modern endoscopy of the alimentary tract

WILLIAM I. WOLFF

HIROMI SHINYA

Modern Endoscopy of the Alimentary Tract

TABLE OF CONTENTS

FII~EROPTICS.

HISTORY OF INSTRUMENT DEVELOPMENT

INSTRUMENTATION FOR UPPER G I ENDOSCOPY .

ESOPHAGOSCOPY

Technic of Fiberoptic Esophagoscopy

Biopsy via the Endoscope .

Miscellaneous Applications

GASTROSCOPY

Historical Background

Indications

Technic

Complications

Gastric Neoplasms

Surgical Applications

Gastritis

Postoperative Gastroscopy

UPPER GASTROINTESTINAL Hti~MORRHAGE

DUODENOSCOPY

AMPULLARY CANNULATION

COLONOSCOPY

History

Terminology .

Technic

Fluoroscopy

Selection of Instruments

Biopsy

Diagnostic Applications

Therapeutic Applications

Complications

Discussion

Summary of Indications for Colonoscopy

Limitations

Future Developments

RELATION OF RADIOLOGY TO ENDOSCOPY

OVERVIEW

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is Director of Surgery at the Beth Israel Medical Center and P ro f~so r of Clinical Surgery at the Mr. Sinai School of Medicine, New York. l i e is also Consultant in Surgery at the Bronx, Manhat tan and M ontrose Veterans Hospitals. He graduated from the Univermty of Maryland School of Medi- cine, where he received the University Prize Gold Medal. Fie served his intern.~hip and residencies on the Second tCornell) Division and Chest Sur- gical Service (Columbia Division) at Bellevue Hospital and at the Bronx Veterans Hospital before joining the attending staffs of both of these insti- tutiorLs, l)r. Wolff' Imgan an a Teaching Fellow and rose to Attending Sur- geon under Dr. L. M. Rou.~elot at St.. Vincent's Hospital in New York. Dr. Wolff served an A~ociate Prok.~sor of Surgery at the New York Univer- sity Medical School prior to the creation of the Mt. Sinai Medical School. Dr, Wolff and Dr. Shinya founded a program in fiberoptic endoscopy of the uplmr gastrointestinal tract and in colonoscopy. They also intrcxtuced the technic of colonic polylmctomy via the colonoscope.

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is Chief o f t h e Surgical Endoscopy Unit at Beth Israel Medical Center and A~,~t~iate Prof~,~or of Surgery at the Mr. Sinai School el Medicine, New York, l)r. Shinya graduated from the Juntendo School of Medicine in Tokyo and served his internship at the United Stafes Naval H ~ p i t a l in Tokyo. His residency was completed at Beth Israel Medical Center and included a year at the New York University Bellevue Medical Center. with which Beth Israel was then affiliated. Following his r~.'idency. Dr. Shinya became Dr. Wolff's a~q.sociat~a. Dr. Shinya maintains an active intere.~t in tim design of new endoscopic approache.s to the study of the entire gastrointestinal tract and in the improvement of present ir~qtrumentation.

IN M E D I C I N E , as in other areas of h u m a n endeavor, "seeing is believing." Unders tanding of form and function in gastroenterology has in large measure come from observation of the heal thy and the morbid, the viable and the still. Where direct viewing was not possible, indirect approaches were sought. The most notable of these and the most far-reaching in its effects was the demonstra t ion by Wal te r Cannon in 1898, while still a s tudent ,at Harvard, that I)y filling the stomach and intestines with gruel mixed with large amounts of bismuth he could utilize the newly discovered wonder rays of R6ntgen and demonstrate the motor movements of these organs.:~5 How- ever, direct observation in living humans was difficult to achieve, as Wil l iam Beaumont ' s remarkable journals proved.

Specula for peering into body orifices and cavities probably date back to the dawn of history,41.18,a but it was not unti l the mid-n ine teenth century

Thiz work wa.~ supported in part by a grant from the Leon Hess Foundation.

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that optical devices for inspecting body cavities were introduced. The earli- est mention of a rectal speculum is found in a treatise on fistula by Hippoc- rates.l s3 KussmauP n9 generally is given credit for being the first, in 1868, to devise an instrument for looking into the esophagus and stomach.30, 41, 1~9 Calling on a sword swallower as a consultant and subject, he passed 24-30- cm hollow metal tubes into the gullet and at tempted to look through them using the illumination afforded by a gasoline lamp and reflector. Von Miku- licz, however, is regarded as the true father of esophagoscopy and gastroscopy, since, in 1881, he was the first to describe in any detail the interior of the stomach and esophagus.182 Until recently, the rigid nature of available instruments and the shortcomings in illumination curtailed the potential contributions of endoscopy to knowledge of form, function and afflictions of the upper gastrointestinal tract. An awakening of interest and the buds of progress appeared with Schindler's introduction of the semiflexible gastroscope in 1932, 259 but even this advance had limited usefulness and unreal- ized potential.

At the nether end of the al imentary canal, the at tainments of endoscopy were more actual, presumably because anorectal disease was common in an- tiquity41--possibly related to the fact that the horse was a popular means of transportation. The use of rectal specula by Hippocrates has been mentioned. Modern rectocolic endoscopy is said to have begun with Desor- meaux's instrument, introduced in 1853,6.~ and its subsequent elaboration by Kelly.153 This eventually led to the development of the modern sigmoidoscope, which has had so important an influence in recognition and t reatment of diseases of the rectum and sigmoid colon. The fact that pathologic states show relative concentration in the terminal foot or so of the large bowel has contributed to the value of endoscopy in this anatomic area, although the restrictions imposed by instrument rigidity and, to some extent, by poor illumination have also applied here.

In essence, then, until very recently there have been two notable lines of approach to the study and understanding of gastroenterologic disorders, namely, (1) the radiologic--the discovery of x-rays by RSntgen in 1895, the principle of gastric visualization suggested by Hemmeter 122 a year later and its realization by ,2~nnon shortly thereafter and (2) the sigmoidoscopic. In the past decade, n_*"dicine has taken a third major step forward in this field with fiberoptic endoscopy.

FIBEROPTICS

To no one is the modern miracle of fiberoptics more apparent than to the old-time endoscopist. For the first time the esophagus could be entered and examined with ease, the cardio-esophageal junction, the antrum, the pyloric canal and even the duodenum could be brought into view and biopsies could be taken at will under direct vision. Photographs, in color, could be made of any area seen. All these could be realized for the patient with a degree of safety and comfort beyond expectation.

The technic of transmitt ing light waves and optical images along glass or clear plastic fibers is not new a n d the basic principle has been understood since 1870.146 The major developments in the field have occurred since

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1951, with pract ical applicat ion at first in industry. The light t ransmission and light collection efficiency in fiberoptics can be considerably superior to that of the better-known optical components, such as lenses, prisms and mirrors.l~,7

The principle is based on the phenomenon of total in ternal reflection. Total in ternal reflection occurs when light strikes, at critical angles, an interface between a medium of h~igh refractive index, such as glass, with one of low refractive index, such as a i r or a coating on the glass.

Light enter ing one end of a cylindrical rod and str iking the surface at an incident angle greater than the critical angle will advance longi tudinal ly by a series of in ternal reflections and emerge at the other end, e v e n if t h e rod is ben, t s h a r p l y . The coating may be extraordinar i ly thin .... of the order of the wavelength of light. Thus, extremely fine glass or plastic rods can be drawn and coated with a microscopically thin coating of low-refractive mater ia l (usually a different type of plastic or glass), These fibers then are assembled into bundles and these, in turn, into numerous small "mult iple fibers." In the ins t ruments n o w commonly in use, the fiber bundle consists of about 150,000 fine glass fibers, approximate ly 15-20 # in d iamete r (2-3 times the size of a red blood corpuscle), cemented together.

Such fiber bundles are highly flexible and will t ransmit l ight efficiently for considerable distances and with remarkable fidelity from a light source. Moreover, this l ight is "cold," thus obviating the old, fazniliar local heat problem if high intensit ies of i l luminat ion are achieved by using incandes- cent light bulbs.

If the bundle of fibers is so constructed that each fiber occupies the same relative position at the two ends of the bundle, an optical image can be transmittedA4~ The resolution, or detail of what is passed along, is essen- t ial ly a factor of the fneness of the fiber diameter . When high-qual i ty optical glass is used for the fibers, the resolution and color representat ion are of a high order.

HISTORY OF INSTRUMENT DEVELOPMENT

The principle of fiberoptics was first appl ied to medicine with the use of a new type of gastroscope called the "fiberscope," as reported by Hirscho- witz et al. in 1958.130 This gastroscope, completely flexible, permi t ted direct visuatization of the stomach and duodenum. In it, the image was trans- mit ted by the fiberoptic bundle and the i l luminat ion was suppl ied by a set of bronchoscope bulbs placed behind a pr ism at the tip of the instrument . The image was viewed at right angles to the longitudinal axis of the gastroscope. As noted by Colcher,49 this new ins t rument caused an explosion in the field of endoscopy, and progress over the next few years was ext remely rapid. In a short time, Hirschowitz and his co-workers12G, 120 were reporting on the normal and abnormal characterist ics of the s tomach and even the duodenum, where ulcers were seen endoscopically for the first time. As they stated, "Such a flexible ins t rument , the gastroduodenal fiberscope, has been used to examine areas previously inaccessible to endoscopy and has been used in m a n y pat ients where conventional gastroscopy would not have been possible." A renascence of gastroscopy began throughout the world.

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In the same year that Hirschowitz and his associates presented their material formally (1958), Tasaka and Ashizawa of J apan reported on the gastrocamera,2S7 an early version of the tiny camera that could be introduced into the stomach to photograph its interior. The final version of the gastroscope consisted of a tiny camera system at title tip of the instrument and included a lens, flash lamp, air valve and film capsule for color photography (Fig. 1). This method provided adequate lighting and gave e~ccellent photographic detail.l s9 The chief drawback was that the camera was aimed blindly and the Dhotographs, although clear, were quite small (5 ram). This was part ial ly compensated for by an extremely wide angle of view. How- ever, light sources of increased .;nl~.ensity soon enabled satisfactory photographs to be taken via the ocular end of the fiberscope. When it was found that the fiberscope could be introduced into the duodenum and that it also offered the opportunity of biopsy taking, use of the gastrocamera declirmd. In Japan, where the incidence of gastric cancer is very high, and elsewhere it is employed in screening examinationsg87

Modifications of the fiberoptic gastroscope appeared rapidly, and these improved versions permitted better visualization of the esophagus, "inver- sion" maneuvers in the stomach (a "U" turn of the tip, which enables the viewer to examine the cardia from below), means of entering the entire duodenum readily and a variety of end-viewing and side-viewing features. The last allow excellent visualization and cannulation of the ampulla of Vater, for example. Smaller-caliber scopes appeared for pediatric use.

All but the most advanced models are covered in the excellent mono-

b'2G. 1.--A, g-strocamera. B, tip of instrument and spool of film.

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graphs by Nelson j97 Brfihl and Krentz30 and Demling, Ot ten jann and E]sted63 and in the reviews by Morrissey, T a n a k a and Thorsen,l~o Cc~I- cher4S, 49 and Morrissey.187

Although the basic technology was available, the developmen ~, of iaastr~ ments for colonoscopy was not begun until some 10 years ia'ter, po~sibty because the need for a colonoscope did not appear to be as. grez~ as Jt had been for the gastroscope. Beginning in 1957, Matsunaga and co-worker~a80 reported on efforts to examine the sigmoid colon with a modification of "Hie gastrocamera. Oshiba and Watanabe,206 Niwa et al. 198, 199 and Ka~,::~,:~,.awa and Tanaka14.1 worked on the development of a suitable co]onof iberscope over the next few years in Japan. In the United States, p re l imina ry reports on such an ins t rument by Turel1291 were so unfavorable that fur ther efforts were discouraged, unti l Overholt,209 in 1969, used a fiberscope to extend the range of sigmoidoacopy to the proximal sigmoid and descending colon. Dean and ShearmanrJ reported on their difficulties and achievements with a similar ins t rument in England, as did Fox.93

In early 1969, after a very satisfactory experience with the gastrocamera and fiberoptic gastroscope, we undertook evaluation of the colonofiberscope and planned to examine the entire colon, if possible.309 Using fluoroscopy with an image intensifier to guide our early efforts, we found the method to be feasible, safe and of great diagnostic value..~10 Wi th increasing skill and experience, it became possible to use a longer ins t rument , to extend the range of examinat ion all around the colon to the ileocecal valve and to omit fluoroscopy in most cases. By June of 1971, we were able to report our experience with 410 consecutive and uncomplicated colonoscopies before the Society for the Surgery of the Al imenta ry Tract.:~l 1 The passage of a str ing or tube by mouth all the way down the gastrointest inal tract in order to at tach the tip of the colonoscope at the anus for easier retrograde guidance ~ a s proposed by Provenzale and Revignas2:~3 and Hiratsuka125~soon ap-

FI0. 2 . ~ A , ballc~on cemented to tip of colonoc;cope. This is ttseful for blocking lumen of bowel to inject contrm~t material to demort,~trate a fistulous communication, sinus tract, or of bowel beyond an area of narrowing. B, radiograph of sigmoido-vesical fistula demonstrated with aid of colonoscope.

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pea red to be an unnecessa ry precaut ion . Others began r epo r t i ng success in in t roduc ing the i n s t r u m e n t as f a r as the cecum,9~, 195 a l though, by and large, ea r ly efforts were d i rec ted a t e x a m i n a t i o n of the left ha l f of the colon.IS, 61, 67, 68, 93, I15, 118,210, 211, 252, 254

AS exper ience with the i n s t r u m e n t s increased, a n u m b e r of clever acces- sories became available. S h i n y a cemen ted an endo t rachea l bal loon to the t ip of the scope (Fig. 2, A) and found tha t this ass is ted in advanc ing the

Fro. 3 .wA, stiffening device. B, radiograph showing long eolonoscope with tip iI~ cecum, where passage was facilitated '~y use of stiffening device seen on the right. C, .same patient before stiffening, device was advanced.

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, ~ ¢ , . . y , , . . . .

FIG. 4.--Stmre-cautery wiro shown projecting from biopsy channel of colonoscope.

instrument. It was also very useful in blocking off a segment of bowel so as to permit injection of contrast material, such as Gastrografin, to outline a fistulous or sinus tract by radiographic examination (Fig. 2, B). Shinya and Deyhle67 encouraged the manufacturer to produce a stiffening device (Fig. 3, A), which is of great value in straightening out the sigmoid colon and thereby facilitates the introduction of the colonoscope into the right colon and cecum (Fig. 3, B and C).

