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Barendse RM, Musters GD, de Graaf EJR, van den Broek FJC, Consten ECJ, Doornebosch PG, Hardwick JC, de Hingh IHJT, Hoff C, Jansen JM, van Milligen de Wit AWM, van der Schelling GP, Schoon EJ, Schwartz MP, Weusten BLAM, Dijkgraaf MG, Fockens P, Bemelman WA, Dekker E. Randomised controlled trial of transanal endoscopic microsurgery versus endoscopic mucosal resection for large rectal adenomas (TREND Study). Gut 2018; 67:837-846. [PMID: 28659349 DOI: 10.1136/gutjnl-2016-313101] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 05/02/2017] [Accepted: 05/03/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Non-randomised studies suggest that endoscopic mucosal resection (EMR) is equally effective in removing large rectal adenomas as transanal endoscopic microsurgery (TEM), but EMR might be more cost-effective and safer. This trial compares the clinical outcome and cost-effectiveness of TEM and EMR for large rectal adenomas. DESIGN Patients with rectal adenomas ≥3 cm, without malignant features, were randomised (1:1) to EMR or TEM, allowing endoscopic removal of residual adenoma at 3 months. Unexpected malignancies were excluded postrandomisation. Primary outcomes were recurrence within 24 months (aiming to demonstrate non-inferiority of EMR, upper limit 10%) and the number of recurrence-free days alive and out of hospital. RESULTS Two hundred and four patients were treated in 18 university and community hospitals. Twenty-seven (13%) had unexpected cancer and were excluded from further analysis. Overall recurrence rates were 15% after EMR and 11% after TEM; statistical non-inferiority was not reached. The numbers of recurrence-free days alive and out of hospital were similar (EMR 609±209, TEM 652±188, p=0.16). Complications occurred in 18% (EMR) versus 26% (TEM) (p=0.23), with major complications occurring in 1% (EMR) versus 8% (TEM) (p=0.064). Quality-adjusted life years were equal in both groups. EMR was approximately €3000 cheaper and therefore more cost-effective. CONCLUSION Under the statistical assumptions of this study, non-inferiority of EMR could not be demonstrated. However, EMR may have potential as the primary method of choice due to a tendency of lower complication rates and a better cost-effectiveness ratio. The high rate of unexpected cancers should be dealt with in further studies.
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Affiliation(s)
- Renée M Barendse
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | | | | | | | | | | | - James C Hardwick
- Gastroenterology, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Chrisiaan Hoff
- Surgery, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - Jeroen M Jansen
- Gastroenterology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | | | | | - Erik J Schoon
- Gastroenterology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Bas L A M Weusten
- Gastroenterology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Paul Fockens
- Gastroenterology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Willem A Bemelman
- Department of Surgery, Academic Medical Centre, Amsterdam, Netherlands
| | - Evelien Dekker
- Gastroenterology, Academic Medical Centre, Amsterdam, the Netherlands
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Bronzwaer MES, Musters GD, Barendse RM, Koens L, de Graaf EJR, Doornebosch PG, Schwartz MP, Consten ECJ, Schoon EJ, de Hingh IHJT, Tanis PJ, Dekker E, Fockens P. The occurrence and characteristics of endoscopically unexpected malignant degeneration in large rectal adenomas. Gastrointest Endosc 2018; 87:862-871.e1. [PMID: 29030001 DOI: 10.1016/j.gie.2017.09.