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Videoendoscopic anoscopy: A new technique for examining the anal canal
Videoendoscopic anoscopy: a new technique for examining the anal canal Donald J. Lazas, MD Frank M. Moses, MD Roy K.H. Wong, MD Anoscopy is considered the gold s t a n d a r d for the diagnosis of m o s t anal a n d p e r i a n a l pathologic processes.l-3 It offers the best m e a n s to e v a l u a t e hemorrhoids, fissures, a n d o t h e r i n f l a m m a t o r y or m a l i g n a n t lesions of the anal canal.4 U n f o r t u n a t e l y , in the era offiberoptic a n d video endoscopy, anoscopy h a s become a neglected procedure. Sigmoidoscopy, however, is not a s u b s t i t u t e for direct anoscopic e x a m i n a t i o n of the anal canal. Recently, colposcopy h a s been r e p o r t e d as a t e c h n i q u e useful for the diagnosis of anal lesions in p a t i e n t s w i t h H I V disease. 5 A l t h o u g h this procedure offers the a d v a n t a g e of lesion magnification, a certain a m o u n t of practice is required to l e a r n the technique. We discuss a new t e c h n i q u e of videoendoscopic anoscopy a n d p r e s e n t cases t h a t e m p h a s i z e the i m p o r t a n t role it can play in e v a l u a t i n g perianal lesions. METHODS AND MATERIALS Flexible sigmoidoscopy is performed in the standard fashion with a video sigmoidoscope. After completion of the sigmoidoscopic examination, the rectum is emptied of air and secretions and the sigmoidoscope is withdrawn. The clear plastic anoscope (Saniscope, Bard Inc., Murray Hill, N.J.) is then inserted. A black indelible marker is used to mark the innermost and outermost aspect of the anoscope so that relative position in the anal canal can be determined (Fig. 1). The central plunger is withdrawn and large cotton swabs are inserted through the anoscope to clear away residual material. The video sigmoidoscope is then inserted into the channel of the anoscope. Control of the anoscope and distal end of the sigmoidoscope can be maintained using the right hand while the left hand is free to obtain endoscopic photographs. The examination is started with the anoscope at deep insertion and the anal canal is examined as the anoscope is slowly withdrawn. If necessary, the anoscope can be
Received November 8, 1994. For revision December 14, 1994. Accepted January 12, 1995. From Walter Reed A r m y Medical Center, Department o f Gastroenterology, Washington, D.C. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department o f the A r m y or the Department o f Defense. Reprint requests: Frank M. Moses, MD, Walter Reed A r m y Medical Center, Gastroenterology, Washington, D.C. 20307-5001. 37/69/64355
V O L U M E 42, NO. 4, 1995
Figure 1. The clear plastic anoscope is used in conjunction with the video sigmoidoscope. Indelible markings assist in determining relative position in the anal canal. reinserted for a second look. Duration of the anoscopic examination is approximately 60 seconds. Case 1 A 45-year-old man presented with a 2-year history of intermittent rectal bleeding. He described approximately 12 episodes of painless hematochezia with passage of 1 to 2 cups of blood per rectum with occasional spurting of blood into the toilet bowel. These episodes usually followed a bowel movement but on occasion were preceded by a sensation of rectal urgency followed by isolated hematochezia. He had no history of melena, abdominal or rectal pain, or weight loss. His hematocrit had remained unchanged at 45% over the previous 2 years and the coagulation parameters and platelet count were normal. Colonoscopy was performed at the time of his original presentation and was normal. A UGI and small bowel follow-through were also normal. Colonoscopy was repeated after a subsequent episode of hematochezia and was normal. The patient was referred to our institution for evaluation of suspected colonic vascular malformations. He had no other medical problems and was taking no nonsteroidal anti-inflammatory drugs or other medications. His physical examination was normal and his rectal examination revealed no mass or frank blood. The hematocrit was unchanged. Flexible sigmoidoscopy was performed on the day of presentation and was normal. Retroflexed examination of the rectum showed no evidence of internal hemorrhoids (Fig. 2). Videoendoscopic anoscopy was performed ~
GASTROINTESTINAL ENDOSCOPY
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Figure 2. Normal retroflexed examination of rectum (Case 1).
