The impact of open access flexible sigmoidoscopy: a comparison of two services

BACKGROUND: Open access flexible sigmoidoscopy (OAFS) is an integral part of colorectal cancer services. This study compares the impact of two types of open-access flexible sigmoidoscopy services on the utilisation of barium enema and tumour-stage migration. METHODS: This was a non-randomised comparison (over two one-year periods, four years apart) of two unselected groups of patients, with different inclusion criteria, in adjacent similarly populated health districts. One offered a nurse practitioner endoscopy service while the other had a doctor-led colorectal clinic. RESULTS: The doctor-led service with its broad inclusion criteria detected more colorectal cancers [13.2% versus 0.7%; OR = 16.05; 2.16-119.2]. Neither nurse practitioner (130 cases) nor doctor-led (262 cases) flexible sigmoidoscopy reduced the total number of barium enemas [Odds Ratio (OR) = 1.16 (95% CI 1.03-1.3)]. However, the doctor-led service did reduce the number of barium enemas requested by general practitioners (from 249 to 152). The total number of colorectal cancers (detected by all available methods) were similar [OR = 0.82 (0.53-1.25)] and both services resulted in a similar tumour-stage migration [OR = 1.39 (0.31-6.23)]. CONCLUSION: Open access flexible sigmoidoscopy services have minimal impact on the utilisation of radiology services. Broader inclusion criteria of doctor-led services produce a higher cancer-yield. Tumour-stage migration may be related to greater awareness of colorectal cancer symptoms rather than to the type of OAFS.     

Effectiveness of high‐dose barium enema filling for colonic diverticular bleeding

Aim Therapeutic barium enema was first reported in 1970. The long‐term recurrence rate of colonic diverticular bleeding after therapeutic barium enema was compared with that of endoscopic haemostasis. Method This study included 57 consecutive patients admitted between 2003 and 2008 with colonic diverticular bleeding in whom conservative treatment failed to stop bleeding within 3 h of hospital admission. Lower gastrointestinal endoscopy was performed immediately after admission. In 75% of patients, bleeding was from the right colon, and any identifiable source of bleeding was treated by endoscopic haemostasis. Cases with an undetectable source received high‐dose barium impaction therapy. Results Treatment was as follows: Group A (n = 37) solely by endoscopic haemostasis; Group B (n = 11) solely by therapeutic barium enema group, and Group C (n = 9) by endoscopic haemostasis and therapeutic barium enema. At a follow up of seven (median; range: 1–56) months, recurrent bleeding rates were 18/37 (48.6%), 6/11 (54.5%) and 2/9 (22.2%) (P = 0.3930). Conclusion High‐dose barium enema is as effective as endoscopic haemostasis for the prevention of recurrent diverticular bleeding.     

Cholecystectomy and the development of colorectal neoplasia: a prospective study

One hundred asymptomatic patients over 60 years of age who had cholecystectomy carried out at least 10 years earlier underwent double contrast barium enema and sigmoidoscopy. The incidence of colorectal adenomas and carcinomas was compared with age and sex matched controls undergoing routine post mortems. In the post-cholecystectomy group 12% had tumours (8 adenomas greater than 1 cm in diameter, 4 carcinomas). In the control group 3% had tumours (3 adenomas); P = 0.02. This study confirms that patients with a history of cholecystectomy have an increased risk of developing colorectal adenomas and carcinomas.     

Management of barium enema-induced colorectal perforation.

Unless recognized and treated promptly, colorectal perforation induced by barium enema examination is a life-threatening complication. Between 1977 and 1986, 13,000 barium enemas were performed at the Mayo Medical Center. Colorectal perforation occurred in five patients (overall incidence: 0.04%). The two colonic perforations were managed by immediate celiotomy with resection in one and primary repair in the other. The three rectal perforations were managed conservatively in two patients and by proximal diversion in one. All patients recovered. Perforations were believed to be related to the tip of the enema catheter or presumably to excessive hydrostatic pressure. In contrast to other reports, barium enema-induced colorectal perforation is not always fatal when recognized early and treated aggressively. Localized, contained extraperitoneal rectal perforation may be managed conservatively in selected patients.     

