Laparoscopic resection for colorectal polyps: a single institution experience

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.

Hybrid Laparoendoscopic Approaches to Endoscopically Unresectable Colon Polyps

Secondary prevention of colorectal cancer relies on effective screening through colonoscopy and polypectomy. Resection of some polyps can present technical challenges particularly when polyps are large, flat, or behind colonic folds. Laparoscopy as an adjunct to endoscopy can aid in removing difficult colonic polyps without subjecting patients to radical segmental colectomy. Hybrid laparoendoscopic techniques are increasingly reported in literature as alternatives to segmental colectomy for the treatment of polyps that have a high likelihood of being benign. Laparoscopic-assisted colonoscopic polypectomy is the most frequently utilized technique; it harnesses the power of laparoscopy to aid endoscopic polypectomy by flattening folds, mobilizing flexures, and providing retraction. Colonoscopy-assisted laparoscopic wedge and transluminal resection are often reported in older studies and use the visualization provided by intraoperative colonoscopy to guide colonic resection that is limited to the area of the polyp. Laparoscopic-assisted endoscopic full-thickness resection (EFTR) is a relatively recent technique that provides laparoscopic monitoring of EFTR of polyp as well as endoscopic closure of the ensuing defect. Minimally invasive segmental colectomy based on oncologic principles should be utilized when none of the previous techniques are suitable or when malignancy is strongly suspected. The combined use of laparoscopy and endoscopy can expand the endoscopist's armamentarium when dealing with the most challenging polyps, while serving the patients' best interest by limiting the extent of colon resection.

Endoscopic submucosal dissection vs laparoscopic colorectal resection for early colorectal epithelial neoplasia

AIM: To compare the short term outcome of endoscopic submucosal dissection (ESD) with that of laparoscopic colorectal resection (LC) for the treatment of early colorectal epithelial neoplasms that are not amenable to conventional endoscopic removal.

METHODS: This was a retrospective cohort study. The clinical data of all consecutive patients who underwent ESD for endoscopically assessed benign lesions that were larger than 2 cm in diameter from 2009 to 2013 were collected. These patients were compared with a cohort of controls who underwent LC from 2005 to 2013. Lesions that were proven to be malignant by initial endoscopic biopsies were excluded. Mid and lower rectal lesions were not included because total mesorectal excision, which bears a more complicated postoperative course, is not indicated for lesions without histological proof of malignancy. Both ESD and LC were performed by the same surgical unit with a standardized technique. The patients were managed according to a standard protocol, and they were closely monitored for complications after the procedures. All hospital records were reviewed, and the following data were compared between the ESD and LC groups: patient demographics, size and location of the lesions, procedure time, short-term clinical outcomes and pathology results.

RESULTS: From 2005 to 2013, 65 patients who underwent ESD and 55 patients who underwent LC were included in this study. The two groups were similar in terms of sex (P = 0.41) and American Society of Anesthesiologist class (P = 0.58), although patients in the ESD group were slightly older (68.6 ± 9.4 vs 64.6 ± 9.9, P = 0.03). ESD could be accomplished with a shorter procedure time (113 ± 66 min vs 153 ± 43 min, P < 0.01) for lesions of comparable size (3.0 ± 1.2 cm vs 3.4 ± 1.4 cm, P = 0.22) and location (colon/rectum: 59/6 vs colon/rectum: 52/3, P = 0.43). ESD appeared to be associated with a lower short-term complication rate, but the difference did not reach statistical significance (10.8% vs 23.6%, P = 0.06). In the LC arm, a total of 22 complications occurred in 13 patients. A total of 7 complications occurred in the ESD arm, including 5 perforations and 2 episodes of bleeding. All perforations were observed during the procedure and were successfully managed by endoscopic clipping without emergency surgical intervention. Patients in the ESD arm had a faster recovery than patients in the LC arm, which included shorter time to resume normal diet (2 d vs 4 d, P = 0.01) and a shorter hospital stay (3 d vs 6 d, P < 0.01).

CONCLUSION: ESD showed better short-term clinical outcomes in this study. Further prospective randomized studies will be required to evaluate the efficacy and superiority of colorectal ESD over LC.

