Intraoperative Colonoscopy" Preliminary Report* PAT J. MARTIN, M.D., KENNETH A. FORDE, M.D.

From the Department of Surgery, College of Physicians and Surgeons, Columbia University and Presbyterian Hospital, New York, New York

INCREASED PHYSICIAN PROFICIENCY and technical improvements in the colonoscope have made it more useful to the surgeon, endoscopist and patient. The diagnostic potential of colonoscopy is further enhanced by using it intraoperatively. This use of the colonoscope during celiotomy but before colotomy or resection is safe, and often decreases rather than prolongs the operative time. We have analyzed our early experience utilizing intraoperative colonoscopy for 29 patients. Endoscopic evaluation at the time of celiotomy was of value in decision making and/or therapy in 27 of these cases.

margins of resection. There has been no complication related to the use of the colonoscope intraoperatively in this series of patients. Indications

Intraoperative colonoscopy was indicated for the following reasons: inconclusive barium-enema studies ("possible lesion"); inability to achieve successful colonoscopic examination preoperatively because of adhesions or other technical difficulty; visualization or definition of the type of lesion found on bariumenema examiantion; localization of lesions not palpable through the colonic wall; evaluation of the entire colon prior to resection of a "known" lesion to rule out the presence of other lesions, such as polyps, that would not ordinarily be included in the resection.

Materials and Methods

Twenty-nine patients, ranging in age from 50 to 86 years, were examined with an ACMI | single- or d o u b l e - c h a n n e l fiberoptic colonoscope d u r i n g celiotomy. T h e technique has been described by others. 1-a Preparation for the procedure includes mechanical bowel cleansing, positioning the patient on the operating table with legs elevated and knees flexed, the tip of the colonoscope being gently inserted into the rectum and the instrument secured to the operating table. This positioning allows adequate room for subsequent manipulation of the colonoscope. After celiotomy and abdominal exploration, the terminal ileum is occluded with a non-crushing rubber-shod clamp to prevent distention of the small intestine during air insufflation and manipulation of the instrument. With the direct aid and guidance of the surgeon, the colonoscopist advances the instrument to the cecum. The existence of lesions seen on barium-enema examination is verified and the locations of small sessile lesions not palpable through the intestinal wall are ascertained. When active hemorrhage is present, the endoscope is advanced rapidly to the cecum and, on withdrawal, with suctioning and irrigation, the region or site of bleeding and/or presence of other lesions is identified to help delimit the * Received for publication December 27, 1978. Address reprint requests to Dr. Forde: Departmentof Surgery, College of Physicians and Surgeons, 630 West 168 Street, New York, New York 10032.

FIG. 1. Barium-enemastudy, transverse colonic lesion (confirmed by preoperative colonoscopy).The lesion was not palpable at celiotomy.

0012-3706/79/0500/0234 $00.70 9 American Society"of Colon and Rectal Surgeons 234

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TABLE 1. Intraoperative Colonoscopic Examinations That Resulted in Increasing the Limits of Resection Preoperative Barium-enema or Colonoscopic Findings

Intraoperative Colonoscopic Findings

Patient 1

Barium enema studies and colonoscopy: carcinoma of cecum, polyps of ascending and transverse colon

Non-palpable left transverse colonic polyp visualized

Extended ileocolectomy

Patient 2

Barium-enema studies:sigmoidal polyps Colonoscopy: many sessile polyps to 60 cm; adhesions prevented further examination

Diffuse polyposis established

Subtotal colectomy

Patient 3

Status after ileocolectomy for carcinoma Barium-enema studies: numerous lesions of descending and sigmoid colon

Numerous polypoid lesions throughout colon

Subtotal colectomy

Patient 4

Cecal carcinoma, many previous sigmoidoscopic polypectomies

Additional adenomatous polyps with atypia a few cm distal to contemplated line of resection

Extended ileocolectomy

Patient 5

Had previous polypectomies via colonoscope; failed to achieve complete colonoscopic examination because of adhesions. Barium-enema studies suggested a polyp of the hepatic flexure

11 polyps from ileum to sigmoid, clear rectosigmoid; Non-palpable through bowel wall

Extended colectomy, ileum to sigmoid

Operative Procedure

Results Intraoperative colonoscopy was possible and helpful in 27 of 29 cases, modifying the initial plans for operation. O n e failure o c c u r r e d in the case o f a patient whose adhesions were so dense and extensive as to r e n d e r

Fro. 3.

