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The impact of the national bowel screening program in the Netherlands on detection and treatment of endoscopically unresectable benign polyps. Tech Coloproctol 2017; 21:887-891. [PMID: 29149427 PMCID: PMC5700986 DOI: 10.1007/s10151-017-1705-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 10/22/2017] [Indexed: 12/30/2022]
Abstract
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.
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Issa N, Fenig Y, Khatib M, Yasin M, Powsner E, Khoury W. Transanal Endoscopic Microsurgery Combined with Laparoscopic Colectomy for Synchronous Colorectal Tumors: A Word of Caution. J Laparoendosc Adv Surg Tech A 2016; 27:605-610. [PMID: 27992283 DOI: 10.1089/lap.2016.0420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The incidence of malignant synchronous colorectal tumors (SCRT) is between 2% and 5%, and the association of synchronous adenomatous polyps in colon cancer has been reported to be 15%-50%. Surgical resection is the primary treatment option for SCRT not amendable to endoscopic resection. Lesions in adjacent segments are usually treated with more extensive resection; however, there is still some controversy on how to best treat synchronous lesions in separate segments, especially when the rectum is involved. In this study, we aimed to report the outcome of patients with SCRT treated by laparoscopic colectomy combined with Transanal Endoscopic Microsurgery. METHODS Data pertaining patients undergoing combined colectomy and Transanal Endoscopic Microsurgery (TEM) between 2004 and 2014 were retrospectively collected. RESULTS 141 TEM performed in the study period, 9 (6.5%) with combined laparoscopic colectomy were included. Mean age was 69.1 ± 10.6 years. There were 6 (66%) right, 2 (22%) left, and one (11%) sigmoid colectomy. All rectal lesions were benign adenomas, with mean tumor size 2.5 cm, and distance from the verge 9 ± 2.5 cm. Lesions were located in lateral rectal wall in 4, posterior in 4, and anterior in one case. Seven patients had the colectomy before TEM, and 2 had the TEM first. Mean operative time was 245 minutes (range 185-313) for the combined procedures. Median time of hospitalization was 6 days (range 4-11). Six patients (66%) had prolonged postoperative diarrhea. The final rectal pathology reports were adenoma with high-grade dysplasia (HGD) in 5 patients and adenoma with low-grade dysplasia in four cases. The colon pathology was T1 N0 in 3, T2 N0 in one, T3 N1 in one, adenoma with HGD in 2, and no residual tumor in 2 patients. Two patients underwent re-TEM for recurrent adenoma of rectum at 14 and 18 months postoperatively. CONCLUSION The combination of TEM with laparoscopic colectomy is feasible and should be kept in mind as an alternative procedure in case of SCRT. However, more strict selection criteria should be considered and the disadvantages should be discussed with the patient.
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Affiliation(s)
- Nida Issa
- 1 Department of Surgery, Hasharon Hospital, Rabin Medical Center , Petach Tikva, Israel .,2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Yaniv Fenig
- 3 Department of Surgery, Monmouth Medical Center , Long Branch, New Jersey
| | - Muhammad Khatib
- 1 Department of Surgery, Hasharon Hospital, Rabin Medical Center , Petach Tikva, Israel .,2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Mustafa Yasin
- 1 Department of Surgery, Hasharon Hospital, Rabin Medical Center , Petach Tikva, Israel .,2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Eldad Powsner
- 1 Department of Surgery, Hasharon Hospital, Rabin Medical Center , Petach Tikva, Israel .,2 The Sackler School of Medicine, Tel-Aviv University , Tel Aviv, Israel
| | - Wisam Khoury
- 4 Department of Surgery, Rambam Health Care Campus , Haifa, Israel
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Ngamruengphong S, Pohl H, Haito-Chavez Y, Khashab MA. Update on Difficult Polypectomy Techniques. Curr Gastroenterol Rep 2016; 18:3. [PMID: 26714965 DOI: 10.1007/s11894-015-0476-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Endoscopists often encounter colon polyps that are technically difficult to resect. These lesions traditionally were managed surgically, with significant potential morbidity and mortality. Recent advances in endoscopic techniques and instruments have allowed endoscopists to safely and effectively remove colorectal lesions with high technical and clinical success and potentially avoid invasive surgery. Endoscopic mucosal resection (EMR) has gained acceptance as the first-line therapy for large colorectal lesions. Endoscopic submucosal dissection (ESD) has been reported to be associated with higher rate of en bloc resection and less risk of short-time recurrence, but with an increased risk of adverse events. Therefore, the role of colorectal ESD should be restricted to lesions with high-risk morphologic features of submucosal invasion. In this article, we review the recent literature on the endoscopic management of difficult colorectal neoplasms.
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Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Zayed Bldg, Suite 7125B, Baltimore, MD, 21287, USA
| | - Heiko Pohl
- Department of Gastroenterology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Department of Gastroenterology, VA Medical Center White River Junction, White River Junction, VT, USA
| | - Yamile Haito-Chavez
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Zayed Bldg, Suite 7125B, Baltimore, MD, 21287, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins Medical Institutions, 1800 Orleans Street, Zayed Bldg, Suite 7125B, Baltimore, MD, 21287, USA.
