Colonoscopy or sigmoidoscopy: risk of isolated right colon lesions

BACKGROUND: Colorectal cancer is an important cause of death in western countries. Screening methods are based on flexible sigmoidoscopy, a cheap, effective, and less painful procedure, but some important lesions on the right colon can be missed. AIM: Evaluate how many important lesions would be missed if colonoscopy indicated only for patients with distal lesions identified during flexible sigmoidoscopy. MATERIAL AND METHODS: All consecutive colonoscopy performed in the Endoscopy Unit of the Gastroenterology Division of Federal University of S?o Paulo, SP, Brazil, with polyps and cancer suspicious lesions were reviewed. Patients with a second procedure, inflammatory bowel disease or colonic surgery were excluded. RESULTS: We reviewed 101 patients with 38 possible cancer lesions and 70 polyps. The mean age was 62 years (SD 13.7 years) and 45 were male. Forty five lesions were in the right colon, namely 23 adenomas, 10 adenocarcinomas, 1 lymphoma and 11 benign lesion. Among such lesions, 28 were isolated in the right colon (16 adenomas and 7 adenocarcinomas). CONCLUSION: In our study 23 patients (22.77%) had adenomas or adenocarcinomas isolated in the right colon, that would be missed if flexible sigmoidoscopy was used alone.     

CT仿真结肠镜对结肠病变的临床应用探讨

目的 探讨结肠腺瘤。结肠癌,结肠憩室,溃疡性结肠炎,结肠黑变病等病变的ＣＴ仿真结肠镜表现,初步评价其在结肠病灶诊断中的应用价值。方法 ３７例病人（包括２０例结肠腺瘤,６例结肠癌,４例憩室,５例溃疡性结肠炎,结肠黑变病及结肠淀粉样变各１例）行ＣＴ仿真结肠镜并和结肠镜检查结果作对照,男２６例,女１１例,结果 ＣＴ仿真结肠镜对结肠癌和结肠腺瘤、结肠憩室有较高的辨别率,成功地检出了６例结肠癌、１７例结肠腺     

A Study on the Management of Ileus Caused by Cancer in the Left Colon

Abstract: As nasal tube insertion is minimally effective for the management of ileus caused by cancer in the left colon, emergency operations are often necessary for such cases. Recently, a new preoperative colonoscopic procedure, designed with the aim of avoiding emergency operations, was invented. This method, termed colonoscopic retrograde bowel drainage (decompression) (CRBD), can be described as follows : After confirming the lesion colonoscopically, the drainage (decompression) tube is inserted beyond the obstructive lesion along a guide wire or dilator. This method was applied in 17 patients (11 males and 6 females), with an average age 66.8 years (range 44-88 years), one with descending colon cancer, 9 sigmoid colon cancer, 5 rectal cancer and 2 Schnitzler metastasis. The interval from CRBD to surgery was 11.5 days. During this period, preoperative examinations and complete preparation of the colon could be performed. This allowed surgery to be performed electively with the patient in satisfactory condition. The most important benefit of CRBD is that a forward view of obstructive lesions can be obtained with a colonoscope. This direct view procedure reduces the risk of complications. Thus, in properly selected cases, CRBD may allow emergency surgery to be avoided. We conclude that CRBD should be attempted as the initial treatment, before proceeding to surgery.     

Radical colectomy for carcinoma of the colon

Conclusions We believe that carcinoma of the colon is a multicentric organ disease and that a significant number of curable patients are lost because of the development of synchronous or metachronous tumors. These may progress to an inoperable stage before recognition. This group of patients can be saved by a near-total colectomy at the time of the initial procedure. More radical resection of the colon did not increase mortality or morbidity rates to a significant degree in our select group of patients. The ease of follow up by sigmoidoscopy has made it feasible to detect and treat second lesions at the earliest possible moment. In those patients whose prognosis is good for a long life expectancy and in whom the local lesion is considered curable, near-total colectomy appears to be the operation of choice for carcinoma of the colon. Read at the meeting of the American Proctologic Society, Cleveland, Ohio, June 20 to 22, 1966.     

