PTU-052 Management of large sessile colonic polyps by intraoperative colonoscopy with laparoscopic support

Introduction Endoscopic management of large colonic polyps can be challenging, and may lead to incomplete resection/recurrence. Laparoscopic control can facilitate the endoscopic observation and approach to the lesions, and also to recognise and treat complications. Our aim was to study the feasibility and safety of intraoperative colonoscopy (IOC) in facilitating definitive treatment for complex colonic polyps otherwise deemed unsuitable for endoscopic resection. Methods Patients discussed at the MDT with complex colonic polyps (large and sessile, recurrent, non-lifting but no evidence of malignancy), deemed unsuitable for conventional endoscopic resection, were scheduled for IOC. Procedures were performed under GA with surgical support available. Depending on endoscopist’s and surgeon’s preference and after discussion, colonoscopy was performed initially without surgical access, or with laparoscopic control, that could be conventional or with single incision (SILS). A PCF-260 JL was utilised, with a soft distal attachment, ERBE 300D diathermy unit and CO2 for insufflation. Resection techniques included Endoscopic Mucosal resection (EMR), Hybrid Endoscopic Submucosal Dissection (ESD), and conventional ESD. Data on all patients undergoing IOC was collected prospectively and analysed from the hospital computer records. Results Thirteen patients underwent IOC (median age 60, IQR 59.5–75 years). Median size was 5 cm (IQR 4.5–6.7 cm). Macroscopic type was sessile with/without flat portion in 12/13 cases. Ten cases underwent endoscopic resection with laparoscopic control, 2 exclusively endoscopic resection, and one only surgical treatment. Laparoscopic interventions included SILS (2), SILS +Right hemicolectomy (1), laparoscopic control (6), laparoscopy +suture of resection site (1), laparoscopy +right hemicolectomy (2), Endoscopic interventions included EMRp (4), Hybrid ESD (8), all in more than one fragment, and without any significant complications. Median procedure time (including endoscopy and surgery) was 235 min (IQR 150–250). Histology revealed: TVA+LGD (10), TVA+HGD (2), T1 cancer (1)(0.5 mm, R0). Nine patients have undergone endoscopic follow up (median 5 months, IQR 4.25–7.5 months). There were two adenoma recurrences on follow up, managed endoscopically. Conclusion Large/complex colonic polyps can be safely resected by combined endoscopic and laparoscopic approach. In this series colectomy was avoided in 10/13 (77%) cases, with no significant complications. This combined approach should be considered in the armamentarium for the management of large/complex colonic polyps.