Surgical resection of rectal adenoma: A rapid review

Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) for rectal adenomas: a retrospective cohort study of 145 consecutive cases

PURPOSE

Transanal endoscopic microsurgery (TEM) and endoscopic submucosal dissection (ESD) are currently the two most popular methods for resecting large rectal adenomas en bloc. However, damage to the mesorectum in the case of TEM, plus the technical challenges and long procedure times of flexible ESD, are major disadvantages of these procedures. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) is a new technique, combining the ergonomic features of TEM with the minimally invasive approach of ESD. The aim of our study was to assess the feasibility and safety of TEM-ESD for resection of large rectal adenomas.

METHODS

We retrospectively analyzed all TEM-ESD procedures performed in Karlsruhe Municipal Hospital between 2012 and 2019, isolated all cases of adenomas, and analyzed the perioperative and follow-up data of the patients.

RESULTS

We identified 145 cases matching our criteria. The median size of the lesions was 4.2 cm, and the median operating time was 45 min. The en bloc resection rate was 100%, and the complete en bloc resection rate was 78.6%. The overall morbidity rate was 6.9%. In a median follow-up period of 24 months, there was a local recurrence in 4.8% of the cases.

CONCLUSIONS

TEM-ESD is a safe and feasible therapeutic option for resecting large rectal adenomas, offering high en bloc resection and low recurrence rates combined with short operating time and low morbidity. TRIAL REGISTRATION NUMBER (CLINICALTRIALS.GOV): NCT04870931.

Transanal Minimally-Invasive Surgery (TAMIS): Experience with No Closure of the Rectal Defect

Background In transanal minimally-invasive surgery (TAMIS), the closure of the rectal defect is controversial, and endoluminal suture is one of the most challenging aspects. The goal of the present study is to evaluate the short- and medium-term complications of a consecutive series of patients with extraperitoneal rectal injuries who underwent TAMIS without closure of the rectal defect.

Materials and Methods A prospective, longitudinal, descriptive study conducted between August 2013 and July 2019 in which all patients with extraperitoneal rectal lesions, who were operated on using the TAMIS technique, were consecutively included. The lesions were: benign lesions ≥ 3 cm; neuroendocrine tumors ≤ 2 cm; adenocarcinomas in stage T1N0; and adenocarcinomas in stage T2N0, with high surgical risk, or with the patients reluctant to undergo radical surgery, and others with doubts about complete remission after the neoadjuvant therapy. Bleeding, infectious complications, rectal stenosis, perforations, and death were evaluated.

Results A total of 35 patients were treated using TAMIS without closure of the defect. The average size of the lesions was of 3.68 ± 2.1 cm (95% confidence interval [95%CI]: 0.7 cm to 9 cm), their average distance from the anal margin was of 5.7 ± 1.48 cm, and the average operative time was of 39.2 ± 20.5 minutes, with a minimum postoperative follow-up of 1 year. As for the pathologies, they were: 15 adenomas; 3 carcinoid tumors; and 17 adenocarcinomas. In all cases, the rectal defect was left open.

The overall morbidity was of 14.2%. Two patients (grade II in the Clavien-Dindo classification) were readmitted for pain treatment, and three patients (grade III in the Clavien-Dindo classification) were assisted due to postoperative bleeding, one of whom required reoperation.

Conclusion The TAMIS technique without closure of the rectal defect yields good results, and present a high feasibility and low complication rate.

Transanal minimal invasive surgery (TAMIS): safety and feasibility for the resection of benign and malignant lesions of the rectum

Objectives

Radical surgery for rectal tumours has high morbidity. Local excision of such tumours can be achieved without compromising oncologic safety. However tumours that are not accessible to local excision can be approached using Transanal Minimal Invasive Surgery (TAMIS). The aim of our study was to assess feasibility of TAMIS procedure in terms of complications, operating time, resection margin positivity, hospital stay and local recurrence rate.

Material and Methods

Forty eight patients with benign adenomas or early stage adenocarcinoma, within 4 to 12 cm from anal verge who were subjected to TAMIS over a period of 3 years were included in the study. Short and long term outcomes were assessed.

Results

TAMIS was performed for 36 benign adenomas and 12 adenocarcinomas, which were located at an average distance of 6.2 cm from anal verge. The mean operating time was 72 minutes. There were no intraoperative complications.1 (2.08%) patient suffered post operative bleeding, which was managed conservatively. 2 (4.16%) patients developed acute urinary retention who required indwelling catheterisation. Resection margin was positive in 3 (6.25%) benign cases. Average hospital stay was 2.7 days. Local recurrence occurred in 2 (4.16%) villous adenoma patients (after 11 and 13 months), whereas in malignant patients there was no recurrence at a follow up period ranging between 12 to 36 months.

Conclusion

TAMIS is a safe and feasible procedure for benign tumours and early rectal cancers, located in low and middle rectum.

Transanal minimally invasive surgery (TAMIS) for local excision of selected rectal neoplasms: efficacy and outcomes in the first 11 patients

Disposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS) with benefits, when compared to local resection and transanal endoscopic microsurgery (TEM).

Objective To show outcomes and details of the technique.

Method A series of patients with indication for local resection of rectal tumors were submitted to surgery using the TAMIS platform.

Results Eleven patients have been submitted to TAMIS. Distance from anal verge was from 1.5 to 8 cm and maximum tumor diameter was 6 cm. Initial diagnosis of adenoma was the most frequent indication for resection. One partial dehiscence was the only complication seen. Minimal setup time, low cost and the possibility of using regular laparoscopic instruments make TAMIS a good option for transanal resection. The results of this technique are encouraging, concerning the feasibility, maneuverability, upfront cost, setup time, resectability and complication rate. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique that still expects a lot of growing and much remains to be learned.

