Intraoperative Transanal Fiberoptic Colonoscopy: Report of Six Cases Thomas A

Henry Ford Hospital Medical Journal Volume 25 | Number 1 Article 5 3-1977 Intraoperative transanal fiberoptic colonoscopy: Report of six cases Thomas A. Fox Jr. Peter A. Haas Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Fox, Thomas A. Jr. and Haas, Peter A. (1977) "Intraoperative transanal fiberoptic colonoscopy: Report of six cases," Henry Ford Hospital Medical Journal : Vol. 25 : No. 1 , 33-36. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol25/iss1/5 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med Journal Vol 25, No 1, 1977 Intraoperative transanal fiberoptic colonoscopy Report of six cases Thomas A. Fox, Jr., MD and Peter A. Haas, MD* Intraoperative transanal fiberoptic colo THE use of the flexible fiberoptic colono- noscopy is presented as an alternative to scope in thediagnosisof colonic disease and transcolonic procedures to remove colonic the removal or biopsy of most colonic le polyps, or to excise or biopsy other intra sions located above the rectosigmoid have luminal les ions. This method should be con become fairly well standardized. The advan sidered when the standard transanal tages of this techn ique are its safety'" and the colonoscopy has failed. The results with this lack of the operative complications which procedure have been excellent. The method may occur with a laparotomy and trans also can be applied to patients who have colonic polypectomy, excision or biopsy. colonic lesions and are to undergo elective The mortality rate for laparotomy and trans procedures such as hysterectomy and colonic removal of a lesion is approximately cholecystectomy. 0.5%^'^ and the incidences of morbidity, mainly wound infection, range from 10%'to 30%°. Fiberoptic colonoscopy circumvents most of these problems. However, even in the hands of the most experienced colonoscopist, passage of the colonoscope and location of the polyp or other lesion may be impossible in the occa sional patient^. Most frequently, the bowel may be impossible to negotiate because of fixation in the pelvis from previous surgery or inflammation. Often a very redundant *General Surgery Division III sigmoid loop or a high lying and sharply angulated splenic flexure prevents passage Address reprint requests to Dr. Fox at Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, of the instruments. The lesion may be inac Ml 48202. cessible because it is located in a large 33 Fox and Haas redundant cecum or ascending colon. The rest of the colon can be completely and lesion may be located on the wall of the easily examined. As the colonoscope is bowel in such a way that it remains hidden withdrawn, the insufflated air is removed to from the view of the operator. Also, since facilitate closure of the abdominal incision. transanal colonoscopy is usually performed with the patient sedated, but awake, an The following three case reports illustrate occasional patient will be completely the procedure and its advantages. uncooperative. When a transanal attempt was unsuccess Case report #1 ful, two courses of action were previously A 63-year-old white woman was hospitalized available: Transabdominal transcolonic ex on October 5, 1975, for evaluation of a gener ploration could be performed, or the pa alized dermatitis and a 27-pound weight loss. An occult malignancy was suspected and an exten tient's condition could be monitored with sive evaluation was performed. A barium enema frequent barium enemas. If the latter course revealed two 2 cm-sized polyps in the right was selected, any change in the size or transverse colon. configuration of the lesion could be identi On October 23, 1975, transanal colonoscopy fied. As this method is tedious and uncom was attempted in the colonoscopy suite, but the fortable, patient acceptance of it is often endoscopist was unable to pass the colonoscope quite low; but it may be the procedure of around the splenic flexure. Intraoperative transa nal colonoscopy was recommended and accepted choice for patients who are at high risk for an by the patient. abdominal exploration. However, histologi cal diagnosis is lacking in these cases. On October 27, 1975, laparotomy and transa nal colonoscopy were performed. With the assist ance of the operating surgeon, the colonoscope In a few patients, to minimize the risks and was easily passed into the transverse colon. One polyp was easily removed, but after the second yetto accomplish polypectomy or identify a polyp was snared there was a malfunction of the suspected lesion, laparotomy has been com snare and a transcolonic colotomy and polypec bined with transanal colonoscopy. tomy were performed. Both polyps were reported to be adenomatous. The patient had an uneventful postoperative course and was discharged on November 6, 1975. Method Comment: This case demonstrates the Following routine bowel preparation, the value of intraoperative transanal colono patient is positioned