Local excision is gaining acceptance as standard treatment for T1 colon cancer (CC); however, not all patients are eligible for endoscopic resection. Colonoscopy-assisted laparoscopic wedge resection (CAL-WR) is a relatively new technique that could fill the gap between endoscopic resection and major surgery. The aim of this study was to analyze the oncological safety of CAL-WR for CC.

A retrospective cohort study was performed, including patients that underwent CAL-WR for CC. Exclusion criteria were double tumors, <1 year follow-up, previous other colorectal malignancy, inflammatory bowel disease or synchronous metastases. The primary outcome was disease recurrence and the secondary outcome was overall survival.

Fifty-three patients were included; 35 patients were diagnosed with T1 CC. CAL-WR was radical (R0) for all T1 CC in 94.3% and 94.7% for tumors with deep submucosal invasion (sm2-3 Kikuchi). The mean follow-up was 3.3 years (Q1: 2.0; Q3: 4.3) for disease recurrence and 4.2 years (Q1: 2.8; Q3: 5.2) for overall survival. None of the patients with T1 CC had disease recurrence or died due to their malignancy. There were 14 patients with a T2 and 4 patients with a T3 CC, 17/18 patients underwent completion surgery. Three patients with T2 and one with T3 CC developed a locoregional recurrence (peritoneal). One patient with T3 CC developed lung metastases. Two patients with T3 and one with T2 CC died due to their malignancy.

This study suggests that CAL-WR is oncologically safe as treatment for T1 CC. The safety of incidental CAL-WR for >T1 CC, followed by completion surgery, remains unclear. Prospective studies are needed to evaluate these results.

Major innovation into how we pursue diagnosis and therapies for gastrointestinal (GI) diseases is urgently needed to seek better, less invasive, and less costly innovations in diagnostic and therapeutic interventions in the GI tract. Learning from prior paradigm shifts in cardiac and vascular we present here several initial steps we have undertaken to follow the endoluminal path, using advanced imaging methods, including endoscopy, and data management with avoidance of entry into a body cavity when possible. We will review the benefit and ease of incorporating routine fluoroscopy with endoscopy to improve safety and efficiency. We describe the development of "hybrid" procedure rooms for GI interventions and rationale for their use. We also emphasize the importance of collaborating with interventional radiologists, software engineers, and data specialists. We predict major improvement in outcomes in both diagnosis and treatment will follow.

Advanced endoscopy has been shown to be useful in the diagnosis and treatment of both benign and low-grade malignant colorectal lesions. In fact, advanced endoscopic procedures are being adopted as standard approaches to these lesions in many places around the world; however, their implementation in the United States has not been as widespread. We ascribe the difficulty in implementation to two reasons: (1) lack of advanced endoscopic training and (2) failure in reimbursement models as they relate to endoscopy. In this article, we hope to describe these barriers and inspire colorectal surgeons to try and overcome them. As surgical specialists with a mastery of endoscopic techniques, colorectal surgeons would be able to maximize benefit for their patients and minimize health care costs in the long run.

The current literature describes a variety of techniques detailed under the name of combined endoscopic-laparoscopic surgery (CELS) procedures. This systematic review of literature assessed the outcomes of colonoscopic-assisted laparoscopic-wedge resection (CAL-WR) in particular to evaluate its feasibility to remove colonic lesions that do not qualify for endoscopic resection.

Electronic databases (PubMed, Embase, and Cochrane) were searched for studies evaluating CAL-WR for the treatment of colonic lesions. Studies with missing full text, language other than English, systematic reviews, and studies with fewer than ten patients were excluded. The quality of the studies was assessed using the Newcastle-Ottawa Scale.

Out of 68 results, duplicate studies (n = 27) as well as studies that did not meet the inclusion criteria (n = 32) were removed. Nine studies were included, encompassing 326 patients who underwent a CAL-WR of the colon. The technical success rate varied from 93 to 100%, with an R0 resection rate of 91-100%. Morbidity ranged from 6% to 20%. The quality of the included studies was rated as low to moderate and contained heterogeneous terminology, methodology, and outcome measures.

