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PubMed1998

How well can surgeons perform colonoscopy?

BACKGROUND: Little recent data exist relative to the efficacy or postprocedural complications of surgeons performing diagnostic or therapeutic colonoscopy. Therefore, the aim of this study was to retrospectively assess the outcome of colonoscopy performed by surgeons. METHODS: The charts of 2,069 patients who underwent colonoscopy between January 1992 and April 1995 by one of four surgeons at one of two centers were reviewed. Parameters included demographics, indications, procedures and findings, pathology, major complications, length of procedures and dosage of medication. RESULTS: 2,069 colonoscopies were performed for the following indications: 877 polyp surveillance, 509 cancer surveillance, 287 rectal bleeding, 282 family history of colon cancer, 127 change in bowel habits, 112 polyps found by flexible sigmoidoscope or barium enema, 92 inflammatory bowel disease, 48 preoperation, and 58 other indications. Some patients had more than one indication. The cecum could not be intubated in 73 cases (3.5%) due to narrowing and stricture [33] redundancy [18], poor preparation [14], and other miscellaneous conditions [8]. The average procedure time in the 1, 023 cases in which it was measured was 34.7 min. Average sedation doses were 2.1 mg of midazolam and 75.2 mg of meperedine in these same cases. The 2,069 colonoscopies included 1,878 biopsies, 353 polypectomies, and 139 other procedures. Some patients had multiple therapeutic interventions. Findings included 2,107 polyps, the pathology of which included 907 tubular; 62 tubulovillous and 41 villous adenomas, 325 hyperplastic polyps, and 68 carcinomas. There were five major complications after polypectomies (0.2%) including two cases of bleeding and three perforations. The two patients with bleeding were admitted to hospital, one for observation for 2 days and the other for colonoscopy, coagulation, and transfusion of 3 units of blood. Of the three patients with perforation, one underwent hospitalization for intravenous antibiotics and the other two for surgery (0.01%). Surgery included one resection with primary closure of the sigmoid perforation and one colostomy. CONCLUSIONS: This study confirms the observation that colonoscopy performed by surgeons is safe and rapid whether performed as a therapeutic or as a diagnostic procedure.

Adolescent↗

PubMed2002

Transanal endoscopic microsurgery excision: is anorectal function compromised?

PURPOSE: Transanal endoscopic microsurgery is a new technique that has not yet found its place in routine practice. The procedure results in dilation of the anal sphincter with a large-diameter operating sigmoidoscope, sometimes for a prolonged period. The purpose of the present study was to assess the effect of transanal endoscopic microsurgery on anorectal function. METHODS: Eighteen consecutive patients undergoing transanal endoscopic microsurgery excision of rectal tumors, of whom 13 were available for evaluation, were included. Continence was scored by a numeric scale before surgery and at three and six weeks after surgery. Anorectal physiology studies were performed preoperatively and six weeks postoperatively with manometry, pudendal nerve motor terminal latency, anal mucosal electrosensitivity, rectal balloon volume studies, and endoanal ultrasound. RESULTS: There was a significant reduction in mean anal resting pressure (104 +/- 32 cm H2O before surgery, 73 +/- 30 cm H2O after surgery; P = 0.0009). There was no significant change in squeeze or cough pressure, pudendal nerve terminal motor latency, anal mucosal electrosensitivity, or rectal balloon study volumes. Fall in resting pressure was significantly correlated with length of operating time (r2 =0.39, P = 0.047). There was no significant change in mean continence score after surgery. CONCLUSION: Transanal endoscopic microsurgery results in a reduction in internal sphincter tone. This did not affect continence in a short-term study.

Adult↗

PubMed1986

Training resident physicians in fiberoptic sigmoidoscopy. How many supervised examinations are required to achieve competence?

Twenty-five resident physicians performed 495 fiberoptic sigmoidoscopic examinations that were graded for overall skill according to a six-point competence scale. In general, 24 to 30 examinations were required to become competent at fiberoptic sigmoidoscopy. Trainees with prior rigid sigmoidoscopy experience achieved competence more quickly than those with no prior rigid sigmoidoscopy experience. As experience increased, unassisted insertion distance and luminal visualization increased, insertion time and assisted time decreased, and management scores and percent correct diagnoses improved. Trainees detected 93 to 100 percent of polyps and cancers viewed by the experienced sigmoidoscopist once competence was achieved. These data indicate that programs for training primary care physicians in fiberoptic sigmoidoscopy are feasible, help define the number of examinations required to become competent, and indicate that such trainees should be effective in cancer screening.

