel either pre- or intraoperatively, it may then be assumed that pyloric stenosis does not exist and no drainage procedure is required during parietal cell vagotomy. Again, the size of the endoscope serves as both a dilator and as a calibrating instrument in this particular area.
ENDOSCOPIC DUODENOSCOPY Although in most instances, examinations of the ampulla of Vater and transampullary cannulation of either the pancreatic or common bile
INTRAOPERATIVE ENDOSCOPY
139
ducts should be carried out as a part of a preoperative examination, this maneuver is also possible and greatly facilitated by intraoperative manipulation. In this case a side-viewing endoscope is employed and much time is saved by simply having the surgeon insert the endoscope by transmural manipulation as it is brought into the stomach, through the pylorus and by having him position it opposite the area of the ampulla. The surgeon simply anchors the instrument in place while the cannulation is carried out. This avoids the necessity of opening the duodenum for transampullary cannulation by manual methods and avoids the risk of subsequent duodenotomy leak. This maneuver can be especially useful in reoperative procedures on the biliary tract when scarring and adhesion formation may make the common bile duct extremely difficult to identify within the porta hepatis. In patients with biliary stricture, percutaneous or transhepatic cholangiography may be used to define the upper limits of the stricture, while intraoperative retrograde cannulation of the common duct may be used to define the lower limits of the stricture. The method may be applied to pancreatography, although this is usually a preoperative maneuver as retrograde cannulation in the awake patient becomes more widely available. In one recent operative case, intraoperative duodenoscopy prevented a serious surgical error. CASE 1. JL was a 41-year-old white male who was admitted to the University of Illinois Hospital with symptoms resembling gastric outlet obstruction for which he had had several duodenal ulcer type operations in the past. The patient had experienced difficulty since childhood and indeed had had multiple gastric and duodenal ulcers diagnosed. Initial radiographic and endoscopic examination of this patient suggested an obstruction at the juncture of the second and third portions of the duodenum. Since no prior films or records were available, there was a question whether this obstruction might be due to adhesion formation within the area, partial malrotation, partial atresia, or annular pancreas. At operation the patient was found to have a thick fibrous band extending across that area of the duodenum which corresponded to the site of the obstruction. The fibrous band resembled multiple other adhesions present from previous operations. There was no gross pancreatic tissue present in the band. The "obstructing" band was excised and sent to pathology for frozen section examination. It was found to contain several islands of pancreatic tissue, thereby confirming the diagnosis of annular pancreas. Due to the known association of duodenal webs, etc., with this lesion, although no obstruction could be palpated within the duodenum lumen, intraoperative endoscopy was carried out. This demonstrated a very thin, soft web within the lumen of the duodenum with an opening approximately 8 to 10 mm in diameter. This partial obstruction was relieved by a longitudinal incision through the duodenal wall and web and onlay of a Roux-en-Y loop of jejunum. Failure to carry out intraoperative endoscopy would have left the web intact.
In other instances, intraoperative endoscopy has been useful in determining whether or not extrinsic compression of the duodenum resulted from an overlying superior mesenteric artery, etc.
