doi:10.1111/codi.12512
Original article
Endolaparoscopic removal of colonic polyps C. Goh, J. P. Burke, D. A. McNamara, R. A. Cahill and J. Deasy Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland Received 15 July 2013; accepted 12 October 2013; Accepted Article online 5 December 2013
Abstract Aim A proportion of colonic polyps is not amenable to exclusively colonoscopic removal due to their location, size or tortuosity of the colon. A combined laparoscopic/colonoscopic polypectomy or endolaparoscopic polypectomy (ELP) is an alternative to formal segmental resection. We present our experience of ELP. Method This is a retrospective review of a consecutive series of patients who underwent ELP for preoperatively diagnosed benign polyps between 2010 and 2013. Data are presented as median (interquartile range, IQR). Results Thirty patients commenced ELP. Eighteen were male and the median (IQR) age was 65.4 (61.6– 73.5) years. Of 30 attempted cases, 22 (73%) underwent successful ELP surgery. Patients in whom combined ELP surgery was unsuccessful were converted to laparoscopic colectomy (one) or colonic mobilization and colotomy (seven). The median operation time for successful ELP was 105 (75–125) min. The complication rate was 13.3% and the median length of stay was
Introduction Large colonic polyps or those lying in or behind a haustral fold can be challenging to remove endoscopically. Although endoscopic submucosal dissection (ESD) has been performed for these polyps, the technique is not widely available and does not provide a solution in certain cases [1]. Consequently, for such unresectable polyps, segmental colectomy is generally recommended to prevent malignant transformation [2]. Laparoscopic segmental colectomy results in less blood loss, a shorter length of hospital stay and lower postoperative shortterm morbidity compared with open colectomy [3]. Although less invasive, laparoscopic colectomy still poses significant potential morbidity. Furthermore, between 2001 and 2008 only 7% of elective resections in the UK were performed laparoscopically [4]. Correspondence to: Mr Joseph Deasy, Beaumont Hospital, Dublin, Ireland. E-mail: [email protected]
2.0 (1.0–3.0) days for successful ELP compared with 5.5 (3.5–6.8) days for converted patients (P = 0.014). The median polyp size was 14 (10–22) mm; eight (26.7%) had high-grade dysplasia with two cases of invasive cancer identified. Conclusion A combined endoscopic–laparoscopic approach provides an alternative to segmental resection for treating challenging colonic polyps. This approach appears to be safe and effective and should be offered to selected patients with benign colonic polyps. Keywords Laparoscopy, benign polyps
colonoscopy,
polypectomy,
What does this paper add to the literature? The current study demonstrates in a consecutive series of patients that endolaparoscopic polypectomy has a success rate of 73%, has minimal morbidity and identifies invasive disease in 7% of cases.
First reported by Beck and Karulf in 1993 [5] as an alternative to colonic resection, combined endolaparoscopic polypectomy (ELP) is an alternative to segmental resection in select patients [6]. In patients who have difficult but benign polyps, endoscopic removal of the polyps with laparoscopic assistance may obviate the morbidity associated with resection. In the current study, the technique and experience of our institution in ELP for endoscopically unresectable polyps is presented, the specific object being to define the success rate, associated complications and incidence of high-grade dysplasia and invasive disease identified using this procedure.