Preoperative chemoradiotherapy affects postoperative outcomes and functional results in patients treated with transanal endoscopic microsurgery for rectal neoplasms

BACKGROUND

The aim of this study was to quantify the incidence of short-term postoperative complications and functional disorders at 1 year from transanal endoscopic microsurgery (TEM) for rectal neoplasms, to compare patients treated with TEM alone and with TEM after preoperative chemoradiotherapy (CRT) and to analyse factors influencing postoperative morbidity and functional outcomes.

METHODS

A retrospective study was conducted on all patients treated with TEM for rectal neoplasms at our institution in January 2000-December 2017. Data from a prospectively maintained database were retrospectively analysed. Patients were divided into two groups: adenoma or early rectal cancer (no CRT group) and locally advanced extraperitoneal rectal cancer with major or complete clinical response after preoperative CRT (CRT group). Short-term postoperative mortality and morbidity and the functional results at 1 year were recorded. The two groups were compared, and a statistical analysis of factors influencing postoperative morbidity and functional outcomes was performed. Functional outcome was also evaluated with the low anterior resection syndrome (LARS) score (0-20 no LARS, 21-29 minor LARS and 30-42 major LARS).

RESULTS

One hundred and thirteen patients (71 males, 42 females, median age 64 years [range 41-80 years]) were included in the study (46 in the CRT group). The overall postoperative complication rate was 23.0%, lower in the noCRT group (p < 0.001), but only 2.7% were grade ≥ 3. The most frequent complication was suture dehiscence (17.6%), which occurred less frequently in the noCRT group (p < 0.001). At 1 year from TEM, the most frequent symptoms was urgency (11.9%, without significant differences between the CRT group and the noCRT group); the noCRT group experienced a lower rate of soiling than the CRT group (0% vs. 7.7%; p: 0.027). The incidence of LARS was evaluated in 47 patients from May 2012 on and was 21.3% occurring less frequently in the noCRT group (10% vs. 41.2%; p: 0.012). Only 6.4% of the patients evaluated experienced major LARS. In multivariate analysis, preoperative CRT significantly worsened postoperative morbidity and functional outcomes.

CONCLUSIONS

TEM is a safe procedure associated with only low risk of severe postoperative complications and major LARS. Preoperative CRT seems to increase the rate of postoperative morbidity after TEM and led to worse functional outcomes at 1 year after surgery.

Surgical and postoperative evaluations of rectal adenomas excised with a rigid proctoscope

PURPOSE

This study presents the surgical and postoperative results achieved with a rigid proctoscope using the transanal endoscopic technique to excise rectal adenomas. The results are compared to the results obtained with other currently employed transanal techniques.

METHODS

We investigated the medical records of patients who underwent transanal endoscopic operations from April 2000 to June 2018 at two tertiary referral centers for colorectal cancer.

RESULTS

This study included 99 patients. The mean age was 65.3 ± 13.3 years. The average size of the adenomas was 4.6 ± 2.3 cm, and their average distance to the anal border was 5.6 ± 3.3 cm. The average operative time was 65.3 ± 41.7 min. In 48.5% of the operations, the specimen was fragmented, and in 59.6% of the cases, the microscopic margins were free. The rates of postoperative complications and relapse were 5% and 19%, respectively. The mean follow-up was 80 ± 61.5 months.

CONCLUSIONS

The described proctoscope proved to be a viable technique with results similar to other techniques, with the advantage that it allowed greater accessibility for surgeons. Therefore, its use could be implemented and become widespread in surgical practice.

Endoscopic full-thickness resection of early colorectal neoplasms using an endoscopic submucosal dissection knife: a retrospective multicenter study

Background and study aims  Endoscopic full-thickness resection allows resection of early gastrointestinal neoplasms not amenable to conventional endoscopic resection techniques, due to their location, presence of submucosal fibrosis, or suspected deep mural invasion. It is typically achieved using a dedicated over-the-scope device (full-thickness resection device or FTRD). The aim of our study was to evaluate the feasibility, safety, and clinical outcomes of endoscopic full-thickness resection using an endoscopic submucosal dissection (ESD) knife. Patients and methods  Consecutive patients who underwent full-thickness endoscopic resection at six tertiary care centers from August 2010 to June 2017 were retrospectively included. We conducted a comparative analysis of patient characteristics, technical success, adverse events, and time to discharge between patients treated by a full-thickness resection using an ESD knife. Results  Twenty-one procedures were performed using an ESD knife. En-bloc resection and R0 resection rates were 95.2 % and 65 %, respectively. Clinical symptoms of perforation occurred in 66.7 %. There was no need for surgery or additional endoscopic procedures. Conclusion  Endoscopic full-thickness resection of early colorectal neoplasms using an ESD knife might be feasible and safe. It allows complete resection of lesions with no limitation in size. The technique may be preferable to an other-the-scope resection device in lesions larger than 20 mm, and to surgery in selected cases of low-risk T1 colorectal carcinomas, non-lifting adenomas, submucosal tumors, or technically challenging lesion locations.

McKittrick Wheelock Syndrome Treated by Transanal Minimally Invasive Surgery: A Single-Center Experience and Review of the Literature

INTRODUCTION

McKittrick Wheelock Syndrome (MKWS) is a rare syndrome characterized by secretory diarrhea, dehydration, prerenal acute kidney injury, and severe electrolyte abnormalities caused by a large hypersecretory villous adenoma located in the rectum or rectosigmoid junction. Transabdominal (laparoscopic) procedures are the most described procedures in the treatment of MKWS. We report an alternative surgical approach, transanal minimally invasive surgery (TAMIS), to solve this syndrome.