Limited utility of preoperative studies in preparation for colostomy closure

Numerous diagnostic and therapeutic practices are used in an attempt to reduce the morbidity of colostomy closures. Our principal aim was to evaluate the role of preoperative studies, specifically barium enemas and endoscopic examinations, performed before colostomy closures. Additionally, we wished to identify other practices involved in the perioperative management of patients undergoing colostomy closure that influenced morbidity. The records of 100 consecutive patients who underwent elective colostomy closure at University of Louisville Hospital between January 1989 and July 1995 were reviewed. Wound infection was the most common complication (12%). Various bowel preparations were equivalent in efficacy and did not influence the complication rate. Intermittent wound irrigation with antibiotics for 3 days postoperatively, via subcutaneous drains, was associated with a low incidence of incision infection. Preoperative barium enema or sigmoidoscopy were often performed but rarely useful. Performing these examinations merely increased hospital cost without a corresponding decline in morbidity.     

Impact of video colonoscopy on stage and outcome of patients with symptomatic colorectal cancer

Background Double-contrast barium enema still is regarded by many as the investigation of choice for patients with large bowel symptoms. The aim of this study was to compare the stage and outcome of patients with colorectal cancer diagnosed by video colonoscopy (VC) and barium enema (BE) in a single institution.Methods Between July 1997 and December 2001, data were gathered prospectively in a series of 489 patients presenting consecutively with symptomatic colorectal cancer. Selection of patients for either VC or BE investigation was made by the clinician who examined the patient in the clinic. Of the 489 patients, 82 were excluded because they presented acutely or other methods were used for the diagnosis.Results A diagnosis of colorectal cancer was determined by VC for 292 patients and by BE for 115 patients. The patients in both groups were similar in terms of age, gender, and site of disease. Stage 1 disease (T1/2NO) was diagnosed for 87 (29.8%) patients in the VC group, as compared with 10 (8.7%) in the BE group (p < 0.0001). Early colorectal cancer (T1) was diagnosed for 43 patients in the VC group as compared to 1 patient in the BE group (p < 0.0001). During a median follow-up period of 33 months, 8.2% of the patients in the VC group had experienced recurrence after curative resection, as compared with 17.4% of the patients in the BE group p = 0.018). Freedom from disease (p = 0.02) and overall survival (p = 0.03) were significantly increased in the VC group.Conclusions Videocolonoscopy used as the investigation of choice for patients with large bowel symptoms detects colorectal cancer at an earlier stage and has a significant impact on the outcome for this condition.     

The value of auditing negative lower GI investigations preceding a final diagnosis of colorectal cancer

Objective  To review all preceding 'negative' large bowel investigations in patients with a final diagnosis of colorectal cancer, and to examine whether delayed diagnosis was associated with worse outcome.
Method  Details were gathered on all patients with a new diagnosis of colorectal adenocarcinoma presenting over 4.5 years. For each patient the hospital's clinical workstation and radiology and endoscopy databases were interrogated for all flexible sigmoidoscopies, colonoscopies and barium enemas during the 5 years prior to diagnosis.
Results  Among the 570 patients, 28 (5%) had undergone colonoscopy and/or flexible sigmoidoscopy that had not shown colorectal cancer during the 5 years preceding final diagnosis, and a further 28 (5%) had undergone 'negative' barium enemas. Polyp surveillance might have missed four lesions destined to become malignant. Correspondingly there were three patients undergoing IBD surveillance found to have CRC, having had a negative complete colonoscopy within the preceding 5 years. Among patients undergoing de novo colonoscopy for diagnosis the true miss rate was only one patient per year. At August 2007, 29 (58%) of those with delayed diagnosis were still alive, compared with 216 (42%) of those diagnosed during initial investigation (χ² = 5.04, P  <   0.05).
Conclusions  Colonoscopic miss rates are in line with previous studies. The application of simple clinical ground rules will avoid most pitfalls. The methodology described herein may assist in auditing the quality assurance of lower gastrointestinal diagnostic services. Despite the delay, late diagnosis was found to be associated with improved survival and a lower likelihood of metastatic disease.     