In September of 1969, after an adequate experience in diagnostic colonoscopy had been acquired, we began to explore the therapeutic application of the procedure with the e;ndoscopic excision of pedunculated polyps situated beyond the reach of the conventional sigmoidoscope. Using a homemade snare device (Fig. 4) connected to the customary type of electrocautery unit,309-316 and exercising reasonable care, sessile as well as pedtmculated polyps could be resected endoscopically throughout the entire colon. At the time of this writing, more than 600 polyps, 0.5 cm in diameter or larger, have been removed successfully, with no deaths and with only 2 complications, neither of which required operative intervention.316 At least an equal number of smaller polyps have been either removed or fulgurated after biopsy.

Others have begun to report similar favorable experiencesJ8, 68-70, 96, 118,. 279 and it is quite clear that this new approach will progressively replace laparotomy and c01.0tomy, or colectomy, except under special circumstances, to be discussed in detail later. The cumulative experience by all the workers in the field will shortly enhance our knowledge of the nature, clinical significance and optimal management of polypoid tumors of the large intestine.

INSTRUMENTATION FOR UPPER GI ENDOSCOPY

Changes occur with such frequency as to make any observations on a given instrument obsolete by the time this monograph goes to press. New models appear with a frequency discouraging to the budget-minded individual. Fortunately, most of the changes are minor and, for the most part, the endoscopes are durable and trouble-free. In selecting any part icular

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model, the endoscopist should analyze the use to which it will be put and investigate the local servicing facilities provided by the manufacturer . All three current manufacturers , Olympus Corporation, American Cystoscope Makers, Inc. and Machida are reliable and produce endoscopes of high quality.43, 48, ,t9

The gastrocamera, mentioned previously, is a most ingenious ins t rument developed in J a p a n after 1950.2s7 It photographs directly the gastric lumen. Pictures taken in this manner are clearer and provide more detai l than those made through an eyepiece-attached camera.

The ins t rument contains an extremely smal l camera built into its distal tip (see Fig. 1). The ins t rument tip is flexible, allowing the camera to be aimed in any direction. There is a device for the insuffiation of air into the stomach, but there are no facilities for biopsy or cytology studies. The film is 4 mm in diameter and 32 pictures can be taken on one roll. The camera has a fixed-focus lens nystem and objects 0.5-10 cm away can be photographed clearly. Tlle lens has a wide angle of about 80 °. The camera is a imed either blindly or under fluoroscopic guidance. In J apan , it is used p r imar i ly for screening purposes or for pre l iminary examina t ion of the stomach.

The upper gastrointest inal fiberscopes are of two main types--end-on- viewing and side-viewing. The end-on-viewing scopes were designed for examinat ion of the esophagus, stomach and duodenum with a single instrument. Current ly avai lable are the Olympus models GIF type D, J F - D and GIF-P; the American Cystoscope Makers ' ACMI F8; and the Machida FDS. These scopes are widely used for diagnosis of diseases in the esophagus, stomach and duodenum and are par t icu lar ly useful for examinat ion at the t ime of acute upper gastrointestinal hemorrhage.

The end-on-viewing scopes are somewhat more difficult to introduce into the esophagus and into the duodenum as compared to the side-viewing instruments. The re may also be some bl ind angles, par t icular ly along the lesser curvature in the prepyloric area, in pat ients with the " J " type of stomach.a9 These scopes are more difficult to pass through the pylorus when the sphincter l u m e n is eccentric, defo~.,zned or constricted. The i r introduction into the second and third portions of the duodenum is more difficult and one does not get near ly as good a view of the ampul la of Vater as through the side-viewing endoscopes. Moreover, cannulat ion of the ampul la is not feasible with this type of instrument .

The side-viewing scopes were originally designed for a complete examination of the stomach. Hirschowitz 's or iginal ins t rument was of this type. The lengthened versions are now the pr incipal means by which to examine the duodenum. The models current ly available are the ACMI FCB 95 and FCB 1002, the Olympus J F type B and the Mach ida FDS. These models have roughly the same specifications: the Olympus J F has an angle of visual field of 64 ° and a range of observation from 5 m m to 60 mm. The tip of the in- s t rument is 10 m m in d iameter and can be flexed 120 ° up and down and 90 ° side to side. Wi th this type of scope, excellent visualization of the ampul la of Vater is obtained and catheters may be placed for retrograde contrast visualization of the bi l iary and pancreat ic duct systems.

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ESOPHAGOSCOPY

Until very recently, endoscopic examinat ion of the esophagus was performed exclusively by means of rigid instruments , proximally or distal ly lighted, that usual ly were not provided with an optical lens system. The procedure was regarded as difficult and potent ial ly dangerous and it required special expert ise on the part of the examiner. It was an uncomfort- able, sometimes harrowing, experience for the pa t ient - - to a point at which many surgeons selected general anesthesia in preference to topical anesthe- s i a - a n d it was only with a great deal of persuasion that patients would consent to repeat examinat ions under topical anesthesia. Among poorly t ra ined endoscopists, compl ica t ions- -par t icu lar ly perforat ions--were fre- quent. For the experienced surgeon, they were uncommon--bu t only because he was keenly aware of their grave na ture and acutely conscious of all the safeguards required.

Despite successful insertion of the ins t rument , the distal esophagus (par- t icularly the entire gastroesophageal junct ion) often could not be fully visualized. This impor tan t zone, "the pr ime seat of esophagitis, ulceration, v a r i c e s . . . Mallory-Weiss syndrome and many malignancies,"222 might not be studied carefully. Varices, unless very large or otherwise prominent , were difficult to dis t inguish from folds in the collapsed esophagus53.54; e.g., two experienced endoscopists viewing the same cases at the same time varied in in terpre ta t ion by 30%.54

The over-aU accident rate with conventional esophagoscopy in one collected series 219 was 0.25%, with 1 of 4 of these patients dying. Accidents consisted main ly of perforations, with anesthet ic "reactions" second in frequency. Since this l isting was collected p r imar i ly from "active" endoscopists who were accredited specialists in the field, the figures quoted undoubtedly are on the low side.

Wi th the appearance of the fiberoptic scope on the scene, all this has changed--dras t ica l ly , and for the better.127.12s On a large scale, the procedure now is performed safely by any number of well-trained gastroenterologists or surgeons, with minimal patient discomfort. Serial examinat ions or follow-up studies can be under taken with little or no patient resistance, and excellent photographic records can be kept for comparisons or for teaching purposes--something accomplished only with difficulty via the conventional esophagoscope.

Since we have switched to fiberoptic scopes, well over 5,000 upper gastrointest inal diagnostic examinat ions of the entire esophagus have been performed without an incident. More than 600 of these were in pat ients with acute massive upper gastrointestinal hemorrhage (vide infra). The diagnostic accuracy of these lat ter studies has been well over 95%.

TECHNIC OF FIBEROPTIC ESOPHAGOSCOPY

The procedure can be done on an ambula tory basis. The pat ient is requested to abstain from food and drink for 6 hours prior to the examination. Premedica t ion varies from giving nothing to 50 mg of meperidine (Dem-

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erol) and/or 2-10 mg of diazepam (Valium) administered intravenously, after having the patient gargle for 1 minute with a topical anesthetic agent (viscous Xylocaine).

With the patient lying comfortably on his left side, the tip of the scope is introduced through a mouthpiece and the patient is asked to swallow. The instrtnnent then is advanced slowly (under direct vision through the eyepiece) as the esophagus is gently insufflated with air. Liquid contents are aspirated readily. With moderate distention, peristaltic action is observed and motility disorders often are recognizable. The "Z-line" representing the junction of the esophageal mucosa with that of the cardia can be seen and its level measured. With moderate inflation, an incompetent cardiac sphincter will appear patulous and its elevated position in the presence of a hiatal hernia is readily appreciated. Reflux is seen commonly under these circumstances and liquid material can be aspirated. The tip of the instrument is advanced into the stomach with ease.

Hirschowitz12S sums up the favorable features of the method as follows: "(1) Very easy and safe passage without anesthesia, rapid examination, superb perspective and close view detail; (2) excellent illumination and light transmission, so that both still and motion pictures of high quality can be obtained with unmodified cameras and light sources, at speeds which avoid blurring due to vascular or respiratory movement; and (3) the capacity for adequate pinpoint biopsy or aspiration of material for cytology."

As a mat ter of fact, the only really objectionable feature of the method is the high cos~ of the instruments.

BIOPSY VIA THE ENDOSCOPE

The fiberoptic instruments have a channel through which a flexible biopsy forceps is introduced (Fig. 5, A - C and Plate 1), allowing for biopsies to be taken under direct vision. In our experience, this is an eminently safe procedure, several thousand biopsies having been done without ill effect. Safety is in part ensured by the small size of the bite (2-3 ram) and the flexibility of the instrument shaft. Of course, the observer should have some idea of what he is biopsying and we do not recommend snipping away at esophageal varices.

The superficial nature of the forceps bite must be fully appreciated,90 for it may lull the inexperienced endoscopist into a false sense of security. A clinical suspicion of malignancy may be allayed by a superficial biopsy labeled "normal mucosa" or "chronic esophagitis" on histologic examination. If the lesion is at all suspect, the examination should be repeated and multiple rebiopsies taken from a number of sites956, 216 Even if these reports continue to be "negative," one may wish to reserve judgment. On a number of occasions, when our clinical suspicions were aroused and we did not agree with the pathologist's report of benign histologic findings, we have resorted to conventional esophagoscopy and biopsy and have come up with the confirmation of a suspected malignancy. This is particularly true in carcinoma of the esophagus, which is notorious for its ability to spread in the submucosaI plane.193,256 The overlying mucous membrane may be intact, and unless one gets the deeper bitemwhich is possible only with the

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I Distal End ' . .... @

A Forceps Chat~oe! ' Walter Feeding Noz,71¢

Lighl Guides

FI0. 5 .~A, diagram showing tip of fibemcope. B, biopsy forc.eps emerging from tip of inatru- meng. C, biopsy forceps with tiny polyp to show size.

larger biopsy forceps employed through the rigid instrument---one may miss the diagnosis entirely.90

Biopsies are also important in the diagnosis of reflux esophagitis and of a Barret t type of esophageal epithelium, which represents the results of continued reflux. 193 We believe strongly that esophagitis, except in its advanced stages, cannot be diagnosed radiologically or by mere endoscopic observation.168 Confirmation of the diagnosis by biopsy is important prior to repair of a sliding hiatal hernia; in the absence of proved esophagitis if is doubtful that the hernia is the real cause of the patient 's symptoms or that operation is indicated.:305 Esophagoscopy and biopsy often are instrumental in finding the source of bleeding or explaining the presence of anemia in patients with hiatal hernia. Postoperatively, the effectiveness of hiatal hernia repair and the connection of gastroesophageal reflux can be evaluated by esophagoscopy. 246

In a patient with esophageal cancer, washings for cytologic studies may be a useful adjunct to biopsy. We have encountered a number of instances in which the cytology reports have demonstrated cancer cells whereas the biopsies indicated benignity. In view of the notoriously poor record of surgical cure for carcinoma of the esophagus, radiation therapy is used in many centers, either definitively or as a prelude to operation. Most radiation therapists are reluctant to embark on a treatment program without histologic verification of the diagnosis and knowledge of the cell type. En- doscopy supplies this information by biopsy and/or cytology studies.

Moreover, malignant lesions of the cardia or upper portion of the stomach, clearly delineated by x-ray studies, have a tendency to extend superi- orly and involve the distal esophagus. The presence and upper l imi~ of such an extension are best determined endoscopically. With this informa-

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tion, the surgeon is better able to plan his operat ive a t tack on the tumor. In secondary involvement of the esophagus by contiguous extrinsic dis-

ease processes or tumors, endoscopy should be par t of the over-all diagnostic approach.

MISCELLANEOUS APPLICATIONS

Ease of performance and ready patient acceptance have made fiberoptic esophagoscopy a very useful procedure in our institution. We have employed it under the following additional circumstances.

I. POSTIRRADIATION FOLLOW-UP FOR CARCINOMA.--The effectiveness of radiation therapy in destroying esophageal cancer often is difficult to. evaluate by radiologic means alone. The shortcomings are in two directions: In some instances, the barium esophagogram appears to demonstrate complete resolution of the neoplastic process, whereupon esophagoscopy and biopsy prove the presence of persistent disease. Such patients then might be considered for an attempt at esophageal resection. In other instances, a radiologic deformity persists. Here, too, endoscopy may provide a conclusive answer and the x-ray defect may not be associated with residual neoplastic disease.

Some patients who enjoy an initial favorable response to irradiation may have a return of dysphagia and show a zone of narrowing on barium swallow. Such changes are not invariably associated with recurrence of the tumor, a distinction that usually can be made by esophagoscopy. Should the lesion be fibrous, we w,mld prefer to institute a program of dilatation. On the other hand, for a cancer recurrence, we generally resort to the placement of an earle-esophageal prosthesis to restore swallowing ability.30G

2. POSTOPERATIVE FOLLOW-UP.uPatients who have undergone esophageal resection may develop strictures at the levels of the different anastom.oses. Sometimes it is extremely difficult to differentiate between tumor recurrence and inflammatory or fibrous narrowing by radiographic examination only.

Esophagoscopy can resolve this dilemma. To explain the changes found by history and radiographic examination, we have seen endoscopically recurrent tumor, acute anatomic angulations, suture granulomata and fibrous strictures and have treated some of the benign postoperative conditions, such as suture granuloma and fibrous stricture, by endoscopic manipulation°

3. ACHALASIA.wThe dilated sigmoid type of esophagus may show advanced degrees of inflammation and bleed from ulcerations due to the stag- nation of food. Esophagoscopy with the rigid instrument may be noninfor- mative83 and at times even dangerous. The flexible instrument can provide a safe and effective means of examination under such circumstances.

For the treatment of achalasia we have found the "brusque" dilatation2Sl using a Starck dilator to be quite effective and frequently use this method primarily. Although the dilator can be positioned fluoroscopically, we have found that the flexible esophagoscope can be passed parallel to the Starck dilator, permitting control of proper placement of the dilator and direct observation of the dilatation by fracture of the extramucosal esophageal wall.