Figure 4. Videoendoscopic anoscopy: close-up view demonstrating superficial blood vessels on surface of internal hemorrhoids (Case 1).
Case 3
Figure 3. Videoendoscopic anoscopy demonstrating 4 columns of internal hemorrhoids. Arrows indicate dominant columns (Case 1).
A 32-year-old man presented complaining of intermittent, severe anal pain that was exacerbated by the passage of hard stool. He had no history of rectal bleeding or trauma and there were no other gastrointestinal symptoms. Visual inspection of the external anal canal revealed an area in the posterior midline that was suspicious for an anal fissure. Digital examination following the application of a topical anesthetic was notable for tenderness within the anal canal. There were no palpable lesions in the anal canal or rectum. Flexible sigmoidoscopy was normal. Videoendoscopic anoscopy revealed two ulcerated areas to the left and right of the posterior midline in the anal canal (Fig. 6). The patient was treated with conservative measures including stool softeners, sitz baths, and a topical anesthetic with complete resolution of his anal pain and documented healing of the anal fissure.
DISCUSSION and revealed four columns of internal hemorrhoids with two dominant columns exhibiting visible superficial blood vessels (Figs. 3, 4). The patient was referred to the general surgery service where he subsequently underwent rubber band ligation therapy of the internal hemorrhoids. There has been no recurrent rectal bleeding since completing his therapy 10 months ago.
Case 2 A 30-year-old man presented complaining of a nontender, nonprotruding anal nodule. He had no other gastrointestinal symptoms and had no other medical illnesses. Digital rectal examination was notable for a 1.0 cm, firm, nontender nodule located 2.0 cm into the anal canal in the right posterior quadrant. Flexible sigmoidoscopy with retroflex examination of the rectum was normal. Videoendoscopic anoscopy revealed a white nodular lesion protruding from the squamocolumnar junction (Fig. 5). The lesion was suspicious for a papilloma versus a hypertrophied anal papilla. He was referred to the general surgery service but subsequently refused surgical excision of the lesion. 352 G A S T R O I N T E S T I N A L E N D O S C O P Y
I n recent y e a r s the clinical i m p o r t a n c e of anoscopy h a s been o v e r s h a d o w e d by the developing technology of fiberoptic a n d video endoscopy. However, reliance on flexible endoscopy m a y lead to missed anal pathologic lesions including hemorrhoids, o t h e r i n f l a m m a tory processes, a n d m a l i g n a n t disease. The cases presented above provide evidence t h a t anoscopy r e m a i n s an i m p o r t a n t clinical tool in the e v a l u a t i o n of c o m m o n anorectal disorders. U n f o r t u n a t e l y , s t a n d a r d anoscopy is often not performed. This m a y be related to the lack of a p p r o p r i a t e equipment, including the anoscope a n d light source, a n d a degree of incompatibility between s t a n d a r d anoscopy a n d flexible sigmoidoscopy. F u r t h e r m o r e , the p a t i e n t m a y need to be repositioned in the knee-chest or inverted positions, which m a y require reconfiguration of the endoscopic table. 6 These are obstacles t h a t m a y both prolong the procedure time a n d add to p a t i e n t discomfort. Additionally, t h e r e m a y be a lack of instruction in g a s t r o e n t e r o l o g y VOLUME 42, NO. 4, 1995
Figure 5. Videoendoscopic anoscopy showing white nodular lesion (large arrow) protruding from the squamocolumnar junction (small arrows) (Case 2).
Figure 6. Videoendoscopic anoscopy showing two fissures (large arrows) to the left and right of the posterior midline. The black mark on the anoscope (small arrow) indicates the anterior midline (Case 3).