Method This was a retrospective, cohort study. Following a review of operating theatre records, patients in whom an ELP was commenced between September 2010 and
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 271–275
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Endolaparoscopic removal of colonic polyps
May 2013 were identified. Patients were included if they were referred with complex but benign-appearing polyps that could not be excised via colonoscopy by the attending endoscopist. These patients included those with large or broad-based polyps, polyps with a base that could not be observed, polyps behind mucosal folds and polyps in tortuous colonic segments, all deemed colonoscopically unresectable due to the risk of thermal injury, incomplete removal, inadequate visualization or a combination of these factors. All referrals for ELP were from consultant gastroenterologists or colorectal surgeons in Beaumont Hospital where the index colonoscopy was performed in the gastrointestinal endoscopy unit. Beaumont Hospital is a tertiary referral centre, one of eight nationally with a catchment area of 0.5 million patients and a referral centre for advanced therapeutic endoscopy. All referring endoscopists had a high volume practice [7] (performing over 500 colonoscopies each year). Patients with rectal polyps were excluded. Surgical technique
Preoperatively, the surgeon due to perform the ELP reviewed all pertinent data (including the colonoscopy report and pictures) and counselled the patient on the nature of the intervention and possibility of escalation. After the induction of general anaesthesia, the patients were placed in the lithotomy position and an orogastric tube and urinary catheter were inserted. The abdomen was prepared and draped in a sterile fashion. First an umbilical 10 mm camera port was inserted and a pneumoperitoneum was established. Two further 5 mm working ports were then placed according to the location of the lesion. The bowel was clamped proximally with atraumatic graspers to prevent distension of the proximal bowel as colonoscopy was instituted. CO2 colonoscopy was performed to locate the lesion within the colon. The base of the polyp was exposed with the use of laparoscopic manipulation. If the polyp was located in a difficult location, the colon was mobilized laparoscopically for better exposure. The lesion was then elevated with a submucosal injection of adrenaline in saline. Polypectomy was performed using a hot rotatable endoscopic snare. While hot-snare polypectomy was performed, the serosal surface of the colon was monitored for thermal injury. The specimen was retrieved with an endoscopic net and extracted transanally. Follow-up
Patients underwent a follow-up colonoscopy 6 months after ELP and further assessment was according to the
272
British Society of Gastroenterology adenoma surveillance guidelines. No patient was lost to follow-up. Statistical analysis
Unless otherwise stated, data are given as median (interquartile range, IQR). Differences in continuous variables were determined using the Mann–Whitney U test. All calculations were performed using SPSS version 12.0 (SPSS Inc., Chicago, Illinois, USA).
Results During the study period 30 patients were offered polyp excision via the ELP technique by three different surgeons. The median age was 65 (62–74) years. Patient demographics and characteristics are shown in Table 1. Preoperatively, all patients were thought to have a benign polyp (including those with high-grade dysplasia), based on review of the images taken during colonoscopy and histological examination of colonoscopic biopsies, and were deemed appropriate for ELP. Polyp characteristics including distribution within the colon are shown in Table 2. The indication for ELP was large size in 17 (56.7%) cases and difficult location in 13 (43.3%) cases as determined by the surgeon/endoscopist at the time of index colonoscopy. Of the 30 patients, 22 (73%) commenced and completed ELP as intended (Table 3). Cross-clamping and support of the colon was performed in all cases. The colon was mobilized to aid polypectomy in two cases, adhesiolysis was needed in three cases and intracorporeal suturing of the polypectomy site was performed in three cases. Seven patients had the relevant colonic segment mobilized laparoscopically and exteriorized via a
Table 1 Patient demographics and characteristics. Age (years) Body mass index (kg/m2) Charlson comorbidity index ASA grade 1 2 3 Sex Female Male Operative time (min) Length of stay (days) Postoperative complications Follow-up (months)
65.4 (61.6–73.5) 26.5 (25.0–29.0) 0.0 (0.0–1.0) 6 (20.0) 13 (43.3) 11 (36.7) 12 18 105 2.0 4 19.8
(40.0) (60.0) (75–125) (2.0–4.5) (13.3) (9.9–27.6)
Data are presented as median (IQR) or n (%).
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Table 2 Polyp characteristics. Polyp size (mm) (median, IQR) Location Caecum Ascending colon Transverse colon Left colon Sigmoid colon Morphology Sessile Pedunculated Histology Tubular adenoma Tubulovillous adenoma Villous adenoma Adenocarcinoma High-grade dysplasia
14 (10–22) 5 3 5 3 14
(16.7) (10) (16.7) (10) (46.6)
14 (46.7) 16 (53.3) 14 13 1 2 8
(46.7) (43.3) (3.3) (6.7) (26.7)
Data are presented as median (IQR) or n (%).