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4. DILATATION OF S T R I C T U R E S . - - T h e sine qua non for dilating esophageal strictures with minimal risk of esophageal rupture is the presence of an intraluminal guide. Available for use with the fiberoptic endoscope is a flexible guidewire with a soft, easily bent tip, wl,.ich may be introduced through the biopsy channel of the instrument. Under direct endoscopic vision, this guide can be insinuated through the stricture and its position then may be checked radiologically. A series of graduated Eder dilators then can be threaded safely over the guidewire left in place21S (Fig. 6).

5. A S S E S S M E N T OF INTRALUI~IINAL T U B E S . N W e have found the various types of endo-esophageal prostheses, namely the Mackler, Celestin, Fell and H/iring tubes, to be useful palliative devices for inoperable or very-poor-risk patients with esophageal obstruction. 806 These tubes occasionally become blocked as the result of mechanical occlusion by food particles, by over- growth of gra~ulation tissue at the proximal funnel and by absence of esophageal peristalsis due to extensive submucosal extension of tumor proximal to the prosthesis. Contrast esophagograms, using Gastrografin or a thin barium mixture, do not always indicate the true nature of the difficulty in these cases. The ease of fiberoptic endoscopy is a blessing for these dis- tressed patients. The cause of the difficulty can be directly inspected and if the problem is due to food blockage, this can be cleaned out and the scope passed through the tube lumen into the stomach.

F~(t. 6 . raThe wire with lhe flexible tip, A and B, is introduced through the biopsy channel of the scope. Under direct vision, it can be irrsinuated through even advanced strictures. The scope then is withdrawn and the flexible spring dilator shaft with a metal olive at its tip, C, is threaded over the wire. C shows also complete set of Eder dilators. (S~.~z Palmer and I3oyce.21t~)

15

6. FOREIGN BODY IN THE ESOPIIAGUS.--The traditional type of open-end esophagoscope presently is the instrument of choice for the extraction of foreign bodies from the esophagus. However, with the appearance of various types of grasping forceps, which can be inserted via the biopsy channel of the fiberoptic scope, it is not unlikely that these versatile instruments will find a role here also.

GASTROSCOPY

HLSTORICAL BACKGROUND

The modern era of gastroscopy began with Schindler's introduction of the semiflexible gastroscope in 1932. Over the next three decades,260 his teach- ings were spread by his trainees and associates throughout the world. How- ever, gastroscopy did not become very popular in most centers and with most clinicians during those 30 years.

The introduction of a flexible fiberoptic instrument by t-Iirschowitz and his associates in 1958 changed the picture over the next decade. The art has developed to an advanced degree in Japan, from whence many innovations have appeared. This reflects, in part, the relatively high frequency of cancer of the esophagus and stomach in that part of the world. 71, 110 Mobile endoscopic units have become available, similar to the mobile units furnished by the American Tuberculosis Association for chest x-ray studies. The people seek endoscopic examination at the first symptoms, sometimes before seeing a physician or before having an x-ray examination. As a result, cancers often are detected at an early stage, favorable for curative treatment.

It is impossible to review in detail all the contributions made by endoscopists to the recognition, understanding and treatment of gastrointestinal diseases or to describe extensively the endoscopic findings in the various pathologic states. However, it is safe to say that in the past decade the endoscopic approach has gained equal footing with radiologic examination in the diagnosis and management of gastrointestinal disease.

INDICATIONS

As suggested by Palmer and Boyce, the indications for gastroscopy are "simply the known or suspected presence of organic stomach disease and the presence of some systemic diseases which may be accompanied by important gastric complications. They are, then, about the same as those for the gastric part of upper gastrointestinal roentgen study." We would like to emphasize the point that the safety of modern gastroscopy is such that the clinician may request endoscopy with the same degree of assurance that he has in ordering an upper gastrointestinal series. To this we would add the suggestion that routine gastroscopy can and should be used in the follow-up evaluation of patients treated for cancers of the stomach and esophagus and for peptic ulcer disease. I t also may have an important role in cancer screening programs. This point warrants further evaluation of potential yields in asymptomatic and symptomatic patients. Gastroscopy is quite useful in following patients with known non-neoplastic processes, particularly gastric ulcers, treated either operatively or nonoperatively. In these condi-

16

tions, gastroscopic findings have not inf requent ly been positive whereas the x-ray study wa~ negative or inconclusive•

TECHNIC

The technic of gastroscopy is mere ly a continuat ion of what has a l ready been described for esophagoscopy. The instrument~ current ly available all possess suffÉcient flexibility to permi t a U turn in the s tomach and to give a good view of the cardia from below. There no longer are any "bl ind" npots, as in the days of rigid or semirigid gastroscopes. All ins t ruments have chan- nels for i rr igation and for b iopsy 'and permit still and cine color photography. Most can be passed easily into the duodenum, so that the usual procedure today is listed in our Unit as "esophago-gastro-duodenoscopy."

Biopsies can be taken under direct vision from any point. Brush specimens and washings are obtainable for cytologic examination.

Wi th the s tomach modera te ly distended with insuffiated air, it is easy to observe gastric peristalsis and deviations from a symmetr ic contraction caused by tumor infi l trat ion or by scarring. Evaluat ion of the postoperative stomach may be difficult at times, as it also may be af ter radiat ion therapy for tumors.

COMPLICATIONS

Complications are not near ly as f requent with the fiberoptic ins t rumenis as with rigid or semirigid gastroscopes.319 We have had no complications in more than 3,000 upper gastrointest inal diagnostic examinations. However, when complications do occur, the most f requent one is per/oration. This may occur in the esophagus, in the s tomach or in the duodenum or j e j u n u m (in postgastroenterostomy pat ients) . It has been est imated to occur with variable degrees of frequency, probably somewhat more often than is indicated in the cases collected or reported in the l i terature. Jones et al.,141 reporting from England in 1951 (before the fiberoptic period), found 59 perforations in 49,000 examinat ions, 9 in the stomach and 50 in the esophagus. Smi th and Tanner,269 from 1943 to 1955, had 25 perforat ions dur ing the course of 7,200 gastroscopies, with none occurring in the stomach. Taylor28S analyzed the mechanisms of these injuries.

In 1957, Pa lmer and Wirts219 undertook a quest ionnaire survey and found an over-all accident rate of 0.079% for gastroscopy (267,175 cases) and 0.25% for conventional esophagoscopy (40,540 cases). They noted among the complications reported a significant incidence of "anesthet ic reactions" (42 cases), with an almost 25% morbidity.

In 1966, Ariga3 (in Japan) and, in 1969, Katz149 (in the United States) reported accidents observed with the gastrofiberscope in 0.039% of 70,000 cases (Ariga) and 0.074% of 32,237 cases (Katz) , respectively. These figures are somewhat surprising; based on our own experience and that of others,9 we believe that the current incidence is much lower.

GASTRIC NEOPLASMS

Cancer o / t he stomach and other tumors, such as polyps and leiomyolnas, are some of the more impor tant conditions studied by endoscopy. As seen in

| 7

the Uni ted States, cancer of the s tomach usual ly is recognized at an advanced stage.l,~5 Most casea are referred for endoscopy only after the diagnosis has been made radiologically. In a collected group, Nelson197 found only 23% of 1,241 gastric cancer pat ients gastroscoped. We have a strong belief tha t this si tuation will change rapidly as endoscopy with the fiberoptic ins t ruments takes hold, as it has in Japan. 232 In the past 2 years, we have encountered three ear ly cancers of the stomach barely penetra t ing to the muscular layer, a phenomenon that is rare in the United States (Plate 2). These are the types of cases in which gastroscopy has so much to offer. Many cancers of the stomach diagnosed by x-ray study are inoperable at the t ime of their diagnosis. As stated by Cooley,55 "Far-advanced cancer is easily diagnosed whereas smal l and presumably ear ly lesions are a challenge for the expert" and "There is no proof that radiological s tudy as rout inely employed is h ighly reliable in excluding ear ly or asymptomat ic cancer." He est imates that a completely normal radiologic examinat ion is reported in the presence of clinical cancer in about 10% of cases.

It is hoped that gastroscopy will fi|l this gap. To detect cancer of the stomach "ea r ly" - -o r while it still is in the "mucosal" stage--offers the greatest chance for cure. It represents a challenge to the endoscopist, who must learn to recognize min imal lesions. We urge that all pat ients with persis tent symptoms of longer than 2-3 weeks' durat ion be referred for gastroscopy, par t icular ly if the results of the x-ray study are negative.253

SURGICAL APPLICATIONS

Gastroscopy can also be of considerable value to the surgeon in his preoperative planning and operative approach. We have encountered a number of leiomyomas diagnosed by gastroscopy (Plate 3). In these patients as well as in those with clear-cut cancer, the operat ion can be tailored to the lesion with no t ime lost from frozen sections, considerations of al ternatives and the like af ter the skin incision has been made. The decision as to an abdominal , thoraco-abdominal or thoracic incision is based on the knowledge that the cardia is involved.

Gastric polyps occur in 0.2-0.43°'/o of autopsies.29s About hal f are adeno- matous177 and mal ignant change is present in 5-10%. 185 They are readily diagnosed by gastroscopy (Plate 4) and may be removed endoscopically using tim snare-cautery device, which we have used widely in the colon. Our experience includes approximate ly 20 pat ients with polyps of the stomach or duodenum.

The cause and pathophysiology of gastric ulcers have been the source of much speculat ion and experimentation.76, 200, 24o W h y acute ulcers and erosions m a y heal rapidly and chronic ulcers remain indolent is not known. Most gastric ulcers are found on the lesser curvature (Plate 5). At times, bleeding m a y occur from the ulcer itself; at other times, it may come from gastric erosions in the presence of an intact ulcer.

Gastric ulcers heal slowly and recur often, f requent ly in the same spot.85 Scarr ing and recurrence may be identified endoscopically long before ei ther becomes apparen t to the radiologist. The question of mal ignancy must always be considered. Here, mul t ip le biopsies or brushings from the ulcer

18

edge may provide the correct diagnosis. Improvement in size and appearance, or partial healing, does not rule out the possibility of malignancy 243,253 Gastroscopy offers a heretofore unparalleled opportunity to observe the effects of various t reatment regimens on these ulcers.7. ,t3 With it, and including biopsy and cytology, a diagnostic accuracy of 97% may be achieved in differentiating between benign and malignant gastric ul- cersA. 90. 156

The relationship of ulcers to various drugs (salicylates), ingested agents (alcohol), burns and stress situations is a subject of great interest.77. 151. 277

GASTmTm

Various form's of gastritis may be diagnosed with preci,Jion via the gastroscope, with biopsy confirmation when necessary. This is important, because radiologic diagnosis of this condition is extremely unreliableAS Similarly, segmental hypertrophic gastritis is almost impossible to differentiate from cancer by barium study.

Erosive gastritis probably is not a single entity. Mucosal ulcerations of a superficial type, not involving the muscularis mucosa, are characteristic. Bleeding may occur and may be massive. Possible pathogenic factors are multiple and include stress, burns, trauma, portal hypertension, neurologic disorders, alcohol, salicylates, steroids and some antibiotics. Erosions are difficult to distinguish from shallow ulcers, a distinction that rests with the pathologist.63 Gastric erosions usualty heal rather rapidly, within 2-8 days.94

POSTOPERATIVE GASTROSCOPY

Operative procedures, such as gastric resection, gastroenterostomy and pyloroplasty, produce anatomic and physiologic alterations that may mask or obscure recurrence of the original condition or the development of a local complication. Diagnosis often is uncertain or unobtainable when traditional radiologic evaluations are applied.97, 23o We have encountered any number of anastomotic ulcers (Plate 6, A) in patients examined during acute bleeding episodes, tile presence of which was not divulged by gastrointestinal series performed either during or shortly after the bleeding incident. Similarly, suture granulomata or polypoid regeneration at the line of anastomosis may produce defects difficult to interpret by x-ray, if they are seen at all. Recurrent cancer may be quite hard to differentiate from struc- tural distortions produced by the operative procedure. In fact, x-ray study of the postoperative stomach has been described as "gilt allgemein als die hohe Schule der Gastroenterologie."*

Therefore, endoscopic evaluation has proved a real boon for the study of the postoperative symptomatic patient. Along parallel lines, we have found that the gastroscope frequently furnished a more accurate follow-up assess- ment of the stomach irradiated for cancer, and has the added advantage of biopsy, should the question of persistence or recurrence arise, since this is not always easy to assessA60

*"the ultimate challenge of gastrointestinal roentgenology. T M

]9

The fiberoptic gastroscope offers visualization of the entire stoma after gastroenterostomy (with or without gastric resection) and the instrument tip usually can be passed for a considerable distance into either the afferent or efferent loop.63, 132 This can be particularly useful when there is an ulcer beyond the level of the anastomosis. Special maneuvers may be required to distinguish the efferent from the afferent limb, and when the latter can be entered, and its contents aspirated and cultured, the findings may prove quite helpful if an "aITerent loop syndrome" is suspected. 63. 79

S tomal ulcers continue to be a vexing problem to the clinician, inasmuch as (1) the symptomatology is variable, (2) radiologic detection is notoriously difficult and (3) they may be the cause of acute bleeding episodes. Their occurrence appears to be related to the residual functioning parietal cell mass. A number of carefully followed series indicates an incidence of 2--25(r/o following gastroenterostomy alone (Small267), 1.2-12.7°Xo after lesser gastric resections without vagotomy (Rhea et al.239), 2-5~o following subtotal gastrectomy alone (Small,267 Goligher et al.I08), 4-27% when vagotomy and a drainage procedure have been done (Gotigher et al.,lO8 Hoerr and Ward,136 Jcrdan142) and 3.3% following subtotal gastrectomy plus vagotomy (Hoerr and Ward136). A number of good analyses of late results in adequately followed postoperative patient,J is available in the litera- ture52, 103. ~06-30s, 134, 136, 5 42, 229, 235 , 251, 255, 267 and these should be familiar to the endoscopist undertaking evaluation of this type of case.

Symptomatic stomal ulcers are missed more often by radiologists than are other forms of so-called peptic ulceration..55 Demling et al.63 describe and illustrate these ulcerations in detail and state that "most stomal ulcers are located in the small intestine, just beyond the suture line and are rarely found in the remaining stomach or at the stomal margin." Palmer and Boyce21S and othera30, 132, 266 report similar findings. This diagnostic challenge is ":deally met by modern methods of endoscopy. They afford a most accurate control of the efficacy of therapy for all forms of peptic ulceration and they reveal par excellence the exacerbating influence of various ulcero- genic factors.63~ 132,267

True stomal ulcers, the product of tt/e peptic ulcer diathesis, rarely re- spond well to a medical regimen and usually require some form of surgical correction.216. 266, 267 This being the case, it is important that the endoscopist have sufficient viewing experience and medical background to distinguish them from local erosions and from sites of suture necrosis, entities that do not carry with them the same therapeutic implications. Here, biopsy, as well as carefully conducted secretory studies, may be of assistance, since true anastomotic ulcers usually do not occur in the absence of hyper- chlorhydria3 or after operations performed for gastric ulcer. Palmer claims that anastomotic ulcers occur more than six times as frequently in patients who have been operated on for duodenal ulcer than among those who had gastrectomy for a gastric ulcer or tumor.

