Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1519_Библиотеки_им_академика_М_И_Перельмана.pdf
149
patients at our institution ever require surgery for their primary tumor while receiv-
ing initial chemotherapy [11]. In this setting, multi-drug chemotherapy has proven
effective and safe in the long-term treatment of metastatic disease. Moreover, in a
subset of patients, current multimodality therapies have substantially improved our
ability to obtain a curative resection at a later date. Given the survival benefits of a
staged or synchronous resection, treatment should focus on improving the probabil-
ity of resection. Clinical judgment, however, should ultimately direct decision-
making, with the goal of optimizing survival and quality of life. In determining a
treatment plan, I very carefully evaluate the patient for symptoms, reviewing colo-
noscopy reports and CT scans. In patients who present with anemia, I generally find
that the symptoms can be managed medically, and this improves within 2–4 cycles
of chemotherapy. In patients with mild obstructive symptoms, I tend to recommend
upfront chemotherapy with careful observation, and find it quite common to see
resolution of symptoms within 2 cycles of treatment. This approach is supported by
data on our patients with locally advanced rectal cancer, in whom we routinely
administer oxaliplatin-based induction chemotherapy and observe high radio-
graphic, clinical and pathologic complete response rates [46]. For patients with sig-
nificant symptoms and/or evidence of proximal dilation on CT scan, I recommend
resection, bearing in mind the increased risk of complications and potential delay in
chemotherapy. Although the data do not support primary tumor resection in patients
with unresectable disease, there is considerable equipoise between strategies, and
there is need for a randomized trial in the future.
References
1. US Cancer Statistics Working Group. United States cancer statistics: 1999–2012 incidence
and mortality webbased report. Atlanta: US Department of Health and Human Services,
Centers for Disease Control; www.cdc.gov/uscs.
2. House MG, Ito H, Gönen M, et al. Survival after hepatic resection for metastatic colorectal
cancer: trends in outcomes for 1,600 patients during two decades at a single institution. J Am
Coll Surg. 2010;210(5):744–52, 752–5. doi:10.1016/j.jamcollsurg.2009.12.040.
3. Martin R, Paty P, Fong Y, et al. Simultaneous liver and colorectal resections are safe for syn-
chronous colorectal liver metastasis. J Am Coll Surg. 2003;197(2):233–41; discussion 241–2.
doi:10.1016/S1072-7515(03)00390-9.
4. Tournigand C, André T, Achille E, et al. FOLFIRI followed by FOLFOX6 or the reverse
sequence in advanced colorectal cancer: a randomized GERCOR study. J Clin Oncol.
2004;22(2):229–37. doi:10.1200/JCO.2004.05.113.
5. Goldberg RM, Sargent DJ, Morton RF, et al. A randomized controlled trial of fluorouracil plus
leucovorin, irinotecan, and oxaliplatin combinations in patients with previously untreated
metastatic colorectal cancer. J Clin Oncol. 2004;22(1):23–30. doi:10.1200/JCO.2004.09.046.
Recommendations
• Patients with unresectable, metastatic colon cancer and an asymptomatic or
minimally symptomatic primary tumor should not undergo resection of the
primary tumor (Evidence quality low, weak conditional recommendation)
14 Utility of Primary Tumor Resection in Asymptomatic
www.ebook3000.com
150
6. Venook AP, Niedzwiecki D, Lenz H-J, et al. CALGB/SWOG 80405: Phase III trial of
irinotecan/5-FU/leucovorin (FOLFIRI) or oxaliplatin/5-FU/leucovorin (mFOLFOX6) with
bevacizumab (BV) or cetuximab (CET) for patients (pts) with KRAS wild-type (wt) untreated
metastatic adenocarcinoma of the colon or re. ASCO Meet Abstr. 2014;32(Suppl 15):LBA3.
http://hwmaint.meeting.ascopubs.org/cgi/content/abstract/32/15_suppl/LBA3. Accessed 14
Dec 2015.
7. Scoggins CR, Meszoely IM, Blanke CD, Beauchamp RD, Leach SD. Nonoperative manage-
ment of primary colorectal cancer in patients with stage IV disease. Ann Surg Oncol.
1999;6(7):651–7. http://www.scopus.com/inward/record.url?eid=2-s2.0-0032699922&partne
rID=tZOtx3y1.
