J. Coloproctol. (Rio J.) vol.36 número2

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Original

Article

Retrospective

analysis

of

the

elective

tests

of

rigid

proctosigmoidoscopy

performed

in

the

service

of

medical

residency

in

Coloproctology

of

Hospital

Santa

Marcelina

夽

Isaac

José

Felippe

Corrêa

Neto

,

Janaína

Wercka

,

Angelo

Rossi

Silva

Cecchinni

,

Eduardo

Augusto

Lopes

,

Hugo

Henriques

Watté

,

Rogério

Freitas

Lino

Souza

,

Alexander

Sá

Rolim

,

Laercio

Robles

a_{ServiceofColoproctology,DepartmentofGeneralSurgery,HospitalSantaMarcelina,SãoPaulo,SP,Brazil} b_{SociedadeBrasileiradeColoproctologia,Brazil}

c_{ColégioBrasileirodeCirurgia,Brazil}

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Articlehistory:

Received30September2015 Accepted25March2016 Availableonline13April2016

Keywords:

Proctologicalexamination Rigidproctosigmoidoscopy Diagnosis

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Introduction:Proctologicexaminationisadeeplyintimateprocedurewhichdealswithabody areainwhichprejudices,taboosandconstraintsprevail,andmayalsorelatetoprevious trauma;yetthisprocedureisofparamountimportancefortheinvestigationofpatients withsymptomsthatforetellpathologiesassociatedwithdistalcolon,rectumandanus. Objectives:Thisstudyaimedtoanalyzeallcasesscheduledofrigidproctosigmoidoscopy performedbytheColoproctologyService,HospitalSantaMarcelina,in8ofits10yearsof residencyinthespecialty.

Materialsandmethods:Weanalyzedmeanage,genderdistribution,device’sheightofreach inrelationtotheanalverge,thepercentageofabnormaltestsstratifiedtoperform,ornot perform,anoscopyandproctosigmoidoscopy,andmajordiseasesdetected.

Results:844rigidproctosigmoidoscopyproceduresscheduledandperformedbythe Colo-proctologyService,HospitalSantaMarcelina,betweenSeptember2006andAugust2014, wereanalyzed.Thedistributionwassimilarbetweengendersandthemeanagewas51.2 years.Withrespecttothedevice’sheightofreachfromtheanalverge,thesevalueswere stratifiedasfollows:distancereached>15cm,10–15cm,and<10cmfromtheanalverge. Distances>15cmfromtheanalvergewereattainedin692(82%ofRR)tests,between10and 15cmin94(11.1%)tests,and<10cmin58(6.9%)tests.

Conclusion:Inthisstudy,itwasfoundthatproctologyexaminationandrigid proctosigmoi-doscopyaremandatoryproceduresincasesofsymptomsdependingonthesepractices.

©2016SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.This isanopenaccessarticleundertheCCBY-NC-NDlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).

夽

ThisstudywasconductedbytheProgramofMedicalResidencyinColoproctology,DepartmentofGeneralSurgery,HospitalSanta Marcelina,SãoPaulo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:isaacneto@hotmail.com(I.J.F.C.Neto).

http://dx.doi.org/10.1016/j.jcol.2016.03.007

Análise

retrospectiva

de

exames

eletivos

de

retossigmoidoscopia

rígida

realizadas

no

servic¸o

de

residência

médica

de

Coloproctologia

no

Hospital

Santa

Marcelina

Palavras-chave: Exameproctológico Retossigmoidoscopiarígida Diagnóstico

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Introduc¸ão: Oexameproctológico,apesardeprofundamenteíntimoedelidarcomárea do corpo na qual imperam preconceitos, tabus e constrangimento, podendo inclusive relacionar-seatraumasprévios,édesumaimportânciaparaainvestigac¸ãodepacientes comsintomasquepredizempatologiasassociadasaocólondistal,retoeânus.

Objetivos:Analisartodososcasosderetossigmoidoscopiasrígidasrealizadasdeforma agen-dadapeloservic¸odeColoproctologiadoHospitalSantaMarcelinaem8deseus10anosde residênciamédicanaespecialidade.

Materiaisemétodos: Analisou-seamédiadeidade,distribuic¸ãoporsexo,alturadealcance doaparelhoemrelac¸ãoàbordaanal,percentagemdeexamesanormaiscomestratificac¸ão quandorealizadoounãoaanuscopiaeretossigmoidoscopiaeasprincipaisdoenc¸as detec-tadas.

