![References
1. IARC; Cancer incidence in five continents. Volume VIII. IARC Sci Publ, 2002(155): p. 1-781.
2. Gonzalez-Huix Llado, F., M. Figa Francesch, and C. Huertas Nadal, [Essential quality criteria in the indication and
performance of colonoscopy]. Gastroenterol Hepatol, 2010. 33(1): p. 33-42.
3. Rex, D.K., et al., Colorectal cancer prevention 2000: screening recommendations of the American College of
Gastroenterology. Am J Gastroenterol, 2000. 95(4): p. 868-77.
4. Winawer, S.J., et al., Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.
N Engl J Med, 1993. 329(27): p. 1977-81.
5. Hancock, J.H. and R.W. Talbot, Accuracy of colonoscopy in localisation of colorectal cancer. Int J Colorectal Dis, 1995.
10(3): p. 140-1.
6. Piscatelli N, Human N, Osler T; Localizing colorectal cancer by colonoscopy, Arch Surg 2005 Oct; 140(10):932-5
7. Stanciu C, Trifan A, Khder SA, Accuracy of colonoscopy in localizing colonic cancer. Rev Med Chir Soc Med Nat Iasi 2007
Jan-Mar;111(1):39-43.
8. Cho YB, Lee WY, Yun HR, Lee WS, Yun SH, Chun HK; Tumor localization for laparoscopic colorectal surgery. World J Surg
2007 Jul;31(7):1491-5
9. Piscatelli, N., N. Hyman, and T. Osler, Localizing colorectal cancer by colonoscopy. Arch Surg, 2005. 140(10): p. 932-5.](https://image.slidesharecdn.com/colonoscopiclocalisationaccuracyforcolorectalresections-160305081056/85/Colonoscopic-localisation-accuracy-for-colorectal-resections-22-320.jpg)
Colonoscopic localisation accuracy for colorectal resections
- 1. Colonoscopic Localisation Accuracy for Colorectal Resections Damian Ianno BBiom (Hons), Third Year Medical Student, Austin Hospital
- 2. Background •CRC: Second most common cancer in Australia •Colonoscopy: ‘Gold standard’ •Sensitivity of colonoscopy: 85-95% •Lesion localisation: 80-90%, in setting of open resection
- 3. Background • Laparoscopic assisted resections: Common • Correct localisation of lesions is essential to achieving optimal patient outcomes, given incorrect localisation can lead to: - Change in intended operation - Change in bowel segment removed - Incorrect segment of bowel being removed
- 4. Objectives • To assess the accuracy of colonoscopic localisation and its effect on clinical practice • To assess factors associated with incorrect colonoscopic localisation
- 5. Methods • Retrospective study • University teaching hospital • Inclusion: Patients who underwent colonic resection after pre-operative colonoscopy between 2008 and 2013 for a mass lesion • Exclusion: Other institutions, non-mass lesion • Scanned medical records: Demographic, endoscopic, operative and pathological records
- 6. Methods • The data was analysed with SigmaPlot 12.0 • Mann-Whitney rank sum and chi-square tests were used where appropriate with 95% confidence intervals given • A p value of <0.05 was deemed statistically significant
- 7. Division of colon into segments Sigmoid colon Splenic flexure Rectosigmoid colon Descending colon Rectum Ascending colon Transverse colon Caecum Hepatic flexure Ileum
- 8. Demographic Values Age, years: Mean (SD); range 68.1 (±12.1); 25-92 Sex: n male (%) 130 (61.9%) Patients: n 210 Lesions: n 221 Complete colonoscopy achieved: n (%) 164 (74.2%) Incorrectly localised lesions: n (%) 46 (20.8%)
- 9. Parameter Concordant (175) Non-concordant (46) P Gender (M/F) 105/70 25/21 0.600 Age (years) 67.39 (±1.76) 70.82 (±3.21) 0.087 Time (minutes) 26.69 (±2.12) 25.61 (±3.43) 0.92 Size (millimetres) 38.37 (±3.11) 40.57 (±4.92) 0.206 Previous resection 8/175 (4.57%) 2/46 (4.35%) 0.739 Tattoo 76/175 (43.4%) 24/46 (52.17%) 0.371 Distance from anal verge 59/175 (33.7%) 13/46 (28.3%) 0.559 Prep quality - Good - Satisfactory - Poor - Not Recorded 83 (47.4%) 65 (37.1%) 21 (12.0%) 6 (3.43%) 21 (45.7%) 19 (41.3%) 3 (6.5%) 3 (6.5%) 0.562 Complete scope 143/175 (81.7%) 28/46 (60.9%) 0.005
- 10. Parameter Concordant (175) Non-concordant (46) Accuracy, % P Clinicians’ Background - Colorectal - Gastroenterology - General Surgery 93 75 7 15 30 1 86.1% 71.4% 87.5% 0.026 Level of Training - Consultant - Fellow - Nurse - Registrar 76 43 6 48 20 8 5 13 79.2% 84.3% 54.5% 78.7% 0.184
- 11. Distribution of reported location of lesions on colonoscopy Sigmoid colon Splenic flexure Rectosigmoid colon Descending colon Rectum Ascending colon Transverse colon Caecum Hepatic flexure Ileum Unknown1% 17% 10% 7% 5% 1% 6% 25% 7% 20% 1%
- 12. Location of incorrectly localised lesions on colonoscopy Sigmoid colon Splenic flexure Rectosigmoid colon Descending colon Rectum Ascending colon Transverse colon Caecum Hepatic flexure Ileum Unknown1% 0% 17% 7% 10% 11% 7% 20% 5% 4% 1% 4% 6% 9% 25% 24% 7% 20% 20% 0% 1% 2%
- 13. Results • Analysis of pre-operative CT records CT Values CT performed pre-operatively: n (%) 196/221 (88.7%) CT sensitivity in identifying lesion: n (%) 116/196 (59.2%) CT correctly localised lesion: n (%) 84/116 (72.4%) CT correctly localised non-concordant lesion: n (%) 17/44 (38.6%) Note: Only 44 of 46 non-concordant lesions had pre-operative CT performed
- 14. Results • Total of 46 incorrectly localised lesions • 17 lesions required changes to intended surgery • 29 lesions did not: - CT aided correct localisation for 6 lesions - In remaining 23 cases, changes minor enough to not necessitate changes in surgical planning
- 15. Results Changes in surgery Reason n Lap → open conversion for operative reasons - Adhesions - Local invasion - Poor views 2 2 4 • 8 of the 17 lesions that required changes to intended surgery were due to operative reasons
- 16. Results • 9 of the 17 lesions that required changes to intended surgery were due to incorrect location Of the 221 lesions in total, over 4% required changes to surgical procedure due to inaccurate localisation!
