Avoiding colorectal resection for polyps: is CELS the best method?

Background

A significant proportion of colonic polyps are unsuitable for endoscopic removal. A combined endoscopic and laparoscopic approach is an alternative to conventional polypectomy or resection. In this review, we set out to determine whether avoiding segmental resection for benign colonic polyps was a viable option through combined endolaparoscopic surgery (CELS). We examined the methods and classification criteria different centers employed in their reporting. Finally, we determined whether CELS and procedures methodically similar should be considered as the standard of care today.

Methods

A systematic review was performed reporting the outcomes of CELS for benign colorectal polyps. Main outcomes measured included operating time, length of hospital stay and postoperative complications. The CELS data from reports with a larger number of polyps examined were compared to data from representative EMR, ESD and laparoscopic colectomy literature.

Results

Eighteen eligible studies with 532 patients were included. We identified three different CELS techniques: EMR, ESD and full-thickness excision. The operative time for CELS reported in 12 studies varied from 45 to 205 min. The successful endoscopic resection rate ranged from 58 to 100 %. Conversion to open surgery was reported in <5 %. The length of hospital stay varied from 0 to 7 days. Overall postoperative complications ranged from 0 to 18 %. The reports of CELS with more than 20 polyps presented 74–91 % successful rate. In comparison with laparoscopic group, CELS groups showed shorter operation time (92–145 vs 125–199 min) and length of hospital stay (1–1.5 vs 4–11 days).

Conclusions

CELS and similar procedures are viable options for intestinal polyps removal. Moving forward, we suggest methods to standardize CELS procedure reporting. The reported outcomes of CELS indicate that it should be seen as a viable alternative to segmental resection when endoscopic methods alone do not suffice.

     

Endoscopic resection of large sporadic non-ampullary duodenal polyps: efficacy and long-term recurrence

Background

Endoscopic resection is an alternative to surgery for removal of large duodenal polyps. There are limited data on the safety, efficacy, and long-term recurrence data after endoscopic resection of sporadic, non-ampullary, and large duodenal polyps.

Objective

Our aim was to evaluate the safety and short-term outcomes of the endoscopic removal of the large sporadic duodenal polyps and to determine long-term risk of recurrence and factors predicting recurrence on follow-up.

Methods

Patients with large (>10 mm) sporadic non-ampullary duodenal polyps underwent endoscopic resection from 2001 to 2012 at the Cleveland Clinic. Patients underwent endoscopic polypectomy and argon plasma coagulation. The main outcome measurements were complete polypectomy, complications, short- and long-term recurrence.

Results

A total of 54 patients were included. The mean patient age was 66.4 years. The mean polyp size was 15.1 ± 5.4 mm. Most polyps (N = 48, 88.9 %) were sessile polyps. The median follow-up time was 10.8 (range 0.5–120) months. Most lesions were located in the second part of the duodenum (N = 41, 75.9 %). Adenomas were found in 46 (85.2 %) of lesions overall. Tubular adenoma was the most common histology type found in 33 cases (71.7 %). Tubulovillous and villous were found in 12 (26.1 %) and 1 (2.2 %) cases, respectively. On follow-up, 50 (92.6 %) achieved complete resection with tumor free margins post resection. The 30-day risk of major complications was 5.6 % (N = 3), 1 with perforation and 2 with delayed bleeding. Recurrence was documented in 29 % (N = 16) of patients. All recurrences were managed endoscopically except for one patient who required surgery. The recurrence rate was higher for patients who had villous component in their adenomas compared to those with tubular alone (p = 0.03).

Conclusions

Endoscopic resection is effective for treating large duodenal adenomas. Adenomas with villous features are more likely to recur. Almost all recurrences can be managed endoscopically.     

Transanal Endoscopic Microsurgery (TEM) Facilitated by Video-Assistance and Anal Insertion of a Single-Incision Laparoscopic Surgery (SILS®)-Port: Preliminary Experience

Objective

Transanal endoscopic microsurgery (TEM) is an established method for the resection of benign and early malignant rectal lesions. Very recently, TEM via an anally inserted single incision laparoscopic surgery (SILS^®)-port has been proposed to overcome remaining obstacles of the classical TEM equipment.

Methods

Nine patients with a total of 12 benign or early stage malignant rectal polyps were operated using the SILS^®-port for TEM. Patients’ and polyps’ characteristics, perioperative and postoperative complications, as well as operating and hospitalization time were recorded.