Resultados: Foramavaliadas844retossigmoidoscopiasrígidasrealizadaspeloservic¸ode ColoproctologiadoHospitalsantaMarcelina,deformaagendada,entresetembrode2006e agostode2014.Adistribuic¸ãofoisemelhanteentreossexoseamédiadeidadefoide51,2 anos.

Comrelac¸ãoàalturaemrelac¸ãoàbordaanal,estratificou-seessesvaloresemmaiorque 15cm,entre10e15cmdabordaanalealcanceinferiora10cmdabordaanal.Em692exames foipossívelalcancesuperiora15cmdabordaanal(82%dasRR),em94(11,1%)entre10e 15cm,eem58(6,9%)exames,abaixode10cm.

Conclusão: Verificou-seemnossoestudoqueoexameproctológicoearetossigmoidoscopia rígidasãomandatórioemcasosdesintomatologiaqueassimonecessitem.

©2016SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda.Este éumartigoOpenAccesssobalicençadeCCBY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Proctologicexaminationisadeeplyintimateprocedure,which dealswithabodyareainwhichprejudices,taboosand con-straintsprevail,andmayalsorelatetoprevioustraumaand abuseissues;yetthisprocedureisofparamountimportance forthe investigation ofpatients with symptomsthat fore-tell pathologies associated with distal colon, rectum and anus,suchasbleeding,changeinbowelhabits,abdominalor perinealpain,mucorrhea,tenesmus,rectalpull,anal inconti-nence,analprolapseortumor,anemia,andothers.

Therefore, it is emphasized that this approach should be done (where appropriate, depending on patient’s com-plaints)byallmedicalassistants,notonlybygeneralsurgeons, digestivetractsurgeonsand,morespecifically,by coloproc-tologists.However,amoredetailed assessmentofthe anal area,rectumanddistalcolonwiththehelpofanoscopyand rigidproctosigmoidoscopyshouldbeperformed,preferablyby morejadedprofessionals.Rigidproctosigmoidoscopy(RR)is thatpartofaproctologicphysicalexaminationthatdepends on greater expertise and knowledge of the region. This examinationconsistsofdirectvisualization ofthemucosal surfaceoftherectumanddistalsigmoidcoloninavariable length,dependingontheequipment,thephysician’s exper-tise,andthepatient’sanatomicalconfiguration,notablyatthe

rectosigmoidtransition.InordertoachieveaneffectiveRR, someprinciplesshouldbefollowed1_:

- speed:theexaminationshouldbeperformedintheshortest possibletimeandwithdueeffectiveness;

- minimum air-blowing: excess air during the procedure causesdiscomfortandpaintothepatient;

- thedoctorshouldtalktothepatientduringthe examina-tion:theobjectiveistoexplain,reassureand,ifpossible,to distractthepatient;

- onedoesnotcauseiatrogenicproblems,mainlybleeding, mucosallaceration,andthemostdreadedofall complica-tions:rectalperforationduringtheexamination.

Themaincontraindicationstothis examinationare rep-resented by an acute diverticulitis, suspected peritonitis, hemorrhoidalthrombosis,analfissure,perianalabscess,anal stenosisandanearlypostoperativeperiodofacolorectalor orificialsurgery.

Objective

Materials

and

methods

Thisisaretrospectiveanalysisofall RRexaminations per-formedelectivelybythe ServiceofColoproctology, Hospital SantaMarcelina,in8ofits10yearsofmedicalresidencyin thespecialty.

Previouslytotheexamination,allpatientsunderwent ret-rogradebowelpreparationwithaglycerinsolution12%.Forthe examination,patientshaveadoptedtheknee-chestposition, exceptwhentherewerecontraindicationsoranyage-related limitation.

Meanage, genderdistribution, the origin ofthe patient (i.e.,whetherfrominternalorexternalservice),thedevice’s height ofreach from the anal verge, percentage of abnor-maltestswithstratification(withor withoutanoscopyand proctosigmoidoscopy),andmajordiseasesdetected.RR pro-ceduresperformedduringoutpatientvisitswereexcluded.

