ACTA MEDICA LITUANICA. 2017. Vol. 24. No. 1. P. 18–24 © Lietuvos mokslų akademija, 2017 Laparoscopic colorectal for colorectal polyps: experience of ten years

Audrius Dulskas1, Background. or its combination with is the next step for “difficult” polyps. The purpose of the paper was to Žygimantas Kuliešius1, review the outcomes of the laparoscopic approach to the management of “difficult” colorectal polyps. Narimantas E. Samalavičius1, 2 Materials and methods. From 2006 to 2016, 58 patients who under- went laparoscopic treatment for “difficult” polyps that could not be treat- 1 Department of Abdominal and ed by endoscopy at the National Cancer Institute, Lithuania, were includ- General Surgery and Oncology, ed. The demographic data, the type of surgery, length of post-operative National Cancer Institute, stay, complications, and final pathology were reviewed prospectively. Vilnius, Lithuania Results. The mean patient was 65.9 ± 8.9 years of age. Laparoscop- ic mobilization of the colonic segment and colotomy with removal of 2 Clinic of Internal Diseases, Family Medicine and the polyp was performed in 15 (25.9%) patients, laparoscopic segmental Oncology, Faculty of Medicine, in 41 (70.7%) cases: anterior rectal resection with par- Vilnius University tial total mesorectal excision in 18 (31.0%), sigmoid resection in nine Vilnius, Lithuania (15.5%), left hemicolectomy in seven (12.1%), right hemicolectomies in two (3.4%), ileocecal resection in two (3.4%), resection of transverse colon in two (3.4%), and sigmoid resection with transanal retrieval of specimen in one (1.7%). Two patients (3.4%) underwent laparoscopic- assisted endoscopic polypectomy. The mean post-operative hospital stay was 5.7 ± 2.4 days. There were four complications (6.9%). All pa- tients recovered after conservative treatment. The mean polyp size was 3.5 ± 1.9 cm. Final histopathology revealed hyperplastic polyps (n = 2), tubular adenoma (n = 9), tubulovillous adenoma (n = 31), carcinoma in situ (n = 12), and invasive cancer (n = 4). Conclusions. For the management of endoscopically unresectable polyps, laparoscopic surgery is currently the technique of choice.

Keywords: laparoscopic surgery, , , endo- scopic polypectomy, difficult polyp

INTRODUCTION in 2013. For developed countries, it ranked sec- ond for incidence and mortality, and in developing Globally, (CRC) ranked third countries it ranked fourth for both incidence and for cancer incidence and fourth for cancer death mortality (1). Adenomatous colorectal polyps have Correspondence to: Audrius Dulskas, Department of Abdom- a malignant potential well described in Vogelstein’s inal and General Surgery and Oncology, National Cancer In- adenoma-carcinoma sequence (2, 3). CRC preven- stitute, 1 Santariškių St, Vilnius LT-08406, Lithuania. E-mail: tion depends largely on the detection and removal [email protected] of adenomatous polyps. There are several methods Laparoscopic surgery for colorectal polyps 19 to remove polyps by using either endoscopic, MATERIALS AND METHODS surgical, or combined methods (4). Patients who have known adenomas and refuse removal devel- From April 2006 to August 2016, over 1,500 endo- op colon cancer at the rate of 4% after 5 years and scopic polypectomies were performed at the De- 14% after 10 years, which is higher than that of partment of Abdominal and General Surgery and the general population (5). Endoscopic removal of Oncology of the National Cancer Institute, Lith- polyps has been shown to arrest subsequent de- uania. During this period more than 450 lapa- velopment of carcinoma (6). roscopic colorectal operations were performed. Most of the polyps can be removed endoscop- A prospectively maintained database was used to ically using well-established principles. However, identify all patients who underwent laparoscopic there is a group of polyps that are challenging polypectomy for polyps that could not be removed even to the most advanced endoscopist. These so- by endoscopy due to