Ten-year experience of endoscopic transanal resection

Endoscopic treatment outcomes of laterally spreading tumors with a skirt (with video)

BACKGROUND AND AIMS

A "skirt" is a slightly elevated flat lesion with wide pits occasionally observed at the margin of laterally spreading tumors (LSTs). However, the endoscopic treatment outcomes of LSTs with skirts have not been clarified. The aim of this study was to evaluate the endoscopic treatment outcomes of LSTs with skirts.

METHODS

Between February 2006 and March 2014, 996 LSTs were retrospectively examined to assess the clinicopathologic characteristics, procedure time, en bloc resection rate, R0 resection rate, adverse events, and local recurrence rate of endoscopic submucosal dissection (ESD) and of endoscopic resection.

RESULTS

Endoscopic treatment was performed in 35 cases of LSTs with skirts (ratio of ESD to endoscopic piecemeal mucosal resection [EPMR], 32:3) and 961 cases of LSTs without skirts (ratio of ESD to EMR to EPMR to polypectomy, 381:275:114:191). LSTs with a skirt were associated with a significantly higher recurrence rate (P < .01). In both ESD and EPMR, LSTs with a skirt were associated with a higher recurrence rate when compared with LSTs without a skirt (odds ratio, 12.7; P = .032, and odds ratio, 12.3; P = .061, respectively). Multivariate analysis demonstrated that the presence of the skirt and piecemeal resection were significant predictors of local recurrence.

CONCLUSIONS

LSTs with skirts had a significantly higher local recurrence rate after endoscopic treatment compared with LSTs without skirts, especially after EPMR. Therefore, ESD should be recommended as an endoscopic treatment for LSTs with skirts to minimize local recurrence.

[Avoiding peristomal skin problems]

Peristomal irritation is one of the most common complications in patients with a stoma. In many cases, prevention is limited to the care provided during the post-operative period. However, it can start before the operation by improving the physical condition of the patient. It continues during the perioperative period with the surgical technique. Prevention advice can be given during these three key stages of the patient's treatment.

Clinical competence in the surgery of rectal cancer: the Italian Consensus Conference

BACKGROUND AND AIM

The literature continues to emphasize the advantages of treating patients in "high volume" units by "expert" surgeons, but there is no agreed definition of what is meant by either term. In September 2012, a Consensus Conference on Clinical Competence was organized in Rome as part of the meeting of the National Congress of Italian Surgery (I Congresso Nazionale della Chirurgia Italiana: Unità e valore della chirurgia italiana). The aims were to provide a definition of "expert surgeon" and "high-volume facility" in rectal cancer surgery and to assess their influence on patient outcome.

METHOD

An Organizing Committee (OC), a Scientific Committee (SC), a Group of Experts (E) and a Panel/Jury (P) were set up for the conduct of the Consensus Conference. Review of the literature focused on three main questions including training, "measuring" of quality and to what extent hospital and surgeon volume affects sphincter-preserving procedures, local recurrence, 30-day morbidity and mortality, survival, function, choice of laparoscopic approach and the choice of transanal endoscopic microsurgery (TEM).

RESULTS AND CONCLUSION

The difficulties encountered in defining competence in rectal surgery arise from the great heterogeneity of the parameters described in the literature to quantify it. Acquisition of data is difficult as many articles were published many years ago. Even with a focus on surgeon and hospital volume, it is difficult to define their role owing to the variability and the quality of the relevant studies.

Palliative care and end-stage colorectal cancer management: The surgeon meets the oncologist

