Laparoscopic resection for endoscopically unresectable colorectal polyps: analysis of 525 patients

Laparoscopic wedge resection as an alternative to laparoscopic oncological colon resection for benign endoscopically unresectable colon polyps

AIM

The aim of this study was to investigate, by comparing clinical and histological outcomes, whether laparoscopic (hybrid) wedge resection (LWR) could be a less invasive and safe alternative to laparoscopic oncological colon resection (OCR) for patients with an endoscopically unresectable, suspected benign, colon polyp.

METHOD

All patients with an endoscopically unresectable colon polyp who were referred for surgery between 2009 and 2018 and without biopsy-proven colon cancer were identified from a prospectively maintained database. Patients with macroscopic features of malignancy during endoscopy were excluded. Clinical and histological results for patients who underwent OCR or LWR were reviewed.

RESULTS

One hundred-and-twenty-two patients were included. Ninety-seven patients underwent OCR and 25 LWR. Major complications occurred in 16.7% (n = 16) of the OCR group compared with 4.0% (n = 1) of the LWR group (p = 0.06). In the OCR group the anastomotic leakage rate was 6.3% (n = 6) and the mortality rate 3.1% (n = 3). No anastomotic leakage or deaths occurred in the LWR group. The median length of hospital stay after OCR was 5 days [interquartile range (IQR) 5-9 days)] compared with 2 days (IQR 2-4 days) after LWR (p < 0.0001). Definite pathology showed a malignancy rate of 4.2% (n = 4) in the OCR group and 4.0% (n = 1) (without high-risk features) in the LWR group.

CONCLUSION

This study shows that LWR was associated with significantly lower complication rates and acceptable oncological risks compared with OCR. Therefore we suggest that LWR is a safe alternative treatment, next to other endoscopic options. The treatment that is most suitable for an individual patient should be discussed in a multidisciplinary meeting.

Referrals for surgical removal of polyps since the introduction of a colorectal cancer screening programme

AIM

Implementation of the Dutch national bowel screening programme in 2014 led to an increased rate of detection of polyps. In general, polyps should be removed endoscopically. However, if the size and location of the polyp make endoscopic removal technically difficult, or if there is a suspicion for early (T1) cancer, surgery is the preferred method for removal. An increasing number of these patients are being treated with minimally invasive surgical procedures instead of segmental resection. The aim of this study was to assess the number of referrals for surgery and the type of surgery for polyps since the introduction of the Dutch national bowel screening programme.

METHOD

A retrospective cohort study was performed. Patients who underwent surgery for colorectal polyps between January 2012 and December 2017 were included. Patients with histologically proven carcinoma prior to surgery were excluded. Primary outcomes were the number and type of surgical procedures for polyps.

RESULTS

A total of 164 patients were included. An annual increase in procedures for colorectal polyps was observed, from 18 patients in 2012 to 36 patients in 2017. All the procedures before implementation of the screening programme were segmental resections, and 58.8% of the patients underwent organ-preserving surgery after implementation of the screening. The overall complication rate of organ-preserving surgery was 16.3%, compared with 44.3% for segmental resections (P = 0.001). Overall, invasive colorectal cancer was encountered in 23.8% of cases.

CONCLUSION

The number of referrals for surgical resection of colorectal polyps has doubled since the introduction of the Dutch national bowel screening programme with a substantial shift towards organ-preserving techniques.

Combined endoscopic-laparoscopic surgery (CELS) can avoid segmental colectomy in endoscopically unremovable colonic polyps: a cohort study over 10 years

BACKGROUND

Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings.

METHODS

Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017).

RESULTS

One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection.

CONCLUSION

CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.

Ileocecal Valve Sparing Resection for the Treatment of Benign Cecal Polyps Unsuitable for Polypectomy

Background:

Not all benign-appearance polyps are amenable to endoscopic removal and colectomy is required in some cases. This study aims to compare the early outcomes of cecal wedge resection with ileocecal valve sparring versus standard right colectomy in patients with endoscopically unresectable cecal polyps referred for surgery.

Methods:

From Apr 2010 to Aug 2019, all consecutive patients who underwent cecal wedge resection or right colectomy in ten European centers for a presumed endoscopically benign polyp unsuitable for endoscopic resection were retrospectively analyzed. The primary endpoint was morbidity. Secondary endpoints were operative time and length of hospital stay.

Results:

One hundred and ten patients were included: 25 patients underwent cecal wedge resection and 85 a right colectomy. There were 56 men (51%) and 90% of the procedures were performed laparoscopically. 29 lesions were located at the appendix orifice (26.4%). Mortality was nil. There were no significant differences between both procedures for morbidity rate (20% versus 24.7%) or reoperation (4% versus 4.7%). Cecal wedge was related to shorter operative time (63 min versus 150 min, P = .008) and shorter hospital stay (5 days versus 6 days, P = .049). Only 1 patient had a salvage right colectomy after cecal wedge for a pTis adenoma.

Conclusions:

For benign-appearance cecal polyps unsuitable for endoscopic ablation, cecal wedge resection is safe and should be considered as an attractive alternative to right colectomy.

Can Vascular Endothelial Growth Factors and CD34 Expression Implement NICE (Narrow-Band Imaging International Colorectal Endoscopic) Classification in Colorectal Polypoid Lesion Diagnosis?

BACKGROUND

Vascular endothelial growth factor (VEGF) is a subfamily of growth factors involved in angiogenesis; CD34+ cells are normally found in endothelial progenitor cells and endothelial cells of blood vessels. Colonic adenomatous polyps may not always be completely removable endoscopically, and a preoperative diagnosis might still be necessary. The aim of the study was to evaluate whether VEGF-A, VEGF-C and CD34 mRNA expression along colorectal carcinogenesis steps can implement NICE (Narrow-Band Imaging International Colorectal Endoscopic) classification in the diagnosis of malignancy in colorectal polypoid lesions.

METHODS

Seventy-one subjects with colonic adenoma or cancer who underwent screening narrow-band imaging (NBI) colonoscopy were prospectively enrolled in the MICCE1 project (Treviso center). Polyps were classified according to the NICE classification. Real-time RT-PCR for VEGF-A, VEGF-C and CD34 mRNA expression was performed. Nonparametric statistics, receiver-operating characteristic curve analysis and logistic multiple regression analysis were used.

RESULTS

VEGF-A and CD34 mRNA expression was significantly higher in sessile adenomas than in polypoid ones (p < 0.001 and p = 0.01, respectively). VEGF-A, VEGF-C and CD34 mRNA expression was significantly higher in adenocarcinoma than in adenoma (p = 0.01, p = 0.01 and p = 0.01, respectively). The accuracy of VEGF-A, VEGF-C and CD34 mRNA expression for prediction of malignancy was 0.79 (95% CI 0.65-0.90), 0.81 (95% CI 0.66-0.91) and 0.80 (95% CI 0.65-0.90), respectively, while the accuracy of the NICE classification was 0.85 (95% CI 0.72-0.94). The determination coefficient R2, which indicates the amount of the variability explained by a regression model, for NICE classification alone was 0.24 (p < 0.001). A regression model that included NICE classification and VEGF-C mRNA expression showed an R2 = 0.39 as well as a model including NICE classification and CD34 mRNA levels.