Results

All 12 polyps (ten low-grade adenoma, one high-grade adenoma, one pT₂ carcinoma [preoperatively staged as T₁]) were resected. Local full-thickness bowel wall resection was performed for three lesions and submucosal resection for nine lesions. Median operating time was 64 (range 30–180) min. No conversion to laparoscopic or open techniques was necessary. The median maximum diameter of the specimen was 25 (range 3–60) mm, fragmentation of polyps was avoidable in 11 of 12 (92 %) lesions, and resection margins were histologically clear in 11 of 12 (92 %) polyps. Only one patient, in whom three lesions were resected, experienced a complication as postoperative hemorrhage. No mortality occurred. Median hospitalization time was four (range 1–14) days.

Conclusions

SILS^®-TEM is a feasible and safe method, providing numerous advantages in application, handling, and economy compared with the classical TEM technique. SILS^®-TEM might become a promising alternative to classical TEM. Randomized, controlled trials comparing safety and efficacy of both instrumental settings will be needed in the future.     

Colorectal polyps: when should we tattoo?

Background

Current guidelines recommend tattooing of suspicious-looking lesions at colonoscopy without a reference to the size of the polyp. However, the endoscopist has to make a judgement as to which lesion may be malignant and require future localisation based on the appearance and size of the polyp. The aim of this study was to determine the relationship between endoscopic polyp size and invasive colorectal cancer so as to inform tattooing practice for patients taking part in the national bowel cancer screening programme (BCSP).

Methods

Data of BCSP patients who had undergone a polypectomy between October 2008 and October 2010 were collected from a prospectively maintained hospital endoscopic database. Histology data were obtained from electronic patient records.

Results

A total of 165 patients had undergone 269 polypectomies. Their median age was 66?years and 66?% were men. The mean endoscopic polyp size was 10.7?mm (SD?=?±8?mm). Histologically, 81?% were neoplastic with 95?% showing low-grade and 5?% high-grade dysplasia. Eight patients were found to have invasive malignancy within their polyp. The risk of invasive malignancy within a polyp was 0.7?% (1/143) when the endoscopic polyp size was <10?mm; the risk increased to 2.4?% (2/83) when the polyp size was 10–19?mm and 13?% (5/40) when the polyp was >20?mm. This trend was statistically significant (p?=?0.001). About 23?% of the patients had the site of their polyp tattooed; the mean size of the tattooed polyps was 21?mm (range?=?15–50?mm). Consequently, 25?% of malignant polyps and 63?% of polyps with high-grade dysplasia were not tattooed.

Conclusion

The risk of polyp cancer among BCSP patients increases significantly when the endoscopic polyp size is ≥10?mm. We recommend that all polyps ≥10?mm be tattooed.     

Snaring large serrated polyps

Background

Serrated polyps of the large bowel are potentially premalignant, difficult to see, but important to remove. Few studies describe the technique or outcomes of serrated polypectomy. We sought to present outcomes of a series of polypectomies of large serrated polyps in comparison to a series of endoscopic resections of large adenomas.

Methods

This retrospective, comparative, single endoscopist study was performed in an outpatient colonoscopy department of a tertiary referral medical center. Patients had outpatient colonoscopy where a large (≥2 cm) serrated polyp or adenoma was removed. Outcomes were completeness of excision and complications of polypectomy. A database of endoscopic polypectomies was reviewed. Polypectomy of large serrated polyps was compared with polypectomy of large adenomas.

Results

There were 132 large serrated polyps in 112 patients and 563 adenomas in 428 patients. More serrated polyps were right sided (120 of 130, 92.3 %, vs. 379 of 563, 67 %) (p < 0.0001). The serrated polyps were smaller than the adenomas (mean 25.5 ± 7.9 mm standard deviation) versus 36.8 ± 16.9 mm standard deviation (p < 0.001). There were four complications of serrated polypectomy in four patients (4 % of polyps, 5 % of patients): three postpolypectomy bleeds and one postpolypectomy syndrome. There were 33 complications of adenoma removal (31 postpolypectomy bleeding and two postpolypectomy syndrome) (6.9 % of polyps, p = 0.376, 8.4 % of patients, p = 0.371). On follow-up, 36 of 51 patients (71 %) with serrated polyps had metachronous lesions compared to 133 of 298 patients (45 %) with adenomas (p < 0.0001). There were fewer residual polyps in the serrated group (4 of 47 vs. 64 of 298, p = 0.001).