Forward-viewing radial-array echoendoscope for staging of colon cancer beyond the rectum

AIM:To evaluate feasibility of the novel forward-viewing radial-array echoendoscope for staging of colon cancer beyond rectum as the first series.METHODS:A retrospective study with prospectively entered database.From March 2012 to February 2013,a total of 21 patients(11 men)(mean age 64.2 years)with colon cancer beyond the rectum were recruited.The novel forward-viewing radial-array echoendoscope was used for ultrasonographic staging of colon cancer beyond rectum.Ultrasonographic T and N staging were recorded when surgical pathology was used as a gold standard.RESULTS:The mean time to reach the lesion and the mean time to complete the procedure were 3.5 and 7.1min,respectively.The echoendoscope passed through the lesions in 13 patients(61.9%)and reached the cecum in 10 of 13 patients(76.9%).No adverse events were found.The lesions were located in the cecum(n=2),ascending colon(n=1),transverse colon(n=2),descending colon(n=2),and sigmoid colon(n=14).The accuracy rate for T1(n=3),T2(n=4),T3(n=13)and T4(n=1)were 100%,60.0%,84.6%and 100%,respectively.The overall accuracy rates for the T and N staging of colon cancer were 81.0%and52.4%,respectively.The accuracy rates among traversable lesions(n=13)and obstructive lesions(n=8)were 61.5%and 100%,respectively.endoscopic ultrasound and computed tomography had overall accuracy rates of 81.0%and 68.4%,respectively.CONCLUSION:The echoendoscope is a feasible staging tool for colon cancer beyond rectum.However,accuracy of the echoendoscope needs to be verified by larger systematic studies.     

Motion - computerized tomographic colography is a better method for screening for polyps: arguments against the motion.

Computerized tomographic (CT) colography is an exciting technique whereby images of the colonic wall and lumen can be obtained without colonoscopy. It is not as good as conventional colonoscopy, however, because of both inherent and performance limitations. Among the former is the inability to visualize subtle mucosal lesions, such as alterations in colour or pliability. More importantly, CT colography is strictly a diagnostic technique, and does not allow biopsy or removal of polyps. The vigorous bowel preparation required for this procedure can be very unpleasant for the patient, and includes purgatives followed by distension of the colon with air. Unlike with colonoscopy, adherent stool can be difficult to distinguish radiologically from polyps or cancers; as a result, many patients require colonoscopy anyway. The major performance limitations of CT colography are poor sensitivity and specificity compared with conventional colonoscopy. Rectal lesions, flat adenomas and diminutive adenomas are especially difficult to detect, and false-positive results are also common. In addition, the procedure is expensive and less cost effective than colonoscopy. CT colography takes relatively little patient time, but a substantial amount of time is needed for the radiologist to interpret the images. Interobserver variability is high. For all of these reasons, CT colography cannot be recommended as a screening test for colorectal neoplasia.     

Three-dimensional MR and axial CT colonography versus conventional colonoscopy for detection of colon pathologies

AIM: To evaluate the sensitivity and specificity of MR colonography (MRC) and CT performance in detecting colon lesions, and to compare their sensitivity and specificity with that of conventional colonoscopy. METHODS: Forty-two patients suspected of having colonic lesions, because of rectal bleeding, positive fecal occult blood test results or altered bowel habits, underwent the examinations. After insertion of a rectal tube, the colon was filled with 1000-1500 mL of a mixture of 9 g/L NaCI solution, 15-20 mL of 0.5 mmol/L gadopentetate dimeglumine and 100 mL of iodinized contrast material. Once colonic distension was achieved, three-dimensional gradient-echo (3D-GRE) sequences for MR colonography and complementary MR images were taken in all cases. Immediately after MR colonography, abdominal CT images were taken by spiral CT in the axial and supine position. Then all patients were examined by conventional colonoscopy (CC). RESULTS: The sensitivity and specificity of MRC for colon pathologies were 96.4% and 100%, respectively. The percentage of correct diagnosis by MRC was 97.6%. The sensitivity and specificity of CT for colon pathologies were 92.8%, 100%, respectively. The percentage of correct diagnosis by CT was 95.2%. CONCLUSION: In detecting colon lesions, MRC achieved a diagnostic accuracy similar to CC. However, MRC is minimally invasive, with no need for sedation or analgesics during investigation. There is a lower percentage of perforation risk, and all colon segments can be evaluated due to multi-sectional imaging availability; intramural, extra-intestinal components of colonic lesions, metastasis and any additional lesions can be evaluated easily. MRC and CT colonography are new radiological techniques that promise to be highly sensitive in the detection of colorectal mass and inflammatory bowel lesions.     

