Endoscopic transanal resection using the urological resectoscope in the management of patients with rectal villous adenomas

BACKGROUND AND AIMS

This study reviewed the outcome of endoscopic transanal resection (ETAR) for the treatment of patients with villous rectal adenomas (VRA).

PATIENTS AND METHODS

This study included 28 consecutive patients who underwent ETAR for VRA between October 1992 and December 2000. All tumors were believed to be benign (clinical examination, endorectal ultrasonography, multiples biopsies) A retrospective evaluation of the outcome of ETAR was performed.

RESULTS

Thirteen patients (46.4%) had a large VRA with a tumor length of more than 5 cm. The tumor involved the anterior rectal wall in ten cases. Ten patients (35.7%) required more than one procedure. Median operating time was 35 min (range 20-50). Morbidity was 5% ( n=2); no patient died. Median postoperative stay was 3 days (range 1-5). Three patients (9.3%) were confirmed on histology as having adenocarcinoma of the rectum and underwent a conventional surgical procedure. At a median follow-up of 5 years (2.5-10.5), two recurrences were noted.

CONCLUSION

Our data suggest that the technique of transanal resection has a limited but valuable place in rectal surgery. ETAR is a simple, minimally invasive, and economical method for treatment of patient with VRA. ETAR should be performed in collaboration with an experienced urological endoscopist. ETAR is a useful addition to the surgeon's armamentarium together with laser destruction and transanal endoscopic microsurgery.

Endoclipping for Gastric Perforation After Endoscopic Polypectomy: An Alternative Treatment to Avoid Surgery

A 47-year-old woman underwent endoscopic polypectomy of a villous adenoma in the lesser curvature of the gastric antrum. Shortly after the procedure, she complained of severe abdominal pain. An abdominal x-ray showed air under the diaphragm, suggestive of gastric perforation. On re-endoscopy, the cavity at the site of polypectomy was closed using endoscopically applied metallic clips. She was treated with intravenous hyperalimentation, omeprazole, and antibiotics for 10 days. Ingestion of food was started 10 days after admission, and she was discharged without any complaints. She is free of symptoms on follow-up after 8 months, and endoscopy showed complete healing of the perforation. The procedure is the third described for the stomach in the English literature and emphasizes the use of endoclipping in selected cases of small and well-defined perforations.

Serrated adenomas of the appendix

AIMS

A review of the literature indicated that only one case of serrated adenoma of the appendix has been recorded. The aim was to explore the possible occurrence of serrated adenomas of the appendix at the department of pathology, Karolinska Institute and University Hospital, Stockholm, Sweden.

METHODS

Between January 1993 and December 2003, 38 non-carcinoid, non-neoplastic, or neoplastic polyps or tumours of the appendix were surgically removed at this hospital. All filed histological sections (haematoxylin and eosin stained) were reviewed.

RESULTS

Of the 38 lesions, four were hyperplastic polyps, 10 serrated adenomas, six villous adenomas, and the remaining eight mucinous adenocarcinomas without a remnant adenoma. Serrated adenomas accounted for six of the 11 adenomas without invasion, and four of the 15 adenomas with invasive carcinoma. At the time of surgical resection, four of the 10 serrated adenomas had evolved into invasive carcinomas, in addition to 11 of the 16 villous adenomas.

CONCLUSIONS

Serrated and villous adenomas of the appendix appear to be highly aggressive lesions, more aggressive than similar adenomas in the colon and rectum. Of the seven cases with a hyperplastic polyp, one concurred with a serrated adenoma, two with a serrated adenoma having an invasive carcinoma, and one with invasive carcinoma without a remnant adenomatous structure. At present, there is an increased awareness that some hyperplastic polyps of the colon and rectum may evolve into serrated adenomas. Whether this pathway is also valid for the appendix vermiformis should be investigated in a larger number of cases.

High frequency of colorectal adenoma in patients with duodenal adenoma but without familial adenomatous polyposis

BACKGROUND

Duodenal adenomas are extremely common in patients with familial adenomatous polyposis. However, it is uncertain whether patients with duodenal adenomas without familial adenomatous polyposis are at greater risk for colorectal neoplasia and, therefore, should routinely undergo surveillance colonoscopy. The aim of this study was to determine whether there is a correlation between non-papillary duodenal adenoma without familial adenomatous polyposis and colorectal adenoma.