Table 3 Characteristics of converted cases. Overall Colotomy Laparoscopic colectomy Indications Large size Difficult location Failed polypectomy Ulcer or central umbilication
8 (26.6) 7 (23.3) 1 (3.3) 2 3 2 1
(25.0) (37.5) (25.0) (12.5)
the muscularis propria; Haggitt level 4 [8]). There was no lymphovascular invasion or tumour budding and 15 lymph nodes were free of tumour. One further patient who underwent ELP for a sigmoid polyp was found to have an invasive moderately differentiated adenocarcinoma within the polyp extending 5 mm into the submucosa (Haggitt level 4) reaching 1 mm from the resection margin. There was no lymphovascular invasion or tumour budding. Upon completion of laparoscopic sigmoid colectomy no residual tumour was identified and 19 lymph nodes were free of tumour. The median operation time for successful ELP was 105 (75–125) min. Median length of stay was significantly shorter for successful ELP (2, 1–3 days) compared with converted patients (5.5, 3.5–6.8 days) (P = 0.014). Four (13.3%) patients in whom ELP was attempted developed postoperative complications – one post polypectomy bleed which resolved with conservative treatment, one postoperative ileus (defined by nausea/vomiting, inability to tolerate oral diet, absence of flatus with radiological confirmation occurring for four postoperative days [9]) and two patients experienced urinary retention that required re-catheterization. Of the 30 patients who underwent ELP, two (6.7%) had further polyps distant from the initial polypectomy site at a median follow-up of 20 (10–28) months. Both patients underwent colonoscopic polypectomy and had benign pathology.
Data are presented as n (%).
Discussion small extraction site to facilitate colotomy, polyp excision and primary closure owing to technical difficulties. All polypectomy resection margins were clear. One patient underwent a laparoscopic right hemicolectomy because of concern of malignancy due to failure of the polyp to lift on submucosal infiltration and a central ulcer and had cancer proved on final histology (moderately differentiated adenocarcinoma in a tubulovillous adenoma extending into the submucosa but not
Previous series have examined this combined technique, concluding it to be a safe and effective method to avoid colectomy and to remove difficult polyps in the majority of cases (Table 4). Success rates of ELP range from 74% to 88% with complication rates of 9–18%. The introduction of a National Bowel Cancer Screening Programme in England has resulted in an increase in the diagnosis of early stage disease and the screened population tend to have more benign and larger polyps
Table 4 Outcome of endolaparoscopic polypectomy (ELP) in previous series reporting 10 or more patients. Patient numbers
First author
Year
Lee [6] Cruz [23] Wood [24] Grunhagen [13] Franklin [25]
2013 2011 2011 2011
65 25 13 11
2009
176
Country
LOS (days)
Complications (%)
ELP success (%)
Operative time (min)
Mean polyp size (cm)
HGD (%)
Cancer (%)
USA USA UK Netherlands
1 1.5 2 1
9 8 15 18
74 76 77 82
145 93 – 45
3.0 2.4 – 2.0
11 – – 9
8 4 8 9
USA
1.1
9
88
97
3.7
–
4
LOS, length of stay; HGD, high-grade dysplasia.
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[10]. Before ESD and further novel techniques such as full-thickness polyp excision [11] are validated, the technique presented here is an attractive alternative to segmental colectomy. Regarding the technical challenge of the procedure, the main difficulty encountered was colonic distension making the laparoscopic view more difficult. The use of atraumatic graspers to cross-clamp the colon proximal to the site of the polyp to prevent distension proximally was particularly helpful. For this we used laparoscopic DeBakey tissue forceps, which are long enough to traverse the colon. Second, the laparoscopic light can trans-illuminate the colon so periodically the laparoscope must be turned away at key times to prevent a distorted endoscopic view. Finally, to inspect the colon fully for serosal injury at the end of ELP or to mobilize the colon in failed cases, the colon must be entirely colonoscopically decompressed, but this was not found to be technically difficult and can be helped by external colonic compression under laparoscopic guidance. Laparoscopic assistance during colonoscopic polypectomy can help by invaginating the colon to assist in snaring a sessile polyp and mobilizing the colon to provide better access and exposure; also full-thickness injury to the colon can be detected and repaired laparoscopically. A recent case controlled study demonstrated that intraoperative colonoscopy does not complicate the outcome of laparoscopic intestinal resection [12]. Colonoscopy was performed with CO2 which is rapidly absorbed and results in minimal unwanted colonic distension [6]. The rate of invasive cancer identified in the specimen following removal by ELP ranges from 4% to 9% and 6.7% in the current series is typical, but the 26.7% rate of high-grade dysplasia observed is higher than previously reported [6,13]. It must be remembered that the operative experience of segmental colectomy for an endoscopically unresectable polyp is far greater than that of novel techniques such as ELP. The incidence of invasive cancer after segmental colectomy for an endoscopically unresectable polyp is 13–22% [14,15] with risk factors including left sided colonic location [2,16,17], high-grade dysplasia [2,16] and size [16]. While the macroscopic appearance of the polyp as determined by the Paris consensus classification [18] is important, the definitive diagnosis of malignant invasion is given by the final pathology report. If a malignant polyp is identified, subsequent colectomy is indicated after endoscopic removal if the resection margin is deemed to be involved (< 1 mm), where invasive cancer reaches the base of a pedunculated polyp (Haggitt level 4) or the deeper layer of the submucosa of a sessile polyp (Kikuchi level 3), where there is poor differentiation and perhaps when lymphovascular invasion is present [19].