Laparoscopic colorectal surgery for colorectal polyps: single institution experience

Introduction

Because of their difficult location or size, some polyps are impossible to remove with a flexible colonoscope and must be surgically removed. Laparoscopy is a great alternative.

Aim

To assess outcomes of a laparoscopic approach for the management of difficult colorectal polyps.

Material and methods

From 2006 to 2014, patients with polyps that could not be treated by endoscopy were included. Demographic data, histology of the biopsy, type of surgery, length of postoperative stay, complications and final pathology were reviewed prospectively.

Results

Forty-two patients with a mean age of 64.9 ±8.4 underwent laparoscopic polypectomy. Laparoscopic mobilization of the colonic segment and colotomy with removal of the polyp was performed for 12 (28.6%) polyps. Laparoscopic segmental bowel resection was performed in 30 (71.4%) cases: anterior rectal resection with partial total mesorectal excision in 12 (28.6%), left hemicolectomy in 7 (16.6%), sigmoid resection in 6 (14.3%), ileocecal resection in 2 (4.76%), resection of transverse colon in 2 (4.76%) and sigmoid resection with transanal retrieval of specimen in 1 (2.38%). Mean postoperative hospital stay was 5.9 ±2.6 days. There were 4 complications (9.5%). All patients recovered after conservative treatment. Mean polyp size was 3.6 ±2.2 cm. Final pathology revealed polyps (n = 2), tubular adenoma (n = 6), tubulovillous adenoma (n = 20), carcinoma in situ (n = 10) and invasive cancer (n = 4). Two of these patients underwent laparoscopic left hemicolectomies 14 and 10 days after laparoscopic colotomy and polypectomy.

Conclusions

For the management of endoscopically unresectable polyps, laparoscopic polypectomy is currently the technique of choice.

Is There an Indication for Surgical Resection in Colorectal Adenoma?

BACKGROUND

Due to the adenoma-carcinoma sequence, complete removal of colorectal polyps is essential.

METHOD

This article analyzes the role of surgery in the removal of colorectal adenoma.

RESULTS

Nowadays, most adenomas are removed properly by endoscopic methods. Also in the resection of giant polyps and recurrent adenoma endoscopic data is convincing. Therefore, surgical resection of colorectal adenomas is required in the case of endoscopic inaccessibility. Reasons for this may be the location of the polyp, incomplete endoscopic resection, or suspected malignancy. Endoscopic or limited surgical resection of malignant adenomas is acceptable only if 'low-risk' criteria are fulfilled. Otherwise oncologic radical resection is recommended. In general, radical resection is also necessary in the case of polyps that are not suitable for endoscopic removal, because here the rate of colorectal carcinoma is high.

CONCLUSION

If a surgical approach is necessary, minimally invasive surgery in the hands of an experienced laparoscopic surgeon is a suitable option. Adenomas in the lower two thirds of the rectum are suitable for transanal full-thickness resection. This is done by conventional resection or transanal endoscopic microsurgery. The histopathological preparation of these specimens provides diagnostic and therapeutic benefits, particularly compared to piecemeal resection of early carcinoma.

Combined endoscopic-laparoscopic resection of colon polyps

AIMS

To analyze the current literature on combined endoscopic-laparoscopic resection of colon polyps and to compare this new approach to standard laparoscopic colonic resection for polyps not suitable for endoscopic resection.

RESULTS

Several studies demonstrated that with a combined endoscopic-laparoscopic approach, polyps were successfully resected in 82-91% with a low morbidity of 3-10% and a short hospital stay of 1-2 days. Segmental laparoscopic resection was necessary in only 9-12%, but had a conversion rate to open surgery of 15% with an average hospital stay of 6-11 days. A cancerous polyp was found in 6-13% after a combined approach, with lymph node metastasis in 6%. Recurrent polyps after a combined endoscopic-laparoscopic resection seem to be rare, but follow-up of most studies is short and incomplete.

CONCLUSION

Combined endoscopic-laparoscopic resection of colon polyps is feasible, safe, and has a high success rate. Malignant lesions can be treated laparoscopically during the same operation, avoiding the need for a second procedure, and with good long-term oncologic outcome.