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/24/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Large non-pedunculated rectal polyps are most commonly resected by endoscopic mucosal resection (EMR) or transanal endoscopic microsurgery (TEM). Despite pre-procedural diagnostics, unexpected rectal cancer is incidentally encountered within the resected specimen. This study aimed to compare the diagnostic assessment and procedural characteristics of lesions with and without unexpected submucosal invasion. METHODS A post-hoc analysis of a multicenter randomized trial (TREND study) was performed in which patients with a non-pedunculated rectal polyp of ≥3 cm without endoscopic suspicion of invasive growth were randomized between EMR and TEM. RESULTS Unexpected rectal cancer was detected in 13% (27/203) of patients; 15 after EMR and 12 after TEM. Most consisted of low-risk T1 cancers (78%, n = 18). There were no differences in the diagnostic assessment between lesions with and without unexpected submucosal invasion. Diagnostic biopsies revealed similar rates of high-grade dysplasia (28% [7/25] vs 18% [26/144]). When compared with EMR of adenomas, EMR procedures of unexpected cancers had a lower success rate of submucosal lifting (60% vs 93%, P < .001), were more often assessed as endoscopically incomplete (33% vs 10%, P = .01), and were more frequently terminated prematurely (60% vs 8%, P = .001). CONCLUSIONS Diagnostic assessment of large non-pedunculated rectal polyps revealed similar characteristics between unexpected cancers and adenomas. Unexpected cancers during EMR were non-lifting in 40%, endoscopically assessed as incomplete in 33%, and terminated prematurely in 60%. In treatment-naive patients, these factors should raise suspicion of malignancy and need discussion in a multidisciplinary team meeting for decision on further treatment strategies.
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Affiliation(s)
- Maxime E S Bronzwaer
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Gijsbert D Musters
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Renée M Barendse
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Lianne Koens
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Eelco J R de Graaf
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Pascal G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan de Ijssel, the Netherlands
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - Esther C J Consten
- Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Pieter J Tanis
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Evelien Dekker
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Verseveld M, Barendse RM, Gosselink MP, Verhoef C, de Graaf EJR, Doornebosch PG. Transanal minimally invasive surgery: impact on quality of life and functional outcome. Surg Endosc 2015; 30:1184-7. [PMID: 26139488 PMCID: PMC4757623 DOI: 10.1007/s00464-015-4326-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 05/05/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND Transanal minimally invasive surgery (TAMIS) is emerging as an alternative to transanal endoscopic microsurgery. Quality of life (QOL) and functional outcome are important aspects when valuing a new technique. The aim of this prospective study was to assess both functional outcome and QOL after TAMIS. METHODS From 2011 to 2013, patients were prospectively studied prior to and at least 6 months after TAMIS for rectal adenomas and low-risk T1 carcinomas using a single-site laparoscopy port. Functional outcome was determined using the Faecal Incontinence Severity Index (FISI). Quality of life was measured using functional [Faecal Incontinence Quality of Life (FIQL)] and generic (EuroQol EQ-5D) questionnaires. RESULTS The study population consisted of 24 patients 13 men, median age 59 (range 42-83) with 24 tumours [median distance from the dentate line 8 cm (range 2-17 cm); median tumour size 6 cm(2) (range 0.25-51 cm(2)); 20 adenomas; 4 low-risk T1 carcinomas]. Post-operative complications occurred in one patient (4 %; grade IIIb according to Clavien Dindo classification). Compared to baseline, FISI remained unaffected (9.8 vs 7.3; P = 0.26), FIQL remained unaffected, and EuroQol EQ-5D improved (EQ-VAS: 77 vs 83; P = 0.04). CONCLUSION There was no detrimental effect of TAMIS on anorectal function. Overall QOL was improved after TAMIS, probably due to removal of the tumour, and at 6 months was equal to the general population.
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Affiliation(s)
- Maria Verseveld
- Department of General Surgery, IJsselland Hospital, P.O. Box 960, Capelle aan den Ijssel, The Netherlands. .,Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands.