Colorectal cancer (CRC) is a common neoplasia in the Western countries, with considerable morbidity and mortality. Every fifth patient with CRC presents with metastatic disease, which is not curable with radical intent in roughly 80% of cases. Traditionally approached surgically, by resection of the primitive tumor or stoma, the management to incurable stage IV CRC patients has significantly changed over the last three decades and is nowadays multidisciplinary, with a pivotal role played by chemotherapy (CHT). This latter have allowed for a dramatic increase in survival, whereas the role of colonic and liver surgery is nowadays matter of debate. Although any generalization is difficult, two main situations are considered, asymptomatic (or minimally symptomatic) and severely symptomatic patients needing aggressive management, including emergency cases. In asymptomatic patients, new CHT regimens allow today long survival in selected patients, also exceeding two years. The role of colonic resection in this group has been challenged in recent years, as it is not clear whether the resection of primary CRC may imply a further increase in survival, thus justifying surgery-related morbidity/mortality in such a class of short-living patients. Secondary surgery of liver metastasis is gaining acceptance since, under new generation CHT regimens, an increasing amount of patients with distant metastasis initially considered non resectable become resectable, with a significant increase in long term survival. The management of CRC emergency patients still represents a major issue in Western countries, and is associated to high morbidity/mortality. Obstruction is traditionally approached surgically by colonic resection, stoma or internal by-pass, although nowadays CRC stenting is a feasible option. Nevertheless, CRC stent has peculiar contraindications and complications, and its long-term cost-effectiveness is questionable, especially in the light of recently increased survival. Perforation is associated with the highest mortality and remains mostly matter for surgeons, by abdominal lavage/drainage, colonic resection and/or stoma. Bleeding and other CRC-related symptoms (pain, tenesmus, etc.) may be managed by several mini-invasive approaches, including radiotherapy, laser therapy and other transanal procedures.

Endoscopic management of refractory benign colorectal strictures

In colonoscopic study, benign colorectal strictures with or without symptomatic pain are not rarely encountered. Benign colorectal stricture can be caused by a number of problems, such as anastomotic stricture after surgery, inflammatory bowel disease, postendoscopic submucosal dissection, diverticular disease, ischemic colitis, and so on. There are various modalities for the management of benign colorectal stricture. Endoscopic balloon dilatation is generally considered as the primary treatment for benign colorectal stricture. In refractory benign colorectal strictures, several treatment sessions of balloon dilatation are needed for successful dilatation. The self-expandable metal stent and many combined techniques are performed at present. However, there is no specific algorithmic modality for refractory benign colorectal strictures.

Safety and long-term results of endoscopic transanal resection in treating rectal adenomas: 15 years' experience

BACKGROUND

Endoscopic transanal resection (ETAR) is a scarcely used technique to treat large or sessile rectal adenomas not amenable to polypectomy. The purpose of this study was to evaluate safety and long-term results of ETAR in treating rectal adenomas in three hospitals over 15 years.

METHODS

Patients who underwent ETAR during 1996-2010 were retrospectively analyzed with respect to patient, adenoma, and operative characteristics, earlier operations, complications, follow-up time, recurrence rates, recurrence treatment, and cancer incidence.

RESULTS

Ninety-two patients underwent a total 111 ETARs to treat rectal adenoma. The mean age of patients was 71 years, and the median ASA class 3. Twenty-eight patients previously had received other treatments for rectal adenoma. Incidental carcinoma was found in eight patients. Sixty-seven adenomas were treated with only one ETAR and 17 with two or three ETARs. Sixty-seven patients did not have a recurrence, whereas 14 patients had an adenoma recurrence and 3 patients developed invasive carcinoma during a mean follow-up of 30 months. Complications occurred in 14 patients; all were minor, except for one explorative laparotomy without findings. No mortalities or conversions to open surgery occurred.

CONCLUSIONS

ETAR is a minimally invasive and safe technique with inexpensive instrumentation to treat rectal adenomas that are not amenable to polypectomy. Adenoma recurrence rate was 15% and cancer incidence 3% in follow-up.

Comparing endoscopic submucosal dissection with transanal resection for non-invasive rectal tumor: a retrospective study

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is an alternative to transanal resection (TAR) in treating rectal adenomas, intramucosal cancers, and superficial submucosal cancers. The purpose of this study is to compare the clinical efficacy between ESD and TAR for non-invasive rectal tumors.

METHODS

Between January 1998 and December 2006, 85 patients with preoperative diagnosis of non-invasive rectal tumors were treated by ESD or TAR. En-bloc resection, local recurrence, complication, procedure time, and hospital stay were evaluated retrospectively using a prospectively-completed database.

RESULTS

Mean resection sizes were 40 mm and 39 mm in diameter for the ESD and TAR groups, respectively. En-bloc resections with a negative resection margin were achieved in 67% (35/52) of the ESD group, which was significantly higher than the 42% (14/33) in the TAR group. Sixty-three lesions were diagnosed as curative resection, histopathologically. There was no local recurrence in the ESD group, but five local recurrences developed in the TAR group. Two rectal perforations, one minor delayed bleeding, and one subcutaneous emphysema in the ESD group were successfully managed conservatively. There were one minor delayed bleeding and two anesthesia-related complications in the TAR group. The ESD group had a shorter hospital stay than the TAR group (4.9 days vs 7 days), but a longer procedure time (131 min vs 63 min).