Persistent sutures and suture ulcers are found occasionally after gastric surgery and ustmlly are not significant.97,268 They are not commonly symptomatic but they may bleed.97, 216, 26s Described by Paterson as long ago as 1909,22~ their existence still is not generally appreciated, according to Dem- ling et al.63 and Smal1266 (Plate 6, B).

20

Cancer in the gastric remnant a[ter parlial gastrectomy ]or benign conditions is not common but is being recognized with increasing frequency121 as pat ients with subtotal gas t rectomy are reaching advanced age. Here , too, diagnosis is best established by gastroscopylS6 and con f rmed by biopsy or cytology s tudy of gastric washings. Allegedly, the age incidence is the same as tha t for pat ients who have not had gastric surgery.I l l Cure is possible only if the lesion is recognized early,IS6 and the ear ly lesion may require endoscopic biopsy to distinguish it from other conditions.63, 186

Various forms of gastrit is have been noted in the postoperat ive gastric mucosa.63 Since biopsy mater ia l is reported as abnormal, revealing superficial or chronic gastrit is in a high percentage of patients, including some who are asymptomat ic , the importance of such reports is difficult to assess. Certainly, when the pat ient has significant symptoms, the clinic'~an should refllse to be lulled into a false sense of securi ty by accepting "gastr i t is" as an adequate diagnosis but should ini t ia te a vigorous search for other explana- tions of the pat ient ' s trouble.

UPPER GASTROINTESTINAL HEMORRHAGE

Perhaps nowhere in the field of gastroenterology has fiberoptic endoscopy had more impact than on the problem of acute upper gastrointest inal hemorrhage (Plate 7). This applies par t icular ly to the "massive" bleeding episode.

Managemen t of these pat ients a lways is difficult and complicated. First , there is the compelling need for volume replacement. Second, the under- lying condition responsible for the bleeding incident mus t be evaluated and treated. Third , some of these individuals have silent blood coagulat ion defects to begin with and these problems are triggered and complicated by repeated transfusions of stored blood. Fourth , m a n y pat ients are aged33, 81,114,258 or have associated systemic diseases,Sl, i14 the management of which must be coordinated with the replacement of lost blood. Fifth, prolonged hemorrhage and volume replacement may have secondary adverse effects on other organ systems, notably the cardiovascular, the pulmonary and the renal.a8, ~4 And, last, if the bleeding cannot be controlled swiftly by nonoperat ive means, ear ly surgical intervention for the control of hemorrhage becomes an absolute necessity.

Some or all of these factors combine to make the normal diagnostic mo- dalities appear as a formidable and, at times, futile undertaking. Obtaining a history indicative of peptic ulcer disease or hiatal hernia, or sea lching out the s t igmata of liver disease in order to point the finger of suspicion a t esophageal varices, a re shopworn t radi t ional approaches tha t provide a t best an educated guess at the correct etiologic diagnosis.34 Individual pa- t ients cannot be t rea ted on the basis of "statist ical probabili t ies."

T ranspor t ing the pa t ien t to the x-ray depar tmen t for an emergency gastrointest inal series, par t icular ly in the small hours of the morlfing, obviously is a complicated task. I t is best accomplished if and when there is a quiescent interval between acute bleeding episodes. However, the yield from such a method of investigation leaves a great deal to be desired, par- t icularly since a thorough radiologic s tudy cannot be accomplished under

21

the circumstances. Cooley~5 states "Every experienced radiologist is im- pressed by the number of patients with massive gastrointestinal bleeding in which he is unable to find the source." Reports of the accuracy of radiologic diagnosis in acute upper GI hemorrhage from 15% to 50% and the method has fallen into disuse over the past decade.

In the past, efforts were made to implicate or exclude esophageal varices by esophagoscopy using t h e r i g i d open-end scope--a difficult, somewhat risky and usually nonproductive approach---ox by splenoportography. The latter method, 'performed properly, can demonstrate varices and measure portal pressures with a high degree of accuracy.66,248, 2a9 But, again, it involves transport of the patient to the x-ray depar tment and, even if varices are shown to be present, there is no assurance that they are the cause of hemorrhage. Splenic pulp manometry has been offered as an emergency diagnostic measure that can be done at the bedside,220 but this, too, provides only an inferential diagnosis.

In recent years, a more precise angiographic method for the detection of the bleeding source has been devised and this technic promises a high degree of diagnostic accuracy if it is performed during the bleeding, episode.ll. 12, 2~ The method haz the added advantage that bleeding frequently may be controlled by the ivffusion of Pitressin via the angiography cathe- ter.5, 2,~ Again, the team effort and facilities required, particularly at odd and unexpected hour~ may limit widespread use of this new and valuable rnodality.

Emerge-hey upper gastrointestinal endoscopy with fiberoptic instruments has a great deal to offer. The procedure is rapid, safe and informative. I t can be performed at the bedside or in the emergency room. This vigorous diagnostic approach to the problem of acute upper gastrointestinal bleeding, first suggested by Carter and Zamcheck3S and long espoused by Palmer215 and other experienced endoscopists,26, 27, 31, 131, 271,319 is n o w being carried out in many centers.94,117, 150, ?.510 280 Most of the reports unfavorable to endoscopy deal with the clinical experience prior to the past 5 years.ll4 It is important to emphasize that to be of value, the endoscopic examination must be done during the acute bleeding phase. Delays of even a few days may !~,.~;~ to an ir~c:.:rrect diagnosis.94,131

At the Be*&. Israel Medical Center we started such a progr~am more than 6 years ago and have done to date more than 600 emergency endoscopies for bleeding: There has been no mortali ty, an insignificant morbidity and an accuracy of well _over 95°-/o in determining the site of bleeding.

For the surgeon called in on, or following from the onset, a pat ient with bleeding, the information provided by endoscopy is of critical importance. For decades, surgeons have struggled with the problems of localizing the source of bleeding at the operating table and of deciding what to do when no active bleeding and no obvious cause for the bleeding can be found. For reasons not clearly understood, hemorrhage sometimes ceases after induc- ti9n of anesthesia and completion of the laparotomy incision. Since no further operative procedure seems indicated, the patient may be closed and returned to his room, only to have the bleeding start afresh.59 From such discouraging experiences came about the "blind "gastrectomy"~a subtotal gastric resection performed in the hope that the removed tissue would

22

ei ther encompass the bleeding point or b r ~ g about functional changes that would discourage its reactivation.36, 59

Appropr ia te measures for surgical t r ea tment of the bleeding duodenal , gastric or anastomotic ulcer are covered well in the li terature, but the best method for deal ing with dif/use hemorrhagic gastritis remains a chal lenging problem, par t icu lar ly in some 15% of these cases that come to operation.77,170, 181,214 The cause of this as yet incompletely understood condition still is under investigation77 and suggested surgical procedures range from vagotomy to total gastrectomy. The reported shortcomings of the s tandard procedures (subtotal gastrectomy or vagotomy and pyloroplasty) impose an added burden on the surgeon and support his need for an accurate diagnosis before operat ion is undertaken.34, 36. 181

Pat ients with l iver disease and demonstra ted esophageal varices were, in the past, subjected to emergency portal-systemic shunt ing operations in an effort to reduce por ta l pressure and thereby control bleeding. Only with the advent of emergency endoscopy did the realization come about that despite the presence of varices or increased portal pressure, the major i ty of these patients were not bleeding from the varices themselves but from other sources, most of which are not responsive to a shunt ing operation.

Wi th the flexible csophagogastroduodenoscope, emergency examinat ion of a "GI bleeder" is a much easier procedure than with the old rigid or semiflexible ins t ruments . Each endoscopist has his own routine in performing the procedure. Pa t ien ts are not a lways pouring out blood constant ly and we have found unremi t t ing vigorous bleeding as an obstacle to examinat ion in less than at 1 ~o of cases. In most pat ients , active hemorrhage is inter- mit tent . In our program, however, no effort is made to time the endoscopic procedure with cessation of bleeding, for undue procrastination may be deleterious. We see the pat ient as soon as we are asked to do so.

If the pat ient is vomit ing blood profusely, gastric lavage with cold sal ine general ly will provide enough clearing to permi t endoscopy. Other pat ients may retch and spontaneously evacuate the stomach and esophagus, and this should be encouraged and abetted by the endoscopist, ~s it is one of the best means of ensur ing evacuation of large clots. The abili ty to inflate the esophagus and stomach with air during the fiberoptic examinat ion provides better viewing than previously was possible with the rigid scopes. Moroover, the instmlment lens can be washed at will. General ly , if the exact bleeding point or points cannot be identified precisely, an experienced endoscopist usual ly can say whe ther the bleeding is coming from the esophagus, the proximal stomach, the distal stomach, the duodenum or from mul t ip le sites. This knowledge alone is of great value, par t icu lar ly to the surgeon. Since the beginning of this program at our insti tution, it has never been necessary to perform a blind gastrectomy on a pat ient who was endoscoped prior to operation. In a few instances, surgeons have asked for endoscopy dur ing laparotomy and, even under these circumstances, endoscopy sometimes has proved helpful in locating the source of bleeding.280 (If in t raoperat ive endoscopy is done, the surgeon should compress the distal duodenum or proxi- ma l j e junum between his fingers to prevent air distention of the small bowel.)

Table 1 gives the causes responsible for bleeding in 471 of our cases that

23

i i l l i i J i I t -

T A B L E 1 . - - C A U S E S FOR BLEEDING IN 471 CASES (FROM JANUARY, 1970)

SOURC~; CAUS~ TOT^L % Esophagus 50 . . . . . . . 10.6%

Varices* 29 6.1 Es~phagitis 16 3.4 Carcinoma 3 0.6 Mallory-Weiss 2 0.4

Stomach ............. .. 245 . . . . . . . . . . . . . . . . . . 52.0% Acute gastri t ist 88 18.7 Ulcer 118 25.0 Carcinoma 28 5.9 Polyps 4 0.8 I~iomyoma 6 1.3 Telangiectasia (O-W-R) ~: 1 0.2

Duodenum . 135 . . . . . . . . . . 9.8.6% Ulcer§ 128 27.2 Erosive duodenitis 7 1.5

Marginal ulcer. 18. 3.8% Undiagnesed 9-3 . . . . . . 4.3%

No bleeding site 9 1.9 Bleeding excessive 14 2.4

TOTAL 471 100% Complications: None

*Pltt~ 13 cases with nonbleeding varices. tErosive gastritis present but deemed not pr imary catme of bleeding in:

50% witb esophageal varices; 5.4% v, ith gastric ulcer; 15.5% with duodenal ulcer.

$Osler-Weber-Rendu. §3 had associated nonbleeding gastric ulcer.

were analyzed recently. Reports of a similar nature have appeared from other clinics.94, 117, 151, 28o

A body of new and important facts have emerged from the data provided by early endoscopy: (1) a sizable percentage o/ bleeding lesions are quite superficial--so-called erosive or hemorrhagic gastritis--and these cannot be disclosed by customary radiologic technics; (2) bleeding sites o/ten are multiple rather than single2SO and it may be difficult, if not impossible, to determine the dominant source; (3) the nature of the bleeding source may involve more than a single type o~ lesion, as, for example, an erosive gastritis or reflux esophagitis superimposed on varices280; (4) patients may not always bleed from known lesions.25, 2so In our series, we found some patients with a known and demonstrable gastric ulcer bleeding from a hemorrhagic gastritis and some patients with known and visible esophageal varices bleeding from gastric erosions; (5) the pattern of etiologic/actors caus#~g bleeding depends ~r,. large measure on the patient population served by the institution involved. In other words, in certain clinics, the incidence of esophageal varices will be high and in others quite low, depending on the drinking habits of the local populace.

I t is difficult to answer the question of how much changing patterns of bleeding etiology can be attr ibuted to more accurate diagnosislSl and how much to altered living styles. Drugs such as aspirin, alcohol, steroids and anticoagulants are being used with increasing frequency, and such usage was elicited from the history in 50~o of one group of patients.ll4 In another

24

study, 1 pat ient in 3 among a group hospitalized from 1963 through 1967 took drugs as opposed to only 1 pat ient in 12 seen from 1953 through 1957.2~8 Bleeding from hemorrhagic gastritis and stress ulcers seems definitely to be on the increase.33, s2, 110, 280 In part, this is a reflection of the early use of endoscopy, since these lesions cannot be diagnosed by x-ray studies.

DUODENOSCOPY

In 1961, Hirschowitz,126 whose pioneering efforts culminated in universal acceptance of the fiberoptic endoscope and moved the ins t rumenta t ion out of the "Model T" era, was the first to report endoscopic examinat ion of the duodenum. By the following year, he and his associates129 reported a 50rYe success rate hi entering the duodenum. Others soon reported comparable s u c c e s s . 3 1 , ,16, 207,264

Fur the r advances in ins t rumenta t ion in the late 1960s resulted in a flood of reports from J a p a n indicating a newly acquired ease of entry and examination of the duodenum.148 Soon thereafter, mere inspection of the duodenal interior was succeeded by concentrated study of selected impor tan t areas, such as the ampul la of Vater, examined and cannu |a ted by Watson in 1965297 and others,148. 205 and of specific pathologic conditions.148, 205, 264 By 1971, groups were reporting a 95.7-100/°7o success rate in enter ing the duodenum.148

The second par t of the duodenum can be entered with the longer forward- viewing ins t rument but it was only the side-viewing ins t ruments that made complete duodenoscopy a reality.~,~, 4,~, 48

As a consequence of this technical progress, it became possible to diag- nose or rule out the presence of duodenal ulcers, ulcer scars and deformities, diverticula, polyps, "duodenit is" (an ent i ty of uncer ta in specificity) and carcinomas of the duodenum, papil la of Vater and, sometimes, the head of the pancreas.'l~. ~,ss, 20n. 264 Where duodenal ulcers could not be seen "en face" because the pylorus was deformed or constricted, preventing duodenal entry, sometimes they could be viewed at a distance through the pyloric ring.14s Moreover, the observation of mal ignancy often could be verified by a biopsy accomplished with great ease and safety via tbe endoscope.