teaching programs on the proper technique of anoscopic examination. Videoendoscopic anoscopy is a new technique t h a t can be performed as an extension of standard flexible sigmoidoscopy. The procedure can be performed in a time-efficient manner, adding no more t h a n 60 seconds to the flexible sigmoidoscopic examination. Furthermore, the procedure can easily be performed with the patient in the left lateral position. The technique of videoendoscopic anoscopy t h a t we have described offers several advantages over standard anoscopy. Importantly, this technique provides a fourfold to fivefold magnification of both normal and abnormal structures in the anal canal, which undoubtedly will result in improved sensitivity over standard anoscopy for the detection of important pathologic lesions. When used in conjunction with the videoanoscopic technique, the clear plastic anoscope (Saniscope) allows for the examination of the entire anal canal simultaneously. The video capability and image magnification make this technique ideal for teaching purposes. Furthermore, electronic documenration is beneficial when surgical consultation becomes necessary. Additionally, this technique is extremely portable and can be used to evaluate patients in both the intensive care unit and ambulatory settings. Infection control has become of paramount importance in the era of HIV disease. Videoendoscopic anoscopy allows for the operator's face to be removed from the path of fecal spraying, thus diminishing the risk of infection transmission and enhancing the attractiveness of the procedure and operator acceptability. Colonoscopic evaluation is always necessary in patients older t h a n 40 years who present with overt or occult rectal bleeding because 24% to 64% will have a second lesion discovered in addition to internal hemorrhoids.7, s However, as case one illustrates, hemorVOLUME 42, NO. 4, 1995
rhoids may go unrecognized as a significant cause of rectal bleeding unless anoscopy is performed. Although internal hemorrhoids can be detected during endoscopy using both retroflexion and pull-through techniques, these methods lack the sensitivity of anoscopy. In a prospective comparison of these techniques, Kelly et al. 9 showed that retroflexion and pull-through detected 54% and 78% of internal hemorrhoids, respectively, when compared with anoscopy. The case that we have presented underscores the importance of anoscopy in the evaluation of all patients presenting with rectal bleeding. Videoendoscopic anoscopy allows for precise diagnosis of nonprolapsing internal hemorrhoids and photographic documentation facilitates the process of surgical referral for definitive therapy. Moreover, therapeutic modalities such as rubber band ligation and injection sclerotherapy could be used in association with videoendoscopic anoscopy to treat hemorrhoids. Other lesions of the anal canal can be readily diagnosed with this new technique. Lesions such as anal fissures and squamous papillomas may be identified by both appearance and location within the anal canal. The relative position of an anal fissure within the anal canal can be important, with most benign fissures occurring in the posterior mid]ine. Position can easily be determined using the technique of videoendoscopic anoscopy by marking the innermost and outermost aspect of the clear plastic anoscope with an indelible marker (Fig. 1). In summary, the newly described technique of videoendoscopic anoscopy is a valuable resource in the evaluation of all patients with suspected anal or perianal lesions. This procedure is easy to learn and provides a time efficient way to evaluate the anal canal. The extended visualization and magnification proGASTROINTESTINAL ENDOSCOPY
353
vided b y this t e c h n i q u e allows for a m o r e t h o r o u g h e x a m i n a t i o n of t h e a n a l canal a n d i m p r o v e d diagnostic accuracy. T h e low cost a n d e x t r e m e p o r t a b i l i t y ensure t h a t this procedure can be p e r f o r m e d in a n y pat i e n t in a n y hospital setting. REFERENCES 1. Abcarian H, Alexander-Williams J, Christiansen J, Hohanson J, Killingback M. Benign anorectal disease: definition, characterization and analysis of treatment. Am J Gastroenterol 1994; 89:S182-93. 2. Spiro HM, ed. Clinical gastroenterology. 4th ed. New York, New York: McGraw-Hill, 1993:810. 3. Carman ML, ed. Colon and rectal surgery. 3rd ed. Philadelphia: J.B. Lippincott, 1993:5.