METHODS

Twenty-five patients with non-papillary duodenal adenomas without familial adenomatous polyposis, seen from January 1990 to April 2003, were retrospectively evaluated.

RESULTS

Non-papillary duodenal polyps were diagnosed by endoscopy in the 25 patients. Of these, 21 underwent colonoscopy and one underwent proctoscopy. The mean age of these 22 patients (12 women, 10 men) was 69 years (range 50-83 years). Sixteen of the 22 patients (72.7%) with duodenal adenomas had associated colorectal adenomas. A total of 38 adenomas and one colorectal cancer were detected. The mean size of the polyps was 6.2 mm (range 3-15 mm). The adenomas were removed by snare excision or with a biopsy forceps.

CONCLUSIONS

Based on the results of this uncontrolled, retrospective study, the frequency of colorectal adenomas in patients with duodenal polyps without familial adenomatous polyposis appears to be increased compared with the general population. All patients with duodenal polyps should undergo surveillance colonoscopy for colorectal adenomas. A prospective study to definitively establish the frequency of colorectal adenomas in these patients is warranted.

Surgical management of large sessile villous and tubulovillous adenomas of the lower rectum

BACKGROUND

Large sessile adenomas of the rectum are premalignant lesions necessitating complete removal.

METHODS

We reviewed the data on 20 consecutive patients with large (>or=2 cm) sessile villous and tubulovillous adenomas of the lower two thirds of the rectum (<or=11 cm from the anal verge). Median (range) adenoma diameter and distance from the anal verge were 5 (2-8) and 7 (4-11) cm, respectively. All 11 patients with an adenomatous circumferential involvement of >or=50% or an endosonographic staging of >or=uT2 underwent a low anterior resection of the rectum. The remaining 9 patients underwent a posterior full-thickness local bowel wall resection (modified Mason procedure). The median (range) follow-up period was 3.8 (0.7-8.2) years.

RESULTS

Preoperative biopsy examination successfully excluded invasive carcinoma. Overstaging, however, occurred in 9 of 12 patients (75%) undergoing endosonography, resulting in surgical overtreatment of 4 patients. A curative resection (R0) was always achieved. Five patients had complications, but there was no in-hospital mortality and no cases of local recurrence. 4 out of 19 patients complained of minor stool incontinence, and 3 patients reported incomplete rectal emptying or constipation. Fourteen patients described the operative result as excellent (n = 7) or good (n = 7).

CONCLUSIONS

Endosonography may lead to overstaging and overtreatment. An individualized approach based on the degree of adenomatous circumferential involvement and endosonographic staging showed no mortality, low morbidity, no local recurrence, and good functional medium-term results.

Analysis of Ki-ras and p53 gene mutations in laterally spreading tumors of the colorectum

A laterally spreading tumor (LST) is considered to be a specific subtype of superficial colorectal tumors, in view of its characteristic clinicopathological features. We attempted to compare genetic alterations found in LST (>10 mm) with those found in IIa-type adenomas (10 mm or less (small superficial elevated lesion)) and conventional polypoid adenomas (>10 mm). In addition, multiple sampling by microdissection was performed for 14 LST to examine genetic heterogeneity in the Ki-ras and p53 gene mutation patterns. Polymerase chain reaction, single-strand conformation polymorphism and direct sequencing were used to analyze Ki-ras and p53 gene mutations in 73 sporadic colorectal adenomas: 28 LST; 22 IIa-type adenomas; and 23 polypoid adenomas. Ki-ras gene mutations were found more frequently in LST (6/28 tumors) and polypoid adenomas (6/23 tumors) than in IIa-type adenomas (2/22 tumors), although this difference was not statistically significant. The frequency of p53 gene mutations in the 28 LST was 25% (7/28), which was significantly higher than that found in IIa-type adenomas (P < 0.05). However, although p53 gene mutations were found more frequently in LST than in polypoid adenomas, this difference was not statistically significant. Seven LST exhibited a combination of wild-type and mutant-type tumor cells having the p53 gene mutation pattern, whereas a pattern of different Ki-ras gene mutations was found in two of three LST that exhibited Ki-ras gene mutation heterogeneity. We suggest that the LST exhibited a characteristic pattern in terms of the Ki-ras as well as the p53 gene mutation pattern, thereby supporting the hypothesis that LST is a specific subtype of colorectal tumors.