on the operating room scopy and polypectomy. The entire colon table as for a synchronous combined ab was inspected and two polyps excised. Al dominoperineal resection. Once the abdo though a colotomy had to be performed, this men is opened by the surgical team, the was due to a mechanical malfunction of the colonoscopist introduces the instrument via equipment and should rarely occur. the anus. The colon should be occluded above the suspected site of the lesion in order not to distend the colon unnecessarily Case report #2 by the air insufflated during the examination. The colonoscope is advanced in the usual A 36-year-old white woman was hospitalized on January 5, 1973, for evaluation of right lower fashion, but with transabdominal guidance. quadrant pain and diarrhea. The patient had Once the polyp or other lesion is located, undergone an appendectomy at 13 years of age. snare excision or biopsy is undertaken. The The physical examination and laboratory studies werewithin normal limitsexceptforacecal defect ability of the surgeon can hasten the pro revealed by the barium enema. cedure of guiding the colonoscope to the site and manipulating the colon sothatthe lesion The patientwas scheduled fortransanal colono can be readily snared or biopsied. Once the scopy in the colonoscopy suite, but after discuss ing the procedure, she insisted on intraoperative lesion has been removed or biopsied, the colonoscopy. .'.4 Intraoperative transanal colonoscopy On January 10,1973, the patient underwent an Results uneventful intraoperative transanal colonoscopy. The lesion in the cecum was found to be an Intraoperative transanal colonoscopy has inverted appendiceal stump. The patient had a benign postoperative course and was discharged been performed on six patients. Five of these on January 19, 1973. patients had unsuccessful transanal colono scopy in thecolonoscopy unit, and the other Comment: This case illustrates the value patient refused this procedure. In each case, of colonoscopy in evaluating suspicious le the procedure was performed easily, the sions found by a barium enema. Combined lesion identified, if present, and polypec inspection, palpation and colonoscopic vi tomy performed in three patients. There was sualization were adequate to establish the no morbidity or mortal ity associated with the nature of the lesion. Previously, a cecotomy procedure. and excision of this lesion would have been performed. Discussion Case report #3 The removal of all polyps larger than 1 cm A45-year-old white woman was evaluated for a history of intermittent episodes of right upper in diameter has been an accepted surgical quadrant pain. Gastrointestinal roentgenograms procedure^ because of possible malignancy. showed cholelithiasis and a possible polyp in the In most situations, the polyps can be easily splenic flexure of the colon. The patient was admitted to the hospital on May 26, 1975, for removed by the transanal colonoscopic pro elective cholecystectomy and polypectomy. cedure, with minimal morbidity and mor Results of physical examination and laboratory tality. Other suspicious lesions in the colon studies were within normal limits except for the are also often evaluated by transanal colono findings by x-ray of gallstones and possible colo scopy. The difficulties with prolonged obser nic polyp. On May 27, 1975, transanal colono scopy was attempted in thecolonoscopy suite, but vation and repeated contrast studies of the the instrument could not be passed through the colon are primarily in patient anxiety, ex sigmoid curve. On May 28, 1975, intraoperative pense, and discomfort and in the uncertainty transanal colonoscopy was performed to the cecum and no polyps were found. A routine of the histologic composition of the lesion. cholecystectomy was made quite difficult by the marked distention of the entire colon. The closure of the incision was also made difficult. When the patient has the combination of increased surgical risk (because of obesity, Comment: This case demonstrates a valid diabetes, or heart disease), and a lesion that reason for combining laparotomy with trans is inaccessible to the colonoscope, the phys anal colonoscopy. The patient had a sus ician is faced with a difficult therapeutic pected polyp in the splenic flexure of the decision. The alternative method we pro colon and proven cholelithiasis. Since the pose— intraoperative transanal colono patient was to undergo laparotomy for cho scopy with either polypectomy, excision or lecystectomy, it would seem logical to per biopsy of the lesion — reduces the anesthe form intraoperative colonoscopy in the sia time and eliminates the need to transgress operating room rather than colonoscopy in the colonic wall. Both morbidity and mor the out-patient unit. However, we prefer the tality are certainly far less than occurs with out-patient unit because in this situation, the the transcolonic procedures.

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