CONCLUSIONS

This study demonstrated that VEGF-C and CD34 mRNA levels might be useful to stratify colorectal polyps in different risk of progression classes by implementing the accuracy of the NICE classification. Studies on in vivo detection of these markers are warranted.

Endoscopic Step Up: A Colon-Sparing Alternative to Colectomy to Improve Outcomes and Reduce Costs for Patients With Advanced Neoplastic Polyps

BACKGROUND

The optimal strategy for colonic polyps not amenable to traditional endoscopic polypectomy is unknown. Endoscopic step up is a promising strategy for definitive treatment.

OBJECTIVE

The purpose of this study was to determine whether endoscopic step up leads to improved outcomes and decreased costs compared with planned colectomy for endoscopically unresectable colon polyps.

DESIGN

This was a retrospective review of a prospective database.

SETTING

The study was conducted at a tertiary referral center.

PATIENTS

Consecutive patients referred for endoscopically unresectable colon polyps 15 to 50 mm in size were included.

INTERVENTIONS

Patients underwent planned colectomy or endoscopic step up at the surgeon's discretion. Endoscopic step up began with diagnostic colonoscopy in the operating room. If the polyp was amenable to endoscopic removal, endoscopic mucosal resection or endoscopic submucosal dissection was performed with progression to combined endoscopic-laparoscopic surgery or laparoscopic colectomy, as indicated.

MAIN OUTCOME MEASURES

The primary outcome was 30-day adverse events. We also examined length of stay, hospital charges, insurer payments, and polyp recurrence.

RESULTS

A total of 52 patients underwent planned colectomy (48 laparoscopic), and 38 underwent endoscopic step up (28 endoscopic mucosal resection, 2 endoscopic submucosal dissection, 6 combined endoscopic-laparoscopic surgery, and 2 colectomy). Compared with planned colectomy, endoscopic step-up patients had fewer complications (13% vs 33%; p = 0.03) and shorter length of stay (median, 0 vs 4 d; p < 0.001). There was 1 readmission in the endoscopic step-up group and 5 in the planned colectomy group. Endoscopic step-up patients had lower hospital costs ($4790 vs $13,004; p < 0.001) and insurer payments ($2431 vs $19,951; p < 0.001). One-year polyp recurrence-free survival was 84% (95% CI, 67%-93%) in endoscopic step-up patients. All of the recurrences were benign, <1 cm, and managed endoscopically.

LIMITATIONS

The study was limited by its nonrandomized design and short follow-up.

CONCLUSIONS

An endoscopic step-up approach to colon polyps is associated with less morbidity, decreased healthcare costs, and colon preservation in 95% of patients. Additional studies are needed to evaluate long-term quality of life and polyp recurrence in this group. See Video Abstract at http://links.lww.com/DCR/B188.

ENDOSCOPIC STEP UP

UNA ALTERNATIVA A COLECTOMíA PARA PRESERVACIóN DE COLON CON LOS PROPóSITOS DE MEJORAR RESULTADOS Y REDUCIR COSTOS EN PACIENTES CON PóLIPOS NEOPLáSICOS AVANZADOS: Se desconoce la estrategia óptima para los pólipos de colon no susceptibles a la polipectomia endoscópica tradicional. Endoscopic Step Up es una estrategia prometedora para el tratamiento definitivo.Determinar si Endoscopic Step Up produce mejores resultados y menores costos en comparación con la colectomía programada para pólipos de colon endoscópicamente no resecables.Revisión retrospectiva de una base de datos prospectiva.Centro de referencia de tercer nivel.Pacientes consecutivos remitidos para pólipos de colon endoscópicamente irresecables de tamaño 15-50 mm.Los pacientes se sometieron a colectomía programada o Endoscópico Step Up a discreción del cirujano. Endoscopic Step Up comenzó con una colonoscopia diagnóstica en el quirófano. Si el pólipo era susceptible de extirpación endoscópica, la resección endoscópica de la mucosa o la disección submucosa endoscópica se realizaba con progresión a cirugía endoscópica-laparoscópica combinada o colectomía laparoscópica, según a cosnideraciones clínicas en el transoperatorio.El resultado primario fue los eventos adversos a 30 días. Duración de la estadía hospitalaria, los cargos hospitalarios, los pagos de las aseguradoras y la recurrencia de pólipos también fueron examinados.Un total de 52 pacientes se sometieron a colectomía programada (48 laparoscópicas) y 38 se sometieron a Endoscopic Step Up (28 resección endoscópica de la mucosa, 2 disección submucosa endoscópica, 6 cirugía endoscópica-laparoscópica combinada y 2 colectomía). En comparación con la colectomía programada los pacientes endoscópicos Step Up tuvieron menos complicaciones (13% versus 33%, p = 0.03) y una estadía hospitalaria más corta (mediana 0 versus 4 días, p <0.001). Hubo 1 reingreso hospitalario en el grupo Endoscopic Step Up y 5 en el grupo de colectomía programada. Los pacientes endoscópicos Step Up tuvieron costos hospitalarios más bajos ($ 4,790 versus $ 13,004, p <0,001) y pagos de la aseguradora ($ 2,431 versus $ 19,951, p <0,001). La supervivencia libre de recurrencia de pólipos a un año fue del 84% (IC 95% 67-93) en pacientes endoscópicos Step Up. Todas las recurrencias fueron benignas, <1 cm, y manejadas endoscópicamente.Diseño no aleatorizado y seguimiento corto.El abordaje endoscópico Step Up para pólipos de colon se asocia con menos morbilidad, disminución de los costos de atención médica y preservación del colon en el 95% de los pacientes. Se ocupan más estudios para evaluar la calidad de vida a largo plazo y la recurrencia de pólipos en este grupo. Consulte Video Resumen en http://links.lww.com/DCR/B188. (Traducción-Dr Adrián Ortega Robles).

Efficacy and safety of cap-assisted endoscopic mucosal resection of ileocecal valve polyps

Background and study aims  Standard endoscopic mucosal resection (EMR) of ileocecal valve (ICV) polyps is challenging. Cap-assisted endoscopic mucosal resection (C-EMR) can be performed when polyps are not easily amenable to standard EMR. Current literature is limited regarding its efficacy and safety for ICV polyps. The objectives of this study were to assess the efficacy and safety of C-EMR for ICV polyps. Patients and methods  A retrospective review was conducted from September 2008 to November 2018 at a tertiary care center. Patients included in the study underwent C-EMR for ICV polyps by a single gastroenterologist (LHJ). Polyps were successfully eradicated if they were removed en-bloc as confirmed by pathology, or had a negative biopsy on follow-up colonoscopy. Outcomes of the procedures were evaluated, including complete adenoma clearance and adverse events. Results  Twenty-one ICV polyps were removed with C-EMR. Median polyp size was 15 mm (range, 5-45). The rate of complete adenoma clearance was 100 %. Procedure-related complications occurred in five patients (24 %): delayed GI bleeding (4.8 %) and deep mucosal resection/visible vessel (14.3 %). Three patients had subsequent surveillance colonoscopies at 8, 56, and 67 months, respectively. The third patient was found to have a 6-mm flat polyp at the edge of the previous polypectomy site. This was treated with C-EMR and repeat colonoscopy 6 months later did not show residual. Conclusion  C-EMR is highly effective in treating ICV polyps with a low complication rate. It is our suggested method in approaching ICV polyps that are difficult to remove via standard freehand snare EMR technique.