INTRAOPERATIVE ENDOSCOPY OF THE SMALL BOWEL Endoscopes currently available do not allow examination of the small bowel beyond the ligament of Treitz and infrequently above the
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ilecocecal valve in the awake patient. Suggestions have been made for examination of the small bowel by passage of a string from above, to which a very long endoscope could be attached and drawn through the small bowel. Most of these methods have proven unsuccessful and all of them have the potential danger of perforation of the small bowel. The long colonoscope, passed from above, readily lends itself to intraoperative examination of the entire length of the small bowel. CASE 2. EW was a 29-year-old black female who was admitted to the University of Illinois Hospital with a 4-month history of iron deficiency anemia and persistently guaiac positive stools. Exhaustive examination of both her upper and lower gastrointestinal tracts by standard endoscopic methods and by radiographic methods was unrevealing. Small bowel barium examinations were read as normal on three separate occasions. The patient persisted with guaiac positive stools and chronic blood loss of approximately one unit per week. She was transferred to the surgery service where, at exploratory laparotomy, a previously sterilized 175 cm ACMI colonoscope was passed orally through her stomach and into the small bowel by the operating surgeon. Twenty-five centimeters distal to the ligament of Treitz, a flat 11/2 cm, sessile, adenomatous polyp was encountered in the wall of the jejunum. A blood clot was observed in the center of the polyp. There was blood within the lumen of the small bowel distal to the polyp, although not in sufficient quantity to be detected by the operating surgeon. Prior to insertion of the endoscope, the surgeon had palpated the entire small bowel and has been unable to localize any lesion. The location of the polyp was marked by pressing the tip of the endoscope against it so that the surgeon could place a suture at that location. The remainder of the small bowel and the colon to the mid transverse portion were then examined by pleating the bowel on the endoscope. The surgeon stretched the bowel ahead of the instrument so that its entire wall could be examined by the endoscopist, positioned at the head of the table. No other lesions were found. The endoscope was withdrawn and the polyp bearing area of the jejunum wedged out and single layer anastomosis accomplished. Pathologic examination of the resected specimen demonstrated the presence of the sessile, adenomatous polyp which was benign in character. Since that time the patient has experienced no further episodes of melena and the chronic blood loss has stopped.
Although we have not otherwise had occasion to completely examine the small bowel in this fashion, any number of other reasons for the procedure might be imagined.
INTRAOPERATIVE COLONOSCOPY This is the only area in which intraoperative endoscopy of the alimentary tract has been reported by other authors.l, 3 Colonoscopy itself, in the awake patient, is, at least, a time-consuming procedure. The reason is the difficult passage of the instrument through the redundant sigmoid and because of the sharp angulations of the splenic and hepatic flexures. No difficulty is encountered in intraoperative endoscopy, since the surgeon may manipulate the endoscope around all the acute bends in the colon and simply draw it to the cecum. The method has proven useful both in our hands and by others in patients with single or multiple polyps of the colon who require open excision because of the size of the polyp and for the exclusion of other colonic lesions. Polyps are frequently multiple and, if very small, may not be palpable by the
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surgeon at the time of operation. We now suggest that any patient undergoing laparotomy for polypectomy should have intraoperative endoscopy of the entire large bowel to exclude any other previously undiscovered lesions. Intraoperative colonoscopy is faster than standard colonoscopy and adds essentially no risk to the procedure. The use of this method in patients with carcinoma of the colon is probably not indicated due to the excessive manipulation of the tumor by passage of the endoscope through it, as well as the risk of disseminating tumor cells throughout the remainder of the colon by insertion of the endoscope through the tumor to the cecum. This might theoretically result in a high incidence of suture line recurrence of tumor, although this has not been proven. Intraoperative colonoscopy for lower gastrointestinal bleeding has, in our hands, remained a theoretical application of this modality. The reason for this is that if a patient is bleeding sufficiently rapidly from a colonic lesion to require laparotomy, the volume of bleeding is usually sufficient to make colonoscopy virtually impossible. Current instruments now in use are not equipped with large enough suction and washing channels to keep up with the influx of blood into the colon so that the examiner never has a clear field of view through the endoscope. Such methods as superior and inferior mesenteric arterial angiography remain the diagnostic modalities of choice in the patient with severe colonic bleeding. Since these methods may also be followed by pressor infusion into the vessels to control the bleeding, angiography offers an additional advantage over colonoscopy. Certainly, colonoscopy is indicated in the patient who has had a demonstrable lower gastrointestinal bleeding episode; this may be carried out in the awake patient. Since the most common cause of massive lower gastrointestinal bleeding is diverticular disease, once the bleeding has stopped colonoscopy is of little value in determining which diverticulum has bled. The use of colonoscopy to localize the site of bleeding in colonic lesions, especially diverticular disease, awaits the development of new instrumentation.