MATERIALS AND METHODS

All patients who underwent transanal endoscopic microsurgery or TAMIS were included in a prospectively collected database in our center. Between 1996 and 2015, 3 patients were found to have MKWS and treated by TAMIS. Demographics, characteristics of the adenoma, surgery-related data, and outcome were analyzed.

RESULTS

The first patient had a villous adenoma 0-12 cm from the anal verge. After TAMIS, she complained of a stenosis that was successfully treated by dilatation. The second patient had an impressive bulky tumor in the rectum. An endoscopic mucosal resection was attempted twice, but incompletely. Pathology analysis showed villous adenoma with high-grade dysplasia and intramucosal carcinoma. One year after TAMIS, a recurrence was detected and treated by an abdominal-perineal resection. A TAMIS was performed in the third patient because of a giant villous circular adenoma, but because of high mucus and fluid production, no proper overview could be obtained. Together with opening of the peritoneum, this prompted us to convert to a laparoscopic Hartmann procedure. Besides this technical difficulty, the patient recovered uneventful.

CONCLUSIONS

MKWS is a rare syndrome and missed diagnosis could result in life-threatening situations. Different endoscopic and surgical treatments are described to solve this syndrome. TAMIS should be considered as a rectum-preserving surgical treatment option for such extensive adenomas.

Transanal Endoscopic Operation for Benign Rectal Lesions and T1 Carcinoma

Background and Objectives:

Transanal endoscopic operation (TEO) is a minimally invasive technique used for local excision of benign and selected malignant rectal lesions. The purpose of this study was to investigate the feasibility, safety, and oncological outcomes of the procedure and to report the experience in 3 centers.

Methods:

Retrospective review of a prospectively collected database was performed of all patients with benign lesions or ≤cT1N0 rectal cancer who underwent TEO with curative intent at 3 Belgian centers (2012 through 2014).

Results:

Eighty-three patients underwent 84 TEOs for 89 rectal lesions (37 adenomas, 43 adenocarcinomas, 1 gastrointestinal stromal tumor, 1 lipoma, 2 neuroendocrine tumors, and 5 scar tissues). Operative time was associated with lesion size (P < .001). Postoperative complications occurred in 13 patients: 7 hemorrhages, 1 urinary tract infection, 1 urinary retention, 2 abscesses, 1 anastomotic stenosis, and 1 entrance into the peritoneal cavity. Median hospital stay was 3 days (range, 1–8). During a median follow-up of 13 months (range, 2–27), there was 1 recurrence.

Conclusion:

Although longer follow-up is still necessary, TEO appears to be an effective method of excising benign tumors and low-risk T1 carcinomas of the rectum. However, TEO should be considered as part of the diagnostic work-up. Furthermore, the resected specimen of a TEO procedure allows adequate local staging in contrast to an endoscopic piecemeal excision. Nevertheless, definitive histology must be appreciated, and in case of unfavorable histology, radical salvage resection still has to be performed.

Significance of defect closure following transanal local full-thickness excision of rectal malignant tumors

Transanal excision (TAE) for rectal tumors is increasingly applied and it is generally recommended that the defect following full-thickness excision should be closed. The aim of this study was to compare the complications and anal function following TAE between cases where the defect was closed and those where it was not. A total of 43 consecutive rectal malignant tumor patients eligible for TAE were investigated. Regarding anorectal function, incontinence was assessed using the Wexner score. The defect of the rectum was closed in 21 of the 43 patients. There were no significant differences between the two groups regarding gender, distance from the anal verge, tumor size, diagnosis and tumor site. There was a significantly higher number of postoperative complications of all grades and ≥Clavien-Dindo grade IIIa in the closure group (P=0.02 and 0.04, respectively). Regarding the Wexner score, there was no significant difference between the two groups (P=0.24). Compared with the closure group, the non-closure group had significantly fewer postoperative complications of all grades and ≥Clavien-Dindo grade IIIa. Moreover, there was no significant difference regarding the anorectal function between the two groups. Thus, suturing the rectal defect is not necessarily recommended following TAE.

Transanal minimally invasive surgery (TAMIS) with a GelPOINT® Path for lower rectal cancer as an alternative to transanal endoscopic microsurgery (TEM)

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique. However, TEM has not yet achieved widespread use. Recently, transanal minimally invasive surgery (TAMIS) using single-port surgery devices has been reported. In the present study, TAMIS using a GelPOINT^® Path was performed in six patients with lower rectal cancer. A complete full-thickness excision was performed in all cases. The patient characteristics, operative techniques and operative outcomes were evaluated. The mean age of the patients was 63.0 years (range: 48-76). The mean operating time and blood loss were 86 min (range: 55-110) and 5 ml (range 0-10), respectively. There were no instances of morbidity or mortality. Additional transabdominal rectal resection was not performed, and adjuvant chemoradiotherapy was performed in all cases. The mean Wexner score was 0.6 (range: 0-3; n=5) at 6 months, and 0 (range: 0; n=4) at 12 months. TAMIS using a GelPOINT^® Path was revealed to be easy and safe to perform. Although only a small number of cases were treated, the anal function following surgery was shown to be favorable, and the operation was demonstrated to be sufficiently feasible. Based on these results, TAMIS may, in time, assume a major role in the resection of large adenomas and early rectal cancers.

Transanal Minimally Invasive Surgery: Review of Indications and Outcomes from 75 Consecutive Patients

BACKGROUND

Transanal minimally invasive surgery (TAMIS) is an advanced local excision platform that helps overcome technical limitations and morbidity associated with other resection methods. Our goal was to review the indications and outcomes of TAMIS in a large series.

STUDY DESIGN

A review of a prospective database identified patients who underwent TAMIS from 2010 to 2014. Demographic, perioperative, short-term outcomes, and recurrence data were analyzed.

