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Combined endoscopic-laparoscopic surgery (CELS) can avoid segmental colectomy in endoscopically unremovable colonic polyps: a cohort study over 10 years

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Abstract

Background

Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings.

Methods

Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017).

Results

One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection.

Conclusion

CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.

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References

  1. Levine JS, Ahnen DJ (2006) Adenomatous polyps of the colon. New Engl J Med 355:2551–2557. https://doi.org/10.1056/NEJMcp063038

    Article  CAS  PubMed  Google Scholar 

  2. Winawer SJ, Zauber AG, Ho MN, O’Brien MJ, Gottlieb LS, Sternberg SS, Waye JD, Schapiro M, Bond JH, Panish JF, Ackroyd F, Shike M, Kurtz RC, Hornsby-Lewis L, Gerdes H, Stewart ET (1993) Prevention of colorectal cancer by colonoscopicpolypectomy. New Engl J Med 329:1977–1981. https://doi.org/10.1056/NEJM199312303292701

    Article  CAS  PubMed  Google Scholar 

  3. Ferlitsch M, Moss A, Hassan C, Bhandari P, Dumonceau J-M, Paspatis G, Jover R, Langner C, Bronzwaer M, Nalankilli K, Fockens P, Hazzan R, Gralnek I, Gschwantler M, Waldmann E, Jeschek P, Penz D, Heresbach D, Moons L, Lemmers A, Paraskeva K, Pohl J, Ponchon T, Regula J, Repici A, Rutter M, Burgess N, Bourke M (2017) Colorectal polypectomy and endoscopic mucosal resection (EMR): european society of gastrointestinal endoscopy (ESGE) clinical guideline. Endoscopy 49:270–297. https://doi.org/10.1055/s-0043-102569

    Article  PubMed  Google Scholar 

  4. Fujishiro M, Goto O, Kakushima N, Kodashima S, Muraki Y, Omata M (2007) Endoscopic submucosal dissection of stomach neoplasms after unsuccessful endoscopic resection. Digest Dis 39:566–571. https://doi.org/10.1016/j.dld.2007.01.026

    Article  CAS  Google Scholar 

  5. Zhou P-H, Yao L-Q, Qin X-Y (2009) Endoscopic submucosal dissection for colorectal epithelial neoplasm. SurgEndos 23:1546–1551. https://doi.org/10.1007/s00464-009-0395-5

    Article  Google Scholar 

  6. Wichmann MW (2005) Immunological effects of laparoscopic vs open colorectal surgery. Arch Surg 140:692. https://doi.org/10.1001/archsurg.140.7.692

    Article  PubMed  Google Scholar 

  7. Joo JS, Amarnath L, Wexner SD (1998) Is laparoscopic resection of colorectal polyps beneficial? SurgEndosc 12:1341–1344. https://doi.org/10.1007/s004649900852

    Article  CAS  Google Scholar 

  8. Pokala N, Delaney CP, Kiran RP, Brady K, Senagore AJ (2007) Outcome of laparoscopic colectomy for polyps not suitable for endoscopic resection. SurgEndosc 21:400–403. https://doi.org/10.1007/s00464-006-9069-8

    Article  Google Scholar 

  9. Lo SH, Law WL (2005) Laparoscopic colorectal resection for polyps not suitable for colonoscopic removal. SurgEndosc 19:1252–1255. https://doi.org/10.1007/s00464-004-2220-4

    Article  CAS  Google Scholar 

  10. Benedix F, Köckerling F, Lippert H, Scheidbach H (2008) Laparoscopic resection for endoscopicallyunresectable colorectal polyps: analysis of 525 patients. SurgEndosc 22:2576–2582. https://doi.org/10.1007/s00464-008-0059-x

    Article  Google Scholar 

  11. Lee SW, Garrett KA, Shin JH, Trencheva K, Sonoda T, Milsom JW (2013) Dynamic article. Dis Colon Rectum 56:869–873. https://doi.org/10.1097/DCR.0b013e3182821e58

    Article  PubMed  Google Scholar 

  12. Lee MK, Chen F, Esrailian E, Russell MM, Sack J, Lin AY, Yoo J (2013) Combined endoscopic and laparoscopic surgery may be an alternative to bowel resection for the management of colon polyps not removable by standard colonoscopy. SurgEndosc 27:2082–2086. https://doi.org/10.1007/s00464-012-2714-5

