Int J Colorectal Dis (2015) 30:111–118 DOI 10.1007/s00384-014-2052-2
ORIGINAL ARTICLE
Improving lesion localisation at colonoscopy: an analysis of influencing factors Adam S. Bryce & Mark S. Johnstone & S. J. Moug
Accepted: 25 October 2014 / Published online: 7 November 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Colonoscopy detects colorectal cancer and determines lesion localisation that influences surgical planning. However, published work suggests that the accuracy of lesion localisation can be low as 60 %, with implications for both the surgeon and the patient. This work aims to identify potential influencing factors at colonoscopy that could lead to improved lesion localisation accuracy. Methods A multi-centred, prospective, observational study was performed that identified patients who were undergoing planned curative resection for a colorectal lesion. Localisation of a lesion at colonoscopy was compared to the intra-operative lesion localisation to determine accuracy of colonoscopic localisation. Patient factors and colonoscopic factors were recorded to determine any influencing factors on lesion localisation at colonoscopy. Results One hundred and eleven patients were analysed: mean age 67.4 years (range 27–89); male:female ratio 1.3:1; symptomatic referrals (n=78, 70.3 %); and previous abdominal surgery in 27 patients (24.3 %). Complete colonoscopy was recorded in 78 patients (70.3 %). In 88 patients (79.3 %), colonoscopic lesion localisation matched the intra-operative location. Pre-operative CT imaging was unable to identify the tumour in 24 cases (21.8 %). Potential influencing patient and colonoscopic factors on accurate lesion localisation at colonoscopy found complete colonoscopy to be the only significant factor (p=0.008). Conclusion Colonoscopic lesion localisation was found to be inaccurate in 79.3 % cases, and with pre-operative CT unable A. S. Bryce : M. S. Johnstone School of Medicine, University of Glasgow, Glasgow G12 8QQ, UK S. J. Moug (*) Department of Surgery, Royal Alexandra Hospital, Paisley PA2 9PN, UK e-mail: [email protected]
to detect all lesions, this study confirms that accurate lesion localisation in the modern era is increasingly reliant on colonoscopy. Incomplete colonoscopy was the only significant factor that influenced inaccurate lesion localisation at colonoscopy. Keywords Colonoscopy . Lesion localisation . Influencing factors
Introduction Colonoscopy is the gold standard modality for the detection of colorectal cancer and, along with radiological imaging, determines lesion localisation leading to optimal pre-operative surgical planning [1, 2]. However, the accuracy of colonoscopy for segmentally localising tumours within the bowel is unclear with previous publications, with varying methodology, stating accuracies from as low as 59.7 to 98.3 % [1–15]. Colorectal surgical resection in the modern era is influenced by the reduced tactility of more frequently performed laparoscopic surgery and the earlier detection of smaller colorectal lesions through the NHS Bowel Cancer Screening Programme (NHSBCSP) [16, 17]. To determine accurate lesion localisation at colonoscopy in this modern era, we recently performed a prospective multi-centred observational study that found inaccurate lesion localisation in 19 % of patients that led to an on-table alteration in surgical management in 6 % [18]. Furthermore, pre-operative CT imaging could not detect these smaller lesions in almost 30 % of cases, confirming the reliance of modern day surgical planning on colonoscopy. The aim of this paper was to build on our initial work by performing an analysis of potentially influencing factors on accurate lesion localisation at colonoscopy.
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Int J Colorectal Dis (2015) 30:111–118
Patients and methods Patients were recruited to this prospective, multi-centred, observational study from five West of Scotland colorectal centres over a six-month period from October 2011 to March 2012 and over a seven-month period from October 2012 to April 2013. This study was registered with the Clinical Effectiveness Departments of NHS Greater Glasgow and Clyde and NHS Ayrshire and Arran health boards. All patients were undergoing colonoscopy because of a positive faecal occult blood test through NHSBCSP (screening patients) [17] or because they presented to primary care with symptoms which warranted referral for colonoscopic examination (symptomatic patients). All colonoscopies were performed or supervised by consultants who routinely performed symptomatic and screening colonoscopies. Eligible patients were identified either at colonoscopy or upon discussion of their management at multi-disciplinary team (MDT) meetings of colorectal teams at each recruiting centre. Patients were included if they met all of the following criteria: patient had a primary colorectal tumour, tumour was identified at colonoscopy and patient underwent elective, curative, surgical resection. Patients were excluded if treated with neo-adjuvant chemoradiotherapy (as they would undergo multiple staging investigations), or surgical resection was palliative. True tumour location was defined as the intra-operative location, and this was compared to the locations at preoperative colonoscopy and on radiological imaging (computed tomography (CT)). The bowel was divided into nine segments/locations to standardise reporting. Colonoscopic location was reported at the time of the colonoscopy with the
following patient details recorded: age, sex, screening or symptomatic referral, previous abdominal surgery (including colorectal resections) and previous colorectal surgery only. Colonoscopic factors recorded were as follows: complete colonoscopy, difficulties encountered (e.g. diverticular disease, sigmoid looping) and use of a magnetic endoscopic imaging guide (MEI). Intra-operative tumour location was reported directly after resection by the operating surgeon by means of a standardised questionnaire. In addition, the surgeon also recorded the following: details of any intraoperative changes and accuracy of tattoo placement at colonoscopy. All categorical variables were analysed with chi-squared or Fisher’s exact tests. All numerical variables were analysed with t tests, with appropriate generation of 95 % confidence intervals. All analyses were performed on SPSS® software version 18 (SPSS, Chicago, Illinois, USA), and p values of