RESULTS

There were 75 patients with 76 lesions analyzed. Mean age was 64.0 years (SD 11.6 years) and mean BMI was 27.4 kg/m(2) (SD 4.7 kg/m(2)). Median American Society of Anesthesiologists (ASA) score was 2 (range 1 to 4). There were 59 benign (77.3%) and 17 malignant (22.7%) lesions: 6 pT0, 6 pT1, 4 pT2, and 1 pT3. Median lesion distance from the anal verge was 10 cm (range 6 to 16 cm). Mean operative time was 76.0 minutes (SD 36.1 minutes). Three patients had intraperitoneal entry; all were closed transanally, but 2 had temporary diverting ileostomies fashioned to ensure healing. Median length of stay was 1 day (range 0 to 6). One patient had a fragmented lesion (1.3%). Five patients had positive margins: 2 in palliative pT2 resections, and 3 in pT1, pT2, and gastrointestinal stromal tumor (GIST) patients. They were managed with radical resection (pT1 and pT2 lesions) and surveillance/medical oncology (GIST). Postoperatively, 3 patients had complications (bleeding, rectal stricture, and recto-vaginal fistula), and all were managed nonoperatively. After median follow-up of 39.5 months (range 10.5 to 65.3 months), 1 pT1 patient with negative margins developed a local recurrence and underwent salvage APR.

CONCLUSIONS

Transanal minimally invasive surgery is a viable option for excision of benign or early stage rectal masses, with mid-term oncologic outcomes comparable to those of radical resection. Further, TAMIS minimizes the morbidity and can allow more patients to benefit from the minimally invasive approach.

Transanal Minimally Invasive Surgery: State of the Art

The treatment for rectal cancer and benign rectal lesions continues to progress in the arena of minimally invasive surgery. While surgical excision of the primary mass remains essential for eradication of disease, there has been a paradigm shift towards less invasive resection methods. Local excision is increasing in popularity for its low morbidity and excellent functional results in select patients. Transanal minimally invasive surgery (TAMIS) is a new technology developed to elevate the practice of local excision to state-of-the-art resection. The goal of this article is to evaluate the history, short-term outcomes, and evolution of the TAMIS technique for excision of benign and malignant rectal neoplasia.

Endoscopic submucosal dissection versus local excision for early rectal cancer: a systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) and local excision (LE) are minimally invasive procedures that can be used to treat early rectal cancer. There are no current guidelines or consensus on the optimal treatment strategy for these lesions. A systematic review was conducted to compare the efficacy and safety of ESD and LE. A meta-analysis was conducted following all aspects of the Cochrane Handbook for systematic reviews and preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. To perform the statistical analysis, the odds ratio (OR) was used for categorical variables and the weighted mean difference (WMD) for continuous variables. Four studies, involving a total of 307 patients, were identified. The length of hospital stay was longer in the group of patients undergoing LE [weighted mean difference (WMD) -1.94; 95% CI -2.85 to -1.02; p < 0.0001]. The combined results of the individual studies showed no significant differences as regards en-bloc resection rate (OR 0.82; 95% CI 0.25-2.70; p = 0.74), R0 resection rate (OR 1.53; 95% CI 0.62-3.73; p = 0.35), overall complication rate (OR 0.67; 95% CI 0.26-1.69; p = 0.40), and tumor size (WMD 0.57; 95% CI -3.64 to 4.78; p = 0.79) between ESD and LE. When adopting the fixed effect model which takes into account the study size, ESD was associated with a lower recurrence rate than LE (OR 0.15; 95% CI 0.03-0.87; p = 0.03), while with the random-effect model the difference was not significant (OR 0.18; 95% CI 0.02-2.04; p = 0.17). Over the last decade improvements in technology have improved the technical feasibility of rectal ESD. In specialized centers with highly experienced endoscopists, ESD can provide high-quality en-bloc excision of rectal neoplasms equivalent to traditional local excision.

Practice parameters for early rectal cancer management: Italian Society of Colorectal Surgery (Società Italiana di Chirurgia Colo-Rettale; SICCR) guidelines

The introduction of new technologies for diagnosis and screening programs led to an increasing rate of early detection of colorectal cancer. This, associated with the evolution of endoscopic techniques of local excision, led to the assessment of new strategies to reduce morbidity related to treatment, especially for early rectal cancer (ERC). Nevertheless, the definition of ERC and its staging and treatment algorithm are still under debate. The Italian Society of Colorectal Surgery developed practice guidelines to provide recommendations on the diagnosis, staging and treatment of ERC. A systematic review on the topic was performed by a multidisciplinary group of experts selected based on their clinical and scientific expertise in endoscopy, endoscopic ultrasound, magnetic resonance and surgery, with the aid of an external international audit.

A scoping review of rapid review methods

BACKGROUND

Rapid reviews are a form of knowledge synthesis in which components of the systematic review process are simplified or omitted to produce information in a timely manner. Although numerous centers are conducting rapid reviews internationally, few studies have examined the methodological characteristics of rapid reviews. We aimed to examine articles, books, and reports that evaluated, compared, used or described rapid reviews or methods through a scoping review.

METHODS

MEDLINE, EMBASE, the Cochrane Library, internet websites of rapid review producers, and reference lists were searched to identify articles for inclusion. Two reviewers independently screened literature search results and abstracted data from included studies. Descriptive analysis was conducted.

