Multicentre study of surgical referral and outcomes of patients with benign colorectal lesions

Colonoscopic-assisted laparoscopic wedge resection for colonic neoplasms: a systematic review

OBJECTIVES

The current literature describes a variety of techniques detailed under the name of combined endoscopic-laparoscopic surgery (CELS) procedures. This systematic review of literature assessed the outcomes of colonoscopic-assisted laparoscopic-wedge resection (CAL-WR) in particular to evaluate its feasibility to remove colonic lesions that do not qualify for endoscopic resection.

MATERIALS AND METHODS

Electronic databases (PubMed, Embase, and Cochrane) were searched for studies evaluating CAL-WR for the treatment of colonic lesions. Studies with missing full text, language other than English, systematic reviews, and studies with fewer than ten patients were excluded. The quality of the studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

Out of 68 results, duplicate studies (n = 27) as well as studies that did not meet the inclusion criteria (n = 32) were removed. Nine studies were included, encompassing 326 patients who underwent a CAL-WR of the colon. The technical success rate varied from 93 to 100%, with an R0 resection rate of 91-100%. Morbidity ranged from 6% to 20%. The quality of the included studies was rated as low to moderate and contained heterogeneous terminology, methodology, and outcome measures.

CONCLUSIONS

There is insufficient high-quality data and substantial variation in outcome measures to draw firm conclusions regarding the value of CAL-WR. Although CAL-WR is a promising local resection technique for endoscopically unremovable neoplasms of the colon, further investigation of this technique in well-designed prospective, multicenter studies with predefined outcome measures is required.Trial registration: A protocol for this systematic review was registered in PROSPERO with the number CRD42023407966.

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.

Setting up a regional expert panel for complex colorectal polyps

BACKGROUND AND AIMS

Advanced endoscopic resection techniques for complex colorectal polyps have evolved significantly over the past decade, leading to a management shift from surgical to endoscopic resection as the preferred treatment. However, in practice, interhospital consultation and appropriate referral management remain challenging, leading to unnecessary surgical resections. To support regional care for patients with complex colorectal polyps, facilitate peer consultations, and lower thresholds for referrals, an expert panel consultation platform was initiated in the northwestern region of the Netherlands.

METHODS

We initiated a regional expert panel in the northwestern region of the Netherlands for patients with complex colorectal polyps and studied the implementation, adaption, and clinical impact. All panel consultations between June 2019 and May 2021 were retrospectively analyzed, and user satisfaction among panel members was evaluated.

RESULTS

Eighty-eight patients with complex colorectal polyps from 11 of 15 participating centers (73.3%) were discussed in our panel. The most common reason for panel consultation was suspicion of invasive cancer in 36.4% (n = 32). After panel consultation, 43.2% of the consulting endoscopists (n = 38) changed their initial treatment strategy, and in 63.6% (n = 56) patients were referred to another endoscopy center. Of 26 cases submitted with a primary proposal for surgical treatment, surgery was avoided in 7 (26.9%). User satisfaction was rated high in most participating centers (91.7%).

CONCLUSIONS

Our study shows that implementation of and consultation with a regional expert panel can be a valuable tool for endoscopists to guide and optimize treatment of complex colorectal polyps and facilitate interhospital referrals in a regional network.

Colonoscopic-Assisted Laparoscopic Wedge Resection for Colonic Lesions: A Prospective Multicentre Cohort Study (LIMERIC-Study)

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of a modified colonoscopic-assisted laparoscopic wedge resection.

SUMMARY BACKGROUND DATA

The use of segmental colectomy in patients with endoscopically unresectable colonic lesions results in significant morbidity and mortality. CAL-WR is an alternative procedure that may reduce morbidity.

METHODS

This prospective multicentre study was performed in 13 Dutch hospitals between January 2017 and December 2019. Inclusion criteria were (1) colonic lesions inaccessible using current endoscopic resection techniques (judged by an expert panel), (2) non-lifting residual/recurrent adenomatous tissue after previous polypectomy or (3) an undetermined resection margin after endoscopic removal of a low-risk pT1 colon carcinoma. Thirty-day morbidity, technical success rate and radicality were evaluated.

RESULTS

Of the 118 patients included (56% male, mean age 66 years, SD ± 8 years), 66 (56%) had complex lesions unsuitable for endoscopic removal, 34 (29%) had non-lifting residual/recurrent adenoma after previous polypectomy and 18 (15%) had uncertain resection margins after polypectomy of a pT1 colon carcinoma. CAL-WR was technically successful in 93% and R0 resection was achieved in 91% of patients. Minor complications (Clavien-Dindo I-II) were noted in 7 patients (6%) and an additional oncologic segmental resection was performed in 12 cases (11%). Residual tissue at the scar was observed in 5% of patients during endoscopic follow-up.

CONCLUSIONS

CAL-WR is an effective, organ-preserving approach that results in minor complications and circumvents the need for major surgery. CAL-WR therefore deserves consideration when endoscopic excision of circumscribed lesions is impossible or incomplete.