FIG. 2. Intraoperative colonoscopic appearance, showing villous adenoma.

Gross specimen, showing villous adenoma.

even intraoperative colonoscopy impossible. She had a submucosal lipoma o f the cecum, which was excised via colotomy. T h e o t h e r failure occurred, early in o u r e x p e r i e n c e in the case o f a patient who h a d massive h e m o r r h a g e . In this case even a previously colonoscopically biopsy-proven 1.5 cm carcinoma o f the splenic flexure could not be visualized. Eleven patients were e x a m i n e d by c o l o n o s c o p y intraoperatively to visualize lesions seen on bariume n e m a e x a m i n a t i o n or to locate small lesions not palpable t h r o u g h the intestinal wall, as well as to det e r m i n e w h e t h e r e x t e n d e d resection, local wedge resection, or colotomy and p o l y p e c t o m y would be indicated.

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TABLE 2. lntraoperative Colonoscopy to Rule Out Other Lesions Prior to Colonic Resection

Preoperative Diagnosis

Intraoperative Colonoscopic Findings

Operative Procedure

Patient 6

Lower gastrointestinal bleeding; Angiography showed numerous Arteriovenous malformations, distal ileum and cecum

Negative for other lesions

Ileocolectomy

Patient 7

Lower gastrointestinal bleeding; Angiography showed arteriovenous malformations of mid-ileum

Negative to transverse colon

Ileal resection

Example 1: A 64-year-old man had a preoperative bariumenema examination that demonstrated a polypoid cecal mass. The surgeon decided on exploration, but requested intraoperative colonoscopy, which disclosed a smooth-surfaced submucosal lesion. The mass was excised without intestinal resection, and pathologic examination showed that it was a subnmcosal lipoma. This patient was spared ileocolectomy. Example 2: A 68-year-old woman, on barium-enema examination had a 1.5 cm polyp in the descending colon. Preoperative colonoscopic examination disclosed and proved by biopsy an unsuspected 2-cm mid-sigmoidal carcinoma. The lesion could not be palpated at celiotomy, and the colonoscope was used to locate it accurately, to insure adequate margins of resection. In addition, a 1.5 cm adenomatous polyp of the descending colon was removed colonoscopically prior to sigmoidal resection. Example 3" A 79-year-old woman with barium-enema findings of a transverse colonic polyp (Figs. 1-3) had had an unsuccessful colonoscopic examination preoperatively, presumably because of postoperative adhesions. At exploration, the presence of dense adhesions was confirmed and the lesion could not be palpated. It was localized with intraoperative colonoscopy and appeared to be a benign villous adenoma. A limited (wedge) resection was done and the patient was spared a more extensive procedure for benign disease.

Example 4: A 62-year-old man had a normal barium-enema examination, but colonoscopy disclosed 1.5-by-l.5-cm ulcerating exophytic lesion in the distal descending colon, which biopsy showed was a carcinoma. Intraoperative colonoscopy was used to locate the lesion for the surgeon. The patient underwent sigmoidal resection and another (sigmoidal) polyp was removed colonoscopically.

I n f i v e c a s e s ( T a b l e 1) t h e c o l o n o s c o p i c f i n d i n g s resulted in increasing the amounts of colon resected.

A n i n t e r e s t i n g g r o u p o f f o u r p a t i e n t s ( T a b l e 4) underwent intraoperative colonoscopy for lesions

T w o p a t i e n t s ( T a b l e 2) u n d e r w e n t i n t r a o p e r a t i v e c o l o n o s c o p y to r u l e o u t t h e p r e s e n c e o f o t h e r l e s i o n s p r i o r to r e s e c t i o n . B o t h p a t i e n t s h a d h a d l o w e r gastrointestinal bleeding, and angiographic examinations had revealed arteriovenous malformations of the cecal area. In both cases intraoperative colonoscopic examinations did not show any other source of b l e e d i n g , a n d i l e o c o l e c t o m y was p e r f o r m e d . I n six c a s e s ( T a b l e 3) i n t r a o p e r a t i v e c o l o n o s c o p y w a s d o n e to l o c a t e l e s i o n s n o t s e e n o n p r e o p e r a t i v e barium-enema examination, but diagnosed on preoperative colonoscopy.