RESULTS

We included 100 articles plus one companion report that were published between 1997 and 2013. The studies were categorized as 84 application papers, seven development papers, six impact papers, and four comparison papers (one was included in two categories). The rapid reviews were conducted between 1 and 12 months, predominantly in Europe (58 %) and North America (20 %). The included studies failed to report 6 % to 73 % of the specific systematic review steps examined. Fifty unique rapid review methods were identified; 16 methods occurred more than once. Streamlined methods that were used in the 82 rapid reviews included limiting the literature search to published literature (24 %) or one database (2 %), limiting inclusion criteria by date (68 %) or language (49 %), having one person screen and another verify or screen excluded studies (6 %), having one person abstract data and another verify (23 %), not conducting risk of bias/quality appraisal (7 %) or having only one reviewer conduct the quality appraisal (7 %), and presenting results as a narrative summary (78 %). Four case studies were identified that compared the results of rapid reviews to systematic reviews. Three studies found that the conclusions between rapid reviews and systematic reviews were congruent.

CONCLUSIONS

Numerous rapid review approaches were identified and few were used consistently in the literature. Poor quality of reporting was observed. A prospective study comparing the results from rapid reviews to those obtained through systematic reviews is warranted.

[TEO: minimally invasive surgery of the rectum. A short review]

The equipment and technique of transanal endoscopic microsurgery was developed by Buess in the early 80s. The technique was more refined, and the indication was widened since then. Excellent oncological results can be achieved with good patient selection with this less invasive technique and the complication rate is very low in contrast to conventional techniques. Nowadays the transanal endoscopic microsurgery is the "gold standard" in the treatment of benign lesions and low risk T1 cancer of the rectum.

Giant rectal villous adenoma: Surgical approach with rectal eversion and perianal coloanal anastomosis

INTRODUCTION

Colorectal cancer is an important cause of death. Most cases of colon and rectal cancer arise from a preexisting adenomatous polyp. However, if colorectal polyps are very large or not accessible for endoscopic ablation, or if they cannot be removed without an increased risk of perforation, surgical procedures are required.

PRESENTATION OF CASE

The case of a patient with a giant villous adenoma of the rectum is described. The patient had diarrhea for 2 years associated with asthenia. Colonoscopy revealed a sessile lesion in the rectum measuring 14cm in the largest diameter. Rectal eversion technique was used, resecting the lesion under direct visibility and an external coloanal anastomosis was performed. Surgery was satisfactory and the resection margins were free.

DISCUSSION

Removal of these polyps should be performed aiming to reduce the incidence of colorectal cancer, as well as to control local and systemic symptoms, such as diarrhea and fluid and electrolyte disorders, mainly in villous adenomas. Various surgical techniques are proposed, but in extensive circumferential lesions of the rectum they are difficult to apply. The rectal stump eversion technique was described by Maunsell (1892), for rectal cancer.

CONCLUSION

Eversion of the rectal stump and external coloanal anastomosis may be a good surgical alternative for resecting giant rectal adenomas.

Transanal single-port microsurgery for rectal tumors: minimal invasive surgery under spinal anesthesia

BACKGROUND

Transanal minimally invasive surgery (TAMIS) for rectal tumors has been introduced as an alternative approach to transanal endoscopic microsurgery (TEM). TEM has some limitations, such as the need for special equipment, expensive cost, and steep learning curve. In this study, we address the technical feasibility of TAMIS under spinal anesthesia and its short-term postoperative outcomes.

METHODS

From July 2011 to September 2012, 25 consecutive patients with middle or upper third rectal masses underwent TAMIS. Tumors were located 6-17 cm from the anal verge. After spinal anesthesia, a single-incision laparoscopic surgery port was inserted into the anal canal. With this access, conventional laparoscopic instruments, including a grasper and monopolar electrocautery and suction device, were used to perform the transanal excision. A hook-type monopolar electrocautery or harmonic scalpel was used for dissection. The defect of the rectum was closed by interrupted sutures. Data concerning demographics, details of operative procedure, postoperative pain, and pathologic results were collected prospectively. To evaluate anal sphincter injury, an endoanal ultrasonography and fecal incontinence severity index survey were performed at 3-6 months after the operation.

RESULTS

Of the 25 patients, nine had adenocarcinomas, nine had neuroendocrine tumors, three had tubular adenomas with high-grade dysplasia, three had tubular adenomas, one had a tubulovillous adenoma, and one had a gastrointestinal stromal tumor. The median distance from the tumor mass to the anal verge was 9.0 (range 6-17) cm. The median operative time was 45.0 (range 20-120) min. All patients received TAMIS without conversion to laparoscopic resection. There were no intraoperative complications or postoperative morbidity. The median postoperative hospital stay was 3.0 (range 2-7) days. No sphincter injury was detected by endoanal ultrasonography.

CONCLUSIONS

TAMIS under spinal anesthesia is a safe and feasible technique for resection of middle and upper rectal masses. Spinal anesthesia is adequate for this procedure.

Treatment of preoperatively diagnosed colorectal adenomas by transanal endoscopic microsurgery: the experience in China

INTRODUCTION

Colorectal adenoma is a recognized precancerous lesion that has the potential for malignant transformation. Surgical resection of colorectal adenomas is required for exact diagnosis and treatment. The aim of this study is to assess the safety and therapeutic effect of transanal endoscopic microsurgery for preoperatively diagnosed colorectal adenomas.

METHODS

From September 2006 to February 2011, 45 patients with preoperatively diagnosed colon and rectal adenomas underwent transanal endoscopic microsurgery. The clinical data of these patients were reviewed.

RESULTS

The mean tumor diameter was 2.2 cm, mean operative time was 65 min, and the mean estimated blood loss was less than 10 mL. There was no conversion to transabdominal procedure. The mean tumor distance from the anal verge was 8.2 cm. Four patients had perforation into the peritoneal cavity during full-thickness resection; these were repaired by continuous suturing, and there was no postoperative leakage after 1 week of fasting. The surgical margins of specimens were negative in 44 patients. Complications included rectal bleeding in one patient, acute urinary retention in one patient and pulmonary infection in one patient. The mean postoperative hospital stay was 4.5 days. Only one patient experienced incontinence of hard stool 6 months after surgery. The patients were followed up for a median period of 42 months, with four cases of tumor recurrence observed.

