ENDOLUMINAL SURGERY OUTCOMES IN 1005 LESIONS
Carla F. Justiniano*, Ilker Ozgur, David Liska, Tracy L. Hull, Scott Steele, Emre Gorgun
Colorectal Surgery, Cleveland Clinic, Cleveland, OH
Endoluminal surgery has become an established technique worldwide for resection of neoplastic colorectal lesions not amenable to conventional removal; yet, its use in North America remains sparse. The authors report an 11-year experience of endoluminal surgery at a quaternary referral center.
A retrospective review was performed of a prospectively collected database of patients who underwent advanced endoluminal techniques for removal of neoplastic lesions between 2011 and 2021 at a quaternary care hospital in the United States. Patients underwent either endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), hybrid EMR (combines ESD with EMR), combined endoscopic laparoscopic surgery (CELS), endoscopic full-thickness resection (EFTR), or single port endorobotic resection (SP). We evaluated patient and lesion characteristics, procedures and outcomes, pathology, and post-procedure complications.
Of the 1005 lesions resected among 846 patients, the median patient age was 66 (range: 22-94), 53% were male, and 35% of patients had ASA (American Society of Anesthesiology) categories 3 or 4 comorbidity burdens. The procedure was performed in the operating room in 40% of cases and 60% were performed in the endoscopy suite. The lesions were most commonly located in the cecum (32%), the ascending colon (19%), and the sigmoid colon (11%). Median lesion size was 30 mm (4-160). The most common Paris classifications among the lesions were 0-IIa (37%), Is (18%) and 0-IIa+c (7%). ESD was used for 53%, hybrid EMR for 33%, EMR for 8%, CELS for 5%, SP for 1% and EFTR for 1%. Median procedure time was 83 minutes (10-420). The resection was en-bloc in 54% of lesions, piecemeal in 41% and incomplete in 4%. Fifty-two percent of procedures included a closure device such as endoclips. Ten percent experienced a post-procedure complication within 30 days including most commonly delayed bleeding in 42 (4%) patients, perforation or abscess in 21 (2%) and abdominal pain requiring observation in 14 (1%). No deaths were observed. The most common pathology findings were tubular adenoma (43.8%), tubulovillous adenoma (26.4%) and sessile serrated adenoma (14.7%). Adenocarcinoma was found in 6.7% of lesions and high-grade dysplasia was noted in 18.6%. Nine-percent of lesions have experienced neoplastic recurrence which have been re-resected with endoscopic techniques.
Endoluminal surgery is a complex yet safe procedure, with low morbidity rates, no observed mortality and low rates of incidental cancer. Colorectal surgeons can utilize endoluminal surgery to address difficult lesions while preserving the colon and rectum, and additional operating room tools, like laparoscopy, can be deployed by surgeons to complete the task as needed.
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