Colonoscopy-assisted laparoscopic wedge resection for a large symptomatic colonic lipoma

A colonic lipoma is an uncommon lesion that is linked with clinical symptoms in only a small portion of patients. Patients with large lipomas are often referred for major surgery, which is associated with significant morbidity and mortality. In this case, we described a female patient with recurrent episodes of gastrointestinal blood loss, abdominal pain and colocolic intussusceptions due to a large, lumen-filling, obstructive lipoma in the splenic flexure. On abdominal CT, a lesion of 3.6 cm was visualised with a fat-like density without solid components. Considering its benign nature, we intended to preserve the colon by deroofing the upper part of the lesion and then performing a colonoscopy-assisted laparoscopic wedge resection. During reassessment, auto-amputation of part of the lesion was observed, most likely as a result of long-lasting mechanical effects, which made it possible to perform solely a wedge resection with an excellent outcome.

Colonoscopic-assisted laparoscopic wedge resection versus segmental colon resection for benign colonic polyps: a comparative cost analysis

AIM

The colonoscopic-assisted laparoscopic wedge resection (CAL-WR) is proven to be an effective and safe alternative to a segmental colon resection (SCR) for large or complex benign colonic polyps that are not eligible for endoscopic removal. This analysis aimed to evaluate the costs of CAL-WR and compare them to the costs of an SCR.

METHOD

A single-centre 90-day 'in-hospital' comparative cost analysis was performed on patients undergoing CAL-WR or SCR for complex benign polyps between 2016 and 2020. The CAL-WR group consisted of 44 patients who participated in a prospective multicentre study (LIMERIC study). Inclusion criteria were (1) endoscopically unresectable benign polyps; (2) residual or recurrence after previous polypectomy; or (3) irradically resected low risk pT1 colon carcinoma. The comparison group, which was retrospectively identified, included 32 patients who underwent an elective SCR in the same period.

RESULTS

Colonoscopic-assisted laparoscopic wedge resection was associated with significantly fewer complications (7% in the CAL-WR group vs. 45% in the SCR group, P < 0.001), shorter operation time (50 min in the CAL-WR group vs. 119 min in the SCR group, P < 0.001), shorter length of hospital stay (median length of stay 2 days in the CAL-WR group vs. 4 days in the SCR group, P < 0.001) and less use of surgical resources (reduction in costs of 32% per patient), resulting in a cost savings of €2372 (£2099 GBP) per patient (P < 0.001).

CONCLUSION

Given the clinical and financial benefits, CAL-WR should be recommended for complex benign polyps that are not eligible for endoscopic resection before major surgery is considered.

Alteration of the Exhaled Volatile Organic Compound Pattern in Colorectal Cancer Patients after Intentional Curative Surgery-A Prospective Pilot Study

As current follow-up modalities for colorectal carcinoma (CRC) have restricted sensitivity, novel diagnostic tools are needed. The presence of CRC changes the endogenous metabolism, resulting in the release of a specific volatile organic compounds (VOC) pattern that can be detected with an electronic nose or AeonoseTM. To evaluate the use of an electronic nose in the follow-up of CRC, we studied the effect of curative surgery on the VOC pattern recognition using AeonoseTM. A prospective cohort study was performed, in which 47 patients diagnosed with CRC were included, all of whom underwent curative surgical resection. Breath testing was performed before and after surgery using the AeonoseTM. A machine learning model was developed by discerning between the 94 pre-and postoperative breath samples. The training model differentiated between the pre-and postoperative CRC breath samples with a sensitivity and specificity of 0.78 (95%CI 0.61-0.90) and 0.73 (95%CI 0.56-0.86), respectively, with an accuracy of 0.76 (95%CI 0.66-0.85), and an area under the curve of 0.79 (95%CI 0.68-0.89). The internal validation of the test set resulted in an accuracy of 0.75 (95%CI 0.51-0.91) and AUC of 0.82 (95%CI 0.61-1). In conclusion, our results suggest that the VOC pattern of CRC patients is altered by curative surgery in a short period, indicating that the exhaled VOCs might be closely related to the presence of CRC. However, to use AeonoseTM as a potential diagnostic tool in the clinical follow-up of CRC patients, the performance of the models needs to be improved through further large-scale prospective research.

Limited wedge resection for T1 colon cancer (LIMERIC-II trial) - rationale and study protocol of a prospective multicenter clinical trial

BACKGROUND

The sole presence of deep submucosal invasion is shown to be associated with a limited risk of lymph node metastasis. This justifies a local excision of suspected deep submucosal invasive colon carcinomas (T1 CCs) as a first step treatment strategy. Recently Colonoscopy-Assisted Laparoscopic Wedge Resection (CAL-WR) has been shown to be able to resect pT1 CRCs with a high R0 resection rate, but the long term outcomes are lacking. The aim of this study is to evaluate the safety, effectiveness and long-term oncological outcomes of CAL-WR as primary treatment for patients with suspected superficial and also deeply-invasive T1 CCs.

