Clinical significance of diminutive polyps of the rectum and sigmoid colon.

A retrospective review of 637 consecutive colonoscopies with polypectomy in 526 patients was performed to determine the association of small polyps of the rectum and sigmoid colon with more proximal colonic neoplasms. All colonic polyps were proximal to the sigmoid colon in 117 procedures. Proximal neoplasms were found in 32 percent of patients with a single polyp in the rectum or sigmoid colon. The incidence increased to 83 percent for those with three or more polyps. The occurrence of proximal colonic neoplasms was not affected by the size or histologic type of the rectosigmoid polyps. These findings would suggest that total colonic evaluation be considered in all patients with a polyp in the rectum or sigmoid colon regardless of the size or histologic type of the polyp.

Protein C activity, stage of disease, and vascular thrombosis in colon carcinoma.

To determine the etiology of the increased incidence of postoperative deep venous thrombosis (DVT) in patients with carcinoma of the colon, serum levels of protein C were measured preoperatively in 65 patients with colorectal adenocarcinoma. Noninvasive lower-extremity Doppler studies were performed on all patients prior to discharge to assess patency of the deep veins. Six patients (9%) were found to have DVT. The protein C level was considered elevated if it was greater than 125% of control values and reduced if less than 75% of control values. The development of DVT was found to be independent of the serum carcinoembryonic antigen, albumin, total protein, hemoglobin, hematocrit, platelet count, prothrombin time, partial thromboplastin time, and the patient's age and percentage of ideal body weight. There was an inverse relationship between the protein C level (p less than 0.001), Dukes stage of the tumor (p less than 0.001), and the development of DVT. Linear regression analysis revealed that only the tumor stage and the protein C level could be used to predict the development of DVT. The data show that for these patients with colorectal malignancy, the development of DVT may be related to decreased levels of protein C.

Small bowel obstruction after colon resection for benign and malignant diseases.

To determine the etiology and outcome of patients with small bowel obstruction after a colon resection for benign and malignant diseases, the medical records of 118 patients who underwent 120 laparotomies for small bowel obstruction were reviewed. Contrary to previous reports, benign adhesions were responsible for the obstruction in all patients with a history of benign colon disease, 82.6 percent of patients with a history of adenocarcinoma of the colon without known recurrence, and 30.1 percent of patients with known recurrent malignancy. The morbidity and mortality was more related to the etiology of the obstruction rather than the preoperative delay or operative procedure performed. Considering the high likelihood of adhesive obstruction in patients with a history of, or known, metastatic colorectal carcinoma, it is suggested that these not deter surgeons from aggressive early surgical intervention in these patients who develop small bowel obstruction.

Reliability of colonoscopy.

In an effort to determine the reliability of colonoscopy the authors retrospectively reviewed preoperative colonoscopic findings and compared them with the postoperative pathologic specimen reports. Only lesions greater than 0.5 cm were included in the comparison. Over a 13-year period, 429 patients with colorectal cancer underwent preoperative colonoscopy. Four hundred thirteen (97 percent) of the colonoscopic examinations correlated with the pathologic specimen, but, in 16 cases (3 percent), lesions were missed. In total, 17 adenomatous polyps and 3 cancers were found in the surgical specimens that were not documented at colonoscopy. Eighteen patients had total preoperative colonoscopy and total abdominal colectomy, which makes for a reliable model to judge the accuracy of colonoscopy. In these 18 patients, 17 of the pathologic specimens correlated with the endoscopic findings, which yields an accuracy rate of 94 percent. Blind areas in the colon, plus misjudgment that the scope had reached the cecum, are responsible for the majority of colonoscopic errors.

Guidelines for use of the flexible fiberoptic sigmoidoscope in the management of the surgical patient.

Based on data from many clinical studies and programs, guidelines are presented for application of the flexible fiberoptic sigmoidoscope in the management of the surgical patient. The flexible fiberoptic sigmoidoscope has proved to be an instrument of extraordinary capability in detecting colorectal neoplasms with yields being two or three times greater than those of the rigid sigmoidoscope in the symptom-resolution, polyp and cancer surveillance patient categories. In addition, the practical advantages of the narrow diameter, flexibility, and length of the fiberoptic sigmoidoscope are readily appreciated when the surgeon finds that he can satisfactorily examine patients with rectal or sigmoid strictures, marked angulations, or contracted lumens in whom a rigid scope would be unsuitable. Data from the authors' comparative study of more than 3000 patients have permitted the development of not only guidelines for the application of the flexible fiberoptic sigmoidoscope but an appreciation of the modified role of the rigid sigmoidoscope and the proper relationship between the flexible fiberoptic sigmoidoscope and the flexible fiberoptic colonoscope. A most important consideration is based on data regarding the site distribution of 400 benign premalignant neoplasms detected in the comparative study. The even distribution of these lesions throughout the terminal 50 cm of colorectum underscores the need to examine as much of the colorectum as possible.

Electrical ileal perforation: an unusual complication of colonoscopy.

A case of electrical burn perforation of the ileum is described, occurring after colonoscopic snare polypectomy from the left colon. An adequate explanation of the cause of this complication has yet to be determined.

Sigmoidoscopic examinations with rigid and flexible fiberoptic sigmoidoscopes in the surgeon's office: a comparative prospective study of effectiveness in 1,012 cases.

The results obtained from 1,012 examinations in an on-going, cooperative study indicate that the overall yield provided by use of the flexible fiberoptic sigmoidoscope is 3.2 times greater than that of examinations with the rigid sigmoidoscope. More than twice (2.4 times) the number of polyps and more than three times the number of cancers were detected with the flexible fiberoptic sigmoidoscope. Experienced endoscopists can perform an examination with the flexible fiberoptic sigmoidoscope expeditiously in the office with minimal patient preparation, a high level of patient and physician acceptance, and relative safety when the usual mandatory colonoscopic precautions and guidelines are obeyed. The extraordinary advantages demonstrated by this study warrant wide clinical application of the flexible fiberoptic sigmoidoscope. We strongly recommend provision be made for appropriate training of physicians in the use of the instrument.

Arterio-enteric fistulas.

The colorectal surgeon may well see arterioenteric fistulas in patients who have rectal bleeding. The initial bleeding usually stops, allowing time for evaluation, which should be done promptly because subsequent bleeding may be fatal. Exploratory laparotomy is frequently necessary to arrive at the correct diagnosis. Surgical management necessitates individual assessment of each case, but best results seem to be obtained when the infected graft is completely removed.

Volvulus of the sigmoid colon.

A study of 37 patients with sigmoid volvulus is presented. Subsequent bouts of recurrent volvulus are very common after sigmoidoscopic intubation, and overall mortality rates are high. Surgical resection is the preferred method of treatment.