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Zhan T, Hahn F, Hielscher T, Betge J, Kähler G, Ebert MP, Belle S. Frequent co-occurrence of high-grade dysplasia in large flat colonic polyps (>20 mm) and synchronous polyps. BMC Gastroenterol 2015; 15:82. [PMID: 26160557 PMCID: PMC4498525 DOI: 10.1186/s12876-015-0312-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 06/29/2015] [Indexed: 12/24/2022] Open
Abstract
Background Large colonic polyps are associated with advanced dysplasia, but prevalence and characteristics of synchronous polyps in patients with large flat colonic polyps are poorly investigated. This study aims to characterize clinicopathological features of large flat colonic polyps and their impact on occurrence and characteristics of synchronous polyps. Methods A total of 802 patients that underwent endoscopic mucosal resection (EMR) of flat colonic polyps >20 mm from 2003 to 2014 in an academic endoscopy unit were retrospectively analyzed for size, location and histology of large polyps and synchronous polyps. Results Average size of large polyps was 34.1 mm (range 20–150 mm, standard deviation 16.1 mm). Histology included 52.5 % adenomas with low-grade dysplasia (LGD), 26.7 % with high-grade dysplasia (HGD), 9.6 % serrated polyps and 11.2 % adenocarcinomas. The majority of large polyps were localized in the proximal colon (61 %). 72.2 % of adenocarcinomas were found in the distal colon, while 80.5 % of all serrated polyps were detected in the proximal colon. Increase in polyp size, advanced age and location in the distal colon were associated with presence of HGD/adenocarcinoma in large polyps, as identified by multivariate analysis. Synchronous polyps were detected in 67.2 % of patients undergoing complete colonoscopy during EMR. Presence of HGD/adenocarcinoma in the large polyp, localization of any synchronous polyp in the rectosigmoid colon and occurrence of multiple synchronous polyps were associated with presence of HGD/adenocarcinoma in synchronous polyps. Conclusions Synchronous polyps are frequently found in patients with large flat colonic polyps. The prevalence of synchronous polyps with high grade dysplasia is highest in patients with large flat polyps containing HGD/adenocarcinoma. Electronic supplementary material The online version of this article (doi:10.1186/s12876-015-0312-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tianzuo Zhan
- Division of Signaling and Functional Genomics, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 580, D-69120, Heidelberg, Germany. .,Department of Internal Medicine II, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, D-68167, Mannheim, Germany.
| | - Felix Hahn
- Department of Internal Medicine II, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, D-68167, Mannheim, Germany.
| | - Thomas Hielscher
- Division of Biostatistics, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, D-69120, Heidelberg, Germany.
| | - Johannes Betge
- Division of Signaling and Functional Genomics, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 580, D-69120, Heidelberg, Germany. .,Department of Internal Medicine II, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, D-68167, Mannheim, Germany.
| | - Georg Kähler
- Central Interdisciplinary Endoscopy Unit, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, D-68167, Mannheim, Germany.
| | - Matthias P Ebert
- Department of Internal Medicine II, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, D-68167, Mannheim, Germany.
| | - Sebastian Belle
- Department of Internal Medicine II, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, D-68167, Mannheim, Germany. .,Central Interdisciplinary Endoscopy Unit, Universitätsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Theodor-Kutzer Ufer 1-3, D-68167, Mannheim, Germany.
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Dynamic article: combined endoscopic-laparoscopic surgery for complex colonic polyps: postoperative outcomes and video demonstration of 3 key operative techniques. Dis Colon Rectum 2015; 58:363-9. [PMID: 25664717 DOI: 10.1097/dcr.0000000000000311] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Combined endoscopic-laparoscopic surgery is a novel technique that can be used to avoid bowel resection for complex colon polyps that are not amenable to colonoscopic resection. OBJECTIVE The aim of this study was to evaluate the safety and outcomes of combined endoscopic-laparoscopic surgery for complex colonic polyps. DESIGN This study is a retrospective review of consecutive combined endoscopic-laparoscopic surgeries. SETTING This study was conducted at a single institution. PATIENTS All patients that underwent combined endoscopic-laparoscopic surgery for a complex colonic polyp at our center from October 2009 to October 2013 were followed. Each patient's lesion was assessed by a therapeutic endoscopist before referral for combined endoscopic-laparoscopic surgery, and was deemed unresectable based on size, broad base, or location of the polyp. MAIN OUTCOME MEASURES Intraoperative and postoperative complications, length of hospital stay, and recurrence were the primary outcomes measured. RESULTS Thirty consecutive patients underwent combined endoscopic-laparoscopic surgery. Twenty (66.7%) patients underwent laparoscopic-assisted colonoscopic polyp excision (10 of these excisions were facilitated by Endoloop placement at the polyp base), 9 (30%) patients underwent colonoscopic-assisted laparoscopic cecectomy, and 1 (3.3%) patient was converted from a colonoscopic-assisted laparoscopic cecectomy to a laparoscopic ileocolic resection. The median length of hospital stay was 2 days (range, 1-16). Twenty-nine (96.7%) of the final pathology results were benign, with 10 (33.3%) showing high-grade dysplasia. One (3.3%) final pathology result was positive for a well-differentiated adenocarcinoma. This patient subsequently underwent a laparoscopic right hemicolectomy and chemotherapy for node-positive disease. One (3.3%) patient experienced a recurrent benign polyp at the previous excision site, which was removed by colonoscopy. The time to detection of recurrence was 274 days. LIMITATIONS This study looked at a small group of patients, over a short follow-up period. However, all consecutive patients were captured, and there were no losses to follow-up. CONCLUSIONS Combined endoscopic-laparoscopic surgery for complex benign colonic polyps is a safe procedure, with good clinical outcomes and low recurrence rates.
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