Therapeutic colonoscopy

Efficacy and safety of the band and slough technique for endoscopic therapy of nonampullary duodenal adenomas: a case series

BACKGROUND

Endoscopic resection of nonampullary duodenal adenomas (NADAs) is effective but carries substantial procedural risks. Therapeutic banding for treatment of duodenal mucosal neoplasia has not been studied. We report a novel band and slough (BAS) technique for therapy of NADA without endoscopic resection.

OBJECTIVE

Efficacy and safety of BAS.

DESIGN

Retrospective review of a prospective database.

SETTING

Community hospital.

PATIENTS

Patients with sporadic and familial biopsy-proven NADA without invasive cancer undergoing BAS.

INTERVENTION

Patients were treated with BAS without endoscopic resection on an outpatient basis. A follow-up telephone call was made by a nurse at 24 hours. Follow-up endoscopy was performed at 8 weeks, with further therapy of residual NADA. In patients with minimal residual NADA not amenable to banding, argon plasma coagulation (APC) "touch-up" was used. Subsequent endoscopic surveillance was performed.

MAIN OUTCOME MEASUREMENTS

Complete histologic remission of NADA after successful BAS and postprocedure bleeding, perforation, and pain.

RESULTS

Ten patients, average age 65 years, 6 male, with sporadic/familial adenomatous polyposis NADA 8 of 2 (6 tubular adenoma and 4 tubulovillous adenoma) were treated. Mean (largest) NADA was 12.5 mm (20 mm). Five patients achieved complete remission after a single session. Among 5 patients requiring further therapy, 3 were treated with repeat banding with or without APC and 2 with APC alone. The average number of bands per session was 4.4. Patients were followed up to 24 months without NADA recurrence. None of the patients had acute or delayed adverse events of bleeding, perforation, or postprocedure pain.

LIMITATIONS

Lack of polyp tissue retrieval.

CONCLUSION

BAS appears to be a safe and potentially effective endoscopic treatment for NADA. However, larger studies are needed to corroborate these findings.

Tension Pneumothorax, Pneumoperitoneum, and Cervical Emphysema following a Diagnostic Colonoscopy

Colonoscopy is currently a widespread procedure used in screening for colorectal cancer. Iatrogenic colonic perforation during colonoscopy is a serious and potentially life-threatening complication that can cause significant morbidity and mortality. “Triple pneumo” (a combination of pneumothorax, pneumomediastinum, and pneumoperitoneum) following colonoscopy is a rare but a serious condition requiring immediate diagnosis and emergent intervention. In majority of these cases a colonic perforation is the initial injury that is followed by pneumothorax and pneumomediastinum through the potential anatomical connection with retroperitoneal and mediastinal spaces. In this rare case report we are presenting a case of “triple pneumo” with no evidence of colonic perforation. This patient developed a simultaneous pneumoperitoneum, pneumomediastinum, and a tension pneumothorax requiring immediate tube thoracostomy. This case may raise the awareness on the likelihood of these serious complications after colonoscopy.

Efficacy, risk factors and complications of endoscopic polypectomy: Ten year experience at a single center

AIM: To examine the efficacy and complications of colonoscopic resection of colorectal polypoid lesions.

METHODS: We retrospectively reviewed 1354 polypectomies performed on 1038 patients over a ten-year period. One hundred and sixty of these were performed for large polyps, those measuring ≥ 20 mm. Size, shape, location, histology, the technique of polypectomy used, complications, drugs assumption and associated intestinal or extra intestinal diseases were analyzed. For statistical analysis, the Pearson χ² test, NPC test and a Binary Logistic Regression were used.

RESULTS: The mean patient age was 65.9 ± 12.4 years, with 671 men and 367 women. The mean size of polyps removed was 9.45 ± 9.56 mm while the size of large polyps was 31.5 ± 10.8 mm. There were 388 pedunculated and 966 sessile polyps and the most common location was the sigmoid colon (41.3%). The most frequent histology was tubular adenoma (55.9%) while for the large polyps was villous (92/160 -57.5%). Coexistent malignancy was observed in 28 polyps (2.1%) and of these, 20 were large polyps. There were 17 procedural bleeding (1.3%) and one perforation. The statistical analysis showed that cancer is correlated to polyp size (P < 0.0001); sessile shape (P < 0.0001) and bleeding are correlated to cardiac disease (P = 0.034), tubular adenoma (P = 0.016) and polyp size.