SUMMARY Intraoperative endoscopy of the gastrointestinal tract is probably much more widely used than has been publicized in the recent literature. Application of this new tool to the surgical armamentarium depends only on the limits of the imagination of the operating surgeon and his endoscopist colleague, in most cases, the gastroenterologist. The operative maneuverability of current endoscopes make every portion of the gastrointestinal tract accessible to direct visualization without incision into it, both by the operating surgeon and by the endoscopist. For the full potential of this modality to be realized, the same sort of cooperation between gastrointestinal surgeon and gastroenterologist must be achieved as currently exists between cardiac surgeon and cardiologist and between transplant surgeon and nephrologist. Once this cooperation has been established, application of these tools to gastrointestinal diseases should become commonplace in gastrointestinal surgery.
c.
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REFERENCES 1. Espiner, H. J., Salmon, P. R., Teague, R. H., and Read, A. E.: Operative colonscopy. Br. Med. J., 1 :453-454, 1973. 2. Kusakari, K., Nyhus, L. M., Gillison, E. W., and Bombeck, C. T.: An endoscopic test for completeness of vagotomy. Arch. Surg., 105:386-391,1972. 3. Richter, R. M., Littman, L., and Levowitz, B. S.: Intraoperative fiberoptic colonoscopy. Arch. Surg., 106:228,1973. 840 S. Wood Chicago, Illinois 60612
Intraoperative Esophagoscopy, Gastroscopy, Colonoscopy, and Endoscopy of the Small Bowel
C. Thomas Bombeck, MD.
*
Since the advent of fiberoptic instrumentation in the field of gastroenterology in the mid-1960's, great strides have been made in diagnostic endoscopy of lesions of both the upper gastrointestinal tract, extending down to the third portion of the duodenum, and the entire colon. Recently, the addition of more sophisticated instrumentation has allowed therapeutic intervention in many diseases of the gastrointestinal and biliary tract in these areas. One application of fiberoptic endoscopy, however, has been largely overlooked. This is the intraoperative use of these long, pliable endoscopes to allow visualization of the interior of the entire gastrointestinal tract without the necessity of opening the bowel at the operating table. Incision into the gastrointestinal tract in any of its portions is associated with a definite incidence of leakage from the suture line and is almost always associated with gross contamination of the operative field resulting in what has been termed the "clean contaminated wound." The incidence of wound infection in clean contaminated wounds is much greater than that in noncontaminated wounds. Various methods have been used to reduce this increased infection rate such as antibiotic irrigation, but a definite risk persists. If the necessity for opening the gastrointestinal tract is avoided, none of these risks are incurred. The fiberoptic endoscope, either the side- or end-viewing upper gastrointestinal endoscope or the end-viewing colonoscope, has a number of definite advantages which lend themselves readily to intraoperative use. These are: 1. The endoscopes are pliable tubes ranging from 44 to 50 French in diame-
ter which can readily be manipulated around any curve in the gastrointestinal tract by the operating surgeon through the operative field. 2. The tip of the endoscope can be "steered" in almost all models currently "Associate Professor of Surgery and Chief, Section of Surgical Gastroenterology, The Abraham Lincoln School of Medicine, University of Illinois at the Medical Center, Chicago Supported in part by USPHS grant AM 11835, the West Side Veterans Administration Hospital and by the Ray and Joan Kroc Endowment Fund.
Surgical Clinics of North America- VoL 55, No.1, February 1975
135
c.
136
3.
4.
5.
6.
