SAN FRANCISCO — A combined laparoscopic-endoscopic approach can be effective in treating difficult colonic polyps, Dr. Morris E. Franklin Jr. said at the annual meeting of the Society of Laparoendoscopic Surgeons.
In a case series of 144 patients from whom 190 polyps were removed during laparoscopically monitored colonoscopic polypectomy (LMCP), only 4% required conversion to full-thickness resection, said Dr. Franklin of the Texas Endosurgery Institute, San Antonio.
The patients resumed eating an average of 6 hours after the surgery, stayed in the hospital an average of 1.1 days, and returned to full activity in an average of 2 days. In all, 10% of the patients experienced minor complications and none had major complications.
During an average of 74 months of follow-up, no patients experienced a recurrence and only three needed reoperation, in each case because of a new polyp in a different segment.
“Our gastroenterologists now selectively send patients that have difficult polyps for this procedure,” Dr. Franklin said. The best candidates for LMCP are patients whose polyps are difficult to remove with a colonoscope alone. Removal may be difficult because of the size, location, or number of polyps.
Common indications include sessile broad-based polyps, very large polyps, or polyps that are difficult to reach, either because they are behind a fold or at a difficult angle. Dr. Franklin also finds the technique useful in cases of redundant sigmoid colon, which can make it difficult to get to polyps on the right side.
In performing the procedure, the laparoscopist works alongside the colonoscopist. To properly coordinate the procedure, it is crucial that each physician can see both monitors.
The laparoscopist begins by lysing the adhesions and mobilizing the colon. “We found that if we could straighten out the sigmoid, it makes passage of the colonoscope very rapid and therefore cuts down on the time for this procedure,” Dr. Franklin said.
The next step is to clamp the proximal bowel prior to the colonoscopy with polypectomy under microscopic guidance.
The laparoscopist monitors the serosal surface during the polypectomy, and sutures the polypectomy site if necessary. Occasionally the laparoscopist will perform a colotomy for a very large polyp that can't be removed with the colonoscope alone. Sometimes the laparoscopist will perform a full-thickness or segmental resection, particularly if the polyp appears likely to be cancerous. Frozen section evaluation is obtained on each specimen.
Dr. Franklin noted that the one disadvantage of LMCP is that the surgeon is reimbursed at a higher rate for segmental resections, but “if we're doing something good for the patients, that probably it's beneficial to all.”
Dr. Franklin disclosed receiving research funds, serving as a consultant, and serving on the speaker's bureau for several manufactures of medical devices.