    Article  Google Scholar 

  13. Yan J, Trencheva K, Lee SW, Sonoda T, Shukla P, Milsom JW (2011) Treatment for right colon polyps not removable using standard colonoscopy: combined laparoscopic-colonoscopic approach. Dis Colon Rectum 54:753–758. https://doi.org/10.1007/DCR.0b013e3182108289

    Article  PubMed  Google Scholar 

  14. Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The clavien-dindo classification of surgical complications. Ann Surg 250:187–196. https://doi.org/10.1097/SLA.0b013e3181b13ca2

    Article  PubMed  Google Scholar 

  15. Leicher LW, de Vos tot NederveenCappel WH, van Westreenen HL (2017) Limited endoscopic-assisted wedge resection for excision of colon polyps. Dis Colon Rectum 60:299–302. https://doi.org/10.1097/DCR.0000000000000716

    Article  PubMed  Google Scholar 

  16. Serra-Aracil X, Gil-Barrionuevo E, Martinez E, Mora-López L, Pallisera-Lloveras A, Serra-Pla S, Garcia-Nalda A, Puig-Divi V, Campo R, Navarro-Soto S (2020) Combined endoscopic and laparoscopic surgery for the treatment of complex benign colonic polyps: a video vignette. Tech Coloproctol 24:491–493. https://doi.org/10.1007/s10151-020-02171-3

    Article  CAS  PubMed  Google Scholar 

  17. Golda T, Lazzara C, Zerpa C, Sobrino L, Fico V, Kreisler E, Biondo S (2019) Risk factors for ileocolic anastomosis dehiscence; a cohort study. Am J Surg. https://doi.org/10.1016/j.amjsurg.2019.11.020

    Article  PubMed  Google Scholar 

  18. Golda T, Kreisler E, Rodriguez G, Miguel B, Biondo S (2018) From colorectal to general surgeon in the management of left colonic perforation: a cohort study. Int J Surg (London, England) 55:175–181. https://doi.org/10.1016/j.ijsu.2018.05.732

    Article  Google Scholar 

  19. Franklin ME, Portillo G (2009) Laparoscopic monitored colonoscopicpolypectomy: long-term follow-up. World J Surg 33:1306–1309. https://doi.org/10.1007/s00268-009-9967-8

    Article  PubMed  Google Scholar 

  20. Franklin ME, Leyva-Alvizo A, Abrego-Medina D, Glass JL, Treviño J, Arellano PP, Portillo G (2007) Laparoscopically monitored colonoscopicpolypectomy: an established form of endoluminal therapy for colorectal polyps. SurgEndosc 21:1650–1653. https://doi.org/10.1007/s00464-007-9237-5

    Article  Google Scholar 

  21. Jayaram A, Barr N, Plummer R, Yao M, Chen L, Yoo J (2019) Combined endo-laparoscopic surgery (CELS) for benign colon polyps: a single institution cost analysis. SurgEndosc 33:3238–3242. https://doi.org/10.1007/s00464-018-06610-z

    Article  Google Scholar 

  22. Marres CCM, Buskens CJ, Schriever E, Verbeek PCM, Mundt MW, Bemelman WA, van de Ven AWH (2017) The impact of the national bowel screening program in the Netherlands on detection and treatment of endoscopicallyunresectable benign polyps. TechnColoproctol 21:887–891. https://doi.org/10.1007/s10151-017-1705-x

    Article  CAS  Google Scholar 

  23. Wilhelm D, von Delius S, Weber L, Meining A, Schneider A, Friess H, Schmid RM, Frimberger E, Feussner H (2009) Combined laparoscopic–endoscopic resections of colorectal polyps: 10-year experience and follow-up. SurgEndosc 23:688–693. https://doi.org/10.1007/s00464-008-0282-5

    Article  Google Scholar 

  24. Nakajima K, Sharma SK, Lee SW, Milsom JW (2016) Avoiding colorectal resection for polyps: is CELS the best method? SurgEndosc 30:807–818. https://doi.org/10.1007/s00464-015-4279-6

    Article  Google Scholar 

  25. Garrett K, Lee S (2015) Combined Endoscopic and Laparoscopic Surgery. Clin Colon Rectal Surg 28:140–145. https://doi.org/10.1055/s-0035-1555005