THOMAS BOMBECK
available to allow localization of any lesions encountered by simply pressing the tip of the endoscope against the side of the inflated bowel at the site of the lesion. The lesion then becomes localized as a spot of light on the bowel which is readily visible to the surgeon at the operating table. All of the current endoscopes are equipped with "cold light" sources which allow transillumination of the bowel wall. This is useful both for the localization of lesions and for various mucosal staining techniques which will be described below. Because the average size of the endoscopes ranges from 44 to 50 French, the instrument itself may be used to calibrate various sphincters or narrowed areas in the gastrointestinal tract. In many instances it may serve as a dilator. Almost all endoscopes are equipped with external cameras so that the existence and location of any lesion encountered may be photographically recorded, both for teaching purposes and for documentation of the existence of such lesions in the patient's record. Although insertion and manipulation of the endoscope at the operating table by a trained endoscopist, either gastroenterologist or surgeon, is highly desirable, it is not entirely necessary. Most endoscopy, when used for diagnostic purposes in the awake patient, requires a highly trained individual who, above all, must be sufficiently thorough that he can be certain that he has seen the entirety of that portion of the gastrointestinal tract mucosa which he is examining. This primary requirement is very easily satisfied at the operating table since the surgeon may steer the tip of the endoscope by simply manipulating it through the viscus. The surgeon can then observe the area at which the endoscope is pointed without the geographic confusion which frequently occurs during standard endoscopy. Once the endoscope is inserted, the surgeon may simply look through the eyepiece which is being held by a nonsterile person in the operating room and thereby visualize whatever he is pointing at within the gastrointestinal tract. Using techniques such as these, the surgeon may examine the entirety of the gastrointestinal tract from within its lumen by simply pleating the large and small bowel on one of the longer instruments inserted either from above or from below.
Our Surgical Gastroenterology Clinic has either acquired possession of, or has access to, almost every known make of gastrointestinal endoscope. Because of this, we have had the opportunity to make innovative applications of these endoscopes in many areas of intraoperative endoscopy. It is the purpose of this article to report several of these instances.
INTRAOPERATIVE ESOPHAGOSCOPY Intraoperative endoscopy of the esophagus has several applications. In this area the endoscope may be inserted and may be used to define the upper limits of esophageal narrowing when a benign esophageal stricture is the object of the operative procedure. Previously appli~d methods have included the passage of various size dilators from both above and below, but these have all depended upon the "feel" of the operating surgeon. The upper extent of the stricture may now be directly visualized, and indeed the size of the stricture may be calibrated by attempted passage of the endQscope through it. Once the stricture has been opened, such as for application of a serosal patch, the endoscope itself may be used as a large stent so that an adequate esophageal lumen is thereby insured. Since passage of the endoscope is always
INTRAOPERATIVE ENDOSCOPY
137
carried out under direct vision through the endoscope eyepiece, there is little danger of perforation of the esophagus with this method. These perforations, although readily recognizable and remediable at the time of operation when using a rigid endoscope and various size dilators, do represent a nuisance and may occur at an area other than that of the intended incision into the esophageal wall. They therefore represent a source of dangerous potential postoperative leakage. In patients with previous operative procedures in the area of the gastroesophageal junction, when there are multiple adhesions and much scar tissue obscuring the area, the endoscope may be used to define the true gastroesophageal junction. This junction is often not readily apparent at the operating table. Finally, since most of the endoscopes have metal tips or at least a metal tip protected by a disposable rubber ring, the surgeon may use the tip of the endoscope as a rigid object upon which he may cut down in order to open the esophagus or stricture. This does not injure the endoscope if care is taken to avoid incising the pliable covering above the metal tip and avoids the difficult situation of the oblique incision made through a thickened esophageal wall. This maneuver is also especially useful in patients with achalasia. The esophagus may be distended with air allowing the surgeon to easily define the circular muscle fibers of the lower esophagus. These fibers may be cut without incising the esophageal mucosa during the performance of a standard Heller myotomy. Once this incision is accomplished, the endoscope is simply inserted next to a 20 French nasogastric tube which has already been inserted and both are used as stents for the performance of a large, loose Nissen fundoplication. The technique of fundoplication prevents the subsequent reflux which might be expected as a complication of this operation.
