Colonoscopic-assisted laparoscopic wedge resection versus segmental colon resection for benign colonic polyps: a comparative cost analysis.

AIM: The colonoscopic-assisted laparoscopic wedge resection (CAL-WR) is proven to be an effective and safe alternative to a segmental colon resection (SCR) for large or complex benign colonic polyps that are not eligible for endoscopic removal. This analysis aimed to evaluate the costs of CAL-WR and compare them to the costs of an SCR. METHOD: A single-centre 90-day 'in-hospital' comparative cost analysis was performed on patients undergoing CAL-WR or SCR for complex benign polyps between 2016 and 2020. The CAL-WR group consisted of 44 patients who participated in a prospective multicentre study (LIMERIC study). Inclusion criteria were (1) endoscopically unresectable benign polyps; (2) residual or recurrence after previous polypectomy; or (3) irradically resected low risk pT1 colon carcinoma. The comparison group, which was retrospectively identified, included 32 patients who underwent an elective SCR in the same period. RESULTS: Colonoscopic-assisted laparoscopic wedge resection was associated with significantly fewer complications (7% in the CAL-WR group vs. 45% in the SCR group, P < 0.001), shorter operation time (50 min in the CAL-WR group vs. 119 min in the SCR group, P < 0.001), shorter length of hospital stay (median length of stay 2 days in the CAL-WR group vs. 4 days in the SCR group, P < 0.001) and less use of surgical resources (reduction in costs of 32% per patient), resulting in a cost savings of €2372 (£2099 GBP) per patient (P < 0.001). CONCLUSION: Given the clinical and financial benefits, CAL-WR should be recommended for complex benign polyps that are not eligible for endoscopic resection before major surgery is considered.

Limited wedge resection for T1 colon cancer (LIMERIC-II trial) - rationale and study protocol of a prospective multicenter clinical trial.

BACKGROUND: The sole presence of deep submucosal invasion is shown to be associated with a limited risk of lymph node metastasis. This justifies a local excision of suspected deep submucosal invasive colon carcinomas (T1 CCs) as a first step treatment strategy. Recently Colonoscopy-Assisted Laparoscopic Wedge Resection (CAL-WR) has been shown to be able to resect pT1 CRCs with a high R0 resection rate, but the long term outcomes are lacking. The aim of this study is to evaluate the safety, effectiveness and long-term oncological outcomes of CAL-WR as primary treatment for patients with suspected superficial and also deeply-invasive T1 CCs. METHODS: In this prospective multicenter clinical trial, patients with a macroscopic and/or histologically suspected T1 CCs will receive CAL-WR as primary treatment in order to prevent unnecessary major surgery for low-risk T1 CCs. To make a CAL-WR technically feasible, the tumor may not include > 50% of the circumference and has to be localized at least 25 cm proximal from the anus. Also, there should be sufficient distance to the ileocecal valve to place a linear stapler. Before inclusion, all eligible patients will be assessed by an expert panel to confirm suspicion of T1 CC, estimate invasion depth and subsequent advise which local resection techniques are possible for removal of the lesion. The primary outcome of this study is the proportion of patients with pT1 CC that is curatively treated with CAL-WR only and in whom thus organ-preservation could be achieved. Secondary outcomes are 1) CAL-WR's technical success and R0 resection rate for T1 CC, 2) procedure-related morbidity and mortality, 3) 5-year overall and disease free survival, 4) 3-year metastasis free survival, 5) procedure-related costs and 6) impact on quality of life. A sample size of 143 patients was calculated. DISCUSSION: CAL-WR is a full-thickness local resection technique that could also be effective in removing pT1 colon cancer. With the lack of current endoscopic local resection techniques for > 15 mm pT1 CCs with deep submucosal invasion, CAL-WR could fill the gap between endoscopy and major oncologic surgery. The present study is the first to provide insight in the long-term oncological outcomes of CAL-WR. TRIAL REGISTRATION: CCMO register (ToetsingOnline), NL81497.075.22, protocol version 2.3 (October 2022).

Diagnostic value of radiological staging and surveillance for T1 colorectal carcinomas: A multicenter cohort study.