Pulmonary staging in colorectal cancer--is computerised tomography the answer?

INTRODUCTION: Pulmonary staging in colorectal cancer (CRC) has traditionally been carried out by means of plain chest radiograph (CXR), although computerised tomography (CT) imaging of the chest is increasingly being performed for this purpose. The aim of this study was to assess the value of pre-operative thoracic CT for pulmonary staging in CRC. PATIENTS AND METHODS: Data were collected prospectively on all patients referred into hospital over a 20-month study period for double contrast barium enema evaluation of symptoms suggestive of an underlying CRC. Patients with a CRC went on to have a staging intravenous, contrast-enhanced CT of the chest, abdomen and pelvis prior to an out-patient appointment with a colorectal surgeon. The CXRs of those patients in whom a radiological abnormality was seen on thoracic CT were reviewed blindly by an independent consultant radiologist. RESULTS: A total of 403 barium enemas were performed, of which 38 demonstrated a CRC (9%). In those patients diagnosed with CRC, nine (24%) had an abnormality on thoracic CT. Four patients with positive thoracic CTs had chemotherapy and or radiotherapy with no surgery. One patient underwent colectomy, and 2 patients who had primary lung tumours as opposed to metastases also underwent colectomies. One patient received palliative care only. In addition, one of the patients underwent multiple, non-diagnostic thoracic investigations prior to a diagnosis of sarcoidosis being made and then proceeding to surgery. An independent consultant radiologist reviewed seven out of the nine CXRs of patients with an abnormality on thoracic CT without knowledge of the clinical diagnosis, and reported three of the CXRs to be normal. CONCLUSIONS: Thoracic CT appears to improve the accuracy of pulmonary staging in CRC allowing a more appropriate level of intervention. However, CT is likely to identify more benign radiological abnormalities than CXR alone, and investigations should not occur to the detriment of treating the primary tumour.     

Follow-up of patients with colorectal cancer

In our follow-up study of 65 patients after curative surgery for colorectal cancer, tests other than history and physical examination detected only two cases of potentially curable recurrent colorectal cancer. As a routine follow-up test, carcinoembryonic antigen determination is preferable to computerized tomographic scanning, since the sensitivity and specificity of carcinoembryonic antigen and computerized tomographic scanning were found to be equivalent and carcinoembryonic antigen is much less expensive. There was no benefit to the routine use of liver function tests or chest roentgenograms during follow-up. Since barium enema contributed little to what colonoscopy accomplished with greater comfort to the patient, barium enemas should be used only when colonoscopy is not totally successful in reaching the cecum. The most beneficial aspect of the follow-up of these patients is probably the elimination of future metachronous lesions by removal of small, benign polyps.     