INTRAOPERATIVE GASTROSCOPY Intraoperative endoscopy of the stomach has several diagnostic and therapeutic uses. In the gastrointestinal bleeder it is a common occurrence for the patient to stop bleeding upon induction of anesthesia. When this occurs, it is extremely difficult to examine the entire interior of the stomach for the possible source of bleeding without virtually incising the anterior gastric wall from one end to the other. Before the advent of intraoperative endoscopy, it was our practice to insert a large, sterile operating proctoscope into the stomach to visualize the gastroesophageal junction and those more inaccessible portions of the fundus of the stomach. This method, although better than attempting to evert the gastric mucosa around the fundus to visualize it, gave very poor visualization of the dome of the gastric fundus. This difficult area is now readily accessible to the end-viewing gastroscope. This instrument is inserted after washing of the interior of the stomach, and simply retroflexed by the operating surgeon to view the gastroesophageal junction for possible Mallory-Weiss tears or other possible sources of bleeding such as gastric varices.
138
c.
THOMAS BOMBECK
Gastric polyps are frequently difficult to palpate through the wall of the stomach, and when these are too large to remove endoscopically, they may require laparotomy for their excision. The endoscope may simply be inserted, the polyp visualized, and the base of the polyp pressed outward toward the surgeon by the tip of the examining endoscope. This allows the surgeon to simply make a small incision in that area and to wedge the polyp out without a large gastrotomy. We have previously reported a method for determination of completeness of vagotomy 2 by the use of transendoscopic staining of the gastric mucosa. The normal pH of the gastric mucosa, even the completely vagally denervated gastric mucosa, is approximately 1.5. This is exclusive of the ability of the mucosa to secrete liquid hydrochloric acid into the lumen of the stomach. When the mucosa is neutralized by washing with sodium bicarbonate solution, the vagally denervated mucosa will require in excess of 1 hour to return to a pH of less than 3, while vagally innervated mucosa will return to a pH of less than 3, usually within 15 minutes. If atropinization of the patient is avoided, this method may be used during operation to determine whether or not a vagotomy is complete. In many cases it may locate the intact branch of the vagus nerve in cases of partial vagotomy, since the area of the stomach supplied by that particular nerve will change the color of an indicator dye such as Congo red much more quickly than will the remainder of the stomach to which vagal innervation has been severed. We have repeatedly applied this method in the human. The results obtained by endoscopic testing agree closely with those obtained by more standard means such as the Hollander test. The above cited method may, of course, be used to define the upper limit of the gastric antrum when antrectomy is carried out. In this situation, endoscopy is really not necessary since all that need be done is to wash out the stomach with sodium bicarbonate solution, spray the mucosa of the inflated stomach with Congo red solution, and then insert a fiberoptic light source of any sort. The transilluminated parietal cellbearing area will appear black, while the antrum of the stomach will appear its normal red-orange color. Since we have begun a study of highly selective or parietal cell vagotomy in the treatment of duodenal ulcer, we prefer not to apply this operation in patients with pyloric stenosis. The normal caliber of the pyloric channel is approximately 1.5 cm. This is equivalent to 47 to 48 French, the size of most endoscopes. If the endoscope can be inserted through the pyloric channel either pre- or intraoperatively, it may then be assumed that pyloric stenosis does not exist and no drainage procedure is required during parietal cell vagotomy. Again, the size of the endoscope serves as both a dilator and as a calibrating instrument in this particular area.