Conclusions

Removal of large serrated colorectal polyps is no more complicated than polypectomy of similarly sized adenomas. However, large serrated polyps have a higher rate of metachronous polyps than similarly sized adenomas and surveillance should be adapted to reflect these findings.     

Endoscopic piecemeal resection of large colorectal polyps with long-term followup

Background

Colonoscopic removal of large colorectal polyps is challenging and requires advanced endoscopic technique. Successful endoscopic management not only avoids the morbidity of surgery but also risks perforation, hemorrhage, and recurrence.

Methods

This study is a retrospective review of a prospectively maintained database of all patients undergoing cautery snare piecemeal polypectomy for large colorectal polyps by a single operator over 20 years with long-term followup.

Results

231 patients underwent 269 piecemeal polypectomies over a 20 year period. The complication rate was 4.3 %. Malignancy was identified in 25 (10.8 %) of patients. Local recurrences occurred in 24 % of patients with benign adenomas. The vast majority of these were managed with repeat endoscopy. Overall, benign large polyps were managed successfully endoscopically in 94.4 % of patients.

Conclusions

Piecemeal polypectomy is effective and safe for the management of large colorectal polyps. With long-term followup, the recurrence rate is appreciable, but most recurrences can be successfully managed with further endoscopic intervention. More complex techniques such as endoscopic submucosal dissection are usually unnecessary.     

Management of the colorectal polyp referred for resection: A case-matched comparison of advanced endoscopic surgery and laparoscopic colectomy

Background

Colonoscopy is the gold standard for colorectal screening and surveillance. Advanced endoscopic polypectomy techniques such as endoscopic submucosal dissection (ESD) have been introduced to remove large colorectal polyps. Our aim was to compare the outcomes of patients who underwent ESD with those of who underwent laparoscopic colectomy for benign colorectal polyps.

Efficacy of endoscopic mucosal resection using a dual-channel endoscope compared with endoscopic submucosal dissection in the treatment of rectal neuroendocrine tumors

Background

Conventional endoscopic mucosal resection (EMR) for removing rectal neuroendocrine tumors (NETs) has a high risk of incomplete removal because of submucosal tumor involvement. EMR using a dual-channel endoscope (EMR-D) may be a safe and effective method for resection of polyps in the gastrointestinal tract. The efficacy of EMR-D in the treatment of rectal NET has not been evaluated thoroughly.

Methods

From January 2005 to September 2011, a total of 70 consecutive patients who received EMR-D or endoscopic submucosal dissection (ESD) to treat a rectal NET <16 mm in diameter were included to compare EMR-D with ESD for the treatment of rectal NETs.

Results

The EMR-D group contained 44 patients and the ESD group contained 26 patients. The endoscopic complete resection rate did not differ significantly between the EMR-D and ESD groups (100 % for each). The histological complete resection rate also did not differ significantly between groups (86.3 vs. 88.4 %). The procedure time was shorter for the EMR-D group than for the ESD group (9.75 ± 7.11 vs. 22.38 ± 7.56 min, P < 0.001). Minor bleeding occurred in 1 EMR-D patient and in 3 ESD patients (2.3 vs. 7.6 %). There was no perforation after EMR-D or ESD.

Conclusions

Compared with ESD, EMR-D is technically simple, minimally invasive, and safe for treating small rectal NETs contained within the submucosa. EMR-D can be considered an effective and safe resection method for rectal NETs <16 mm in diameter without metastasis.     

TEMS: results of a specialist centre

Introduction

Transanal endoscopic microsurgery (TEMS) is becoming more widespread due to the increasing body of evidence to support its role. Previous published data has reported recurrence rates in excess of 10 % for benign polyps after TEMS.

Methods

Bradford Royal Infirmary is a tertiary referral centre for TEMS and early rectal cancer in the UK. Data for all TEMS operations were entered into a prospective database over a 7-year period. Demographic data, complications and recurrence rates were recorded. Both benign adenomas and malignant lesions were included.