There is insufficient high-quality data and substantial variation in outcome measures to draw firm conclusions regarding the value of CAL-WR. Although CAL-WR is a promising local resection technique for endoscopically unremovable neoplasms of the colon, further investigation of this technique in well-designed prospective, multicenter studies with predefined outcome measures is required.Trial registration: A protocol for this systematic review was registered in PROSPERO with the number CRD42023407966.

Combined endoscopic robotic surgery is a surgical technique that modifies traditional endoscopic laparoscopic surgery with robotic assistance to aid in the removal of complex colonic polyps. This technique has been described in the literature but lacks patient follow-up data.

This study aimed to evaluate the safety and outcomes of combined endoscopic robotic surgery.

A retrospective review of a prospective database.

East Jefferson General Hospital, Metairie, Louisiana.

Ninety-three consecutive patients who underwent combined endoscopic robotic surgery from March 2018 to October 2021 were included in the study.

Operative time, intraoperative complication, 30-day postoperative complication, hospital length of stay, and follow-up pathology report results were the main outcome measures.

Combined endoscopic robotic surgery was completed in 88 of 93 participants (95%). Among the 88 participants who completed combined endoscopic robotic surgery, the average age was 66 years (SD = 10), BMI was 28.8 kg/m 2 (SD = 6), and history of previous abdominal surgeries was 1 (SD = 1). Median operative time was 72 minutes (range, 31-184 minutes) and polyp size was 40 mm (range, 5-180 mm). The most common polyp locations were the cecum, ascending colon, and transverse colon (31%, 28%, 25%). Pathology mainly demonstrated tubular adenoma (76%). Data on 40 patients who underwent follow-up colonoscopy were available. The average follow-up time was 7 months (range, 3-22 months). One patient (2.5%) had polyp recurrence at the resection site.

Limitations for our study include a lack of randomization and follow-up rate to assess for recurrence. The low compliance rate may be due to procedure cancelations/difficulty scheduling because of changing coronavirus disease 2019 guidelines.

Compared to literature-reported statistics for its laparoscopic counterpart, combined endoscopic robotic surgery was associated with decreased operation times and resection site polyp recurrence. See Video Abstract at http://links.lww.com/DCR/C208 .

ANTECEDENTES:La cirugía robótica endoscópica combinada es una técnica quirúrgica que modifica la cirugía laparoscópica endoscópica tradicional con asistencia robótica para ayudar en la extracción de pólipos colónicos complejos. Esta técnica está previamente descrita en la literatura, pero carece de datos de seguimiento de los pacientes.OBJETIVO:Evaluar la seguridad y los resultados de la cirugía robótica endoscópica combinada.DISEÑO:Revisión retrospectiva de una base de datos prospectiva.AJUSTE:Hospital General East Jefferson, Metairie LouisianaPACIENTES:Noventa y tres pacientes consecutivos y sometidos a cirugía robótica endoscópica combinada por un solo cirujano colorrectal desde marzo de 2018 hasta octubre de 2021.PRINCIPALES MEDIDAS DE RESULTADO:Tiempo operatorio, complicación intraoperatoria, complicación posoperatoria a los 30 días, duración de la estancia hospitalaria y resultados del informe patológico de seguimiento.RESULTADOS:La cirugía robótica endoscópica combinada se completó en 88 de 93 (95%). Entre los 88 participantes que completaron la cirugía robótica endoscópica combinada, la edad promedio fue de 66 años (desviación estándar = 10), índice de masa corporal de 28,8 (desviación estándar = 6) y el historial de cirugías abdominales previas de 1 (desviación estándar = 1). La mediana del tiempo operatorio y el tamaño de los pólipos fueron 72 minutos (rango 31-184 minutos) y 40 milímetros (rango 5-180 milímetros), respectivamente. Las ubicaciones de pólipos más comunes fueron el ciego, colon ascendente y transverso (31%, 28%, 25%). La patología demostró principalmente adenoma tubular (76%). Los datos de 40 pacientes sometidos a una colonoscopia de seguimiento estaban disponibles. El tiempo medio de seguimiento fue de 7 meses (rango 3-22 meses). Un paciente (2,5%) presentó recurrencia polipoidea en el sitio de resección.LIMITACIONES:Las limitaciones de nuestro estudio incluyeron la falta de aleatorización y la tasa de seguimiento para evaluar la recurrencia. La baja tasa de seguimiento puede deberse a la renuencia del paciente en hacerse una colonoscopia o cancelaciones de procedimientos por la dificultad para programar debido a cambios de COVID-19.CONCLUSIÓN:En comparación con las estadísticas reportadas en la literatura para su contraparte laparoscópica, la cirugía robótica endoscópica combinada se asoció con reducción en tiempos de operación y recurrencia de pólipos en el sitio de resección. Consulte Video Resumen en http://links.lww.com/DCR/C208 . (Traducción - Dr. Fidel Ruiz Healy ).