ORIGINAL ARTICLE
Improving lesion localisation at colonoscopy: an analysis of influencing factors Adam S. Bryce & Mark S. Johnstone & S. J. Moug
Accepted: 25 October 2014 / Published online: 7 November 2014 # Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose Colonoscopy detects colorectal cancer and determines lesion localisation that influences surgical planning. However, published work suggests that the accuracy of lesion localisation can be low as 60 %, with implications for both the surgeon and the patient. This work aims to identify potential influencing factors at colonoscopy that could lead to improved lesion localisation accuracy. Methods A multi-centred, prospective, observational study was performed that identified patients who were undergoing planned curative resection for a colorectal lesion. Localisation of a lesion at colonoscopy was compared to the intra-operative lesion localisation to determine accuracy of colonoscopic localisation. Patient factors and colonoscopic factors were recorded to determine any influencing factors on lesion localisation at colonoscopy. Results One hundred and eleven patients were analysed: mean age 67.4 years (range 27–89); male:female ratio 1.3:1; symptomatic referrals (n=78, 70.3 %); and previous abdominal surgery in 27 patients (24.3 %). Complete colonoscopy was recorded in 78 patients (70.3 %). In 88 patients (79.3 %), colonoscopic lesion localisation matched the intra-operative location. Pre-operative CT imaging was unable to identify the tumour in 24 cases (21.8 %). Potential influencing patient and colonoscopic factors on accurate lesion localisation at colonoscopy found complete colonoscopy to be the only significant factor (p=0.008). Conclusion Colonoscopic lesion localisation was found to be inaccurate in 79.3 % cases, and with pre-operative CT unable A. S. Bryce : M. S. Johnstone School of Medicine, University of Glasgow, Glasgow G12 8QQ, UK S. J. Moug (*) Department of Surgery, Royal Alexandra Hospital, Paisley PA2 9PN, UK e-mail: [email protected]
to detect all lesions, this study confirms that accurate lesion localisation in the modern era is increasingly reliant on colonoscopy. Incomplete colonoscopy was the only significant factor that influenced inaccurate lesion localisation at colonoscopy. Keywords Colonoscopy . Lesion localisation . Influencing factors
Introduction Colonoscopy is the gold standard modality for the detection of colorectal cancer and, along with radiological imaging, determines lesion localisation leading to optimal pre-operative surgical planning [1, 2]. However, the accuracy of colonoscopy for segmentally localising tumours within the bowel is unclear with previous publications, with varying methodology, stating accuracies from as low as 59.7 to 98.3 % [1–15]. Colorectal surgical resection in the modern era is influenced by the reduced tactility of more frequently performed laparoscopic surgery and the earlier detection of smaller colorectal lesions through the NHS Bowel Cancer Screening Programme (NHSBCSP) [16, 17]. To determine accurate lesion localisation at colonoscopy in this modern era, we recently performed a prospective multi-centred observational study that found inaccurate lesion localisation in 19 % of patients that led to an on-table alteration in surgical management in 6 % [18]. Furthermore, pre-operative CT imaging could not detect these smaller lesions in almost 30 % of cases, confirming the reliance of modern day surgical planning on colonoscopy. The aim of this paper was to build on our initial work by performing an analysis of potentially influencing factors on accurate lesion localisation at colonoscopy.
112
Int J Colorectal Dis (2015) 30:111–118
Patients and methods Patients were recruited to this prospective, multi-centred, observational study from five West of Scotland colorectal centres over a six-month period from October 2011 to March 2012 and over a seven-month period from October 2012 to April 2013. This study was registered with the Clinical Effectiveness Departments of NHS Greater Glasgow and Clyde and NHS Ayrshire and Arran health boards. All patients were undergoing colonoscopy because of a positive faecal occult blood test through NHSBCSP (screening patients) [17] or because they presented to primary care with symptoms which warranted referral for colonoscopic examination (symptomatic patients). All colonoscopies were performed or supervised by consultants who routinely performed symptomatic and screening colonoscopies. Eligible patients were identified either at colonoscopy or upon discussion of their management at multi-disciplinary team (MDT) meetings of colorectal teams at each recruiting centre. Patients were included if they met all of the following criteria: patient had a primary colorectal tumour, tumour was identified at colonoscopy and patient underwent elective, curative, surgical resection. Patients were excluded if treated with neo-adjuvant chemoradiotherapy (as they would undergo multiple staging investigations), or surgical resection was palliative. True tumour location was defined as the intra-operative location, and this was compared to the locations at preoperative colonoscopy and on radiological imaging (computed tomography (CT)). The bowel was divided into nine segments/locations to standardise reporting. Colonoscopic location was reported at the time of the colonoscopy with the
following patient details recorded: age, sex, screening or symptomatic referral, previous abdominal surgery (including colorectal resections) and previous colorectal surgery only. Colonoscopic factors recorded were as follows: complete colonoscopy, difficulties encountered (e.g. diverticular disease, sigmoid looping) and use of a magnetic endoscopic imaging guide (MEI). Intra-operative tumour location was reported directly after resection by the operating surgeon by means of a standardised questionnaire. In addition, the surgeon also recorded the following: details of any intraoperative changes and accuracy of tattoo placement at colonoscopy. All categorical variables were analysed with chi-squared or Fisher’s exact tests. All numerical variables were analysed with t tests, with appropriate generation of 95 % confidence intervals. All analyses were performed on SPSS® software version 18 (SPSS, Chicago, Illinois, USA), and p values of