It soon became apparen t that the direct visual examinat ion led to greater precision and reliabil i ty in the diagnostic approach to duodenal diseases. Kasugai and co-workers 14s reported that of 136 cases in which the radiologist reported only "deformity" of the duodenum as presumptive evidence of ulcer disease, they were able to show a definite ulcer scar in 67 patients and an "open ulcer" in 28 others. Belber 15 found that endoscopy demonstrated 94% of 70 ulcer craters and x-ray examinat ion only 64%. Ref inements in such radiologic technics as hypotonic duodenography10.2o, 8o have narrowed this gap, but this form of study is not done by the rank-and-file radiologists or gastroenterologists.

With the tradit ional zeal of the new explorer in describing and mapl)ing out the features of this new lerri iory, a spate of articles have been presented that a t tempt to classify the anatomic and pathologic var iants encountered. The value of and practical need for such analyses have not yet been demonstrated.

25

Duodeni t i s is a diagnosis that is being made with increasing frequency since the advent of duodenoscopy.15, 98 However, the validity of such an interpretat ion, par t icular ly when it is made without biopsy, as indicative of a true clinicopathologic state is open to question. 40, 42, 9s Endoscopic studies have shown that duodenal ulcers are not usual ly accompanied by inf lammatory changes in the bulb.40, 42 Certainly, with the large numbers of gastroenterologists and endoscopists who have learned to use the fiberoptic ins t ruments we can expect to learn a great deal more in the near future about the natural history and response to therapy of duodenal disease, par t icular ly duodenal ulcer (Plate 8). It also is not unreasonable to assume that earl ier detection of duodenal and ampul la ry neoplasms will occur at an asymptomat ic stage, when endoscopic examinat ion is carried out for other reasons. Thus, cancers of the duodenum and ampul la ry area, which carry with them a better outlook in terms of curative surgical resection than cancer of the pancreatic head,17, 173, 228 will be discovered and operated on under more favorable circumstances.

AMPULLARY CANNULATION

One of the most exciting and unexpected benefits of fiberoptic endoscopy has been the discovery that it is possible to visualize and cannula te the ampul la of Vater (Plate 9) with the side-viewing scopes that can be introduced into the second portion of the duodenum. By this route, entry is obtained to the bil iary and pancreat ic duct systems, which then can be injected with contrast mater ia l and visualized radiologically. This provides a new means for study of the jaundiced pat ient and access to the pancreas, an organ long frustrat ing to the diagnostician because of its sequestered anatomic position. Some of the available diagnostic technics to demonstrate tumors of the pancreas are listed by Baum and Howe10 as follows: indirect methods include conventional bar ium meal, cineradiography, hypotonic duodenography, percutaneous cholangiography, splenoportography and cavography; direct methods include retroperitoneal gas insufflation, selective ar ter iography, operative pancreatography and Magna scan with 75Se methionine.

Watson 297 first described endoscopic visualization of the ampul la of Vater.

The first report of cannulat ion of the ampul la and visualization of the bi l iary and pancreatic ducts using an endoscope was by McCune et al. 172 The relative safety with which the pancreat ic ducts could be outlined by racliologic means was demonstrated in the intraoperat ive technic described by I)oubilet, Poppel and Mu~holland.74 Additional reports soon followed attest ing to the usefulness of the procedure,152, 289 although some regarded it as dangerous227--an at t i tude not borne out by clinical experience. In 1968, Rabinov and Simon235 described an ingenious peroral method of cannulat ing the ampul la under fluoroscopic guidance, but the procedure was t ime-consuming and not consistently successful. Following McCune 's report of his successes util izing a side-viewing fiberoptic duodenoscope, the procedure gained rapid acceptance in Japan.202,203, 285. 286 It was arduous and t ime-consuming at first, and cannulat ions were accomplished successfuliy in

26

only 30-75% of all attempts, with different groups achieving different success rates but all improving with experience to a near perfect score.22, 24, a2, a4, 57, 58, 14s, zoo, 25o, zgG A wide variety of clinical conditions were diagnosed and, as Kasugui et al.14s state, "I t is evident that EPCG (endoscopic pancreatocholangiography) can define and c!arify lesions which previously could not be elucidated without laparotomy." They describe the normal and abnormal pancreatocholangiogram. Ogoshi et al. 2o~ were able to cannulate and obtain satisfactory duct visualization in 90% of 252 patients, with

86 to. contrast filling of the pancreatic duct in 98% and of the biliary tract in az They described in detail their abnormal x-ray findings and warned against false positives, false negatives and air-bubble artifacts. They observed no adverse reactions in applying the method to patients with acute pancreatitis, al though'this is controversial. In chronic pancreatitis, the films can de- lineate the severity and extent of ductal deformity and the presence of cal- culi, pseudocysts and cancers.

Retrograde c h o l a n g i o g r a p h y is more difficult to perform but is capable of bringing about a diagnosis of ductal carcinoma and calculous disease, which might otherwise be impossible without surgical intervention.

In England, two early reports by Cotton et al. r,7, ms emphasized the great diagnostic Value of the method and gave the following indications for study: (1) persistent jaundice of the obstructive type, (2) suspected biliary tract disease and (3) suspected pancreatic disease. Patients were selected for endoscopic retrograde cholangiopancreatography (ERCP) in preference to pancreatic cytology studies, angiography and isotope scanning, but only after s tandard investigations had failed to establish a diagnosis firmly. The contrast substances used were Urografin (60%) or Hypaque (25%). Cotton e t al . 's careful technic is described in detail and their over-all success rate

Of. for cannulation is 70 ~o They note a "happy tendency for the cannula to enter the more relevant duct system first" and were able to outline this duct system in 70% of attempts. When the "wrong" duct was filled first, appropriate maneuvers rendered the other duct radiopaque in more than half their cases.

In another report by this group, Blumgart et al.U2 analyzed the problem of the jaundiced patient and found that ERCP gave a definitive diagnosis in 75% of patients (66 of 87). In 15 others, laparotomy was avoided when the study showed the extrahepatic duct system to be normal. They avoided using the method when the serum test for Australia antigen was positive, for fear of transmitt ing hepatitis. Although this stance has some theoretic merit, there are those who avoid the dilemma by not testing for Australia antigen.

Percutaneous transhepatic cholangiography was used only when E R C P failed to provide a diagnosis or when it was desirable to visualize the upper end of a ductal obstruction. We have used the combination of bothS8 and believe it has considerable merit, particularly for primary carcinoma of the biliary ducts, in which delineation of the proximal and distal extent of the lesion may help in planning the surgical approacha08 along the lines so mas- terfully described by Longmire et al.i 69 The advantage of E R C P over transhepatic cholangiography allegedly is greater safety and the fact that it does not have to be followed immediately by operation. This is Crue, although

27

the English group did not have the same high diagnostic success with transhepatic cholangiography alone that we have experienced.S8

Blumgart et al. pointed out the advantages of E R C P over the usual radiologic studies and over hypotonic duodenography. They also emphasized its availability when jaundice is too deep to permit the use of intravenous cholangiography. They stated that "in cases of suspected obstructive jaundice, there is no longer any need for a prolonged period of observation before deciding on laparotomy. Successful E R C P can precisely confirm or refute the dia~,mosis of obstruction." Surgeons, universally, will applaud this attitude.

In the United States, reports by Vennes and Silvis 296 and by Braasch and Gregg::4 are available. Vennes believes that the method has major diagnostic potential but suggests that "this is the most difficult of the currently employed gastrointestinal endoscopy procedures." Both grvups predict that the method will have greater clinical application in diseases of the biliary tree than in pancreatic conditions. Undoubtedly there is a need, in the absence of an obvious advanced stricture or calculus, to know just what con- stitutes a normal and an abnormal pancreat~gram.

Most of the reports indicate a surprising dearth of complicat ions following E R C P aside from a transient elevation in serum and urine amylase values. Rapid injection of contrast material and overdistention by injection pressure or an overload of cnntrast material is warned against by all. The English group encountered two instances of coliform septicemia, both re- sponding well to prompt antibiotic therapy. Septicemia has been encountered by others. The risk of transmitting hepatitis by the procedure still is not well defined.

In short, then, endoscopic retrogra~:~e pancreatocholangiography (E1RCP) is a potentially valuable procedure requiring, in the words of Cotton, "a practised endoscopist, an enthusiastic radiologist (with his sophisticated equipment) and at least one know',edgeable technical assistant."

MorrisseylSS has questioned th~s in the form of an editorial "To Cannu- late or Not to Cannulate." I-Ie argues that the expense of iustruments and skilled personnel required, the long practice needed to at tain technical pro- ficiency and the possible complications all militate against too ready an acceptance of the method. But, as pointed out by Cotton and in Safrany's report, a striking improvement can be expected in success rate and time needed for cannulation with increasing experience.

In his lecture on "Progress in the Surgical Treatment of Pancreatic Dis- ease," Rodney Smith st2tes, "The indication for surgery should be clear and the correct operation . . . selected for each individual patient."270 Endo- scopic retrograde pancreatocholangiography helps make this possible.

In our experience, we have not attained the same degree of success in cannulating the appropriate duct systems as reported above. Certairfly success rates improve with experience. One obstacle to better accomplish- ment in the United States has been the failure to have Buscopan--a relax- ant of the ampullary sphincter--approved.

Technical factors are extremely important, as described by Blumgart et al. 22 False positive findings may lead to unnecessary operations (Fig. 7) and therefore must be kept to a minimum.

28

PLATE I PLATE 2, A

PLATE 2, B

PLATE 2, C

PI,ATE 1 . - - E n d o s c o p i c view of t iny po lyp pr ior 1o removal (see Fig. 5). In such a (.~tse, b iopsy is t a n l a m o u n t lo excision. (The.se t iny po lyps are n o t included in p o l y p e c t o m y sta| isli(:s.)

PLATE 2 . - - A , endos rop ic view of :dmllow ulcer of grenter curwl ture nspec! of ston~ach. Sew~ral biopsies anti r y t o l o g y s |ud ies were repor led ~L,~ nega l ive for m a l i g n a n r y . IJ and ( ' , surg i ra l spec imen showing shal low ulcer. Surgical and gross pal hologic d iagnoses were: benign ulrer . Mir roseopic examinat ior t s showed ea r ly adenoenrc inoma, " w i t h the nml ignant g lands con- tained wititin the museu la r i s mucosae "

29

Fw,. 7 (top).--Y~etrograde visua l iza t ion of b i l i a ry t r ac t in pa t i en t with clinical p ic ture of obs t ruc t ive j aundice and h i s to ry of c o m m o n duc t su rge ry for calculus 1 y e a r previously . A shows duodenoscope in place anti bile ducts filled with con t ras t ma te r i a l . In B there is a filling defect (arrow.c) diagnosed as a calculus. At explora t ion , nothing was found in the com- m o n bile duct , which was of normal cal iber.

Fw,. 8 (bottom).--Endoscopic re t rograde cannu la t ion of a m p u l l a of Va~er with v isual iza t ion of panc rea t i c duc t (A) and b i l i a ry s y s t e m (B) . A calculus is seen a t ~),e lower end (arrow).

Good pancreatograms (Fig. 8) can be very satisfying, but help offered by such duct delineation in determining the proper surgical procedure in cases of chronic relapsing pancreatitis still is a matter requiring further study.

COLONOSCOPY

tOSTORY

The historical development of the colonoscope has already been briefly reviewed and we refer to other publications for greater detai]..~09, 317 It is

30

inevi tab le tha t this impress ive tool will a t t a in an i m p o r t a n t diagnost ic and the rapeu t i c role, for it is essen t ia l ly an extens ion of s igmoidoscopy and proctosigmoidoscopy. According to Paulson,222 "Proctos igmoidoscopy with biopsy is the best s ingle diagnost ic me thod in d isorders affect ing the rec tum and lower s igmoid." I t appea r s a lmost inescapable that eolonoscopy will be accepted in hospi ta ls and cl inics th roughout the world as more ind iv idua ls are t r a ined in its use, technics are s impl i f ied and perfected and i n s t rumen t s are improved and modified according to need. Th i s can and mus t occur if for no o ther reason than its potent ia l with respect to cancer of the colon. Cancer of the large in tes t ine is the most common form of visceral cancer in the Uni ted States" and it is a curable disease, it not indeed a p reven tab le one! Pred i spos ing factors and po ten t ia l ly m a l i g n a n t condi t ions are qui te well recognized, the lesion is slow-growingt'.~2,273 and the ana tomic disposi- t ion of the large bowel is such tha t it lends i tself read i ly to surgical excision. W i t h the colonoscope, p recancerous lesions can be identif ied, biopsied and somet imes removed, and cancers can be diagnosed when s y m p t o m s still a re m i n i m a l and the disease is ye t at a curable stage. It has been var ious ly esti- ma ted tha t at least 3 of 4 pa t ien ts migh t be saved by ear l i e r diagnosis and proml)t treatment.2, 1:.~, 60,262

TERMINOLOGY

T h e terms "colonoscopy" and "co/oscopy" a re both used in connect ion wi th endoscopic examina t i on of the colon. We have no s t rong feelings in this regard but have prefe r red the te rm "colonoscopy,":~07 because (1) it is ety- mological ly correct, (2) i t is a l r eady in most medica l dictionaries2S. 73, '-,75 and (3) it is less l ikely to be confused with "co loscopy" - -a te rm appl ied to the inser t ion of a s teri l ized, rigid s igmoidoscope into the bowel dur ing celi- o tomy ( lal)arotomy)275--or with "colposcol)y," an en t i r e ly di f ferent procedure.

TECHNIC

ANESTllESlA.mDiagnostic colonoscopy is done on an a m b u l a t o r y basis wi thout general or local anes thes ia . Al though some au thors r ecommend genera l anesthesia,16, 1t5 we believe tha t this is not only unneces sa ry but ac tua l ly cont ra indica ted .

Our pa t ien ts f requen t ly receive p remedica t ion of m e p e r i d i n e (Demerol ) 50-75 mg a n d / o r d iazepam (Val ium) 2-1.0 rag, admi n i s t e r ed in t ravenous ly i m m e d i a t e l y before the examina t ion . W e have had no adverse effects with this regimen in several thousand colonoscopies.