CONCLUSION

Transanal endoscopic microsurgery is a safe and effective technique for excising large adenomas in the mid and upper rectum and in the lower sigmoid colon. It is also an oncologically preferred method for T1 focal carcinomas that develop from villous adenomas.

Screening for colorectal neoplastic lesions following acute diverticulitis: Would a sigmoidoscopy suffice?

AIM: To investigate the yield of colorectal malignant or premalignant lesions during colonoscopy performed following an episode of acute diverticulitis.

METHODS: A prospectively maintained electronic database of a public teaching hospital (Modbury Hospital, South Australia) was searched for international classification of diseases codes for acute diverticulitis from July 2007 to June 2011. The electronic database and each patient’s medical records were reviewed for demographic data, clinical presentation, investigation results, colonoscopy details and surgical intervention.

RESULTS: Two hundred and nineteen patients were diagnosed with acute diverticulitis with a median age of 60 years (range 24-93). One hundred and thirty-nine patients (63.5%) had follow-up screening colonoscopy, with the median interval between the episode of acute diverticulitis and colonoscopy being 8 wk (range: 1-66). Colonoscopy revealed polyps in 21 patients (15%) and no cases of colorectal cancer. Of the 21 patients with polyps, there were 14 patients (10%) with tubular/villous adenomas (13 in rectosigmoid region and 1 in descending colon).

CONCLUSION: Detection of colorectal cancer in patients undergoing routine colonoscopy following acute diverticulitis is rare. However, colonic polyps in the left colon are noted. A flexible sigmoidoscopy is an adequate screening tool in such patients. A complete colonoscopy reserved for patients with family history of colorectal cancer or with polyps detected on flexible sigmoidoscopy to evaluate the rest of the colon.

Transanal minimally invasive surgery (TAMIS) using a new disposable device: our initial experience

Disposable single-port surgery devices have been used for transanal minimally invasive surgery (TAMIS). Their advantage, compared to transanal endoscopic microsurgery, is that they do not require special equipment or training. The aim of this study was to assess our initial experience using the single-site laparoscopic (SSL™) access system (Ethicon Endo-Surgery, Cincinnati, OH, USA) for TAMIS. Five patients eligible for local excision of rectal tumors, four males and one female, mean age 58 years (range 50-78), underwent surgery using the SSL™ device. The average distance from anal verge was 4 cm (range 1-6). Four patients had an initial diagnosis of adenoma, and one had a previous endoscopic excision of a T1 adenocarcinoma with positive margins. In one patient, due to the lack of exposure, the procedure was converted to a low anterior resection. In the remaining four patients, average setup time was 7 minutes (range 4-15) and average operative time was 52 minutes (range 38-72). All resection margins were tumor free. There were no postoperative complications. Two of the presumed adenomas were intramucosal adenocarcinomas, while one patient had a T2 tumor and underwent radical surgery. Although at the present time the appropriate use of local excision is still under debate, TAMIS is a technique with great potential. Because of its simplicity and similarity with conventional laparoscopic surgery, it can be learned easily by surgeons not trained in transanal endoscopic microsurgery.

TransAnal Minimally Invasive Surgery (TAMIS) with SILS™ port versus Transanal Endoscopic Microsurgery (TEM): a comparative experimental study

BACKGROUND

TransAnal Minimally Invasive Surgery (TAMIS) has been proposed as an alternative to Transanal Endoscopic Microsurgery (TEM) for resection of benign polyps and early cancers of rectum. Since clinical application has begun in the absence of any experimental validation, we assessed its feasibility and efficacy ex vivo in a pilot study.

METHODS

In a dedicated trainer box for transanal procedures, 10 surgeons with no experience in transanal surgery were asked to perform a dissection/suture task using both TAMIS and TEM in randomly allocated order. Surgeons were asked to dissect two identically drawn lesions of ~3 cm in larger diameter. Precision of dissection was assessed using a quantitative photographic method, while the time needed for dissection and suturing was considered a measure of quantitative evaluation. Each participant expressed a subjective opinion regarding difficulty with dissection, difficulty with suturing, vision quality, and conflict between instruments on a scale from 1 to 5.

RESULTS

No difference was observed between the two techniques regarding the accuracy of dissection as the margin was interrupted along 4.1 % of the circumference in the TEM group compared with 2.48 % in the SILS group (P = 0.271). Dissection and suturing were significantly quicker in the TEM group [04:30 vs. 06:35 min (P = 0.049) and 14:34 versus 19:18 min (P = 0.003)]. In three cases in the SILS group, completing the suture was not considered possible, and the procedures were terminated by TEM. Subjective evaluation revealed a better appreciation of TEM in all proposed comparisons: dissection (2.6 vs. 3.5, P = 0.004), suturing difficulty (3.1 vs. 4.6, P < 0.001), quality of vision (2.3 vs. 2.8, P = 0.18), and instrument conflicts (3.1 vs. 4.0, P = 0.054).

CONCLUSIONS

In the ex vivo setting, both techniques were comparable for achieving a good dissection, although TAMIS failed to prove effective in suturing the rectal wall. Moreover, TEM was significantly quicker despite the small groups and was better appreciated by the surgeons.

Transanal endoscopic microsurgery: what indications in 2013?