Ischemia-induced tissue remodeling: magnetic enteral gastrostomy in a porcine model Jonathan F. Grier, Michael B. Ibach, Warren D. Grafton, Charles F. Gholson,
MD MD MD MD
G a s t r o s t o m y is one of the oldest o p e r a t i o n s performed. 1-4 W i t h r e f i n e m e n t s in surgical a n d anesthetic technique, it h a s become safe in spite of t h e g e n e r a l l y debilitated p o p u l a t i o n in w h o m it is performed. 5,6 I n t r o d u c t i o n of t h e p e r c u t a n e o u s endoscopic g a s t r o s t o m y (PEG) 7 w a s the n e x t a d v a n c e m e n t in g a s t r o s t o m y technique, affording s e v e r a l a d v a n t a g e s over surgical methods, s l ° T h e r e c e n t explosion of laparoscopic technology h a s p r o m p t e d m i n i m a l l y i n v a s i v e p l a c e m e n t of g a s t r o s t o m i e s for p a t i e n t s who are not c a n d i d a t e s for PEG. 11, 12 T h e u s u a l indication for g a s t r o s t o m y is inability to tolerate a n oral diet in the s e t t i n g of a functional g a s t r o i n t e s t i n a l t r a c t a n d a m e a n i n g f u l life expectancy. 13 A l t h o u g h c o m m o n l y
Received November 10, 1994. For revision November 30, 1994. Accepted January 24, 1995. From the Departments of Medicine and Pathology, Louisiana State University Medical School, Shreveport, Louisiana. Abstract presented at the annual meeting of the American Gastroenterological Association, May 1995, San Diego, Calif. (Gastroenterology 1995;108:A104). A patent for the technology described in this manuscript has been submitted by Research Corporation Technologies through an agreement with Louisiana State University. Reprint requests: Charles F. Gholson, MD, P.O. Box 33932, 1501 Kings Highway, Shreveport, LA 71130-3932. 0016-5107/95/4204-035455.00 +0 GASTROINTESTINAL ENDOSCOPY Copyright © 1995 by the American Societyfor GastrointestinalEndoscopy 37/69/63951
354 GASTROINTESTINAL ENDOSCOPY
4. Smith LE. Hemorrhoids: a review of current techniques and management. Gastroenterol Clin North Am 1987;16:79-91. 5. Surawicz CM, Kirby P, Critchlow C, Sayer J, Dunphy C, Kiviat N. Anal dysplasia in homosexual men: role of anoscopy and biopsy. Gastroenterology 1993;105:658-66. 6. Powell DW. Anoscopy and rigid sigmoidoscopy. In: Drossman DA, eds. Manual of gastroenterologic procedures. New York: Raven Press, 1987:125-32. 7. Shinya H, Cwern M, Wolf G. Colonoscopicdiagnosis and management of rectal bleeding. Surg Clin North Am 1982;62:897903. 8. Pines A, Shemesh E, Bat L. Prolonged rectal bleeding associated with hemorrhoids: the diagnostic contribution of colonoscopy. South Med J 1987;80:313-4. 9. Kelly SM, Sanowski RA, Foutch PG, Bellapravalu S, Haynes WC. A prospective comparison of anoscopy and fiberendoscopy in detecting anal lesions. J Clin Gastroenterol 1986;8:658-60.
p e r f o r m e d b e c a u s e of neurologic i m p a i r m e n t , the list of indications for g a s t r o s t o m y continues to increase. T h e p o p u l a r i t y of n e w e r g a s t r o s t o m y techniques, however, should not o v e r s h a d o w t h e i r significant shortcomings. P r e s e n t technology r e q u i r e s surgery, laparoscopy, endoscopy, or p e r c u t a n e o u s p u n c t u r e d e p e n d i n g on the m e t h o d u s e d as well as a n e s t h e s i a (general, i n t r a v e n o u s , local), antibiotic coverage, postp r o c e d u r e analgesics, a n d delayed refeeding a f t e r t h e procedure. To a d d r e s s t h e s e issues, we t e s t e d t h e hypothesis t h a t a s m a l l i n t r a g a s t r i c m a g n e t e n g a g e d to a l a r g e r m a g n e t on the a b d o m i n a l wall would occlude blood flow to t h e i n t e r v e n i n g tissue. T h e e n s u i n g localized i s c h e m i a would r e s u l t in infarction a n d r e s o r p t i o n of t h a t tissue. As i n t e r v e n i n g tissue is resorbed, the i n t r a g a s t r i c m a g n e t would m i g r a t e tow a r d s t h e l a r g e r m a g n e t on t h e a b d o m i n a l wall, leaving t h e s t o m a c h a d h e r e n t to t h e a b d o m i n a l wall, crea t i n g a g a s t r o s t o m y in its p a t h . T h i s t e c h n i q u e could obviate surgery, ]aparoscopy, endoscopy, p e r c u t a n e ous p u n c t u r e , anesthetics, antibiotics, a n d analgesics. We also expect to u s e the s t o m a c h for feeding continu o u s l y while t h e g a s t r o s t o m y forms. MATERIALS AND METHODS