Pl~EPARATION.~Preparation of the pa t ien t for colonoscopy is not difficult but requires careful a t ten t ion to the prescr ibed regimen. W e recommend a fluid diet only for 24 hours pr ior to examina t ion , castor oil 45 ml the evening before and a tap-writer enema unti l re turns are c lear to be admin i s t e r ed at letlst 2 hours before examina t ion time. On this routine, most pa t ien ts are well cleansed. T h e impor tance of an absolute ly clean bowel cannot be over- emphas ized , for unless the bowel is well p repared , per fora t ions m a y occur and lesions m a y be missed. Should the pa t i en t present with an i nadequa t e l y

31

, i i

~,.. .... , . ~ ~ , - ~ ¢ ; , , , a ~ .

• ~ :~.:.; ' : ' , ~ ,7 . ; rd~ . " ,

PLATE 3, B Pt.ATE 3, A

PLATE 4, A PLATE 4, B

PLATE 8

[)LATE 3 . - - L e i o m y o m a of greater curvature of s tomach as viewed through gastroscOl)e.

PLATE 4 . - -Gas t r i c polyps as seen through tile gasir(~cope.

PLATE 5 . - -Endoscop ic view of chronic gastric ulcer at incisura angularis.

32

PLATE 6, A PLATE G, B

PI,ATI~ 7, ]~]

DLATE 7. A

|~LA'r['~ 6 . ~ A , anas tomot ic uh'er seen at time of acute hemorrhage. Upl)er ga.~troirdeslinal series within 48 hour~ failed t o s h o w this lesion. B, ench)srol)ic view of suture uh'er at lille of a rials {or¢los is .

J'LATg 7 - - A , disial esol)|ulgus of patient with ~truie upper gasirointeslin~d hemorrhage as sc.,.eli Ihrotl/.lh esuI)h~0Iogas|roscope. A lhromhus r~m I)e seetl ill a blec(ling varix. B. s tomach of another Imtienl wilh acute bleeding episode, t His tory of sa l icyla te inge.~iion obtained. ) -I']ndus- (:opy showed extensive hemorrhagic gastritis.

33

cleansed bowel, ano the r immed ia t e e n e m a m a y be adequate ; otherwise, the procedure,, mus t be l)ostponed and the p r epa ra t i on regimen con t inued for ano ther 24 hours. To do otherwise is to ask for trouble.

EXAMINATION.-- -The pa t ien t lies on the e x a m i n i n g table in the r ight re- cumbent posit ion with the examine r s i tua ted in front. Most pa t i en t s m a y be examined wi thou t change from this position. W h e n fluoroscopy is used, the l)atient is rolled back to a supine posit ion once the i n s t r u m e n t has been advanced beyond the s igmoid colon, and the s tudy is cont inued in th is position. Inser t ion of the i n s t r u m e n t is preceded by a careful digi tal e x a m i n a t i o n of the rec tum with a wel l - lubr ica ted finger. Somet imes surpr i ses resul t from this s imple maneuver , such as f inding a wel l -advanced rectal cancer. T h e lubr icated tip of the scope then is in t roduced gently through the anus into the rectum. T h e r e is absolutely no need for any of the in t roduc tory specula suggested by some manufac tu re r s . T h e i n s t r u m e n t then is advanced through the rectosigmoid by a combina t ion of d i rec t v isual iza t ion of the l u m e n and a sense of pa lpa t ion t r ansmi t t ed th rough the ins t rument . Air insuf l ta t ion to open up the bowel should be minimal" a t thiz stage. W a t c h i n g for the lumen, the i n s t r u m e n t is advanced under d i rec t vision to the expected level of the lesion. W h e n e v e r feasible, examina t ion should cont inue beyond this point to the full length of the ins t rument . As the scope is wi thdrawn slowly, the en- t ire c i rcumference of the bowel mus t be scrut in ized careful ly . Somet imes lesions a re concealed behind an angu la t i on or a valvular fold and somet imes the bowel, te lescoped on the i n s t rumen t , s l ips r ap id ly awffy as the ins t rumen t is w i thdrawn . In order not to miss any th ing , the scope m u s t be re- advanced and aga in removed slowly. N u m e r o u s authors have addressed themselves to the technical aspects of inse r t ion of the instrument.68,196, 252

At the level of the lesion, biopsies or washings for cul ture or cytologic s tudy are taken.

T h e reasons b e h i n d full inser t ion of the ins t rument , even beyond the a rea of concern, have come with exper ience and knowledge of colonic lesions. In the case of polyps, the possibil i ty of one or more addi t iona l polyps is greatl.~4, 2,12,281 and, more impor t an t ly , the choice of f inding an unsuspec ted ca r c inoma ' i s real enough to w a r r a n t the ext ra effort. ~20, ~9z, 263, 283, 298, 316 W h e n a cancer is encountered, aga in one should a t t emp t to survey the bowel proximal to the lesion, if this can be accomplished. Some t imes one or more polyps a re seen tha t one should remove endoscopica!!y or a t the t ime of operat ion. H e a l d a n d Lockbar t -Mummery116 reported associa ted ben ign tumors in 60% of~their cases of colorectal cancer ; a l though some appea red dur ing pos topera t ive follow-up, m a n y of these undoubted ly were p resen t but missed at the t ime of the or iginal resection. Polyps in associa t ion wi th cancer at the time o] diagnosis have been repor ted as follows: Swin ton and Weakley,283 25%; S h e p h e r d and Jones ,26325~; Welch,298 25~,; Morson and Bussey, 192 33%; Helwig,119 50%. I t is e x t r e m e l y difficult to f ind such lesions dur ing operation,51, ~J6 pa r t i cu la r ly in obese pat ients , even if opera t ive colotomy and coloscopy through m u l t i p l e incisions in the bowel are added.62, 91, 15~, 157, z83, 28~ T h e r e is some indica t ion tha t in t roduc ing the fiberoptic colonoscope per anus du r ing the operat ive procedure m a y prove to be of some benef i t in this regard.g2,241

Moreover , p a t i e n t s with cancer of t he coIorectum m a y have synch ronous

34

cancers tha t a re overlooked or m a y develop me tach ronous colonic carcino- mata . Mul t ip le colonic cancer has been covered in several excel lent reports,:~2, 101, 12z, 1~;.t, 19~, 226,246 Hea ld and Loekhar t -Mummery ,116 Ginzburg and Dreiling,102 S p r a t t and Hoag,273 P e a b o d y and Smithwick22.~ and o thers have suggested tha t subsequent ly discovered, a l legedly m e t a c h r o n o u s new growths ac tua l ly were synchronous t umor s missed a t the first opera t ion .

CASE 1 . - - A 49-year-old while male. P a t i e n t had a br ief episode of rectal bleeding for which sigmoidoscol)y and b a r i u m e n e m a were done. T h e fo rmer was negative; the l a t t e r revealed a ca r c inoma of the proximal ascending colon. Before con templa t ed r ight hemicolec tomy, colonoscopy was requested. T h e lesion in the ascending colon was verified. However , a n o t h e r p r i m a r y ca rc inoma and a polyp were found in the sigmoid colon. Sub to ta l colectomy was car r ied out encoml)assing all lesions (P la te 10).

FLUOROSCOPY

Fluoroscopy was used regular ly in our initial 25-30 pat ients when, for the first time, we used the fiberol)tic i n s t r u m e n t to examine the colon beyond the rectosigmoid area . I t short ly becan,e a p p a r e n t that this addi t ional fea- tu re usua l ly is not requi red routinely and now it is used in unde r lOO;, of all examina~,ions. At present , fluoroscopic a n d / o r x - ray s tudy is added unde r the following c i rcumstanees :

1. W h e n the sigmoid colon is acute ly angu la t ed or fixed as the resul t of a previous ope ra t ion (usual ly pelvic in women) or previous i n f l a m m a t o r y disease (usual ly diver t icul i t is) .

2. W h e n the sigmoid colon is excessively long trod redundan t . 3. For equivocal lesions on ba r ium enema , to verify tha t the a rea in que~s

tion has been en te red and examined. 4. For cecal lesions, to confirm cecal en t ry . 5. For d e m o n s t r a t i o n of sinuses or f istulae, where con t ras t m¢lterial can

be injected d i rec t ly into the t rac t vi~! the colonoscope. T h e r e is reason to avoid fluoroscol)y as much as possible becaose of ra(li~l-

tion exposure to pa l ien ts as well as to examine r s , and hecause x- rad ia t ion causes physical d a m a g e to the glass fibers of the ins t rument , giving them a yellowish discoloration.2,~2

,SELECTION OF INSTRUMENTS

The i n s t r u m e n t s genera l ly in use a t tile p resen t are those t ha t reach to about the mid t r ansve r se colon ( A C M I FO-9000 P - - 1 0 5 cm and O l y m p u s C F - M B - - 1 1 I cm) and those tha t pe rmi t examina t ion of tile en t i re colon (Olympus C F - L B - - 1 8 6 cm, A C M I FO-9000 P1~--165 cm and M a c h i d a ~ 183 cm). T h e i n s t r u m e n t we conducted our origin~d studies wi th was the O lympus C F - S B , 86 cm in length and reach ing to about the splenic flexure on full t )enetrat ion. Th is model is no longer available.

Rout ine e x a m i n a t i o n s should he conducted wi th the 105-cm or 111-cm in- s t ruments , pa r t i cu l a r ly for the f r e s h m a n endoscopist , as the longer scopes a re more c u m b e r s o m e to handle.

35

PLATE 8 PLATE 9

PLATE 10 PLATE 11

PLATE 12

PLATE 8.--Endoscopic view of chronic duodenal ulcer.

PLATE 9.~Endtxscopic view of cannula entering ampulla of Vater.

PLATE 10.---Surgical specimen from Case 1" showing synchronous carcinomas of ascending colon and sigmoid colon plus a polyp in the latter area. Only the tumor of the ascending colon appeared in the barium enema.

PLATE l l . - -Surg ica l ly resected colon of a patient with known colonic polyps of many years ' duration and numerous barium enema studies. In addition to the multil)le polyps, a fairly large carcinoma is seen in the ascending colon in. this subtotal colectomy specimen. Lymph nodes were fr~e.

PLATE 12.---Surgical specimen showing early pr imary cancer of the cecum disclosed by colonoscopy.

36

With a very redundant sigmoid colon, frequently it is difficult to advance the instrument beyond the midtransverse colon, since the axial forces required to advance the tip are dissipated by expansion of a sigmoid loop. Here, the stiffening device (see Fig. 3, A) mentioned previously has great usefulness. Placed on the scope prior to insertion, it is advanced after the tip of the instrument has entered the ascending colon, or beyond, producing the effect shown in Figure 3, B, whereupon further progress becomes considerably easier to achieve. We have not had experience with the various wires and other devices designed to accomplish the same end.

BIoPsY

Biopsy may be taken under direct vision by the special flexible biopsy forceps that are provided by the manufacturers. These are inserted via the biopsy channel. They are rather small (see Fig. 5 and Plate 1), measuring 2-3 cm in diameter when closed and 6-8 cm when fully opened. A useful application of the biopsy forceps is to assist in estimating the size of a particular lesion. The eyepiece of the colonoscope provides a magnification factor of 12.5. Such is the clarity of vision through the instrument that objects are in focus from a few millimeters to infinity, so that distance of the instrument tip from a particular lesion will influence its apparent size. By placing the biopsy forceps alongside, in a closed position, one is provided with a rapid comparison marker. (With experience, an endoscopist can make surprisingly accurate estimates of size without this device.)

Biopsy is a surprisingly safe procedure, and, as noted previously, we have performed several thousand without adverse effect. One must be aware of the fact that the biopsy is rather superficial and may not get deep enough to demonstrate a submucosal lesion.

At this point, it is quite important to recognize the fact that biopsies have only a relative value. In inflammatory disease, the site of biopsy must be selected carefully and in only a few conditions will biopsy be pathogno- monic. For polyps, biopsy can never rule out the possibility of malignancy and sometimes cannot be depended on to furnish accurate information with respect to the histologic variety of the polyp. Only complete excision and multiple sectioning can prevent the possibility of invasive cancer. We have emphasized this point in previous communications, as have many others before us.6, 1~9, :7,~. 191. 293 Frozen sections done from the whole lesion have serious limitations as well, unless there is extensive carcinomatous change, since freezing mutilates the specimen and impedes careful study of what remains of it. We warn strongly against this. Biopsies, removed portions of polyps or whole polyps should be fixed in routine fashion to permit optimal pathologic evaluation.

We have found316 that polyps cannot always be categorized as "adenomatous" or "villous," a fact brought out by Welch, 298 who refers to these as "villoglandular," and by Morson,191 who terms them "papillary." These polyps have a mixed epithelium, adenomatous in parts, villous in others, and a particular biopsy may come from one or the other area in such cases. We have had a fair number of cases in which the histologic classification of the polyp, based on biopsy, had to be changed when the polyp subsequently

37

was excised and studied completely. This is of more than passing interest in terms of mal ignan t potential, since the l i terature is filled with descrip- tions of cancerous changes that occur much more often in villous polyps than in the adenomatous variety. We are in the process of s tudying the problem as it applies to the mixed or "vi l loglandular" polyps.

Washings for cytologic s tudy are also obtained readi ly via the colonoscope. Although general ly the biopsy provides better information, there is a place for cytologic studies. A number of benign conditions, notably mul t ip le polyposis and extensive chronic ulcerative colitis of long duration, have long been recognized as predisposing to cancer or as a precancerous lesion.109, 191, 290 In such colons, where mul t ip le biopsies fail to show malignant change, washings may prove positive. Since cancer is of mul t icentr ic origin in these diseases, cytologic study has much to offer.

DIAGNOSTIC APPLICATIONS

The benefits derived from direct visual observation of the interior of a hollow viscus have long been apparen t and no one will deny the great con- tr ibutions afforded by proctoscopy and sigmoidoscopy.

In essence, colonoscopy now extends the advantages of sigrnoidoscopy all the way to the cecum and even the te rminal i leum, which we and others196 have been able to enter on a number of occasions. We have, for some t ime now, been able to observe the ileocecal valve with cine studies performed through the colonoscope (Fig. 9).

At present, colonoscopy serves as a backup procedure to the contrast enema. This occurs in a number of ways. A symptomat ic pat ient has one or more bar ium enema studies performed that demonstra te an equivocal radio-

38

Fro. 10.--Radiograph of contrast enema showing constricting lesion of proximal descending colon. Colonoscopy proved this to be an extrinsic lesion. At operation a carcinoma of tho tail of the pancreas wa~ found (Case 2).

logic abnormal i ty . Since ma l ignancy cannot be excluded, surgical explora- tion is the only al ternative to a suspenseful regimen of watching, waiting and repeat ing the contrast enema at a rb i t rary intervals. Should the stools demonstrate the presence of occult blood, the urgency is augmented. Care- ful cytologic studies can be ext remely useful when performed properly,237 but most inst i tut ions are not geared to this form of testing. With colonoscopy, the area in question can be examined and biopsied and a definitive decision can be made.

