Endoscopy 2013; 45(S 02): E167-E168
DOI: 10.1055/s-0032-1326462
Cases and Techniques Library (CTL)
© Georg Thieme Verlag KG Stuttgart · New York

Full-thickness laparoendoscopic stapled excision of colonic lesion in a porcine ex vivo model

A. Brigic
1  Department of Surgery, St. Mark’s Hospital and Academic Institute, Watford Road, London, United Kingdom
2  Wolfson Unit for Endoscopy, St. Mark’s Hospital and Academic Institute, Watford Road, London, United Kingdom
,
A. Southgate
3  Northwick Park Biomedical Institute, Biomedicine, Watford Road, London, United Kingdom
,
P. D. Sibbons
3  Northwick Park Biomedical Institute, Biomedicine, Watford Road, London, United Kingdom
,
S. K. Clark
1  Department of Surgery, St. Mark’s Hospital and Academic Institute, Watford Road, London, United Kingdom
,
C. Fraser
2  Wolfson Unit for Endoscopy, St. Mark’s Hospital and Academic Institute, Watford Road, London, United Kingdom
,
R. H. Kennedy
1  Department of Surgery, St. Mark’s Hospital and Academic Institute, Watford Road, London, United Kingdom
› Institutsangaben
Weitere Informationen

Corresponding author

R. Kennedy
Department of Surgery
St. Mark’s Hospital and Academic Institute
Watford Road
London, HA1 3UJ
UK   
Fax: +44 208 2354108   

Publikationsverlauf

Publikationsdatum:
25. Juni 2013 (online)

 

The introduction of the National Bowel Cancer Screening Programme in the United Kingdom has resulted in an increasing number of patients requiring hemicolectomy for endoscopically unresectable benign colonic polyps [1] [2]. Laparoscopic hemicolectomy with en bloc mesenteric resection is a morbid intervention as death (2 %), anastomotic leakage (7 %), and other complications (34 – 46 %) can occur [3]. These patients derive no additional benefit from removal of the mesentery and a new, less invasive treatment option is required. We report a modified version of the previously published Full-thickness Laparoendoscopic EXcision (FLEX) technique [4].

A porcine colon specimen was placed in a handmade laparoscopic training box ([Fig. 1]). A 2 – 3-cm simulated colonic polyp was made by submucosal injection of India ink. Three pairs of brace bars (Prototype BraceBar system; Olympus, Tokyo, Japan) ([Fig. 2]) were placed endoscopically, 1 cm away from the edge of the polyp, delineating a circumferential clearance margin. Cinching of the brace bars resulted in full-thickness eversion of the colonic wall containing the simulated lesion. The specimen was excised with a laparoscopic linear stapler (ENDOPATH ETS-45; Ethicon Endo-surgery, Cincinnati, Ohio, USA) placed below the brace bars. The average procedure time (from placement of brace bars to specimen excision) was 46 minutes, resulting in four full-thickness colonic specimens, median diameter of 4.8 cm (3.7 – 6.3 cm). All specimens contained three pairs of brace bars with clear resection margins ([Fig. 3] and [Fig. 4]). Endoscopic examination demonstrated widely patent lumen without evidence of stenosis at excision sites.

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Fig. 1 a, b Handmade laparoscopic training box containing a colonic specimen.
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Fig. 2 a Overview of brace bar placement at 3, 9, and 12 and 6 o’clock positions. b Endoscopic placement of brace bars 1 cm away from the edge of the lesion. c Cinched brace bars evert the area of the bowel containing the simulated lesion. The everted segment is retracted using a laparoscopic grasper and the specimen excised with a laparoscopic linear stapler. This results in a simultaneous closure of the colon and the excised specimen. Adequate clearance margin is achieved by placing the stapler below the brace bars.
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Fig. 3 Stapled colonic specimen avoiding the risk of peritoneal contamination with potentially malignant cells.
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Fig. 4 Excised colonic specimen.

This proof-of-concept study demonstrates the feasibility of achieving full-thickness colonic specimens exceeding 6 cm in diameter. Accurate endoscopic placement of the brace bars ensures completeness of excision while laparoscopic overview minimizes the risk of collateral damage. Importantly, lesion resection with simultaneous closure of the defect is achieved effectively and simply by use of a standard linear stapling device. The eversion FLEX is safe for in vivo assessment as a potential alternative to hemicolectomy in selected patients.

Acknowledgments

Olympus Keymed and Ethicon Endo-surgery provided technical support. We are grateful for the support of Ms Cathy Grey, Research Theatre Manager, and Mr Aaron Southgate, Northwick Park Institute for Medical Research, London, United Kingdom. Mr Southgate produced the figures and Mr Stephen Preston assisted with video editing.

Endoscopy_UCTN_Code_TTT_1AT_2AZ


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Competing interests: None


Corresponding author

R. Kennedy
Department of Surgery
St. Mark’s Hospital and Academic Institute
Watford Road
London, HA1 3UJ
UK   
Fax: +44 208 2354108   


Zoom Image
Fig. 1 a, b Handmade laparoscopic training box containing a colonic specimen.
Zoom Image
Fig. 2 a Overview of brace bar placement at 3, 9, and 12 and 6 o’clock positions. b Endoscopic placement of brace bars 1 cm away from the edge of the lesion. c Cinched brace bars evert the area of the bowel containing the simulated lesion. The everted segment is retracted using a laparoscopic grasper and the specimen excised with a laparoscopic linear stapler. This results in a simultaneous closure of the colon and the excised specimen. Adequate clearance margin is achieved by placing the stapler below the brace bars.
Zoom Image
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Fig. 3 Stapled colonic specimen avoiding the risk of peritoneal contamination with potentially malignant cells.
Zoom Image
Fig. 4 Excised colonic specimen.