Evaluation of polypectomy quality indicators of large nonpedunculated colorectal polyps in a nonexpert, bowel cancer screening cohort

BACKGROUND AND AIMS

With the introduction of the national bowel cancer screening program, the detection of sessile and flat colonic lesions ≥20 mm in size, defined as large nonpedunculated colorectal polyps (LNPCPs), has increased. The aim of this study was to examine the quality of endoscopic treatment of LNPCPs in the Dutch screening program.

METHODS

This investigation comprised 2 related, but separate, substudies (1 with a cross-sectional design and 1 with a longitudinal design). The first examined prevalence and characteristics of LNPCPs in data from the national Dutch screening cohort from February 2014 until January 2017. The second, with screening data from 5 endoscopy units in the Southern part of the Netherlands from February 2014 until August 2015, examined performance on important quality indicators (technical and clinical successes, recurrence rate, adverse event rate, and surgery referral rate). All patients were part of the national Dutch screening cohort.

RESULTS

In the national cohort, an LNPCP was detected in 8% of participants. Technical and clinical success decreased with increasing LNPCP size, from 93% and 96% in 20- to 29-mm lesions to 85% and 86% in 30- to 39-mm lesions and to 74% and 81% in ≥40-mm lesions (P < .001; P = .034). The cumulative recurrence rate at 12 months increased with LNPCP size, from 9% to 22% and 26% in the respective size groups (P = .095). The adverse event rate was 5%. The overall surgical referral rate for noninvasive LNPCPs was 7%.

CONCLUSIONS

In this performance of 2 substudies, it was shown that quality parameters for endoscopic resection of large polyps in the Dutch screening cohort are not reached, especially in ≥30-mm polyps. Endoscopic resection of large polyps could benefit from additional training, quality monitoring, and centralization either within or between centers.

Volume of surgical interventions for benign colorectal tumors – an analysis of 3510 surgical and endoscopic resections in the single colorectal center in Poland

Introduction: Colorectal cancer is the most frequent neoplasm of the whole gastrointestinal track. Due to screening colonoscopy program, colorectal lesions are often diagnosed at early stage. The vast majority of them are possible to remove endoscopically. However, a substantial percentage of benign lesion in Western centers are still operated. The aim of this article was to determine the percentage of surgical resections due to benign adenomas in the reference center of endoscopic submucosal dissection (ESD) and colorectal surgery in Poland. Materials and Methods: Retrospective analysis of 3 510 patients operated from 2015 to 2019 in Center of Bowel Treatment in Brzeziny. Results: We have analyzed 3 510 endoscopic and surgical procedures performed in the colon: 601 ESDs; 1 002 endoscopic mucosal resections (EMRs); and 1,907 surgical resections. Out of 601 ESDs, 57 invaded the submucosa, of which 29 (4.8%) were non-therapeutic ESDs. In 5 patients, due to occurrence of post-ESD perforation, an additional surgical intervention was necessary. Out of the 1,002 EMRs, 22 cases (2.2%) were diagnosed with deeply infiltrating cancers, which required a surgery. The overall percentage of the need for surgery in the endoscopically treated patients (ESD + mucosectomy) was 3.5% (56/1 603). Among resection surgeries, 15 of them (0.8%) ended with the diagnosis of a benign lesion in the postoperative histopathological examination. Conclusions: Inclusion advanced endoscopic techniques such as ESD to routine clinical practice in colorectal centers gives clear benefits for the patients. Well defined and standardized process of qualifying for appropriate treatment allows to significantly reduce the percentage of abdominal approach surgery due to benign colorectal lesions.  

Postoperative Hospital Outcomes of Elective Surgery for Nonmalignant Colorectal Polyps: Does the Burden Justify the Indication?

INTRODUCTION

Despite the increasing availability of advanced endoscopic resections and its favorable safety profile, surgery for nonmalignant colorectal polyps has continually increased. We sought to evaluate readmission rates and outcomes of elective surgery for nonmalignant colorectal polyps on a national level in the United States.

METHODS

The Nationwide Readmissions Database (2010-2014 [International Classification of Diseases, Ninth Revision] and 2016-2018 [International Classification of Diseases, 10th Revision]) was used to identify all adult subjects (age ≥18 years) who underwent elective surgical resection of nonmalignant colorectal polyps. Multivariable analyses were performed for predictors of postoperative morbidity and 30-day readmission.

RESULTS

Elective surgery for nonmalignant colorectal polyps was performed in 108,468 subjects from 2010 to 2014 and in 54,956 subjects from 2016 to 2018, most of whom were laparoscopic. Postoperative morbidity and 30-day readmission rates were 20.5% and 8.5% from 2010 to 2014, and 13.0% and 7.6% from 2016 to 2018, respectively. Index admission mortality rates were 0.3-0.4%; mortality rates were higher in those with postoperative morbidity. Multivariable analyses revealed that male sex, ≥3 comorbidities, insurance status, and open surgery predicted an increased risk of both postoperative morbidity and 30-day readmission. In addition, postoperative morbidity (2010-2014 [odds ratio 1.58; 95% confidence interval 1.44-1.74] and 2016-2018 [odds ratio 1.55; 95% confidence interval 1.37-1.75]) predicted early readmission.