ENDOSCOPIC DUODENOSCOPY Although in most instances, examinations of the ampulla of Vater and transampullary cannulation of either the pancreatic or common bile
INTRAOPERATIVE ENDOSCOPY
139
ducts should be carried out as a part of a preoperative examination, this maneuver is also possible and greatly facilitated by intraoperative manipulation. In this case a side-viewing endoscope is employed and much time is saved by simply having the surgeon insert the endoscope by transmural manipulation as it is brought into the stomach, through the pylorus and by having him position it opposite the area of the ampulla. The surgeon simply anchors the instrument in place while the cannulation is carried out. This avoids the necessity of opening the duodenum for transampullary cannulation by manual methods and avoids the risk of subsequent duodenotomy leak. This maneuver can be especially useful in reoperative procedures on the biliary tract when scarring and adhesion formation may make the common bile duct extremely difficult to identify within the porta hepatis. In patients with biliary stricture, percutaneous or transhepatic cholangiography may be used to define the upper limits of the stricture, while intraoperative retrograde cannulation of the common duct may be used to define the lower limits of the stricture. The method may be applied to pancreatography, although this is usually a preoperative maneuver as retrograde cannulation in the awake patient becomes more widely available. In one recent operative case, intraoperative duodenoscopy prevented a serious surgical error. CASE 1. JL was a 41-year-old white male who was admitted to the University of Illinois Hospital with symptoms resembling gastric outlet obstruction for which he had had several duodenal ulcer type operations in the past. The patient had experienced difficulty since childhood and indeed had had multiple gastric and duodenal ulcers diagnosed. Initial radiographic and endoscopic examination of this patient suggested an obstruction at the juncture of the second and third portions of the duodenum. Since no prior films or records were available, there was a question whether this obstruction might be due to adhesion formation within the area, partial malrotation, partial atresia, or annular pancreas. At operation the patient was found to have a thick fibrous band extending across that area of the duodenum which corresponded to the site of the obstruction. The fibrous band resembled multiple other adhesions present from previous operations. There was no gross pancreatic tissue present in the band. The "obstructing" band was excised and sent to pathology for frozen section examination. It was found to contain several islands of pancreatic tissue, thereby confirming the diagnosis of annular pancreas. Due to the known association of duodenal webs, etc., with this lesion, although no obstruction could be palpated within the duodenum lumen, intraoperative endoscopy was carried out. This demonstrated a very thin, soft web within the lumen of the duodenum with an opening approximately 8 to 10 mm in diameter. This partial obstruction was relieved by a longitudinal incision through the duodenal wall and web and onlay of a Roux-en-Y loop of jejunum. Failure to carry out intraoperative endoscopy would have left the web intact.
In other instances, intraoperative endoscopy has been useful in determining whether or not extrinsic compression of the duodenum resulted from an overlying superior mesenteric artery, etc.
INTRAOPERATIVE ENDOSCOPY OF THE SMALL BOWEL Endoscopes currently available do not allow examination of the small bowel beyond the ligament of Treitz and infrequently above the
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ilecocecal valve in the awake patient. Suggestions have been made for examination of the small bowel by passage of a string from above, to which a very long endoscope could be attached and drawn through the small bowel. Most of these methods have proven unsuccessful and all of them have the potential danger of perforation of the small bowel. The long colonoscope, passed from above, readily lends itself to intraoperative examination of the entire length of the small bowel. CASE 2. EW was a 29-year-old black female who was admitted to the University of Illinois Hospital with a 4-month history of iron deficiency anemia and persistently guaiac positive stools. Exhaustive examination of both her upper and lower gastrointestinal tracts by standard endoscopic methods and by radiographic methods was unrevealing. Small bowel barium examinations were read as normal on three separate occasions. The patient persisted with guaiac positive stools and chronic blood loss of approximately one unit per week. She was transferred to the surgery service where, at exploratory laparotomy, a previously sterilized 175 cm ACMI colonoscope was passed orally through her stomach and into the small bowel by the operating surgeon. Twenty-five centimeters distal to the ligament of Treitz, a flat 11/2 cm, sessile, adenomatous polyp was encountered in the wall of the jejunum. A blood clot was observed in the center of the polyp. There was blood within the lumen of the small bowel distal to the polyp, although not in sufficient quantity to be detected by the operating surgeon. Prior to insertion of the endoscope, the surgeon had palpated the entire small bowel and has been unable to localize any lesion. The location of the polyp was marked by pressing the tip of the endoscope against it so that the surgeon could place a suture at that location. The remainder of the small bowel and the colon to the mid transverse portion were then examined by pleating the bowel on the endoscope. The surgeon stretched the bowel ahead of the instrument so that its entire wall could be examined by the endoscopist, positioned at the head of the table. No other lesions were found. The endoscope was withdrawn and the polyp bearing area of the jejunum wedged out and single layer anastomosis accomplished. Pathologic examination of the resected specimen demonstrated the presence of the sessile, adenomatous polyp which was benign in character. Since that time the patient has experienced no further episodes of melena and the chronic blood loss has stopped.