Angiodysplasia

Angiodysplasia is a recently recognized important cause of lower intestinal bleeding in older patients. Although angiography is an established procedure for the diagnosis of angiodysplasia, colonoscopy is being used increasingly for evaluation of lower intestinal bleeding. In order to define the nature of bleeding due to angiodysplasia and the appropriate role of colonoscopy, 80 patients diagnosed by angiography, pathology, or colonoscopy were reviewed. Bleeding attributable to angiodysplasia varied from acute life-threatening hemorrhage to occult blood in stools. Thirteen patients with angiodysplasia had no bleeding and were identified incidentally by colonoscopy performed for other indications. Eighty-nine percent of the lesions were located in the right colon and there was a mean of 1.5 angiodysplastic lesions per patient. The sensitivity of colonoscopy compared to angiography and pathology was 68% overall and 81% when the colon was completely examined and lesions were located in the colon. The predictive value of a positive colonoscopic diagnosis was 90% in this population. Colonoscopy should be employed as an initial study in patients with chronic or mild acute rectal bleeding.     

Management of the Poorly Prepared Colonoscopy Patient: Colonoscopic Colon Enemas as a Preparation for Colonoscopy

Purpose Colonoscopic colon enema is an option for the management of patients who are suboptimally prepared for colonoscopic examination because of retained fecal material. Methods After colonoscopy is performed and the colonoscopist has reached the right colon and the colon is deemed to be inadequately prepared, the contents of two commercially available bisacodyl enemas are combined and instilled into the right colon via the colonoscope biopsy channel. Patients are allowed to recover from propofol sedation, expel the lumenal contents, resedated, and examined. Results In this fashion, 21 patients during a 19-month period were successfully cleansed of their retained fecal contents, permitting satisfactory colonoscopic examinations. This avoided the need for postponement of the procedure. Conclusions Colonoscopic colon enema is an innovative and simple option available to the colonoscopist to manage the patient with an inadequately prepared colon. Presented at the meeting of the American College of Gastroenterology, Philadelphia, Pennsylvania, October 12 to 17, 2007.     

Leptin reduces the development of the initial precancerous lesions induced by azoxymethane in the rat colonic mucosa

BACKGROUND & AIMS: Recent studies suggest that leptin, a hormone involved in food intake regulation, released into the circulation and gastrointestinal juice, may be a growth factor for intestine and may be involved in carcinogenesis; however, data are contradictory. This study investigates in rat colonic mucosa (1) the effects of hyperleptinemia on epithelial cell proliferation and development of aberrant crypts, earliest preneoplastic lesions, and (2) whether luminal leptin affects cell proliferation. METHODS: Leptin (1 mg/kg/d) or vehicle was administered systemically by miniosmotic pump in Fischer 344 rats either for 7 days (BrdU-labeling indices study) or 23 days (azoxymethane-induced colonic lesions study). The effects of injections or continuous infusion of leptin into the colon were also studied. RESULTS: In systemic leptin-treated rats, plasma leptin levels were 4- to 5-fold increased (P < 0.008 to P < 0.001); labeling indices were higher in proximal colon than in pair-fed control rats (P = 0.006) but unaffected in distal colon. Unexpectedly, in azoxymethane-treated rats, leptin significantly inhibited aberrant crypt foci formation in the middle and distal colon compared with controls (P = 0.006). Under these conditions, plasma insulin levels were reduced by 41%-58%, but gastrin levels were unchanged. In controls, luminal immunoreactive leptin reached the colon. A 3.6-fold increase in intraluminal leptin had no effect on epithelial cell proliferation. CONCLUSIONS: This study provides the first evidence that leptin reduces the development of chemically induced precancerous lesions in colon, perhaps through decreased insulinemia, and thus does not support an important role for leptin in carcinogenesis promotion. Moreover, the study indicates that leptin is not a potent growth factor for normal intestine.     

Rectocolonic exfoliative cytology

An instrument employing saline lavage with simultaneous suction has been devised. This instrument can assist in a) maintaining optimal visualization free of obscuring debris or hemorrhage and b) obtaining material for cytologic examination from the visualized 25-cm length of rectosigmoid and the more proximal bowel. Experience to date reveals excellent correlation of histologic and cytologic diagnoses for lesions within range of the proctoscope and for strictures in which roentgen and biopsy data are inconclusive. A high degree of accuracy (75%) has been demonstrated for sigmoid and left colon lesions. The technic is suitable for the general population as well as those with a higher risk of malignant degeneration (to facilitate the early diagnosis of cancer). Physician time and patient discomfort can be kept to a minimum, and the technic may be applicable as an office procedure.This study was supported in part by USPHS Senior Clinical Traineeship (RM-00031-F-3-01) and the American Cancer Society.     