| | - Renée M Barendse
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | | | - Cornelis Verhoef
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Eelco J R de Graaf
- Department of General Surgery, IJsselland Hospital, P.O. Box 960, Capelle aan den Ijssel, The Netherlands
| | - Pascal G Doornebosch
- Department of General Surgery, IJsselland Hospital, P.O. Box 960, Capelle aan den Ijssel, The Netherlands
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Verseveld M, Barendse RM, Dawson I, Vos EL, de Graaf EJR, Doornebosch PG. Intramucosal carcinoma of the rectum can be safely treated with transanal endoscopic microsurgery; clinical support of the revised Vienna classification. Surg Endosc 2014; 28:3210-5. [PMID: 24939156 DOI: 10.1007/s00464-014-3593-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 05/06/2014] [Indexed: 12/19/2022]
Abstract
AIM The revised Vienna criteria were proposed for classifying rectal neoplasia and subsequent treatment strategies. Restaging intramucosal carcinoma to a non-invasive subgroup seems logical, but clinical support is lacking. In this study, we investigated whether distinction between intramucosal carcinomas (IMC) and rectal adenoma (RA) is of clinical relevance and whether these neoplasms can all be similarly and safely treated by transanal endoscopic microsurgery (TEM). METHODS All consecutive patients with IMC and RA, treated with TEM between 1996 and 2010 in tertiary referral centre for TEM were included. Long-term outcome of 88 IMC was compared to 356 pure rectal adenomas (RA). Local recurrence (LR) rate was the primary endpoint. Risk factors for LR were analysed. RESULTS LR was diagnosed in 7/88 patients (8.0 %) with IMC and in 33/356 patients with primary RA (9.3 %; p = 0.700) and LR-free survival did not differ (p = 0.438). Median time to recurrence was 10 months (IQR IMC 5-30; RA 6-16). Overall recurrence occurred mainly in the first 3 years (38/40; 95 %). None of the LR revealed malignancy on pathological evaluation. No differences could be found in complication rates (IMC 9 %; RA 13 %; p = 0.34). Metastases did not occur in either group. Independent risk factors for LR were irradical margins at final histopathology (HR 2.32; 95 % CI 1.17-4.59; p = 0.016) and more proximal tumours (HR 0.84; 95 % CI 0.77-0.92; P = <0.001). CONCLUSION In this study, IMC of the rectum and RA have similar recurrence rates. This supports the revised Vienna classification. Both entities can be safely treated with TEM.
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Affiliation(s)
- Maria Verseveld
- Department of Surgery, IJsselland Hospital, P.O. Box 960, Capelle aan den IJssel, The Netherlands,
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Barendse RM, Oors JM, de Graaf EJR, Bemelman WA, Fockens P, Dekker E, Smout AJPM. The effect of endoscopic mucosal resection and transanal endoscopic microsurgery on anorectal function. Colorectal Dis 2013; 15:e534-41. [PMID: 23746076 DOI: 10.1111/codi.12311] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 02/16/2013] [Indexed: 02/08/2023]
Abstract
AIM The study assessed the impact on anorectal function of endoscopic mucosal resection (EMR) and transanal endoscopic microsurgery (TEM) of large rectal adenomas. METHOD Patients with a large (≥ 3 cm) rectal adenoma undergoing EMR or TEM were included. Self-reported faecal incontinence was assessed using the Colorectal Functional Outcome (COREFO) questionnaire and the Wexner Incontinence Grading Scale. Anorectal manometry was performed before and at 6 months after treatment to measure anal resting (ARP) and squeeze pressure (SP), squeeze endurance (SE), the rectoanal inhibitory reflex (RAIR), rectal volumetry of first sensation (FS), first urge (FU), maximum tolerable volume (MTV) and rectal compliance (RC). RESULTS Twenty-four patients were included in the study, of whom 11 underwent EMR and 13 underwent TEM. The mean adenoma size was 51 ± 19 mm and the median distance from the anal verge was 3 cm (interquartile range 1-10 cm). Follow-up data were available from 20 patients; one patient had died and three had undergone total mesorectal excision. Incontinence for liquid stool and Wexner score decreased significantly after treatment. In contrast, none of the measured parameters of anorectal motility (ARP, SP, SE, RAIR, RC) and perception (FS, FU, MTV) was affected by adenoma resection. No differences were found in baseline and follow-up incontinence and functional parameters between intervention groups, except for postprocedural ARP, which was lower after TEM than after EMR. CONCLUSION Continence in patients with a large rectal adenoma improved after EMR or TEM, probably due to decreased rectal mucus production. Anal sphincter pressure, rectoanal reflexes, rectal sensation and compliance were not affected by adenoma resection.