CASS 2. - -A 64-year-old white male. Pa t ien t gave a history of in te rmi t ten t constipation. Rout ine sigmoidoscopy was negative. A contrast enema showed a constricting lesion of the proximal descending colon, the nature of which was not clear (Fig. 10). Colonoscopy proved it to be extrinsic in relation to the bowel. Fu r the r studies, including angiography, suggested a cancer of the tail of the pancreas, which was proved at laparotomy.

We believe that colonoscopy will have its most impor tan t appl icat ion in recognizing cancer at an early stage. Colon cancer should be a curable disease, yet the cure rate has not changed significantly in recent years,2, 23, 113, 247,276 a l though almost 3 of 4 pat ients might be saved by ear ly diagnosis and treatment.2, 13, 60, 262 W h e n symptoms become manifest , the disease has gone beyond the point of successful t rea tment in more than half the patients.23, 99, 100

Recent improvements in salvage have come about as the result of technical improvements in therapy.18, 35, 47, 78, 242, 274,295 Focusing at tent ion on recognition and removal of precancerous lesions, such as polyps, conceiv- ably may improve the results. ~ 3, 313-316 Children are not excluded from these considerations.175

Although colon carcinoma is a slowly growing tumor, there are well-

39

, ~ : . t

.~ '~:.

. . ~ lMdmU I ¢ ~ " t / l z . ~ : ~ ' . t ' t~ .~ tdm~g~" ~2.~..,.~:~.*~¢t li~lffmflit~ll,~.~':~l~, t, ~

r

I l

FXG. 11 .~A and B, barium enema studies from Case 3 showing apparent polypoid lesion in cecum. C, colonoscope in place. No abnormal i ty was found (false positive x-ray studies).

recognized limitations to radiologic detection of establ ished lesions.301,302 Marte l and Robins179 found diagnosis delayed in 93 of 500 consecutive cases of colon cancer. Forty-seven of the delays were associated with a negative bar ium enema report.

In our experience, m a n y pat ients have been saved from unnecessary operations or have been spared costly and harmful delays by having colonoscopy in those si tuations in which the radio!ogic findings are ambiguous.

We have had a number of examples in which the x-ray films have been in terpreted positively and in which colonoscopy for confirmation has proved the absence of any intr insic lesion or has shown the presence of a lesion not requir ing surgical t reatment. This is par t icular ly true of cecal lesions.

CASh 3 .mA 65-year-old white female. Recent change in bowel habits led to a barium, enema examination. A polypoid lesion was demonstra ted in the cecum on several views (Fig. 11, A and B). Colo,~loscopy was performed (C) and the cecum as well as the remainder of the colon were found to be en- t i rely normal.

CASE 4 . - -A 65-year-old white male. Pa t ien t had vague abdominal com- plaints. Stools were negative for occult blood and routine sigrnoidoscopy was negative. Bar ium enema showed a constant filling defect in the cecum (Fig. 12). Pat ient was scheduled for laparotomy, when colonoscopy was roquestt~d. A smalt l ipoma (submucosal) was found and operation was canceled. Pa t ien t has remained well with no change in the lesion, radiographi- ta l ly or endoscopically, over the past 2 years.

Another a rgument for colonoscopy, even in the presence of a positive r:~diologic diagnosis, is the relative frequency with which addit ional unsuspected lesions are disclosed, as noted previously. This is especially true of polyps, but when the unsuspected and radiologieally undisclosed lesion is a cancer, the importance of endoscopic backup becomes critical.

Cash 5 . - -A 67-year-old white male. This patient, the brother of a physi- ,'i:~n, h~ld known colonic polyps of m a n y years ' dura t ion diagnosed by

40

FIG. 1 2 . ~ R a d i o g r a p h of cont ras t en em a f rom Case 4 showing filling defect in cecal area. Scheduled l ap a ro to m y was canceled when colonoscopy proved this to be a benign l ipoma.

bar ium enemas on a re_tuber of occasions over the years. We were asked to colonoscope h im and remove the polyps endoscopically, as he had known mit ra l valvular disease. Colonoscopy disclosed tile presence of mul t ip le polyps but also a fa i r ly advanced carcinoma. Pla te 11 shows the surgical specimen. The lymph nodes were free.

Occasionally patients are encountered, with or without gastrointest inal symptoms, who have a chronic anemia and occult blood in their stools. Re- peated contrast enemas may demonstra te no cause. Here, colonoscopy fre- quent ly can provide the a n s w e r - - a n area of telangiectasia, an unsuspected polyp or even an early occult cancer.

CASE 6 .wA 55-year-old white male. Pa t ien t had in te rmi t ten t abdominal discomfort for which he sought medical advice. Examina t ion revealed only a low-grade anemia and stools were tested for occult blood and reported positive. Contrast enema was reported as negative (Fig. 13). Two additional ba r ium enemas over a period of 3 months were also reported as negative. Colonoscopy was requested. An ear ly cancer of the cecum was disclosed, which was removed surgical ly (Plate 12).

By offering an opportuni ty for biopsy, colonoscopy provides the means for histologic verification of a radiologic diagnosis and, at the same time, provides observation and photographic records of the gross morphology. This is par t icu la r ly de3irab!e when radiat ion therapy is p lanned prior to contemplated operation.

Cer ta in disease conditions recognized as precancerous,109, 124,171,191,290 such as longstanding ulcerative colitis, present such high risk that total colectomy has been recommended as a prophylact ic measure.29, ~z4,290, 299

The radiologic approach is quite inadequate for the ear ly detection of ma-

41

FrG. 13. - - -Contras t enema s t u d y f rom Case 6. T h i s was one of three x - r ay examina t ions repor t ed as nega t ive in a 55-year-o ld m a n with in t e rmi t t en t abdomina l d i scomfor t and guaiac- pos i t ive stools. Wi thou t co lonoscopy, his ca r c inoma of the cecum would not have been diagnosed a t an ea r ly s tage (see P l a t e 12).

l ignant changes.I, 5G, t05, 124,162. 257 Indeed, Morson and Pang:94 have suggested routine rectal biopsy in an effort to identify precancerous areas. Certainly, colonoscopy has much to offer for these patients, if only to extend the range of rectosigmoidoscopy.

The difficulties in dil~erentiating between various inflammatory states, par t icu lar ly between ulcerative and granulomatous colitis, have been the subject of numerous discussions in the literature.29, 104, Is7, 178, 23s Adding endoscopic to radiologic evaluat ion may help clar ify the picture to some extent.

In terms of assessing the ef[ectiveness o[ various medical regimens and drugs u s e d i n the t rea tment of these inf lammatory states, the clinician has depended on symptomatic , laboratory and radiologic evidence of improvement. Now he can add direct visual examinat ion and biopsy to these factors.

In a diagnostic capacity, colonoscopy can be used for [ollow-up examination in pat ients who have had resections of cancer or polyps. Local recurrence of colon cancer is of low incidence,13, 32. I16, 224,225 of the order of 10°-/o,75 and the frequency of metachronous neoplasms or overlooked synchronous tumors has a l ready been alluded to. When both cancer and one or more polyps are resected, the chances of s~tbsequent cancer are twice as great, according to Bussey, Wallace and Morson.32

After polypectomy, the tendency to develop one or more addit ional polyps is well documented: Ki r sne r et al.l~4 found a 41~o recurrence rate

42

in pa t ien ts followed 4 or more yea r s and a second polyp a l r e a d y presen t in 12% of the i r group. 2'12 J u d d and Carlisle14.~ discovered tha t in pa t ien t s who had a t ranscolonic excision of polyps, az 28zo developed addi t iona l polyps a f t e r 5 y e a r s and 07 . 6 ,,, had carc inomas . H u d s o n and MuldonlaS repor ted a 31% recu r rence ra te and K a p p and Quintero147 one of 30%.

CASS 7 . m A 53-year-old whi te female. This pa t i en t was r e fe r red to us 1 y e a r a f t e r having had t r an sabdomina l polypectomies for a d e n o m a t o u s polyps of the t r ansve r se and sigmoid colons. Pos tope ra t ive ly she had developed hepa t i t i s and i n t e r m i t t e n t smal l bowel obs t ruc t ions requ i r ing rehospi ta l iza- tion. Recen t r ecu r ren t passage of blood per rec tum led to a ba r ium e n e m a and diagnosis of addi t iona l polyps. At colonoscopy, a 1.5 X 1.5-cm peduncu- la ted polyp was resected a t the 35-cm level and a 0.7 X 0.7-cm sessile polyp a t the l l 0 - c m level. Both were a d e n o m a t o u s polyps histologically.

T h e re la t ive ease and the lack of d i s c o m f o r t - - f a r less t h a n with s imple s i g m o i d o s c o p y - - m a k e pa t i en t accep tance of colonoscopy very high; this is an i m p o r t a n t factor in fos ter ing follow-up studies.

T h e r ap id i ty with which pho tographs , both still and cine, m a y be m a d e via the colonoscope (as with o the r endoscopic i n s t r u m e n t s ) is i m p o r t a n t for t each ing and for compar i son purposes. T h e i n s t r u m e n t m a y be connected readi ly with a television c a m e r a for mul t ip le viewing and these examina - t ions can be recorded in color or on v ideotape for i m m e d i a t e or l a te r play- ~ c k o

THERAPEUTIC APPLICATIONS

T h e r a p e u t i c appl ica t ions of colonoscopy a re now well es tabl ished although not as ye t widely available. W h e n we unde r took endoscopic excision of colonic polyps using a s n a r e - c a u t e r y device in 1969, we were only too keenly a w a r e of tile potent ia l hazards . Fo r this reason, all such pa t ien ts a re hospi tal ized, fully eva lua t ed and p repa red , so t ha t should abdomina l opera- t ion for a compl ica t ion be requ i red no t ime is ]ost.312, 314-316

Tab le 2 shows a recent ana lys i s of polyps removed a n d sor ted by size. Tab le 3 describes the i r locahon in the colon a n d the i r morphologic t y p e - - p e d u n c u l a t e d or sessile. R e m o v e d polyps a re p h o t o g r a p h e d immed ia t e ly using a Po la ro id camera , which provides a p e r m a n e n t record of the i r size a n d gross morphologic characteristics315 (Fig. 14).

T A B L E 2.--COLONOSCOPIC POLYPECTOMY: SIZE OF REMOVED POLYPS, THROUGH JULY 1.973

SIZE NUMBER 0.5--0.9 c m 131 1 .0 -1 .9 c m 325 2 . 0 - 2 . 9 c m 111 3.0--3.9 c m 36 4 . 0 - 4 . 9 c m 6 5.0 c m 7

ToTAl, 616

43

T A B L E 3 . ~ C O L O N O S C O P I C POLYPECTOMY" GROSS M O R P H O L O G Y AND LOCATION,

THROUGH J U L Y 1 9 7 3

LOCATION PEDUNCULATED SESSILE TOTAL Rectum 8 4 J2 Sigmoid colon 275 32 307 Descending colon 176 22 198 Splenic flexure 11 5 16 Transverso colon 39 14 53 Ascending colon and

cecum 19 11 30 TOTAL 528 88 616

Only polyps 0.5 cm in diameter or larger are considered in this series, since polyps of smaller size rarely, if ever, show malignant change. Large, sessile polyps sometimes are removed in piecemeal fashion.a12 Analysis of the polyps on the basis of histopathology is shown in Table 4.

The common forms of neoplastic polyps and those that are of immediate concern may be classified as (1) adenomatous polyps, (2) villous adenoraas, (3) mixed or villoglandular polyps (papillary adenomas, according to Mor- son) (Fig. 15) and (4) polypoid carcinomas. The last group consists of polypoid lesions, entirely carcinomatous, in which no remnant of any of the previous groups can be found. Radiologically and endoscopically, these often are indistinguishable from the other types. One can only speculate as to their mode of origin. Grinnell and Lane,it2 in their extensive review, state that they have never seen, or found reported, a primary carcinoma of the colon under 0.7 cm in diameter.

at 45, m !e,.,el'. , .

Ill(

AT 60 Ct~,. [EVEL

• . . . . o ,v, I 2 - 3 4 5

FIO. 14.---Shows Polaroid pictures (reduced by 28%) of endoscopically removed polyps. These photographs serve as a permanent view of size and gross morphology.

44

T A B L E 4 . - -COLONOSCOPIC POLYPECTOMY: PATHOLOGY, T H R O U G H JULY 1973

Adenomatous polyps 309 With " a t y p i a " or carcinoma in situ 15 With superficial carcinoma 6

Villous or papillary adcnoma 63 With "at'yp-ia" or carcinoma in situ 7 With superficial carcinoma 8

Mixed villous and adenomatous polyps 150 With " a t y p i a " or carcinoma in situ 12 With superficial carcinoma 8

"Mucosa l" polyps 25 Miscellaneous (inflammatory, fibrovascular,

juvenile) 9 Unretrieved 42 Malignant polyps 18

"Polypoid adenocarcinoma 6 Villot~s adenoma with invasive carcinoma 7 Adenomatous polyp with invasive carcinoma 5

TOTAL 616

T h e key fact to be a sce r t a ined wi th respect to the first th ree ca tegor ies is the presence or absence o[ malignancy. In order to cons ider the problem in- te l l igent ly, one m u s t define precisely w h a t is m e a n t by the t e rm "mal ig- n a n t . " Th i s is not as s imple as it m i g h t a p p e a r on the su r face and is one of the causes of con t roversy with respect to the m a l i g n a n t potent ia l of colonic polyps.39, 84, 89, 112,140, t91-]93, 272,293,298 One m a y find in the polyp mucosa changes t ha t r ange f rom "focal a t y p i a " to " c a r c i n o m a in '~itu" to full- blown but "superf ic ia l carcinoma."316 Unless p e n e t r a t i o n deep to the muscular is mucosa can be d e m o n s t r a t e d N a n d somet imes this dis t inct ion can be m a d e only by carefu l and n u m e r o u s sections t ha t e l imina te a r t i f a c t s - - mos t pathologis ts ag ree t h a t the polyp is not cl inically ma l ignan t . A super -

FIG. 15.--Villoglandular or mixed type of polyp. Photomicrograph shows villous pattern on left and adenomatous pattern in the same field on the right.