Outcomes in 2748 patients referred to a colorectal two-week rule clinic

OBJECTIVE: To assess the 3-year outcomes of a nurse-led, one-stop, 2-week rule (TWR) clinic for suspected colorectal cancer (CRC) in a large teaching hospital. METHOD: Data were collected prospectively from January 2002 to December 2004. In total, 2748 patients were seen over the 3-year period. The ratio of male:female subjects was 1190:1558 (43%:57%). Median age at presentation was 66 years (range 17-96). RESULTS: A total of 1363 (49.6%) nonconforming referrals were made; 1300 patients (47.3%) underwent flexible sigmoidoscopy during their initial assessment in clinic; 1439 patients (52.4%) underwent a barium enema during the course of their investigation; 2503 patients (91.1%) were seen within 14 working days. The median overall wait for the initial clinic appointment was 10 days. The annual number of patients seen was similar over the 3-year period. A total of 174 cancers (6.3%) were identified which accounted for 36.4% of all CRCs diagnosed during the study period. Nineteen cancers presented in the nonconforming group (1.6% of all non-conforming patients). Rectal tumours accounted for 59.8% (n = 104) of all cancers diagnosed while right-sided tumours accounted for only 10.9% (n = 19). Advanced tumours accounted for 73.0% (n = 127) of the total; 133 (76.4%) cancer patients underwent some form of surgical intervention. CONCLUSION: A specialist nurse-led, one-stop TWR clinic for suspected colorectal cancer is sustainable and can be run successfully with over 90% of referrals seen within the targeted time period. The proportion of non-conforming referrals was high and a large number of advanced and unstaged tumours was observed. Low numbers of proximal tumours were detected.     

The fate of anastomotic sinuses after total mesorectal excision for rectal cancer

Objective  Chronic anastomotic sinus is a recognized complication of total mesorectal excision (TME) surgery. We observed two patients who developed new tumours within chronic anastomotic sinuses 6 and 19 years after initial surgery. The aim of this study was therefore to report the incidence and outcome of anastomotic sinuses, thus identifying those at potential risk of malignant change.
Method  We retrospectively reviewed patient records and radiology reports to identify potentially curative rectal cancer cases between 1998 and 2005.
Results  In a consecutive series of 100 TMEs with ileostomy, there were 70 males and 30 females, aged 66 (33–88) years. Anastomosis was by double staple technique. A policy of instant enema was used prior to ileostomy closure. Eighty-six patients had instant enemas. Of the 14 that did not, four died prior to enema, one returned to theatre for sepsis, three had their anastomoses assessed by sigmoidoscopy alone. Six had incomplete records. Of the 86 patients, eight presacral sinuses were identified. Three sinuses closed spontaneously. Five persisted of whom two required further surgery.
Conclusion  Persistent anastomotic sinuses occurred in 5% after curative TME. Malignant transformation can occur. Active treatment for chronic sinuses should, therefore, be considered.     

Is total colonic evaluation for anal cancer necessary?

The purpose of this study was to evaluate the necessity of total colonic evaluation in patients diagnosed with anal cancer. We reviewed the cases of 69 patients treated for neoplasm of the anus from January 1973 through November 1998. Patients underwent a barium enema, flexible sigmoidoscopy or colonoscopy; findings from these procedures were analyzed. Anal pathology included: squamous cell carcinoma, 48 patients (72%); adenocarcinoma, 6 patients (9%); and squamous cell carcinoma in situ, 10 patients (15%). Chemoradiation was completed in 41 patients (61%), and 6 patients (9%) underwent abdominal perineal resection. Wide excision was the primary therapy in 15 patients (22%). Procedures included: colonoscopy, 31 patients (46%); flexible sigmoidoscopy only, 15 patients (22%); barium enema only, 3 patients (5%); and a combination of flexible sigmoidoscopy and barium enema, 18 patients (27%). Eighty-five per cent of patients had a normal colonic evaluation. Ten patients (15%) had single or multiple polyps identified. Six adenomatous polyps and two hyperplastic polyps were found. No synchronous colorectal malignancy was identified. We conclude that colonoscopy is an integral part of colonic surveillance in patients diagnosed with anal carcinoma, but our study fails to find evidence to support such intervention. The standard screening recommendation for colorectal cancer based on age and risk factors is appropriate intervention for patients diagnosed with anal cancer; anal cancer itself does not appear to be one of these risk factors.     