size, location, and/or risk of called “difficult polyps” comprise about 10–15% complications. The exact reasons why the refer- of all polyps (7). They may be difficult to remove ring endoscopist could not achieve endoscopic because of their size, configuration, and location polypectomy were not avail­able. All consenting in the colon. For example, large sessile polyps or patients aged 18 years and older with histologi- polyps spanning two folds present technical chal- cally confirmed adenoma were included in this lenges (8). Criteria for sessile polyps that can be study. Invasive carcinoma was the criterion for ex- managed by endoscopic mucosal resection (EMR) clusion. The demographic data, past surgical his- is continually evolving with the majority of such tory, the type of surgery, length of post-operative lesions being safely and effectively treated through stay, complications, final pathology, and the stage endoscopy (9). Repeat for endoscop- of cancer (if present) were analysed prospectively. ic resection at expert centres is an appropriate next step and can often result in successful en- The surgical technique doscopic management. However, no matter how All laparoscopic procedures were performed by skilled the endoscopist or how many different me- skilled surgeons in the department. Preopera- thods are used, there remains a subset of polyps tive polyp marking was used if the polyp was not that cannot be removed completely using the en- in the cecal area. For marking in doscopic approach alone. For these polyps surgi- the morning of the operation was used. Pre-opera- cal treatment is usually the next step. The majority tive bowel preparation the day before surgery and of patients with difficult polyps will undergo seg- intravenous broad-spectrum antibiotics (Cefurox- mental colon resection even if the polyp appears ime and Metronidazole) on induction anaesthesia completely benign. Some patients may historical- were routine. For hand-assisted laparoscopic sur- ly undergo a and polypectomy for only gery (HALS) a 6 cm umbilical incision was made benign polyps (10). There are, however, hybrid for the hand-port insertion. Trocars were placed methods that combine endoluminal and endocav- according to the type of procedure. If a bowel re- itary approaches to offer less radical and minimal- section was performed, the vascular pedicles were ly invasive resections for the benign-appearing initially isolated by a medial to lateral approach, difficult polyp. The use of laparoscopy assistance the ureters identified, and a ligation of the vessels in dealing with polyps is usually a last-resort ma- performed. Bowel mobilization was then complet- noeuvre when all other options are exhausted. ed laparoscopically. The specimens were retrieved The potential advantages of laparoscopic over through the trans-umbilical incision and colotomy, open surgery are faster recovery, a low rate of inci- and polypectomy (if the polyp was benign looking sional , lesser blood loss, improved pulmo- with proven biopsy, not circular, and possible to nary function, earlier return of bowel function, remove) or resection and anastomosis performed decreased post-operative hospital stay, improved extra-corporeally. Contraindications for colotomy quality of life, and the reduction of peritoneal ad- and polyp removal were: a circular polyp, a dys- hesions (11). There have been a number of small plastic polyp in the initial biopsy, and the risk of reports on laparoscopic removal of colorectal bowel stenosis. For laparoscopic anterior resections polyps (11, 12). intra-corporeal anastomosis with an endoanal 20 Audrius Dulskas, Žygimantas Kuliešius, Narimantas E. Samalavičius