Variation in colectomy rates for benign polyp and colorectal cancer

BACKGROUND

Removal of pre-cancerous polyps on screening colonoscopy is a mainstay of colorectal cancer (CRC) prevention. Complex polyps may require surgical removal with colectomy, an operation with a 17% morbidity and 1.5% mortality rate. Recently, advanced endoscopic techniques have allowed some patients with complex polyps to avoid the morbidity of colectomy. However, the rate of colectomy for benign polyp in the United States is unclear, and variation in this rate across geographic regions has not been studied. We compared regional variation in colectomy rates for CRC versus benign polyp.

METHODS

We performed a retrospective population-based study of Medicare beneficiaries undergoing colectomy for CRC or benign polyp, using the 100% Medicare Provider Analysis and Review files from 2010 to 2015. We used multivariable linear regression to obtain population-based colectomy rates for CRC and benign polyp at the hospital referral region (HRR) level, adjusted for age, sex, and race.

RESULTS

Of 280,815 patients, 157,802 (65.8%) underwent colectomy for CRC compared to 81,937 (34.2%) for benign polyp. Across HRRs, colectomy rates varied 5.8-fold for cancer (0.32-1.84 per 1000 beneficiaries). However, there was a 69-fold variation for benign polyp (0.01-0.69). While the rate of colectomy for CRC was correlated with the rate of colectomy for benign polyp (slope = 0.61, 95% CI 0.48-0.75), HRRs with the lowest or highest rates of colectomy for CRC did not necessarily have similarly low or high rates for benign polyp.

CONCLUSIONS

The use of colectomy for benign polyp is much more variable compared to CRC, suggesting overuse of colectomy for benign polyp in some regions. This variation may stem from provider-level differences, such as endoscopists' referral practice or skill or surgeons' decision to perform colectomy, or from limited access to advanced endoscopists. Interventions to increase endoscopic resection of benign polyps may spare some patients the morbidity and cost of surgery.

What is the cost of endoscopic submucosal dissection (ESD)? A medico-economic study

Introduction

Endoscopic submucosal dissection (ESD) is the gold-standard treatment for superficial lesions of the digestive tract. No medico-economic study has been conducted in Europe.

Material and methods

A monocentric study was conducted including all patients undergoing ESD between January 2015 and December 2017. The global cost of hospital stays was measured by microcosting, and revenue was based on the diagnosis-related group (DRG) system. The primary objective was to assess the cost/revenue balance. A medico-economic comparison with surgery was performed as a secondary outcome.

Results

A total of 193 patients were prospectively included. The cost per procedure was €3463.79, subtracted from a €2726.84 revenue, with a deficit of -€736.96 per stay. Presence of comorbidities/complications increasing DRG value was the only predictive factor for a positive budgetary balance in a multivariate analysis (odds ratio 49.21, 95% confidence interval 11.3-214.25, p < 0.0001). In comparison with surgery, ESD was associated with shorter length of stay (11 vs 2 days; p < 0.0001) and lower morbidity (28% vs 14%; p = 0.061), lower cost (€8960 vs €1770; p < 0.0001).

Conclusion

The ESD cost/revenue balance is negative in 80% of cases. Given the benefits of ESD in terms of patient morbidity and financial savings compared with surgery, the implementation of a specific ESD reimbursement is warranted.

Management of Large Cecal Polyps: When Can the Ileocecal Valve Be Spared?

BACKGROUND

Endoscopic mucosal resection comprises the first-line treatment for large cecal polyps. With up to 14% of unresectable colonic polyps harboring malignancy, the management of endoscopically unresectable cecal polyps remains an oncologic right hemicolectomy, which can be associated with substantial postoperative morbidity.

OBJECTIVE

This study compares the outcomes of patients with cecal polyps who underwent either endoscopic mucosal resection, a cecectomy, or a right hemicolectomy.

DATA SOURCES

Patients undergoing either endoscopic mucosal resection, partial cecectomy, or right hemicolectomy from 2008 to 2017 at a single tertiary care institution were selected.

STUDY SELECTION

This was a retrospective cohort study.

MAIN OUTCOME MEASURES

The primary outcomes measured were the rate of malignancy, complication rate, estimated blood loss, and hospital length of stay between surgical cohorts.

RESULTS

One hundred twenty-nine patients with cecal polyps were identified, of which 52 were referred for surgery. Nineteen underwent partial cecectomy and 33 (27.3%) underwent right hemicolectomy. Two patients undergoing cecectomy required conversion to hemicolectomy because the resected specimen did not contain the polyp. The 2 surgical cohorts did not differ significantly regarding age, sex, or ASA classification. Procedural complication rates were higher among those undergoing hemicolectomy compared with those undergoing cecectomy (37.1% versus 5.9%, p = 0.02). Estimated blood loss (50 vs 10 mL, p = 0.02), operative duration (98 vs 76 minutes, p = 0.009), and length of stay (4 vs 2 days, p < 0.001) were higher in patients undergoing hemicolectomy than in those undergoing cecectomy. No invasive malignancies were identified on final pathology within the cecectomy cohort.

LIMITATIONS

Single-institution data and retrospective design were limitations of this study.

CONCLUSIONS

In tertiary centers, the majority of large cecal polyps are benign and can be addressed by using endoscopic mucosal resection. When involvement of the appendiceal orifice or ileocecal valve precludes endoscopic treatment, surgical resection is the standard of care. In the subset of cases not involving the ileocecal valve and without preoperative evidence of malignancy, partial cecectomy spares the ileocecal valve and can offer reduced postoperative morbidity compared with a formal right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/A674.

Management of complex polyps of the colon and rectum

PUPRPOSE

Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options.

METHODS

A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum.

RESULTS

Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery.

CONCLUSION

Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

The impact of the national bowel screening program in the Netherlands on detection and treatment of endoscopically unresectable benign polyps

Background

In January 2014, a national bowel cancer screening program started in the Netherlands. The program is being implemented in phases until 2019. Due to this program, an increase in patients referred for a colorectal resection for benign, but endoscopically unresectable polyps, is expected. So far, most resections are performed according to oncological principles despite no pre-operative histological diagnosis of malignancy. The aim of this study was to analyze the increase in referred patients during the first year of the screening program and to compare pathological results and clinical outcome of resections of patients undergoing resection for benign polyps before and after implementation of screening.