Mechanical preparation of the large bowel for elective surgery. Comparison of whole-gut lavage with the conventional enema and purgative technique

In this prospective, randomized study, 121 elective colorectal surgery patients had whole-gut lavage (n = 67) or enemas and purgatives (n = 54). Patient characteristics were well matched. Intravenous metronidazole and tobramycin were administered preoperatively initially in 53 patients, with the remaining 68 patients receiving the drugs perioperatively. Bowel preparation was satisfactory (minimal or no contents remaining) in 92.8 percent of patients with whole-gut lavage and 92.6 percent with enemas and purgatives (p = 0.72). Nasogastric tube insertion was poorly tolerated by 39 percent of the patients receiving whole-gut lavage, and enema tube insertion by 23 percent with enemas and purgatives. Fluid infusion tolerance was similar with both techniques. Abdominal wound sepsis occurred in 22 patients (18.8 percent), being unrelated to mechanical preparation or antimicrobial prophylaxis (p = 0.19). Colostomy closure was associated with a 42.8 percent sepsis rate. Excluding this group, wound sepsis with the remaining procedures was 13 percent (statistically significant, p = 0.03). Other complications included intraabdominal abscesses (3.3 percent), anastomotic leaks (2.5 percent), eviscerations (1.6 percent), and an operative mortality of 1.6 percent. We have concluded that whole-gut lavage and enemas and purgatives are equally efficacious mechanically with similar associated wound sepsis rates.     

Short‐term and long‐term outcomes of patients with malignant large bowel obstruction

Objective: The aim of the present study was to review our experience in the surgical management of patients with obstructing colorectal cancers over an 11‐year period, 1987–1997. Patients and methods: Retrospective review of case records of 275 patients (male: 177; female 98) who had undergone emergency surgery for obstructing colorectal cancers was performed. Tumours proximal to splenic flexure were defined as proximal tumours while those at or below the splenic flexure were defined as distal tumours. Results: The obstruction was caused by proximal tumours in 88 (32%) patients. The resection rate and the primary anastomotic rate were higher for proximal tumours compared with distal tumours (95.5%vs 85.6%, P = 0.014; 92%vs 30.5%, P < 0.001). For distal tumours, stoma rate was found to be influenced by the following factors: preoperative albumin level, duration of observation after admission, operating surgeons’ years of experience, bowel perforation and site of the obstructing tumour. Multivariate analysis disclosed that surgeons’ experience was the only independent factor predicting stoma formation. The in‐hospital mortality and the anastomotic leakage rates were 15.3% and 5.6%, respectively. Tumour stage was the only prognostic factor affecting the disease‐free survival after curative resection. The 5‐year disease‐free survival rates for Dukes’ B and C disease were 66% and 37.2%, respectively. Conclusions: Tumour stage was a significant prognostic factor for patients with obstructing colorectal cancers. Emergency surgery for distal tumours should preferentially be performed by more experienced surgeons in order to achieve a higher anastomotic rate.     

A prospective randomized single-blind comparison of three methods of bowel preparation for outpatient flexible sigmoidoscopy

Background Preparation for outpatient flexible sigmoidoscopy using a self-administered phosphate enema is the standard practice in our unit, but it provides acceptable bowel preparation in only 80% of patients. This study compared two methods of bowel preparation with the current standard in an attempt to improve efficacy and acceptability. Methods From January to September 2003, patients scheduled for out-patient flexible sigmoidoscopy were prospectively randomized to 3 groups: group 1: one Fleet enema 2 h pre-procedure; group 2: two Fleet enemas, one on the evening prior to sigmoidoscopy and one 2 h pre-procedure; group 3: lactulose 30 ml orally 48 and 24 h prior to sigmoidoscopy, plus a single Fleet enema 2 h pre-procedure. A patient questionnaire was used to assess side effects and tolerance. The endoscopists questionnaire assessed the indication for the procedure, quality of preparation, depth of insertion, and pathological findings identified. Power calculations were based on the 80% acceptable preparation rate obtained using a single enema. Results For this study, 305 patients were randomized to the three groups. Patient data were available for 261 patients (group 1 = 105; group 2 = 81; group 3 = 75), and endoscopist data were available for 251 patients (group 1 = 97; group 2 = 79; group 3 = 75). No difference was noted between the groups with regard to age, gender, procedure indication, grade of endoscopist, or patient acceptability variables (ease of use: p = 0.09; assistance required: p = 0.11; cramps experienced: p = 0.84; alternative method: p = 0.25). There was no significant difference between the groups in terms of depth of insertion (p = 0.42—chi-squared test) or abnormalities noted (p = 0.34—chi-squared test). Nor was there any difference in the quality of preparation of patients in group 1 versus group 2 (p = 0.39—Fishers exact test) or group 1 versus group 3 (p = 0.13—Fishers exact). However, lactulose + Fleet resulted in significantly fewer patients with acceptable preparation compared with those who administered two Fleet enemas (p = 0.02— Fishers exact test). Conclusions The addition of a Fleet enema or oral lactulose over and above a single Fleet enema gives no significant improvement in the acceptability or efficacy of bowel preparation. Presented as a poster at the Digestive Disease Week, New Orleans in May 2004 Abstract published in Gastrointest Endosc 2004; 59(5): 127     