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.

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.

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%).

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.

The study objective was to evaluate combined endoscopic and robotic surgery, a novel surgical technique modifying traditional combined endoscopic laparoscopic surgery through robotic assistance, and characterize a series of patients who underwent the modified operative technique.

A retrospective case series was performed. The first thirty-seven consecutive patients who underwent combined endoscopic robotic surgery by a single colorectal surgeon from March 2018 to October 2019 were included. Main outcome measures included operative time, intra-operative complication, 30-day post-operative complication, and hospital length of stay.

Combined endoscopic and robotic surgery was performed in 37 cases, 32 (86.5%) of which saw the technique through to completion. Median operative room time was 73 min (range 31-184 min). No intraoperative complications occurred and 2 (6.3%) experienced 30-day post-operative complications. Median hospital length of stay was 1.1 days (range 0.2-2.0 days). Median polyp size was 35 mm (range 20-130 mm). Polyps were resected from the following locations: cecum (37.5%), ascending colon (28.1%), transverse colon (21.9%), descending colon (3.1%), sigmoid colon (6.3%), and rectum (3.1%). Pathology demonstrated 77.4% tubular adenoma, 12.9% sessile serrated adenoma, 6.5% dysplasia, and 3.2% signet cell adenocarcinoma.

Combined endoscopic robotic surgery was associated with decreased operative time, complication rates, and hospital length of stay compared to literature-reported statistics for combined endoscopic laparoscopic surgery. Increased confidence with 3-dimensional visualization and intracorporeal suturing using combined endoscopic and robotic surgery was noted. Additional studies are needed to further define the role of robotics in combined endoscopic surgery.

Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment.

Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated.

Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5-6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82.4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study.

CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

The aim of this study was to evaluate the safety and efficacy of a modified colonoscopic-assisted laparoscopic wedge resection.

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.

This prospective multicentre 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 pT1 colon carcinoma. Thirty-day morbidity, technical success rate and radicality were evaluated.

Of the 118 patients included (56% male, mean age 66 years, SD ± 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.

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.

"Endoscopically unresectable" benign polyps identified during screening colonoscopy are often referred for segmental colectomy. Application of advanced endoscopic techniques can increase endoscopic polyp resection, sparing patients the morbidity of colectomy. This retrospective case-control study aimed to evaluate the success of colon preserving resection of "endoscopically unresectable" benign polyps using advanced endoscopic techniques including endoscopic mucosal resection, endoscopic submucosal dissection, endoluminal surgical intervention, full-thickness laparo-endoscopic excision, and combined endo-laparoscopic resection.