One male and two female pigs (Sus scrofa domesticus), aged 2 to 3 months and weighing 15 to 20 kg were studied. Criteria of the National Research Council for care and use of laboratory animals in research were carefully followed, and the experimental protocol was approved by the Institutional Review Board of the Louisiana State University School of Medicine in Shreveport. After an overnight fast each animal was sedated with intramuscular xylazine (2 mg/kg) and ketamine (10 mg/kg). Pig 1 underwent complete esophagogastroduodenoscopy with a video gastroscope (Olympus GIF100, Olympus America Inc., Lake Success, N.Y.) while in the left lateral decubitus position. A Steigmann-Goff overtube (Bard, Tewksbury, Mass.) was placed in the esophagus over the gastroscope, and the gastroscope was removed. VOLUME 42, NO. 4, 1995
Received November 8, 1994. For revision December 14, 1994. Accepted January 12, 1995. From Walter Reed A r m y Medical Center, Department o f Gastroenterology, Washington, D.C. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department o f the A r m y or the Department o f Defense. Reprint requests: Frank M. Moses, MD, Walter Reed A r m y Medical Center, Gastroenterology, Washington, D.C. 20307-5001. 37/69/64355
V O L U M E 42, NO. 4, 1995
Figure 1. The clear plastic anoscope is used in conjunction with the video sigmoidoscope. Indelible markings assist in determining relative position in the anal canal. reinserted for a second look. Duration of the anoscopic examination is approximately 60 seconds. Case 1 A 45-year-old man presented with a 2-year history of intermittent rectal bleeding. He described approximately 12 episodes of painless hematochezia with passage of 1 to 2 cups of blood per rectum with occasional spurting of blood into the toilet bowel. These episodes usually followed a bowel movement but on occasion were preceded by a sensation of rectal urgency followed by isolated hematochezia. He had no history of melena, abdominal or rectal pain, or weight loss. His hematocrit had remained unchanged at 45% over the previous 2 years and the coagulation parameters and platelet count were normal. Colonoscopy was performed at the time of his original presentation and was normal. A UGI and small bowel follow-through were also normal. Colonoscopy was repeated after a subsequent episode of hematochezia and was normal. The patient was referred to our institution for evaluation of suspected colonic vascular malformations. He had no other medical problems and was taking no nonsteroidal anti-inflammatory drugs or other medications. His physical examination was normal and his rectal examination revealed no mass or frank blood. The hematocrit was unchanged. Flexible sigmoidoscopy was performed on the day of presentation and was normal. Retroflexed examination of the rectum showed no evidence of internal hemorrhoids (Fig. 2). Videoendoscopic anoscopy was performed ~
GASTROINTESTINAL ENDOSCOPY
351
Figure 2. Normal retroflexed examination of rectum (Case 1).
Figure 4. Videoendoscopic anoscopy: close-up view demonstrating superficial blood vessels on surface of internal hemorrhoids (Case 1).
Case 3
Figure 3. Videoendoscopic anoscopy demonstrating 4 columns of internal hemorrhoids. Arrows indicate dominant columns (Case 1).
A 32-year-old man presented complaining of intermittent, severe anal pain that was exacerbated by the passage of hard stool. He had no history of rectal bleeding or trauma and there were no other gastrointestinal symptoms. Visual inspection of the external anal canal revealed an area in the posterior midline that was suspicious for an anal fissure. Digital examination following the application of a topical anesthetic was notable for tenderness within the anal canal. There were no palpable lesions in the anal canal or rectum. Flexible sigmoidoscopy was normal. Videoendoscopic anoscopy revealed two ulcerated areas to the left and right of the posterior midline in the anal canal (Fig. 6). The patient was treated with conservative measures including stool softeners, sitz baths, and a topical anesthetic with complete resolution of his anal pain and documented healing of the anal fissure.
