VANCOUVER – Combined endolaparoscopic surgery may offer a good option for patients with difficult but benign polyps, judging by results of a retrospective study.
Difficult benign colonic lesions are typically treated with bowel resection, but even when this is performed laparoscopically, significant morbidity is seen, according to Dr. Sang W. Lee of the department of surgery at New York–Presbyterian Hospital and Cornell University, New York. He suggested that combined endolaparoscopic surgery (CELS) is a safe and effective alternative.
Photo Laird Harrison/Elsevier Global Medical News
Dr. Sung W. Lee
Dr. Lee and his colleagues looked at the records of 66 patients who were taken to the operating room for CELS at New York–Presbyterian. The patients had been referred after failure to clear polyps, mostly because the polyps were large or in difficult locations based on biopsy or endoscopic photographs. Only those patients with at least a year of follow-up including a colonoscopy were included, and those with successful colonoscopic polypectomies were excluded.
The surgeons used CO2 colonoscopy to avoid bowel distention.
"The idea is that if you have a difficult polyp, or a polyp that is located at difficult location, or a very large polyp, then you can laparoscopically help get exposure of that polyp so you can take it out endoscopically," said Dr. Lee at the annual meeting of the American Society of Colon and Rectal Surgeons. "And if you [damage] the bowel wall, you can recognize and repair it laparoscopically."
Once in the operating room, 10 patients were converted to laparoscopic colectomy before CELS was attempted because of suspicion of cancer.
Of the 56 patients in whom the procedure was attempted, 13 were converted to colectomy because of technical difficulty. Two were converted because of suspicion of cancer after the combination procedure was completed.
Of the 12 patients in whom cancer was suspected (10 before the procedure and 2 after), 4 patients had confirmed cancer, giving the team a 33% successful prediction rate. Conversely, of 54 patients thought to have benign polyps, only 1 patient (1.9%) was later found to have cancer.
The largest polyps were the most likely to contain cancer, but even among those greater than 4 cm in diameter, only 13 (7.6%) contained cancer, suggesting that size alone is not an absolute contraindication to performing CELS, said Dr. Lee.
Almost half of the patients went home the day after the procedure. The median time in the operating room was 150 minutes, and the complication rate was 4.4%, said Dr. Lee. Of 41 patients for whom CELS was successful, 5 had limited recurrence. And of those five, four had repeat colonoscopy to repeat the removal of polyps; one had a delayed laparoscopic colectomy, but in this patient the final pathology was benign, he said.
The presentation drew one question from the audience: "Of those patients that you suspected had cancer and who were converted to colectomy, the majority of them were benign. Is there a way to avoid those colectomies that weren’t needed?"
"I would rather be on the safe side," said Dr. Lee. "Unless you take the polyp out completely, you’re not going to know if there’s a cancer there. It’s a little bit of a conundrum, but if you suspect cancer based on the morphology, go ahead and perform a laparoscopic colectomy."
Dr. Lee disclosed that he has served as a speaker and consultant for Covidien, as a course faculty member for Olympus America and Applied Medical, and as a principal investigator for Applied Medical.