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Affiliation(s)
- R M Barendse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Barendse RM, Dijkgraaf MG, Rolf UR, Bijnen AB, Consten ECJ, Hoff C, Dekker E, Fockens P, Bemelman WA, de Graaf EJR. Colorectal surgeons' learning curve of transanal endoscopic microsurgery. Surg Endosc 2013; 27:3591-602. [PMID: 23572216 DOI: 10.1007/s00464-013-2931-6] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/08/2013] [Indexed: 01/05/2023]
Abstract
BACKGROUND Transanal endoscopic microsurgery (TEM) is a technically demanding key technique in minimally invasive rectal surgery. We investigated the learning curve of colorectal surgeons commencing with TEM. METHODS All TEM procedures of four colorectal surgeons were analyzed. Procedures were ranked chronologically per surgeon. Outcomes included conversion, postoperative complications, procedure time, and recurrence. Backward multivariable regression analysis identified learning curve effects and other predictors. RESULTS Four surgeons resected 693 rectal lesions [69.9 % adenoma/25.5 % carcinoma; median size 20 cm(2); interquartile range (IQR) 11-35; 7 ± 4 cm ab ano]. A total of 555 resections (80.1 %) were histopathologically radical (R0). Conversion (4.3 %) was influenced by a learning curve [odds ratio (OR) 0.991 per additional procedure; 95 % confidence interval (CI) 0.984-0.998] and by lesion size. Postoperative complications depended only on the individual surgeon and lesion size in benign lesions (10.4 % complications). A learning curve (OR 0.99; 95 % CI 0.988-0.998) and peritoneal entrance affected complications in malignant lesions (13.3 %). Procedure time [median 55 min (IQR 30-90)] was influenced by a learning curve [B -0.11 (95 % CI -0.14 to -0.09)], individual surgeon, single-piece resection, peritoneal entrance, lesion size, and rectal quadrant. Recurrence of benign lesions (4.5 %) depended on lesion size, R0 resection, and prior resection attempts. Recurrence of malignant lesions (8.9 %) depended on 3D stereoscopic view, lesion size, full-thickness resection, and length of follow-up. Recurrence-free survival of patients operated during the 36th through 80th procedure per surgeon was significantly shorter than in patients operated during procedures 1-35 and 81 onwards. CONCLUSIONS A surgical learning curve affected conversion rate, procedure time, and complication rate. It did not influence recurrence rates, possibly due to evolving patient populations. This first insight into the learning curve of TEM stresses the importance of quality monitoring and centralisation of care.
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Affiliation(s)
- Renée M Barendse
- Department of Gastroenterology and Hepatology, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, The Netherlands,
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Barendse RM, van den Brandt S, Dekker E, Fockens P. [McKittrick-Wheelock syndrome]. Ned Tijdschr Geneeskd 2013; 157:A5567. [PMID: 23328026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND The McKittrick-Wheelock syndrome is rare and is characterized by hypersecretion of fluids and electrolytes by a large rectal villous adenoma. Untreated disease may cause fatal renal failure or arrhythmia. We present 2 cases with different symptoms. CASE DESCRIPTIONS An 83-year-old female with long-standing renal failure of unknown origin was admitted due to dehydration with recurrent collapse and electrolyte imbalance. Colonoscopy was performed because of persistent diarrhoea, which revealed an extensive rectal adenoma. After endoscopic mucosal resection, electrolyte values normalized entirely. A 66-year-old male presented with malaise, weight loss and severe renal failure. A giant rectal adenoma was found. After endoscopic mucosal resection, the electrolyte imbalance disappeared and renal function normalized. A fibrotic remnant required surgical removal and revealed submucosally invasive carcinoma. CONCLUSION In rare cases, renal failure and electrolyte imbalance may be caused by large rectal adenomas.