circular stapler was done. Hand-assisted laparo- of the colonic segment and colotomy and removal scopic surgery was performed for polyps local- of the polyp were performed on 15 (25.9%) patients ized in the descending colon, sigmoid and , (Table 2). Laparoscopic segmental bowel resection which was possible for specimen retrieval through was performed in 41 (70.7%) cases (Tables 2 and 3). the trans-umbilical incision. If a straight laparos- There were 23 polyps in the sigmoid colon (39.7%), copy was performed, mobilization of the bow- 19 (32.8%) polyps in the rectum, four in ascending el was performed using the standard technique. colon (6.9%) and cecum (6.9%), three in the trans- The segment was brought through the incision verse colon (5.2%), two in the descending colon above the mobilized bowel and colotomy, and pol- (3.4%) and left flexure (3.4%), and one in the right ypectomy or small resection and anastomosis were flexure (1.7%). Hand-assisted laparoscopic surgery done. If a hybrid laparoscopic-assisted endoscop- was performed on 37 patients, straight laparosco- ic polypectomy was performed, the laparoscopic py on 19, and laparoscopic-assisted procedure on part was performed as same previously described two patients. The mean post-operative hospital stay technique with the patient in lithotomic position was 5.7 ± 2.4 days (range from 1 to 14 days). All and endoscopist standing between patients legs. patients but four (6.9%) recovered well and had an The follow-up was performed under our institu- uneventful post-operative course. Four post-op- tional guidelines: colonoscopy annually. erative complications were encountered (periop- erative morbidity – 6.9%): urinary tract infection Statistical analysis in two patients, partial ileus in one, and urinary All statistical analyses were performed using soft- retention in one. All patients recovered after con- ware (Statistical Package for the Social Sciences, servative treatment (Grade II according to Cla- SPSS Inc., Chicago, IL, USA). All data are present- vien-Dindo classification). There were no deaths or ed as mean ± standard deviation for parametric, conversions in our group. The mean polyp size was and median for nonparametric data. 3.5 ± 1.9 cm (range from 1 to 10 cm). Final his- topathology revealed polyps (juvenile and hyper- RESULTS plastic n = 2), tubular adenoma (n = 9), tubulovil- lous adenoma (n = 31), carcinoma in situ (n = 12) Patients’ demographics are shown in Table 1. Pa- and invasive cancer (n = 4): pT1 in three cases tients’ body mass index was 28.5 ± 6.3 kg/m2 and pT2 neuroendocrine cancer in one (Table 4). (range: 22–36 kg/m2). Thirteen patients (22.4%) Two of these patients underwent laparoscopic left had multiple polyps (2 or more). 26 (44.8%) pa- tients had comorbidities: 24 of them (41.4%) cardi- Table 2. Laparoscopic surgical procedures performed ac, two (3.4%) diabetes. Laparoscopic mobilization on 58 patients with “difficult” polyps Surgical procedure Site of bowel Number Table 1. Demographic data of 58 patients who under- performed went surgical treatment for “difficult” polyps Laparoscopy-assisted 1 Variable n (%) endoscopic polypectomy Righ hemicolectomy 2 Male 29 (50%) Right colon Ileo-cecal resection 2 Female 29 (50%) Colotomy 4 65.9 ± 8.9 (range: 50 Mean age Transverse Colotomy 1 to 83 years) colon Bowel resection 2 Previous abdominal surgery 2 (3.4%) Descending Left hemicolectomy 1 Preoperative pathology colon Colotomy 2 Adenoma 50 (86.2%) Laparoscopy assisted 1 Ca in situ 8 (13.8%) endoscopic polypectomy Sigmoid Mean post-operative 5.7 ± 2.4 days (range Left hemicolectomy 6 colon hospital stay from 1 to 14 days) Colotomy 8 Conversion rate 0 Sigmoid resection 10 Mortality rate 0 Rectum Anterior resection 18 Laparoscopic surgery for colorectal polyps 21

Table 3. Surgical procedures performed on 58 patients with “difficult” polyps Procedure n (%) Colotomy and removal of polyp 15 (25.9%) Laparoscopic bowel resection 41 (70.7%) Anterior rectal resection 18 (31.0%) Sigmoid resection 9 (15.5%) Left hemicolectomy 7 (12.1%) Ileocaecal resection 2 (4.76%) Right hemicolectomy 2 (3.4%) Resection of transverse colon 2 (3.4%) Sigmoid resection with transanal retrieval of specimen 1 (1.7%) Laparoscopic-assisted endoscopic polypectomy 2 (3.4%)

