Endoscopy

David Irabor

University College Hospital Ibadan, Nigeria

Surgical gastrointestinal

endoscopy in a tropical low

socio-economic population.

Key words:

Surgeon, Flexible endoscopy, Third world.

ABSTRACT

Introduction: Flexible fiberoptic endoscopy in this institution (University

College Hospital Ibadan Nigeria) had traditionally been performed by the

gastroenterologists of the internal medicine department. Thus surgical patients are

referred to the physicians to have endoscopy done. This situation was felt not to be

ideal by the author who believed that surgeons should be able to scope their own

patients for diagnostic and even therapeutic purposes.

Objectives: To demonstrate that surgeons are in a better position to scope their own

patients expediently, safely and satisfactorily. Also to share with others the scope

of indications for endoscopy that the average general surgeon in a developing

country may handle.

Methods: A prospective study noting the indications for endoscopy, the findings

at endoscopy and the demographic indices of the scoped patients by the single

surgeon-endoscopist over a period of 26 months.

Results: Roughly 2 patients per month were scoped. Mean age of 54 years. The

Male: Female ratio was 1.6: 1. Twenty-three gastroscopies were performed during

that period with carcinoma of the stomach, duodenitis and chronic duodenal ulcer

being most common findings. The 18 sigmoidoscopies yielded hemorrhoids, rectal

cancer and sigmoid colon cancer commonly while the colonoscopies yielded varied

conditions like carcinoma of the colon, diverticulosis, colonic Kaposi sarcoma and

studies that were grossly normal in 4 patients.

Conclusion: It is expedient and appropriate for surgeons to perform flexible

fiberoptic endoscopy. Formal or informal training can always be arranged for

interested residents.

Reduction of costs for scoping may encourage greater patient load.

INTRODUCTION

    Fiberoptic colonoscopy is about 43 years old now.

Improvement in instruments led rapidly to wide acceptance

of colonoscopy in diagnosis and therapy of colorectal

diseases1. The diagnosis of benign and malignant neoplasms

was revolutionized by colonoscopy. Flexible fiberoptic

endoscopes have now replaced rigid endoscopes because of

the enhanced safety, ease of application and ability to link to

a monitor (videoscopes) so that the patient may even follow

the procedure. The use of these flexible fiberoptic endoscopes

for both upper and lower gastrointestinal tract examinations

started in the University College Hospital Ibadan as far back

as 1986; however most of these examinations were carried

out by the physicians of the gastroenterology unit2. Some

sporadic endoscopies were done by one surgeon from 1989

to 1990, but when he left the service for another appointment

requests for endoscopy on surgical patients were sent to the

medical gastroenterologists. Recently, the hospital purchased

new scopes for the use of all stakeholders (gastrointestinal

surgeons, medical gastroenterologists, pulmonologists,

otorhinolaryngologists and thoracic surgeons). Now the surgical

gastroenterology division does its own endoscopy. Each unit

has its own day for doing endoscopy. The gastrointestinal

surgical unit has Friday morning and afternoon allocated for

endoscopy.

    This is the first report of the experience of a surgeon

performing both upper and lower gastrointestinal endoscopies

in the University College Hospital Ibadan, Nigeria.

     MATERIALS AND METHODS

    The city of Ibadan has a population of about 2.5 million

inhabitants and the University College Hospital serves as

the only tertiary center in this city where flexible fiberoptic

endoscopy is performed. The surgical gastrointestinal diseases

commonly encountered in this locality that are appropriate

for endoscopy include bleeding duodenal or gastric ulcers,

carcinoma of the stomach, carcinoma of the esophagus,

haemorrhoids, fistula-in-ano and colorectal carcinoma.

      The endoscopy suite has Olympus gastrofiberscopes,

sigmoidoscopes and colonoscopes. Recently the Federal

Government of Nigeria through VAMED Consult purchased

some Pentax scopes (gastrofiberscope and sigmoidoscope) for

the endoscopy unit. All the scopes require an adaptor head to

convert them to videoscopes.

    Preparation of patients: About 75% of the patients are

scoped on outpatient basis. These patients present to the

surgical outpatients clinic on a Thursday and are scheduled for

endoscopy on a Friday one week from then. For the patients

requiring lower gastrointestinal endoscopy we usually prefer

the 5-day bowel preparation consisting of semisolid or liquid

diet, oral liquid paraffin 30 ml at night, bisacodyl (Dulcolax)

tablets; 2 at night for 2 days. For those patients on admission

we add daily enema saponis. During this period also, the

retroviral and hepatitis screenings are usually done. When the

patient is on the couch, an intravenous line is set up while

the nurses manually record the vital signs. We usually sedate

the patients with a cocktail of intravenous diazepam and

pentazocine. Patients for upper gastrointestinal endoscopy

have additional atropine and buscopan injections.

     RESULTS.

     In the 26 month period (3-10-2003 to 31-12-2006) we

scoped 55 patients. This averages about 2 patients a month.

Their ages ranged from 19 to 85 years with a mean age of

54 years. The male: female ratio was 1.6: 1.Twenty-three

gastroscopies, 18 sigmoidoscopies and 14 colonoscopies were

performed during this period. For the gastroscopies, the age

range was from 30 to 85 years, with a mean of 56.4 years and

a male: female ratio of 1.5:1. The sigmoidoscopies showed

an age range of 33 to 78 years, a mean age of 51.6 years and

a male: female ratio of 1.6:1.Colonoscopy records showed an

age range of 19 to 72 years, a mean of 52.4 years and a male:

female ratio of 2.5:1.

     The outcomes of the various examinations are as follows:

     Upper GI endoscopy: Carcinoma of the stomach (7),

duodenitis (6), chronic duodenal ulcer (5), atrophic gastritis

(2), achalasia (1), reflux esophagitis (1) and carcinoma of the

first part of the duodenum (1). The patient with the achalasia

had to be abandoned as she regurgitated almost 600ml of

esophageal contents as soon as the scope was in her pharynx.

Thankfully she did not aspirate the contents and went on to do

barium swallow which showed a grossly dilated esophagus

with narrowing at the cardia.

     Sigmoidoscopy: Hemorrhoids (6), rectal cancer (2),

colon cancer (2), normal study (8) – the indications for these

were suspected rectovaginal fistula post-radiotherapy in a

patient with cervical cancer, fistula-in-ano, tenesmus, painful

defecation, rectosigmoid mass, left iliac fossa mass, bleeding

per rectum and 1 year follow-up after anterior resection for

rectosigmoid cancer.

     Colonoscopy: Carcinoma of the colon (4), post-excision

of a malignant rectal polyp (1), colonic diverticulosis (1),

nodular Kaposi sarcoma in transverse colon (1), hemorrhoids

(1), ulcerative colitis (2) and 4 normal studies of which 3 were

for constipation ?cause and 1 for a left flank mass. In one

patient the scope could not traverse the hepatic flexure of the

colon because of pain. The other patient in whom the scope

did not reach the caecum was the patient with Kaposi sarcoma

who had stenosis of the transverse colon lumen because of the

tumor.

     There were no complications in this series. Many of the

patients complained about abdominal bloating and cramps

after colonoscopy which were temporary. This was attributed

to the distension of the bowel by the insufflated gas during the

procedure.

    DISCUSSION.

    Tertiary hospitals all over the world have different

arrangements for ensuring endoscopic examination on their

patients. Some may have specialist endoscopists who are

neither physicians nor surgeons; others may have either

surgeons or physicians doing their own endoscopies. The

latter group seems to do a lot more of upper gastrointestinal