DISCUSSION and revealed four columns of internal hemorrhoids with two dominant columns exhibiting visible superficial blood vessels (Figs. 3, 4). The patient was referred to the general surgery service where he subsequently underwent rubber band ligation therapy of the internal hemorrhoids. There has been no recurrent rectal bleeding since completing his therapy 10 months ago.
Case 2 A 30-year-old man presented complaining of a nontender, nonprotruding anal nodule. He had no other gastrointestinal symptoms and had no other medical illnesses. Digital rectal examination was notable for a 1.0 cm, firm, nontender nodule located 2.0 cm into the anal canal in the right posterior quadrant. Flexible sigmoidoscopy with retroflex examination of the rectum was normal. Videoendoscopic anoscopy revealed a white nodular lesion protruding from the squamocolumnar junction (Fig. 5). The lesion was suspicious for a papilloma versus a hypertrophied anal papilla. He was referred to the general surgery service but subsequently refused surgical excision of the lesion. 352 G A S T R O I N T E S T I N A L E N D O S C O P Y
I n recent y e a r s the clinical i m p o r t a n c e of anoscopy h a s been o v e r s h a d o w e d by the developing technology of fiberoptic a n d video endoscopy. However, reliance on flexible endoscopy m a y lead to missed anal pathologic lesions including hemorrhoids, o t h e r i n f l a m m a tory processes, a n d m a l i g n a n t disease. The cases presented above provide evidence t h a t anoscopy r e m a i n s an i m p o r t a n t clinical tool in the e v a l u a t i o n of c o m m o n anorectal disorders. U n f o r t u n a t e l y , s t a n d a r d anoscopy is often not performed. This m a y be related to the lack of a p p r o p r i a t e equipment, including the anoscope a n d light source, a n d a degree of incompatibility between s t a n d a r d anoscopy a n d flexible sigmoidoscopy. F u r t h e r m o r e , the p a t i e n t m a y need to be repositioned in the knee-chest or inverted positions, which m a y require reconfiguration of the endoscopic table. 6 These are obstacles t h a t m a y both prolong the procedure time a n d add to p a t i e n t discomfort. Additionally, t h e r e m a y be a lack of instruction in g a s t r o e n t e r o l o g y VOLUME 42, NO. 4, 1995
Figure 5. Videoendoscopic anoscopy showing white nodular lesion (large arrow) protruding from the squamocolumnar junction (small arrows) (Case 2).
Figure 6. Videoendoscopic anoscopy showing two fissures (large arrows) to the left and right of the posterior midline. The black mark on the anoscope (small arrow) indicates the anterior midline (Case 3).
teaching programs on the proper technique of anoscopic examination. Videoendoscopic anoscopy is a new technique t h a t can be performed as an extension of standard flexible sigmoidoscopy. The procedure can be performed in a time-efficient manner, adding no more t h a n 60 seconds to the flexible sigmoidoscopic examination. Furthermore, the procedure can easily be performed with the patient in the left lateral position. The technique of videoendoscopic anoscopy t h a t we have described offers several advantages over standard anoscopy. Importantly, this technique provides a fourfold to fivefold magnification of both normal and abnormal structures in the anal canal, which undoubtedly will result in improved sensitivity over standard anoscopy for the detection of important pathologic lesions. When used in conjunction with the videoanoscopic technique, the clear plastic anoscope (Saniscope) allows for the examination of the entire anal canal simultaneously. The video capability and image magnification make this technique ideal for teaching purposes. Furthermore, electronic documenration is beneficial when surgical consultation becomes necessary. Additionally, this technique is extremely portable and can be used to evaluate patients in both the intensive care unit and ambulatory settings. Infection control has become of paramount importance in the era of HIV disease. Videoendoscopic anoscopy allows for the operator's face to be removed from the path of fecal spraying, thus diminishing the risk of infection transmission and enhancing the attractiveness of the procedure and operator acceptability. Colonoscopic evaluation is always necessary in patients older t h a n 40 years who present with overt or occult rectal bleeding because 24% to 64% will have a second lesion discovered in addition to internal hemorrhoids.7, s However, as case one illustrates, hemorVOLUME 42, NO. 4, 1995