Table 4. Final histopathology of 58 resected specimens Surgical options include colotomy with pol- Histopathology result N (%) ypectomy in the case of pedunculated polyps and small colectomy in the case of large, broad-base Hyperplastic polyp 2 (3.45) polyps. Polyps that have established or even pos- Invasive cancer (pT1, T2) 4 (6.90) sible development of malignant transformation Tubular adenoma 9 (15.51) require a formal oncologic resection with central Ca in situ 12 (20.69) vascular ligation and lymphadenectomy (11, 15, Tubulovillous adenoma 31 (53.45) 16). In our study, we performed 15 (25.9%) colo- tomies with mobilization of the colon and pol- hemicolectomies 14 and 10 days after laparoscop- ypectomy, and 41 (70.7%) bowel resections. Some ic colotomy and polypectomy. All the patients authors are against colotomy because of the high were followed with colonoscopy for 12 months possibility of exposing the abdominal cavity to post-operatively, then yearly thereafter. The mean cancer cells (17). Two patients underwent lapa- follow-up was 2 years (range: 6 months – 5 years). roscopic-assisted endoscopic polypectomy. Only There was no incidence of recurrence or any late two larger studies assessing this technique have complications. been recently published (18, 19). Authors con- cluded that this technique is safe for benign pol- DISCUSSION yps and if malignancy is suspected laparoscopic colectomy can be performed without delay. Adenomatous polyps are known as precursors of In our previous report we showed that a pol- colorectal cancer (2, 3). The rate of adenomas con- yp larger than 2.0 cm in diameter carries a risk taining invasive cancer has been estimated as high as of malignancy (10). Furthermore, Wasif et al. almost 10% (7). There are many modalities for treat- showed that polyps larger than 3 cm could be ment of difficult polyps. With improved technical completely excised only in 67–75% of cases, thus tools and techniques endoscopic polyp removal still questioning the endoscopic approach (5). In our remains the first line choice for treatment (13). How- present study, a large polyp size is the common- ever, even after a complete endoscopic resection of est cause for laparoscopic removal of colorectal a polyp, the residual malignant disease (in the colon polyps after a suspected malignancy. The median wall or regional lymph nodes) can be as high as 39% size of these large polyps was 3.5 ± 1.9 cm (range: in malignant polyps with unfavorable histology (14). 1–10 cm). It is difficult to reliably predict which So the risks and benefits of laparoscopic surgery patients would have invasive cancer after removal. versus endoscopic treatment alone favour the lapa- In general, polyps smaller than 2 cm, soft in con- roscopic or hybrid laparoendoscopic approach (13). sistency are nonulcerated, and demonstrate regu- According to some authors, majority of patients with lar pit and vascular patterns are more likely to be difficult polyps will undergo segmental colon resec- benign (13). The association between the increas- tion even if the polyp appears completely benign (6). ing polyp size and the possibility of harbouring 22 Audrius Dulskas, Žygimantas Kuliešius, Narimantas E. Samalavičius

cancer is well known. This is well shown in our of early post-operative recovery and should be con- study: four of 49 (8.2%) polyps of 2 cm or more in sidered as standard care today. size (two 2 cm and two 5 cm) harboured invasive cancer (Table 5). Conflict of interest The authors declare no conflict of interest.

