Professional Documents
Culture Documents
Advances in Gastrointestinal
Endoscopic Techniques
David E. Beck, MD
Department of Colon and Rectal Surgery, Ochsner Clinic Foundation,
1514 Jefferson Highway, New Orleans, LA 70121, USA
0039-6109/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2006.05.003 surgical.theclinics.com
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Table 1
Stains used for chromoendoscopy
Type of stain Stain Mechanism Clinical use
Contrast Indigo Pools in Highlights small
carmine crypts/folds/ mucosal irregularities mucosal lesions
Absorptive Lugol’s Absorbed by Outlines intestinal
solution glycogen-containing metaplasia
epithelium
Methylene Absorbed by Intestinal
blue intestinal/colonic metaplasia metaplasia
Toluidine Absorbed by nucleic acid of Squamous cell cancer of
blue malignant epithelium esophagus
Cresyl Absorbed by colonic Identification of pit
violet epithelium surrounding pattern
pits
Reactive Congo Red at alkaline pH, Demonstrates areas of
red blue/black at acid pH gastric secretion
demark the outline of polyps to aid excision [10]. Specific situations in which
chromoscopy is being used include differentiating colon polyps (hyperplastic
versus adenomas, or folds versus adenomas), screening/surveillance, neo-
plastic margins, and residual tissue [11].
Chromoscopy is cumbersome, time consuming, and can be messy. Few
endoscopy units have these dyes readily available. Although mainly a re-
search tool, these techniques merit further evaluation to define their roles
in routine clinical practice.
Magnification endoscopy
Optic or electronic magnification can enlarge images and improve visual-
ization of normal and abnormal epithelium. High-resolution endoscopy is
available and involves an increase in magnification up to 1.5, an increase
in pixels (eg, O400,000 versus 100,000 to 200,000 for earlier videoscopes),
and a higher-speed electronic shutter [1]. These modifications usually are
performed in the video chips and the video processors. Special processors
and high-resolution monitors often are required to take full benefit of this
technology.
These instruments allow the colonoscopist to recognize the honeycomb
pit pattern and to discern nonspecific erythremia from mucosal hemorrhage
and angiectasis [1]. High-resolution colonoscopy is especially suited for
chromoscopy, because surface patterns are crisp and margins of sessile
lesions are delineated well.
Magnification endoscopy is a technique that is used for the examination
of subtle changes on the mucosa and colonic crypts [1,10,12]. Using scopes
with a movable lens (similar to the lens of a microscope) to zoom, images
can be magnified from 3 to 170 (most in the range of 10–35). The
current scopes use dials, levers, or electronic foot pedals to move the lens.
The distance between the tip of the scope and the mucosa, the presence or
absence of fluid, and movement affect the viewing field and the quality of
the image. These factors have hindered the value of endoscopic
magnification in the proximal colon, but have allowed it to be useful in
the rectum. Applications has been directed toward identification of aberrant
crypt foci that are believed to be precursors of adenomas and cancer [12,13].
Aberrant crypt foci are enlarged colonic crypts that typically are grouped
together. When viewed under magnification chromoscopy they appear as
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an elevated mound of markedly enlarged crypts [1]. These lesions may serve
as intermediate markers and predictors for colorectal neoplasia [13,14].
Magnification is used frequently for anal cryptography and in the evalu-
ation of Barrett’s esophagitis, but remains a research tool for the colon.
High-resolution endoscopes are now available commercially. Widespread
availability will help to delineate the value of this technology.
Colonic marking
Unless a lesion is adjacent to the ileocecal valve or located in the rectum,
it is difficult to localize its exact location in the colon accurately. Localiza-
tion is important for small lesions or polyps that may not be palpable during
open surgery, and if laparoscopic surgery or endoscopic follow-up is
anticipated [15]. For lesions that are not confirmed with radiologic studies,
such as barium enemas or CT scans, some type of colonic marking can be
helpful.
Tattooing
Tattooing of the bowel has been performed with India ink, tattoo ink
(Lasting Impressions Inc., Englewood, New Jersey), or carbon particles
(SPOT, GI Supply, Camp Hill, Pennsylvania). The India ink is permanent,
can be difficult to obtain, and lacks US Food and Drug Administration
(FDA) approval [16]. The carbon particle solution is approved by the
FDA and has been reported to last up to 38 months [17]. A list of commer-
cially available agents is obtainable at the American Society of Gastrointes-
tinal Endoscopy Web site [18].
The technique of tattooing is similar to other mucosal injection methods.
The needle is exposed and passed at a tangential angle into the mucosa. Care
is taken to maintain a superficial entry to avoid a transmural or intraperito-
neal injection. A fluid bleb is produced by injection of 0.2 mL to 1 mL of
solution (Fig. 1A). If a bleb is not apparent the needle is withdrawn and re-
positioned. The tattoos should be placed just distally to the lesion. If
operative localization is desired, two or three additional tattoos should be
placed in a circumferential location (Figs. 2 and 3).
