Reply to: doi:10.1007/s00464-009-0668-z: Combined laparoscopic–endoscopic resection of colorectal polyps: 10-year experience and follow-up evaluation
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- Wilhelm, D., von Delius, S., Meining, A. et al. Surg Endosc (2010) 24: 733. doi:10.1007/s00464-009-0684-z
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Thisarticle tries to answer the question about the feasibility of laparoscopically assisted resection of difficult “benign” polyps. It would have been useful if the data presented had been contextualized with regard to the number of patients who underwent alternative or open procedures?
Primarily, open resection of benign, even difficult polyps, is no longer the therapy of choice and almost dispensable since the introduction of combined procedures to our department in the early 1990s. Thus, all patients received the combined approach at first. Seven patients (5%) underwent conversion to open surgery due to suspicion of malignant disease (n = 3, according to institutional policy), bowel perforation during colonoscopy (n = 1), difficult closure of the colotomy (n = 2), and incomplete resection of a rectal lesion (n = 1). This was clearly stated in the article. If the polyps were classified as endoscopically resectable in a routine preoperative endoscopic examination, this was the preferred therapy.
The definition of polyps deemed unresectable by colonoscopy was accepted as subjective. However, was there any screening or repeat colonoscopy by an experienced colonoscopist?
All the patients had received a colonoscopy by an experienced endoscopist before presenting to our institution. However, preoperative recolonoscopy routinely performed could preserve about 5% of patients from surgical treatment. Concrete endoscopic snare resection had even been attempted for 27 of the patients but was unsuccessful. Moreover, we note that with laparoscopic assistance, only eight polyps were endoscopically approachable, as displayed in Table 2.
Voloyiannis et al.  found that selective colonoscopy for 171 of 252 patients referred led to avoidance of resection for 101 patients. As a result, 58% of these were rescoped, and 40% of all the patients referred avoided resection. This resection rate may improve with the relatively new technique of colonoscopic (endoscopic) mucosal resection described by Saito et al. .
The percentage of resections avoided by recolonoscopy was comparably low in our series, as already mentioned. However, all referring practitioners are highly experienced endoscopists, and the low avoidance rate may be due to the fact that the classification of polyps as unresectable is justified to a great extent. The technique of endoscopic submucosal dissection for large colonic adenomas, as described by Saito et al. , is very demanding but attracting initial interest in Japan. In the Western world, endoscopic submucosal resection still is in its infancy and not a standard procedure. Additionally, it is associated with a much higher complication rate.
The authors are to be complimented for their honest appraisal of complications at 25%.
This rate of 25% included every complication, from potentially fatal cardiac arrhythmias to banal urinary tract infections. By reporting every complication, even if not associated with surgery, we tried to balance for every eventual underreporting attributable to the retrospective nature of the study.
Because the study is retrospective in nature, the complication rate probably is higher, leading to difficulties in determining the causes or relevance of reported complications with the procedure. An undeclared percentage of data is being determined by the lead clinician or by patient recall at a later date. Have the authors used a validated scale to classify their complications, and because intraabdominal abscesses often result from small leaks, do they warrant merely “minor” status?
As stated in the article, complications were classified according to previous large studies dealing with laparoscopic surgery .
The inclusion of colonoscopic follow-up assessment is a useful adjunct, although other trials have used 1-year screening to ensure that no polyps are missed. Wade et al.  report an adenoma rate of 58% at a 1-year colonoscopic follow-up assessment, with 9% of the patients having adenomas larger than 10 mm, which probably represent missed adenomas.
Chandra et al. cite a study older than 25 years. In the meantime, several studies investigating tandem colonsocopy have shown that the adenoma miss rate for relevant adenomas (i.e., those with a diameter of ≥10 mm) is about 2% . Deductively routine colonoscopic follow-up assessment after 1 year is an antiquated proceeding and not according to current guidelines.
Did the polyps found at rescoping correlate with previous resections?
The question is clearly answered in the article. Metachronous lesions (i.e., lesions away from the primary location of resection) were found in 31 patients (29%, relating to patients with colonoscopic follow-up assessment), 8 of whom showed macroscopic or microscopic characteristics of advanced lesions (i.e., adenomas 10 mm in diameter or larger and lesions with a villous component, high-grade dysplasia, or cancer). These findings confirm those from other studies. The 29% overall rate of adenoma recurrence in our study was similar to that in previous reports, which ranged from 32 to 42% at 3 to 4 years [3–5]. A local relapse of a tubulovillous adenoma occurred for one patient (0.9%, relating to the patients with colonoscopic follow-up assessment).
Drs. D. Wilhelm, S. von Delius, A. Meining, H. Feussner have no conflicts of interest or financial ties to disclose.