Background
Endoscopic Mucosal Resection (EMR) and endoscopic submucosal dissection (ESD) have revolutionized the approach to large precancerous and early cancerous colorectal polyps allowing for minimally invasive curative resection. However, segmental colectomy remains the accepted treatment for polyps not easily amenable to ESD or EMR. Combined laparo-endoscopic surgery (CLES) for local excision of difficult polyps offers decreased morbidity and shorter in-hospital stay compared with segmental colectomy. Here, we report outcomes of recently adopted multidisciplinary approach involving CLES for resection of large colorectal polyps at a large veteran’s affair (VA) referral medical center
Methods
This is an ongoing single-institution VA prospective cohort study between December 2021 and July 2023. Adult VA patients with large colorectal polyps that had unsuccessful attempt at EMR or ESD or deemed not a candidate for endoscopic resection by a therapeutic endoscopist were included. A multidisciplinary review is undergone selecting veterans to undergo polypectomy with a colorectal surgeon and therapeutic endoscopist using simultaneous laparoscopic and endoscopic instrumentation. Aim of this approach was to provide endoscopic resection (en-bloc or piecemeal) with laparoscopic assistance by colon manipulation, however, all patients were also consented for segmental colectomy. Variables, including demographics and procedure characteristics, in addition to outcomes were included
Results
A total of 6 veterans were selected for CLES. All veterans were men, with median age of 73 years (range 48 to 78), and a median Charlson Comorbidity Index of 4.5 (range 1-14). A total of eight polyps were removed (table 1). Median polyp size was 35 mm (range 12-50 mm). resected polyps were found to be tubular or tubulovillous histology without high-grade dysplasia or malignancy. The median operating time was 93 minutes (range 58-198). Technical success, defined as successful hybrid approach without need for segmental surgical resection was 100%. There were no intraoperative or postoperative complications. The median length of hospital stay was 0.5 days (range 0-1) and all patients were discharged home. However, two veterans re-presented with gastrointestinal bleeding from EMR site requiring repeat endoscopy with successful hemostasis. All patients had follow up surveillance, with one patient presenting with local recurrence at site, treated with endoscopic mucosal resection
Conclusion
This multidisciplinary approach of combined laparo-endoscopic surgery, a first of its kind at a VA medical center, is a safe and effective alternative to segmental colectomy for the removal of polyps in veterans not amenable to advanced endoscopic resection techniques. Continued studies are underway to adequately select veterans and polyp characteristics that most benefit from this hybrid approach