Clinical Competence↗

PubMed1987

Intestinal spirochetosis in homosexual men.

Previous studies have demonstrated intestinal spirochetosis in rectal biopsy specimens from 2 to 7 percent of heterosexual and 36 percent of homosexual patients, but the role of intestinal spirochetosis in the pathogenesis of intestinal disease remains unclear. To assess the clinical, histologic, and microbiologic correlates of intestinal spirochetosis in a high-risk group, rectal biopsy specimens from 130 homosexual men, 92 percent of whom had intestinal symptoms, were evaluated. All men were extensively evaluated for rectal and enteric pathogens. Intestinal spirochetosis was identified in rectal biopsy specimens from 39 (30 percent) men; 15 percent of biopsy specimens revealed intestinal spirochetosis on hematoxylin and eosin plus alcian blue staining, and positive results were found in 30 percent on silver staining. No rectal biopsy specimens from 79 control patients with a variety of gastrointestinal symptoms demonstrated evidence of spirochetosis on hematoxylin and eosin, alcian blue, or silver staining (p less than 0.0001). Fifty-six percent of rectal biopsy specimens from men with intestinal spirochetosis were normal, and no specific histologic abnormality was correlated with intestinal spirochetosis. There were no differences in the presence of or type of intestinal symptoms, sigmoidoscopic appearance of the mucosa, type of sexual practice, or prior antibiotic use in men with and without spirochetosis. Other intestinal pathogens were frequent in both groups, and only rectal gonorrhea was significantly associated with intestinal spirochetosis. It is concluded that homosexual men with intestinal symptoms have an increased prevalence of spirochetosis, often in association with Neisseria gonorrhoeae. Independent association of spirochetosis with clinical or histologic findings could not be demonstrated.

Biopsy↗

PubMed1977

A hard look at colonoscopy.

The fiberoptic colonscope represents a significant diagnostic and therapeutic acheivement in the management of colonic disease. Despite some claims to the contrary, it is not universally simple, rapid, thorough, reliable, and inexpensive or without morbidity and mortality. Until these goals are achieved through future refinements, modifications, and new instrumentation, it is strongly recommended that the indications for colonscopy be sharply defined to include the following: (1) Investigation of colonic lesions seen on two successive or one air-contrast barium enema examination. Pedunculated polyps less than 1 cm in diameter can be observed. (2) Preoperative investigation of patients with demonstrable colorectal cancer (to rule out synchronous lesions). (3) Postoperative evaluation after colectomy for carcinoma where the anastomosis is above the reach of a sigmoidoscope. (4) Evaluation of patients with inflammatory bowel disease of the colon. (5) Investigation of persistent occult or gross rectal bleeding when anoscopy, sigmoidoscopy, and barium studies are negative. Patients who represent prohibitive surgical risks because of age or systemic disease should not be considered as candidates for colonoscopy without compelling indications. The decision to biopsy rather than remove or fulgerate a detected lesion must be left to the judgment and experience of the endoscopist. The morbidity that follows polypectomy or fulgeration of sessile lesions less than 0.5 cm in diameter probably exceeds the incidence of carcinoma.

Barium Sulfate↗

PubMed1979

Pneumatosis cystoides intestinalis. Report of two cases involving the descending colon.

Two cases of pneumatosis cystoides intestinalis of the descending colon are described in which the presenting symptoms were abdominal pain and changed bowel habits, respectively. The diagnosis in both cases was established radiologically and sigmoidoscopically. Because the symptoms were persistent and severe, surgical excision of the involved segment of the large bowel was performed. The postoperative result was good and both patients remain free of symptoms.

Colonic Diseases↗

PubMed1980

Elective resection for colorectal cancer in Vermont: 1971--1975.

An analysis of 612 patients undergoing elective resection for colon and rectal cancer in Vermont during the period 1971 to 1975 indicates an increasing incidence of cancers of the cecum and ascending colon, an increased number of Duke's A cancers, a synchronous cancer rate of 6 percent, an overall operative mortality of 6.5 percent, a wide variance in postoperative stay and a relatively small experience per operating surgeon. Only one third of colorectal cancers can be visualized through the rigid sigmoidoscope. Better screening techniques that are simple, reliable, inexpensive and safe must be developed to locate proximal lesions before they metastasize to lymph nodes and distant sites. Further trials with stool blood testing are recommended.

Adenocarcinoma↗

PubMed1991

A critical analysis of the largest reported mass fecal occult blood screening program in the United States.