Results

A total of 164 patients (65 % male), with a mean age of 68 years were included; 114 (70 %) of the lesions resected were benign adenomas, and 50 (30 %) were malignant lesions. Median polyp size was 4 (range 0.6–14.5) cm. Mean length of operation was 55 (range 10–120) min. There were no recurrences in any patients with a benign adenoma resected; two patients with malignant lesions developed recurrences. Three intra-operative complications were recorded, two rectal perforations (repaired primarily, one requiring defunctioning stoma), and a further patient suffered a blood loss of >300 ml requiring transfusion. Six patients developed strictures requiring dilation either endoscopically or under anaesthetic in the post-operative period.

Conclusions

We have demonstrated that TEMS procedures performed in a specialist centre provide low rates of both recurrence and complication. Within a specialist centre, TEMS surgery should be offered to all patients for rectal lesions, both benign and malignant, that are amenable to TEMS.     

Adenomas of the Ampulla of Vater: A comparison of Outcomes of Operative and Endoscopic Resections

Background

Data comparing operative and endoscopic resection of adenomas of the ampulla of Vater are limited. Our aims were to evaluate and compare the long-term results and outcomes of endoscopic and operative resections of benign tumors of the ampulla of Vater as well as to determine which features of benign periampullary neoplasms would predict recurrence or failure of endoscopic therapy and therefore need for operative treatment.

Methods

Retrospective review of all patients treated for adenomas of ampulla of Vater at our institution from 1994 to 2009.

Results

Over a 15-year span, 180 patients (mean age 59 years) were treated for benign adenomas of the ampulla of Vater with a mean follow-up of 4.4 years. Obstructive jaundice was more common in the operative resection group (p?=?0.006). The adenomas were tubular in 83 patients (44 %), tubulovillous in 77 (45 %) and villous in 20 (11 %). Endoscopic resection alone was performed in 130 patients (78 %). Operative resection was performed in 50 patients (28 %), with pancreatoduodenectomy in 40, transduodenal local resection in 9, and pancreas-sparing total duodenectomy in 1. Nine patients who underwent endoscopic resection initially were endoscopic treatment failures. Fifty-eight percent of endoscopically treated patients required one endoscopic resection, while 58 (42 %) required two or more endoscopic resections (range 2–8). Patients who underwent operative resection had larger tumors with a mean size of 3.7?±?2.8 versus 1.8?±?1.5 cm in those treated by endoscopic resection (p?p?=?0.02). Intraductal extension and ulceration had no effect on recurrence if completely resected endoscopically (p?=?0.41 and p?=?0.98, respectively). Postoperative complications occurred in 58 % of patients, and post-endoscopic complications in 29 % (p?p?=?0.006); 4 % of recurrences had invasive carcinomas. When comparing patients who underwent local resections only (endoscopic and operative), there was no difference in the recurrence rate between endoscopic resection and operative transduodenal resection (32 versus 33 %; p?=?0.49). The need for two or more endoscopic resections for complete tumor removal was associated with 13-fold greater risk of recurrence (p?Conclusion There is no significant difference between endoscopic and local operative resections of benign adenomas of ampulla of Vater; recurrences are more common when two or more endoscopic resections are required for complete tumor removal. Appropriate adenomas for endoscopic resection included tumors <3.6 cm that do not extend far enough intraductally (on EUS) to preclude an endoscopic snare ampullectomy.     

Factors affecting the treatment of multiple colorectal adenomas

Background

Currently, no guidelines exist for the treatment of patients with multiple colorectal adenomas (MCRAs) (>10 but <100 synchronous nondiminutive polyps of the large bowel). This retrospective study aimed to investigate the clinical and molecular factors related to different treatments for MCRAs.

Methods

Patients with MCRAs were consecutively enrolled from January 2003 to June 2011. Sequencing of their APC and MutYH genes was performed. The clinical, molecular, and family histories of the patients were collected using the Progeny database. The patient treatments were divided into three groups of increasing clinical weight: endoscopic polypectomy, segmental resection, and total colectomy. A logistic regression analysis of clinicomolecular factors related to different treatment options was performed.

