The ”FLEX” procedure: a new technique for full-thickness laparo-endoscopic excision in the colon

Background and study aims: Colonic lesions unsuitable for endoscopic resection and some early cancers that have been incompletely excised endoscopically, are generally treated by segmental colectomy, even though local excision might be adequate. The aim of this study was to develop a laparo-endoscopic procedure for full-thickness local excision of the colon.

Methods: After detailed planning using story-boarding to discuss each step of the procedure, both nonsurvival and survival experiments were performed in seven 50-kg pigs. The technique used was as follows: a simulated colonic polyp was created by endoscopic ink injection; this was inverted using laparo-endoscopically placed BraceBars passing from the outside to the inside of the colon; after laparoscopic over-sewing of the inversion in two layers, endoscopic full-thickness excision was performed. Pigs were sacrificed immediately (n = 3) or between 7 and 9 days after surgery (n = 4).

Results: The procedure was performed without operative perforation or hemorrhage in a median of 233 min (range 201 – 245 min), and achieved full-thickness excision in all procedures. Specimen diameter was a median of 2.5 cm (range 2 – 3 cm). All survival pigs convalesced without complication and, at autopsy, normal luminal diameter was confirmed without any peritoneal reaction, hernia or sepsis. Bursting pressures were a median of 245 mmHg (range 240 – 260 mmHg), with the site of bursting being in normal colon in all but one pig.

Conclusions: This is a novel technique that permits full-thickness laparo-endoscopic excision (FLEX) of a colonic lesion as an alternative to segmental colectomy.

References

• 1 Ho Y H, Low D, Goh H S. Bowel function survey after segmental colorectal resections.  Dis Colon Rectum. 1996;  39 307-310
• 2 Dworkin M J, Allen-Mersh T G. Effect of inferior mesenteric artery ligation on blood flow in the marginal artery-dependent sigmoid colon.  J Am Coll Surg. 1996;  183 357-360
• 3 Rouffet F, Hay J M, Vacher B et al. Curative resection for left colonic carcinoma: hemicolectomy vs. segmental colectomy. A prospective, controlled, multicenter trial. French Association for Surgical Research.  Dis Colon Rectum. 1994;  37 651-659
• 4 Abraham N S, Young J M, Solomon M J. Meta-analysis of short-term outcomes after laparoscopic resection for colorectal cancer.  Br J Surg. 2004;  91 1111-1124
• 5 Varadhan K K, Neal K R, Dejong C H et al. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: A meta-analysis of randomized controlled trials.  Clin Nutr. 2010;  29 434-440
• 6 Wilhelm D, von Delius S, Weber L et al. Combined laparoscopic-endoscopic resections of colorectal polyps: 10-year experience and follow-up.  Surg Endosc. 2009;  23 688-693
• 7 Trunzo J A, Poulose B K, McGee M F et al. The diagnostic efficacy of natural orifice transluminal endoscopic surgery: is there a role in the intensive care unit?.  Surg Endosc. 2010;  24 2485-2491
• 8 Ikeda K, Sumiyama K, Tajiri H. Use of a new multi-tasking platform for endoscopic full thickness resection (EFTR) in a porcine model.  Gastrointest Endosc. 2009;  69 AB121
• 9 Cahill R A, Sheehan K M, Scanlon R W et al. Effects of a selective cyclo-oxygenase 2 inhibitor on colonic anastomotic and skin wound integrity.  Br J Surg. 2004;  91 1613-1618
• 10 Hoeppner J, Crnogorac V, Marjanovic G et al. Small intestinal submucosa for reinforcement of colonic anastomosis.  Int J Colorectal Dis. 2009;  24 543-550
• 11 Olson K H, Balcos E G, Lowe M C, Bubrick M P. A comparative study of open, laparoscopic intracorporeal, and laparoscopic assisted low anterior resection and anastomosis in pigs.  Am Surg. 1995;  61 197-201
• 12 Faiz O, Brown T, Colucci G, Kennedy R H. A cohort study of results following elective colonic and rectal resection within an enhanced recovery programme.  Colorectal Dis. 2009;  11 366-372
• 13 Tanaka S, Oka S, Kaneko I et al. Endoscopic submucosal dissection for colorectal neoplasia: possibility of standardization.  Gastrointest Endosc. 2007;  66 100-107
• 14 Nishiyama H, Isomoto H, Yamaguchi N et al. Endoscopic submucosal dissection for colorectal epithelial neoplasms.  Dis Colon Rectum. 2010;  53 161-168
• 15 Delaney C P, Champagne B J, Marks J M et al. Tissue apposition system: new technology to minimize surgery for endoscopically unresectable colonic polyps.  Surg Endosc. 2010;  24 3113-3118
• 16 Lorenz C, Nimmesgern T, Back M, Langwieler T E. Transanal single port microsurgery (TSPM) as a modified technique of transanal endoscopic microsurgery (TEM).  Surg Innov. 2010;  17 160-163
• 17 UK Colorectal Cancer Screening Pilot Group . Results of the first round of a demonstration pilot of screening for colorectal cancer in the United Kingdom.  BMJ. 2004;  329 133
• 18 Saikawa Y, Otani Y, Kitagawa Y et al. Interim results of sentinel node biopsy during laparoscopic gastrectomy: possible role in function-preserving surgery for early cancer.  World J Surg. 2006;  30 1962-1968
• 19 Kitagawa Y, Kitajima M. Endoscopic treatment combined with laparoscopic sentinel node mapping for superficial gastrointestinal cancers.  Endoscopy. 2007;  39 471-475
• 20 Cahill R A, Leroy J, Marescaux J. Localized resection for colon cancer.  Surg Oncol. 2009;  18 334-342
• 21 Cahill R A, Leroy J, Marescaux J. Could lymphatic mapping and sentinel node biopsy provide oncological providence for local resectional techniques for colon cancer? A review of the literature.  BMC Surg. 2008;  8 17
• 22 Cahill R A, Bembenek A, Sirop S et al. Sentinel node biopsy for the individualization of surgical strategy for cure of early-stage colon cancer.  Ann Surg Oncol. 2009;  16 2170-2180
• 23 Meijerink W J, van der Pas M H, van der Peet D L et al. New horizons in colorectal cancer surgery.  Surg Endosc. 2009;  23 1-3
• 24 Cahill R A, Mortensen N J. Intraoperative augmented reality for laparoscopic colorectal surgery by intraoperative near-infrared fluorescence imaging and optical coherence tomography.  Minerva Chir. 2010;  65 451-462
• 25 Ueno H, Mochizuki H, Hashiguchi Y et al. Risk factors for an adverse outcome in early invasive colorectal carcinoma.  Gastroenterology. 2004;  127 385-394