CONCLUSION

ESD was more effective than TAR in treating non-invasive rectal tumors, with a lower recurrence rate and shorter hospital stay.

Endoscopic transanal resection of rectal adenomas using the urological resectoscope

OBJECTIVE

Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital.

METHOD

Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed.

RESULTS

Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10-65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2-162 months), local recurrences occurred in 13% (n = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections.

CONCLUSION

ETAR is simple and safe for managing rectal adenomas.

Surgical resection of rectal adenoma: A rapid review

Transanal excision (TE), endoscopic transanal resection (ETAR) and transanal endoscopic microsurgery (TEM) can be used to remove adenomatous polyps. However, their use is limited by the size or location of the tumor. TE is limited to the lower rectum, TEM offers better access to lesions in the middle and upper rectum, and ETAR is used less frequently than it deserves for resection of rectal lesions.

Endoscopic trans-anal resection of rectal tumours: critical appraisal of an interdisciplinary approach

OBJECTIVE

Endoscopic trans-anal resection (ETAR) is an accepted technique for treating benign rectal adenomas that relies on technical expertise with the urological resectoscope. We present our experience with ETAR in an interdisciplinary setting combining the decision-making of the colorectal surgeon with the technical skill of the urologist.

METHOD

Assessment of all patients with adenomas and their subsequent care was organized by the colorectal team. Those with carpet-like rectal adenomas were referred to the urologist for ETAR performed using a Storz-Olympus 27/28Ch resectoscope, with roller-ball for haemostasis and glycine for irrigation.

RESULTS

Twenty-four patients (43-93 years, median 71 years; 14 men and 10 women) underwent 51 ETAR procedures from 1999 to 2005, with a median of two (range 1-6) procedures per patient. Complete clearance was achieved on 25 occasions. Two intra-operative extra-peritoneal perforations occurred which were managed conservatively. There were four cases of postoperative haemorrhage, two of which required a repeat procedure to secure haemostasis. Four patients had postoperative pyrexia that settled with oral antibiotics. Mean tumour distance from the anal verge was 7 cm (range 2-12 cm); the mean tumour area was 8 cm(2) (range 3-20 cm(2)); the mean operating time was 34 min (range 15-60 min) and the mean hospital stay was 32 h (range 24-120 h).

CONCLUSION

An interdisciplinary approach to ETAR uses available clinical resources efficiently as the colorectal surgeon does need to acquire the technical skills of endoscopic resection. Our results compare favourably with other published series and this approach can be adopted by any centre where colorectal and urological surgeons work together.

The influence of histopathologic criteria on the long-term prognosis of locally excised pT1 rectal carcinomas: results of local excision (transanal endoscopic microsurgery) and immediate reoperation

PURPOSE

Local excision of early rectal cancer is a controversial issue, which is in part because of differences in the evaluation of histopathologic criteria. This prospective study was designed to determine prognostic factors for recurrences and the need for reoperation.

METHODS

In 105 of 118 patients with pT1 carcinomas and local excision, results of recurrence rates and ten-year cancer-free survival were studied separately according to different histologic criteria (R0, R1, Rx, R < or = 1 mm, high-/low-risk situation), tumor localization (anterior, posterior, lateral wall and third of rectum), size, and degree of resection (full-thickness/partial wall). Patients were grouped into local excision (n = 89) and local excision followed by reoperation (n = 21). Risk classification was performed by division into "low-risk" carcinomas after local R0-resection (Group A) and unfavorable histologic results after local resection (R1, Rx, R < or = 1 mm, high-risk situation; Group B).

RESULTS

Local recurrence rates after local R0-resection of low-risk carcinomas were 6 percent, whereas patients in Group B with local resection were 39 percent. The recurrence risk in those patients was significantly reduced to 6 percent by reoperation (P = 0.015). In addition, ten-year, cancer-free survival was 93 percent in Group B after reoperation compared with 89 percent in patients of Group A after local excision alone.

CONCLUSIONS

Local R0-resection in cases with low-risk pT1 carcinomas represents an oncologically adequate therapy, which results in similar survival rates compared with primary radical surgery of pT1N0M0 rectal carcinomas. High recurrence rates are observed in tumors with unfavorable histologic result (Group B) requiring further treatment. In these cases immediate reoperation reduces the recurrence rate to 6 percent.