A prospectively maintained institutional database identified 95 patients referred for "endoscopically unresectable" benign polyps from 2015 to 2018. Cases were compared to 190 propensity score matched controls from the same database undergoing elective laparoscopic colectomy for other reasons. Primary outcome was rate of complete endoscopic polyp removal. Secondary outcomes included length of stay, unplanned 30-day readmission and reoperation, 30-day mortality, and post-procedural complications.

Advanced endoscopic techniques achieved complete polyp removal without colectomy in 66 patients (70%). Failure was most commonly associated with previously attempted endoscopic resection and occult malignancy. Compared with matched colectomy controls, endoscopic polyp resection resulted in significantly shorter hospital length of stay (1.13 ± 2.41 vs 3.89 ± 4.57 days; p < 0.001), lower unplanned 30-day readmission (1.1% vs 7.7%; p < 0.05), and fewer postoperative complications (4.2% vs 33.9%; p < 0.001). Unplanned 30-day reoperation (2.1% vs 4.4%; p = 0.34) and 30-day mortality (0% vs 0.6%; p = 0.75) trended lower.

Endoscopic resection of complex polyps can be highly successful, and it is associated with favorable outcomes and decreased morbidity when compared with segmental colon resection. Attempting colon preservation using these techniques is warranted.

Combined endoscopic and laparoscopic surgery (CELS) has emerged as a promising method for managing complex benign lesions that would otherwise require major colonic resection. The aim of this study was to describe the different techniques and to evaluate the safety of CELS, assess its outcomes in a technique that is scarcely widespread in our environment.

Observational retrospective study, short-term outcomes of patients undergoing CELS for benign colon polyps from October 2018 to June 2020 were evaluated. Postoperative outcomes, length of hospital stay and pathological findings were evaluated.

Seventeen consecutive patients underwent CELS during the study period. The median size of the lesion was 3.5 cm (range 2.5 - 6.5 cm), the most frequent location was the cecum (10 from 17). Most patients treated with CELS underwent an endoscopic-assisted laparoscopic wedge resection (11 from 17). In four patients this resection was combined with another CELS technique, and two patients underwent an endoscopic-assisted laparoscopic segment resection. The success rate of CELS in our series was in 14 from 17 (82,4%). The median operative time was 85 min (range 50-225 min). The median hospital stay was 2 days (range 1-15 days). One patient experienced an organ/space surgical site infection which did not require further intervention. Four lesions were shown to be malignant by postoperative pathology study.

CELS is a safe and multidisciplinar technique that requires collaboration between gastroenterologists and surgeons. It can be considered as an alternative to colonic resection for complex benign colonic polyps.

Combined-Endoscopic-Laparoscopic-Surgery (CELS) was developed for benign colonic polyps, endoscopically unresectable, to avoid segmental colectomy. This observational study aims to compare surgical outcomes of endoscopically unresectable colonic polyps treated laparoscopically before and since the institutional introduction of CELS. Primary endpoint was postoperative morbidity and mortality; secondary endpoints were time of hospitalization and histopathological findings.

Charts of all patients with preoperative diagnosis of benign colonic tumors, treated laparoscopically at our institution from 1/2010 to 2/2020 were reviewed. Patients with polyps (1) affecting ileocecal valve, (2) occupying > 50% of the circumference, (3) ≥ 3 endoscopically unresectable polyps, (4) inflammatory bowel disease, (5) polyps within diverticular area post diverticulitis, (6) rectal polyps (7) foreseen impossibility of laparoscopy (8) preoperatively biopsy proven invasive adenocarcinoma were excluded. Group I consists of all patients potentially treatable by CELS but operated by laparoscopic colonic resection as CELS was not yet institutionally established. Group II includes all patients treated with CELS (since 11/2017).