Methods

Patients referred for colorectal resection without biopsy-proven cancer between January 2009 and January December 2014 were identified from a prospectively maintained database. Patients with endoscopically macroscopic features of carcinoma were excluded.

Results

Seventy-six patients were included. Forty-seven patients (61.8%) were operated on in the 5 years prior to implementation of the screening program, and 29 patients (38.2%) were operated during the first year of implementation of the screening program. The overall malignancy rate before the introduction of the program was 14.1 and 6.6% after it had started (p = .469). All resections were performed laparoscopically; the conversion rate was 3.9% (n = 3). The overall mortality rate was 2.7% (n = 2), major complications (Clavien–Dindo > 3b) occurred in 11.8% (n = 9) of patients. The anastomotic leakage rate was 3.9% (n = 3).

Conclusions

The number of patients referred for benign polyps tripled after introduction of the screening program. With an overall major morbidity and mortality rate of 11.8%, it seems valid to discuss whether an endoscopic excision with advanced techniques with or without laparoscopic assistance would be preferable in this patient group, accepting a 6.6% reoperation rate for additional oncological resection with lymph node sampling in patients in whom a malignancy is found on histological analysis of the complete polyp.

Laparoscopic colorectal surgery for colorectal polyps: experience of ten years

Background. Laparoscopy or its combination with endoscopy is the next step for “difficult” polyps. The purpose of the paper was to review the outcomes of the laparoscopic approach to the management of “difficult” colorectal polyps.

Materials and methods. From 2006 to 2016, 58 patients who underwent laparoscopic treatment for “difficult” polyps that could not be treated by endoscopy at the National Cancer Institute, Lithuania, were included. The demographic data, the type of surgery, length of post-operative stay, complications, and final pathology were reviewed prospectively.

Results. The mean patient was 65.9 ± 8.9 years of age. Laparoscopic mobilization of the colonic segment and colotomy with removal of the polyp was performed in 15 (25.9%) patients, laparoscopic segmental bowel resection in 41 (70.7%) cases: anterior rectal resection with partial total mesorectal excision in 18 (31.0%), sigmoid resection in nine (15.5%), left hemicolectomy in seven (12.1%), right hemicolectomies in two (3.4%), ileocecal resection in two (3.4%), resection of transverse colon in two (3.4%), and sigmoid resection with transanal retrieval of specimen in one (1.7%). Two patients (3.4%) underwent laparoscopic-assisted endoscopic polypectomy. The mean post-operative hospital stay was 5.7 ± 2.4 days. There were four complications (6.9%). All patients recovered after conservative treatment. The mean polyp size was 3.5 ± 1.9 cm. Final histopathology revealed hyperplastic polyps (n = 2), tubular adenoma (n = 9), tubulovillous adenoma (n = 31), carcinoma in situ (n = 12), and invasive cancer (n = 4).

Conclusions. For the management of endoscopically unresectable polyps, laparoscopic surgery is currently the technique of choice.

Colorectal polypoid lesions and expression of vascular endothelial growth factor in a consecutive series of endoscopic and surgical patients

Colorectal cancer incidence in patients undergoing screening protocols is decreasing because of the higher rate of discovered preneoplastic colonic lesions; however, adenomatous polyps may not always be removable endoscopically and surgery may still be necessary. The aim of this study was to assess the vascular endothelial growth factor expression in the different steps of colorectal carcinogenesis to explore its potential role as a marker of malignancy in polypoid lesions. A total of 92 subjects with colonic adenoma or cancer who underwent screening colonoscopy or surgery were prospectively enrolled. Real-time reverse transcription polymerase chain reaction for VEGF-A messenger RNA expression and immunohistochemistry for VEGF-A were performed. Immunoassays for VEGF-A, VEGF-C, VEGFR-1, VEGFR-2, and VEGFR-3 were also performed. Non-parametric statistics, receiver operating characteristic curve analysis, and logistic multiple regression analysis were used. VEGF-A messenger RNA expression was higher in patients with high-grade dysplasia or colorectal cancer than in those with low-grade dysplasia adenomas (p = 0.01). At immunohistochemistry, VEGF-A expression was significantly higher in colorectal cancer patients compared to dysplastic adenomas (p < 0.001), and the accuracy of VEGF-A expression for prediction of malignancy was 91.7 (95% confidence interval = 78.7-97.9). VEGF-C protein expression was lower in colorectal cancer patients than in simple adenomas (p = 0.02). VEGF-A levels were directly correlated to polyp size (rho = 0.73, p = 0.0062). Multivariate analysis demonstrated that malignancy and polyp size were independent predictors of VEGF-A mucosal levels. This study demonstrated that the VEGF-A expression changes along the colorectal carcinogenesis pathway showing a neat step up at the passage from high-grade dysplasia to invasive cancer. This feature might potentially be useful to stratify colorectal polyps in different risks of progression classes. Moreover, the high level of VEGF-A expression predicted the presence of lymphovascular invasion with good accuracy.

A minor but deadly surgery of colonic polypectomy in an elderly and fragile patient: a case report and the review of literature

Background

Epithelial dysplasia and adenomatous polyps of colorectum are precancerous lesions. Surgical removal is still one of the important treatment approaches for colorectal polyps.

Case presentation

A male patient over 78 years was admitted due to bloody stool and abdominal pain. Colonoscopic biopsy showed a high-grade epithelial dysplasia in an adenomatous polyp of sigmoid colon. Anemia, COPD, ischemic heart disease (IHD), arrhythmias, and hypoproteinemia were comorbidities. The preoperative preparation was carefully made consisting of oral nutritional supplements (ONS), blood transfusion, cardiorespiratory management, and hemostatic therapy. However, his illness did not improve but deteriorate mainly due to polyp rebleeding during preparative period. The open polypectomy was performed within 60 min under epidural anesthesia. Postoperative treatments included oxygen inhalation, bronchodilation, parenteral and enteral nutrition, human serum albumin, antibiotics, and blood transfusion. Unluckily, these did not significantly facilitate to surgical recovery on account of severe comorbidities and complications. The most serious complications were colonic leakage and secondary abdominal severe infection. The patient finally gave up treatment due to multiple organ dysfunction syndromes.

Conclusions

The polypectomy for colonic polyp is a seemingly minor but potentially deadly surgery for patients with severe comorbidities, and prophylactic ostomy should be considered for the safety.

Does Cancer Risk in Colonic Polyps Unsuitable for Polypectomy Support the Need for Advanced Endoscopic Resections?

BACKGROUND

There is a continuing debate on the best approach for endoscopically benign large polyps that are unsuitable for conventional endoscopic resection. This study aimed to estimate the cancer risk in patients with endoscopically benign unresectable colonic polyps referred for surgery.

STUDY DESIGN

We assessed patients with an endoscopic diagnosis of benign adenoma deemed not amenable to endoscopic removal, who underwent colectomy between 1997 and 2012. Patients with preoperative diagnoses of cancer, inherited polyposis syndrome, inflammatory bowel disease, and synchronous pathology requiring surgery were excluded.

