William I. Wolff

Morphology, Anatomic Distribution and Cancer Potential of Colonic Polyps: An Analysis of 7,000 Polyps Endoscopically Removed

The concept of a polyp-cancer sequence is assuming increasing credibility as a factor in the development of colorectal cancer. Colonoscopy permits most colonic polyps to be endoscopically removed and studied pathologically. Of various polyp types encountered in the colon only neoplastic polyps are regarded as having malignant potential. Neoplastic polyps include tubular adenomas (formerly, adenomatous polyps), villous adenomas and villotubular adenomas (formerly, mixed or tuboglandular polyps). Cancerous changes must penetrate the muscularis mucosae for a polyp to be regarded as clinically malignant. The present report analyzes a series of 5,786 adenomas from over 7,000 polyp endoscopically removed. The largest number of each type of adenoma presented in the sigmoid colon, followed by the descending colon in terms of frequency. In all zones tubular adenomas were most common, villous least. Abnormal cellular change, from dysplasia to carcinoma in situ to invasive cancer was most frequently found in the sigmoid colon and, in all colon sectors, increased as the villous componency of the polyp increased. However, all categories of neoplastic polyps showed malignant changes. Polyp size, long recognized as a factor, was shown to be importantly related to malignant change, but invasive cancer was found even in polyps less than 1 cm in diameter. In addition, the incidence of malignancy rose parallel to the frequency of synchronous and metachronous polyps. A vigorous program for detection and endoscopic removal of colorectal polyps is recommended as a means of reducing the incidence of colorectal cancer.

Polypectomy via the fiberoptic colonoscope. Removal of neoplasms beyond reach of the sigmoidoscope.

Abstract Polyps of the colon and rectosigmoid, potentially precancerous lesions, have heretofore required laparotomy and colotomy for removal. Against a background experience of 1600 fiberoptic colonoscopies without complication a program in endoscopic removal of colonic polyps from all parts of the colon was undertaken. Three hundred and three polyps, 0.5 to 5.0 cm in diameter, were safely removed by this technic. Bleeding, controlled by transfusion therapy, occurred, in one patient, and minor bleeding in four others.

CEA levels in patients with colorectal polyps

Preoperative plasma CEA levels were measured in 93 selected patients with histologically defined colorectal adenomata removed at fibroptic colonoscopy in order to determine whether CEA levels are elevated in patients with colonic polyps, or vary with different histologic patterns. None of the patients had inflammatory bowel disease, previous history of carcinoma, or evidence of liver disease. Fifteen percent of the patients had elevated CEA levels (≥2.5 ng/ml; Hansen method), and two‐thirds of these were between 2.5 and 4.0 ng/ml. Increased association of elevated CEA levels was noted with old age, villous adenomas (2‐to 4‐fold), and increased tumor size ((2.3‐cm diameter; 2‐fold), but not with foci of dysplasia or carcinoma in situ as such. One‐half (7/14) of the patients with elevated CEA levels showed the following: two patients had villous tumors with carcinoma in situ, one had a villous adenoma, two had mixed villous and tubular adenomas (with a high proportion of villous pattern), and two were subsequently shown to have carcinoma elsewhere in the colon. It is uncertain that the polyps were the source of the elevated circulating CEA levels; other factors including smoking and patient selection need to be considered. This preliminary study suggests that patients with colorectal adenomata and elevated circulating CEA may be at higher risk for the development of carcinoma. Further follow‐up studies of the malignant potential of the polyp‐bearing colon are essential.

Earlier diagnosis of cancer of the colon through colonic endoscopy (colonoscopy).

Colonoscopy is a major advance in the diagnosis, treatment, and investigation of diseases of the colon and rectum, particularly cancer. Based on our early experience, this technique can be expected to bring malignant and premalignant lesions of the large intestine to clinical attention at an earlier stage and thus effect a higher cure rate. The large majority of colonic polyps can be removed from all levels of the colon safely by the endoscopic route, eliminating the need for laparotomy in most cases and reducing costs of care materially. Errors in radiologic diagnosis, positive, negative, or equivocal, can be materially reduced when there is endoscopic confirmation. Thus, colonoscopy and the contrast enema may be regarded as complementary studies. Colonoscopy is an extremely safe method of study when carried out in expert hands; it can be done on an ambulatory basis. There is an urgent need for good training programs to ensure adequate availability of the method to the public. The technique is also an excellent means of followup for patients who have been treated for cancer, polyps, or inflammatory diseases of the colon and rectum. Pertinent and illustrative case material gleaned from a clinical experience of over 4000 colonoscopies and 600 endoscopic polyp removals is presented.

