An organ-sparing approach: endoscopic submucosal hydrodissection followed by appendectomy to remove giant synchronous adenomas in a patient with prior left hemicolectomy

Post written by Felipe Ramos-Zabala, MD, PhD, from the Department of Gastroenterology, HM Montepríncipe University Hospital, HM Hospitales Group, Boadilla del Monte, and the Department of Clinical Sciences. School of Medicine, University of CEU San Pablo, Boadilla del Monte, Madrid, Spain.

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In this video case report, we present a patient  who had a previous left hemicolectomy for sigmoid adenocarcinoma, who was diagnosed with large synchronous adenomas in the cecum and appendix at endoscopic follow-up. The patient was initially deemed unresectable and considered for colectomy. However, assessing the patient’s surgical history, sequential treatment of these lesions was considered to be most appropriate to avoid a colectomy.

The cecal polyp was resected with ESD using the ERBEJET 2 hydrodissection system and T-type hybrid knife. To facilitate formation of the mucosal flap, we adopted the clip-flap method. For appendicular polyp cecal we decided the simplest and pragmatic treatment was with a wedge resection appendectomy, allowing preservation of the ileocecal valve.

This case underscores the importance of a peri-operative clearing colonoscopy to rule out synchronous lesions, as it appears that these lesions were missed 3 years earlier when the patient was diagnosed with a sigmoid colon cancer.

The primary point we would like to highlight in this video case report is that discussion within multidisciplinary teams can be provide an organ preservation approach for ‘unresectable’ noninvasive polyps. Advanced therapeutic endoscopic techniques can remove most early neoplasms, preserve the colon and prevent unnecessary surgical procedures for the majority of patients. In this case report, the sequential combination of endoscopic and surgical was highly beneficial to the patient’s quality of life.

The second point we want to highlight is the use of the concept “endoscopically unresectable” in colonoscopic report documentation. We believe that this concept should be reserved for lesions with suspected deep malignant invasion, where endoscopic resection would not be curative. When a polyp is complex to resect, we believe that a referral to a tertiary center for removal should be considered, before deeming the polyp as unresectable. In this context, a second-look endoscopy performed by a therapeutic endoscopist is value added.

This report demonstrates that teamwork by therapeutic endoscopists and surgeons can be very beneficial for patients with non-invasive polyps, where providing an organ preservation approach can avoid unnecessary surgeries that have a major impact on the patients.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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