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Colonoscopic localisation accuracy for colorectal resections

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The Australasian Students’ Surgical Conference (ASSC) is the leading surgical conference for medical students in Australia and New Zealand. ASSC is designed to coincide yearly with the RACS Annual Scientific Conference and was held this year in Perth, Western Australia from 1-3 May 2015.

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Colonoscopic localisation accuracy for colorectal resections

  1. 1. Colonoscopic Localisation Accuracy for Colorectal Resections Damian Ianno BBiom (Hons), Third Year Medical Student, Austin Hospital
  2. 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. 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. 4. Objectives • To assess the accuracy of colonoscopic localisation and its effect on clinical practice • To assess factors associated with incorrect colonoscopic localisation
  5. 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. 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. 7. Division of colon into segments Sigmoid colon Splenic flexure Rectosigmoid colon Descending colon Rectum Ascending colon Transverse colon Caecum Hepatic flexure Ileum
  8. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

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