Laparoscopic right colectomy vs laparoscopic-assisted colonoscopic polypectomy for endoscopically unresectable polyps: a randomized controlled trial

AIM

A randomized controlled trial (RCT) was conducted to test the null hypothesis that there is no difference in complication rates and length of stay (LOS) between laparoscopic right colectomy (LRC) and laparoscopic-assisted colonoscopic polypectomy (LACP) for endoscopically unresectable polyps of the right colon.

METHOD

A single-centre RCT (NCT01986699) was conducted on patients with polyps of the right colon deemed by the gastroenterologist to be unresectable. Patients underwent a repeat colonoscopy with biopsy by an interventional endoscopist and were allocated to LRC or LACP. Patients with a nonlift sign, dysplasia, adenocarcinoma, inflammatory bowel disease or familial adenomatous polyposis were excluded from the trial. The study was powered to detect a 73% difference in the LOS which required 17 patients in each arm with an α error of 0.05 and a power of 95%.

RESULTS

Thirty-four patients were comparable for age (P = 0.919), gender (P = 0.364), body mass index (P = 0.634), American Society of Anesthesiologists class (P = 0.388) and previous abdominal surgery (P = 0.366). There was no significant difference in the preoperative morphology (P = 0.485), location (P = 0.297), size (P = 0.690) or histology of the polyps (P = 0.779). LRC patients experienced a longer operating time (180 vs 90 min; P = 0.001), required more intravenous infusion (3.1 vs 2.0 l; P = 0.025), took significantly longer to pass flatus (2.88 vs 1.44 days; P < 0.001), resumed solid food later (3.94 vs 1.69 days; P < 0.001) and had a longer postoperative LOS (4.94 vs 2.63 days; P < 0.001). Postoperative complications (P = 0.656), readmissions (P = 0.5) and reoperations (P = 0.5) did not differ. Final size (P = 0.339) and histology (P = 0.104) of the polyps did not differ. There were four cancers in the LRC arm. At follow-up colonoscopy with biopsy of the scar in 10 patients at 15.3 months, one patient had recurrence of the polyp at the site of the previous LACP.

CONCLUSION

LACP and LRC had similar complication rates, but LOS was shorter after LACP.

Simulated training in colonoscopic stenting of colonic strictures: validation of a cadaver model

AIM

There are currently no available simulation models for training in colonoscopic stent deployment. The aim of this study was to validate a cadaver model for simulation training in colonoscopy with stent deployment for colonic strictures.

METHOD

This was a prospective study enrolling surgeons at a single institution. Participants performed colonoscopic stenting on a cadaver model. Their performance was assessed by two independent observers. Measurements were performed for quantitative analysis (time to identify stenosis, time for deployment, accuracy) and a weighted score was devised for assessment. The Mann-Whitney U-test and Student's t-test were used for nonparametric and parametric data, respectively. Cohen's kappa coefficient was used for reliability.

RESULTS

Twenty participants performed a colonoscopy with deployment of a self-expandable metallic stent in two cadavers (groups A and B) with 20 strictures overall. The median time was 206 s. The model was able to differentiate between experts and novices (P = 0. 013). The results showed a good consensus estimate of reliability, with kappa = 0.571 (P < 0.0001).

CONCLUSION

The cadaver model described in this study has content, construct and concurrent validity for simulation training in colonoscopic deployment of self-expandable stents for colonic strictures. Further studies are needed to evaluate the predictive validity of this model in terms of skill transfer to clinical practice.