Intraoperative Colonoscopy Research Articles

Telerobotic-assisted Laparoscopic Right Hemicolectomy

We previously reported that telerobotic-assisted laparoscopic colectomy was feasible and could be accomplished safely. Nonetheless, we found that the current iteration of da Vinci was not well suited to a lateral to medial (LtM) dissection of the colonic mesentery. The motion scaling made the large excursion arcs required for adequate exposure in a LtM dissection cumbersome to achieve. As a result, the aim of this study was to compare the ability of the da Vinci telerobotic surgical system to perform telerobotic-assisted laparoscopic right hemicolectomy using a LtM dissection with a medial to lateral (MtL) dissection technique. We compared 8 consecutive da Vinci-assisted laparoscopic right hemicolectomies performed using a LtM dissection to 8 consecutive operations using a MtL dissection technique. Results were compared using analysis of variance. Age for the 2 groups were not significantly different: LtM 64 (43 to 71) years and MtL 56 (39 to 68) years. Body mass index was similar: LtM 27 (22 to 34) and MtL 25 (20 to 32) kg/m. Total surgical time (including cystoscopy and intraoperative colonoscopy) were similar: LtM 212 (188 to 610) minutes and MtL 203 (135 to 220) minutes. There was no significant difference in lymph node harvest: LtM 12 (3 to 20) lymph nodes and MtL 18 (3 to 35) lymph nodes. There were no deaths or anastomotic leaks in either groups. Median length of stay was similar for both groups: LtM 5 (3 to 10) days and MtL 4 (2 to 9) days. da Vinci-assisted laparoscopic right hemicolectomy using a MtL dissection technique achieves similar outcomes as a LtM dissection approach.

Acute diverticulitis after Duhamel–Martin procedure for total colonic Hirschsprung’s disease

A 28-year-old man with a history of total colonic Hirschsprung's disease treated with a Duhamel-Martin procedure in infancy, presented with signs and symptoms of acute colonic diverticulitis. Flexible sigmoidoscopy demonstrated a 20 cm jejunocolonic anastomosis, consistent with his previous operation in childhood, with a large diverticulum at the proximal end of the anastomosis containing fecal concretions. The patient returned one month later after a course of antibiotics for definitive resection of the diverticulum. Intra-operative colonoscopy localized three large diverticula and resection of the involved segment was performed. The case is presented as an adult complication of total colonic Hirschsprung's disease treated with childhood resection and reconstruction.

Colonoscopic-Assisted Laparoscopic Resection of a Colon Lipoma

We report the case of a 51-year-old man who had abdominal distension and intermittent cramping pain for 4 months. A lower gastrointestinal double-contrast study revealed a protruding mass at the transverse colon. Endoscopic ultrasonography showed a lesion arising from the submucosal layer. Instead of a laparotomy, the lesion was removed laparoscopically with the assistance of a colonoscope. No operative morbidity was noted. With future improvements of this technique, tumors that are difficult to remove with colonoscopy can be excised laparoscopically without the aid of an endoscopic stapler. In our case, the tumor was localized intraoperatively and extracted using the intraoperative colonoscopy. This double-scope technique is safe and cost-effective for some difficult colonic lesions.

Intraoperative colonoscopy in patients with colorectal cancer.

Sixty-seven patients underwent intraoperative colonoscopy during elective surgery for colorectal cancer. Complete examination of the colon was achieved in 65 patients (97 per cent), albeit with insertion through a colotomy in three (4 per cent). A synchronous carcinoma was found in six patients (9 per cent), which necessitated a change of planned surgical procedure. Synchronous polyps were detected and removed in 24 patients (36 per cent); two had polyps with carcinoma in situ. The mean age of patients with synchronous carcinoma was significantly higher than that of those without (74.1 versus 61.2 years, P = 0.02). Intraoperative colonoscopy took a mean of 15 min surgical time and only two minor complications (serosal lacerations) were encountered. In patients with colorectal cancer, intraoperative colonoscopy allows complete assessment of the colon and identifies synchronous lesions.

Management of major colonic haemorrhage.

Major colonic haemorrhage remains a difficult diagnostic and therapeutic problem. We propose that those patients who continue to bleed after resuscitation are best served by immediate laparotomy. High flow antegrade irrigation and intra-operative colonoscopy can then be used to localize the site of bleeding and allow appropriate excisional surgery rather than blind colonic resection.