RESULTS

There were 439 patients (220 [50.1%] men; median age 67 years [range 27 to 97 years]) who underwent colectomy. Of 439 patients, 346 (79%) underwent preoperative endoscopy at our institution. Most of the polyps were located in the right colon (394 of 439, 89.7%), with the majority in the cecum (199 of 394, 45.3%). Polyp morphology was as follows: sessile (n = 252, 57.4%), pedunculated (n = 109, 24.8%), and flat (n = 78, 17.8%). Endoscopic pathology revealed high-grade dysplasia in 88 (20%) patients. Mean colonoscopic and postoperative polyp sizes were 3.0 cm (range 0.3 to 10 cm) and 2.7 cm (range 0 to 11 cm), respectively (p < 0.001). Final surgical pathology revealed cancer in 37 patients (8%). Polyp location, morphology, and histologic types were similar between the benign and malignant polyps. Cancer stages were: stage I (23 patients), stage II (11 patients), and stage III (3 patients).

CONCLUSIONS

For the majority of endoscopically benign colonic polyps, an oncologic colonic resection may be unnecessary, so advanced endoscopic resection techniques or laparoscopic-assisted polypectomy should be considered. When bowel resection is needed, the resection should be performed, obeying oncologic principles and techniques.

Hybrid Laparoendoscopic Approaches to Endoscopically Unresectable Colon Polyps

Secondary prevention of colorectal cancer relies on effective screening through colonoscopy and polypectomy. Resection of some polyps can present technical challenges particularly when polyps are large, flat, or behind colonic folds. Laparoscopy as an adjunct to endoscopy can aid in removing difficult colonic polyps without subjecting patients to radical segmental colectomy. Hybrid laparoendoscopic techniques are increasingly reported in literature as alternatives to segmental colectomy for the treatment of polyps that have a high likelihood of being benign. Laparoscopic-assisted colonoscopic polypectomy is the most frequently utilized technique; it harnesses the power of laparoscopy to aid endoscopic polypectomy by flattening folds, mobilizing flexures, and providing retraction. Colonoscopy-assisted laparoscopic wedge and transluminal resection are often reported in older studies and use the visualization provided by intraoperative colonoscopy to guide colonic resection that is limited to the area of the polyp. Laparoscopic-assisted endoscopic full-thickness resection (EFTR) is a relatively recent technique that provides laparoscopic monitoring of EFTR of polyp as well as endoscopic closure of the ensuing defect. Minimally invasive segmental colectomy based on oncologic principles should be utilized when none of the previous techniques are suitable or when malignancy is strongly suspected. The combined use of laparoscopy and endoscopy can expand the endoscopist's armamentarium when dealing with the most challenging polyps, while serving the patients' best interest by limiting the extent of colon resection.

Hybrid NOTES: Combined Laparo-endoscopic Full-thickness Resection Techniques

Advances in laparoscopic surgery and therapeutic endoscopy have allowed these minimally destructive procedures to challenge conventional surgery. Because of its theoretic advantages and technical feasibility, laparoendoscopic full-thickness resection is considered to be the most appropriate option for subepithelial tumor removal. Furthermore, combination of laparoscopic and endoscopic approaches for treatment of neoplasia can be important maneuvers for gastric cancer resection without contamination of the peritoneal cavity if the sentinel lymph node concept is established. We are certain that the use of laparoendoscopic full-thickness resection will provide valuable experience that will allow operators to safely develop endoscopic full-thickness resection skills.

British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps

These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.

Endoscopic submucosal dissection vs laparoscopic colorectal resection for early colorectal epithelial neoplasia

AIM: To compare the short term outcome of endoscopic submucosal dissection (ESD) with that of laparoscopic colorectal resection (LC) for the treatment of early colorectal epithelial neoplasms that are not amenable to conventional endoscopic removal.

METHODS: This was a retrospective cohort study. The clinical data of all consecutive patients who underwent ESD for endoscopically assessed benign lesions that were larger than 2 cm in diameter from 2009 to 2013 were collected. These patients were compared with a cohort of controls who underwent LC from 2005 to 2013. Lesions that were proven to be malignant by initial endoscopic biopsies were excluded. Mid and lower rectal lesions were not included because total mesorectal excision, which bears a more complicated postoperative course, is not indicated for lesions without histological proof of malignancy. Both ESD and LC were performed by the same surgical unit with a standardized technique. The patients were managed according to a standard protocol, and they were closely monitored for complications after the procedures. All hospital records were reviewed, and the following data were compared between the ESD and LC groups: patient demographics, size and location of the lesions, procedure time, short-term clinical outcomes and pathology results.

RESULTS: From 2005 to 2013, 65 patients who underwent ESD and 55 patients who underwent LC were included in this study. The two groups were similar in terms of sex (P = 0.41) and American Society of Anesthesiologist class (P = 0.58), although patients in the ESD group were slightly older (68.6 ± 9.4 vs 64.6 ± 9.9, P = 0.03). ESD could be accomplished with a shorter procedure time (113 ± 66 min vs 153 ± 43 min, P < 0.01) for lesions of comparable size (3.0 ± 1.2 cm vs 3.4 ± 1.4 cm, P = 0.22) and location (colon/rectum: 59/6 vs colon/rectum: 52/3, P = 0.43). ESD appeared to be associated with a lower short-term complication rate, but the difference did not reach statistical significance (10.8% vs 23.6%, P = 0.06). In the LC arm, a total of 22 complications occurred in 13 patients. A total of 7 complications occurred in the ESD arm, including 5 perforations and 2 episodes of bleeding. All perforations were observed during the procedure and were successfully managed by endoscopic clipping without emergency surgical intervention. Patients in the ESD arm had a faster recovery than patients in the LC arm, which included shorter time to resume normal diet (2 d vs 4 d, P = 0.01) and a shorter hospital stay (3 d vs 6 d, P < 0.01).

CONCLUSION: ESD showed better short-term clinical outcomes in this study. Further prospective randomized studies will be required to evaluate the efficacy and superiority of colorectal ESD over LC.

Oncologic colorectal resection after endoscopic treatment of malignant polyps: does endoscopy have an adverse effect on oncologic and surgical outcomes?

BACKGROUND

Early colorectal cancer is increasingly treated by endoscopic removal. In cases of incomplete resection or high-risk carcinoma, additional surgery is necessary.

OBJECTIVE

To evaluate the frequency of subsequent oncologic surgery after endoscopic resection of colorectal cancer, the rate of lymph node metastasis, residual cancer, and morbidity and mortality rates of the operation. Any eventual adverse effect of the prior endoscopic therapy on the surgical and oncologic outcome was assessed.

DESIGN

Retrospective review of prospectively collected data.

SETTING

University hospital.

PATIENTS

Sixty-six consecutive patients with incomplete endoscopic treatment and need for additional surgery between 2004 and 2011.

INTERVENTION

The data of these patients were compared with those of a group of patients with surgery for early colorectal cancer during the same period without prior endoscopic resection as the control group.