Treatment of early rectal tumours by transanal endoscopic microsurgery in Hong Kong: prospective study

OBJECTIVE

To summarise the results of transanal endoscopic microsurgery for the treatment of rectal villous adenoma and early rectal tumours.

DESIGN

Prospective study.

SETTING

Regional hospital, Hong Kong.

PATIENTS

Consecutive patients between November 1995 and January 2003.

INTERVENTION

Transanal endoscopic microsurgery.

MAIN OUTCOME MEASURES

Intra-operative morbidity and mortality, complication rate, operating time, postoperative morbidity and mortality, recurrence rate and correlation between preoperative ultrasonography staging and postoperative pathological staging.

RESULTS

Thirty-two patients with rectal villous adenoma and early rectal carcinoma were registered, 31 of whom (14 men and 17 women) were included in the study. The median tumour size was 2.5 (range, 1-8) cm and the median operating time was 95 (45-220) minutes. The median follow-up period was 23 (2-92) months, and there was no local recurrence. There was no operation-related mortality and the resection margins were all clear. Complications included temporary flatus incontinence (n=2), acute retention of urine (n=1), exacerbation of chronic obstructive airway disease (n=1), and secondary haemorrhage in a patient on aspirin.

CONCLUSIONS

Transanal endoscopic microsurgery is a safe procedure and can achieve good local tumour control. It is ideal in the management of rectal villous adenomas at stages pT0 and pTis. Its application is now extended to the treatment of early rectal carcinoma at stage pT1 with curative intent. For tumours at stage pT2 or later, it can also serve as a good option for local palliation.

Diagnostische Bedeutung und Akzeptanz der Vorsorgekoloskopie - erste Ergebnisse

BACKGROUND

In Germany screening colonoscopy was introduced into the national program on colorectal cancer prevention in October 2002 for asymptomatic subjects older than 55 years. It is the aim of this program to reduce the rate of mortality of colorectal cancer (CRC) during the next decade. Up to now no data are available concerning the outcome and patient tolerance of screening colonoscopy.

METHODS

Patients were enrolled in the prospective study between October 2002 and June 2003. The diagnoses from colonoscopy and complications were recorded. A short interview provided information on individual family risks of CRC. During June 2003 all subjects were handed a questionnaire to evaluate their satisfaction and tolerance concerning screening colonoscopy. All subjects were offered sedation (Disoprivan: Propofol).

RESULTS

A total of 1117 subjects (776 [69.5 %] female, 341 [30.5 %] male) underwent screening colonoscopy; age: 64.3 +/- 6.9 years. 1104 (98.8 %) requested sedation. In 1090 cases (97.6 %) colonoscopy was completed to the cecum (photographic documentation of cecal landmarks). A total of 11 patients had invasive cancer (1 %), 4 of these had adenomas containing invasive carcinoma. The stage was T1/N0 or T2/N0. A total of 138 (12.4 %) patients had 168 polypoid lesions, which were treated by complete polypectomy. 402 small polypoid lesions (< 0.5 cm) were only detected by biopsy. In this group 233 adenomas (20.9 %) were found. Complications were: 1 perforation and 4 haemorrhages after polypectomy. Patient tolerance was very high. 99.4 % of all subjects agreed to a control colonoscopy or recommended screening colonoscopy to their relatives and friends.

CONCLUSION

Screening colonoscopy is an effective and well-accepted method in our unit for gastroenterology. The high prevalence of adenoma and invasive carcinoma suggests that screening colonoscopy should be provided for all persons at the age of 55, especially for men.

[Tubulo-villous rectal tumours. Results of surgical resection in relation to histotype (30 years' experience)]