Colonofiberscopic management of colonic polyps

ConclusionsEndoscopic 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.

Quantitative thermography as a predictor of breast cancer

The lack of specific, consistent diagnostic criteria has lessened the value of thermography in the diagnosis of mammary cancer. In an effort to improve the diagnostic accuracy of this technique, a numerical procedure was devised based on the evaluation of four features of the breast thermogram. Each was shown to be a statistically valid indicator of malignancy. In combination, as a diagnostic score, they were even more reliable. The development of a color technique provided a simple means for quantitating three of these features. Normal patients and patients with proven breast tumors were thermographed and scored. Optimal weighting, by linear discriminant analysis, did not improve the results significantly. Three sets of weights for the four diagnostic criteria were used in the multiple logistic function in order to generate probability tables which related all possible diagnostic scores to the chance of having cancer. The observed results, in this small series, compared favorably with those predicted by the model.

Torulopsis glabrata fungemia during prolonged intravenous alimentation therapy.

FUNGAL infections, rare in surgical patients, may follow prolonged antimicrobial therapy or may occur when systemic resistance factors are depleted. Saprophytic fungi, consistently present in the e...

Experimental Microvascular Suture Anastomosis

To evaluate the limits imposed by blood vessel size on success or failure of vascular anastomosis by suture techniques, tiny vessels in young CFN rats were anastomosed by microsuture technique, using the Zeiss operating microscope at 16 and 25 magnifications. In series I aortae averaging 1.3 mm external diameter prior to manipulation were divided transversely and rejoined by suture anastomosis. In series II inferior venae cavae averaging 2.7 mm external diameter prior to manipulation were similarly treated. In series III both of these procedures were performed in each animal. There were ten animals in each group.Of 40 consecutive anastomoses only three were not patent when the animals were sacrificed three weeks after surgery. Two of the failures were arterial, and one was venous. This high success rate was achieved only when certain refinements in technique had been perfected.The feasibility of suture anastomosis of extremely small veins as well as arteries has been demonstrated.

Bronchial spasm during general anaesthesia

SummaryTwo cases of severe bronchial spasm in patients under general anaesthesia are presented. In the first case the bronchial spasm, according to our clinical impression, was due to histamine release following a rapid intravenous injection of 15 mg of d-tubocurarine; 100 mg of lignocaine, administered intravenously, abolished the spasm. In the second case the spasm was induced reflexly by the intubation of the trachea in a patient under thiopentone anaesthesia; 40 mg of procaine, intravenously, ended the attack. The possible mechanisms by which local anaesthetic drugs may induce relaxation of the bronchial muscle are discussed.RésuméNous avons présenté deux cas de spasme bronchique grave chez des malades sous anesthésie générale. Dans le premier cas, c’est notre diagnostic clinique, le spasme bronchique a été causé par une décharge ďhistamine à la suite de ľinjection rapide de 15 mg de d-tubocurarine par voie endoveineuse; ce spasme a cédé après ľinjection de 100 mg de lignocaïne. par voie endoveineuse. Dans le second cas, nous avons attribué le spasme à un réflexe provoqué par ľintubation endotrachéale chez un malade anesthésié au thiopentone; tout est entré dans ľordre après ľinjection de 40 mg de procaine par voie endoveineuse. Nous avons discuté les mécanismes possibles par lesquels les anesthésiques locaux peuvent faire céder le spasme de la musculature bronchique.

Management of surgical problems in patients on methadone maintenance

One hundred patients on methadone maintenance admitted to our surgical service were analyzed. The average duration of prior narcotics abuse was ten years and was followed by an average of 2.2 years of methadone maintenance treatment. Sixty-three patients were admitted on an emergency basis, half of these for trauma. Sixty-two patients underwent operative procedures. There were four deaths, none directly related to methadone use. Five patients were admitted for intestinal obstruction secondary to methadone ingestion. This disease entity results from fecal impaction which is induced by methadones spastic effect on the gastrointestinal tract. Evidence of chronic liver disease was present in half the patients. The associated medical illnesses presented no problems with anesthesia. WHILE METHADONE MAINTENANCE WAS CONTINUED IN THE ACCUSTOMED DOSAGE, POSTOPERATIVE ANALGESIA WAS ACCOMPLISHED SATISFACTORILY WITH 5O TO 100 MG DOSES OF MEPERIDINE AT 3 HOUR INTERVALS, AS REQUIRED.