rhoids may go unrecognized as a significant cause of rectal bleeding unless anoscopy is performed. Although internal hemorrhoids can be detected during endoscopy using both retroflexion and pull-through techniques, these methods lack the sensitivity of anoscopy. In a prospective comparison of these techniques, Kelly et al. 9 showed that retroflexion and pull-through detected 54% and 78% of internal hemorrhoids, respectively, when compared with anoscopy. The case that we have presented underscores the importance of anoscopy in the evaluation of all patients presenting with rectal bleeding. Videoendoscopic anoscopy allows for precise diagnosis of nonprolapsing internal hemorrhoids and photographic documentation facilitates the process of surgical referral for definitive therapy. Moreover, therapeutic modalities such as rubber band ligation and injection sclerotherapy could be used in association with videoendoscopic anoscopy to treat hemorrhoids. Other lesions of the anal canal can be readily diagnosed with this new technique. Lesions such as anal fissures and squamous papillomas may be identified by both appearance and location within the anal canal. The relative position of an anal fissure within the anal canal can be important, with most benign fissures occurring in the posterior mid]ine. Position can easily be determined using the technique of videoendoscopic anoscopy by marking the innermost and outermost aspect of the clear plastic anoscope with an indelible marker (Fig. 1). In summary, the newly described technique of videoendoscopic anoscopy is a valuable resource in the evaluation of all patients with suspected anal or perianal lesions. This procedure is easy to learn and provides a time efficient way to evaluate the anal canal. The extended visualization and magnification proGASTROINTESTINAL ENDOSCOPY
353
vided b y this t e c h n i q u e allows for a m o r e t h o r o u g h e x a m i n a t i o n of t h e a n a l canal a n d i m p r o v e d diagnostic accuracy. T h e low cost a n d e x t r e m e p o r t a b i l i t y ensure t h a t this procedure can be p e r f o r m e d in a n y pat i e n t in a n y hospital setting. REFERENCES 1. Abcarian H, Alexander-Williams J, Christiansen J, Hohanson J, Killingback M. Benign anorectal disease: definition, characterization and analysis of treatment. Am J Gastroenterol 1994; 89:S182-93. 2. Spiro HM, ed. Clinical gastroenterology. 4th ed. New York, New York: McGraw-Hill, 1993:810. 3. Carman ML, ed. Colon and rectal surgery. 3rd ed. Philadelphia: J.B. Lippincott, 1993:5.
Ischemia-induced tissue remodeling: magnetic enteral gastrostomy in a porcine model Jonathan F. Grier, Michael B. Ibach, Warren D. Grafton, Charles F. Gholson,
MD MD MD MD
G a s t r o s t o m y is one of the oldest o p e r a t i o n s performed. 1-4 W i t h r e f i n e m e n t s in surgical a n d anesthetic technique, it h a s become safe in spite of t h e g e n e r a l l y debilitated p o p u l a t i o n in w h o m it is performed. 5,6 I n t r o d u c t i o n of t h e p e r c u t a n e o u s endoscopic g a s t r o s t o m y (PEG) 7 w a s the n e x t a d v a n c e m e n t in g a s t r o s t o m y technique, affording s e v e r a l a d v a n t a g e s over surgical methods, s l ° T h e r e c e n t explosion of laparoscopic technology h a s p r o m p t e d m i n i m a l l y i n v a s i v e p l a c e m e n t of g a s t r o s t o m i e s for p a t i e n t s who are not c a n d i d a t e s for PEG. 11, 12 T h e u s u a l indication for g a s t r o s t o m y is inability to tolerate a n oral diet in the s e t t i n g of a functional g a s t r o i n t e s t i n a l t r a c t a n d a m e a n i n g f u l life expectancy. 13 A l t h o u g h c o m m o n l y