DISCUSSION

In this investigation of national practices, elective surgery for nonmalignant colorectal polyps remains common. There is considerable risk of adverse postoperative outcomes, which highlights the importance of increasing awareness of the range of endoscopic resections and referring subjects to expert endoscopy centers.

IMPACT OF SCREENING ON SHORT-TERM MORTALITY AND MORBIDITY FOLLOWING TREATMENT FOR COLORECTAL CANCER

BACKGROUND AND AIMS

The aim of this study was to describe short-term changes in morbidity and mortality associated with the implementation of screening for colorectal cancer in Denmark.

MATERIALS AND METHODS

Prospective cohort study with inclusion of all patients aged 50-75 years treated for colorectal cancer between 1 March 2014 and 31 December 2015 in Denmark. Adjusted hazard ratios were calculated for 30 and 90 days mortality using Cox Regression. We made two adjusted models-a "basic" adjusted for screening status, sex, age, smoking, alcohol consumption, and cancer type and an "advanced" that also included body mass index and American society of Anesthesiologists score in analyses. Relative risks were calculated for postoperative surgical and medical complications.

RESULTS

In total, 5348 patients were included. In the "basic model," adjusted risk of 30 and 90 days total mortality was reduced in the screen-detected group (p < 0.01, HR = 0.43, CI = 0.24-0.76) and (p < 0.01, HR = 0.45, CI = 0.30-0.69). In the "advanced model," only 90 days total mortality was significantly reduced in the screen-detected group (p = 0.01, HR 0.59, CI = 0.39-0.90). No significant changes were found with regard to surgical and medical complications, respectively, (p = 0.05 (CI = 0.76-1.00) and p = 0.47(CI = 0.74-1.15)).

CONCLUSION

This nationwide study showed that screening for colorectal cancer was associated with a lower 90 days total mortality although no significant improvements were seen with regard to morbidity.

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.

pT1 Colorectal Cancer Detected in a Colorectal Cancer Mass Screening Program: Treatment and Factors Associated with Residual and Extraluminal Disease

Simple Summary

Our study has evaluated the burden of pT1 CRC (confined to submucosa) detected during the first round of a CRC screening program, the surgery related complications and the factors related to four relevant outcomes: initial endoscopic resection, surgery rescue and residual disease after endoscopic resection and, finally, extraluminal disease after surgical resection. 38% of the CRC were detected in this stage.74.9% were initially resected endoscopically and 43.8% did not require surgery. There were inhospital surgical complications in 30.7%, mainly mild with no death and complications after discharge in 16.3% of the patients Residual disease was detected in 12 (4.3%) after endoscopic resection and extraluminal disease in 18 (8.6%) patients after surgery. We have determined several variables independently associated with the four outcome variables evaluated.

Abstract

The aim of this study is to describe the treatment of pT1 colorectal cancer (CRC) in a mass screening program, the surgery-related complications and the factors associated with residual disease after endoscopic resection and extraluminal disease after surgery. We included in this retrospective analysis all the pT1 CRC detected in the Galician CRC screening program between May 2013 and June 2019. We determined which variables were independently associated with the outcomes of the study through a multivariable logistic regression analysis. We included 370–354 pT1 N0(X), 16 pT1N1- out of the 971 CRC detected; 277 (74.9%) were resected endoscopically and 162 (43.8%) were not referred to surgery. There were surgical complications in 30.7% and 16.3% of the patients during hospitalization and after discharge. Residual disease was detected in 12 (4.3%) after endoscopic resection and extraluminal disease in 18 (8.6%) patients after surgery. The variables independently associated with initial endoscopic resection were a pedunculated morphology (OR 33.1, 95% CI 4.3–254), a diameter ≥ 20 mm (OR 3.94, 95% CI 1.39–11.18) and a Site–Morphology–Size–Access score < 9 (OR 428, 95% CI 42–4263). The variables related with surgery rescue were a piecemeal resection (OR 4.48, 95% CI 1.48–13.6), an infiltrated/nonevaluable resection border (OR 7.44, 95% CI 2.12–26.0), a non-well-differentiated histology (OR 4.76, 95% CI 1.07–20.0), vascular infiltration (OR 8.24, 95% CI 2.72–25.0) and a Haggitt 4 infiltration of the submucosa (OR 5.68, 95% CI 2.62–12.3). Residual disease after endoscopic resection was associated with an infiltrated/nonevaluable resection border (OR 34.9, 95% CI 4.08–298), a non-well-differentiated histology (OR 6.67, 95% CI 1.05–50.0), and the vascular infiltration of the submucosa (OR 7.61, 95% CI 1.55–37.4). The variables related with extraluminal disease after surgical resection were no endoscopic resection (OR 4.34, 95% CI 1.26–14.28), a non-well-differentiated histology (OR 4.35, 95% CI 1.39–14.29) and the lymphatic infiltration of the submucosa (OR 4.8, 95% CI 1.32–17.8). In a CRC screening program, although most of pT1 CRC are candidates for endoscopic treatment, surgery is a safe procedure. We have defined some easy to evaluate variables that can be used in the decision-making process.