Results

The study comprised 80 patients (32 women, 40 %) with a median age of 53 years (range 13–74 years). The median number of polyps was 33 (range 10–90).The cases included 62 diffuse polyposis, 18 segmental polyposis coli and synchronous colorectal carcinomas (CRC; 34 cases, 43%). The pathogenetic mutations were biallelic MutYH (n = 19, 24 %) and APC (n = 4, 5 %). The mean follow-up period was 74 months (median 43 months, range 1–468 months). Endoscopic polypectomy was performed in 25 cases (31 %), segmental resection in 16 cases (20 %), and total colectomy in 39 cases (49 %). The logistics regression analysis, considering all the patients, showed that the number of polyps, the presence of CRC, and mutation were correlated with more intensive treatment. For the patients without CRC, only the number of polyps was correlated with the severity of the treatment (p > 0.0166). “On the ROC (receiver operating characteristic) curve, 25 was the number of polyps that best discriminated between surgical and endoscopic therapy.

Conclusions

The majority of patients with MCRAs undergo surgery. For patients without CRC, only the number of polyps, and not the presence of a disease-causing mutation, is correlated with increased heaviness of treatment. Patients with more than 25 polyps are more likely to undergo a surgical resection.     

Colonic Endolumenal Stenting Devices and Elective Surgery Versus Emergency Subtotal/Total Colectomy in the Management of Malignant Obstructed Left Colon Carcinoma

Background

Traditionally, left-sided acute bowel obstruction is treated by a staged procedure because immediate resection and anastomosis in a massive distended and unprepared colon carries a high complication rate. Total abdominal colectomy is a one-stage procedure that will remove synchronous proximal neoplasms, reduce the risk of subsequent metachronous tumor, and avoid stoma. Colorectal stents are being used for palliation and as a bridge to surgery in obstructing colorectal carcinoma, making elective surgery straightforward, enabling easily mobilization and resection of the colon with a possible trend toward reduction in postoperative complication rates compared to emergency surgery. The purpose of this work was to compare the procedures of endoscopic stenting followed by elective colectomy versus total abdominal colectomy and ileorectal anastomosis in the management of acute obstructed carcinoma of the left colon as regards feasibility, safety, and clinical outcomes

Methods

From January 2009 through May 2012, 60 patients were randomized to either emergency stenting followed by elective resection (ESER group) or total abdominal colectomy and ileorectal anastomosis (TACIR group).

Results

Twenty nine patients (96.7 %) had successful stenting and underwent elective surgery 7–10 days later (ESER group). Postoperative complications were encountered in four patients in the ESER group compared to 15 patients in the TACIR group (p?=?0.012). Anastomotic leakage was encountered in one patient (3.3 %) in the TACIR group. There were no operative mortalities in the present study. Within the first three postoperative months, the TACIR group patients had significantly more frequent bowel motions per day compared to the ESER group patients although (p?=?0.013). In both study groups, the follow-up duration ranged from 6 to 40 months with a median of 18 months. Recurrent disease was encountered in five patients (17.2 %) in the ESER group compared to four patients (13.3 %) in the TACIR group (p?=?0.228).

Conclusion

Both techniques are feasible, safe, and produce comparable oncological outcomes. However, endoscopic stenting followed by elective resection was associated with significantly less postoperative complications and bowel motions per day.     

Endoscopic resection of ampullary neoplasms: a single-center experience

Background

An ampullary tumor, whether malignant or not, must be completely resected. A benign adenoma has the potential for malignant transformation. Currently, endoscopic papillectomy with curative intent is increasingly performed for benign papillary tumors. This study aimed to evaluate the outcome of endoscopic papillectomy performed for ampullary tumors at a single center.

Methods

From July 2003 to June 2008, 22 patients with a diagnosis of ampullary tumors determined by endoscopic retrograde cholangiopancreatography (ERCP) were treated using endoscopic resection of the tumors. Endoscopic resection was performed in a radical fashion analogous to polypectomy for colon adenomas.

Results

The 22 patients (9 men and 13 women) had an average age of 58 ± 14 years (range, 19–85 years). The median follow-up period was 169 days (range, 14–903 days). The papillary lesions ranged in size from 8 to 33 mm. The rate of concordance between the endoscopic forceps biopsy and the resected specimen was 50% (9/18) according to the Vienna classification. Complete endoscopic resections were performed for 17 of 22 the cases (77.3%). The median length of hospital stay was 4 days (range, 2–11 days), and there were no readmissions for complications. Endoscopic complications occurred for 5 (22.7%) of the 22 patients: postpapillectomy pancreatitis for 4 patients, bleeding for 1 patient, and retroperitoneal perforation for 1 patient. However, no procedure-related deaths occurred. After the papillectomy, a pathologically incomplete resection was noted in 10 cases, including submucosal invasion of an adenocarcinoma with lateral clean resection margins.