Laparoscopic colectomy without mechanical bowel preparation

Mechanical bowel preparation prior to colorectal surgery may reduce infectious complications, facilitate tumor localization, and allow intraoperative colonoscopy, if required. However, recent data suggest that mechanical bowel preparation may not facilitate a reduction in infectious complications. During laparoscopic colectomy, manual palpation is blunt, thereby potentially compromising tumor localization. The aim of this study was to assess the utility of mechanical bowel preparation in laparoscopic colectomy. A retrospective medical record review of all patients who underwent laparoscopic colectomy was performed. Patients were divided into two groups: those who had preoperative mechanical bowel preparation (Group A) or those who did not (Group B). All relevant perioperative data were reviewed and compared. Two hundred patients underwent laparoscopic colectomy; 68 (34%) were in Group A and 132 (66%) were in Group B. Sixteen (8%) patients required intraoperative colonoscopy for localization and were evenly distributed between the two groups. The incidence of conversion to laparotomy was slightly higher in Group B (14 vs 9%) due to difficult localization in some cases; however, this difference did not reach statistical significance. Furthermore, there was no significant difference in the postoperative complication rate between the two groups. Specifically, an anastomotic leak and a wound infection were recorded in 4 and 12% of patients in Group A compared to 3 and 17% in Group B, respectively. Laparoscopic colectomy may be safely performed without preoperative mechanical bowel preparation, although difficult localization may lead to a slightly higher conversion rate. Appropriate patient selection for laparoscopic colectomy without mechanical bowel preparation is essential. Furthermore, bowel preparation should be considered in cases of small and nonpalpable lesions.

Laparoscopic Resection of Duplicated Sigmoid Colon Under the Guidance of Intraoperative Colonoscopy

Colonic duplications are rare congenital malformations. Complete surgical removal is the treatment of choice. The authors report a case of sigmoid colonic duplication successfully treated by laparoscopic resection under the guidance of intraoperative colonoscopy.

Primary Amyloidosis Presenting as Recurrent Ischemic Colitis

Ischemic colitis has a myriad of causes. Primary amyloidosis is a rare cause of ischemic colitis with only a few case reports in the literature. We present an unusual case of ischemic colitis due to primary amyloidosis. A 69 year old woman, with history of activated protein C resistance and lower extremity deep vein thrombosis on chronic warfarin treatment, presented with 1-day history of bloody diarrhea and crampy abdominal pain. Three weeks before, she was hospitalized with similar symptoms at another medical facility and diagnosed with ischemic colitis by colonoscopy. After a week of bowel rest, total parental nutrition, and intravenous antibiotics, her symptoms had resolved. She remained asymptomatic until the night prior to her current admission. She was afebrile with a blood pressure of 108/66 mm Hg and a pulse of 109 beats per minute. Physical examination was significant for mild tenderness to palpation in the lower abdomen, without peritoneal signs. Laboratory evaluation revealed normal white blood cell count, hemoglobin of 11.9 g/dL, and an International Normalized Ratio of 5. Abdominal computed tomography showed nonspecific thickening of the colonic mucosa from the splenic flexure to the descending colon. Sigmoidoscopy revealed multiple large ulcers with areas of mucosal necrosis in the proximal sigmoid colon. Biopsies showed focal ulceration with necroinflammatory exudate. Mesenteric angiogram was unremarkable. On hospital day 7, she underwent a total colectomy with end ileostomy after ischemic changes were observed from mid transverse colon to rectosigmoid junction on intraoperative colonoscopy. Histology revealed extensive amyloidosis involving the omentum and entire colon with deposition in the muscularis mucosa, submucosa, and subserosa. Perivascular deposition of amyloid with luminal narrowing was also present. Serum electrophoresis and immunofixation revealed an IgG lambda monoclonal band, while a bone marrow biopsy showed 5–10% lambda restricted plasma cells. Our case illustrates that primary amyloidosis presenting as recurrent ischemic colitis may be missed despite thorough history, laboratory evaluation, radiographic studies and endoscopic biopsies.

Intraoperative carbon dioxide colonoscopy: a safe insufflation alternative for locating colonic lesions during laparoscopic surgery

Intraoperative colonoscopy (IOC) is useful for locating colonic pathologies during laparoscopy, but bowel distention compromises the subsequent visualization and procedure. Carbon dioxide (CO2), with its rapid absorption, has been proved effective for alleviating bowel distention in ambulatory settings. Its intraoperative role, however, has never been studied. This study aimed to assess the feasibility, safety, and advantages of CO2-insufflated IOC during laparoscopy. For this study, CO2-insufflated IOC was performed for 20 patients under CO2 pneumoperitoneum. Parameters, including end-tidal CO2 (ETCO2) and minute volume, were prospectively registered. Time until resolution of bowel distention was determined by laparoscopic evaluation. All lesions were located by CO2-insufflated IOC in 15 min. During IOC, ETCO2 increased, but remained within normal values, and was quickly compensated with minimal hyperventilation. Bowel distention totally disappeared in 21 min, allowing immediate initiation of laparoscopic procedures under adequate visualization. The findings show that CO2-insufflated IOC during laparoscopy is feasible, safe, and of practical value for minimizing bowel distention without impeding the subsequent visualization and procedure.