TESTICULAR AND PARATESTICULAR TUMOURS IN CHILDREN: 30 YEARS’ EXPERIENCE

Background : Testicular or paratesticular tumours in children are rare, making it difficult to achieve the best management for these life-threatening diseases. The aim of this study is to review patients during a 30-year period with these tumours and assess clinical aspects to improve management. Methods : The records of 68 patients from 1967 to 1996 were reviewed with respect to age at diagnosis, affected sites, presentation, clinical diagnosis, operation, pathology and prognosis. Results : The most common presentation was a painless scrotal mass (84%). The most common testicular tumour was mature teratoma (n = 27) followed by yolk sac tumour (n = 17). Thirteen patients had paratesticular rhabdomyosarcoma. Two teratocarcinomas, three leydig cell tumours, two sertoli cell tumours, one granulosa cell tumour, one fibroma, one gonadoblastoma, and one secondary tumour from acute myeloid leukaemia were found also. Testis-sparing surgery was performed in 21 of 33 patients with benign tumours (27 teratoma, three leydig cell tumours, two sertoli cell tumours, one fibroma), which caused no recurrence. Only two patients with rhabdomyosarcoma and one with mixed germ cell tumour died of their disease. Conclusion : Recent combined therapy with surgery and chemotherapy against primary testicular and paratesticular tumours has improved prognosis. Testis-sparing surgery should be considered for benign tumours.     

"Pulling the plug"--management of meconium plug syndrome in neonates

BackgroundThe significance of meconium plug syndrome (MPS) is unclear but has been associated with Hirschsprung’s disease and magnesium tocolysis. We reviewed our experience to attempt to identify any potential association with these conditions and to review our outcomes.MethodsUsing the International Classification of Diseases, Ninth revision, code for meconium obstruction, patient charts were identified during the 1998–2008 period. A total of 61 cases of MPS were found, after excluding 7 of meconium ileus. Data regarding the hospital course and outcomes were collected and analyzed.ResultsApproximately 30% of patients had spontaneous resolution of the meconium plug without any treatment. Of those patients requiring treatment, contrast barium enema was used, with 97% success. Only 2 patients required surgical intervention owing to worsening distension and subsequent peritonitis. When we stratified the patients according to gestational age of >36 and <36 wk, contrast barium enemas were performed 2.2 ± 1.8 versus 8.6 ± 7.8 d after birth (P = 0.003), respectively, and the lower gestational age patients had a longer length of stay. Contrast barium enema was still successful in 94% of patients with a gestational age of <36 wk. Magnesium tocolysis was noted in 16% of the cases, and Hirschsprung’s disease was only found in 3.2% of patients.ConclusionsPatients with MPS have excellent outcomes, independent of gestational age. Contrast barium enema remains the initial diagnostic and treatment of choice for patients with MPS. Also, although previous reports have shown a link between magnesium tocolysis and Hirschsprung’s disease with MPS, our experience suggests otherwise.     