Conclusions

The findings showed that an endoscopic papillectomy was safe and effective for benign-appearing adenomas with negative biopsy results for a malignancy. This procedure should be considered as the initial intervention in such cases. The decision whether to perform a pancreatoduodenectomy can be made after the pathology report of the resected specimen is obtained from the endoscopic papillectomy.     

Endoscopic papillectomy,single-centre experience

Background

Endoscopic removal of benign tumours of papilla is increasing. Our aim was to evaluate the outcome of endoscopic resection of papillary tumours.

Methods

In the years 2000–2012, 61 papillectomies were performed in Helsinki University Central Hospital. The cases were analysed retrospectively.

Results

There were 35 patients with benign tumour of papilla without familial adenomatous polyposis (FAP), 16 patients with FAP and 10 patients with ampullary cancer. Jaundice and bile duct dilation were risk factors for malignancy (p < 0.001). In benign tumours, the recurrence rate was 25.5 %. In 5/51 benign tumour cases (9.8 %), a pancreaticoduodenectomy was performed. The remaining cases were treated endoscopically. Neither tumour size, resection in one piece or piecemeal technique, nor coagulation of resection margins had an effect on the development of residual tumour. The total complication rate was 24.6 %. Pancreatitis developed in six patients (9.8 %, 3 mild and 3 moderate). In benign tumour cases, pancreatic stent decreased pancreatitis rate (p = 0.045). In cases where only a pancreatic sphincterotomy was performed, the risk of pancreatitis was high 4/7 (57 %). Bleeding was the most common complication (18 %). Only one patient was operated due to complication, a post-papillectomy bleeding. In six out of seven non-operated cancer patients, the disease progressed.

Conclusion

Endoscopic papillectomy is an effective procedure for treating benign papillary tumours. Jaundice and bile duct dilation are more common in malignant tumours. Pancreatic stent decreases the risk of post-papillectomy pancreatitis. Pancreatic sphincterotomy without stenting carries a high risk of pancreatitis. For papillary cancer, surgery is recommended.     

Percutaneous ultrasound-guided bowel wall core biopsy: a nonconventional way of diagnosis of gastrointestinal lesions

Background

Patients with gastrointestinal lesions; unsuccessfully diagnosed by endoscopy are challenging to gastroenterologists. We aimed to study the role and safety of ultrasound, its guided biopsy in visualizing and diagnosing these bowel lesions.

Patients and methods

Sixty-three patients with endoscopically and/or imaging documented gastrointestinal lesions were prospectively enrolled. All had detailed high-frequency (5–8 MHz) transabdominal bowel ultrasound examination to identify, localize and characterize the lesions, which were further biopsied using ultrasound guidance.

Results

Lesions were histo-pathologically diagnosed; 57 (90.5 %) were malignant and 6 (9.5 %) were benign. Ultrasound was able to localize all the lesions. They were characterized as focal in 12 (19.1 %) and diffuse bowel wall involvement in 51 (80.9 %) patients. Ultrasound was capable of suggesting the nature of diffuse bowel involvement whether benign or malignant in 94.1 %. Comparing malignant diffuse bowel lesions and benign ones; the former had greater mean wall thickness (2.2 vs. 1.1 cm), loss of layering pattern (87.2 vs. 50 %), asymmetrical pattern of involvement (78.7 vs. 0 %), short length of affected segment (87.2 vs. 50 %) and paucity of perilesional findings. Ultrasound-guided core biopsy was diagnostic in 60 (95.2 %) patients with no reported complications. Diagnostic laparotomy was resorted to in 3 (4.8 %). Ultrasound-guided bowel wall core biopsy had sensitivity of 98.2 % in diagnosing malignant lesions and specificity of 66.6 % in benign lesions.

Conclusion

High-frequency transabdominal ultrasound and ultrasound-guided core biopsy of bowel lesions are potentially safe and effective diagnostic methods in select gastrointestinal lesions whenever conventional endoscopic diagnosis was unsuccessful, thus avoiding unnecessary diagnostic surgical procedures.     