CONCLUSION: The endoscopic resection is a simple and safe procedure for removing colon rectal neoplastic lesions and should be considered the treatment of choice for large colorectal polyps. The polyp size is an important risk factor for malignancy and for bleeding.

Colonoscopic Perforation and Bleeding of the Colon Can be Treated Safely without Surgery

The incidence of colonoscopic perforation of colon is about 0.3 per cent. The incidence of colonoscopic bleeding is about 0.6 per cent. Many of those patients undergo unnecessary operations. In order to assess the outcome of nonoperative management of those patients with postcolonoscopic perforation and bleeding, the records of 5120 patients who underwent colonoscopies from September 1, 1988 to June 30, 2003 were retrospectively reviewed with attention paid to colonoscopic perforation and bleeding. Their symptoms, management, and outcome were reviewed. There were 2765 male and 2355 female patients. Ages ranged from 9 to 91 years. A total of 1902 patients (37.1%) had polyps removed. Six patients (0.1%) had colonoscopic perforation. All of them presented with abdominal pain 1 to 4 days after colonoscopic polypectomy. All had subphrenic free air or subcutaneous emphysema on the radiogram. All were treated nonoperatively with nothing by mouth and intravenous fluids and antibiotics in the hospital and recovered uneventfully. Six patients (0.1%) had colonic bleeding that occurred 1 to 14 days after colonoscopic polypectomy. All of them were managed by repeat colonoscopy with injection of epinephrine. All recovered without further bleeding. Therefore, postcolonoscopic perforation and bleeding can be treated nonoperatively. It is safe and cost effective. The mortality and morbidity are very low.

A prospective analysis of 13,580 colonoscopies. Reevaluation of credentialing guidelines

BACKGROUND

The aims of this study were to assess the safety and efficacy of surgeons performing colonoscopy, and to use the results to reevaluate currently available credentialing guidelines.

METHODS

A prospective outcomes study was designed to include all members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES). End points were related to the efficacy and safety of colonoscopy. Credentialing guidelines were reviewed.

RESULTS

Between April 1998 and September 1999 13,580 colonoscopies were prospectively entered into a database. The most common indications were rectal bleeding, colonic polyps, and change in bowel habits. The colonoscopy was normal or revealed only diverticulosis or nonspecific inflammation in 8,473 (62.4%), lower gastrointestinal bleeding in 4 (0.03%), polyps in 4,645 (34.2%), and tumors in 458 (3.4%) patients. The most common biopsy methods for polyps or tumors were the snare (n = 1,728; 34%), the hot (n = 1,600; 31%), and the cold (n = 1,340; 22%) procedures. The colonoscopy was complete in 12,495 cases (92%), requiring a mean procedure time of 22.7 min (range, 1-170 min). Intraprocedural complications included arrhythmia (n = 14; 0.1%), bradycardia (n = 115; 0.8%), hypotension (n = 171; 1.2%), and hypoxia (n = 806; 5.6%). Postprocedural complications were seen in 27 patients (0.2%). Bleeding (n = 10; 0.07%) was managed by observation alone (n = 9; 0.06%) and repeat colonoscopy with transfusion (n = 1; 0.01%). Perforation (n = 10; 0.07%) was treated successfully by observation with conservative management (n = 5; 0.05%) and surgery (n = 5; 0.05%); severe abdominal pain (n = 4; 0.03%) was managed by observation and conservative therapy; and bronchospasm (n = 2; 0.015%) was managed by observation and supportive care. One single mortality (0.007%) was that of a 70-year-old man with a massive lower gastrointestinal hemorrhage who had a cardiac arrest in the recovery room following colonoscopy. The complication rate was not significantly associated statistically with either the level of experience or the number of prior or annual colonoscopies. However, prior colonoscopic experience did have an impact on the completion rate (p < 0.001) and was inversely proportional to the time to completion (p < 0.001). Similarly, the number of annual colonoscopies affected the completion rate and was inversely correlated with the time to completion (p < 0.001).

CONCLUSIONS

This large prospective outcomes study showed that colonoscopy performed by surgeons can be rapidly and successfully done with acceptably low morbidity and mortality. There was no association between experience and complications. However, a minimum of 50 prior colonoscopies and 100 annual colonoscopies were associated with a significant improvement in the rate of completion. There was also a significant correlation between both prior and ongoing annual experience and the time required for the examination. No minimum number of cases can be mandated for credentialing to perform "safe" colonoscopies.