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 ¤  Abstract
 ¤ Introduction
 ¤ Case Report
 ¤ Discussion
 ¤  References
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 Table of Contents     
UNUSUAL CASE
Year : 2017  |  Volume : 13  |  Issue : 3  |  Page : 219-221
 

'Natural orifice' transcolostomy full-thickness excision of colonic tumour


Department of Surgery, Division of Colon and Rectal Surgery, Southcoast Health, New Bedford, Massachusetts; Department of Medical Science, Section of Medical Education, Alpert Medical School of Brown University, Rhode Island, USA

Date of Submission04-Jun-2016
Date of Acceptance29-Aug-2016
Date of Web Publication12-Jun-2017

Correspondence Address:
Victor E Pricolo
300B Faunce Corner Road, North Dartmouth, MA 02747
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9941.199608

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 ¤ Abstract 

This technical note describes a novel technique, not previously found in the surgical or endoscopic literature: A combined endoscopic and surgical approach to perform a full-thickness excision of a colonic tumour. At the time of colonoscopy via stoma, a large sessile polyp in the descending colon was detected but could not be safely resected endoscopically. The lesion was exteriorised by prolapsing the distal colon through the colostomy, then excised surgically with adequate margins in a full-thickness fashion. This approach was more complete than an endoscopic approach and less invasive than a segmental colectomy and redo colostomy. It may prove useful to surgical endoscopists facing a similar clinical situation in their practice.


Keywords: Colonoscopy via stoma, colorectal polyps, endoscopic polypectomy


How to cite this article:
Pricolo VE. 'Natural orifice' transcolostomy full-thickness excision of colonic tumour. J Min Access Surg 2017;13:219-21

How to cite this URL:
Pricolo VE. 'Natural orifice' transcolostomy full-thickness excision of colonic tumour. J Min Access Surg [serial online] 2017 [cited 2020 Jan 25];13:219-21. Available from: http://www.journalofmas.com/text.asp?2017/13/3/219/199608



 ¤ Introduction Top


Removal of adenomatous polyps is unquestionably the most important step in colorectal cancer prevention. Although most polyps can be safely removed by various endoscopic techniques with forceps or snares, some may pose special challenges as a result of size, shape or location. Several endoscopic techniques have been reported to provide technical tips in such circumstances.[1],[2] In cases not suitable for safe endoscopic removal, a surgical resection may still be necessary, preferably by laparoscopic technique, and assisted by appropriate tattooing techniques.[3] In rare cases, where the polyp is located proximal to a colostomy, a surgical resection and redo of the colostomy may be required.[4] On the other hand, in such a clinical situation, given the growing applications of natural orifice surgical and interventional techniques (natural orifice transluminal endoscopic surgery), one may also consider an even less invasive approach similar to a transanal excision of a rectal tumour.[5] This report describes a new technique, not reported before in the literature, that required no sedation or local anaesthesia, was carried out at the time of colonoscopy and provided equally safe and effective definitive treatment of the tumour.


 ¤ Case Report Top


A 74-year-old man, who had undergone a descending colostomy for a sigmoid stenosis secondary to radiation therapy 10 years earlier, underwent a colonoscopy via stoma on March 5, 2015. He was found to have a 4 cm × 2 cm sessile polyp in the descending colon, about 8 cm proximal to his stoma. Given the size of the polyp and its location, an adequate colonoscopic polypectomy could not be carried out, mostly because the lumen of the colon could not be properly insufflated during the procedure and the visualisation was very unsatisfactory. The patient was referred for segmental resection and redo colostomy. On digital and endoscopic examination, the colon appears redundant, and the descending colon proximal to the stoma could be successfully prolapsed by and maintained in an everted position with the assistance of 4 Babcock clamps [Figure 1]. Adequate exposure was achieved and the patient did not require sedation or local anaesthetics. The healthy mucosa, 1 cm from the tumour, was circumferentially marked with a cautery. After traction sutures had been placed, the cautery was also used for the transmural dissection. The tumour was completely excised in a full-thickness fashion and submitted for pathologic examination [Figure 2] and [Figure 3]. The bowel wall was closed primarily with a single layer of running polyglactin suture, in a transverse fashion, to maintain an adequate lumen [Figure 4]. The bowel was reduced back deep to the stoma level. The patient left the outpatient facility the same day and had an uneventful recovery. The pathology report revealed a villous adenoma, with severe dysplasia, completely excised with negative resection margins. At 1-year follow-up, there was no evidence of residual or recurrent tumour.
Figure 1: The colonic polyp is maintained in an exteriorised position using Babcock clamps

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Figure 2: The polyp is being excised in a full-thickness fashion. Note traction sutures and mesenteric fat

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Figure 3: The polyp is completely excised with a 1 cm margin

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Figure 4: The colonic defect is closed in a transverse fashion, to prevent a luminal stricture, with full-thickness running absorbable suture material

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 ¤ Discussion Top


This technical note, after literature review, appears to be the first report of a 'natural orifice' transcolostomy excision of a tumour, with a technique similar but not comparable to a full-thickness transanal excision of a rectal tumour. In fact, the ability to prolapse the distal pre-colostomy colon facilitated the procedure, which was done in a completely awake patient, without local anaesthesia, in an ambulatory setting. This technique may prove useful, as a less invasive alternative to segmental resection and redo colostomy. It would be applicable to benign adenomas or carcinoma in situ lesions. It is more definitive and safer than an attempt at colonoscopic polypectomy, where the inability to maintain adequate insufflation of the lumen may lead to inadequate excision or procedure-related complications such as perforation or bleeding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Jung M. The 'difficult' polyp: Pitfalls for endoscopic removal. Dig Dis 2012;30 Suppl 2:74-80.  Back to cited text no. 1
    
2.
Backes Y, Moons LM, van Bergeijk JD, Berk L, Ter Borg F, Ter Borg PC, et al. Endoscopic mucosal resection (EMR) versus endoscopic submucosal dissection (ESD) for resection of large distal non-pedunculated colorectal adenomas (MATILDA-trial): Rationale and design of a multicenter randomized clinical trial. BMC Gastroenterol 2016;16:56.  Back to cited text no. 2
    
3.
Lo SH, Law WL. Laparoscopic colorectal resection for polyps not suitable for colonoscopic removal. Surg Endosc 2005;19:1252-5.  Back to cited text no. 3
    
4.
Rashid OM, Nagahashi M, Takabe K. Minimally invasive colostomy revision for palliation of large stomal prolapse and an adherent sliding peristomal hernia. Am Surg 2013;79:E167-8.  Back to cited text no. 4
    
5.
Sallinen V, Santti H, Liukkonen T, Hellström P, Mäkelä J, Puolakka VM, et al. Safety and long-term results of endoscopic transanal resection in treating rectal adenomas: 15 years' experience. Surg Endosc 2013;27:3431-6.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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