Clipping
An alternative to tattooing is placement of endoscopic clips [7]. The clips
can be identified by palpation in open operative procedures or with ultra-
sound in laparoscopic procedures. Because the clips are placed in the
mucosa, their duration is short and they should be used for localization
only if the surgery is planned shortly after the endoscopic procedure.
Another option is to take an abdominal radiograph at the completion of
the endoscopic procedure. The residual air in the colon provides an air
contrast enema, and the clips can identify the segment of colon that contains
the lesion (Figures 4 and 5). Two or three clips should be placed in
ADVANCES IN GASTROINTESTINAL ENDOSCOPIC TECHNIQUES 853
Crohn’s strictures. Five patients had strictures at the site of a previous ileo-
transverse colon anastomosis. They obtained a sustained improvement in
five patients over a follow-up period of 18 to 24 months, but were unsuccess-
ful in two patients. In a more recent, larger series, Dear and Hunter [23]
reported balloon dilatation in 22 patients who had Crohn’s strictures. Six-
teen patients were dilated successfully, although one third of the patients
required more than two dilatations. Six patients failed balloon treatment
and required surgery. There were no complications after any of the 71
dilatations performed. Lastly, Miller and colleagues [24] reported
successfully treating an endometriotic stricture of the sigmoid colon.
Thus, balloon dilatation in selected patients seems to be safe and effective
in eliminating the need for additional surgeries.
Intestinal strictures result from several conditions. Benign conditions,
such as inflammation (inflammatory bowel disease) or postoperative anasto-
mosis, often respond to dilatation. Several endoscopically guided balloons
are available. For colonic use, the balloons range in size from 6 mm to 20
mm in diameter. The technique involves placing a guidewire across the
stricture. The balloon catheter is advanced over the guidewire to the
midpoint of the stricture and is inflated with a pressure- or volume-
controlled handle.
Colonic stents
Intraluminal colonic stents are an extension of technology that initially
was used for vascular, biliary, and esophageal obstructive pathology [25].
The main indication for their use is in the treatment of colonic obstruction:
(1) in an attempt to obtain adequate mechanical bowel preparation before
definitive resection (a bridge to surgery), and (2) for palliation in patients
who are poor operative candidates because of comorbid disease or a limited
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Table 2
Advantages and disadvantages of procedures for managing chronic obstruction
Procedure Advantages Disadvantages
Resection without No anastomosis, time to Repeat operation, stoma
anastomosis optimize patient’s nutritional (stoma closure never
status and comorbidities performed in 25%),
before anastomosis combined mortality
rate 6%–12%
Subtotal colectomy No stoma, no bowel Lengthier operation,
preparation needed increased bowel frequency,
liquid stool (especially
an issue in older patients
and for lesions in the distal
sigmoid and rectum);
mortality 3%–11%
Resection with on-table No stoma, no additional Time consuming, risk for
colonic irrigation operation required anastomosis (dilated,
primary anastomosis edematous colon;
malnourished patient)
Colonic stenting, delayed Opportunity to stage Risks for perforation,
resection, primary patient before surgery, migration of stent,
anastomosis opportunity to correct reobstruction
nutritional/comorbid
factors
ADVANCES IN GASTROINTESTINAL ENDOSCOPIC TECHNIQUES 857
are covered ones, but tumor ingrowth leads to reobstruction. Covered stents
have less tumor ingrowth but lack FDA approval [43]. Patients with normal
mucosa, as is seen in obstruction secondary to extrinsic compression, also
are at higher risk for stent migration. Stents typically migrate distally and
have been expelled by way of the anus without complication. More
commonly they are removed using endoscopic biopsy forceps or a snare.
In addition to large bowel obstruction from malignancy, colonic stenting
has been applied to benign disease but with less success. Disease processes
that are managed with stents include strictures from diverticular disease
and intestinal fistulas [44,45]. Binkert and colleagues [39] performed a cost
analysis of patients who were treated with colonic stents. Twelve of 13
patients were stented successfully, and 10 underwent subsequent operations
for their tumor. They compared these patients with a control group of
patients that was treated with initial surgery at the same hospital. Overall,
an average cost reduction of 20% was demonstrated in the stented group.
This group also had shorter hospitalization (6.1 days), fewer surgical proce-
dures, and fewer ICU days. A second analysis by Targownik and colleagues
[46] also showed that early colonic stent placement was less expensive than
was emergency surgery for acute malignant obstruction because of the
avoidance of a second operation to reestablish intestinal continuity.
In conclusion, colonic stenting is an effective and safe tool in the manage-
ment of malignant, left-sided colorectal obstruction. It provides an
opportunity for adequate bowel cleansing, medically optimizing the patient,
and conversion of an emergent surgical problem into an elective one in
which primary anastomosis is more likely to be performed. It also affords
the treating surgeon the chance to stage the patient, and, thereby, to select
out patients who would not benefit from further surgery while providing
acceptable palliation of obstructive symptoms. Recurrent obstruction can
be treated frequently with repeat stenting.