45

FIG. 16.--A, photomicrograph of polyp showing "focal atypia. '° Nuclei are hyperpigment/~l but there is no evidence of cancerous change. B, photomicrograph showing trarL~ition from normal mucous membrane (right) to atypical gland (le/t).

ficial "cancer" of this type has never been shown to metastasize. The cx- planat ion for this has come with the exquisite electron microscope studies by Fenoglio et al.,85 which show tha t only the area deep to the muscular is mucosa is supplied with lymphatics.

Excluding ent i re ly minor al terat ions such as "cell a typ i a " (Fig. 16, A) and "carcinoma in s i tu" (Fig. 16, B) , we have divided our polyps into group A-- those with superficial ca rc inoma- -and group B-- those with "invasive" cancer, i.e., extension deep to the muscular is mucosa. Our mater ia l has yielded a carcinoma incidence of 6.2~Vo, of which 3 .2~ were superficial (group A) and 3.0°-/0 invasivc ....... or clinically mal ignant (group B) (Fig. 17 and Table 5).

46

/

t~

Fro. 17.--A, photomicrograph showing a true superficial cancer not extending beneath the muscularis mucosa (group A in text). B, photomicrograph showing a surface cancer extending deep to th~ muscularis mucosa. This is " invas ivo" cancer (group B in text). C, another example of "inva~ivo" cancer in an adenomatous polyp removed endoscopically.

Interpretat ion of material obviously requires a close working relationship between surgeon and pathologist. We cannot emphasize too strongly the wisdom of reviewing problem cases t~te-h-t6te with the pathologist, and most certainly of doing so before any major decision is made with respect to surgical intervention. The field is f raught with such lack of uniformity in the use of terminology that to act on the basis merely of a written report or on the gross aspect of a polyp endoscopically excised is foolhardy.

The total management o[ "malignant" polyps has been touched on else- where316 and is the subject of a continuing study by us. Patients with polypoid carcinomas should have laparotomy and seg~nental bowel resection. Patients whose polyps show only superficial cancer (group A) require nothing hlr ther than the polypectomy and serial foliow-up examination. For

T A B L E 5 . - -MALIGNANCY IN POLYPS (FROM 616 POLYPECTOMIES)

Superficial (noninvasive) carcinoma 3.2% Invasive carcinoma 3.0~o

47

group B those with invasive ma l ignancy- -one must decide whether the s t romal invasion extends down to or close to the l ine of polyp amputat ion. Where it does not, general ly nothing fur ther than regular periodic re- examina t ion is required. Although the l i terature contains examples of metastasis ~rom such lesions,19, 86, 119, 158, 161,176, 192, 212 two facts emerge from close scrut iny of the reported mater ia l : (1) that histologic analyses showed an exceptionally mal ignan t cellular appearance in all those polyps having metastases and (2) that these examples are quite rare. 89, 283, 294 Therefr, re, in the absence of a high degree of cel lular mal ignancy (an exceptional occurrence) , the added risks of operat ion far outweigh the chances of lym- phat ic spread.

For those polyps in which tumor cells extend down to or close to the plane of resection, a complementary bowel resection has been recommended by us in the past. Whe the r we will continue to do so in all cases is not certain at the t ime of this writing. Three poor-risk pat ients in this category have had no fur ther operat ion and no recurrence; of 13 pat ients operated on, 8 had no residual lesion in the surgical specimen..~16 The ease of follow-up by colonoscopy and the excellent magnif ied view one gets of the polypectomy site make it likely that local recurrence or persistence could be detected readi ly when present, and treated accordingly.

COMPLICATIONS

In our experience with endoscopic removal of more than 600 polyps over 0.5 cm in d iameter (and of at least an equal number of smal le r ones) we have had but two significant immedia te complications: one pat ient was bleeding for several hours and the other suffered a min ima l ly symptomat ic perforat ion af ter endoscopic excision of a small wide-based polypoid carcinoma. Both pat ients responded to nonoperat ive measures.

A smal l number of pat ients (under 10) have had de layed bleeding 3 or more days postpolypectomy. In none was rehospi tal izat ion or t ransfusion therapy required.

The specter of explosion hazard has been raised and, as a result, the in- sufitation of carbon dioxide gas dur ing polypectomy has been suggested by some present ly involved in this work. We believe that this is totally unnecessary, having done more than a thousand polypectomies and fulgurat ions without incident. T h e properly prepared colon should be free from explosive gases, and the constant in terchange of gas contents as the ins t rument is advanced, blowing air in and sucking it out, should fur ther reduce this hazard.

We know of no instance of an explosion reported dur ing colonoscopy. All cases coming to our a t tent ion occurred dur ing sigmoidoscopy or proctoscopy where the bowel may have been inadequa te ly cleansedA63, 318

However, we believe tha t our pract ical experience has now been confirmd exper imenta l ly as a result of the work of Ragins et al.236 Working in our laboratory, they analyzed colonic gas contents on insert ion of the instru- men t and at the t ime of polypectomy. At no t ime was the crit ical concentration of explosive gases even approximated.

48

D~SCUSSlON

Length o] hospital stay in the usual endoscopic polypectomy case is now under 2 days. The patients are admitted during the afternoon prior to the procedure and discharged on the morning after. Preoperative evaluation includes a complete review of past history and medications; review of x-ray studies; complete physical examination; laboratory studies, including a 12- channel chemistry profile, urinalysis, electrocardiogram, blood typing and study for coagulation defects; and routine admission pulmonary function evaluation. As noted previously, we would like to leave nothing to chance should a complication require laparotomy.

Even with this, the financial savings are l~rge in comparison to the ex- penses incurred with the removal of colonic polyps by the abdominal route, which entails a hospital stay of 7-10 days, anesthesia fees, operating room charges and possibly blood transfusions and private-duty nursing.

Other reports have appeared in the li terature on the subject of endoscopic polypectomy, usually with considerable degrees of success and safety.18, ~9, 7o, 96,118. 208,278, 279 Sugarbaker278, 279 has reported the removal of 120 polyps with 1 complication; Hedberg 118 excised 125 polyps with no complications; Deyhle69 removed 32 polyps with no complications; Ottenjann208 9 with no complications; Berci and Morgenstern18 excised 91 polyps with 1 complication; Gaisford96 had 62 with 1 complication. Deyhle69 described a special technic by which he removed 7 sessile polyps from *~he right colon. We have removed 99 polyps from the splenic flexure or higher, of which 30 were sessile (see Table 3), without any modification in our customary technic.

The colonoscope has also been used therapeutically by us and others for the removal o[ [oreign bodies.317

Colonoscopy used as a screening examination for the detection of cancer (or other lesions) in (a) the asymptomatic and (b) the symptomatic patient has not as yet been carried out. This study awaits the availability of an adequate number of trained colonoscopists and the added proof of its safety.21 However, careful studies on the effectiveness of sigmoidoscopy as a screening tooD23 have shown that this is a worthwhile approach and that when cancer is discovered under these circumstances a resection for cure rate of the order of 96°-/o is possible.

SUMMARY OF INDICATIONS FOR COLONOSCOPY

On the basis of the foregoing, the indications for colonoscopy can be outlined as follows:

I. For Diagnosis A. X-ray studies equivocal B. X-ray studies negative--symptoms positive C. X-ray studies positive--for confirmation D. Bleeding---overt or occult

II. For Biopsy A. To confirm malignancy by tissue sections B. Diagnosis knownmmalignancy suspected

(chronic ulcerative colitis, multiple polyposis, etc.)

49

III. For Polyps A. Therapeutic removal B. Polyp is diagnosed--? other polyps C. Polyp is diagnosed--? cancer also D. Cancer is diagnosed--? polyps also

IV. For Follow-up A. After resection for cancer B. Postpolypectomy C. Efficacy of medical therapy (inflammatory diseases)

V. For Foreign Bodies Diagnosis removal

VI. For Screening VII. For Clinical Investigation

LIMITATIONS

Also in summary should be listed the limitations o[ colonoscopy, the dan- gers being (1) perforation, (2) hemorrhage, (3) missing a lesion and (4) misinterpreting a lesion.

i. Inadequate preparation--colonoscopy should never be performed on an inadequately prepared bowel.

2. Acute inflammatory diseasewsuch as fulminating ulcerative colitis, acute granulomatous colitis, acute diverticulitis, etc.

3. Massive hemorrhage--may prevent adequate visualization. 4. Recent operation--may disrupt suture fines. 5. Suspected per/oration--foreign body, recent operation, etc. 6. Stenotic lesionsmmay prevent passage. 7. Radiation necrosis. 8. Pelvic adhesions with acute angulation, usually the result of previous

gynecologic surgery or recurrent episode of diverticulitis. 9. Lack of skill and experience of examiner.

10. Haste.

FUTURE DEVELOPMENTS

Innovations are being presented with encouraging frequency. Shinya has utilized a special scope for the examination of the entire small bowel (Fig. 18). The instrument resembles a Miller-Abbott or Cantor tube and the balloon at the tip facilitates its advance. Introduced in the same manner as the long intestinal tube, it generally reaches the ileocecal valve in 48 hours. Then the examiner withdraws it slowly, examining the small intestine lining as he does so. As yet, there are no facilities for biopsy or obtaining cytology specimens with this device.

RELATION OF RADIOLOGY TO ENDOSCOPY

One thing endoscopy has done is to point up the shortcomings or limitations of radiologic methods of diagnosis to a degree greater than was ever recognized before. For example, the appreciation of the important role of

50

FIo. 18.--A, small intestinal endoscope, which is passed in similar fashion to a long intestinal (Miller-Abbott) tube. B, position of instrument at 24 hours. C, position of instrtm~ent at 48 hours, prior to withdrawal.

superficial erosi ,ns or gastritis as a cause of massive upper gastrointestinal bleeding came about only as a result of a vigorous endoscopic approach214- 216 to the problem. These superficial changes are not detectable radiologi- catly, particularly under the circumstances of the acute hemorrhagic episode.

Many radiologists and some clinicians unfortunately regard endoscopy as a threat to radiology or a n a t t e m p t to denigrate the contributions of that discipline. They point with satisfaction (and often heat) to publications in which exquisite refinements of the radiologic art have provided information equally precise and detailed to that furnished by the endoscopist. These can and should be acknowledged with pride, but the fact of the mat ter is that on the battlefront on which disease is being foughtmin the physician's office and in the radiology department of the community hospital-- this level of achievement is not attained with any degree of regularity, if at a11.307

51

Endoscopy and radiology complement each other to an immensely satisfying degree and have a great deal to offer to each other. Our radiologists, who have participated i n our endoscopic progran-,s from the beginning,311 un- stintingly and with enthusiasm, now almost routinely suggest endoscopy in their reports when the radiologic findings are inconclusive or unsatisfactory. Each specialty can be a challenge to the other and, like teammates in sport, by introducing an element of healthy competition, can be stimulated to increasingly higher levels of performance.

The alliance of endoscc~py and radiology inevitably will grow closer with the passage of time because of the mutuali ty of their interests where the gastrointestinal tract is concerned. We have encouraged and promoted the inclusion of radiologists in symposia and pane!s on endoscopy and believe that, with time, the interchanges will be bidirectional.

OVERVIEW

The veritable explosion that has occurred in the field of endoscopy since the introduction of fiberoptic instruments has been reviewed. The li terature is already voluminous and numerous texts and monographs on various aspects of the discipline are being published. The equipment manufacturers are having a difficult time keeping up with the demand despite the fact that the instruments are extremely expensive (range $2,500-$4,500 each). Sev- eral specialty journals limited to endoscopy have been in print for a number of years and more are likely to be published in several languages. Physi- cians, particularly gastroenterologists and, to a lesser degree, surgeons, are becoming involved and are seeking out training programs. In the Surgical Endoscopy Unit of the Beth Israel Medical Center, where 50-60 endoscopic procedures are performed each week, there is a constan~ stream of visiting physicians from all parts of the United States. At a 1-day program held in J anua ry of 1973 under the auspices of the American Society for Gastro- intestinal Endoscopy and directed to colonoscopy and retrograde cholangiopancreatography, there were more than 300 in attendance and many more were turned away for lack of space. In other words, there is a vigorous and deservedly intense interest in the specialty and it represents one of the most active and productive areas in the whole field of medicine.

The enormous interest in endoscopy manifested over the past half decade parallels its mounting importance in gastroenterology. As a consequence, many physicians, particularly gastroenterologists, have sought special tutoring in this phase of their craft, if it was not available to them during their residency. The shortage of suitable training programs is a mat ter of great concern to all of us who are already deeply involved and to the various societies whose activities include study of the al imentary tract. There obviously is a call for we!l-organized programs in this sector so that the benefits of the modality may be made available to the public as rapidly as possible and in as safe a fashion as we know how. Funding fox" this purpose should have high priority, particularly with respect to cancer detection.

Involvement of all physicians dealing with diseases of alimentation is important. For some time we have advocated more conspicuous involvement of surgeons. A recent editorial by Dent64 on the subject urges that if the

52

surgeon does not himself perform the procedures he at least familiarize himself with its methodology and applications clinically. We believe that endoscopic polypectomies are managed best by surgeons.

An added burden has been placed on the shoulders of those responsible for approving hospital and community endoscopy programs and for the individuals who will be carrying out the procedures. What are the criteria by which competency is determined? This question has been posed to us by any number of concerned physicians. Obviously, solutions are required. Recently, Colcher~0 has written a cogent critique of the matter as an editorial in the Journal o[ the American Medical Association. It is hoped that this very promising new modality will not have its reputation tarnished by misapplications and abuse. Nor is the common good helped by prophets of doom whose carping commentaries attempt to magnify the admitted possibility that complications can and do occur with endoscopy. What is needed are honest facts and figures21 and not random rumors that hint of untoward results but give no information as to how, when and by whom.

R E F E R E N C E S

1. Allcock, J. M.: An a~essment of the accuracy of lhe clinical and radiological diagnosis of carcinoma of the colon, Brit.. J . 1-~diol. 31: 272, 1958.

2. American Cancer Society: 1973 Cancer Facts and Figures (New York: American Cancer Society, Inc.).

3. Ariga, K.: The current aspect of endoscopic examination in Japan, Monograph 20, March, 1966.

4. Arnold, W. Z., Hampton, J . , Olin, W., Glass, H., and Carruth, C.: Gastric lesions, including exfoliative cytology. A diagnostic approach, J .A.M.A. 1117, 1960.

5. Athanasoulis, C. A., Browr., B., and Shapiro, J. H.: Angiography in the diagnosis and nmnagement of bleeding stress ulcers and gastritis. Am. J. Surg. 125: 468, 1973.

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modern endoscopy of the alimentary tract

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