274
In 23% of cases a colotomy was performed to enable an open polypectomy. This technique has the potential to compromise oncological principles and thus, should suspicious endoscopic features exist for invasion (the presence of depressed ulceration, irregular contours, the inability to elevate the polyp), it should not be performed. Furthermore, patients who progress to segmental colectomy due to suspicious features at the time of ELP may be disadvantaged by not having prior staging radiological imaging. Novel techniques for minimally invasive polypectomy continue to evolve, such as full-thickness local excision of the colonic wall with laparoscopic stapling devices [20] and laparoscopic colonic wall inversion followed by full-thickness endoscopic excision [11]. Going forward, the outcomes, morbidity and oncological efficacy of techniques such as ELP compared with standard segmental resection are best evaluated in the setting of a prospective randomized controlled trial. The current study has a number of limitations. It is retrospective and could be subject to a degree of selection bias. Prior series have demonstrated that 74% of challenging polyps referred for colonic resection could ultimately be removed endoscopically [21] and specialist endoscopists have improved success at endoscopic resection alone [22]; thus there may have been an overestimation of the need for ELP. However, given the tertiary referral nature of our institution it is assumed that this effect was minimized. Despite these limitations, the current series adds to the existing body of knowledge that ELP is a safe and effective alternative to colectomy in all parts of the colon for benign polyps which would be difficult or impossible to remove endoscopically.
Author contributions Study conception and design: JP Burke, J Deasy. Provision of study materials or patients: D McNamara, R Cahill, J Deasy. Collection and assembly of data: C Goh, JP Burke. Data analysis and interpretation: all authors. Manuscript writing: all authors. Final approval of the manuscript: all authors.
Conflicts of interest None to declare.
References 1 Zhou PH, Yao LQ, Qin XY. Endoscopic submucosal dissection for colorectal epithelial neoplasm. Surg Endosc 2009; 23: 1546–51.
