Hybrid Laparoendoscopic Approaches to Endoscopically Unresectable Colon Polyps

Abstract

Secondary prevention of colorectal cancer relies on effective screening through colonoscopy and polypectomy. Resection of some polyps can present technical challenges particularly when polyps are large, flat, or behind colonic folds. Laparoscopy as an adjunct to endoscopy can aid in removing difficult colonic polyps without subjecting patients to radical segmental colectomy. Hybrid laparoendoscopic techniques are increasingly reported in literature as alternatives to segmental colectomy for the treatment of polyps that have a high likelihood of being benign. Laparoscopic-assisted colonoscopic polypectomy is the most frequently utilized technique; it harnesses the power of laparoscopy to aid endoscopic polypectomy by flattening folds, mobilizing flexures, and providing retraction. Colonoscopy-assisted laparoscopic wedge and transluminal resection are often reported in older studies and use the visualization provided by intraoperative colonoscopy to guide colonic resection that is limited to the area of the polyp. Laparoscopic-assisted endoscopic full-thickness resection (EFTR) is a relatively recent technique that provides laparoscopic monitoring of EFTR of polyp as well as endoscopic closure of the ensuing defect. Minimally invasive segmental colectomy based on oncologic principles should be utilized when none of the previous techniques are suitable or when malignancy is strongly suspected. The combined use of laparoscopy and endoscopy can expand the endoscopist's armamentarium when dealing with the most challenging polyps, while serving the patients' best interest by limiting the extent of colon resection.

Laparoscopic colorectal surgery for colorectal polyps: experience of ten years

“…There are many modalities for treatment of difficult polyps. With improved technical tools and techniques endoscopic polyp removal still remains the first line choice for treatment (13). However, even after a complete endoscopic resection of a polyp, the residual malignant disease (in the colon wall or regional lymph nodes) can be as high as 39% in malignant polyps with unfavorable histology (14).…”

“…However, even after a complete endoscopic resection of a polyp, the residual malignant disease (in the colon wall or regional lymph nodes) can be as high as 39% in malignant polyps with unfavorable histology (14). So the risks and benefits of laparoscopic surgery versus endoscopic treatment alone favour the laparoscopic or hybrid laparoendoscopic approach (13). According to some authors, majority of patients with difficult polyps will undergo segmental colon resection even if the polyp appears completely benign (6).…”

“…It is difficult to reliably predict which patients would have invasive cancer after removal. In general, polyps smaller than 2 cm, soft in consistency are nonulcerated, and demonstrate regular pit and vascular patterns are more likely to be benign (13). The association between the increasing polyp size and the possibility of harbouring cancer is well known.…”

“…These disadvantages are overcome by HALS or various combinations of laparoscopic-endoscopic procedures, including laparoscopically-assisted endoscopic polypectomy, endoscopically-assisted wedge or anatomical resections, and, finally, an intraoperative tumour location by colonoscopy for achieving oncological resection margins in laparoscopic curative resections. All of these combinations allow a minimally invasive approach for lesions that would otherwise necessitate a laparotomy (6,13). In the dawn of laparoscopy, Fleshman with co-authors recommended performing a mini laparotomy for colonic polyps (24).…”

Combined endolaparoscopic surgery for colon polyps – a video vignette

“… introduced a combined endoscopic and laparoscopic surgical approach of segmental resection of the bowel for benign polyps which were not suitable for colonoscopic resection. Subsequently, several authors have also described this alternative approach .…”