Fecal occult blood testing for the detection of colon cancer remains controversial. We performed a mass screening program from January 24, 1988, to February 19, 1988, with intensive media promotion, including 121 minutes of televised air time. A total of 5,000 primary practitioners were notified by mail. Hemoccult-II tests were distributed to 156,000 individuals; 55,051 (35%) were returned. Ninety-five percent of the respondents were informed of the program by television. A total of 3,375 persons (6%) tested positive for fecal occult blood; of these, 2,469 (73%) informed the center that they saw their physician to initiate a work-up. Information from physicians regarding work-ups was returned on only 1,356 (55%) patients. Diagnostic tests numbered 2,227 (1.6 tests per patient). However, 5% had no testing, 16% had a repeat Hemoccult only, and 35% had neither a barium enema nor colonoscopy performed. Thirty-six colorectal cancers and 212 polyps were identified. The predictive value (i.e., number of cancers per number of patients who tested positive) increased directly by decade. Thirty-three of 36 patients (92%) with cancer underwent either a barium enema or colonoscopy versus only 185 of 438 (42%) patients with a "negative" work-up. Cancers found were carcinoma in situ in 10 patients (29%), Dukes A in 12 (35%), Dukes B in 4 (12%), and Dukes C in 8 (24%); distant metastases were not found in any participant. Thirty-six percent of the tumors were located in either the right or transverse colon. We conclude that: (1) Screening identified early cancers. All were potentially curable and 64% were limited to the bowel wall. (2) Massive Hemoccult distribution was possible over a short interval, but patient and physician compliance was disturbingly low. (3) Total colonic evaluation is mandatory, since at least 36% of tumors were beyond the reach of the flexible sigmoidoscope. (4) Many work-ups were unnecessary (repeat Hemoccults) or inadequate, indicating a need for physician education.

Adult↗

PubMed1987

Olsalazine sodium in the treatment of ulcerative colitis among patients intolerant of sulfasalazine. A prospective, randomized, placebo-controlled, double-blind, dose-ranging clinical trial.

Sixty-six outpatients with active ulcerative colitis who were intolerant of sulfasalazine were treated in a double-blind randomized trial. They received placebo or olsalazine sodium in daily doses of 0.75, 1.5, or 3 g. Overall, 35% of patients receiving olsalazine improved clinically, compared to 16% of patients receiving placebo. When the colitis activity at study entry was compared with that observed at the completion of the study period, statistically significant or nearly significant improvement was demonstrated within the combined olsalazine group (p = 0.01) and within patient groups receiving olsalazine at daily doses of 1.5 g (p = 0.04) and 3 g (p = 0.055). A dose-response relationship was suggested because 16%, 29%, 27%, and 50% of patients improved in the placebo and 0.75-, 1.5-, and 3-g olsalazine groups, respectively, (p = 0.04). A similar pattern of improvement was seen when sigmoidoscopic criteria were used, although a dose-response relationship was not demonstrated. There were no differences between the treatment and placebo groups for any of the adverse effects or laboratory variables reported at baseline or during the trial period. Four patients were withdrawn because of adverse reactions: 2 developed a skin rash while receiving olsalazine and 2 had diarrhea, one while on olsalazine and the other while on placebo. The data suggest that olsalazine is effective for the treatment of ulcerative colitis and is well tolerated among patients intolerant to sulfasalazine.

Adolescent↗

PubMed1987

5-Aminosalicylic acid enema in the treatment of distal ulcerative colitis, proctosigmoiditis, and proctitis.

The efficacy and safety of 4-g 5-aminosalicylic acid enemas were assessed in 153 patients with ulcerative colitis involving up to 50 cm of distal colon. Seventy-six patients received active medication and 77 received a placebo. There were 20 dropouts (6 in the active group and 14 in the placebo group) during the study because of insufficient efficacy. After 6 wk of therapy, 48 of the 76 patients (63%) receiving 5-aminosalicylic acid were considered to be "much improved" by the study physician compared to 22 of the 77 patients (29%) on placebo (p = 0.001). A disease activity index based on patient symptoms and sigmoidoscopic appearance was used to assess efficacy. Mean disease activity index declined 55% for patients on 5-aminosalicylic acid and 24% for patients on placebo (p = 0.0001). Analysis of subgroups indicated that patients most likely to respond were those with disease confined to the 20-40 cm from the anus. Response was not affected by concurrent sulfasalazine, but patients requiring concurrent oral steroids had a diminished response. Rapid onset of efficacy was shown by a significant reduction in rectal bleeding within 3 days of treatment initiation. 5-Aminosalicylic acid enemas are well tolerated and are of benefit in the treatment of ulcerative colitis confined to the distal colon.