8. Ruo L, Gougoutas C, Paty PB, Guillem JG, Cohen AM, Wong WD. Elective bowel resection
for incurable stage IV colorectal cancer: prognostic variables for asymptomatic patients. J Am
Coll Surg. 2003;196(5):722–8. doi:10.1016/S1072-7515(03)00136-4.
9. McCahill LE, Yothers G, Sharif S, et al. Primary mFOLFOX6 Plus Bevacizumab without
resection of the primary tumor for patients presenting with surgically unresectable metastatic
colon cancer and an intact asymptomatic colon cancer: definitive analysis of NSABP trial
C-10. J Clin Oncol. 2012;30(26):3223–8. doi:10.1200/JCO.2012.42.4044.
10. Benoist S, Pautrat K, Mitry E, Rougier P, Penna C, Nordlinger B. Treatment strategy for
patients with colorectal cancer and synchronous irresectable liver metastases. Br J Surg.
2005;92(9):1155–60. doi:10.1002/bjs.5060.
11. Poultsides GA, Servais EL, Saltz LB, et al. Outcome of primary tumor in patients with syn-
chronous stage IV colorectal cancer receiving combination chemotherapy without surgery as
initial treatment. J Clin Oncol. 2009;27(20):3379–84. doi:10.1200/JCO.2008.20.9817.
12. Temple LKF, Hsieh L, Wong WD, Saltz L, Schrag D. Use of surgery among elderly patients
with stage IV colorectal cancer. J Clin Oncol. 2004;22(17):3475–84. doi:10.1200/
JCO.2004.10.218.
13. Saltz LB, Cox JV, Blanke C, et al. Irinotecan plus fluorouracil and leucovorin for metastatic
colorectal cancer. Irinotecan Study Group. N Engl J Med. 2000;343(13):905–14. doi:10.1056/
NEJM200009283431302.
14. Rothenberg ML, Oza AM, Bigelow RH, et al. Superiority of oxaliplatin and fluorouracil-
leucovorin compared with either therapy alone in patients with progressive colorectal cancer
after irinotecan and fluorouracil-leucovorin: interim results of a phase III trial. J Clin Oncol.
2003;21(11):2059–69. doi:10.1200/JCO.2003.11.126.
15. Giessen C, von Weikersthal LF, Hinke A, et al. A randomized, phase III trial of capecitabine
plus bevacizumab (Cape-Bev) versus capecitabine plus irinotecan plus bevacizumab (CAPIRI-
Bev) in first-line treatment of metastatic colorectal cancer: the AIO KRK 0110 trial/ML22011
trial. BMC Cancer. 2011;11:367. doi:10.1186/1471-2407-11-367.
16. Bokemeyer C, Van Cutsem E, Rougier P, et al. Addition of cetuximab to chemotherapy as first-
line treatment for KRAS wild-type metastatic colorectal cancer: pooled analysis of the
CRYSTAL and OPUS randomised clinical trials. Eur J Cancer. 2012;48(10):1466–75.
doi:10.1016/j.ejca.2012.02.057.
17. Mayer RJ, Van Cutsem E, Falcone A, et al. Randomized trial of TAS-102 for refractory
metastatic colorectal cancer. N Engl J Med. 2015;372(20):1909–19. doi:10.1056/
NEJMoa1414325.
18. Grothey A, Van Cutsem E, Sobrero A, et al. Regorafenib monotherapy for previously treated
metastatic colorectal cancer (CORRECT): an international, multicentre, randomised, placebo-
controlled, phase 3 trial. Lancet (London, England). 2013;381(9863):303–12. doi:10.1016/
S0140-6736(12)61900-X.
19. Saltz LB, Clarke S, Díaz-Rubio E, et al. Bevacizumab in combination with oxaliplatin-based
chemotherapy as first-line therapy in metastatic colorectal cancer: a randomized phase III
study. J Clin Oncol. 2008;26(12):2013–9. doi:10.1200/JCO.2007.14.9930.
20. Hurwitz H, Fehrenbacher L, Novotny W, et al. Bevacizumab plus irinotecan, fluorouracil, and
leucovorin for metastatic colorectal cancer. N Engl J Med. 2004;350(23):2335–42. doi:10.1056/
NEJMoa032691.