Single-stage procedure with intraoperative colonoscopy and colonic irrigation in patients with obstructing left-sided colonic cancer

Recently there has been growing acceptance of the one-stage resection and primary anastomosis with intraoperative antegrade irrigation. This study evaluated the efficacy of a newly developed device for performing a single-stage procedure in patients with obstructing left-sided colon cancer. A series of 151 consecutive patients with obstructing left-sided colonic cancer underwent on-table irrigation, resection, and primary anastomosis with the use of a newly developed device; 75 patients on-table colonoscopy. The study spanned a 3 years from September 1999 to August 2002. The observed variables were the volume of irrigated saline, time for irrigation and colonoscopic examination, synchronous pathology, operative mortality and morbidity, time to passage of flatus, restarting day of oral intake, and length of hospital stay. The mean volume of irrigated saline was a mean of 12.5 l (range 1-32) over a mean of 14.2 min (range 1-45). Subsequent colonoscopic examination added a mean of 10.7 min (range 3-15). The incidence of synchronous polyps was 47% (35 of 75 cases) in performing the on-table colonoscopic investigations. On-table colonoscopy induced surgeons to extend resection because of synchronous malignancy attested by frozen biopsy specimen in ten patients and because of mucosal necrosis of the proximal colon in three. There were two anastomotic leakages, six wound infections, and one operative mortality. The time to passage of flatus was an average of 3.6 days (range 1.0-7). The time to oral intake was an average of 4.3 days (range 3-8). The length of hospital stay was 11.7 days (range 6-43). These findings suggest that our device is an effective tool to facilitate acceptance of the one-stage procedure in patients with obstructing left-sided colonic cancer. Specifically, our device enables quick and easy on-table colonoscopy.

The Role of Intraoperative Colonoscopy in Patients with Left Side Colon Cancer Obstruction

Background/Aims: The aim of this study was to evaluate the role of an intraoperative colonoscopy for a single stage operation in patients with a left side colon cancer obstruction. Methods: From September 1999 to August 2002, 62 patients underwent an intraoperative colonoscopy during a single stage operation for a left side colon cancer obstruction. The intraoperative colonic irrigation method and colonoscopy with NICI (New intraoperative colonic irrigator; MITech co., Ltd, Seoul, Korea) was used for the single stage operation. Results: An intraoperative colonoscopy was performed in sixty-two patients (30 men and 32 women) with a mean age of 61.3 years. The location of the left side colon cancer were the rectum in 33 (53.2%) cases, the sigmoid colon in 20 (32.3%) cases and the descending colon in 9 (14.5%) cases. Synchronous polyps were found in 31 (50%) out of the 62 patients. Six (9.7%) patients had a synchronous colon cancer and two (3.2%) patients had a high grade dysplasia. Of these 62 patients, 11 (17.7%) patients required more extensive surgery than dictated by the primary cancer. The operation changes were a total colectomy in 2 cases, an extended resection in 8 cases and a wedge resection in 1 case. Conclusions: An intraoperative colonoscopy in patients with a left side colon cancer obstruction is a useful adjunct to the method of diagnosing a synchronous colonic lesion and its findings may allow a more appropriate surgical procedure.

New Techniques in Colonoscopy

Colonoscopy is the best method for diagnosing neoplastic processes affecting the colon and is frequently the modality by which definitive treatment of these diseases is provided. Surgery has been the mainstay of treatment of colonic obstruction. In the past 15 years, laser, balloon, and stenting technology has provided alternatives to surgery in colonic obstruction from malignant or benign causes. Colonic stents safely treat colonic obstruction either as a bridge to surgery or as palliation. The most common complications are perforation, stent migration, and stent reocclusion. The neodymium:yttrium-aluminum-garnet (Nd:YAG) is the most widely used laser for treating colorectal disease. Its use is described in treating colonic obstruction, bleeding, and staged destruction of villous adenomas. Balloon dilatation has been used to treat benign strictures. Perforation and the need for repeated treatment are the most common complications from its use. A combined approach with laser or balloon dilatation and stenting has also been successfully used. Preoperative marking of small colonic neoplasms aids in localization of the tumor, especially in laparoscopic procedures. Tattooing and metallic clips are the most common methods for marking, are more accurate than preoperative colonoscopic localization, and are less time consuming than intraoperative colonoscopy.