Results

Weevaluated844 RR procedures scheduledand conducted bythe ServiceofColoproctology, HospitalSanta Marcelina, betweenSeptember2006andAugust2014.Themeanagewas 51.2years(13–92years)(Fig.1)and414(49.05%)patientswere male;mostofthetestscamefrominternalhospitalservices, i.e.,622tests(73.7%).Regardingthedevice’sheightofreach fromthe analverge,thevalueswere stratifiedindistances >15cm,10–15cmand<10cmfromtheanalverge.In692 exam-inations,adistance>15cmfromtheanalverge(82%ofRRs) wasreached;in94(11.1%),between10and15cm;andin58 (6.9%)patientsthedevice’sprogressiononlywasupto10cm fromtheanalverge(Fig.2).Inallinwhichtheheightofreach <10cm,thecausewasaninadequatepreparation,painora stenotictumor.Moreover,in14of94tests(14.9%)with progres-sionfrom10to15cm,anexcessiveangulationwasobserved. Theproctosigmoidoscopyhadnormalresultsin677patients (80.2%);butwithrespecttothesecases,inonly270(39.9%)the wholeproctologicalexaminationwasnormal;intheother407 tests(60.1%),somechangewasfound,eitherattheinspection, duringpalpationoratanoscopy.

Ontheother hand,whenthe proctologicalanalysiswas takenasawhole(i.e.,inspection,digitalrectalexamination and palpation,anoscopy and rigidproctosigmoidoscopy),it wasfoundthatthetesthadabnormalresultsin574patients

100

Age distribution

90

80

70

60

50

40

30

20

10

0

Fig.1–Agedistribution.

82.00%

11.10%

>15cm 10-15cm <10cm

6.90%

Fig.2–Heightofrigidrectosigmoidoscopereachinrelation totheanalverge.

(68%),andinonly28.6%ofthesepatientsmoretrainingand expertisewereneededtoachieveadiagnosisbyanoscopyand RR.Thus,ingeneral,thediagnosisoforificialpathologywas onlypossiblewiththeuseofanoscopyandRRin144patients (17.06%);and onlywiththe use ofRR in20patients (2.4%) (Fig.3).

Cancer was diagnosed in63 procedures (7.4%); in44 of these(69.8%),thedigitalrectalexaminationwassufficientfor obtainingthediagnosis ofneoplasia.Thus,itwasobserved thatfrom844RRsperformed,in44(5.2%)ofthemthedigital rectalexaminationwassufficientforthediagnosisofatumor (Fig.4).

Discussion

AccordingtodatafromINCA,2_{between2012and2013518,510} new casesofcancer were diagnosedinBrazil, and specifi-cally withrespecttocolorectal malignancy,30,140subjects wereaffected,withanequivalentdistributionbetween gen-ders.Thisneoplasiaisthefourthmostcommoncancerinmen andthethirdinwomen.Between55and67%3,4_ofcases, colo-rectalcancerisfoundinthedistalsegmentoftheintestinal tract,i.e.inthesigmoidcolonandrectum,andabout35%of thesetumorsarespecificallylocatedintherectum.5

Inthisregard,whenreaching25cmfromtheanalverge, RRallowstheestablishmentofadiagnosisinabout65%ofall colorectalcancers.6_{However,inonly50%oftheprocedures,} the device will progressup to20cmfrom theanal verge.6 Moreover,beingarigidtube,theproctosigmoidoscopeisstill quitesensitiveandspecificinordertomeasuretheheightof thetumorfromtheanalvergeorrectumvalves.

Despite being aninvasive and uncomfortable procedure tothepatient,Elias etal.7_{conductedastudy toverify the} patient’simpressionwithrespecttotheproctology examina-tion bythe residentphysician.In thisstudy,these authors

844 patients

Abnormal - 574

Inspection and DRE – 71.4%

Anoscopy and RR – 28.6%

Diagnosis with anoscopy: 17.6%

Diagnosis with rigid proctosigmoidoscopy: 2.4% Normal - 270

No 93%

Yes 7%

Fig.4–Percentageofneoplasmdiagnosesinanorectal examinationsbyinspection,digitalrectalexamination,

anoscopyandrigidproctosigmoidoscopy.

analyzed100patientsundergoingconsultationandafull proc-tologicaltestthroughectoscopy, digitalrectalexamination, anoscopyandrigidproctosigmoidoscopy.Eliasetal.showed that87%ofpatientsacceptedwellthepresenceofresidents, 11%remainedindifferent,1%foundtheirpresence unpleas-ant,and1%didnotanswer.Regardingtheresidents’gender, nostatisticallysignificantcorrelationwasfoundbetweenthis variableand therefusal oracceptanceoftheirpresenceby patients.

Similarly,Simpson et al. 8 _{conductedan interview with} colorectalsurgeonsfromAustraliaandNewZealand.Ofthe 35professionals who answeredthe questionnaire,30 (85%) routinelyperformRRintheiroffices.