METHODS

In this prospective multicenter clinical trial, patients with a macroscopic and/or histologically suspected T1 CCs will receive CAL-WR as primary treatment in order to prevent unnecessary major surgery for low-risk T1 CCs. To make a CAL-WR technically feasible, the tumor may not include > 50% of the circumference and has to be localized at least 25 cm proximal from the anus. Also, there should be sufficient distance to the ileocecal valve to place a linear stapler. Before inclusion, all eligible patients will be assessed by an expert panel to confirm suspicion of T1 CC, estimate invasion depth and subsequent advise which local resection techniques are possible for removal of the lesion. The primary outcome of this study is the proportion of patients with pT1 CC that is curatively treated with CAL-WR only and in whom thus organ-preservation could be achieved. Secondary outcomes are 1) CAL-WR's technical success and R0 resection rate for T1 CC, 2) procedure-related morbidity and mortality, 3) 5-year overall and disease free survival, 4) 3-year metastasis free survival, 5) procedure-related costs and 6) impact on quality of life. A sample size of 143 patients was calculated.

DISCUSSION

CAL-WR is a full-thickness local resection technique that could also be effective in removing pT1 colon cancer. With the lack of current endoscopic local resection techniques for > 15 mm pT1 CCs with deep submucosal invasion, CAL-WR could fill the gap between endoscopy and major oncologic surgery. The present study is the first to provide insight in the long-term oncological outcomes of CAL-WR.

TRIAL REGISTRATION

CCMO register (ToetsingOnline), NL81497.075.22, protocol version 2.3 (October 2022).

Colonoscopy-Assisted Laparoscopic Wedge Resection for the Treatment of Suspected T1 Colon Cancer

BACKGROUND

Local en bloc resection of pT1 colon cancer has been gaining acceptance during the last few years. In the absence of histological risk factors, the risk of lymph-node metastases (LNM) is negligible and does not outweigh the morbidity and mortality of an oncologic resection. Colonoscopy-assisted laparoscopic wedge resection (CAL-WR) has proved to be an effective and safe technique for removing complex benign polyps. The role of CAL-WR for the primary resection of suspected T1 colon cancer has to be established.

METHODS

This retrospective study aimed to determine the radicality and safety of CAL-WR as a local en bloc resection technique for a suspected T1 colon cancer. Therefore, the study identified patients in whom high-grade dysplasia or a T1 colon carcinoma was suspected based on histology and/or macroscopic assessment, requiring an en bloc resection.

RESULTS

The study analyzed 57 patients who underwent CAL-WR for a suspected macroscopic polyp or polyps with biopsy-proven high-grade dysplasia or T1 colon carcinoma. For 27 of these 57 patients, a pT1 colon carcinoma was diagnosed at pathologic examination after CAL-WR. Histological risk factors for LNM were present in three cases, and 70% showed deep submucosal invasion (Sm2/Sm3). For patients with pT1 colon carcinoma, an overall R0-resection rate of 88.9% was achieved. A minor complication was noted in one patient (1.8%).

CONCLUSIONS

The CAL-WR procedure is an effective and safe technique for suspected high-grade dysplasia or T1-colon carcinoma. It may fill the gap for tumors that are macroscopic suspected for deep submucosal invasion, providing more patients an organ-preserving treatment option.

Presentation of an extraordinary colic: abdominal pain as the first and only utterance of an acquired C1-inhibitor deficiency

C1-inhibitor deficiency is a rare disease which incorporates acute self-limiting intermittent swelling of the subcutaneous tissue and mucous membranes. Attacks most frequently affect the face and/or the upper airway. Isolated angioedema of the small bowel is an uncommon manifestation and often accompanied by diagnostic delay. In the present case, abdominal pain turned out to be the first and only utterance of an acquired C1-inhibitor deficiency, secondary to a splenic marginal zone lymphoma. Imaging showed wall thickening of the small intestine, ascites and splenomegaly. The abdominal pain and intestinal wall thickening with surrounding ascites on imaging spontaneously resolved each episode within 2-3 days. Gastrointestinal manifestations of angioedema may mimic an acute abdomen, and subsequently one-third of these patients undergo unnecessary surgery prior to a definite diagnosis. This emphasises the importance of considering the diagnosis in case of an 'extraordinary colic'.