Experience of endoscopic transanal resections with a urologic resectoscope in 131 patients

PURPOSE

Endoscopic transanal resection of rectal adenomas and other presumably benign lesions is not widespread. The purpose of this study was to evaluate the efficacy and the safety of endoscopic transanal resection.

METHODS

Patients who underwent endoscopic transanal resection at three Stockholm hospitals between 1993 and 2004 were studied retrospectively with respect to patient and lesion characteristics, complications, follow-up time, and recurrence rates.

RESULTS

One hundred eighty endoscopic transanal resection procedures were performed in 131 patients. The tissue diagnosis was adenoma in 160 operative cases, cancer in 12 operative cases, and hyperplasia, fibrosis, or normal mucosa in the remaining 8 operative cases. Among the patients with rectal adenomas, one endoscopic transanal resection was sufficient in 77 cases and in 16 cases the surgery was performed in more than one session because of the large size of the adenoma. In 27 cases there were recurrences that needed additional endoscopic transanal resection or other surgery. The median time until recurrence was seven months, but there were no recurrent rectal carcinomas. In 16 operative cases there were complications. Two patients had to undergo a Hartman's procedure as a result of a bowel perforation, and one patient had to be reoperated on because of bleeding. There were no perioperative deaths. The median follow-up time without recurrence was 32 (range, 0-67) months.

CONCLUSIONS

Endoscopic transanal resection is a feasible and oncologically safe option for treatment of rectal adenomas, especially in cases where conventional transanal resection or transanal endoscopic microsurgery are unavailable or unsuitable because of the characteristics and localization of the lesion.

Outcome of transvaginal excision of large rectal adenomas

PURPOSE

The purpose is to recommend a new approach-transvaginal excision-for large rectal adenomas and audit its results after being performed by dedicated surgeons at a specialized colorectal unit.

METHODS

The surgical outcome of 11 patients undergoing transvaginal excision between July 1995 and March 2000 was reviewed. Data were collected retrospectively and no patients were lost to follow-up.

RESULTS

Eleven patients underwent the procedure during the study period. Follow-up ranged from 7 to 75 months. There were complications in two patients. One had urinary retention, the other developed a rectal stenosis, which was resolved with multiple balloon dilatations. There was only one recurrence detected. None of the patients died.

CONCLUSIONS

Transvaginal local excision is an alternative and feasible technique for the treatment of selected large sessile rectal adenomas that carries low mortality and complication rates.

A prospective analysis of extended endoscopic mucosal resection for large rectal villous adenomas: an alternative technique to transanal endoscopic microsurgery

INTRODUCTION

Endoscopic mucosal resection is a safe resection tool for selected flat, sessile and lateral spreading tumours of the colon. Transanal microsurgical resection of select rectal neoplastic lesions is another accepted modality. Recent data suggests transanal microsurgery may have high complication rates. We conducted a prospective clinicopathological evaluation of an extended endoscopic mucosal resection technique for highly selected lesions of the rectum and assessed outcome data over a maximal 24-month period.

PATIENTS AND METHODS

Eighty-three patients with known rectal neoplastic lesions underwent chromoscopic colonoscopy and on-table staging using a high-frequency (12.5 MHz) mini-probe EUS by a single endoscopist. Patients with T2 or node positive disease were referred for surgery. Following extended endoscopic mucosal resection patients were followed-up at 3, 6, 12 and 24 months post 'index' resection with chromoscopic endoscopy and EUS. Procedural complications, recurrence rates and outcome data were collected.

RESULTS

Sixty-two patients fulfilled inclusion criteria. Median procedure time was 48 mins (range 32-126). Lateral spreading tumours (median diameter 30 mm; range 18-42 mm) and sessile lesions (median diameter 38 mm; range 25-86 mm) accounted for 19% and 81% of lesions, respectively. Ninety-seven percent of patients undergoing EMR were discharged within 6-h of procedure. Thirty-day re-admission and death rate was 0%. Bleeding complications occurred in 5/62 (8%) of patients with all achieving complete haemostasis using endo clips. None required transfusion. There were no procedural related complications or perforations. Overall 'cure' rate at a median follow-up of 16 months was 98%.