Lasers in colonoscopy
It is possible to transmit lasers fiber optically, and argon and Nd:YAG
lasers are being used clinically. The Nd:YAG laser beam scatters more on
impact and is not absorbed as readily by red-pigmented areas. It also pen-
etrates deeper into tissue, which allows for greater destruction of large
tumors [47,48]. The Nd:YAG laser has been used to destroy colon and rectal
polyps; stop bleeding and relieve obstruction secondary to colorectal can-
cers; and control radiation proctitis, hereditary hemorrhagic telangiectasia,
angiodysplasias, and photoablation of colorectal adenomas [49]. The laser
also has been used in place of operative diversion in hopeless clinical
situations, such as hemorrhage, obstruction, or prohibitive operative risk
in patients who had advanced colorectal carcinoma.
The Nd:YAG laser and the argon plasma coagulator (which is not a laser)
also have been used to control bleeding secondary to radiation proctitis [50].
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the relevant direction. Close the snare loop gently, to the mark or by feel
until it is snug, ideally near the top of the stalk at its narrowest part. Leave
a short segment of normal tissue on the stalk to help pathologic interpreta-
tion. Initial snare closure should be gentle, because the loop may be posi-
tioned incorrectly. Once the wire has cut into polyp tissue it may be
difficult to release and reposition it. With longer stalks, if there is a suspicion
of malignancy, it may be possible and desirable to snare lower down on the
stalk to increase the chance of resecting all invasive tissue in the stalk.
If the loop is stuck in the wrong position or it is apparent that the polyp
cannot be transected safely, releasing the snare loop is made easier by lifting
the snare up over the polyp head and pushing it into the colon, with the
whole colonoscope if necessary. It is almost always possible to dismantle
the snare or to sacrifice it by cutting it with the wire cutters, withdrawing
the colonoscope and leaving the loop in situ. Either the polyp head will
fall off and the snare will be expelled, or another attempt can be made
with a second snare.
Electrocoagulate using a low-power current (15W or dial setting 2.5–3)
with the snare loop kept gently closed against the neck of tissue to create favor-
able circumstances for electrocoagulation. Apply the current for 2 to 5 seconds
at a time, watching for visible swelling or whitening. When the snared portion
of the stalk or base is coagulating visibly, gently squeeze the handle more
tightly while continuing electrocoagulation; transection will start.
Be certain to observe the polyp head as it falls off, because it can be lost.
If a polyp is lost, try to identify the dependent portion of the bowel where
the head is likely to be. If not visible, irrigate with some water by way of
a syringe and watch where it flows; if the water just refluxes back over the
lens, then the polyp also will be behind the instrument tip. The endoscope
is withdrawn to find the specimen. Retrieval of the specimen may be with
the snare, basket, or retrieval device, or by aspiration through the channel
into a filtered suction trap. When numerous polyps are present it may be
necessary to snare/transect some specimens of medium size to allow them
to be aspirated and so save time.
Various other techniques for excising large polyps or flat lesions have
been described as saline assisted polypectomy, strip biopsy, or endoscopic
mucosal resection. Investigators have used submucosal injections of fluid
or suction devices to elevate the lesion, and cautery snares or knives with
single- or double-channel scopes [54–57]. Sessile lesions up to 5 cm in diam-
eter have been removed; however, those that occupy more than one third of
the colonic circumference or involve two haustral folds usually are too large
for safe endoscopic removal. Similarly, the inability to elevate a colonic
lesion adequately using submucosal injection indicates that endoscopic re-
moval may not be possible [55]. If in doubt, it is better to perform piecemeal
excision at different endoscopic sessions to lessen the risk for full-thickness
bowel wall injury. This method also gains time for histologic assessment,
which may help in case of a malignancy.
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Control of bleeding
Endoscopic bleeding is prevented best by using the techniques that were
described previously. When it does occur several techniques are available.
These include irrigation or injection of epinephrine solutions, fulguration
or cautery, clipping, or resnaring. Another option is a preassembled
single-use endoscopic ligating device (PolyLoop, Olympus America, Inc.,
ADVANCES IN GASTROINTESTINAL ENDOSCOPIC TECHNIQUES 863
Melville, New York). This device, which can be passed through the biopsy
port of a colonoscope, has a detachable nylon loop that can ligate a polyp
stalk securely. The device can be used on a bleeding polyp stalk or placed on
the stalk proximal to a planned snare site.
Summary
An increasing number of techniques for endoscopic diagnosis and treat-
ment is being described. Endoscopic surgeons should be familiar with these
techniques. Although many of the diagnostic techniques, other than mark-
ing, do not have widespread clinical application, the therapeutic techniques
that were described in this article are being used successfully in increasing
numbers of appropriately selected patients. Additional experience and tech-
nologic advances will refine the endoscopic therapy that is available to pa-
tients with colorectal diseases.
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