Thanks to major advances in the field of surgical techniques and neoadjuvant chemoradiation therapy, along with more accurate pre-operative staging tools and the widespread introduction of population-based screening programs, treatment of rectal cancer has been evolving over the past few decades, moving towards a more tailored approach. This has brought a shift in the treatment algorithm of benign rectal lesions and selected early rectal cancers, for which today transanal endoscopic microsurgery (TEM) is accepted as an effective alternative to abdominal surgery.

In 2013, topics of controversy are the role of TEM in the treatment of more advanced rectal cancers, in cases of complete pathological response after chemoradiation therapy and the role of TEM as a platform for single-port surgery and NOTES. This article reviews the current indications for TEM and the future perspectives of this approach in the treatment of rectal tumors.

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.

Previous transanal endoscopic microsurgery for rectal cancer represents a risk factor for an increased abdominoperineal resection rate

BACKGROUND

Transanal endoscopic microsurgery (TEM) represents a surgical option in the treatment of selected early rectal cancers. However, when definitive histopathology shows negative prognostic factors, rectal resection with total mesorectal excision (TME) is recommended to reduce the risk of recurrence. No studies have yet analyzed the impact of previous TEM on the perioperative outcomes of immediate laparoscopic TME (LTME) for rectal cancer. The aim of this study was to evaluate the perioperative outcomes of LTME after TEM for rectal cancer.

METHODS

This study was a retrospective analysis of a prospective database. All patients undergoing LTME within 8 weeks after full-thickness TEM for rectal cancer between January 2001 and December 2011 were included. Each patient was matched on the basis of demographic and clinical characteristics with two patients undergoing primary LTME for rectal cancer during the same period. Age, gender, body mass index, tumor distance from the anal verge, tumor size, neoadjuvant chemoradiation, previous TEM, rectal wall defect size created during TEM, and intraoperative complications were included in a multivariate analysis to identify risk factors for abdominoperineal resection (APR).

RESULTS

A total of 17 patients undergoing TEM followed by LTME were compared to 34 patients undergoing primary LTME. Mean operative time of LTME after TEM was significantly higher (206 vs. 188 min, P = 0.025). APR was more frequently performed after TEM [odds ratio (OR) 5.25, P = 0.028] and in male patients (OR 9.04, P = 0.034). On multivariate analysis, a previous TEM was the only independent predictor of APR (OR 4.13, P = 0.046). The incidence and severity of postoperative complications were similar in both groups. Mesorectum integrity was complete in all cases.

CONCLUSIONS

LTME after TEM is a challenging procedure, with a significantly higher risk of APR compared to primary LTME. Future improvements in preoperative patient selection for TEM are needed to reduce this risk.

Transanal endoscopic microsurgery for rectal neoplasms. How I do it

INTRODUCTION

Transanal endoscopic microsurgery (TEM) has revolutionized the technique and outcomes of transanal surgery, becoming the standard of treatment for large sessile rectal adenomas, and may represent a possible treatment modality for early rectal cancer.

METHODS

A full-thickness excision is made on the rectal wall down to the perirectal fatty tissue. The specimen is retrieved transanally. After the parietal defect is disinfected, the wound is closed with one or more running sutures secured with silver clips.

RESULTS

Peritoneal perforation during TEM is not associated with adverse short-term or oncologic outcomes. The postoperative morbidity rate ranges between 2 % and 15 %, and in most cases, complications can be conservatively managed. The local recurrence rate of large adenomas is about 6 %, and most recurrences can be safely re-resected by TEM. TEM represents an effective treatment for pT1 sm1 rectal malignancies, while pT1 sm2-3 and pT2 should be considered at high risk of recurrence if treated by TEM alone. Finally, TEM does not influence anorectal function or quality of life.

CONCLUSION

TEM is a safe procedure and provides excellent functional and oncologic outcomes in the treatment of large sessile benign rectal lesions and selected early rectal cancers.

Transanal endoscopic microsurgery

The aim of oncologic surgery is radical cancer treatment with preservation of function and quality of life. Almost 30 years ago, transanal endoscopic microsurgery (TEM) revolutionised the technique and outcomes of transanal surgery, first becoming the standard of treatment for large rectal adenomas, then offering a possibly curative treatment for early rectal cancer, and finally generating discussion on its potential role in combination with neoadjuvant therapies for the treatment of more invasive cancer. TEM afforded the advantage of combining a less invasive transanal approach with low recurrence rates thanks to enhanced visualization of the surgical field, which allows more precise dissection. We describe the current indications, the preoperative work-up, the surgical technique (with the aid of a video), postoperative management and results obtained in an over 20-year-long experience. Designed as an accurate means to allow excision of benign rectal neoplasms with a very low morbidity rate, TEM today is indicated as a curative treatment of malignant neoplasms that are histologically confirmed as pT1 sm1 carcinomas. T1 sm2-3 and T2 lesions should at present be included in prospective trials. Accurate preoperative staging is essential for optimal selection of patients. Patients with clear indication for TEM should be referred to specialized medical centres experienced with the technique.

Transanal endoscopic video-assisted (TEVA) excision

BACKGROUND

Transanal endoscopic video-assisted (TEVA) excision represents an alternative approach for the surgical treatment of middle and upper rectal lesions not amenable to colonoscopic removal. Utilizing principles of single-incision laparoscopic surgery, this novel minimally invasive approach optimizes access for safe and complete removal of these lesions without the need for a formal rectal resection. We describe our technique and early outcomes with TEVA excision.

METHODS

Between March 2010 and September 2011, TEVA excision was performed for patients presenting for management of rectal lesions not amenable to colonoscopic or standard transanal removal. Patients were selected if they presented with benign disease or superficial adenocarcinoma, and the proximal extent of the lesion extended beyond 8 cm from the anal verge. Demographic, intraoperative, and postoperative data were assessed. A SILS™ port was placed in the anal canal for access in all cases. Standard laparoscopic instruments were utilized for visualization, full-thickness transanal excision, and primary closure.