MAIN OUTCOME MEASUREMENTS

Rate of lymph node metastasis and residual cancer, perioperative morbidity and mortality.

RESULTS

The lymph node metastasis rate after oncologic resection was 8.6%, and the residual cancer rate was 41%. Risk factors for residual cancer were macroscopic incomplete resection (P < .0001), positive resection margins (P = .03), and piecemeal resection (P = .004). No mortality was observed. Perioperative morbidity, mortality, and oncologic outcome were not significantly different in the group with prior endoscopic resection compared with the primarily operated group.

LIMITATIONS

Retrospective study.

CONCLUSION

Endoscopic treatment of malignant polyps does not worsen surgical and oncologic outcomes in cases of subsequent surgery. Because mortality and morbidity are low, oncologic resection generally should be done in the presence of risk factors for residual cancer.

Is There an Indication for Surgical Resection in Colorectal Adenoma?

BACKGROUND

Due to the adenoma-carcinoma sequence, complete removal of colorectal polyps is essential.

METHOD

This article analyzes the role of surgery in the removal of colorectal adenoma.

RESULTS

Nowadays, most adenomas are removed properly by endoscopic methods. Also in the resection of giant polyps and recurrent adenoma endoscopic data is convincing. Therefore, surgical resection of colorectal adenomas is required in the case of endoscopic inaccessibility. Reasons for this may be the location of the polyp, incomplete endoscopic resection, or suspected malignancy. Endoscopic or limited surgical resection of malignant adenomas is acceptable only if 'low-risk' criteria are fulfilled. Otherwise oncologic radical resection is recommended. In general, radical resection is also necessary in the case of polyps that are not suitable for endoscopic removal, because here the rate of colorectal carcinoma is high.

CONCLUSION

If a surgical approach is necessary, minimally invasive surgery in the hands of an experienced laparoscopic surgeon is a suitable option. Adenomas in the lower two thirds of the rectum are suitable for transanal full-thickness resection. This is done by conventional resection or transanal endoscopic microsurgery. The histopathological preparation of these specimens provides diagnostic and therapeutic benefits, particularly compared to piecemeal resection of early carcinoma.

Postoperative morbidity and mortality among Veterans Health Administration patients undergoing surgical resection for large bowel polyps (bowel resection for polyps)

BACKGROUND

Large bowel polyps with malignant characteristics or those that are too large to remove colonoscopically may require bowel resection.

METHOD

We performed a retrospective review of 126 Veterans Health Administration patients who underwent elective resections for colonoscopically unresectable colorectal polyps over a 10-year period. We evaluated the association of patient characteristics and operative management on the composite outcome of 30-day postoperative morbidity and mortality.

RESULTS

98% of patients were males. Mean age was 65.1 years. Most patients had comorbidities, including cardiac or vascular disease (47.4%), diabetes mellitus (54%), and tobacco (41%) or alcohol (32.5%) use. The majority (85.7%) of patients were considered to be in American Society of Anesthesiologists (ASA) physical status classifications III and IV. 92% of resections were completed via laparotomy. Thirty-day postoperative morbidity and mortality occurred among 40 (31.7%) patients. Fifty-six patients (44.4%) had operative specimens with malignant features. The only comorbidity statistically associated with 30-day morbidity and mortality was body mass index >30.

CONCLUSION

Approximately one third of patients had significant postoperative morbidity or mortality. Clinical pathways chosen to treat colonoscopically unresectable polyps should be tailored to patients' conditions and the characteristics of their colorectal lesions.

Full-thickness laparoendoscopic colonic excision in an experimental model

Background

Patients requiring surgery for complex colonic polyps traditionally undergo colectomy, with significant risks. Typically in excess of 10–30 cm of colon is removed at laparoscopic or open surgery lasting over 60 min. This study details the preclinical development of a rapid, minimally invasive, limited full-thickness colonic resection.

Methods

Both survival and non-survival procedures were performed in anaesthetized 70-kg pigs. A simulated colonic polyp was created by endoscopic ink injection with a clearance margin delineated by circumferential placement of mucosal argon plasma coagulation marks. Full-thickness eversion of the bowel was achieved using endoscopically placed anchors and the polyp was excised using a laparoscopic stapler. In survival procedures, pigs were killed under anaesthetic 8 days after surgery. All pigs underwent post-mortem examination.

Results

Five procedures were performed (5 pigs). The median (range) procedure duration was 26 (20–31) min, with a specimen diameter of 5·1 (4·5–6·3) cm. The postoperative recovery of survival animals (4 pigs) was uneventful. At post-mortem evaluation the resection sites were well healed with no evidence of stenosis, intra-abdominal infection or inadvertent organ damage. Histological assessment of anastomoses showed mucosal repair and restoration of submucosal continuity.

Conclusion

Full-thickness localized colonic excision with this technique provides a large specimen with adequate healing in a porcine model.

Presented to the Annual Meeting of the Association of Surgeons of Great Britain and Ireland, Glasgow, UK, May 2013; published in abstract form as Br J Surg 2013; 100(Suppl 7): 2

Combined endoscopic-laparoscopic resection of colon polyps

AIMS

To analyze the current literature on combined endoscopic-laparoscopic resection of colon polyps and to compare this new approach to standard laparoscopic colonic resection for polyps not suitable for endoscopic resection.

RESULTS

Several studies demonstrated that with a combined endoscopic-laparoscopic approach, polyps were successfully resected in 82-91% with a low morbidity of 3-10% and a short hospital stay of 1-2 days. Segmental laparoscopic resection was necessary in only 9-12%, but had a conversion rate to open surgery of 15% with an average hospital stay of 6-11 days. A cancerous polyp was found in 6-13% after a combined approach, with lymph node metastasis in 6%. Recurrent polyps after a combined endoscopic-laparoscopic resection seem to be rare, but follow-up of most studies is short and incomplete.

CONCLUSION

Combined endoscopic-laparoscopic resection of colon polyps is feasible, safe, and has a high success rate. Malignant lesions can be treated laparoscopically during the same operation, avoiding the need for a second procedure, and with good long-term oncologic outcome.

Colectomy for endoscopically unresectable polyps: how often is it cancer?

BACKGROUND

Colonoscopy has an established role in reducing the burden of colorectal cancer through early detection and removal of polyps. For endoscopically unresectable polyps, colectomy is generally indicated to prevent malignant transformation or to remove cancer already present.

OBJECTIVE

This study aimed to determine the incidence of malignancy and the factors predictive of malignancy in surgically resected benign polyps. DESIGN/PATIENTS/SETTING: This study was a retrospective chart review of patients undergoing a colectomy for a colonic polyp (no preoperative diagnosis of cancer) in 4 hospitals within the Mayo Clinic Health System.

MAIN OUTCOME MEASURES

Patient characteristics, endoscopic location and size, and preoperative and operative polyp pathology were tabulated. Correlations between these features and the finding of invasive carcinoma on surgical pathology were assessed.