Table 5. Cancer risk according to the polyp size Received 8 September 2016 Number of Incidence of Accepted 14 March 2017 Size polyps (n58) cancer (%) <=1 cm 2 0 References >1 cm, <2 cm 7 0 >=2 cm, <5 cm 38 2 (5.2%) 1. Global Burden of Disease Cancer Collabo- >=5 m 11 2 (18.2%) ration. The Global Burden of Cancer 2013. JAMA Oncol. 2015; 1: 505–27. In colorectal surgery, we have been using lap- 2. Sievers CK, Zou L, Pickhardt PJ, Matkows­ aroscopy for ten years. The results of our study, kyj KA, Albrecht D, Kim DH, et al. Modeling the post-operative hospital stay, and complications the rise of intratumoral heterogeneity in grow- are comparable to those reported in the literature ing, static, and regressing human colorectal (20–23), with no mortality or conversions docu- polyps. Cancer Research Supplement. 2016: mented in our cases. 151–151. Straight laparoscopic procedures have known dis- 3. Cho KR, Vogelstein B. Genetic alterations in advantages: a lack of tactility and the difficulties in the adenoma-carcinoma sequence. Cancer. defining the extent of the resection (6, 23). These dis- 1992; 70: 1727–31. advantages are overcome by HALS or various com- 4. Monkemuller K, Neumann H, Malferthein- binations of laparoscopic-endoscopic procedures, er P, Fry LC. Advanced colon polypectomy. including laparoscopically-assisted endoscopic pol- Clin Gastroenterol H. 2009; 7: 641–52. ypectomy, endoscopically-assisted wedge or anatom- 5. Wasif N, Etzioni D, Maggard MA, Tomlin- ical resections, and, finally, an intraoperative tumour son JS, Ko CY. Trends, patterns, and outcomes location by colonoscopy for achieving oncological re- in the management of malignant colonic pol- section margins in laparoscopic curative resections. yps in the general population of the United All of these combinations allow a minimally invasive States. Cancer. 2011; 117: 931–7. approach for lesions that would otherwise necessi- 6. Winter H, Lang RA, Spelsberg FW, Jauch KW, tate a (6, 13). In the dawn of laparosco- Hüttl TP. Laparoscopic colonoscopic rendez- py, Fleshman with co-authors recommended per- vous procedures for the treatment of polyps forming a mini laparotomy for colonic polyps (24). and early stage carcinomas of the colon. Int J However, the authors experienced some difficulties Colorectal Dis. 2007; 22: 1377–81. of inability to perform a splenic flexure mobilization 7. Zhang M, Shin EJ. Successful endoscopic through mini laparotomy. In general, compared to strategies for difficult polypectomy. Curr Opin mini laparotomy, it is easier to perform an extended Gastroenterol. 2013; 29: 489–894. mobilization and resection with HALS (25). 8. Pishvaian AC, Al-Kawas FH. Retroflexion in the colon: A useful and safe technique in CONCLUSIONS the evaluation and resection of sessile polyps during colonoscopy. Am J Gastroenterol 2006; Large colonic polyps unresectable at colonoscopy 101: 1479–83. are associated with a high rate of unsuspected can- 9. Moss A, Bourke MJ, Williams SJ, Hourigan LF, cer, and these polyps require a formal oncologic Brown G, Tam W, et al. Endoscopic mucosal re- colectomy rather than a trans-colonic polypectomy. section outcomes and prediction of submucosal Laparoscopic colectomy offers a safe and effective cancer from advanced colonic mucosal neopla- means of eradicating these polyps with the benefits sia. . 2011; 140: 1909–18. Laparoscopic surgery for colorectal polyps 23

10. Dulskas A, Samalavicius NE, Gupta RK, Za- 18. Franklin ME Jr, Portillo G. Laparoscopic mon- bulis V. Laparoscopic colorectal surgery for itored colonoscopic polypectomy: long-term colorectal polyps: single institution experi- follow-up. World J Surg. 2009; 33: 1306–9. ence. Videosurgery and Other Miniinvasive 19. Garrett KA, Lee SW. Combined endoscopic Techniques. 2015; 10: 73–8. and laparoscopic surgery. Clin Colon Rectal 11. Hauenschild L, Bader FG, Laubert T, Surg. 2015; 28: 140–5. Czymek R, Hildebrand P, Roblick UJ, et al. 20. Church J, Erkan A. Scope or scalpel? Laparoscopic colorectal resection for benign A matched study of the treatment of large polyps not suitable for endoscopic polypecto- colorectal polyps. ANZ J Surg 2016 [Epub my. Int J Colorectal Dis. 2009; 24: 755–9. ahead of print]. 12. Pokala N, Delaney CP, Kiran RP, Brady K, 21. Schwenk W, Haase O, Neudecker J, Muller JM. Senagore AJ. Outcome of laparoscopic colec- Short term benefits for laparoscopic colorectal tomy for polyps not suitable for endoscopic resection. Cochrane Database Syst Rev. 2005; resection. Surg Endosc. 