Inthiscontext,Diogenesetal.9 _{intendedtoevaluatethe} proctosigmoidoscopyfindingsinacolorectalcancerscreening inasymptomaticpatientsover50years.Withthatinmind, theseauthors studied208patientsintheperiodof approx-imately one year, achieving 94.73% of normal results; in theremaining5.26%,thepresenceofhyperplasticor adeno-matouspolypswasdiagnosed,andnotonecaseofmalignancy inthesamplestudiedwasfound.

Between1989and1996,Balkanetal.10_{evaluated119RR} proceduresin100patientsaged8monthsto14years with complaintsofanalbleeding.Theseauthorsusedasexclusion criteriathe presenceofanal fissure,hemorrhoidsand anal infection.Theprocedurehadabnormalresultsin60patients andtheprimarydiagnosiswasarectalpolypin53.3%ofcases, followedbyproctitisin26.7%.Ofthosepatientswitharectal polyp,theauthorsestablishedthediagnosisbydigitalrectal examinationin66%ofcases,withafalse-positiverateof25% andafalse-negativerateof12%.

Studiesontheapplicability ofRR arerelatively rareand dated,mainlywithreferencetotheacquisitionand progres-sivedevelopmentofmodernmethodsfortherectalwork-up.

Selbyetal.6_{showedthatpatientsundergoingrigid} proctosig-moidoscopy in colorectal cancer screenings in the 10-year periodpriortothe study hadonly30% offatalcancerrisk versussubjectsnotscreenedformalignancyinthegroupof patientsalreadyknowntobecarriersofrectal,rectosigmoid transition,ordistalsigmoidcancer.

In addition, and highlighting the usefulness of RR – even whenthe most advancedpropaedeutics are available – Schoellhammer et al.11 _{set out to determine the degree} towhich rectaland rectosigmoidtumorsshowed achange intheirtreatment, basedontheheightofmeasuredinjury obtainedwithRRandcolonoscopy.Withthatinmind,these authorssubdividedtheir53patientsexaminedbycolonoscopy intocarriersofinjuryinthelower rectum(0–7cmfrom the anal verge), middle rectum (8–11cm from the anal verge), highrectum(12–15cmfromtheanalverge)andrectosigmoid region(>15cmfromtheanalverge);thisdone,theseauthors comparedtheirfindingswiththesedistancesobtainedwith RR.

Alsointhisstudy,whenlow,mediumandhighrectaland rectosigmoidtumorswereanalyzed,itsauthorsobserved dif-ferencesinthemeasureddistancefromtheanalvergetothe injurybycolonoscopyversusRR:0.8cm,1.8cm, 3.1cm and 5cmrespectively.Thus,anintermediateKappaindexbetween thedifferencesofheightmeasurementsofthelesioninthe highrectumandthesigmoidregionwasobtained,showing thatthemostproximaltheneoplasiawaslocatedrelativeto theanalverge,thegreaterthediscrepancybetweenthe mea-surementsobtainedbycolonoscopyandRR.Moreover,these authorsreportedthattheadditionofRRpreviouslytothe ther-apeuticdecisionmakingchangedthetreatmentplanin25% ofpatients.11

Although this isa testusuallyapplied during coloproc-tological consultation, the presenceoffecal residue in the rectummaycompromiseitseffectivenessinsuchawaythat, withrespecttotheneedtopreparetheareaforarigid proc-tosigmoidoscopy,itisknownthatabout50%ofthetestshave limitationsduetothepresenceoffecalresidue.12

Withthatinmind,Bulmeretal.13 _conducteda random-izedstudyinvolving131patientsinordertocomparesubjects withretrogradedistalmechanicalpreparationversus those whodidnotmakeanypreparation.Itwasfoundthatamong thosepatientsundergoingbowelpreparation,itwaspossible toinspectmorethan75%oftherectalmucosacircumference in79%ofpatients.Ontheotherhand,amongthosesubjects who didnotundergopreparation,thiswasonlypossiblein 26.2%(p<0.05).Moreover,amongthosesubjectsundergoing bowel preparation, it was possible to introducethe device in 83.3%ofpatients; asto those subjectswithout prepara-tion,thiswasonlypossiblein46.2%oftheexaminedpatients (p<0.05).

Conclusion

orificialpathology.Thus,thankstoitssimplicityandthe abil-itytobecarried out anypracticing doctor, thistestshould neverbeoverlooked.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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