M. Pezold et al.
151
21. Cirocchi R, Trastulli S, Abraha I, et al. Non-resection versus resection for an asymptomatic
primary tumour in patients with unresectable stage IV colorectal cancer. Cochrane Database
Syst Rev. 2012;8. http://www.scopus.com/inward/record.url?eid=2-s2.0-84866761228&partn
erID=tZOtx3y1.
22. Clancy C, Burke JP, Barry M, Kalady MF, Calvin CJ. A meta-analysis to determine the effect
of primary tumor resection for stage IV colorectal cancer with unresectable metastases on
patient survival. Ann Surg Oncol. 2014;21(12):3900–8. doi:10.1245/s10434-014-3805-4.
23. Platell C. A randomised phase III multicentre trial evaluating the role of palliative surgical
resection of the primary tumour in patients with metastatic colorectal cancer. In:
ACTRN12609000680268; 2012.
24. Obichere. Chemotherapy with or without surgery in treating patients with metastatic colorectal
cancer that cannot be removed by surgery. In: ClinicalTrials.gov Study No. NCT01086618; 2012.
25. Rahbari NN, Lordick F, Fink C, et al. Resection of the primary tumour versus no resection
prior to systemic therapy in patients with colon cancer and synchronous unresectable metasta-
ses (UICC stage IV): SYNCHRONOUS—a randomised controlled multicentre trial
(ISRCTN30964555). BMC Cancer. 2012;12:142. doi:10.1186/1471-2407-12-142.
26. ’t Lam-Boer J, Mol L, Verhoef C, et al. The CAIRO4 study: the role of surgery of the primary
tumour with few or absent symptoms in patients with synchronous unresectable metastases of
colorectal cancer--a randomized phase III study of the Dutch Colorectal Cancer Group
(DCCG). BMC Cancer. 2014;14:741. doi:10.1186/1471-2407-14-741.
27. Yoon YS, Kim CW, Lim S-B, et al. Palliative surgery in patients with unresectable colorectal
liver metastases: a propensity score matching analysis. J Surg Oncol. 2014;109(3):239–44.
doi:10.1002/jso.23480.
28. Yun J-A, Huh JW, Park YA, et al. The role of palliative resection for asymptomatic primary
tumor in patients with unresectable stage IV colorectal cancer. Dis Colon Rectum.
2014;57(9):1049–58. doi:10.1097/DCR.0000000000000193.
29. Karoui M, Roudot-Thoraval F, Mesli F, et al. Primary colectomy in patients with stage IV
colon cancer and unresectable distant metastases improves overall survival: results of a multi-
centric study. Dis Colon Rectum. 2011;54(8):930–8. doi:10.1097/DCR.0b013e31821cced0.
30. Tarantino I, Warschkow R, Worni M, et al. Prognostic relevance of palliative primary tumor
removal in 37,793 metastatic colorectal cancer patients: a population-based propensity score-
adjusted trend analysis. Ann Surg. 2015;262(1):112–20. doi:10.1097/SLA.0000000000000860.
31. Seo GJ, Park JW, Yoo SB, et al. Intestinal complications after palliative treatment for asymp-
tomatic patients with unresectable stage IV colorectal cancer. J Surg Oncol. 2010;102(1):94–9.
doi:10.1002/jso.21577.
32. Ferrand F, Malka D, Bourredjem A, et al. Impact of primary tumour resection on survival of
patients with colorectal cancer and synchronous metastases treated by chemotherapy: results
from the multicenter, randomised trial Fédération Francophone de Cancérologie Digestive
9601. Eur J Cancer. 2013;49(1):90–7. doi:10.1016/j.ejca.2012.07.006.
33. Watanabe A, Yamazaki K, Kinugasa Y, et al. Influence of primary tumor resection on survival
in asymptomatic patients with incurable stage IV colorectal cancer. Int J Clin Oncol.
2014;19(6):1037–42. doi:10.1007/s10147-014-0662-x.
34. Matsumoto T, Hasegawa S, Matsumoto S, et al. Overcoming the challenges of primary tumor man-
agement in patients with metastatic colorectal cancer unresectable for cure and an asymptomatic
primary tumor. Dis Colon Rectum. 2014;57(6):679–86. doi:10.1097/DCR.0000000000000025.
