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Management of Large Cecal Polyps: When Can the Ileocecal Valve Be Spared?

Kulaylat, Audrey S., M.D.1; Boltz, Melissa M., D.O., M.B.A.2; Moyer, Matthew, M.D.3; Mathew, Abraham, M.D.3; McKenna, Kevin, M.D.1; Messaris, Evangelos, M.D., Ph.D.1

doi: 10.1097/DCR.0000000000001159
Original Contributions: Benign
Denotes Associated Video Abstract
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BACKGROUND: Endoscopic mucosal resection comprises the first-line treatment for large cecal polyps. With up to 14% of unresectable colonic polyps harboring malignancy, the management of endoscopically unresectable cecal polyps remains an oncologic right hemicolectomy, which can be associated with substantial postoperative morbidity.

OBJECTIVE: This study compares the outcomes of patients with cecal polyps who underwent either endoscopic mucosal resection, a cecectomy, or a right hemicolectomy.

DATA SOURCES: Patients undergoing either endoscopic mucosal resection, partial cecectomy, or right hemicolectomy from 2008 to 2017 at a single tertiary care institution were selected.

STUDY SELECTION: This was a retrospective cohort study.

MAIN OUTCOME MEASURES: The primary outcomes measured were the rate of malignancy, complication rate, estimated blood loss, and hospital length of stay between surgical cohorts.

RESULTS: One hundred twenty-nine patients with cecal polyps were identified, of which 52 were referred for surgery. Nineteen underwent partial cecectomy and 33 (27.3%) underwent right hemicolectomy. Two patients undergoing cecectomy required conversion to hemicolectomy because the resected specimen did not contain the polyp. The 2 surgical cohorts did not differ significantly regarding age, sex, or ASA classification. Procedural complication rates were higher among those undergoing hemicolectomy compared with those undergoing cecectomy (37.1% versus 5.9%, p = 0.02). Estimated blood loss (50 vs 10 mL, p = 0.02), operative duration (98 vs 76 minutes, p = 0.009), and length of stay (4 vs 2 days, p < 0.001) were higher in patients undergoing hemicolectomy than in those undergoing cecectomy. No invasive malignancies were identified on final pathology within the cecectomy cohort.

LIMITATIONS: Single-institution data and retrospective design were limitations of this study.

CONCLUSIONS: In tertiary centers, the majority of large cecal polyps are benign and can be addressed by using endoscopic mucosal resection. When involvement of the appendiceal orifice or ileocecal valve precludes endoscopic treatment, surgical resection is the standard of care. In the subset of cases not involving the ileocecal valve and without preoperative evidence of malignancy, partial cecectomy spares the ileocecal valve and can offer reduced postoperative morbidity compared with a formal right hemicolectomy. See Video Abstract at http://links.lww.com/DCR/A674.

1 Department of Surgery, Division of Colon and Rectal Surgery, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania

2 Department of Surgery, Division of General Surgery and Surgical Oncology, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania

3 Department of Medicine, Division of Gastroenterology, The Pennsylvania State University, College of Medicine, Hershey, Pennsylvania

Funding/Support: None reported.

Financial Disclosures: None reported.

Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, WA, June 10 to 14, 2017.

Correspondence: Evangelos Messaris, M.D., Ph.D., The Pennsylvania State University, College of Medicine, Department of Surgery, 500 University Dr, PO Box 850, H137, Hershey, PA 17033. E-mail: emessaris@pennstatehealth.psu.edu

© 2018 The American Society of Colon and Rectal Surgeons