V5 - Cecal Polyp Resection Using Full-Thickness Laparoendoscopic Excision (FLEX)

Purpose/Background: With the increasing number of colonoscopies being performed in the United States annually, largely driven by lowered recommended screening age for colorectal cancer, polyp detection rates have also steadily increased. This increase has led to higher detection of complex polyps, often necessitating more advanced endoscopic techniques or surgical intervention for complete removal. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) enable en-bloc resection of select lesions, however complete resection is sometimes limited by anatomical constraints, polyp features, and the steep learning curve associated with these techniques. Combined endoscopic-laparoscopic surgery (CELS) has emerged as a valuable approach for the colorectal surgeon, significantly reducing the need for segmental colectomies for polyps previously deemed unresectable and thereby minimizing morbidity and mortality associated with formal bowel resection. The full-thickness laparoendoscopic excision (FLEX) technique, which is similar to CELS, enables laparoscopic wedge resection of the colon under direct endoscopic visualization. FLEX has demonstrated safety and efficacy in the excision of complex polyps. Here, we present a video demonstration of the FLEX procedure for the treatment of a cecal polyp that was unsuccessfully treated with EMR.

Methods/Interventions: The patient is a 57-year-old male with a large residual ascending colonic polyp following partial EMR. The patient initially underwent EMR with partial piecemeal removal of two polyps: a 5cm polyp in the proximal ascending colon and a 2cm polyp in the cecum. The pathology showed tubulovillous adenoma for the cecal lesion and focal high-grade dysplasia within fragments of tubulovillous adenoma extending to the tissue edges for the ascending polyp. Given the extension to the tissue edges and incomplete removal of the ascending colonic polyp, the patient was scheduled for definitive surgical resection with endoscopic assistance. The patient was taken to the operating room and placed in lithotomy position. Laparoscopic trocars were placed, and CO2 colonoscopy was performed. A scarred, multi-lobulated polyp was noted in the proximal ascending colon/cecum adjacent to the appendiceal orifice but away from the ileocecal valve (ICV). Decision was made to proceed with full-thickness laparoendoscopic excision (FLEX). A bowel grasper was used to grasp the appendix and splay out the cecum, and then an endoGIA stapler was used to resect the cecum and proximal ascending colon away from the ICV. The terminal ileum was intubated endoscopically and confirmed to be uninvolved in the resection line. The specimen was extracted and the opened on the back table to confirm complete inclusion of the polyp as well as adequate margins.

Results/Outcomes: The patient tolerated the procedure well and was discharged home on postoperative day one. The patient was evaluated in clinic three weeks postoperatively and found to have no issues. Final pathology showed tubular adenoma with no margin involvement. Patient is scheduled to undergo repeat colonoscopy in six months.

Conclusion/Discussion: Full-thickness laparoendoscopic excision is a viable approach for the removal of complex colonic polyps in select patients for whom colon-preservation is appropriate.