colonoscopic localisation accuracy for colorectal resections
TRANSCRIPT
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Colonoscopic Localisation Accuracy
for Colorectal Resections
Damian IannoBBiom (Hons), Third Year Medical Student, Austin Hospital
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Background•CRC: Second most common cancer in Australia•Colonoscopy: ‘Gold standard’•Sensitivity of colonoscopy: 85-95%•Lesion localisation: 80-90%, in setting of open
resection
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Background• Laparoscopic assisted resections: Common • Correct localisation of lesions is essential to
achieving optimal patient outcomes, given incorrect localisation can lead to:
- Change in intended operation- Change in bowel segment removed- Incorrect segment of bowel being removed
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Objectives• To assess the accuracy of colonoscopic localisation
and its effect on clinical practice
• To assess factors associated with incorrect colonoscopic localisation
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Methods• Retrospective study • University teaching hospital• Inclusion: Patients who underwent colonic
resection after pre-operative colonoscopy between 2008 and 2013 for a mass lesion• Exclusion: Other institutions, non-mass lesion• Scanned medical records: Demographic,
endoscopic, operative and pathological records
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Methods• The data was analysed with SigmaPlot 12.0• Mann-Whitney rank sum and chi-square tests
were used where appropriate with 95% confidence intervals given• A p value of <0.05 was deemed statistically
significant
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Division of colon into segments
Sigmoid colon
Splenic flexure
Rectosigmoid colon
Descending colon
Rectum
Ascending colon
Transverse colon
Caecum
Hepatic flexure
Ileum
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Demographic Values
Age, years: Mean (SD); range 68.1 (±12.1); 25-92
Sex: n male (%) 130 (61.9%)
Patients: n 210
Lesions: n 221
Complete colonoscopy achieved: n (%) 164 (74.2%)
Incorrectly localised lesions: n (%) 46 (20.8%)
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Parameter Concordant (175) Non-concordant (46) PGender (M/F) 105/70 25/21 0.600Age (years) 67.39 (±1.76) 70.82 (±3.21) 0.087Time (minutes) 26.69 (±2.12) 25.61 (±3.43) 0.92Size (millimetres) 38.37 (±3.11) 40.57 (±4.92) 0.206Previous resection 8/175 (4.57%) 2/46 (4.35%) 0.739Tattoo 76/175 (43.4%) 24/46 (52.17%) 0.371Distance from anal verge 59/175 (33.7%) 13/46 (28.3%) 0.559Prep quality- Good- Satisfactory- Poor- Not Recorded
83 (47.4%)65 (37.1%)21 (12.0%)6 (3.43%)
21 (45.7%)19 (41.3%)3 (6.5%)3 (6.5%)
0.562
Complete scope 143/175 (81.7%) 28/46 (60.9%) 0.005
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Parameter Concordant (175) Non-concordant (46) Accuracy, % PClinicians’ Background-Colorectal-Gastroenterology-General Surgery
93 757
15 30 1
86.1%71.4%87.5%
0.026
Level of Training- Consultant- Fellow - Nurse - Registrar
76 436 48
20 8 5 13
79.2%84.3%54.5%78.7%
0.184
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Distribution of reported location of lesions on colonoscopy
Sigmoid colon
Splenic flexure
Rectosigmoid colon
Descending colon
Rectum
Ascending colon
Transverse colon
Caecum
Hepatic flexure
IleumUnknown1%
17%
10%
7%
5% 1%
6%
25%
7%
20%1%
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Location of incorrectly localised lesions on colonoscopy
Sigmoid colon
Splenic flexure
Rectosigmoid colon
Descending colon
Rectum
Ascending colon
Transverse colon
Caecum
Hepatic flexure
IleumUnknown1% 0%
17% 7%
10% 11%
7% 20%
5% 4% 1% 4%
6% 9%
25% 24%
7% 20%
20% 0%1% 2%
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Results• Analysis of pre-operative CT records
CT Values
CT performed pre-operatively: n (%) 196/221 (88.7%)
CT sensitivity in identifying lesion: n (%) 116/196 (59.2%)
CT correctly localised lesion: n (%) 84/116 (72.4%)CT correctly localised non-concordant lesion: n (%) 17/44 (38.6%)
Note: Only 44 of 46 non-concordant lesions had pre-operative CT performed
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Results• Total of 46 incorrectly localised lesions• 17 lesions required changes to intended surgery• 29 lesions did not:
- CT aided correct localisation for 6 lesions- In remaining 23 cases, changes minor enough to not necessitate changes in surgical planning
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Results
Changes in surgery Reason n
Lap → open conversion for operative reasons - Adhesions - Local invasion - Poor views
224
• 8 of the 17 lesions that required changes to intended surgery were due to operative reasons
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Results• 9 of the 17 lesions that required changes to
intended surgery were due to incorrect location
Of the 221 lesions in total, over 4% required changes to surgical procedure due to inaccurate
localisation!
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Colonoscopic location (planned procedure) --> Actual location (actual procedure) n
• Sigmoid (open left hemicolectomy) --> Caecum (open right hemicolectomy) • Descending colon (laparoscopic anterior resection) --> Transverse colon (open
extended right hemicolectomy) • Hepatic flexure (open extended right hemicolectomy --> Caecum (open right hemicolectomy) • Hepatic flexure (laparoscopic right hemicolectomy) --> Transverse colon (laparoscopic extended right hemicolectomy) • Hepatic flexure (laparoscopic extended right hemicolectomy) --> Ascending colon
(laparoscopic right hemicolectomy) • Sigmoid (laparoscopic anterior resection) --> Rectum (laparoscopic low anterior
resection) • Splenic flexure (laparoscopic left hemicolectomy) --> Descending colon (laparoscopic anterior resection)
11
1
1
1
3
1
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Discussion• Overall accuracy in line with other studies (≈80%)• Incomplete scope a significant factor in incorrect
localisation → deprived of important landmarks • Emphasis on location may be higher amongst
colorectal surgeons → consideration for resection • CT, although helpful, cannot be relied upon to
correctly localise lesions, especially when colonoscopy has been unreliable
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Limitations• Retrospective study• Heterogeneous group• Observer bias → colorectal surgeon likely to be
both endoscopist and surgeon • No standardised method of description for
location
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Conclusion• Incorrect localisation can have serious clinical
consequences• Localisation is particularly inaccurate if the
colonoscopy is not complete• Endoscopy training should have a higher
emphasis on correct identification of lesion location on colonoscopy
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Conclusion• All lesions not in rectum or at caecal pole should
be tattooed to help intraoperative localisation if resection is being considered• A formal guideline to describe position in the
colon should be created
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