Laparoscopic "radical appendectomy" is an effective alternative to endoscopic removal of cecal polyps.

The endoscopic removal of cecal polyps can be complicated by hemorrhage, perforation, or incomplete resection. Laparoscopic radical appendectomy represents a safe alternative for the definitive resection and accurate pathologic evaluation of selected cecal polyps. Patients with cecal cap polyps not involving the ileocecal valve were candidates for laparoscopic radical appendectomy. Intraoperative colonoscopy and resection of the appendix and cecum to the level of the ileocecal valve were accomplished via three midline ports. For each patient, histologic evaluation by frozen section ruled out malignancy and ensured complete resection. Five patients, four of whom had significant medical comorbidities, presented with large adenomatous polyps contained within the cecum. Each polyp was determined to be unresectable endoscopically; therefore, a laparoscopic radical appendectomy was performed. One patient with cirrhosis also underwent intraoperative liver ultrasonography and biopsies, which contributed to the longest operative time and hospital stay. The histologic diagnosis by frozen section was benign for each patient. The mean operative time was 95 minutes, and the mean length of hospital stay was 1.8 days. No postoperative complications were observed during a mean follow-up of 6 months. Laparoscopic "radical appendectomy" is an effective treatment for selected cecal adenomatous polyps. Our ability to resect the polyps completely and avoid a standard right hemicolectomy supports this approach.

広範な腸管壊死を来した虚血性腸炎の３例

We saved 3 patients from gangrenous ischemic enteritis. Patient 1; a 57-year-old woman in shock 24 hours after her first admission was found in an emergency laparotomy to have intestinal necrosis from the ileum to the descending colon, necessitating subtotal ileocolectomy. Three days later, intraoperative endoscopy in a second-look operation showed that the necrotic area extended to the small intestine, and a resection of the necrotic intestine and a ileosigmoidstomy were done. Patient 2; a 78-year-old man found with necrosis of the rectal mucosa during colonoscopy, underwent emergency laparotomy showing transmural necrosis from the descending colon to the upper rectum. The necrotic colon was resected and a tube colostomy was established in the cecum. Five days later, intraoperative endoscopy showed partial mucosal necrosis of the ileum end, and a stoma was formed in the cecum preserving the Bauhin valve. Patient 3; a 72-year-old woman who developed shock and diagnosed with gangrenous ischemic colitis based on computed tomography had serosa of the entire colon normal in color, but mucosal necrosis of the colon was identified by intraoperative colonoscopy. The necrotic colon was resected and a stoma formed in the ascending colon. All 3 patients survived with a fair quality of life, including diarrhea control. Total resection of an intestine with mucosal necrosis is for short-term life but may ruin the quality of life due to short bowel syndrome. Necrosis of the intestine may progress after the first operation. Careful therapic strategy including secondlook operation is required for patients with gangrenous ischemic enteritis. Intraoperative endoscopy is helpful for evaluating the resection.

Targeted laparoscopic abdominal adhesiolysis.

Postoperative abdominal pathogenic bands may produce intermittent subocclusive intestinal crises or chronic abdominal pain. Laparotomy has been widely used to define the diagnosis and perform adhesiolysis, but recurrences of the bands are frequent. Laparoscopy may reduce their incidence; nevertheless, 10-25% of cases recur with this procedure as well. Instead of using widespread adhesiolysis to treat this condition, a successful outcome may be achieved by removing only the pathogenic bands. It is thus essential to identify them. In order to do so, we performed a combined laparoscopic-endoscopic procedure. Following an abdominal focused radiological and endoscopic workup, two patients with intermittent abdominal pain from colonic subocclusion underwent laparoscopic adhesiolysis. This procedure was guided by intraoperative colonoscopy. During laparoscopic exploration of the abdominal cavity, intraoperative colonoscopy revealed the site of the obstacle whichcorresponded precisely to the position of the colonoscopic intraluminal. Thus, we identified the location of the transit obstacle and selected the bands to be removed. We then performed a targeted adhesiolysis. There were no postoperative complications. Symptom-free abdominal function was achieved in both cases 3 days after the operation. Both patients are symptom-free 1 year after treatment. Our preliminary experience indicates that this combined procedure, if properly performed (i.e., with a minimal amount of air inflation), is helpful in performing correct laparoscopic adhesiolysis.

How to prevent port-site metastases in laparoscopic colorectal surgery.