TABLE 3. Intraoperative Colonoscopy to Locate Lesions Discovered Preoperatively by Use of Colonoscopy but Not Seen on Barium-enema Studies

Preoperative Barium-,enema Preoperative Colonoscopic Diagnosis Diagnosis

Intraoperative Colonoscopic Findings

Negative

Ulcerated, exophytic

Another 1-cm polyp at 12 cm

Patient 9 Patient 10 Patient 11

Possible sigmoidal polyp Megacolon only Descending colonic polyp

Location of non-palpable lesion Location of non-palpable lesion Location of non-palpable lesion

Patient 12

Sigmoidal polyps

Diffuse polyposis established

Subtotal colectomy

Patient 13

Polyp in hepatic flexure

Polypoid carcinoma Carcinoma Unsuspected sigmoidal carcinoma Numerous sessile polyps to 60 cm; adhesions prevented further examination Previous colonoscopic removal of five sigmoidal polyps; failure of full evaluation because of adhesions

Sigmoidal resection: Colonoscopic polypectomy Sigmoidal resection Subtotal colectomy Sigmoidal resection

Polyps from cecal area to sigmoid

Subtotal colectomy

Patient

8

Operative Procedure

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TABLE 4. Intra@erative Colonoscopyfor Lesions Seen on Barium-enema Studies,

after Failure of Preoperative Colonoscopy (? Because of Adhesions)

Barium-enema Findings Patient 14

Proximal sigmoidal lesion

Patient 15

Transverse colonic polyp; previous left colectomy Sessile transverse colonic polyp Transverse colonic lesion

Patient 16 Patient 17

Intraoperative Colonoscopic Findings

Operative Procedure

Diverticular disease of sigmoid Negative

Left hemicolectomy (diverticulosis only) No resection* or colotomy

Negative

Lysis ot adhesions; no resection Resection colon to mid-ascending colon; large abscess and 2 En terocolonic--colonic fistulas

Inflammatory disease of left colon

* Follow-up barium-enema study and colonoscopic examination negative.

seen on barium-enema examination, but preoperative colonoscopy had not been possible, presumably because of adhesions from previous operations. Example 5: A 65-year-old woman had undergone previous partial colectomy for carcinoma and was scheduled for repair of a large ventral hernia. Preoperative barium-enema examination showed a possible transverse colonic polyp. Intraoperative colonoscopy disclosed no abnormality, and she underwent repair of her ventral hernia as an uncontaminated procedure by avoiding a colotomy. Follow-up barium-enema studies showed no abnormality. Discussion

Colonoscopic evaluation of lesions and therapeutic colonoscopy for polypectomy and biopsy have become commonplace and beneficial. With adequate skill and care the instrument can also be used with ease and efficiency in solving many problems during abdominal operations for colonic disease. The colonoscope may be used as a complimentary diagnostic aid with the barium-enema study or angiogram in localizing sites of hemorrhage. The limits of resection

may be extended or restricted by what the endoscopist observes. Lesions not palpable through the intestinal wall can be localized and margins of resection decided upon. Conclusion

Colonoscopy performed in the operating room at celiotomy, but prior to colotomy, is of definite value in the intraoperative assessment of colonic disease, especially with reference to the need for and extent of resection. By avoiding colotomies, contamination of the peritoneal cavity and wound can be obviated, with concomitant diminished morbidity. References i. Eisenberg HW: Fiberoptic colonoscopy: Intraoperative colonoscopy (syrup). Dis Colon Rectum 19: 405, 1976. 2. Marcozzi G, Montori A: Endoscopy during operation: New diagnostic possibilities. Chit Gastroenterol 6: 23, 1972 3. Richter RM, Littman L, Levowitz BS: Intraoperative fiberoptic colonoscopy: Localization of nonpalpable colonic lesions. Arch Surg 106: 228, 1973

Intraoperative colonoscopy: preliminary report.

Intraoperative Colonoscopy" Preliminary Report* PAT J. MARTIN, M.D., KENNETH A. FORDE, M.D. From the Department of Surgery, College of Physicians and...
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