35. Tsang WY, Ziogas A, Lin BS, et al. Role of primary tumor resection among chemotherapy-
treated patients with synchronous stage IV colorectal cancer: a survival analysis. J Gastrointest
Surg. 2014;18(3):592–8. doi:10.1007/s11605-013-2421-0.
36. Chan TW, Brown C, Ho CC, Gill S. Primary tumor resection in patients presenting with meta-
static colorectal cancer: analysis of a provincial population-based cohort. Am J Clin Oncol.
2010;33(1):52–5. doi:10.1097/COC.0b013e31819e902d.
37. Ahmed S, Fields A, Pahwa P, et al. Surgical resection of primary tumor in asymptomatic or
minimally symptomatic patients with stage IV colorectal cancer: a Canadian province experi-
ence. Clin Colorectal Cancer. 2015;14(4):e41–7. doi:10.1016/j.clcc.2015.05.008.
14 Utility of Primary Tumor Resection in Asymptomatic
www.ebook3000.com
152
38. Verberne CJ, de Bock GH, Pijl MEJ, Baas PC, Siesling S, Wiggers T. Palliative resection of
the primary tumour in stage IV rectal cancer. Colorectal Dis. 2012;14(3):314–9.
doi:10.1111/j.1463-1318.2011.02618.x.
39. Venderbosch S, de Wilt JH, Teerenstra S, et al. Prognostic value of resection of primary tumor
in patients with stage IV colorectal cancer: retrospective analysis of two randomized studies
and a review of the literature. Ann Surg Oncol. 2011;18(12):3252–60. doi:10.1245/
s10434-011-1951-5.
40. Cetin B, Kaplan MA, Berk V, et al. Bevacizumab-containing chemotherapy is safe in patients
with unresectable metastatic colorectal cancer and a synchronous asymptomatic primary
tumor. Jpn J Clin Oncol. 2013;43(1):28–32. doi:10.1093/jjco/hys175.
41. Boselli C, Renzi C, Gemini A, et al. Surgery in asymptomatic patients with colorectal cancer
and unresectable liver metastases: the authors’ experience. Onco Targets Ther. 2013;6:267–72.
doi:10.2147/OTT.S39448.
42. Diakos CI, Charles KA, McMillan DC, Clarke SJ. Cancer-related inflammation and treatment
effectiveness. Lancet Oncol. 2014;15(11):e493–503. doi:10.1016/S1470-2045(14)70263-3.
43. Turner N, Tran B, Tran PV, et al. Primary tumor resection in patients with metastatic colorectal
cancer is associated with reversal of systemic inflammation and improved survival. Clin
Colorectal Cancer. 2015;14(3):185–91. doi:10.1016/j.clcc.2015.02.004.
44. Maeda K, Shibutani M, Otani H, et al. Prognostic value of preoperative inflammation-based
prognostic scores in patients with stage IV colorectal cancer who undergo palliative resection
of asymptomatic primary tumors. Anticancer Res. 2013;33(12):5567–74. http://www.scopus.
com/inward/record.url?eid=2-s2.0-84891454298&partnerID=tZOtx3y1.
45. NCCN. Clinical Practice Guideliens in Oncology. Colon Cancer. NCCN.org.
46. Schrag D, Weiser MR, Goodman KA, et al. Neoadjuvant chemotherapy without routine use of
radiation therapy for patients with locally advanced rectal cancer: a pilot trial. J Clin Oncol.
2014;32(6):513–8. doi:10.1200/JCO.2013.51.7904.
M. Pezold et al.
153© Springer International Publishing Switzerland 2017
N. Hyman, K. Umanskiy (eds.), Difficult Decisions in Colorectal Surgery,
Difficult Decisions in Surgery: An Evidence-Based Approach,
DOI 10.1007/978-3-319-40223-9_15
Chapter 15
Management of Large Sessile Cecal Polyps
Brett Howe and Richard L. Whelan
Overview/Introduction
The subject matter of this chapter are large sessile adenomas of the cecum. The
audience is presumed to be general or colorectal surgeons who regularly perform
colonoscopy. This chapter is intended for a Western audience. It is important to note
that the literature referenced in this chapter pertains to large bowel adenomas and is
not necessarily specific to cecal lesions.