BACKGROUND: The role of radiological staging and surveillance imaging is under debate for T1 colorectal cancer (CRC) as the risk of distant metastases is low and imaging may lead to the detection of incidental findings. OBJECTIVE: The aim of this study was to evaluate the yield of radiological staging and surveillance imaging for T1 CRC. METHODS: In this retrospective multicenter cohort study, all patients of 10 Dutch hospitals with histologically proven T1 CRC who underwent radiological staging in the period 2000-2014 were included. Clinical characteristics, pathological, endoscopic, surgical and imaging reports at baseline and during follow-up were recorded and analyzed. Patients were classified as high-risk T1 CRC if at least one of the histological risk factors (lymphovascular invasion, poor tumor differentiation, deep submucosal invasion or positive resection margins) was present and as low-risk when all risk factors were absent. RESULTS: Of the 628 included patients, 3 (0.5%) had synchronous distant metastases, 13 (2.1%) malignant incidental findings and 129 (20.5%) benign incidental findings at baseline staging. Radiological surveillance was performed among 336 (53.5%) patients. The 5-year cumulative incidence of distant recurrence, malignant and benign incidental findings were 2.4% (95% confidence interval (CI): 1.1%-5.4%), 2.5% (95% CI: 0.6%-10.4%) and 18.3% (95% CI: 13.4%-24.7%), respectively. No distant metastatic events occurred among low-risk T1 CRC patients. CONCLUSION: The risk of synchronous distant metastases and distant recurrence in T1 CRC is low, while there is a substantial risk of detecting incidental findings. Radiological staging seems unnecessary prior to local excision of suspected T1 CRC and after local excision of low-risk T1 CRC. Radiological surveillance should not be performed in patients with low-risk T1 CRC.

Colonoscopy-Assisted Laparoscopic Wedge Resection for the Treatment of Suspected T1 Colon Cancer.

BACKGROUND: Local en bloc resection of pT1 colon cancer has been gaining acceptance during the last few years. In the absence of histological risk factors, the risk of lymph-node metastases (LNM) is negligible and does not outweigh the morbidity and mortality of an oncologic resection. Colonoscopy-assisted laparoscopic wedge resection (CAL-WR) has proved to be an effective and safe technique for removing complex benign polyps. The role of CAL-WR for the primary resection of suspected T1 colon cancer has to be established. METHODS: This retrospective study aimed to determine the radicality and safety of CAL-WR as a local en bloc resection technique for a suspected T1 colon cancer. Therefore, the study identified patients in whom high-grade dysplasia or a T1 colon carcinoma was suspected based on histology and/or macroscopic assessment, requiring an en bloc resection. RESULTS: The study analyzed 57 patients who underwent CAL-WR for a suspected macroscopic polyp or polyps with biopsy-proven high-grade dysplasia or T1 colon carcinoma. For 27 of these 57 patients, a pT1 colon carcinoma was diagnosed at pathologic examination after CAL-WR. Histological risk factors for LNM were present in three cases, and 70% showed deep submucosal invasion (Sm2/Sm3). For patients with pT1 colon carcinoma, an overall R0-resection rate of 88.9% was achieved. A minor complication was noted in one patient (1.8%). CONCLUSIONS: The CAL-WR procedure is an effective and safe technique for suspected high-grade dysplasia or T1-colon carcinoma. It may fill the gap for tumors that are macroscopic suspected for deep submucosal invasion, providing more patients an organ-preserving treatment option.

Colonoscopic-Assisted Laparoscopic Wedge Resection for Colonic Lesions: A Prospective Multicenter Cohort Study (LIMERIC-Study).