RESULTS

A total of 750 patients met our inclusion criteria. Patients were predominantly male (55.2%) with an average age of 69.4 ± 9.8 years. A majority of polyps were located in the right colon (70.9%). Invasive cancer was identified in 133 patients (17.7%). Multivariate analysis revealed polyps in the left colon (adjusted OR 2.13, 95% CI (1.22-3.72)), and those with high-grade dysplasia (adjusted OR 4.60, 95% CI (2.91-7.27)) were more likely to harbor carcinoma. Age, sex, polyp dimension, and villous features were not predictive of malignancy. Of the patients with cancer, 31 (23.3%) had nodal disease.

LIMITATIONS

This study is limited by its retrospective nature, the change in terminology and technique over time, and the partially subjective nature of an endoscopically unresectable polyp.

CONCLUSIONS

The finding that polyp size and villous features do not strongly predict malignancy differs from previous endoscopic studies. This study confirms that polyps located in the left colon or with high-grade dysplasia are more likely to harbor cancer. The results of this study suggest that endoscopically unresectable polyps are best treated by radical oncologic resection.

Difficult colon polypectomy

Colorectal cancer (CRC) is one of the leading causes of death from cancer in the world. We now know that 90% of CRC develop from adenomatous polyps. Polypectomy of colon adenomas leads to a significant reduction in the incidence of CRC. At present most of the polyps are removed endoscopically. The vast majority of colorectal polyps identified at colonoscopy are small and do not pose a significant challenge for resection to an appropriately trained and skilled endoscopist. Advanced polypectomy techniques are intended for the removal of difficult colon polyps. We have defined a “difficult polyp” as any lesion that due to its size, shape or location represents a challenge for the colonoscopist to remove. Although many “difficult polyps” will be an easy target for the advanced endoscopist, polyps that are larger than 15 mm, have a large pedicle, are flat and extended, are difficult to see or are located in the cecum or any angulated portion of the colon should be always considered difficult. Although very successful, advanced resection techniques can potentially cause serious, even life-threatening complications. Moreover, post polypectomy complications are more common in the presence of difficult polyps. Therefore, any endoscopist attempting advanced polypectomy techniques should be adequately supervised by an expert or have an excellent training in interventional endoscopy. This review describes several useful tips and tricks to deal with difficult polyps.

Oncologic colorectal resection, not advanced endoscopic polypectomy, is the best treatment for large dysplastic adenomas

INTRODUCTION

Endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and partial circumference resection are used for large benign polyps to avoid an "Oncologic" Colorectal Resection (OCR); polyps with invasive cancer require OCR. This review of polyp patients who had OCR was done to stratify polyps into risk groups to guide treatment.

METHODS

Colonoscopy, operative, and pathology reports of patients with adenoma (+/- dysplasia) who had OCR were reviewed. Polyp size, location, and pathology were assessed.

RESULTS

Three hundred eighty-six polyp patients who had OCR were studied. Polyp locations were: right, 263 (68.1%); transverse, 33 (8.6%); sigmoid, 38 (9.8%); rectum, 23 (6.0%); and multiple sites, 13 (3.4%). The preoperative diagnosis was adenoma for 288 (74.6%) and dysplastic adenoma for 98 patients (25.4%). Final pathology revealed 62 invasive cancers (16.1%); 35% (34 out of 98) with dysplasia preoperatively had cancer versus 9.7% (28 out of 288) with adenoma alone (p < 0.0001). The mean lymph node count was 16.0 ± 10.2. Cancer stage breakdown was: stage 1, 74%; stage 2, 8.1%; stage 3, 16%; and stage 4, 1.6%. The mean benign polyp size was 3.0 ± 1.9 versus 3.9 ± 2.4 cm for malignant polyps (p = 0.0008).

CONCLUSION

Over one out of three of dysplastic polyps and 10% of adenomas were invasive cancers. OCR is advised for dysplastic polyps; ESD, EMR, and wedge resection are appropriate for non-dysplastic adenomas.

Laparoscopic-monitored colonoscopic polypectomy: a multimodality method to avoid segmental colon resection

AIM

In some patients with adenoma, snare polypectomy may be technically impossible owing to angulation of the colon or after previous surgery. This may result in a segmental colonic resection, if malignant invasion is thought to be likely. Laparoscopic mobilization of the colon to enable a simultaneous colonoscopy can avoid this difficulty.

METHOD

A feasibility study was performed in 11 patients for whom endoscopic removal was technically impossible due to fibrosis after previous surgery or to anatomical difficulty. In 10, adenoma (histologically benign) had been diagnosed during diagnostic colonoscopy and in the remaining patient the indication was rectal bleeding.

RESULTS

It was possible to perform a full colonoscopy after laparoscopic mobilization in all cases. In nine of the 10 patients with adenoma 11 tubulovillous adenomas were removed endoscopically, and in one the tumour was too large for endoscopic resection even after full mobilization. A laparoscopic segmental resection was performed in this case. In the patient with rectal bleeding, colonoscopy revealed an angiodysplasia of the caecum, also treated by resection. Apart from the two patients having resection, all patients were discharged within 24 h of the procedure. During endoscopic follow up (4-27 months) there were no recurrences.

CONCLUSIONS

Combined laparoscopy and endoscopy enabled removal of adenomas otherwise inaccessible for endoscopic techniques. Thus, segmental colon resections can be avoided in most of these patients.

Treatment for right colon polyps not removable using standard colonoscopy: combined laparoscopic-colonoscopic approach

BACKGROUND

For complex right colon polyps, not removable using colonoscopy, right colon resection is considered the optimal treatment. Combined endoscopic-laparoscopic surgery, using both laparoscopy and CO2 colonoscopy, has been introduced as a new approach for these complex colon polyps with intent to avoid bowel resection.

OBJECTIVE

This study aimed to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery used for treatment of complex right colon polyps.

DESIGN

This is a retrospective study of patients undergoing combined endoscopic-laparoscopic surgery for treatment of benign right colon polyps from 2003 to 2008.

SETTINGS

This is a single-institution study.

PATIENTS

Twenty-three patients with complex right colon polyps were included.

MAIN OUTCOME MEASURES

The main outcome measures included the length of hospital stay, postoperative complications, and polyp recurrence.

RESULTS

Of 23 patients, 20 (87%) patients had their polyp removed successfully by combined endoscopic-laparoscopic surgery and 3 (13%) needed laparoscopic resection, after laparoendoscopic evaluation. The median length of hospital stay was 2 days (range, 1-5), and there were no postoperative complications. Median follow-up time was 12 months. Three patients had recurrent polyps, and the recurrence-free interval at 36 months was 55.7% (95% CI = 8.6%, 87.0%). All recurrences were benign polyps and were removed by colonoscopic snaring.

CONCLUSIONS

Combined endoscopic-laparoscopic surgery can be safely offered to selected patients with benign right colon polyps that can not be removed by colonoscopy. This combined approach may provide a viable alternative to right colon resection for complex benign colon lesions and warrants future investigation.