It is important to realize from the outset that there is presently a huge gulf
between the Far East and the Western Hemisphere regarding the treatment of large
sessile polyps. The high incidence of gastric cancer in Japan led to aggressive
screening programs that were applied nationwide in an effort to detect premalignant
lesions and cancers at an early stage. The technique of Endoscopic Mucosal
Resection (EMR), now a piecemeal resection method, was initially used to obtain
large gastric biopsies. Endoscopic Submucosal Dissection (ESD), which allows en
bloc excision of mucosal lesions with normal tissue margins after submucosal injec-
tions to ‘lift’ the lesion off of the muscularis propria, was next developed for the
management of early gastric cancer [1]. After learning and mastering these methods
in the thick walled stomach a subset of Japanese endoscopists ventured into the
large bowel more than a decade ago. Presently, large sessile polyps in all parts of the
colon are routinely removed via ESD methods in Japan and other countries in the
Far East with completion rates ranging from 80 to 91.5 %, a bleeding rate between
0 and 1.5 %, and perforation rates of 1.4–10.4 % [2–8].
B. Howe, MD • R.L. Whelan, MD (*)
Mount Sinai School of Medicine, Mount Sinai West Hospital,
New York, NY, USA
e-mail: rwhelan@chpnet.org
www.ebook3000.com
154
It should be noted that there are experts who believe that EMR (and not ESD) is
the preferred method for removal of large sessile polyps outside the operating room
setting [9–11]. Certainly, EMR is, by far, the more commonly used polypectomy
method world wide. A clear disadvantage of EMR is that piecemeal resection makes
it impossible to confirm complete resection via pathologic analysis.
It is also important to understand that there is also a large gap between the Far
East and West as regards the ability to accurately distinguish between adenomas,
advanced dysplastic lesions, and superficial cancers based on a lesion’s surface
appearance in the absence of tissue biopsies. Currently used methods include
chromoendoscopy (use of surface dyes to reveal polyp surface anatomy and pit
patterns), narrow band imaging, and magnification (via endoscope up to 150 X).
A separate endoscopic examination may be performed wherein some or all of
the above methods are applied to a large polyp and many photos obtained; in
many centers this data is reviewed by experts at a polyp staging conference [akin
to a tumor board] at which time a consensus diagnosis is made. The ability of
these methods to distinguish between adenomas with varying degrees of dyspla-
sia, SM-1 cancer, and SM-2 cancer has been verified in numerous large case
series [12–16]. The end result is that in Japan far fewer colectomies are done for
large benign sessile colorectal adenomas and noninvasive highly dysplastic
lesions.
At present, a relatively small subset of Western gastroenterologists, are learning
and employing these techniques in a limited number of centers. In an effort to avoid
colectomy and its attendant morbidity and mortality, several combined surgical and
endoscopic polyp removal methods have also been developed and utilized [17–19].
Nonetheless, the vast majority of large sessile lesions in the U.S. are still treated via
segmental colectomy, most often a standard oncologic resection. An assumption of
this chapter is that, where safe and feasible, avoidance of colectomy is desirable.
It should also be noted that the endoscopic and combined endoscopic/laparo-
scopic skill sets and experience of surgeons varies greatly in the U.S. and that we
are on the threshold of substantial changes in this arena. This reality makes general
recommendations applicable to all settings impossible. Each surgeon must look
within their medical/surgical community and, perhaps, refer patients to interven-
tionalists familiar with advanced polypectomy methods or combined laparoscopic/
endoscopic methods. Alternately, having made the commitment to learn one or
more of these newer methods, appropriate training and skills acquisition must take
place prior to embarking on the employment of these techniques. The learning pro-
cess is facilitated by identifying an interested and experienced surgical colleague
who is willing to participate in these cases. The consent process must be honest and
fully explain the potential benefits and complications of the new methods. When
performed by surgeons, in the authors’ opinion, these procedures are best carried
out in the operating room. Also, it is advised that a broad consent be obtained that
gives permission for either endoscopic or laparoscopic surgical removal of the
polyp, via wedge resection or standard colectomy. In the authors institution, these
cases are covered by an Institutional Review Board (IRB) approved protocol and an
IRB consent is obtained prior to surgery [19].