    Article  PubMed  PubMed Central  Google Scholar 

  26. Whelan RL (2011) Laparoscopic-facilitated colonic endoscopic mucosal resection and endoscopic submucosal resection of adenomas: techniques to avoid segmental colectomy. J GastrointestSurg 15:1309–1312. https://doi.org/10.1007/s11605-011-1574-y

    Article  Google Scholar 

  27. Nakajima K, Lee SW, Sonoda T, Milsom JW (2005) Intraoperative carbon dioxide colonoscopy: a safe insufflation alternative for locating colonic lesions during laparoscopic surgery. SurgEndosc 19:321–325. https://doi.org/10.1007/s00464-004-8915-9

    Article  CAS  Google Scholar 

  28. Arezzo A, Passera R, Marchese N, Galloro G, Manta R, Cirocchi R (2016) Systematic review and meta-analysis of endoscopic submucosal dissection vs endoscopic mucosal resection for colorectal lesions. United EurGastroenterol J 4:18–29. https://doi.org/10.1177/2050640615585470

    Article  CAS  Google Scholar 

  29. Winter H, Lang RA, Spelsberg FW, Jauch K-W, Hüttl TP (2007) Laparoscopic colonoscopic rendezvous procedures for the treatment of polyps and early stage carcinomas of the colon. Int J Colorectl Dis 22:1377–1381. https://doi.org/10.1007/s00384-007-0345-4

    Article  CAS  Google Scholar 

  30. Beck DE, Karulf RE (1993) Laparoscopic-assisted full-thickness endoscopic polypectomy. Dis Colon Rectum 36:693–695. https://doi.org/10.1007/BF02238598

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

The authors thank Mr. Bernat Miguel, Data Manager of the Colorectal Unit, General and Digestive Surgery, Bellvitge University Hospital and IDIBELL, University of Barcelona, for the statistical analysis. Authors thank Dr. Federica Mento for the drawings.

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Author notes

  1. Thomas Golda and Claudio Lazzara have contributed equally to this study.

Authors and Affiliations

  1. Department of General and Digestive Surgery, Colorectal Unit, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain

    Thomas Golda, Claudio Lazzara, Maria Sorribas, Ricardo Frago, Esther Kreisler & Sebastiano Biondo

  2. Department of Gastroenterology, Bellvitge University Hospital, University of Barcelona, Barcelona, Spain

    Antonio Soriano

  3. Medical School, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia

    Abdulrahman Alrasheed

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  1. Thomas Golda
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Correspondence to Thomas Golda.

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Disclosures

Drs. Thomas Golda, Claudio Lazzara, Maria Sorribas, Antonio Soriano, Ricardo Frago, Abdulrahman Alrasheed, Esther Kreisler and Sebastiano Biondo have no conflict of interest or financial ties to disclose.

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Presented, in part, at the XXIII Reunion Nacional de la Fundación Asociación Española de Coloproctología, Spain, November 2019.

Supplementary Information

Below is the link to the electronic supplementary material.

Video 1 (LAER: laparoscopy assisted endoscopic resection). Laparoscopic dissection and presentation of the colonic segment, endoscopic en-bloc resection of the polyp (mp4 70586 kb)

Video 2 (EAWR: endoscopy assisted wedge resection). Endoscopic localization of the polyp. Placement of two or more assistance sutures under endoscopic guidance. Uplifting of the colonic segment to perform a wedge resection. The suture line is over-sewn by laparoscopy (mp4 190711 kb)

Video 3 (LAER combined with EAWR). Joint venture procedure of endoscopic polyp reduction and colonic wedge resection. Endoscopic and laparoscopic identification of a large submucosal lipoma provoking invagination and clinical suboclusion. Reduction of the tumor´s diameter by fragmented endoscopic polypectomy; once the – most definitely – benign submucosal tumor is reduced to its base, a wedge resection of the lipoma´s base is performed. Over-sewing the suture line is not shown (mp4 186797 kb)

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Golda, T., Lazzara, C., Sorribas, M. et al. Combined endoscopic-laparoscopic surgery (CELS) can avoid segmental colectomy in endoscopically unremovable colonic polyps: a cohort study over 10 years. Surg Endosc 36, 196–205 (2022). https://doi.org/10.1007/s00464-020-08255-3

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