[Colorectal adenoma: pro conventional/laparoscopic resection]

The knowledge that due to the adenoma-cancer sequence polyps will develop sooner or later into invasive cancer demands the complete removal of colorectal polyps. The majority of polyps can be endoscopically removed. The indications for surgical removal of polyps are a previous incomplete endoscopic resection, location not amenable to endoscopic removal and lesions which are macroscopically highly suspicious for malignancy and cannot be detached by submucosal saline injection. If a surgical approach is indicated minimally invasive surgery in the hands of an experienced laparoscopic surgeon is a suitable option. Adenomas suspicious for malignancy in the lower two thirds of the rectum should not be treated by time-consuming endoscopic submucosal dissection (ESD) and can be quickly and safely removed transanally, conventionally or by transanal endoscopic microsurgery (TEM) by a full thickness én bloc resection. This allows the pathologist to determine the depth of invasion and the completeness of resection in terms of the circumferential margin and a definitive radical surgical approach is only necessary in high risk situations.

Laparoscopic resection for colorectal polyps: a single institution experience

BACKGROUND

Endoscopic polypectomy, although routinely used for the treatment of colorectal polyps, may be limited by polyp size, location and histology. Laparoscopic resection for malignant polyps and polyps not amenable to endoscopic removal has the advantage of adequate disease clearance as well as the short-term benefits of laparoscopic surgery. This study evaluates the outcomes of such an approach.

METHODS

Patients who had laparoscopic resection for colorectal polyps between January 2005 and July 2008 were identified from a prospective database. Polyps that were malignant, large, difficult to snare or incompletely excised, were included. Demographics, perioperative details and histopathology were analysed.

RESULTS

Seventy-eight patients (44 male) with a median age of 62.5 years (range 24-86) were studied. The majority (79%) were laparoscopic anterior resections for sigmoid or rectal polyps. Median operating time was 125 min (range, 65-225). Eight cases (10.3%) were converted to open mainly due to adhesions. There was no post-operative mortality. Perioperative complications occurred in seven patients (8.9%). Median hospital stay was 6 days (range 4-78). Median polyp size was 20 mm (range, 5-75). There were 44 benign polyps (55.7%); majority were tubulovillous adenomas (n= 22), and tubular adenomas (n= 10). Thirty-five patients (44.3%) had invasive cancer, with T1 (n= 27) and T2 (n= 2) tumours. Three of these patients (8.6%) had lymph node metastases. Median number of lymph nodes sampled was six (range 0-23).

CONCLUSION

Laparoscopic resection is safe and effective for colorectal polyps not amenable to colonoscopic removal, and is especially important for adequate clearance in the case of malignant polyps.

Trends, patterns, and outcomes in the management of malignant colonic polyps in the general population of the United States

BACKGROUND

Colonoscopic screening has increased detection of malignant colonic polyps (MPs). The goal of this study was to analyze trends and patterns in the surgical treatment of MPs and to assess outcomes as measured by lymph node retrieval and patient survival.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) registry was queried to identify 19,743 patients with MPs from 1988 to 2003.

RESULTS

The majority of MPs were present in the sigmoid and descending colon (54%), and 38% were tubular, 40% were tubulovillous, and 22% were villous. During the study period, the incidence of MPs increased from 29% to 42% and surgical resection (SR) was increasingly used for treatment, from 54% to 70%. Predictors of SR were aged <70 years (odds ratio [OR], 1.3; 95% confidence interval [95% CI], 1.2-1.4), high-grade tumors (OR, 1.5; 95% CI, 1.2-1.9), diagnosis in 1999 through 2003 (OR, 1.7; 95% CI, 1.5-1.9), villous subtype (OR, 2.3; 95% CI, 2.0-2.6), and right colon location (OR, 8.1; 95% CI, 7.0-9.4). In patients undergoing SR, the mean and median number of lymph nodes was only 4 and 1, respectively. A significant percentage of patients (49%) had no lymph nodes retrieved and a worse overall survival at 5 years compared with patients who had at least 1 lymph node examined (64% vs 74%; P <.001).

CONCLUSIONS

MPs appear to be increasing in incidence, and there is a trend toward increased use of SR for treatment. However, patients undergoing SR for MPs undergo suboptimal assessment of lymph nodes, with a detrimental impact on survival. Adequate lymphadenectomy and lymph node evaluation are crucial to improve outcomes in patients with these potentially curable lesions. Cancer 2011. © 2010 American Cancer Society.

Laparoscopic colectomy using cancer principles is appropriate for colonoscopically unresectable adenomas of the colon

PURPOSE

This study was undertaken to determine the risks of cancer in unresectable polyps and to compare the short-term outcome of laparoscopic colectomy with that of open colectomy for benign polyps.

METHODS

A retrospective review of all patients (n = 165) undergoing colectomy for an adenoma unresectable at colonoscopy was performed on patients collected in a prospective database. One hundred four patients underwent laparoscopic colectomy and 61 underwent open colectomy between 1991 and 2003. Follow-up was 7 to 155 (median, 90) months.

RESULTS

In the laparoscopic group, 85% of the patients underwent a right colectomy and 15% underwent a left colectomy or a sigmoidectomy. Conversion to open colectomy occurred in 4.8% of the cases. Complications occurred in 14% of the patients, including 1 death. The median length of stay was 4 days. At final pathology, cancer was diagnosed in 15 patients: stage I in 8 patients, stage II in 5, and stage III in 2. In the open colectomy group, 69% of the patients underwent right colectomy. The complication rate reached 23% (P = .13), including death in 2 patients. The median length of stay was 6 days (P < .01). Cancer was diagnosed in 6 patients: stage I in 5 patients, and stage II in 1. Proximal (10 cm) and distal (13 cm) margins, lymph nodes harvest (9), incidence of cancer (13%), and high-grade dysplasia (22%) were similar between groups. There were no local recurrences, trocar site implants, or deaths due to cancer.

CONCLUSION

Laparoscopic colectomy for polyps unresectable at colonoscopy is safe. Oncologic resection of the colon should be performed for all colonoscopically unresectable polyps due to the risk of cancer.

Minimal access surgical management of large juvenile polyps in children

BACKGROUND

Juvenile polyps have a reported incidence of up to 2% in individuals younger than of 18 years. Most polyps are small, occur in the distal colon and rectum, and present with bleeding or prolapse. Giant juvenile polyps have been rarely reported.

CASE REPORTS

We encountered 2 unique presentations of very large juvenile polyps in children. A 9-year-old boy presented with recurrent rectal bleeding and anemia because of a single large polyp at the hepatic flexure. A 14-year-old boy presented with abdominal pain secondary to 2 large polyps in the cecum. The polyps were seen on colonoscopy as pedunculated masses larger than 5 cm and were not subjected to biopsy. Both patients underwent laparoscopic colon mobilizations with extracorporeal segmental resection in the first patient and colotomy and polypectomy in the second. Both patients had short hospital stays and excellent outcomes.

CONCLUSIONS

Giant juvenile polyps are rare in children and may not be amenable to colonoscopic removal. They can be resected effectively with minimal access surgical techniques.