Adenomas of the rectum are frequently found during endoscopic examination. We report on our 30 years of experience with the treatment of tubulo-villous adenomas based on histotype. Between 1971 and 2001, 104 villous tumours of the rectum were treated surgically. The patients' average age was 65 years. These were sessile tumours in 69% of cases, pedunculated in 17.5% and flowing tumours in 13.5%. The mean tumour size was 3 cm. They were associated with colon cancer in 15% of cases and with polyadenoma in 10%. They were located in the rectum within 0 to 6 cm of the anal margin in half the cases. These tumours were treated by local excision in 74 cases and by wide excision in 30 cases. The malignant potential of the tumours was 30%, including 10% invasive malignancy. There were no surgical fatalities, but a 6% medical fatality rate was registered. There was a 20% complication rate related to the surgical technique. Twenty patients were lost to follow-up. Out of 84 villous tumours, monitored over a mean survival period of 6.5 years, there were 24 recurrences: 18 underwent endoscopic excision and in 6 cases a wide resection. The various tumour resection techniques and the operative indications of variable difficulty are presented. It would seem, at present, that total resection of the rectum with a colo-anal anastomosis is the best treatment for large flowing villous tumours occupying almost the entire rectum. Thorough preoperative examination and the mastering of various surgical procedures should allow the most suitable choice of treatment for each individual case.

[Bladder villous adenoma: report of a new case]

OBJECTIVES

Villous adenoma is a benign neoplasia, the appearance of which in the urinary tract is extraordinarily unfrequent. We report a new case recently experienced in our department.

METHODS

We report the case with its past urologic history, clinical picture, diagnostic tests, and treatment.

RESULTS

Pathologic report confirmed the diagnosis of bladder villous adenoma, being transurethral resection the only treatment applied to leave the patient disease-free.

CONCLUSIONS

Prognosis of this kind of neoplasia, which is unfrequent, is excellent; being endoscopic resection curative, with no local or distant progression, except in cases associated with adenocarcinoma foci, in which local recurrence or distant metastasis are possible, and a more aggressive treatment might be indicated.

Balloon tamponade to control haemorrhage following transanal rectal surgery

BACKGROUND

Bleeding following transanal rectal surgery can be difficult to manage.

CASE

We report a case where a Minnesota tube was used to achieve haemostasis in a patient with severe bleeding after transanal excision of a large dysplastic polyp.

Endorectal ultrasound detection of focal carcinoma within rectal adenomas

BACKGROUND

The misdiagnosis of a rectal adenoma by biopsy and subsequent finding of invasive cancer after transanal excision is associated with a number of pitfalls. Problems include suboptimal therapy for a potentially curable cancerous lesion, potential tumor transgression of the local site with increased chance for local recurrence, and increased potential for more radical surgery or adjuvant chemoradiation. The utility of endorectal ultrasound (ERUS) in guiding treatment decisions of rectal villous adenomas has been reported, but series are small and are from single institutions. To determine the utility of ERUS in the diagnosis of rectal adenomas, we compared diagnosis made by biopsy alone to diagnosis made by a combination of biopsy and ERUS.

METHODS

A systematic literature review was performed by way of a PubMed search to find articles with the following terms: "biopsy-negative rectal adenomas," "preoperative ERUS diagnosis," and "surgical histopathology." Five studies met the criteria, thus providing data for 258 adenomas. A quantitative meta-analysis was performed on the data.

RESULTS

Among the 258 biopsy-negative rectal adenomas, 24% had focal carcinoma on histopathology. ERUS correctly established a cancer diagnosis in 81% (95% confidence interval 69 to 90) of these misdiagnosed lesions. Thus, ERUS diagnosis of biopsy-negative rectal adenomas could be expected to decrease the need for additional surgery and other associated problems caused by misdiagnosis from 24% to 5%.

CONCLUSIONS

ERUS is a useful adjunct to biopsy in the preoperative workup of rectal villous adenomas, and we recommend its routine use. Accurate preoperative assessment allows the surgeon to counsel the patient appropriately regarding the best operation, the perioperative risks, and the chances of local recurrence.

Die Mobilisation des linken Hemikolons von medial

INTRODUCTION

Laparoscopic surgery of the colon is becoming more and more popular. However, regarding sigmoid resection, controversy remains concerning the extent of mobilisation, particularly regarding the splenic flexure. We developed a technique for anterior resection that meets all surgical standards: the anterior approach.

MATERIALS AND METHODS

From October 1999 to March 2001, 50 patients with benign diseases of the colon underwent laparoscopically assisted sigmoid resection. A completely anterior approach for mobilisation of the left hemicolon was used in all cases. Positioning the patients in Trendelenburg position on the extreme right side enabled primary ligation of the inferior mesenteric vein and artery as well as complete mobilisation of the splenic flexure from the middle. A transanal circular stapling device was used to reanastomose the colon 10-12 cm from the anus.

