Problems in the colonoscopic localization of tumors: Continued value of the barium enema

Abstract

Six patients in whom errors of diagnosis and therapy occurred because of reliance on colonoscopic tumor localization are presented. Three of the patients required a second laparotomy for surgical resection of a tumor that was missed at the first exploration. While endoscopy is regarded as the diagnostic gold standard, there are problems in its use for colonoscopic localization. Reliance on distance measurements may be misleading. Anatomical variants can be confusing. For this reason, a preoperative barium enema for precise delineation and localization of tumors is recommended. When a barium enema is not feasible, such as when a malignant polyp has been removed endoscopically, preoperative endoscopic localization with injection of India ink or intraoperative colonoscopy must be performed.

Endoscopic localization of colorectal cancer: Study of its accuracy and possible error factors

“…In the majority of cases, inadequate localization is favoured by the variable length and mobility of the sigmoid colon as well as by the lack of anatomical and endoscopical marks to define the transition between the sigmoid and descending colon. Surprisingly, other paper report completely opposite data, no finding endoscopic errors when the tumors are located in the descending (18) or the sigmoid colon (2). Finally, the comment that, as in our series, a high number of endoscopic errors has been reported for cecal CRC (12).…”

“…Under certain circumstances, an error will not influence the surgical procedure (right hemicolectomy with a wrong diagnosis between cecum or ascending colon). However several publications have showed that a previous mistaken localization has been responsible of serious situations as resecting a colonic segment not containing the tumor (2,18,20). In all our cases, errors consisted in localizing CRC in the proximal or distal segment to its real surgical situation, and so initial surgical plan had to be modified in only one case, changing to open surgery and intraoperative colonoscopy performance was required in two patients.…”

“…Surgeon previous knowledge of the accurate location of CRC is relevant as the lack of this information may lead to negative consequences in the surgical performance (18)(19)(20). The need of an accurate preoperative localization of the tumor has brought the development of different endoscopic techniques in order to facilitate further tumor identification at the time of surgery, including the use of clips (21)(22)(23) and peritumoral submucosal tattooing (1,22,(24)(25)(26).…”

“…Besides this wide range regarding wrong endoscopic localization, it is remarkable the lack of papers analysing possible factors which can lead to a mistaken localization (9). It is also notorious the lack of agreement concerning the anatomic colonic segments where errors are more frequent (12,14,15,18).…”

Intraoperative fluoroscopy vs. intraoperative laparoscopic ultrasonography for early colorectal cancer localization in laparoscopic surgery

“…Tumor localization techniques for early CRC are necessary, even in open surgery, because early cancer cannot be manually palpated in many cases due to shallow cancer invasion, small size and lack of visible serosal signs [36,37]. Furthermore, laparoscopic early CRC localization may be impossible without the use of localization tools, because tactile sensation is essentially lost laparoscop- ically.…”