Oral cancer screening in the elderly.

Oral cancers represent approximately 3% of all cancers diagnosed in the United States. Oral cancer is one-fifth as common as cancer of the breast, colon, and lung but more than twice as common as cervical cancer. Incidence rates for oral cancer are highest among older men. Epidemiologic data identify alcohol and tobacco as major risk factors associated with the disease. Screening for oral cancer is a simple, non-invasive procedure which can be easily incorporated into the comprehensive assessment of older patients. Oral cancer screening can detect early, localized lesions which are associated with an improved prognosis. Five-year survival rates are more than four times greater in individuals with localized lesions than those with distant metastases. Since older Americans visit their physician more often than their dentist, the physician's medical examination provides an excellent opportunity to screen for oral cancers.     

Intraoperative endoscopy to identify lesions

Intraoperative endoscopy is an important adjunct to surgical therapeutics. Endoscopy can improve the efficiency of operative interventions by localizing lesions and defining the extent of pathology. Different techniques can be employed to facilitate intraoperative endoscopy including sterile scope and nonsterile scope methods. Lesion marking can be accomplished using endoscopic or endoscopically guided surgical means. Air insufflation can often be utilized for easily accessible regions of the gastrointestinal tract (esophagus, stomach, rectum, and distal sigmoid colon). Carbon dioxide insufflation is most useful for extended procedures and accessing more difficult locations of the gastrointestinal tract. Commonly lesions identified endoscopically for surgical resection include gastric ulcers and tumors, small bowel lesions, and colon pathology.     

Laparoscopy Assisted Colectomy with Extracorporeal Anastomosis

Abstract: Laparoscopy assisted colectomy with extracorporeal anastomosis was carried out in five patients. In three patients, the lesions were carcinoma with submucosal invasion and the histological results of the polypectomy specimen indicated the necessity of the subsequent colectomy. In the other two patients the lesions were either adenoma or carcinoma in adenoma. Under pneumoperitoneum, mobilization of the colon was performed using the laparoscopic technique. In three patients the mesenteric vessels of a segment of the colon were ligated and divided extracorporeally. In two patients the mesenteric vessels were clipped and divided intracorporeally. In all cases, extracorporeal resection of the colon and hand suture anastomosis were performed. Surgery time ranged from 3 hours and 20 minutes to 4 hours and 50 minutes. No postoperative complications were experinced. Four patients began to walk on the first postoperative day. Postoperative administration of analgesics was needed in four patients for two days or less after the operation. In all but one case, bowel sounds were audible from the first post-operative day onwards. In only one patient was the postoperative recovery delayed. Although sufficient future studies should be accumulated to confirm the advantages of this procedure, we can expect that laparoscopy assisted colectomy will become a useful procedure for benign and early malignant lesions in which colonoscopic removal was not possible or was suspected to be insufficient. (Dig Endosc 1944; 6 : 52–58)     

胶囊内镜下小肠黏膜特征分析53例

目的:回顾性分析胶囊内镜检查患者53例,认识胶囊内镜下小肠正常黏膜特征及小肠病变黏膜特征.方法:2010-08/2011-08,利用Miro Cam胶囊内镜系统对患者53例行胶囊内镜检查.统计患者的年龄、性别、症状、体征等临床资料,将受检者分为不明原因的消化系出血,疑为功能性胃肠病,腹痛、腹泻、腹胀,便秘,体检等共5组;通过查阅病案及电话回访,搜集资料,将胶囊内镜下所见作出最终的临床诊断;分析胶囊内镜下小肠正常及病变黏膜特征.结果:在53例患者中,1例因吞服胶囊后无图像信号,未能顺利完成胶囊内镜检查;1例因患者吞咽胶囊困难而无法进行;其余51例均顺利到达结肠,到达结肠率为96.22%.胃的平均运行时间为69.78 min,小肠的平均运行时间为513.25 min.48例有消化系疾病的阳性结果,3例未见异常,阳性率为90.57%.在所有疑诊小肠疾病的51例患者中,胶囊内镜小肠病变总的诊断率为92.15%(47/51);空肠及回肠阳性诊断率为52.94%,包括炎症12例(1例临床确诊为Crohn’s病),息肉3例,不明肿块3例,淋巴滤泡增生1例,疑似小肠淋巴管扩张7例,钩虫病1例;同时检出反流性食管炎1例;慢性胃炎26例,糜烂性胃炎7例,胃部息肉3例;结肠炎症3例,结肠息肉5例,大肠黑变病2例.胶囊均自然排出体外,无梗阻等并发症的发生.结论:Miro Cam胶囊内镜是一种非侵入性的检查手段,检查安全,顺应性好;在胶囊内镜下,正常小肠黏膜及病变黏膜均呈现出一定的特征.     