RESULTS

Twenty patients (50% male) with a mean age of 64.6 ± 10.9 years, mean body mass index of 28.2 ± 4.9 kg/m(2), and median American Society of Anesthesiologist score of 2 underwent TEVA excision. Fourteen patients (70%) presented with benign disease and six patients (30%) presented with malignant disease. The mean size of the lesions was 3.0 ± 1.4 cm, and the mean distance from the anal verge was 10.6 ± 2.4 cm. All excisions were successfully completed with a mean operative time of 79.8 ± 25.1 (range, 45-135) min. The mean length of hospital stay was 1.1 ± 0.7 (range, 0-3) days.

CONCLUSIONS

TEVA excision is a safe and feasible approach for local excision of rectal lesions not otherwise amenable to standard techniques. Continued investigation and development will be important to establish its role in minimally invasive colorectal surgery.

Does peritoneal perforation affect short- and long-term outcomes after transanal endoscopic microsurgery?

BACKGROUND

Peritoneal perforation (PP) is frequently reported as a complication of transanal endoscopic microsurgery (TEM). Nevertheless, these concerns have only rarely been addressed in the literature, with no mention of the long-term oncologic consequences of PP.

METHODS

A prospective database was analyzed with the intent to evaluate the influence of PP on the short- and long-term outcomes for patients undergoing TEM.

RESULTS

Peritoneal perforation occurred in 28 (5.8%) of 481 patients who underwent TEM for a rectal neoplasm. The conversion rate to abdominal surgery was 10.7% (3/28). All the conversions occurred during the first 100 TEM procedures (3/100 vs 0/381; p = 0.007). The postoperative morbidity rate was 3.6% (1/28), and the 30-day mortality was nil. Compared with the group of patients who had no peritoneal perforation, the PP group showed a significantly longer operating time (120 vs 60 min; p < 0.001) and a significantly longer hospital stay (6 vs 4 days; p = 0.003). Nevertheless, the global morbidity rate and the type of complications according to Dindo's classification were similar. In the multivariate analysis, the only independent predictor of PP was tumor distance from the anal verge (p = 0.010). During a median follow-up period of 48 months (range, 12-150 months), no liver or peritoneal metastases were detected in 13 patients with rectal cancer.

CONCLUSIONS

Peritoneal perforation does not seem to affect short-term or oncologic outcomes for patients submitted to TEM with full-thickness resection for upper rectum neoplasms. The use of TEM to resect rectal lesions involving the intraperitoneal rectum may therefore represent an intermediate step toward the development of transrectal natural orifice translumenal endoscopic surgery (NOTES) techniques.

Endoscopic submucosal dissection versus local excision for early rectal neoplasms: a comparative study

BACKGROUND

Transanal local excision (LE) is a well-established treatment option for early rectal neoplasms not amenable to complete colonoscopic removal. Endoscopic submucosal dissection (ESD) has been introduced recently as a novel procedure that enables en bloc resection of large rectal neoplasms. To date, no report comparing the two approaches can be found in the literature. This study aimed to compare the short-term clinical outcomes between ESD and LE for early rectal neoplasms.

METHODS

Between 2007 and 2010, 14 patients with early rectal neoplasms deemed not feasible for en bloc endoscopic resection using conventional techniques underwent ESD. They were compared with a matched cohort of 30 patients who had early rectal neoplasms and underwent LE between 2000 and 2009. Short-term clinical outcomes including postprocedure recovery and morbidity were compared between the two groups.

RESULTS

The mean lesion size was comparable between the ESD and LE groups (2.9 vs 2.6 cm; P = 0.423), but the mean distance of the lesions from the anal verge was greater in the ESD group (8.6 vs 5.0 cm; P = 0.001). En bloc resection was achieved for 12 patients (85.7%) in the ESD group and for all the patients in the LE group. The ESD group exhibited a trend toward a longer operative time (77.5 vs 50.0 min; P = 0.081) but lower morbidity (7.1 vs 33.3%; P = 0.076). The time to full ambulation was shorter in the ESD group (0 vs 1 day; P = 0.005), but the hospital stay was similar in the two groups (2.5 vs 4.0 days; P = 0.129).

CONCLUSION

For the treatment of early rectal neoplasms, ESD offers better short-term clinical outcomes in terms of faster recovery and possibly lower morbidity than LE. Further prospective studies with a larger sample are needed to validate the benefits of rectal ESD.

The Ferguson Operating Anoscope as a Minimally Invasive Option for the Treatment of Rectal Tumors

Transanal excision of rectal tumors may be performed using the Ferguson Operating Anoscope (FOA). This retrospective case series evaluates the effectiveness of FOA for the excision of selected benign and malignant rectal tumors. The office records of 97 patients with rectal tumors who underwent FOA transanal excision by a single surgeon from 1999 through 2009 were reviewed. In the 97 patients evaluated, 99 FOA transanal excisions were performed for 39 adenocarcinomas, 55 benign tumors, and five carcinoid tumors. The tumors were 0.5 to 13.5 cm in diameter and located an average of 6.9 cm (range, 1 to 15 cm) from the anal verge. Ninety-one per cent of cases were performed as an outpatient. Postoperative complications occurred in 14 per cent with transient effects on continence in 2 per cent and a mean blood loss of 66 mL. The recurrence rate for favorable T1 rectal cancers was 4.3 per cent and for adenomas was 5.9 per cent. In early follow up of adenomas and favorable T1 carcinomas, FOA transanal excision has similar application, morbidity, and recurrence rates as reported for transanal endoscopic microsurgery for rectal tumors within 15 cm from the anal verge. FOA may be considered a useful option for the minimally invasive treatment of rectal tumors.