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2 Bertelson NL, Kalkbrenner KA, Merchea A et al. Colectomy for endoscopically unresectable polyps: how often is it cancer? Dis Colon Rectum 2012; 55: 1111–6. 3 Rondelli F, Trastulli S, Avenia N et al. Is laparoscopic right colectomy more effective than open resection? A meta-analysis of randomized and nonrandomized studies. Colorectal Dis 2012; 14: e447–69. 4 Mamidanna R, Burns EM, Bottle A et al. Reduced risk of medical morbidity and mortality in patients selected for laparoscopic colorectal resection in England: a population-based study. Arch Surg 2012; 147: 219–27. 5 Beck DE, Karulf RE. Laparoscopic-assisted full-thickness endoscopic polypectomy. Dis Colon Rectum 1993; 36: 693–5. 6 Lee SW, Garrett KA, Shin JH, Trencheva K, Sonoda T, Milsom JW. Long-term outcomes of patients undergoing combined endolaparoscopic surgery for benign colon polyps. Dis Colon Rectum 2013; 56: 869–73. 7 Chukmaitov A, Bradley CJ, Dahman B, Siangphoe U, Warren JL, Klabunde CN. Association of polypectomy techniques, endoscopist volume, and facility type with colonoscopy complications. Gastrointest Endosc 2013; 77: 436–46. 8 Haggitt RC, Glotzbach RE, Soffer EE, Wruble LD. Prognostic factors in colorectal carcinomas arising in adenomas: implications for lesions removed by endoscopic polypectomy. Gastroenterology 1985; 89: 328–36. 9 Vather R, Trivedi S, Bissett I. Defining postoperative ileus: results of a systematic review and global survey. J Gastrointest Surg 2013; 17: 962–72. 10 Brigic A, Cahill R, Bassett P, Clark S, Kennedy R. Shortterm outcomes following hemicolectomy for benign colonic polyps: a prospective case controlled study. Colorectal Dis 2013. [Epub ahead of print]. 11 Kennedy RH, Cahill RA, Sibbons P, Fraser C. The ‘FLEX’ procedure: a new technique for full-thickness laparo-endoscopic excision in the colon. Endoscopy 2011; 43: 223–9. 12 Gorgun IE, Aytac E, Manilich E, Church JM, Remzi FH. Intraoperative colonoscopy does not worsen the outcomes of laparoscopic colorectal surgery: a case-matched study. Surg Endosc 2013; 27: 3572–6. 13 Grunhagen DJ, van Ierland MC, Doornebosch PG, Bruijninckx MM, Winograd R, de Graaf EJ. Laparo-
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Original article
Endolaparoscopic removal of colonic polyps C. Goh, J. P. Burke, D. A. McNamara, R. A. Cahill and J. Deasy Department of Colorectal Surgery, Beaumont Hospital, Dublin, Ireland Received 15 July 2013; accepted 12 October 2013; Accepted Article online 5 December 2013
Abstract Aim A proportion of colonic polyps is not amenable to exclusively colonoscopic removal due to their location, size or tortuosity of the colon. A combined laparoscopic/colonoscopic polypectomy or endolaparoscopic polypectomy (ELP) is an alternative to formal segmental resection. We present our experience of ELP. Method This is a retrospective review of a consecutive series of patients who underwent ELP for preoperatively diagnosed benign polyps between 2010 and 2013. Data are presented as median (interquartile range, IQR). Results Thirty patients commenced ELP. Eighteen were male and the median (IQR) age was 65.4 (61.6– 73.5) years. Of 30 attempted cases, 22 (73%) underwent successful ELP surgery. Patients in whom combined ELP surgery was unsuccessful were converted to laparoscopic colectomy (one) or colonic mobilization and colotomy (seven). The median operation time for successful ELP was 105 (75–125) min. The complication rate was 13.3% and the median length of stay was
Introduction Large colonic polyps or those lying in or behind a haustral fold can be challenging to remove endoscopically. Although endoscopic submucosal dissection (ESD) has been performed for these polyps, the technique is not widely available and does not provide a solution in certain cases [1]. Consequently, for such unresectable polyps, segmental colectomy is generally recommended to prevent malignant transformation [2]. Laparoscopic segmental colectomy results in less blood loss, a shorter length of hospital stay and lower postoperative shortterm morbidity compared with open colectomy [3]. Although less invasive, laparoscopic colectomy still poses significant potential morbidity. Furthermore, between 2001 and 2008 only 7% of elective resections in the UK were performed laparoscopically [4]. Correspondence to: Mr Joseph Deasy, Beaumont Hospital, Dublin, Ireland. E-mail: [email protected]
2.0 (1.0–3.0) days for successful ELP compared with 5.5 (3.5–6.8) days for converted patients (P = 0.014). The median polyp size was 14 (10–22) mm; eight (26.7%) had high-grade dysplasia with two cases of invasive cancer identified. Conclusion A combined endoscopic–laparoscopic approach provides an alternative to segmental resection for treating challenging colonic polyps. This approach appears to be safe and effective and should be offered to selected patients with benign colonic polyps. Keywords Laparoscopy, benign polyps
colonoscopy,
polypectomy,
What does this paper add to the literature? The current study demonstrates in a consecutive series of patients that endolaparoscopic polypectomy has a success rate of 73%, has minimal morbidity and identifies invasive disease in 7% of cases.