B. Howe and R.L. Whelan
155
Treatment Options
Polyp treatment options include: (1) EMR (standard piecemeal snare polypectomy
with/without saline lift), (2) ESD polypectomy, (3) laparoscopic-facilitated colono-
scopic piecemeal polypectomy, (4) “wedge” partial circumference cecectomy, (5)
standard segmental bowel resection. As mentioned, although ESD experts perform
the procedure in the endoscopy suite, presently, in the U.S., the small number of
surgical endoscopists performing ESD or EMR for the large and most challenging
polyps do so in the operating room usually under general anesthesia. In this way,
after the ESD is completed, a laparoscopy can be performed to inspect the bowel for
perforations or weaknesses which, if found, can be closed with seromuscular
sutures. Alternately, if the ESD/EMR attempt fails, then the polyp can be removed
surgically (wedge or segmental resection). Of note, it is mandatory that CO2 gas be
used for endoscopic insufflation of the large bowel when ESD or EMR is performed
in conjunction with laparoscopy in order to avoid bowel distension and loss of the
operative field.
A brief discussion of these methods follows:
EMR and Laparoscopic Inspection
It is strongly advised that a submucosal lift be established prior to snare polypec-
tomy EMR. The lift makes full thickness perforation less likely by increasing the
distance between the muscularis propria and the lesion. Also, failure of a part of
the lesion to lift alerts the endoscopist to the possibility that a cancer may be pres-
ent and invading into the deep muscular layer (vs. scarring from a prior removal
attempt). It is important that a concerted effort be made to fully remove the polyp
during the first attempt since subsequent efforts will be more difficult and associ-
ated with a higher perforation risk due to scarring between the mucosa and muscu-
laris propria. As regards bleeding, rates between 3.1 and 11.3 % have been reported
in EMR series [20–22]. After successful completion of the EMR, a laparoscopy
may be performed to evaluate the bowel wall integrity and repair or to reinforce the
bowel wall if needed. In failed cases a laparoscopic bowel resection can be carried
out.
ESD and Laparoscopic Inspection
The following tools are necessary for ESD: lifting solution, sclerotherapy catheter,
needle knife (variety available), dissection cap (fits on scope tip and facilitates
submucosal dissection), polypectomy snare (specialty snares available), and,
importantly, a high frequency electrosurgical current generator (HFEC, that
15 Management of Large Sessile Cecal Polyps
www.ebook3000.com
156
provides pulsed, adjustable currents). A More detailed description of the method
can be found elsewhere. Briefly, the patient is positioned so that the lesion is “up”.
After injection of the lifting solution (usually with methylene blue added) the
resection margin is superficially marked with the knife (HFEC soft coagulation
setting) after which the mucosa is fully scored for about 25–35 % of the circumfer-
ence. Next the cut mucosal edge is undermined with the knife creating a submuco-
sal pocket into which the scope tip (with dissection cap affixed) is inserted; the
submucosal dissection is then continued beneath the lesion. As needed, the cir-
cumference of the specimen is completely scored. Gravity assists by retracting the
partly detached polyp. A snare may be used to complete the resection. Clips may
be used to close to the mucosal defect. As for EMR, laparoscopic inspection and
repair of the bowel wall (vs wedge or ileocolectomy if major injury is found) may
be performed after ESD completion.
Laparoscopic-Facilitated Colonoscopic Polypectomy Method
Milsom, Franklin, and Lee have championed this method carried out in the operat-
ing room wherein a piecemeal colonoscopic EMR is carried out after submucosal
lift with the help of simultaneous extrinsic manipulation of the polyp and colon
segment via laparoscopic instruments. After polypectomy the bowel wall is
inspected (after submersion under water) via laparoscope and endoscope. Full
thickness injuries and smaller perforations are repaired laparscopically with sero-
muscular sutures. The specimens are removed transanally. If necessary, a laparo-
scopic segmental colectomy can be performed. This method requires an experienced
laparoscopist in addition to an expert endoscopist. The laparoscopic bowel manipu-
lation is challenging and more dangerous than usual because the colon (and possi-
bly the small bowel) is fully insufflated which notably decreases the operative
working space [17–19].