Although we have not otherwise had occasion to completely examine the small bowel in this fashion, any number of other reasons for the procedure might be imagined.
INTRAOPERATIVE COLONOSCOPY This is the only area in which intraoperative endoscopy of the alimentary tract has been reported by other authors.l, 3 Colonoscopy itself, in the awake patient, is, at least, a time-consuming procedure. The reason is the difficult passage of the instrument through the redundant sigmoid and because of the sharp angulations of the splenic and hepatic flexures. No difficulty is encountered in intraoperative endoscopy, since the surgeon may manipulate the endoscope around all the acute bends in the colon and simply draw it to the cecum. The method has proven useful both in our hands and by others in patients with single or multiple polyps of the colon who require open excision because of the size of the polyp and for the exclusion of other colonic lesions. Polyps are frequently multiple and, if very small, may not be palpable by the
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surgeon at the time of operation. We now suggest that any patient undergoing laparotomy for polypectomy should have intraoperative endoscopy of the entire large bowel to exclude any other previously undiscovered lesions. Intraoperative colonoscopy is faster than standard colonoscopy and adds essentially no risk to the procedure. The use of this method in patients with carcinoma of the colon is probably not indicated due to the excessive manipulation of the tumor by passage of the endoscope through it, as well as the risk of disseminating tumor cells throughout the remainder of the colon by insertion of the endoscope through the tumor to the cecum. This might theoretically result in a high incidence of suture line recurrence of tumor, although this has not been proven. Intraoperative colonoscopy for lower gastrointestinal bleeding has, in our hands, remained a theoretical application of this modality. The reason for this is that if a patient is bleeding sufficiently rapidly from a colonic lesion to require laparotomy, the volume of bleeding is usually sufficient to make colonoscopy virtually impossible. Current instruments now in use are not equipped with large enough suction and washing channels to keep up with the influx of blood into the colon so that the examiner never has a clear field of view through the endoscope. Such methods as superior and inferior mesenteric arterial angiography remain the diagnostic modalities of choice in the patient with severe colonic bleeding. Since these methods may also be followed by pressor infusion into the vessels to control the bleeding, angiography offers an additional advantage over colonoscopy. Certainly, colonoscopy is indicated in the patient who has had a demonstrable lower gastrointestinal bleeding episode; this may be carried out in the awake patient. Since the most common cause of massive lower gastrointestinal bleeding is diverticular disease, once the bleeding has stopped colonoscopy is of little value in determining which diverticulum has bled. The use of colonoscopy to localize the site of bleeding in colonic lesions, especially diverticular disease, awaits the development of new instrumentation.
SUMMARY Intraoperative endoscopy of the gastrointestinal tract is probably much more widely used than has been publicized in the recent literature. Application of this new tool to the surgical armamentarium depends only on the limits of the imagination of the operating surgeon and his endoscopist colleague, in most cases, the gastroenterologist. The operative maneuverability of current endoscopes make every portion of the gastrointestinal tract accessible to direct visualization without incision into it, both by the operating surgeon and by the endoscopist. For the full potential of this modality to be realized, the same sort of cooperation between gastrointestinal surgeon and gastroenterologist must be achieved as currently exists between cardiac surgeon and cardiologist and between transplant surgeon and nephrologist. Once this cooperation has been established, application of these tools to gastrointestinal diseases should become commonplace in gastrointestinal surgery.
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REFERENCES 1. Espiner, H. J., Salmon, P. R., Teague, R. H., and Read, A. E.: Operative colonscopy. Br. Med. J., 1 :453-454, 1973. 2. Kusakari, K., Nyhus, L. M., Gillison, E. W., and Bombeck, C. T.: An endoscopic test for completeness of vagotomy. Arch. Surg., 105:386-391,1972. 3. Richter, R. M., Littman, L., and Levowitz, B. S.: Intraoperative fiberoptic colonoscopy. Arch. Surg., 106:228,1973. 840 S. Wood Chicago, Illinois 60612