First reported by Beck and Karulf in 1993 [5] as an alternative to colonic resection, combined endolaparoscopic polypectomy (ELP) is an alternative to segmental resection in select patients [6]. In patients who have difficult but benign polyps, endoscopic removal of the polyps with laparoscopic assistance may obviate the morbidity associated with resection. In the current study, the technique and experience of our institution in ELP for endoscopically unresectable polyps is presented, the specific object being to define the success rate, associated complications and incidence of high-grade dysplasia and invasive disease identified using this procedure.
Method This was a retrospective, cohort study. Following a review of operating theatre records, patients in whom an ELP was commenced between September 2010 and
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 16, 271–275
271
C. Goh et al.
Endolaparoscopic removal of colonic polyps
May 2013 were identified. Patients were included if they were referred with complex but benign-appearing polyps that could not be excised via colonoscopy by the attending endoscopist. These patients included those with large or broad-based polyps, polyps with a base that could not be observed, polyps behind mucosal folds and polyps in tortuous colonic segments, all deemed colonoscopically unresectable due to the risk of thermal injury, incomplete removal, inadequate visualization or a combination of these factors. All referrals for ELP were from consultant gastroenterologists or colorectal surgeons in Beaumont Hospital where the index colonoscopy was performed in the gastrointestinal endoscopy unit. Beaumont Hospital is a tertiary referral centre, one of eight nationally with a catchment area of 0.5 million patients and a referral centre for advanced therapeutic endoscopy. All referring endoscopists had a high volume practice [7] (performing over 500 colonoscopies each year). Patients with rectal polyps were excluded. Surgical technique
Preoperatively, the surgeon due to perform the ELP reviewed all pertinent data (including the colonoscopy report and pictures) and counselled the patient on the nature of the intervention and possibility of escalation. After the induction of general anaesthesia, the patients were placed in the lithotomy position and an orogastric tube and urinary catheter were inserted. The abdomen was prepared and draped in a sterile fashion. First an umbilical 10 mm camera port was inserted and a pneumoperitoneum was established. Two further 5 mm working ports were then placed according to the location of the lesion. The bowel was clamped proximally with atraumatic graspers to prevent distension of the proximal bowel as colonoscopy was instituted. CO2 colonoscopy was performed to locate the lesion within the colon. The base of the polyp was exposed with the use of laparoscopic manipulation. If the polyp was located in a difficult location, the colon was mobilized laparoscopically for better exposure. The lesion was then elevated with a submucosal injection of adrenaline in saline. Polypectomy was performed using a hot rotatable endoscopic snare. While hot-snare polypectomy was performed, the serosal surface of the colon was monitored for thermal injury. The specimen was retrieved with an endoscopic net and extracted transanally. Follow-up
Patients underwent a follow-up colonoscopy 6 months after ELP and further assessment was according to the
272
British Society of Gastroenterology adenoma surveillance guidelines. No patient was lost to follow-up. Statistical analysis
Unless otherwise stated, data are given as median (interquartile range, IQR). Differences in continuous variables were determined using the Mann–Whitney U test. All calculations were performed using SPSS version 12.0 (SPSS Inc., Chicago, Illinois, USA).
Results During the study period 30 patients were offered polyp excision via the ELP technique by three different surgeons. The median age was 65 (62–74) years. Patient demographics and characteristics are shown in Table 1. Preoperatively, all patients were thought to have a benign polyp (including those with high-grade dysplasia), based on review of the images taken during colonoscopy and histological examination of colonoscopic biopsies, and were deemed appropriate for ELP. Polyp characteristics including distribution within the colon are shown in Table 2. The indication for ELP was large size in 17 (56.7%) cases and difficult location in 13 (43.3%) cases as determined by the surgeon/endoscopist at the time of index colonoscopy. Of the 30 patients, 22 (73%) commenced and completed ELP as intended (Table 3). Cross-clamping and support of the colon was performed in all cases. The colon was mobilized to aid polypectomy in two cases, adhesiolysis was needed in three cases and intracorporeal suturing of the polypectomy site was performed in three cases. Seven patients had the relevant colonic segment mobilized laparoscopically and exteriorized via a
Table 1 Patient demographics and characteristics. Age (years) Body mass index (kg/m2) Charlson comorbidity index ASA grade 1 2 3 Sex Female Male Operative time (min) Length of stay (days) Postoperative complications Follow-up (months)
65.4 (61.6–73.5) 26.5 (25.0–29.0) 0.0 (0.0–1.0) 6 (20.0) 13 (43.3) 11 (36.7) 12 18 105 2.0 4 19.8
(40.0) (60.0) (75–125) (2.0–4.5) (13.3) (9.9–27.6)
Data are presented as median (IQR) or n (%).