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Affiliation(s)
- Renée M Barendse
- AMC, afd. Maag-, Darm- en Leverziekten, Amsterdam, the Netherlands
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Barendse RM, van den Broek FJC, van Schooten J, Bemelman WA, Fockens P, de Graaf EJR, Dekker E. Endoscopic mucosal resection vs transanal endoscopic microsurgery for the treatment of large rectal adenomas. Colorectal Dis 2012; 14:e191-6. [PMID: 22023493 DOI: 10.1111/j.1463-1318.2011.02863.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
AIM Large (> 2 cm) rectal adenomas are currently treated by transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). The potential lower morbidity of EMR becomes irrelevant if it is less effective. We aimed to compare the safety and effectiveness of EMR and TEM for large rectal adenomas. METHOD Data from patients undergoing TEM or EMR for a rectal adenoma > 2 cm in eight hospitals were retrospectively collected. Patient- and procedure-related characteristics, complications and recurrences were recorded. As EMR may require several attempts to achieve complete resection, early (after a single intervention) and late (permitting re-treatment for residual adenoma within 6 months) recurrence rates were determined. RESULTS Two hundred and ninety-two (292) patients (49% male; mean age 67 years) were included; 219 were treated by TEM and 73 by EMR. Adenomas treated by EMR were smaller (median 30 vs 40 mm; P = 0.007). Perioperative complication rates were 2% for TEM and 6% for EMR (P = 0.171). Postoperative complications occurred in 24% of TEM patients and in 13% of EMR patients (P = 0.038). Median hospitalization after TEM was 3 days vs 0 days after EMR (P < 0.001). Median follow-up was 12.6 months (0-47 months); Early recurrence rates were 10.2% in TEM patients and 31.0% in EMR patients (P < 0.001); late recurrence rates were 9.6% and 13.8%, respectively (P = 0.386). CONCLUSION After a single intervention, EMR of large rectal adenomas seems less effective, but safer than TEM. When allowing re-treatment of residual adenoma within 6 months, EMR and TEM seem equally effective. A prospective randomized comparison seems to be necessary.
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Affiliation(s)
- R M Barendse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands.
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Barendse RM, Verlaan T, Bemelman WA, Fockens P, Dekker E, Nonner J, de Graaf EJR. Transanal single port surgery: selecting a suitable access port in a porcine model. Surg Innov 2011; 19:323-6. [PMID: 22064488 DOI: 10.1177/1553350611425507] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Single port surgery of rectal tumors may be associated with a shorter learning curve and fewer costs than transanal endoscopic microsurgery. The authors aimed to select the most optimal single access port for transanal employment. Four single access ports (GelPOINT, TriPort, SSL Access System, and SILS) were tested in 2 pigs. Insertion feasibility and intraoperative features of each port were assessed. A rectal excision was attempted using the most suitable port. Insertion of GelPOINT was impossible. SILS and TriPort were easily inserted; however, insufficient stability demanded manual fixation. CO2 leaked through the TriPort trocar ports. Insertion of the 2-cm SSL Access System retractor was difficult, but pneumorectum and surgical circumstances were favorable. Single port transanal surgery may be a promising alternative for transanal endoscopic microsurgery. The SSL Access System was found the most suitable for this indication in a porcine model.