The usefulness of olive oil enema in children with severe chronic constipation

PurposeFew reports have determined the efficacy of olive oil enemas for severe constipation. Here, we review our experience with olive oil enemas in children with severe chronic constipation.MethodsIn our outpatient pediatric surgery department, the charts of 118 patients prescribed with olive oil enemas between January 2010 and November 2019 were retrospectively reviewed. A 1–2 ml/kg olive oil enema was given either alone or followed several hours later by a glycerin enema. Ratings included “very effective (VE),” “effective (E),” “limited (L),” “ineffective (I),” and “unknown (U).”ResultsOne hundred and fifteen (97.5%) patients were able to use olive oil enemas at home. Forty-nine had functional constipation; 43 had anorectal malformation; 40 had Hirschsprung disease; 12 had spina bifida; and 10 had other maladies.Used as an enema, olive oil was effective in treating fecal impaction in 77.6% of patients; as a lubricant, it was effective in treating 76.9% of patients. Efficacy for fecal disimpaction was similar among patients with different underlying disorders.ConclusionOlive oil enemas are useful for more than three-quarters of children with severe chronic constipation. Further study is warranted to add olive oil enemas as an adjunctive treatment in the management of severe constipation.     

Sensitivity of double contrast barium enema and colonoscopy for the detection of colorectal neoplasms

Background: Double contrast barium enema (DCBE) is the examination carried out most frequently for investigation of patients with large bowel symptoms. The aim of this study was to compare the sensitivity of DCBE and colonoscopy for the detection of colorectal cancer and neoplastic polyps ?1 cm. Methods: All patients undergoing DCBE (1389) or colonoscopy (1081) as the primary investigation for large bowel symptoms or for cancer or polyp surveillance in the first 9 months of 1997 at a large teaching hospital were included in this study. At 1 and 2 years following investigation, a computerized search of appropriate diagnosis and procedure codes to detect any missed cancers or polyps was performed for all patients with a normal investigation. Results: Almost 19% of patients in both groups went on to have an additional large bowel investigation over the 2-year period. In the DCBE group, 47 patients (3.5%) had a cancer diagnosed; eight of them had been missed at the primary investigation (sensitivity 83%). In the colonoscopy group, 37 patients (3.4%) had a cancer; one of them had been missed at the primary investigation (sensitivity 97.5%). Neoplastic polyps ?1 cm were diagnosed in 1.6% of the DCBE group and in 7.7% of the colonoscopy group, with sensitivities of 21.7% and 91.4%, respectively. Nine patients (0.6%) had a false positive diagnosis of cancer in the DCBE group; one had an iatrogenic bowel perforation following flexible sigmoidoscopy. Conclusions: Where adequate facilities and expertise exist, colonoscopy should be the investigation of choice for most patients with large bowel symptoms suggestive of neoplastic disease. apd: 14 May 2001     

Effect of preoperative colonoscopy on the incidence of synchronous and metachronous neoplasms

Colonoscopy and air-contrast barium enema performed preoperatively in 389 patients with colorectal cancer revealed synchronous cancer in 4% and polyp in 14%. Nine of the 16 synchronous cancers were located in other surgical segments than the index cancer, and six of the nine were in stage A or B1. Of the 54 synchronous polyps, 28 were located in such other segments. Half of the synchronous cancers and almost half of the synchronous polyps were missed at double-contrast barium enema. All synchronous cancers and three-fourths of the synchronous polyps were detected at colonoscopy. No patient with preoperative colonoscopy presented with metachronous cancer within 3 years from surgery, and only two were subsequently found to have adenocarcinoma arising from an adenomatous polyp. Endoscopic polypectomy was performed in 21 cases during follow-up. Extensive use of preoperative colonoscopy is recommended in the evaluation of colorectal cancer, in order to promote detection of synchronous tumors, reduce the incidence of 'early metachronous' cancer and avoid malignant degeneration of adenomatous polyp.