- 17. Colonoscopic location (planned procedure) --> Actual location (actual procedure) n • Sigmoid (open left hemicolectomy) --> Caecum (open right hemicolectomy) • Descending colon (laparoscopic anterior resection) --> Transverse colon (open extended right hemicolectomy) • Hepatic flexure (open extended right hemicolectomy --> Caecum (open right hemicolectomy) • Hepatic flexure (laparoscopic right hemicolectomy) --> Transverse colon (laparoscopic extended right hemicolectomy) • Hepatic flexure (laparoscopic extended right hemicolectomy) --> Ascending colon (laparoscopic right hemicolectomy) • Sigmoid (laparoscopic anterior resection) --> Rectum (laparoscopic low anterior resection) • Splenic flexure (laparoscopic left hemicolectomy) --> Descending colon (laparoscopic anterior resection) 1 1 1 1 1 3 1
- 18. Discussion • Overall accuracy in line with other studies (≈80%) • Incomplete scope a significant factor in incorrect localisation → deprived of important landmarks • Emphasis on location may be higher amongst colorectal surgeons → consideration for resection • CT, although helpful, cannot be relied upon to correctly localise lesions, especially when colonoscopy has been unreliable
- 19. Limitations • Retrospective study • Heterogeneous group • Observer bias → colorectal surgeon likely to be both endoscopist and surgeon • No standardised method of description for location
- 20. Conclusion • Incorrect localisation can have serious clinical consequences • Localisation is particularly inaccurate if the colonoscopy is not complete • Endoscopy training should have a higher emphasis on correct identification of lesion location on colonoscopy
- 21. Conclusion • All lesions not in rectum or at caecal pole should be tattooed to help intraoperative localisation if resection is being considered • A formal guideline to describe position in the colon should be created
- 22. References 1. IARC; Cancer incidence in five continents. Volume VIII. IARC Sci Publ, 2002(155): p. 1-781. 2. Gonzalez-Huix Llado, F., M. Figa Francesch, and C. Huertas Nadal, [Essential quality criteria in the indication and performance of colonoscopy]. Gastroenterol Hepatol, 2010. 33(1): p. 33-42. 3. Rex, D.K., et al., Colorectal cancer prevention 2000: screening recommendations of the American College of Gastroenterology. Am J Gastroenterol, 2000. 95(4): p. 868-77. 4. Winawer, S.J., et al., Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup. N Engl J Med, 1993. 329(27): p. 1977-81. 5. Hancock, J.H. and R.W. Talbot, Accuracy of colonoscopy in localisation of colorectal cancer. Int J Colorectal Dis, 1995. 10(3): p. 140-1. 6. Piscatelli N, Human N, Osler T; Localizing colorectal cancer by colonoscopy, Arch Surg 2005 Oct; 140(10):932-5 7. Stanciu C, Trifan A, Khder SA, Accuracy of colonoscopy in localizing colonic cancer. Rev Med Chir Soc Med Nat Iasi 2007 Jan-Mar;111(1):39-43. 8. Cho YB, Lee WY, Yun HR, Lee WS, Yun SH, Chun HK; Tumor localization for laparoscopic colorectal surgery. World J Surg 2007 Jul;31(7):1491-5 9. Piscatelli, N., N. Hyman, and T. Osler, Localizing colorectal cancer by colonoscopy. Arch Surg, 2005. 140(10): p. 932-5.
Editor's Notes
- #7: Applied to Chi square with 1 degree of freedom (gender, non-intact, obstructed, completed): Yates correction for continuity: The effect of Yates' correction is to prevent overestimation of statistical significance for small data. Used in certain situations when testing for independence in a contingency table. Gender: Alpha 0.074 Non-intact: 0.065 Obstructed: 0.747 Completed: 1.000 Training: 3 degree of freedom Prep: 3 degree of freedom Who: 1 degree of freedom