Surg Endosc：UCLA开展微侵袭手术切除大型肠道息肉并保持结肠完整

每年有数以百万计的人通过结肠镜成功摘除了肠道息肉。然而当一个性质可疑的息肉体积大于一个玻璃弹珠，或者生长在肠镜难以到达的位置时，患者通常会被转诊给外科医师，并接受部分结肠切除手术以去除息肉——即使在医师不能肯定息肉是否癌变的情况下。由于所有息肉中仅15%是恶性的，许多患者承受了不必要的大手术的风险。而现在他们有了新的选择。

加州大学洛杉矶分校（UCLA）的一个外科和胃肠道医师团队正在开展一项新型、微侵袭性的手术方式摘除大型及难以到达部位的息肉，并保持结肠完整。该术式结合了两种微侵袭技术，目前全美仅少数医疗中心能够开展。在《Surgical Endoscopy》杂志的6月刊上，UCLA的研究者们报道了开展该新技术的经验，即内镜和腹腔镜联合手术（Combination endoscopy and laparoscopy surgery, CELS），并首次将新术式与外科标准术式进行比较。资深作者、UCLA卫生系统和David Geffen医学院结直肠外科项目主任、外科副教授James Yoo医生说，CELS术式结合了最好的微侵袭技术，对于经过选择的患者可能是一个可行的方案。

该团队在研究中比较了2008年8月至2012年10月间两组患者的结果，所有患者均接受手术切除性质可疑的息肉，一组5例接受新术式，而另一组9例接受标准术式。新术式一开始类似结肠镜，由一位胃肠道医师操纵内镜向结肠内推进。内镜上配有小型视频摄像头和光源，能让医师看到身体腔隙内的情况。当内镜发现了息肉，且胃肠道医师做好摘除准备后，外科医师使用微侵袭手术器械，通过腹壁上2-4个微小切口，小心的操纵并调整结肠的位置，使胃肠道医师能获得更好的操作径路，方便息肉摘除。如果息肉处于棘手的位置，如结肠褶皱内，则外科医师可以暂时轻轻将褶皱展平。如果息肉较大且深嵌入肠壁，则外科医师可以通过微型摄像头监视结肠外壁，必要时可在息肉摘除后行小手术修补肠壁。息肉摘除后立即送实验室进行病理分析，以明确良恶性，手术团队和患者则在手术室内等待报告。完成病理分析约需30分钟，若结果显示息肉为恶性，则手术团队进一步实施标准术式，切除受累结肠段。

UCLA的研究报道称，CELS组中所有息肉均成功摘除，而并发症的发生率低于标准术式组。CELS组5例患者中4例、标准术式组9例患者中6例患者的息肉为良性。研究者还发现，新术式的手术时间和住院时间均较短。CELS组和标准术式组的平均手术时间分别为159分钟和205分钟，中位住院时间分别为1晚和5晚。Yoo医师表示，研究中大部分患者的息肉为良性。他们的团队发现，新术式可在经过选择的患者中安全开展，且术后结果优于标准术式。大部分CELS组病例的快速实验室分析的结果是准确的。仅有1例患者一周后的最终病理报告显示息肉为恶性，因此该患者后来被安排接受标准手术。Yoo指出，未来更新的影像和实验室分析技术能使息肉良恶性的鉴别更为容易。

UCLA卫生系统和Geffen医学院消化性疾病部门联席主任，Eric Esrailian医生也参与了研究团队。他认为，虽然这只是一项单中心的小型研究，但新技术能帮助医生提高诊疗水平，为患者提供更多微侵袭手术方案，减少患者的停工时间和手术创伤。医师们还指出，接受CELS手术成功的患者仍然需要随访肠镜检查，外科手术仍然是肠癌、癌变息肉以及CELS术式无法切除的息肉的标准疗法。UCLA的研究团队称，接下来将开展多中心研究以进一步考察CELS术式的使用，更好的总结其对外科手术的影响。

Combined endoscopic and laparoscopic surgery may be an alternative to bowel resection for the management of colon polyps not removable by standard colonoscopy.
BACKGROUND
Benign colon polyps may require bowel resection if endoscopic polypectomy cannot be performed to assess adequately for cancer. However, endoscopic removal still may be possible using combined endoscopic and laparoscopic surgery (CELS). The CELS procedure allows for intra- and extraluminal manipulation of the bowel wall to facilitate polyp removal, thereby avoiding bowel resection. This study evaluated the authors' institutional experience with CELS in this patient population.
METHODS
Between August 2008 and October 2012, all patients referred to undergo surgery for a benign colon polyp were retrospectively reviewed for operative characteristics, pathology, and postoperative outcomes. Of 14 patients, five were considered candidates for CELS and were compared with nine patients who underwent resection.
RESULTS
The average patient age was similar between the two groups (CELS, 64.9 years vs. resection, 68.3 years). The mean polyp size was 2.3 cm in the CELS group and 2.9 cm in the resection group. In the CELS group, polyps were successfully removed in all cases. The mean operating room time was 159 min in the CELS group and 205 min in the resection group. The median hospital stay was 1 day in the CELS group and 5 days in the resection group. No complications occurred in the CELS group. Two patients in the resection group (22 %) experienced a wound infection. One patient had a postoperative ileus (11 %). Four patients in the CELS group had a benign adenoma. One patient had a benign frozen section evaluation, but the final pathology showed adenocarcinoma requiring a subsequent colectomy. In the resection group, six patients had a benign adenoma, and three patients had a T1N0 cancer. In the CELS group, repeat endoscopy was performed an average of 9.9 months after CELS. Two patients had a residual polyp, and two patients had new polyps in a different location. All were successfully removed.
CONCLUSION
For benign-appearing polyps not amenable to endoscopic techniques alone, CELS may be an alternative to formal bowel resection for carefully selected patients. The CELS procedure can be performed safely with minimal morbidity and with outcomes that compare favorably with those of formal colectomy.