Various reports concerning port-site metastasis after laparoscopic surgery for colorectal cancer have created a new concern regarding the use of this technique for the treatment of this malignancy. The real incidence is not yet known; neither are its prognostic implications. Numerous experimental studies, both in vitro and in vivo, have been published since 1994. These studies have analyzed the possible role of pneumoperitoneum and carbon dioxide (CO(2)) and pathophysiology, as well as the influence of minimally invasive techniques on tumor response and immunity. There are no definitive results yet, but there is enough evidence to presume that the etiology of this new complication might derive from surgical technique. We present our 8-year experience with laparoscopic surgery for colorectal cancer. We also review our technique for preventing port-site implants. At this writing, we have had no port metastasis in our series of 320 colorectal cancer cases with a mean follow-up period of 54 months. The steps we follow as a routine in all cases of laparoscopic colorectal cancer are (a) fixation of trocars to the abdominal wall, (b) avoidance of touching the tumor, (c) high vascular ligation, (d) intraoperative colonoscopy and intraluminal irrigation with 5% iodine povidone, (e) specimen isolation before extraction from the abdominal cavity, and (f) intraperitoneal and trocar-site irrigation with a tumoricide solution.

Ultrasound of colonic neoplasia. An intraoperative tool?

The accuracy of intraoperative ultrasound of the colon in the location and assessment of neoplastic lesions at the time of resection has not been reported. An in vitro study was performed, with ultrasound imaging of colonic specimens resected for malignancy. The specimens were imaged empty, surrounded by saline, the lumen filled with saline. Excellent ultrasound images were produced, particularly when the colonic lumen was filled with saline. All lesions were located by this technique, and several impalpable synchronous polyps also were found. In two specimens, the remnants of a malignant polyp not visible with intraoperative colonoscopy were found by specimen ultrasound. The clarity of the image was such that the cancer stage often could be assessed. Direct ultrasound of the colon, using a high-frequency intraoperative probe, produced accurate images of neoplastic lesions in an in vitro setting. This technique may have a role in the intraoperative location and assessment of colorectal cancer.

Life-threatening gastrointestinal hemorrhage due to juvenile polyposis

A 14-yr-old, previously healthy boy presented with massive lower GI hemorrhage. After the routine endoscopic and radiological evaluation, laparotomy and intraoperative colonoscopy revealed multiple polyps in the colon. A hemicolectomy was performed because of the severity of hemorrhage. A diagnosis of juvenile polyposis was made based upon histological findings and the family history. This is an extremely unusual presentation of juvenile polyposis and has been reported only once before. The clinical features, diagnosis, and therapeutic options for juvenile polyposis are discussed. Juvenile polyposis, although a rare condition in the pediatric population, should be considered in the differential diagnosis of life-threatening GI hemorrhage.

Colonoscopic Polypectomy

Colonoscopic polypectomy is a major advance in the therapy of colon neoplasms. The techniques for safe and efficient polyp removal are described. The uses of a variety of ancillary devices are discussed, including clips, loops, submucosal injection of fluid, and several thermal probes, including the argon plasma coagulator. The location of a lesion may be difficult to ascertain by intracolonic landmarks, but can be more precisely determined by X-ray, magnetic imaging, or intraoperative colonoscopy. Alternatively, it is possible to permanently mark the site of polyp removal with a carbon particle submucosal injection to facilitate subsequent localization either by surgery or interval colonoscopy.

A CASE OF SYNCHRONOUS FOUR COLORECTAL CANCER WITH INTUSSUSCEPTION

An 81-year-old man was seen at the hospital because of abdominal distention and severe constipation. An elastic hard tumor was palpable by the digital examination and it was downward with an increase in abdominal muscular pressure. Barium enema showed an intussusception of the sigmoid colon and made it release successfully. Total colonoscopy showed two tumors (Ip, Is) in the rectum, two (type 2, Ip) in the sigmoid colon, one (Ip) in the descending colon, one (Is) in the transverse colon and two (Ip, Is) in the ascending colon. Three of them were diagnosed as adenocarcinoma in their biopsy specimen. We performed low anterior resections for them and local resection for the other tumors under colonoscopy during operation. Pathohistological examination revealed adenocarcinamas in four lesions, with different depth of invasion each other (m, sm. mp, and ss). Other lesions were tubular or tubulo-villous adenoma with cellular atypia ranging from moderate to prominent.It has recently been reported that the hereditary factor seems to be involved in the etiology of multiple colorectal cancer. It is important to interview the patient about their family history and several gene analysis would be required for the patient with risk factors. In the case of multiple colorectal cancers, it is sometimes difficult to decide the extent of colectomy; partial or total colectomy in the number of lesions. Intraoperative colonoscopy is convenient and supportive technique in determining more adequate partial colectomy in the patients with low number of lesions.