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Barendse RM, van den Broek FJC, Dekker E, Bemelman WA, de Graaf EJR, Fockens P, Reitsma JB. Systematic review of endoscopic mucosal resection versus transanal endoscopic microsurgery for large rectal adenomas. Endoscopy 2011; 43:941-9. [PMID: 21971923 DOI: 10.1055/s-0030-1256765] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND STUDY AIMS Large ( > 2 cm) rectal adenomas are currently treated by either transanal endoscopic microsurgery (TEM) or piecemeal endoscopic mucosal resection (EMR). The potential lower morbidity of EMR may become irrelevant if EMR is less effective. The aim of this study was to compare the safety and effectiveness of EMR and TEM for large rectal adenomas. PATIENTS AND METHODS A systematic review of the literature published between January 1980 and January 2009 was conducted. Pooled estimates of the proportion of patients with recurrence or complications in EMR and TEM studies were compared using random effects meta-regression analysis. Early (after single intervention) and late (excluding re-treatment of residual adenoma detected within 3 months) recurrence rates were calculated. RESULTS A total of 20 EMR studies and 48 TEM studies were included. No studies directly compared EMR with TEM. Mean polyp size was 31 mm (range 2 - 86 mm) for EMR vs. 37 mm (range 3 - 182 mm) for TEM (P = 0.02). Early recurrence rates were 11.2 % (95 % confidence interval [CI] 6.0 - 19.9) for EMR vs. 5.4 % (95 %CI 4.0 - 7.3) for TEM (P = 0.04). Late recurrence rates were 1.5 % (95 %CI 0.6 - 3.9) for EMR vs. 3.0 % (95 %CI 1.3 - 6.9) for TEM (P = 0.29). Postoperative complication rates were 3.8 % (95 %CI 2.8 - 5.3) for EMR vs. 13.0 % (95 %CI 9.8 - 17.0) for TEM (P < 0.001). CONCLUSIONS After single intervention, EMR for large rectal adenomas appears to be less effective but safer than TEM. When outcome data for re-treatment of residual adenoma within 3 months are included, EMR and TEM seem equally effective. Nevertheless, the added morbidity of additional EMRs could not be accounted for in this analysis. A prospective randomized trial seems imperative before making recommendations concerning the treatment of large rectal adenomas.
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Affiliation(s)
- R M Barendse
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Barendse RM, Fockens P, Bemelman WA, de Graaf EJR, Dekker E. The significant rectal neoplasm and mucosectomy by transanal endoscopic microsurgery (Br J Surg 2011; 98: 1342-1344). Br J Surg 2011; 98:1495; author reply 1495-6. [PMID: 21887781 DOI: 10.1002/bjs.7693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
The Editors welcome topical correspondence from readers relating to articles published in the Journal. Responses should be sent electronically via the BJS website (http://www.bjs.co.uk). All letters will be reviewed and, if approved, appear on the website. A selection of these will be edited and published in the Journal. Letters must be no more than 250 words in length.
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Fishman LN, Barendse RM, Hait E, Burdick C, Arnold J. Self-management of older adolescents with inflammatory bowel disease: a pilot study of behavior and knowledge as prelude to transition. Clin Pediatr (Phila) 2010; 49:1129-33. [PMID: 20837627 DOI: 10.1177/0009922810379042] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Patients gradually assume responsibility for self-management. This study sought to determine whether adolescents with inflammatory bowel disease (IBD) have developed key skills of self-management prior to the age at which many transfer to adult care. PATIENTS AND METHODS Adolescents aged 16 to 18 years old in the Children's Hospital Boston IBD database (94 total) received a mailed survey assessing knowledge and confidence of their own health information and behaviors. RESULTS Respondents (43%) could name medication and dose with confidence but had very poor knowledge of important side effects. Most patients deferred responsibility mostly or completely to parents for scheduling appointments (85%), requesting refills (75%), or contacting provider between visits (74%). CONCLUSIONS Older adolescents with IBD have good recall of medications but not of side effects. Parents remain responsible for the majority of tasks related to clinic visits and the acquisition of medications.
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Affiliation(s)
- Laurie N Fishman
- Center for Inflammatory Bowel Disease and Division of Gastroenterology and Nutrition, Children's Hospital Boston, Boston, MA 02115, USA.
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