RESULTS

There were conversion and complication rates of 10% each, and three patients needed to be reoperated. The median operating time was 180 min. Patients could be dismissed on the 14th postoperative day.

CONCLUSION

To establish an operative standard, this technique has so far been used only for benign colon diseases. According to our experience, we think that it meets all oncological standards. Use of this technique in the treatment of malignant diseases seems therefore justified.

Laparoscopic-assited colectomy in patients with liver cirrhosis

BACKGROUND

Nonhepatic abdominal surgery, and especially colorectal surgery, is associated with high rates of morbidity and mortality among cirrhotic patients. With proper patient selection and preoperative optimization of the patient's condition, laparoscopic-assisted colectomy could become effective and safe for patients with compensated liver cirrhosis. The aim of this study was to evaluate the safety and feasibility of minimal-access surgery in these patients.

METHODS

Between September 1993 and March 2003, 820 patients underwent laparoscopic-assisted colectomy at our hospital. We studied all patients with liver cirrhosis who underwent this operation.

RESULTS

Seventeen patients with cirrhosis were included in the study. Twelve were Child's A and five were Child's B. The mean operative time was 150 min (ranges 75-280), mean estimated blood loss was 245 ml (ranges 100-250). The conversion rate to open surgery was 29% (five patients). Median length of hospital stay was 5 days. The morbidity rate was 29% (five patients). There were no anastomotic leaks or operative-related deaths. The median follow-up was 21 months.

CONCLUSIONS

Laparoscopic-assisted colorectal surgery can be performed in compensated cirrhotic patients with low morbidity and mortality. Adequate patient selection and expertise in advanced minimal-access surgery are essential to obtain such good results.

Subcutaneous emphysema after associated colonoscopy and transanal excision of rectal adenoma

Non-traumatic subcutaneous emphysema (NSE) is a rare complication of procedures of the digestive tract. To the best of our knowledge, it has never been reported to occur after transanal surgery. Herein we present the first known case of NSE accompanied by retropneumoperitoneum and pneumomediastinum to develop after colonoscopy and full-thickness transanal removal of a rectal polyp.

Phenotypic alteration in malignant transformation of colonic villous tumours: with special reference to a comparison with tubular tumours

AIMS

To clarify the cellular differentiation of colorectal villous tumours in malignant transformation, compared with that of tubular tumours (tubular adenoma and adenocarcinoma arising in tubular adenoma).

METHODS AND RESULTS

Forty-nine cases of colorectal villous tumours [six cases of low-grade villous adenoma, 21 of high-grade villous adenoma (VA), nine of invasive carcinoma in villous adenoma (CIVA), and 13 of pure villous carcinoma (PVC)] and 46 cases of tubular tumours [14 cases of low-grade and 17 of high-grade tubular adenoma (TA), and 15 cases of carcinoma in tubular adenoma (CITA)] were selected for this study based on their expression patterns of CD10 (small intestinal brush border), MUC2 (intestinal goblet cell), and HGM (gastric foveolar epithelium). HGM was more frequently expressed in the adenomatous components of villous tumours (63%) than in those of tubular tumours (14%) (P < 0.05). CD10 expression of high-grade TAs (47%) and carcinomas arising in TA (60%) was significantly higher than that of villous tumours (0%) (P < 0.05).

CONCLUSIONS

There were significant differences in the phenotypic expression of adenoma and adenocarcinoma between villous and tubular tumours, respectively. Villous tumours have a pathway of malignant transformation different from that of tubular tumours. Because of biological differences, colorectal villous tumours should be distinguished from tubular neoplasia. The analysis of the phenotype of colorectal neoplasms is useful for the evaluation of tumour progression.

[Surgical management of abdominal aortic aneurysms with coexistent intestinal disease]

The management of patients suffering from abdominal aortic aneurysms with concomitant intestinal disease is demanding. Surgical procedures have to be evaluated meticulously with regard to morbidity and priority. We retrospectively investigated early and late results of nine patients (eight males, one female) with coincidental aortic and intestinal surgery during the last 9.5 years. The average age was 77 years (range 67-85). One-stage procedures were undertaken twice with implantation of aortic grafts to replace abdominal aortic aneurysms (AAA). During these emergency procedures, an aortoduodenal fistula was repaired in one case and resection of an ischemic segment of the sigmoid colon was resected in another. Seven two-stage procedures were performed as elective surgery. Five AAA were excluded before the intestinal repair. In two cases of urgent visceral pathologies, colon resection was done first, followed by elimination of the AAA. In case of elective surgery, two-stage procedures seem to be safe and effective. However, in certain emergent cases, one-stage procedures with implantation of vascular grafts in combination with colon or bowel surgery might also be justified.