Learning Curve of Transumbilical Single Incision Laparoscopic Cholecystectomy (SILS): A Preliminary Study of 80 Selected Patients with Benign Gallbladder Diseases

Background

Transumbilical single incision laparoscopic surgery (SILS) is a new laparoscopic procedure in which only one transumbilical incision is made, demonstrated as a scarless procedure. Here we report a single-center preliminary experience of transumbilical single incision laparoscopic cholecystectomy (SILC) in the treatment of benign gallbladder diseases, defining a single surgeon’s learning curve.

Methods

A total of 80 patients underwent SILC successfully by a single experienced laparoscopic surgeon. The operation was performed following the routine LC procedure. Then the perioperative demographics were recorded and the operative time was used to define the learning curve.

Results

The study group included 27 male and 53 female patients with gallstones (56 cases), cholesterol polyps (16 cases), an adenomatous polyp (3 cases), adenomyomatosis (1 case), or complex diseases (4 cases), and all consented to undergo SILC. No patient was converted to normal LC or open surgery. There were no perioperative port-related or surgical complications. The average operative time was 46.9 ± 14.6 min. The average postoperative hospital stay was 1.8 ± 1.3 days. The learning curve of the SILC procedures for this series of selected patients confirmed that SILC is a feasible, safe, and effective approach to the treatment of benign gallbladder diseases.

Conclusions

For experienced laparoscopic surgeons, SILC is an easy and safe procedure. Patients benefit from milder pain, a lower incidence of port-related complications, better cosmesis, and fast recovery. The SILC procedure may become another option for the treatment of benign gallbladder diseases for selected patients.     

Should all endoscopically excised rectal polyps be tattooed? A plea for localization

Background

More than 5–8?% of endoscopically removed rectal polyps presumed to be benign contain invasive carcinoma. Tattooing has been advocated for follow-up localization of the resection site. Despite proven benefits, the authors propose that tattooing is not routinely performed when benign-appearing rectal polyps are endoscopically excised, thereby confounding management when invasive cancer is found. The secondary goal of the study was to determine the frequency of localization, polyp characteristics, and accuracy of predicting malignant potential at the authors’ institution.

Methods

All patients with rectal neoplasia discovered during endoscopic polypectomy from 1 January 2003 to 1 August 2010 were retrospectively identified from Temple University Hospital’s Tumor Registry. Demographic and clinical data were extracted from medical records including polyp size, gross appearance, pathology, resection margins, location based on preoperative colonoscopy, initial removal technique, tattoo performance, and ensuing procedures.

Results

During the study period, 49 patients had colonoscopic excision of presumed benign rectal polyps with ensuing diagnosis of neoplasia in the specimen. The malignant histology included adenocarcinoma (n?=?5), carcinoma in situ (n?=?21), carcinoid (n?=?22), and composite carcinoid (n?=?1). Only two polyps were tattooed at the initial polypectomy. Three polyps were “suspicious for malignancy.” None of the suspicious polyps were tattooed. One of the suspicious lesions was an adenocarcinoma, and the remaining two were benign. The distance from the anal verge was noted in only seven patients. The predominant excision technique was hot snare polypectomy (n?=?29). None of the incomplete polyp excisions for 15 patients were “suspicious for malignancy” or tattooed. Several strategies were used to manage incomplete resections including surveillance (40?%), repeat colonoscopic polypectomy (27?%), and surgery (33?%).

Conclusions

Most malignant rectal polyps are neither diagnosed nor tattooed at initial colonoscopy. Moreover, the distance of the polyp from the anal verge is rarely measured, and gross characteristics are not well described. Tattooing of all endoscopically excised rectal polypectomy sites would avoid confounding of subsequent identification and management.     

The diagnostic accuracy of transabdominal ultrasonography needs to be considered when managing gallbladder polyps

Background

Transabdominal ultrasonography (TAUS) is the most commonly used modality to diagnose gallbladder (GB) disease. GB polyps are reported in 1–5.6 % of TAUS studies. Histopathologic studies suggest that there is a relationship between GB polyps and GB cancer. Previous literature suggests GB polyps reported on TAUS do not correlate well with histological findings. There have been recent advances in TAUS technology. We hypothesize the recent advances in TAUS technology have improved the accuracy of TAUS for diagnosing GB polyps.

