Ever tried peeling a gnarly, crooked carrot? The bends make it tough to peel the carrot without leaving any of the outermost layer behind. That situation is similar to the challenge your doctor faces when trying to remove colon polyps (growths) during colonoscopies. And of course, when your doctor has a problem providing needed treatment, that’s a problem for you! Fortunately, a recent breakthrough is making the job easier and safer.
Why this matters: One reason that colonoscopy is so important in the fight against colon cancer is that most polyps can be safely removed during the colonoscopy itself. Though about 85% of polyps are noncancerous, some are precancerous and some are already cancerous. The only way to be sure whether or not a particular polyp poses a cancer threat is to examine it under a microscope—which is why all polyps must be removed. No one wants to take a chance on leaving behind a polyp that could eventually turn into deadly colon cancer.
Normally a gastroenterologist uses a snare, a wire that hooks around the polyp and breaks it off the colon wall. But in about 15% of cases, the polyp is tucked behind a fold…or it’s too large for the snare…or it’s situated in such a way that, in trying to remove it, the doctor risks poking a hole in the patient’s colon. In such cases, a separate surgery called a bowel resection normally is done to cut out the affected section of the colon and then sew the two open ends together. This requires a six-to-eight-inch abdominal incision…and like all major surgery, it carries risks and requires a rather lengthy recovery.
Breakthrough: Now a new, less invasive method is poised to change the way surgeons go about getting rid of those tricky polyps that can’t be removed during colonoscopy. It still requires a procedure separate from the colonoscopy, but it has some real advantages.
The new technique involves simultaneously approaching the polyp endoscopically (from the inside, with instruments and a tiny lighted video camera inserted into the colon via the rectum, just as in a normal colonoscopy)…and laparoscopically, with tools inserted into several small incisions in the abdomen. This technique, called combined endoscopic and laparoscopic surgery (CELS), allows the gastroenterologist to grasp and remove the polyp more easily and safely, without the need for that large abdominal incision.
A recent small but encouraging study from the University of California, Los Angeles (UCLA) compared CELS to traditional bowel resection. The study included 14 patients whose polyps were too large or too awkwardly situated to be removed during their colonoscopies.
In the CELS group, patients were given general anesthesia. Then their abdomens were inflated with carbon dioxide to make it easier for the surgeon to see and maneuver inside (this gas is quickly absorbed and removed by the lungs). A gastroenterologist performed the endoscopic colonoscopy…while at the same time a surgeon, operating laparoscopically, separated the affected part of the colon from the fatty membrane that covers the abdominal organs, thus “relaxing” the colon’s folds and allowing the gastroenterologist easier access to the polyp.
How patients fared: Patients in the CELS group spent slightly less time in surgery and significantly less time in the hospital—an average of just one day, compared with five days for patients in the resection group. In the CELS group, all polyps were successfully removed and there were no complications…but among patients who had the traditional resection, one-third ended up with complications such as wound infection or bowel obstruction.
Looking ahead: In this small study, only patients whose polyps seemed most likely to be benign were eligible for the CELS group. Patients who had polyps that seemed likely to be cancerous—and therefore would require bowel resection to remove the affected portion of the colon—were automatically assigned to the resection group. The fact that their conditions were more serious may have contributed to the higher rate of complications among patients who had the traditional resection. However, before the CELS procedure was developed, all patients who were left with polyps after a colonoscopy had to have a full resection, while in this study more than one-third of the participants were able to take advantage of the less invasive CELS procedure.
CELS is currently available in the US at only a couple of major medical centers. If future studies confirm its advantages, however, CELS may well replace bowel resection for a significant percentage of patients in the not-too-distant future. To find out whether you might be a candidate for CELS, contact the UCLA Colorectal Cancer Treatment Program.
Source: James Yoo, MD, assistant professor of surgery, David Geffen School of Medicine at University of California, Los Angeles, and chief, colon and rectal surgery program, UCLA Health System, both in Los Angeles. His study was published in Surgical Endoscopy.