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Table 2 Polyp characteristics. Polyp size (mm) (median, IQR) Location Caecum Ascending colon Transverse colon Left colon Sigmoid colon Morphology Sessile Pedunculated Histology Tubular adenoma Tubulovillous adenoma Villous adenoma Adenocarcinoma High-grade dysplasia
14 (10–22) 5 3 5 3 14
(16.7) (10) (16.7) (10) (46.6)
14 (46.7) 16 (53.3) 14 13 1 2 8
(46.7) (43.3) (3.3) (6.7) (26.7)
Data are presented as median (IQR) or n (%).
Table 3 Characteristics of converted cases. Overall Colotomy Laparoscopic colectomy Indications Large size Difficult location Failed polypectomy Ulcer or central umbilication
8 (26.6) 7 (23.3) 1 (3.3) 2 3 2 1
(25.0) (37.5) (25.0) (12.5)
the muscularis propria; Haggitt level 4 [8]). There was no lymphovascular invasion or tumour budding and 15 lymph nodes were free of tumour. One further patient who underwent ELP for a sigmoid polyp was found to have an invasive moderately differentiated adenocarcinoma within the polyp extending 5 mm into the submucosa (Haggitt level 4) reaching 1 mm from the resection margin. There was no lymphovascular invasion or tumour budding. Upon completion of laparoscopic sigmoid colectomy no residual tumour was identified and 19 lymph nodes were free of tumour. The median operation time for successful ELP was 105 (75–125) min. Median length of stay was significantly shorter for successful ELP (2, 1–3 days) compared with converted patients (5.5, 3.5–6.8 days) (P = 0.014). Four (13.3%) patients in whom ELP was attempted developed postoperative complications – one post polypectomy bleed which resolved with conservative treatment, one postoperative ileus (defined by nausea/vomiting, inability to tolerate oral diet, absence of flatus with radiological confirmation occurring for four postoperative days [9]) and two patients experienced urinary retention that required re-catheterization. Of the 30 patients who underwent ELP, two (6.7%) had further polyps distant from the initial polypectomy site at a median follow-up of 20 (10–28) months. Both patients underwent colonoscopic polypectomy and had benign pathology.
Data are presented as n (%).
Discussion small extraction site to facilitate colotomy, polyp excision and primary closure owing to technical difficulties. All polypectomy resection margins were clear. One patient underwent a laparoscopic right hemicolectomy because of concern of malignancy due to failure of the polyp to lift on submucosal infiltration and a central ulcer and had cancer proved on final histology (moderately differentiated adenocarcinoma in a tubulovillous adenoma extending into the submucosa but not
Previous series have examined this combined technique, concluding it to be a safe and effective method to avoid colectomy and to remove difficult polyps in the majority of cases (Table 4). Success rates of ELP range from 74% to 88% with complication rates of 9–18%. The introduction of a National Bowel Cancer Screening Programme in England has resulted in an increase in the diagnosis of early stage disease and the screened population tend to have more benign and larger polyps
Table 4 Outcome of endolaparoscopic polypectomy (ELP) in previous series reporting 10 or more patients. Patient numbers
First author
Year
Lee [6] Cruz [23] Wood [24] Grunhagen [13] Franklin [25]
2013 2011 2011 2011
65 25 13 11
2009
176
Country
LOS (days)
Complications (%)
ELP success (%)
Operative time (min)
Mean polyp size (cm)
HGD (%)
Cancer (%)
USA USA UK Netherlands
1 1.5 2 1
9 8 15 18
74 76 77 82
145 93 – 45
3.0 2.4 – 2.0
11 – – 9
8 4 8 9
USA
1.1
9
88
97
3.7
–
4
LOS, length of stay; HGD, high-grade dysplasia.
