Intraoperative Colonoscopies with Laparoscopic Assistance Reduces Unnecessary Bowel Resections and Hospitilization

Objective of the Study
Colonic polyps found during colonoscopy are typically biopsied or removed using cold or hot snares. At times it is very difficult to remove these polyps because they may be large or flat, risking bowel perforation in the process. In addition, access to the polyp may be difficult due to adhesion from previous surgeries, redundancy of the colon, or location of the polyp. Traditionally, these patients are referred to a surgeon for bowel resection. At our institution, repeat colonoscopies are performed in the operating room. If warranted, laparoscopic assistance is used for enhanced colonic visualization, mobilization of the bowel and take-down of adhesions if required. This allows access to polyps that we not previously accessible with traditional colonoscopy. We can be much more aggressive in our polypectomies due to the fact that any full thickness injuries can immediately be repaired laparoscopically. Through this process we believe unnecessary bowel resections and its associated complications have been avoided. We have therefore undertaken this retrospective review to demonstrate the safety and efficacy of perform intraoperative colonoscopies with laparoscopic assistance in patients with benign disease.

Methods
The names of patients scheduled for intraoperative colonoscopies from 2001 through September 2009 were collected. The respective electronic medical records were then reviewed. The data obtained included age, gender, whether laparoscopic assistance was utilized, operation performed (if applicable), location of tumor, intraoperative and postoperative complications, and length of hospital stay. The demographics were then analyzed and the data was then compared between operative or nonoperative (including laparoscopic assisted colonoscopies) groups.

Results
Between March 2001 and September 2009, 106 patients with a diagnosis of benign polyps by colonoscopy underwent repeat intraoperative colonoscopies. The average age was 65 (median 65) with 56% male patients. Of these patients, 74 patients (70%) were successfully treated with colonoscopic polypectomy, 10 of which utilized laparoscopy for mobilization and positioning of the colon.
Of the 32 operative patients (30%), there were 17 colectomies, 7 cecectomies, 5 transanal excisions, 2 low anterior resections, and one colotomy with mass excision. In all but two of the operative patients, laparoscopic assistance was not needed during colonoscopy. These patients underwent formal resections due to size or appearance suspicious for malignancy. In the two patients who underwent laparoscopic assistance, one underwent formal resection after the polyp was determined to be cancerous, while the other could still not be adequately accessed even after mobilization.
There was a significant difference in the length of hospital stay between these groups (p<0.001). The mean stay for the nonoperative group was less than one day (median 0), while the operative group had a mean stay of 5 days (median 4).
Complications included 1 perforation during colonoscopy, 1 patient with continued rectal bleeding after colonoscopy (self resolving), 2 carcinomas originally diagnosed as benign, 1 anastamotic leak, and 1 perioperative surgical site infection.

Conclusion
Intraoperative colonoscopies with laparoscopic assistance can be safely incorporated into a colorectal practice and significantly decrease unnecessary operations, complications, and patient hospitalization.


Session: Podium Presentation

Program Number: S097

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