Endoscopic mucosal resection using a cap: techniques for use and preventing perforation.

Endoscopic mucosal resection (EMR) is one of several local treatments that provide a specimen for histopathological analysis. The authors developed a technique of EMR using a transparent plastic cap (EMRC) in 1992. By using the EMRC procedure, any part of the gastrointestinal tract mucosa can be easily accessed. The technical details of EMRC are described. The authors have performed EMR in 380 cases of gastrointestinal lesions. The most serious complication may be perforation. Two perforations (one in the esophagus and one in the colon) have occurred. By evaluating recorded videotapes, it was determined that the lack of submucosal saline injection was the major cause. Therefore, large volume injection, which creates a large bleb and potentially reduces the risk of perforation, is recommended. Furthermore, target mucosa should be strangulated at the middle part of the created bleb (never strangulated at the base). Particularly in the colon, injecting a sufficient volume of saline and controlling the power of suction are extremely important, because the cap on the colonoscope is relatively large in size.     

Adenomas of the colon and rectum: Histopathology and management

Summary The histopathology of adenomas with changes from the simplest hyperplasia through atypism and various phases of carcinoma is presented. The extent of carcinomatous change present seems to bear a direct proportional relationship to the size of the lesion. There is no controversy regarding the management of adenomas within reach of the sigmoidoscope. Small lesions less than 5 mm in diameter are safely treated by fulguration. Larger lesions are totally excised for biopsy, and further appropriate treatment carried out as indicated. In cases of adenomas requiring laparotomy for removal, there seems fairly general agreement that when the lesions measure less than 1.0 cm it is safe to watch and follow with x-ray observation for changes in size and configuration. In larger colonic lesions, surgical removal is indicated except in those instances where age or poor health make the procedure an undue risk. It is acknowledged that following these precepts an occasional small early carcinoma will be missed. With increasing experience with colonoscopy, we believe that soon most adenomas of the colon will be treated by this method. Transabdominal excision and resection may then be reserved for lesions that for some reason cannot be removed via colonoscopy, and those showing invasive malignancy.     

Clean sweep of the colon

Since 1982, intraoperative colonoscopy has been performed on 66 patients. Preoperative intent was to perform a colonoscopic polypectomy during an intra-abdominal procedure in 44 patients, localize lesions that might subsequently lead to either colon resection or colotomy and polyp excision in 13, localize bleeding sites in 4, determine the extent of inflammatory bowel disease in 2, survey the colon in 2 who did not have preoperative colon radiography, and assess bowel viability in 1. Surgery proceeded as planned in 54 patients; however, colonoscopic findings extended the resection to include additional segments of bowel in 4. In four patients, polypectomy or bowel resection was avoided as a result of the colonoscopic findings. Intraoperative colonoscopy was not possible in four patients. No complications were related directly to this procedure. Intraoperative colonoscopy is a useful adjunct for localizing lesions or "clearing" the colon. In some patients, colonoscopic findings may change the extent of resection performed.     

Successful endoscopic Nd-YAG laser treatment of endobronchial endometriosis

Catamenial hemoptysis is a rare condition that is associated with the presence of intrapulmonary or endobronchial endometrial tissue. Diagnosis of and therapy for this condition are still a matter of debate. We describe a case of endobronchial endometriosis with catamenial hemoptysis. An endobronchial lesion was diagnosed by spiral CT scan, taken at the onset of the menses, and confirmed with flexible bronchoscopy. The patient was successfully treated with endoscopic Nd-YAG laser therapy with a 1-day in-hospital procedure. We suggest that endoscopic laser treatment should be the first line of therapy for central airway endometriosis, provided that the source of bleeding has been conclusively located and all of the lesions can be reached with the bronchoscope.     

Lymphatic cysts of the colon

A patient with a lymphatic cyst of the descending colon is reported. He underwent segmental resection of the colon. The clinical features, pathology, radiology, and treatment of these lesions are reviewed. It is emphasized that these cysts are very rare and cannot be diagnosed radiologically, but must be included in the differential diagnosis of polypoid lesions of the colon.