Received November 10, 1994. For revision November 30, 1994. Accepted January 24, 1995. From the Departments of Medicine and Pathology, Louisiana State University Medical School, Shreveport, Louisiana. Abstract presented at the annual meeting of the American Gastroenterological Association, May 1995, San Diego, Calif. (Gastroenterology 1995;108:A104). A patent for the technology described in this manuscript has been submitted by Research Corporation Technologies through an agreement with Louisiana State University. Reprint requests: Charles F. Gholson, MD, P.O. Box 33932, 1501 Kings Highway, Shreveport, LA 71130-3932. 0016-5107/95/4204-035455.00 +0 GASTROINTESTINAL ENDOSCOPY Copyright © 1995 by the American Societyfor GastrointestinalEndoscopy 37/69/63951
354 GASTROINTESTINAL ENDOSCOPY
4. Smith LE. Hemorrhoids: a review of current techniques and management. Gastroenterol Clin North Am 1987;16:79-91. 5. Surawicz CM, Kirby P, Critchlow C, Sayer J, Dunphy C, Kiviat N. Anal dysplasia in homosexual men: role of anoscopy and biopsy. Gastroenterology 1993;105:658-66. 6. Powell DW. Anoscopy and rigid sigmoidoscopy. In: Drossman DA, eds. Manual of gastroenterologic procedures. New York: Raven Press, 1987:125-32. 7. Shinya H, Cwern M, Wolf G. Colonoscopicdiagnosis and management of rectal bleeding. Surg Clin North Am 1982;62:897903. 8. Pines A, Shemesh E, Bat L. Prolonged rectal bleeding associated with hemorrhoids: the diagnostic contribution of colonoscopy. South Med J 1987;80:313-4. 9. Kelly SM, Sanowski RA, Foutch PG, Bellapravalu S, Haynes WC. A prospective comparison of anoscopy and fiberendoscopy in detecting anal lesions. J Clin Gastroenterol 1986;8:658-60.
p e r f o r m e d b e c a u s e of neurologic i m p a i r m e n t , the list of indications for g a s t r o s t o m y continues to increase. T h e p o p u l a r i t y of n e w e r g a s t r o s t o m y techniques, however, should not o v e r s h a d o w t h e i r significant shortcomings. P r e s e n t technology r e q u i r e s surgery, laparoscopy, endoscopy, or p e r c u t a n e o u s p u n c t u r e d e p e n d i n g on the m e t h o d u s e d as well as a n e s t h e s i a (general, i n t r a v e n o u s , local), antibiotic coverage, postp r o c e d u r e analgesics, a n d delayed refeeding a f t e r t h e procedure. To a d d r e s s t h e s e issues, we t e s t e d t h e hypothesis t h a t a s m a l l i n t r a g a s t r i c m a g n e t e n g a g e d to a l a r g e r m a g n e t on the a b d o m i n a l wall would occlude blood flow to t h e i n t e r v e n i n g tissue. T h e e n s u i n g localized i s c h e m i a would r e s u l t in infarction a n d r e s o r p t i o n of t h a t tissue. As i n t e r v e n i n g tissue is resorbed, the i n t r a g a s t r i c m a g n e t would m i g r a t e tow a r d s t h e l a r g e r m a g n e t on t h e a b d o m i n a l wall, leaving t h e s t o m a c h a d h e r e n t to t h e a b d o m i n a l wall, crea t i n g a g a s t r o s t o m y in its p a t h . T h i s t e c h n i q u e could obviate surgery, ]aparoscopy, endoscopy, p e r c u t a n e ous p u n c t u r e , anesthetics, antibiotics, a n d analgesics. We also expect to u s e the s t o m a c h for feeding continu o u s l y while t h e g a s t r o s t o m y forms. MATERIALS AND METHODS
One male and two female pigs (Sus scrofa domesticus), aged 2 to 3 months and weighing 15 to 20 kg were studied. Criteria of the National Research Council for care and use of laboratory animals in research were carefully followed, and the experimental protocol was approved by the Institutional Review Board of the Louisiana State University School of Medicine in Shreveport. After an overnight fast each animal was sedated with intramuscular xylazine (2 mg/kg) and ketamine (10 mg/kg). Pig 1 underwent complete esophagogastroduodenoscopy with a video gastroscope (Olympus GIF100, Olympus America Inc., Lake Success, N.Y.) while in the left lateral decubitus position. A Steigmann-Goff overtube (Bard, Tewksbury, Mass.) was placed in the esophagus over the gastroscope, and the gastroscope was removed. VOLUME 42, NO. 4, 1995