Methods

Radiology and pathology databases at our tertiary care center were retrospectively searched between January 1, 2000, and December 31, 2010. Ultrasound reports that suggested a GB polyp was present on TAUS were correlated to histopathology in cases where a cholecystectomy was performed. The pathology reports where a GB polyp was found were correlated with preoperative TAUS reports.

Results

There were 102,740 TAUS reports referring to the GB, of which 6,612 (6.4 %) contained search terms suggesting a GB polyp was present. There were 13,278 cholecystectomy pathology reports, of which 159 (1.2 %) included a diagnosis of GB polyp. TAUS detected only 50 % of the polyps identified on histopathology. The sensitivity and specificity of TAUS for diagnosing GB polyps were 50.0 and 98.3 %, respectively. The positive and negative predictive values were 10.5 and 99.8 %.

Conclusions

Despite improvement in TAUS technology, the accuracy for GB polyps remains poor. This needs to be considered when managing patients with TAUS-detected GB polyps. We recommend that the decision to operate on TAUS-detected GB polyps be largely based on symptoms, and following GB polyps with TAUS should be discouraged.     

Differential diagnosis between gallbladder adenomas and cholesterol polyps on contrast-enhanced harmonic endoscopic ultrasonography

Background

Differential diagnosis between gallbladder (GB) adenomas and cholesterol polyps based on ultrasonography or endoscopic ultrasonography (EUS) is challenging because they have similar echogenicity and morphology. We evaluated the usefulness of contrast-enhanced harmonic EUS (CEH-EUS) for differentiating between GB adenomas and cholesterol polyps.

Methods

Between June 2010 and December 2011, a total of 87 patients with GB polyps who underwent a CEH-EUS were reviewed retrospectively.

Results

Of the 87 patients, 57 had a cholecystectomy. Of these, 34 patients were diagnosed with adenoma, cholesterol polyp, adenocarcinoma, or adenomyomatosis pathology. The remaining 23 patients were not diagnosed with GB polyps because their lesions separated from the GB mucosal layer during pathological sampling. On CEH-EUS, homogeneous and heterogeneous enhancement was shown in 6 and 2 patients with adenoma and in 4 and 8 patients with cholesterol polyps, respectively. Sensitivity and specificity of CEH-EUS for differential diagnosis of GB adenomas from cholesterol polyps based on the enhancement pattern were 75.0 and 66.6 %, respectively.

Conclusion

CEH-EUS might be useful for distinguishing GB adenomas and cholesterol polyps based on enhancement patterns. However, an additional technique such as quantitative perfusion analysis is necessary because visual assessment of CEH-EUS images is subjective.     

Endoscopic resection as the first-line treatment for early colorectal cancer: comparison with surgery

Introduction

Endoscopic resection has emerged as an alternative therapeutic option for selected cases of early colorectal cancer. However, even now, few data are available on the comparative effectiveness of endoscopic versus surgical resection of early colorectal cancer. The aim of our study was to compare the clinical outcomes in patients with early colorectal cancer who underwent endoscopic resection and those who underwent surgical resection.

Methods

292 early colorectal cancer lesions in 287 patients who were treated with either endoscopic resection or colorectal surgery (open or laparoscopic colorectal resection) between January 2005 and December 2010 were retrospectively analyzed. After excluding 54 deep submucosal lesions [and/or tumor budding (Grade 2 or 3)], a total of 168 lesions with mucosal/superficial submucosal invasion were treated by endoscopic resection, and 70 lesions with mucosal/superficial submucosal invasion were treated by colorectal surgery.

Results

In the endoscopic resection group, the en bloc resection rate and the complete resection rate were 91.1 and 91.1 %, respectively. In the colorectal surgery group, both the en bloc resection rate and the curative resection rate were 100 %. However, using Log rank test in Kaplan–Meier curve, no significant difference in recurrence rate (including metachronous cancer) during the median follow-up period of 37 months (range, 6–98 months) was observed between the two groups (p = 0.647). In addition, a similar morbidity rate was observed for endoscopic resection compared with surgery (5.4 vs. 5.7 %, p = 0.760). A significantly shorter hospital stay was observed in the endoscopic resection group than colorectal surgery group [median 2 days (range, 2–29) vs. median 10 days (range, 7–37), p < 0.001).

Conclusion

We suggest that endoscopic resection, being equally effective but less invasive than surgery, can be the first-line treatment for well selected early colorectal cancer.