OBJECTIVE: The aim of this study was to evaluate the safety and efficacy of a modified CAL-WR. SUMMARY BACKGROUND DATA: The use of segmental colectomy in patients with endoscopically unresectable colonic lesions results in significant morbidity and mortality. CAL-WR is an alternative procedure that may reduce morbidity. METHODS: This prospective multicenter study was performed in 13 Dutch hospitals between January 2017 and December 2019. Inclusion criteria were (1) colonic lesions inaccessible using current endoscopic resection techniques (judged by an expert panel), (2) non-lifting residual/recurrent adenomatous tissue after previous polypectomy or (3) an undetermined resection margin after endoscopic removal of a low-risk pathological T1 (pT1) colon carcinoma. Thirty-day morbidity, technical success rate and radicality were evaluated. RESULTS: Of the 118 patients included (56% male, mean age 66 years, standard deviation ± 8 years), 66 (56%) had complex lesions unsuitable for endoscopic removal, 34 (29%) had non-lifting residual/recurrent adenoma after previous polypectomy and 18 (15%) had uncertain resection margins after polypectomy of a pT1 colon carcinoma. CAL-WR was technically successful in 93% and R0 resection was achieved in 91% of patients. Minor complications (Clavien-Dindo i-ii) were noted in 7 patients (6%) and an additional oncologic segmental resection was performed in 12 cases (11%). Residual tissue at the scar was observed in 5% of patients during endoscopic follow-up. CONCLUSIONS: CAL-WR is an effective, organ-preserving approach that results in minor complications and circumvents the need for major surgery. CAL-WR, therefore, deserves consideration when endoscopic excision of circumscribed lesions is impossible or incomplete.

Clinical outcome of decompressing colostomy for acute left-sided colorectal obstruction: a consecutive series of 100 patients.

PURPOSE: Aim of our study was to evaluate the outcomes of a consecutive series of patients who were treated with a decompressing colostomy (DC) for acute left-sided colorectal obstruction. METHOD: A consecutive series of 100 patients with acute left-sided colorectal obstruction who underwent DC from January 2015 to August 2020 was retrospectively analyzed. Demographic characteristics, etiology of the obstruction, postoperative morbidity- and mortality rates, DC-related complication and stoma reversal rates were evaluated. RESULTS: Of the 100 included patients, 64 had malignant- and 36 had benign obstruction. The mean age was 69 years, 42% was male, and the ASA score was 2. Morbidity and mortality rates after DC construction were 20 and 2%, respectively. In 39% of the patients, DC ended up as a permanent stoma and in 61% as bridge to surgery (BtS). DC related complication rate was 32%, with a re-intervention rate of 9%. Elective colorectal resection was performed in 59 cases (59%) with subsequent postoperative morbidity rate of 20%. Stoma reversal rate was 77% for the patients who underwent DC as BtS. Stoma reversal was performed in 66% of the patients with benign obstruction and in 36% for oncological obstruction. CONCLUSION: DC as bridge to possible elective resection for acute left-sided colorectal obstruction is an effective strategy with low morbidity and mortality rates and a high stoma reversal rate, especially for benign obstruction. However, DC is less appropriate for patients in whom DC turns out to be a permanent stoma due to a relatively high stoma related complications.

Implications of colonic and extra-colonic findings on CT colonography in FIT positive patients in the Dutch bowel cancer screening program.

OBJECTIVES: In the Dutch National colorectal cancer (CRC) screening program, patients with a positive faecal immunochemical test (FIT) are referred for a colonoscopy. In a small proportion, because of contraindications, a computed tomographic colonography (CTC) is performed to rule out advanced neoplasia. The aim of our study is to evaluate the intra- and extra-colonic yield of CTC and its clinical implications. MATERIALS AND METHODS: In this retrospective cohort study, all FIT positive patients who underwent primary (instead of colonoscopy) or secondary CTC (after incomplete colonoscopy) between January 2014 and January 2018 were included. Relevant intra-colonic lesions on CTC were defined as lesions suspected for CRC or >10 mm. Relevant extra-colonic findings were defined as E3 and E4 using the E-RADS classification. RESULTS: Of the 268 included patients, 66 (24.6%) were suspected to have CRC or 10 mm + lesion on CTC and 56 of them (84.8%) underwent an additional endoscopy. Another 20 patients with <10 mm lesions on CTC underwent additional endoscopy. Overall, 76/268 patients (28.4%) underwent confirmatory endoscopy of which 50 (18.7%) had histologic confirmed advanced neoplasia; 4.9% had CRC and 13.8% advanced adenoma. New relevant extra-colonic findings were detected in 13.8%. CONCLUSIONS: In the Dutch National CRC screening program, a CTC was followed by an endoscopic procedure in more than a quarter of patients, resulting in a significant number of advanced neoplasia. Overall, one out of seven CTCs showed new relevant extra-colonic findings which may lead to further diagnostic/therapeutic work-up. Our results can be important for the informed consent procedure.