One hundred-fifteen consecutive patients were reviewed. Applying exclusion criteria, twenty-three patients form group I and twenty-three group II (female 30.4%, median age 68 years). Groups distributed homogenously for age, BMI (body mass index) and polyps´ localization with most polyps (60.4%) localized in right colon; group II patients had significantly higher American Society of Anesthesiologists (ASA) score. Median operating time, hospital stay and morbidity were significantly less in group II. Postoperative morbidity occurred overall in 14 patients (30.4%), mostly Clavien-Dindo class I-II (26.1%) and significantly less in group II (p = 0.017), Clavien-Dindo III-IV distributed equally (one patient each group) without postoperative mortality. Definitive histopathology showed invasive adenocarcinoma in 8.3% without differences between groups. Two patients with invasive adenocarcinoma after CELS were advised for oncological resection.

CELS is safe and efficient to treat complex, benign colonic polyps by a complete minimal invasive laparoscopic approach. CELS showed better surgical outcomes with less morbidity, no mortality and appropriate pathological results avoiding unnecessary laparoscopic surgery with intestinal anastomosis.

The majority of endoscopically unresectable colon polyps (EUCP) are treated by segmental colectomy. However, up to 90% of EUCP do not harbor malignancy, making colectomy an unnecessary procedure. To minimize unnecessary segmental colectomy, we established a progressive treatment algorithm utilizing colon conservation techniques (CCT). In our progressive CCT algorithm, patients with EUCP first underwent endoscopic submucosal dissection (ESD). If unsuccessful, they progressed to combined endo-laparoscopic surgery (CELS) and ultimately to segmental colectomy, if necessary.

We performed a retrospective analysis of all patients treated by our progressive CCT algorithm from August 2015 to April 2019. Demographic information, polyp characteristics, and clinical outcomes were analyzed. We also compared the outcomes of our CCT algorithm group to 156 patients undergoing segmental colectomy for EUCP at related institutions from August 2015 to August 2018.

A total of 102 EUCP in 97 patients were treated with our progressive CCT algorithm. Of these, 76 of 102 (75.5%) EUCP were removed without requiring segmental colectomy, with 42 EUCP removed via ESD and 34 via CELS. Interval surveillance colonoscopy confirmed that 72 of 97 (74.2%) patients with EUCP treated by CCT completely avoided segmental colectomy. Polyps > 5 cm in size was a significant predictor of CCT failure (OR 3.83, P = 0.03). When compared to an external cohort of patients undergoing segmental colectomy for EUCP, the CCT algorithm was associated with longer operative time, but shorter length of stay, with no difference in postoperative complications. The estimated total healthcare cost of the CCT algorithm was lower than segmental colectomy ($10,956.77 versus $16,692.94), with more dramatic cost savings seen in ESD ($4,492.70) and CELS ($8,507.06).

An established progressive CCT algorithm can result in high colon conservation rate and decrease associated health care costs compared to segmental colectomy. It is a reasonable treatment strategy for patients with EUCP.

Colon cancer continues to be one of the leading causes of mortality and morbidity throughout the world despite the availability of reliable screening tools and effective therapies. The majority of patients with colon cancer are diagnosed at an early stage (stages I to III), which provides an opportunity for cure. The current treatment paradigm of early stage colon cancer consists of surgery followed by adjuvant chemotherapy in a select group of patients, which is directed at the eradication of minimal residual disease to achieve a cure. Surgery alone is curative for the vast majority of colon cancer patients. Currently, surgery and adjuvant chemotherapy can achieve long term survival in about two-thirds of colon cancer patients with nodal involvement. Adjuvant chemotherapy is recommended for all patients with stage III colon cancer, while the benefit in stage II patients is not unequivocally established despite several large clinical trials. Contemporary research in early stage colon cancer is focused on minimally invasive surgical techniques, strategies to limit treatment-related toxicities, precise patient selection for adjuvant therapy, utilization of molecular and clinicopathologic information to personalize therapy and exploration of new therapies exploiting the evolving knowledge of tumor biology. In this review, we will discuss the current standard treatment, evolving treatment paradigms, and the emerging biomarkers, that will likely help improve patient selection and personalization of therapy leading to superior outcomes.