Available online 9 May 2024, 101022

Author links open overlay panel, Abstract

Detection of colon polyps is common and is expected in 20-30% of screening colonoscopies. As the number of colonoscopies performed increases, the detection of advanced and difficult to resect polyps will also rise. These polyps tend to be larger, greater than 2cm, have flat morphology, and are in difficult anatomic locations behind haustral folds or at sharp flexures of the colon. Advanced endoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are useful to remove these polyps. However, many polyps remain unresectable with these techniques. Combined endoscopic laparoscopic surgery (CELS) has shown to be an effective technique to facilitate safe removal of complex polyps. CELS encompasses a variety of techniques including laparoscopic assisted ESD/EMR and laparo-endoscopic full thickness excisions (FLEX). Success rate of CELS ranges from 70-100%, with less than 5% conversion to colectomy. Perioperative outcomes boast shorter hospital length of stay, with low rates of serious post-op complications when compared to colectomy. Malignancy rate after CELS in appropriately selected patients is low, ranging from 1.6%-10% of cases. Polyp recurrence rate after CELS is also low, usually less than 10%. Use of CELS for early-stage cancers remains controversial but maybe adequate in appropriately selected patients. Further evaluation and long-term studies are needed to study its efficacy in cases of known cancer. The purpose of this review is to provide recommendations for use of CELS techniques, appropriate indications, describe technical tips, and review potential future applications.

Section snippetsBackground

Colorectal cancer (CRC) remains one of the most commonly diagnosed malignancies in the United States, and is the second leading cause of cancer death.1 While the overall incidence of colon cancer continues to decline, recent trends indicate an increase in the incidence of CRC in patients under 55 years of age, with nearly 20% of all CRC cases diagnosed in this age group in recent years.1 Robust colon cancer screening protocols have led to an overall decline in colorectal cancer and complete

Indications

Patient selection remains paramount when choosing an intervention for the management of colorectal lesions. Most importantly, pre-operative work-up including biopsy and thorough review of available endoscopy reports should be performed. If suspicion for cancer is high or in question, then further work-up and/or formal resection should be strongly considered before proceeding with CELS. Other factors that should be assessed when determining the usefulness of colon preserving procedures like CELS

Technique

When performing any surgical or endoscopic procedure, pre-operative planning is imperative to success, and this is no different when performing CELS. This approach should be performed in the elective setting after coordination and planning with an experienced multidisciplinary team. In addition to the surgeon and endoscopist, all appropriate equipment and available technicians and experience operating room staff should be readily available to assist as needed.

Perioperative Outcomes

When comparing CELS to segmental resection, patients undergoing colon preserving techniques tend to have shorter hospital length of stay (LOS), operating room time, and overall lower costs of care.19,26,29 Additionally, post-operative opiate use has been shown to be less in patients undergoing CELS compared to laparoscopic colectomy.29 Studies have shown that hospital LOS for patients after CELS ranges from 0-7 days,21 with multiple larger retrospective studies reporting hospital LOS as

Contributions

Contributions to the formulation of this manuscript include: Conceptualization, B.W. and S.L., Literature Review, B.W. and S.L, Original Draft Preparation, B.W. and S.L, Review & Editing, B.W. and S.L., Preparation for Submission B.W. and S.L.

Declaration of competing interest

The authors have no financial interest and no conflict of interests to declare in relation to the content of this manuscript.

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