2007; 21: 400–3. 20: CD003145. 13. Aslani N, Alkhamesi NA, Schlachta CM. Hy- 22. Benedix F, Kockerling F, Lippert H, Scheid- brid laparoendoscopic approaches to endo- bach H. Laparoscopic resection for endo- scopically unresectable colon polyps. J Lapa- scopically unresectable colorectal polyps: roendosc Adv Surg Tech A. 2016; 26: 581–90. analysis of 525 patients. Surg Endosc. 2008; 14. Bujanda L, Cosme A, Gil I, Arenas-Mirave JI. 22: 2576–82. Malignant colorectal polyps. World J Gastro- 23. Benlice C, Costedio M, Stocchi L, Abbas enterol. 2010; 16: 3103–11. MA, Gorgun E. Hand-assisted laparoscop- 15. Nassiopoulos K, Pavlidis TE, Menenakos E, ic vs open colectomy: an assessment from Chanson C, Zografos G, Petropoulos P. Lap- the American College of Surgeons Nation- aroscopic colectomy in the management of al Surgical Quality Improvement Program large, sessile, transformed colorectal polyps. procedure-targeted cohort. Am J Surg. 2016 JSLS 2005; 9: 58–62. [Epub ahead of print]. 16. Jang JH, Balik E, Kirchoff D, Tromp W, Ku- 24. Fleshman JW, Fry RD, Birnbaum EH, Kod- mar A, Grieco M. Oncologic colorectal resec- ner IJ. Laparoscopic-assisted and minilapa- tion, not advanced endoscopic polypectomy, rotomy approaches to colorectal diseases are is the best treatment for large dysplastic ade- similar in early outcome. Dis Colon Rectum. nomas. J Gastrointest Surg. 2012; 16: 165–72. 1996; 39: 15–22. 17. Loungnarath R, Mutch MG, Birnbaum EH, 25. Tajima T, Mukai M, Yamazaki M, Higami S, Read TE, Fleshman JW. Laparoscopic colec- Yamamoto S, Hasegawa S, et al. Comparison tomy using cancer principles is appropriate of hand-assisted laparoscopic surgery and for colonoscopically unresectable adenomas conventional laparotomy for colorectal can- of the colon. Dis Colon Rectum. 2010; 53: cer: interim results from a single institution. 1017–22. Oncol Lett. 2014; 8: 627–32. 24 Audrius Dulskas, Žygimantas Kuliešius, Narimantas E. Samalavičius

Audrius Dulskas, Žygimantas Kuliešius, tiesiosios žarnos rezekcija su daline mezorekta- Narimantas Evaldas Samalavičius line ekscizija – aštuoniolikai (31,0 %), riestinės žarnos rezekcija – devyniems (15,5 %), kairioji LAPAROSKOPINĖ CHIRURGIJA TIESIOSIOS IR GAUBTINĖS ŽARNOS POLIPAMS hemikolektomija – septyniems (12,1 %), dešinioji ŠALINTI: 10 METŲ PATIRTIS hemikolektomija – dviems (3,4 %), ileocekalinio kampo rezekcija – dviems (3,4 %), skersinės žar- Santrauka nos rezekcija – dviems (3,4 %) ir riestinės žarnos Įvadas. Laparoskopija ar jos derinimas su en- rezekcija su preparato šalinimu per anus – vienam doskopija yra puiki alternatyva endoskopiškai (1,7 %) pacientui. Dviems pacientams (3,4 %) nepašalinamiems žarnos polipams šalinti. Tyrimo atlikta laparoskopiškai asistuojanti endoskopinė tikslas – apžvelgti šios metodikos taikymo rezul- polipektomija. Vidutinė pooperacinio periodo tatus. trukmė buvo 5,7 ± 2,4 dienos. Keturiems pacien- Medžiaga ir metodai. Tyrime dalyvavo 58 pa- tams pasireiškė komplikacijos (6,9 %). Nei vienam cientai, 2006–2016 m. operuoti Nacionaliniame iš jų neprireikė reintervencijos. Vidutinis polipo vėžio institute dėl endoskopiškai nepašalinamų dydis 3,5 ± 1,9 cm. Galutinė patologijos diagnozė: polipų. Perspektyviai analizuoti demografiniai hiperplastinis polipas (n = 2), tubulinė adenoma rodikliai, operacijos tipas, pooperacinio periodo (n = 9), tubuloviliozinė adenoma (n = 31), carci- trukmė, komplikacijos ir galutinis histologijos at- noma in situ (n = 12) ir vėžys (n = 4). sakymas. Išvados. Endoskopiškai nepašalinamų storo- Rezultatai. Vidutinis pacientų amžius buvo sios ir tiesiosios žarnos polipų atvejais laparosko- 65,9 ± 8,9 metai. Laparoskopinė žarnos mobi- pija yra pirmo pasirinkimo metodas. lizacija, kolotomija ir polipo šalinimas atlikta Raktažodžiai: laparoskopinė chirurgija, kolek- 15 (25,9 %) pacientų, laparoskopinė žarnos se- tomija, tiesiosios ir gaubtinės žarnos polipas, su- gmentinė rezekcija – 41 (70,7 %) atveju: priekinė dėtingas polipas