Anastomotic recurrence of rectal adenoma after anterior resection

Transanal local excision of posterior benign rectal tumors is usually safe. Here, we report a case of transanal excision of a posterior anastomotic recurrence of a rectal adenoma after a stapled anterior resection that resulted in perforation into the peritoneal cavity.

Endoscopic snare resection of an intrapapillary pedunculated villous adenoma presenting as acute recurrent pancreatitis

Tumors of the papillary region are an unusual and heterogeneous group of neoplasms that arise from the major papilla, the ampulla of Vater, and the peripapillary duodenum. Benign adenomas of the papilla of Vater are an increasingly recognized condition in those with familial adenomatous polyposis syndromes as well as sporadic cases. Papillary adenoma is a recognized but rare cause of acute pancreatitis. We describe a patient who presented with acute recurrent pancreatitis that was attributed to an intrapapillary pedunculated villous adenoma. Following diagnosis by endoscopic needle knife sphincterotomy and endoscopic retrograde cholangiopancreatography, endoscopic snare resection of the adenoma resulted in symptomatic improvement.

Per-anal excision of large, rectal, villous adenomas

PURPOSE

Considering the malignant potential of villous adenoma of the rectum, complete resection at the first intervention is desirable and yet many series suggest that a high recurrence rate must be expected. The experience of one colorectal surgeon in the management of this condition is described.

METHODS

Between 1993 and 2000, 50 patients underwent per-anal resection of villous adenoma. The procedure was conducted in the prone jackknife position unless contraindicated, with dissection performed using a diathermy blade, with particular attention to circumferential and deep margins of excision.

RESULTS

The mean distance of the proximal margin of the tumor from the dentate line was 5.6 (range, 0.5-11) cm. The mean length of the tumor was 5.2 (range, 0.5-9) cm. Mean anesthetic time was 27 (range, 10-110) minutes, and median hospital stay was two (range, 1-14) days. There was no significant perioperative morbidity and no mortality. On histology of ten patients, there were foci of adenocarcinoma. Excision was complete histologically in 49 patients. The median follow-up was 30 (range, 6-91) months. The patient with incomplete excision developed a probable recurrence after six months, which was ablated with diathermy (residual tumor rate, 2.1 percent). Two patients have subsequently developed villous adenoma at different sites within the rectum (metachronous tumor rate, 4.3 percent).

CONCLUSIONS

Many series of this procedure report recurrence in up to 36 percent and significant complication in up to 19 percent of patients. Transanal endoscopic microsurgery has achieved recurrence rates of 2.8 percent and low complication rates but for economic reasons has failed to find a widespread role. This article demonstrates that large, villous tumors of the low and mid rectum can be simply and effectively treated by per-anal resection with recurrence rates equivalent to transanal endoscopic microsurgery.

Complete appendiceal intussusception induced by primary appendiceal adenocarcinoma in tubular adenoma: a case report

A case of complete intussusception induced by appendiceal carcinoma is reported. The patient was a 49-year-old man complaining of rectal bleeding. Barium enema and colonoscopy revealed a cecal polyp; it was interpreted as an inverted appendix with a tumor. Computed tomography showed an invaginated appendix into the cecal cavity. During surgery, the appendix was found to be inverted completely into the cecum; ileocecal resection with regional lymph node dissection was performed. Microscopic examination revealed well-differentiated adenocarcinoma in tubular adenoma. Diagnosis of intussusception with carcinoma of the appendix is often difficult because appendiceal carcinoma with intussusception of the appendix is a rare condition. Although this condition can be diagnosed by radiographic imaging or colonoscopy, computed tomography has also been useful. The clinical manifestation of appendiceal intussusception with primary appendiceal tumor resembles a large cecal polyp, but its treatment differs greatly. Failure to recognize this condition may result in unexpected complications such as consequent peritonitis in case of endoscopic removal.

