Successful endoscopic strategies for difficult polypectomy

"Unresectable" polyp management utilizing advanced endoscopic techniques results in high rate of colon preservation

PURPOSE

"Endoscopically unresectable" benign polyps identified during screening colonoscopy are often referred for segmental colectomy. Application of advanced endoscopic techniques can increase endoscopic polyp resection, sparing patients the morbidity of colectomy. This retrospective case-control study aimed to evaluate the success of colon preserving resection of "endoscopically unresectable" benign polyps using advanced endoscopic techniques including endoscopic mucosal resection, endoscopic submucosal dissection, endoluminal surgical intervention, full-thickness laparo-endoscopic excision, and combined endo-laparoscopic resection.

METHODS

A prospectively maintained institutional database identified 95 patients referred for "endoscopically unresectable" benign polyps from 2015 to 2018. Cases were compared to 190 propensity score matched controls from the same database undergoing elective laparoscopic colectomy for other reasons. Primary outcome was rate of complete endoscopic polyp removal. Secondary outcomes included length of stay, unplanned 30-day readmission and reoperation, 30-day mortality, and post-procedural complications.

RESULTS

Advanced endoscopic techniques achieved complete polyp removal without colectomy in 66 patients (70%). Failure was most commonly associated with previously attempted endoscopic resection and occult malignancy. Compared with matched colectomy controls, endoscopic polyp resection resulted in significantly shorter hospital length of stay (1.13 ± 2.41 vs 3.89 ± 4.57 days; p < 0.001), lower unplanned 30-day readmission (1.1% vs 7.7%; p < 0.05), and fewer postoperative complications (4.2% vs 33.9%; p < 0.001). Unplanned 30-day reoperation (2.1% vs 4.4%; p = 0.34) and 30-day mortality (0% vs 0.6%; p = 0.75) trended lower.

CONCLUSIONS

Endoscopic resection of complex polyps can be highly successful, and it is associated with favorable outcomes and decreased morbidity when compared with segmental colon resection. Attempting colon preservation using these techniques is warranted.

Combined endo-laparoscopic surgery for difficult benign colorectal polyps

Prevention of colorectal cancer (CRC) depends largely on the detection and removal of colorectal polyps. Despite the advances in endoscopic techniques, there are still a subgroup of polyps that cannot be treated purely by endoscopic approach, which comprise of about 10-15% of all the polyps. These so-called "difficult colorectal polyps" are polyps with large size, morphology, at difficult location, scarring or due to recurrence, which have historically been managed by surgical segmental resection. In treating benign difficult colorectal polyps, we have to balance the operative risks and morbidities associated with surgical segmental resection. Therefore, combined endoscopic and laparoscopic surgery (CELS) has been developed to remove this subgroup of difficult benign polyps. We review the currently use of CELS for difficult benign colorectal polyps which includes laparoscopy-assisted endoscopic polypectomy (LACP), full-thickness laparo-endoscopic excision (FLEX) and colonoscopy-assisted laparoscopic wedge resection (CAL-WR).

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.

The short-term outcomes of laparoscopic-endoscopic cooperative surgery for colorectal tumors (LECS-CR) in cases involving endoscopically unresectable colorectal tumors

PURPOSE

Laparoscopic and endoscopic cooperative colorectal surgery (LECS) is widely used for the removal of endoscopically unresectable colonic polyps. We evaluated the invasiveness of LECS in comparison to conventional laparoscopic surgery (CLS) for endoscopically unresectable colorectal tumors.

METHOD

We retrospectively analyzed the data of patients with colorectal adenoma or mucosal cancer and submucosal tumors who underwent either LECS or CLS at a single, high-volume center in Japan between 2004 and 2017. The short-term and oncological outcomes were compared between groups.

RESULTS

Of the 83 eligible patients, 15 underwent LECS and 68 underwent CLS. There was no conversion to open surgery in either group. En bloc resection was achieved in all cases in both groups. The median time to solid diet intake was the same in both groups (2 days, p = 0.39). The median duration of hospital stay after surgery was 6 days (range 4-12 days) in the LECS group and 10 days (range 5-68 days) in the CLS group (p = 0.01). Clavien-Dindo grade ≥ 3 postoperative complications only occurred in the CLS group (two cases, p = 0.37).

CONCLUSION

Our results indicated that LECS is a safe and feasible technique that results in high-quality colorectal polyp resection with quicker recovery and favorable 30-days postoperative outcomes.

Simultaneous Laparoscopic Cholecystectomy and Combined Endoscopic and Laparoscopic Surgery for an Endoluminal Tumor of the Sigmoid Colon: A Case Report

Patient: Female, 70

Final Diagnosis: An endoluminal tumor

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Experience in colon sparing surgery in North America: advanced endoscopic approaches for complex colorectal lesions

BACKGROUND

Need for colon sparing interventions for premalignant lesions not amenable to conventional endoscopic excision has stimulated interest in advanced endoscopic approaches. The aim of this study was to report a single institution's experience with these techniques.

METHODS

A retrospective review was conducted of a prospectively collected database of all patients referred between 2011 and 2015 for colorectal resection of benign appearing deemed endoscopically unresectable by conventional endoscopic techniques. Patients were counseled for endoscopic submucosal dissection (ESD) with possible combined endoscopic-laparoscopic surgery (CELS) or alternatively colorectal resection if unable to resect endoscopically or suspicion for cancer. Lesion characteristic, resection rate, complications, and outcomes were evaluated.

RESULTS

110 patients were analyzed [mean age 64 years, female gender 55 (50%), median body mass index 29.4 kg/m²]. Indications for interventions were large polyp median endoscopic size 3 cm (range 1.5-6.5) and/or difficult location [cecum (34.9%), ascending colon (22.7%), transverse colon (14.5%), hepatic flexure (11.8%), descending colon (6.3%), sigmoid colon (3.6%), rectum (3.6%), and splenic flexure (2.6%)]. Lesion morphology was sessile (N = 98, 93%) and pedunculated (N = 12, 7%). Successful endoscopic resection rate was 88.2% (N = 97): ESD in 69 patients and CELS in 28 patients. Complication rate was 11.8% (13/110) [delayed bleeding (N = 4), perforation (N = 3), organ-space surgical site infection (SSI) (N = 2), superficial SSI (N = 1), and postoperative ileus (N = 3)]. Out of 110 patients, 13 patients (11.8%) required colectomy for technical failure (7 patients) or carcinoma (6 patients). During a median follow-up of 16 months (range 6-41 months), 2 patients had adenoma recurrence.

CONCLUSIONS

Advanced endoscopic surgery appears to be a safe and effective alternative to colectomy for patients with complex premalignant lesions deemed unresectable with conventional endoscopic techniques.

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.