Laparoscopic “Wedge” Partial Circumference Full Thickness
Resection
This method is an option for well placed cecal lesions. A laparoscopic linear GIA
type stapler is used to resect a portion of the cecum containing the polyp (identified
via tattooing and simultaneous colonoscopy). It is critical that the ileocecal (IC)
valve be protected and that the polyp be fully removed. The authors recommend that
the stapler be applied only after the colonoscope has been inserted into the terminal
ileum (protects the valve and TI). After closing the stapler, the colonoscope is with-
drawn into the right colon and the stapler’s position assessed. After resection, the
cecal specimen must be removed from the abdomen and then opened and inspected.
B. Howe and R.L. Whelan
157
If the margin is in question, frozen sections should be obtained. If a clean margin is
not obtained then either more cecum need be removed or an ileocectomy performed.
Practically, it is very difficult to wedge resect polyps that lie between the appendi-
ceal orifice and the IC valve because either the IC valve may need to be partially
resected or the polypectomy is incomplete [17, 19].
Standard Segmental Bowel Resection
Performed laparoscopically, when necessary. The main question here is whether to
do a limited ileocectomy (as for Crohn’s disease) vs a standard oncologic right
hemicolectomy. It is the author’s preference to do a right hemicolectomy because of
the risk that an invasive cancer will be found on final pathology.
Treatment Algorithm
It is also not possible to provide a simple algorithm for the treatment of sessile cecal
polyps because specific characteristics of the polyp (size, degree of dysplasia, fail-
ure to lift, etc.) and the specific location of the polyp (involvement of ileocecal valve
or appendiceal orifice) may dictate treatment. Table 15.1 provides the treatment
option(s) for each of these situations.
Cecal Polyp (Large Sessile)
Prohibitively large polyp
OR high suspicion for
malignancy based on
colonoscopy in OR
Involvement of
Ileocecal valve
Involvement of the
base of the
appendix
High grade
dysplasia with
majority of lesion
still in place
Nonlifting
polyp
All other
polyps
See
Table 2
EMR
Wedge
Resection
Right Colectomy
Wedge
Resection
Ileocolectomy
(versus Right
Colectomy)
Ileocolectomy
(versus Right
Colectomy)
Ileocolectomy
(versus Right
Colectomy)
Right Colectomy
Table 15.1 Treatment algorithm for large sessile cecal polyps
15 Management of Large Sessile Cecal Polyps
www.ebook3000.com
158
Polyp Characteristics
Very large size is a relative contraindication for endoscopic removal (the skill set of
the endoscopist is also a factor); polyps that involve the great majority of the cecum
are best dealt with via bowel resection.
Regarding large sessile polyps for which prior biopsies show high grade dyspla-
sia and where the majority of the polyp remains in place; the two largest series sug-
gest that there is a 30–41% chance of there being invasive cancer on final pathology
[23, 24]. Given the present inability of the vast majority of Western endoscopists to
make the distinction between a highly dysplastic polyp and a cancer based on the
surface appearance or other means, the authors recommend a standard oncologic
right colectomy for patients with large sessile adenomas with high grade
dysplasia.
Polyps that do not fully “lift” with submucosal injection also pose a problem.
Failure to lift may signify either the presence of cancer invading into the muscularis
propria or a scar that is the residua of prior polypectomy attempts. The treatment
options in this situation are: EMR via snare, wedge partial circumference full thick-
ness resection, or ileocolectomy (vs right hemicolectomy).
Location
ESD and complete EMR are not options for lesions involving the ileocecal valve or
appendix base since the inner polyp edge and margin may not be visible or acces-
sible. The appropriate treatment for the former is an ileocolic bowel resection (vs
right colectomy) whereas for the latter a wedge resection may be possible vs. an
ileocolectomy.
Algorithm (for Polyps That Do Not Fall into the Above
Categories) (Table 15.2)
As stated, an assumption has been made that surgical endoscopists would perform
these advanced colonoscopic procedures in the operating room in conjunction with
laparoscopy. Since there are multiple advanced colonoscopic methods that can be
used and because the preference and experience of each surgeon will largely deter-
mine the method chosen, the algorithm includes all 3 methods.
The ESD and EMR methods are listed side by side in the table since the algo-
rithm for each is the same. After successful polypectomy, laparoscopy is done to
interrogate the bowel for perforations and to repair the bowel wall with seromuscu-
lar sutures, if necessary. If the polypectomy is not successful, a wedge resection
would be carried out, if feasible. Laparoscopic-assisted colectomy is reserved for
B. Howe and R.L. Whelan