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Anastomotic stricture is an increasingly common clinical finding. It is thought to arise because of ischemia, disruption, or leakage at an anastomosis site. Its management can be difficult and strictures often are resistant to standard dilation therapy. Major corrective surgery is possible; however, it is technically challenging and not without risk. We have used a circular stapler to excise colorectal strictures, introducing the anvil of the stapler via a proximal stoma or colotomy, drawing the anvil through the stricture with a snare via a colonoscope and affixing it to the body of a circular staple gun and excising the stricture. We have with found this to be an effective treatment in appropriately selected patients.

PURPOSE: Patients with colorectal polyps often display a large kink or distinct mucosal fold in the area where the polypectomy is to take place. As a result, there is a higher risk of perforation or partial ablation during an endoscopic polypectomy. Is it safer to perform an endoscopic polypectomy using the control and assistance of a laparoscope? Can a segment resection of the colon that would otherwise be necessary be avoided? METHODS: An endoscopic polypectomy using a laparoscope was conducted on six patients whose colorectal polyps were in an anatomically unfavorable location. The need for an open or laparoscopic segment resection or colotomy was indicated in all cases. The growth was located in the rectosigmoidal transition in five patients and in the region of the left flexure in one patient. We decided that an endoscopic polypectomy using the assistance of a laparoscope would be the most comfortable and technically elegant method, as well as easy. Except the well-known risks of laparoscopy and endoscopic polypectomy, no other risks have been seen in our patients. The affected area of the colon, the sigma, and the left flexure were mobilized and stretched as much as possible to enable a simultaneous and low-risk endoscopic polypectomy. In one case, we had to conduct a fractionated ablation because of a very wide-based finding. RESULTS: The operation averaged 57 minutes, and no operation-specific complications were observed. Postoperative recovery in the hospital was very short and averaged 2.5 days. The histopathologic findings were benign in all cases, but a serious dysplasia was diagnosed in one patient. CONCLUSIONS: The laparoscopic-assisted polypectomy is a safe method to remove even complicated polyps in anatomically unfavorable locations.

This study reports the preliminary results of a new totally stapled end-to-end colonic anastomosis in 11 dogs. This “triple-stapled” end-to-end anastomosis was performed with one circular staple line and two linear staple lines, eliminating the need for a colotomy or purse-string suture. The fact that the anvil and anvil stem of a new circular stapling device (Premium EEA™) can be detached from the frame of the instrument allows the anvil stem to be brought out through the proximal linear stapled colon. The trocar mounted on the main stem of the circular stapler allows the stem of the main device to be brought out through the distal staple line. Thus, a totally stapled colonic anastomosis is created after mating the anvil stem and main stem of the instrument. The new anastomosis was evaluated radiographically and at necropsy. The use of this technique resulted in no clinically detectable leaks, suggesting that it may facilitate the performance of anterior resections in humans.

Colonoscopy performed in the operating room at celiotomy, but prior to colotomy, is of definite value in the intraoperative assessment of colonic disease, especially with reference to the need for and extent of resection. By avoiding colotomies, contamination of the peritoneal cavity and wound can be obviated, with concomitant diminished morbidity.

I believe that resection, rather than colotomy and polypectomy, is the treatment of choice for adenomas that require surgical operation. The cases presented illustrate why resection is better for adenomas larger than 1 cm, multiple adenomas, and adenomas coexisting with other pathologic conditions. The pathologic findings in these cases show the malignant potential of adenomas.

Endoscopic removal of 343 colonic polyps more than 0.5 cm in size, located from the cecum to the sigmoid colon and beyond the reach of rigid sigmoidoscopes, is reported. Diagnostic colonofiberscopy is a valuable procedure permitting direct visual examination of the entire colon with a high degree of safety. More than 1,800diagnostic colonofiberscopies have been performed in our unit without a single complication. The polypectomy procedures via the colonofiberscope were done without mortality and with only a single immediate complication, which responded to conservative measures. Endoscopic removal of colonic polyps is proposed as a safe, practical alternative to either laparotomy and colotomy or repeated barium-enema studies in the management of the patient with a colonic polyp. The endoscopic approach allows differentiation of malignant from nonmalignant polyps by complete excision, thus permitting definitive cancer therapy measures to be undertaken promptly and with assurance. Endoscopic removal of colonic polyps is not advised for endoscopists who have not first achieved considerable experience and dexterity in diagnostic colonoscopy. Endoscopic removal of colonic polyps is best accomplished by an experienced endoscopist supported by the full spectrum of general hospital resources, after the patient has been thoroughly evaluated medically. It should be carried out on an inpatient basis. When a patient has a colonic polyp, an alert should be maintained for unsuspected colonic cancer unrelated to the polyp, lest the less serious lesion monopolize the clinical situation.

THE FACT that adenomas and carcinomas of the colonic mucosa tend to be mul t ip le and to coexist has become increasingly well substantiated. The re is also considerable evidence that the mucosal adenoma is the lesion which precedes carc inoma of the colon in a highly significant p ropor t ion of cases. Surgeons experienced in this field recognize the l imitat ions of pa lpa t ion of the intact colon in the detect ion of small lesions and in disclosing soft, sessile tumors as large as several centimeters. Meticulous roentgenologic studies by air contrast and high-voltage technics after the use of a bar ium enema will demonst ra te many of these tumors, bu t cannot be depended u p o n to reveal all, par t icular ly if the lesions are less than 1 cm. in diameter. Hence, at the time of laparotomy, the surgeon who seeks to eradicate these lesions is ob l iga ted to take addi t ional reasonable measures to deal with probable undetected neoplasms. I t was to fill this need that the technic of colotomy and coloscopy for direct visualization of the entire mucosa of the colon was devised.