CONCLUSIONS

Extended endoscopic mucosal resection for rectal neoplastic lesions can achieve superior results to those of per-anal excision and trans-anal microsurgery with regard to complications and recurrence rates. Extended endoscopic mucosal resection may be an alternative therapeutic modality in selected patients.

Endoscopic transanal rectal mucosal ablation in the surgical treatment of ulcerative colitis: preliminary results of a novel technique

PURPOSE

We describe a new technique that endoscopically eradicates rectal stump mucosa after total colectomy for ulcerative colitis.

METHODS

Seven patients (5 males; median age, 56 (range, 36-72) years) underwent attempted endoscopic transanal rectal mucosal ablation using the 28-French-gauge urologic resectoscope, either at the time of total colectomy and ileostomy for failed medical therapy (5 patients) or as an alternative to completion proctectomy (2 patients) with rectal stump discharge. All had declined restorative proctocolectomy. Clinical, endoscopic, and histologic follow-up was undertaken during a mean of 15 (range, 3-28) months.

RESULTS

The operative technique evolved during these cases; mucosal ablation was successfully performed leaving a denuded muscular rectal tube in situ in six patients. Mean operative time was 45 minutes. Postoperative endoscopic surveillance has not demonstrated any viable rectal mucosa in these six patients, with only granulation tissue detected histologically. Narrowing of the rectal tube has occurred in two patients. Although all patients report insignificant rectal discharge, urinary and sexual function have remained unchanged.

CONCLUSIONS

Diathermy ablation of the rectal mucosa via endoscopic transanal rectal mucosal ablation avoids the complications of pelvic dissection and might offer an effective alternative to proctectomy for ulcerative colitis.

Transanal excision of rectal villous adenomas by laparoscopic methods

Large villous adenomas of the rectum are not uncommon and will be encountered often by general and colorectal surgeons in their practices. The approach to large adenomas can be via the colonoscope either transabdominally or transanally. A simple transanal method was instituted by the author in 1992 and has been used up to the time of writing. This involves using a 4-cm diameter transanal operating rectoscope with laparoscopic instruments and the laparoscope itself. The results for 13 patients from January 1992 to April 2001 are reviewed. The method is simple and allows access to lesions up to 15 cm from the anal verge with a low incidence of complications, residual disease, and recurrence.

Endoscopic transanal resection of rectal tumours using a urological resectoscope--still has a role in selected patients

INTRODUCTION

Transanal resection of rectal villous adenomas or adenocarcinomas can be carried out using various modalities such as operative excision, fulguration, laser coagulation or cryotherapy. Transanal endoscopic microsurgery is currently not widely available. Transanal resection can provide effective palliation for locally advanced rectal tumours in patients unfit for abdomino-perineal excision of rectum. A urological resectoscope can be safely and repeatedly used to resect advanced primary or locally recurrent rectal tumours by colorectal surgeons with urological expertise. This study reports our experience of treating rectal lesions with endoscopic transanal resection (ETAR) using the urological resectoscope.

METHODS

Patients were identified from one surgeons' prospectively collected operating data. Charts were retrieved and reviewed.

RESULTS

Over a 13-year period a total of 43 ETAR procedures were carried out in 20 patients (11 males; mean age 74 years; range 54-92 years) using the urological resectoscope. Twelve (60%) patients had a single resection; 8 (40%) patients required more than one resection; the mean number of procedures per patient was 2.2 (range 1-8). The median interval between resections for recurrent disease (excluding planned repeat resections) was 340 days (range 168-2337 days). Histopathology revealed rectal adenoma (with varying degrees of dysplasia) in 11 (55%) patients and adenocarcinoma in 9 (45%). The majority (30; 70%) of resections were carried out in patients with benign disease, with 13 (30%) in patients with rectal adenocarcinoma. Mean operating time per resection was 25 min. Thirteen (30%) resections were carried out under spinal anaesthetic. There was no procedure related mortality. There were no cases of haemorrhage, rectal perforation, 'TUR syndrome' or pelvic sepsis. No patients with benign disease subsequently developed an invasive carcinoma.

CONCLUSIONS

Accepting that this technique provides limited histopathological information regarding extent of resection and tumour clearance, our experience demonstrates that ETAR of rectal tumours using the urological resectoscope can provide a minimally invasive, effective and safe means of treating and palliating patients with benign and malignant rectal disease. There remains a place for this technique in selected patients.

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.