The ”FLEX” procedure: a new technique for full-thickness laparo-endoscopic excision in the colon

Abstract

Colonic lesions unsuitable for endoscopic resection and some early cancers that have been incompletely excised endoscopically, are generally treated by segmental colectomy, even though local excision might be adequate. The aim of this study was to develop a laparo-endoscopic procedure for full-thickness local excision of the colon. After detailed planning using story-boarding to discuss each step of the procedure, both nonsurvival and survival experiments were performed in seven 50-kg pigs. The technique used was as follows: a simulated colonic polyp was created by endoscopic ink injection; this was inverted using laparo-endoscopically placed BraceBars passing from the outside to the inside of the colon; after laparoscopic over-sewing of the inversion in two layers, endoscopic full-thickness excision was performed. Pigs were sacrificed immediately (n=3) or between 7 and 9 days after surgery (n=4). The procedure was performed without operative perforation or hemorrhage in a median of 233 min (range 201-245 min), and achieved full-thickness excision in all procedures. Specimen diameter was a median of 2.5 cm (range 2-3 cm). All survival pigs convalesced without complication and, at autopsy, normal luminal diameter was confirmed without any peritoneal reaction, hernia or sepsis. Bursting pressures were a median of 245 mmHg (range 240-260 mmHg), with the site of bursting being in normal colon in all but one pig. This is a novel technique that permits full-thickness laparo-endoscopic excision (FLEX) of a colonic lesion as an alternative to segmental colectomy.