Adult↗

PubMed1989

Colonoscopic screening of persons with suspected risk factors for colon cancer: II. Past history of colorectal neoplasms.

Colonoscopic screening has been recommended for all persons who have had a colorectal adenoma or carcinoma. Such persons have been assumed to be at increased risk of having additional, asymptomatic colorectal neoplasms, the removal of which would reduce morbidity and mortality from colorectal cancer. In this prospective study, initial colonoscopy was performed on 544 asymptomatic subjects with past histories of colorectal index lesions ranging from small tubular adenomas to invasive cancers. In 402 subjects whose worst index lesion was an adenoma, the prevalence of neoplasms detected at colonoscopy, above the reach of the rigid sigmoidoscope, increased with age, male sex, black race, and the number and size of their index adenomas. In 142 subjects whose worst index lesion was invasive cancer, colonoscopy findings were marginally related to age and white race. A subgroup of 133 subjects whose worst index lesion was a single, small (less than 10 mm) tubular adenoma and who had no first-degree relatives with colorectal cancer had only a 3% prevalence of advanced colonic neoplasms (tubular adenomas greater than or equal to 10 mm in diameter; tubulovillous, villous, or severely dysplastic adenomas; or invasive cancers) found on colonoscopy--no greater than would be expected in the general population. Subgroups of the remaining 411 subjects, who had advanced or multiple index lesions, had prevalences of advanced neoplasms ranging from 8% to 18%. These findings indicate that for persons whose only risk factor is a single small tubular adenoma, current screening guidelines could be modified to recommend techniques less costly and less invasive than colonoscopy.

Adenoma↗

PubMedDate not supplied

Fibre-optic sigmoidoscopy compared with the Kato technique in diagnosis and evaluation of the intensity of Schistosoma mansoni infection.

450 patients in Riyadh, Saudi Arabia, complaining of chronic abdominal pain and, coming from different countries endemic for schistosomiasis, were examined endoscopically using fibre-optic colono- or sigmoidoscopes, and rectal biopsies were examined for Schistosoma mansoni ova. After a preliminary study showed that more than 6 biopsies did not increase the positivity rate, 6 biopsies were taken from the rectum and examined by transparency technique. 280 were positive for S. mansoni, 9 of them having in addition S. haematobium. 4 patients had polyps in the sigmoid colon and rectum. When these positive cases were examined using duplicate 50 mg Kato smears, only 160 (57.1%) were positive. There was a highly positive correlation between the intensity of infection as graded by the 2 techniques. We recommend examination of 6 rectal biopsies using fibre-optic sigmoidoscopy when available in small communities with a patchy distribution of schistosomiasis like Saudi Arabia. The method could also be used to exclude schistosomiasis in persons who have moved from rural to urban or non-endemic areas and are unlikely to be re-exposed to infection.

Adolescent↗

PubMed1993

Allergic proctocolitis in infants: a prospective clinicopathologic biopsy study.

Allergic proctocolitis is a major cause of rectal bleeding in infants, but its clinical features and laboratory results are often nonspecific. Our previous retrospective study demonstrated that large numbers of eosinophils in colonic mucosal biopsy specimens were highly associated with cases of allergic proctocolitis. Therefore, we prospectively examined 60 colonic mucosal biopsy specimens from the same sites (4, 8, and 12 cm from the anal verge) in 20 infants with clinically confirmed allergic proctocolitis to validate this morphologic feature, to characterize its distribution, and to correlate these data with the clinical information. The patients (age range, 4 to 304 days) were fed breast milk or a variety of formulas and all presented with rectal bleeding. Sigmoidoscopic examination was abnormal in 19 cases, typically characterized by focal areas of mucosal erythema. The major histologic finding was a strikingly focal increase in the number of eosinophils in all mucosal compartments, with a predilection to aggregate in close association with lymphoid nodules. Eosinophilic infiltration varied not only between biopsies at different sites, but also within individual biopsy specimens. Only 12 of 20 patients (60%) had all three of their biopsy specimens categorized as abnormal; in the remainder, only one (four patients) or two (four patients) of the three biopsy specimens were abnormal. The average number of eosinophils per high-power field of lamina propria for all cases was 15.6. No significant correlation was identified between the number of eosinophils in the mucosa and the patient's age, length of illness, endoscopic appearance, or type of inciting formula. In summary, eosinophils appear to be an excellent marker for infantile allergic proctocolitis. Given the focal distribution of the eosinophils, multiple mucosal biopsy specimens should be obtained and several levels of each examined to confirm the diagnosis.