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[10]. Before ESD and further novel techniques such as full-thickness polyp excision [11] are validated, the technique presented here is an attractive alternative to segmental colectomy. Regarding the technical challenge of the procedure, the main difficulty encountered was colonic distension making the laparoscopic view more difficult. The use of atraumatic graspers to cross-clamp the colon proximal to the site of the polyp to prevent distension proximally was particularly helpful. For this we used laparoscopic DeBakey tissue forceps, which are long enough to traverse the colon. Second, the laparoscopic light can trans-illuminate the colon so periodically the laparoscope must be turned away at key times to prevent a distorted endoscopic view. Finally, to inspect the colon fully for serosal injury at the end of ELP or to mobilize the colon in failed cases, the colon must be entirely colonoscopically decompressed, but this was not found to be technically difficult and can be helped by external colonic compression under laparoscopic guidance. Laparoscopic assistance during colonoscopic polypectomy can help by invaginating the colon to assist in snaring a sessile polyp and mobilizing the colon to provide better access and exposure; also full-thickness injury to the colon can be detected and repaired laparoscopically. A recent case controlled study demonstrated that intraoperative colonoscopy does not complicate the outcome of laparoscopic intestinal resection [12]. Colonoscopy was performed with CO2 which is rapidly absorbed and results in minimal unwanted colonic distension [6]. The rate of invasive cancer identified in the specimen following removal by ELP ranges from 4% to 9% and 6.7% in the current series is typical, but the 26.7% rate of high-grade dysplasia observed is higher than previously reported [6,13]. It must be remembered that the operative experience of segmental colectomy for an endoscopically unresectable polyp is far greater than that of novel techniques such as ELP. The incidence of invasive cancer after segmental colectomy for an endoscopically unresectable polyp is 13–22% [14,15] with risk factors including left sided colonic location [2,16,17], high-grade dysplasia [2,16] and size [16]. While the macroscopic appearance of the polyp as determined by the Paris consensus classification [18] is important, the definitive diagnosis of malignant invasion is given by the final pathology report. If a malignant polyp is identified, subsequent colectomy is indicated after endoscopic removal if the resection margin is deemed to be involved (< 1 mm), where invasive cancer reaches the base of a pedunculated polyp (Haggitt level 4) or the deeper layer of the submucosa of a sessile polyp (Kikuchi level 3), where there is poor differentiation and perhaps when lymphovascular invasion is present [19].
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In 23% of cases a colotomy was performed to enable an open polypectomy. This technique has the potential to compromise oncological principles and thus, should suspicious endoscopic features exist for invasion (the presence of depressed ulceration, irregular contours, the inability to elevate the polyp), it should not be performed. Furthermore, patients who progress to segmental colectomy due to suspicious features at the time of ELP may be disadvantaged by not having prior staging radiological imaging. Novel techniques for minimally invasive polypectomy continue to evolve, such as full-thickness local excision of the colonic wall with laparoscopic stapling devices [20] and laparoscopic colonic wall inversion followed by full-thickness endoscopic excision [11]. Going forward, the outcomes, morbidity and oncological efficacy of techniques such as ELP compared with standard segmental resection are best evaluated in the setting of a prospective randomized controlled trial. The current study has a number of limitations. It is retrospective and could be subject to a degree of selection bias. Prior series have demonstrated that 74% of challenging polyps referred for colonic resection could ultimately be removed endoscopically [21] and specialist endoscopists have improved success at endoscopic resection alone [22]; thus there may have been an overestimation of the need for ELP. However, given the tertiary referral nature of our institution it is assumed that this effect was minimized. Despite these limitations, the current series adds to the existing body of knowledge that ELP is a safe and effective alternative to colectomy in all parts of the colon for benign polyps which would be difficult or impossible to remove endoscopically.
Author contributions Study conception and design: JP Burke, J Deasy. Provision of study materials or patients: D McNamara, R Cahill, J Deasy. Collection and assembly of data: C Goh, JP Burke. Data analysis and interpretation: all authors. Manuscript writing: all authors. Final approval of the manuscript: all authors.
Conflicts of interest None to declare.
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