Which treatment for large rectal adenoma? Preoperative assessment and therapeutic strategy

Robotic endoscopic submucosal dissection and full-thickness excision for laterally spreading tumors of the rectum

Endoscopic submucosal dissection (ESD) is technically demanding and time-consuming. Moreover, it bears a high risk of adverse events compared to other endoscopic methods, due to the lack of tissue manipulation. Robotic technology can significantly reduce the time of the procedure and increase the rate of complete resection for ESD. In the case of an unclear deep margin it allows to proceed to the full-thickness excision of the bowel wall. While the gain over transanal endoscopic microsurgery (TEM) is limited today, the longer systems currently under development will allow these complex procedures to be performed at least in the left side of the colon. The Supplementary video shows the application of the Flex Robotic System to perform an ESD and a full-thickness excision.

Transanal Endoscopic Operation under spinal anaesthesia

Background

Transanal Endoscopic Operation (TEO®) for rectal benign lesions and early rectal cancer may provide better oncological outcomes than flexible endoscopy. The major advantage of flexible endoscopy is that it does not require general anaesthesia. This prospective observational study assessed the feasibility and safety of TEO® performed under spinal anaesthesia.

Methods

The study population comprised eligible consecutive patients who underwent TEO® under spinal anaesthesia with curative or palliative intent for rectal neoplasms larger than 20 mm in diameter or for recurrent lesions of any size. The primary endpoints were feasibility and safety; secondary endpoints were postoperative pain, as measured on a visual analogue scale, heart rate, systolic and diastolic BP, opioid requested, postoperative nausea or vomiting, and urinary retention.

Results

The study included 50 patients (median age 70 years; 29 men and 21 women). No intraoperative complications occurred. The median duration of operation was 60 (range 20–165) min. No opioids were requested during the perioperative or postoperative period. The median postoperative pain score was 0 at 4, 8, 24 and 48 h after surgery. There were no significant fluctuations in heart rate, systolic and diastolic BP up to 48 h after the procedure (P = 0·379, P = 0·386 and P = 0·617 respectively). Postoperative nausea and vomiting occurred in one patient, and urinary retention in four.

Conclusion

TEO® under spinal anaesthesia was safe and feasible with no conversions to general anaesthesia.

A new technique of totally laparoscopic resection with natural orifice specimen extraction (NOSE) for large rectal adenoma

There is no consensus about the best technique to use for the surgical treatment for large rectal adenomas. The advent of laparoscopic surgery has led to the development of several new methods for the treatment of gastrointestinal tumors. This study was designed to introduce an innovative technique of totally laparoscopic resection with natural orifice specimen extraction (NOSE) for large rectal adenomas and to assess the feasibility and safety of the technique. Between February 2011 and January 2014, we performed totally laparoscopic resection with NOSE on 18 patients with a large rectal adenoma. This new technique was successful in all 18 patients. The average size of the adenoma was 4.2 cm. Mean operation time was 108.4 min, and mean intraoperative blood loss was 36.6 ml. The mean time to passing of the first flatus was 2.3 days, and the mean postoperative hospital stay was 7.2 days. Only one patient needed analgesics after the operation. All patients were able to walk within the first 2 days. There were no cases of morbidity and recurrence. Totally laparoscopic resection with NOSE appears to be suitable for selected patients with a large adenoma located in mid- or low rectum.

Transanal endoscopic microsurgery for surgical repair of rectovesical fistula following radical prostatectomy

BACKGROUND

Rectovesical fistula is a rare complication following prostatectomy, associated with significant symptoms such as urinary drainage from anus or faecaluria. While several surgical procedures have been described to treat this condition, none of them has been accepted as the universal standard. Transanal endoscopic microsurgery (TEM) is a well-established endoluminal procedure for local excision of rectal tumors. But its application to the repair of rectovesical fistula has been almost unknown.

METHODS

We performed TEM as a surgical repair for refractory rectovesical fistula developing after radical prostatectomy in 10 patients. Under the magnified three-dimensional view, through the stereoscope, the fistula and the surrounding rectal mucosa were precisely resected. The defect and the muscle layer of the rectum were closed by hand-sew technique in four layers.

RESULTS

Fistula was completely closed in 7 patients, who eventually underwent enterostomy closure, while in the other 3 patients the fistula recurred. In the three recurrent cases, the fistula was associated with wide, tough scar tissue due to previous irradiation, HIFU, or repeated surgical repair attempts.

CONCLUSIONS

Rectovesical fistulas associated with wide, tough scar tissue due to multi-time attempt of surgical repair or any type of energy ablation should not be indicated for repair by TEM. However, for simple fistulas without tough, fibrotic surroundings, TEM can be indicated as a minimally invasive surgical option with very low morbidity, without any incision in healthy tissue for approach.