Local excision of large rectal villous adenomas: long-term results

PURPOSE

Transanal excision of rectal villous adenomas is a widely used surgical technique, because it is a one-step procedure, requiring no sophisticated instrumentation, and allowing complete histologic analysis of the excised tumor. Therefore, it ranks alongside radical surgery and palliative destructive procedures, but its results are highly variable in the published series. This discrepancy may be explained by the variable completeness of tumor excision because of potential dissection difficulties. Because intraoperative exposure may be a major limiting factor, one of us (JF) has developed a tractable cutaneomucous flap procedure to lower the rectal tumor to the anal verge, where control of the dissection line is easier. This retrospective review of consecutive patients operated on during ten-year period reports long-term results after transanal excision for large rectal villous adenomas with the tractable flap technique.

PATIENTS

From 1978 to 1988, 207 consecutive patients (100 males), mean age 68 (range, 24-90) years, were operated on for an apparently benign villous rectal adenoma. Twenty-one patients (10 percent) were referred after failure of previous treatments: 11 endoscopic, 8 surgical, 1 laser, 1 radiotherapy. Mean distance of lower tumor edge from anal margin was 5.6 (range, 0-13) cm and was <10 cm in 82 percent.

RESULTS

Three patients (1.5 percent), including one with a Tis carcinoma, underwent a secondary treatment for immediate gross failure of resection: one further local excision and two palliative laser destructions. Immediate postoperative course was uneventful for 96 percent; there was one death from perineal gangrenous infection, four cases of hemorrhage, and three urinary retentions. Subsequently one case of transient fecal incontinence and 11 medically managed stenoses were noted. Mean size of resected tumor was 5.4 (range, 1-17) cm. Deep excision margins concerned the rectal muscular layers in 199 patients (96 percent) and perirectal fat in 8 (4 percent). Specimen margins were negative for cancer in 175 (85 percent) and positive or unknown in 32 cases. Histologic evaluation demonstrated in situ cancer in 28 (14 percent) and invasive carcinoma in 9 (4 percent). In three patients (1 percent), two abdominoperineal resections were immediately performed (one T2 with a mucinous contingent, one T3) and one adjuvant radiotherapy (one undifferentiated T2). Four patients (2 percent) did not return for postoperative evaluation. For the remaining 198 patients, mean follow-up was 74 +/- 34 (median, 75; range, 1-168) months. Forty-four died from unrelated causes. Recurrence occurred in seven (3.6 percent) and was malignant in two, who subsequently died. Specific recurrence-free probability was 99.5 percent at one year, 96 percent at five years, and 95 percent at ten years. A lesion size >6 cm (10 vs. 1 percent for smaller tumors) and the presence of an invasive carcinoma (20 vs. 3 percent without invasive carcinoma) were significantly associated with an increased probability of recurrence at five years.

CONCLUSION

Providing that adequate intraoperative exposure is obtained and advanced malignant tumors receive immediate secondary treatment, transanal resection of clinically benign, large rectal villous adenomas is safe and effective. It is an alternative to rectal resection, which exposes the patient to potentially adverse effects, and also to destructive procedures, which preclude any histologic evaluation of the tumor.

Prospective study of the functional results of transanal endoscopic microsurgery

BACKGROUND/AIMS

Most clinical research addresses the technological advances and oncological outcomes of transanal endoscopic microsurgery. Our aim was to examine the functional results.

METHODOLOGY

From August 1999 to November 2000, 22 Taiwanese patients (14 men, 8 women; median age, 68 years) undergoing transanal endoscopic microsurgery were prospectively examined. Functional questionnaires and anorectal manometry were assessed before surgery and at 2 weeks, 6 weeks, 3 months, and 1 year.

RESULTS

The median distance from the anal verge to the tumor was 10 cm. The median tumor diameter was 2.0 cm. The median duration of surgery was 120 minutes. No surgical mortality or morbidity and no local recurrence occurred during a median follow-up of 23 months. The mean stool frequency and consistency were significantly better at 3 months after surgery than before surgery. The maximal resting pressure significantly decreased after surgery. The maximal contraction pressure and maximal tolerated volume were significantly lower at 2 and 6 weeks than before surgery; these values recovered at 1 year.

CONCLUSIONS

Transanal endoscopic microsurgery is safe for the cure of benign tumors and the palliative excision of malignant tumors in middle and upper rectum. Anorectal function was preserved and improved, though some anorectal manometric parameters changed over time.