Biopsy↗

PubMed1987

The effect of an oral gold preparation on the gastrointestinal tract motility in two species of experimental animals.

The oral gold preparation, auranofin, used in rheumatoid arthritis has been reputed to cause chronic diarrhea. To investigate this the G.I. tract motility was measured before auranofin therapy and after 1, 3, and 5 weeks of therapy using scintigraphy following indium-111-labeled meals in three beagle dogs. The gastric emptying times of the dogs accelerated throughout the duration of the experiment, although the large bowel transit times did not seem to be affected. The affect of auranofin on the stools of the baboon Papio ursinus was also noted. The baboon stools were observed for any change in consistency. Sigmoidoscopic examination including mucosal biopsies was carried out monthly over a 6-month period. The baboon's stools were noted to become very soft in consistency, but histology indicated no mucosal changes.

Administration, Oral↗

PubMed1992

Crohn's disease presenting as unilateral labial hypertrophy.

We describe a child who had unilateral hypertrophy of the vulva, a rare extraintestinal manifestation of Crohn's disease. A biopsy specimen revealed a noncaseating granuloma. Flexible sigmoidoscopic examination revealed punctate 1 mm lesions with surrounding erythema in the rectum and sigmoid colon. Response to treatment with sulfasalazine was excellent. Gastrointestinal symptoms developed 1 year later when sulfasalazine was discontinued.

Child↗

PubMed1983

Benoxaprofen in the treatment of active ulcerative colitis.

We have conducted an open pilot trial to assess the therapeutic effect of the lipoxygenase inhibitor, benoxaprofen, in 10 patients with active ulcerative proctocolitis. After 18 days treatment with benoxaprofen (600 mg daily) there was no significant change in bowel habit, rectal bleeding, constitutional upset, sigmoidoscopic appearance, mucosal histology, haemoglobin, ESR, serum albumin or serum orosomucoid. Benoxaprofen itself seems unlikely to prove useful in ulcerative colitis, but evaluation of the therapeutic potential of other lipoxygenase inhibitors in inflammatory bowel disease may be worthwhile.

Adolescent↗

PubMed1992

Phase I/II study of external radio frequency phased array hyperthermia and external beam radiotherapy in the treatment of prostate cancer: technique and results of intraprostatic temperature measurements.

As part of an ongoing Phase I/II study at Duke University Medical Center investigating the toxicity and efficacy of external beam radiotherapy plus hyperthermia for deep-seated, locally advanced or recurrent solid tumors, 12 patients with prostate malignancies (adenocarcinoma--11, leiomyosarcoma--1) were treated with radiotherapy plus hyperthermia. Hyperthermia was given after radiotherapy using a Radio Frequency Phase/Amplitude Control Sigma 60 annular phased array device. All patients had simultaneous temperature measurements made in the rectal lumen and within the prostate during at least one hyperthermia session. Intraprostate thermometers were placed via a unique method described herein using both computerized tomography scan and a rigid sigmoidoscope for guidance. We were able to achieve the desired tumor temperature of > or = 42.5 degrees C in only 1/28 (3.5%) of hyperthermia treatments. Subjective symptoms of pain and/or pressure limited power deposition in 79% of hyperthermia treatments. Higher temperatures were achieved in the distal rectum than in the prostate in all treatments, although the differences were not statistically significant. This temperature differential could not be compensated by using phase and amplitude steering. Rectal temperatures adjacent to the prostate were predictive of prostate temperatures. We conclude that using this regional heating technique we were unable to demonstrate an ability to get an advantageous temperature differential between the prostate and normal tissue. This technique is not useful as an adjuvant to radiation therapy for prostate cancer. The usefulness of other regional heating techniques and devices should be explored.

Adenocarcinoma↗

PubMed1988

Emergency department management of retained rectal foreign bodies.

A plastic toothbrush case was removed from the rectum of a prison inmate in the emergency department using a rigid sigmoidoscope and a fogarty catheter. The patient was subsequently discharged from the emergency department. Previous literature regarding rectal foreign bodies has emphasized inpatient treatment and tended to ignore the potential value of the emergency service. Guidelines for selecting appropriate patients for emergency department management are presented and basic principles for safe outpatient removal are reviewed.

Adult↗